1. 全球抑郁及相关心理问题的流行现状
1.1 总体患病率与时间趋势
抑郁症和焦虑症是全球范围内影响广泛的精神障碍，对全球健康构成重大挑战。根据2019年全球疾病负担研究（GBD）的数据，精神障碍在全球疾病负担中位列前十，且自1990年以来，其负担并未在全球范围内呈现下降趋势1。具体而言，抑郁症和焦虑症是导致全球健康相关负担的主要因素2。
进入2020年，COVID-19大流行的爆发对全球心理健康产生了显著影响，加剧了多种导致心理健康状况不佳的决定因素2。多项研究表明，疫情期间抑郁症和焦虑症的患病率显著上升。例如，一项针对儿童和青少年的系统性综述和荟萃分析显示，疫情期间抑郁症状的总体患病率为31%，焦虑症状为31%3。另一项针对COVID-19大流行期间精神健康问题的荟萃分析报告指出，抑郁症、焦虑症、困扰和失眠的总体患病率分别为31.4%、31.9%、41.1%和37.9%4。
更具体的数据显示，COVID-19大流行导致全球新增5320万例重度抑郁症病例和7620万例焦虑症病例，分别使这两种疾病的总患病率增加了27.6%和25.6%2。2020年，重度抑郁症导致全球4940万伤残调整生命年（DALYs），焦虑症导致4450万DALYs2。疫情对女性和年轻人群的影响尤为显著，他们受到的影响比男性和老年人群更大2。从时间趋势来看，全球年龄标准化全因DALY率在2010年至2019年间下降了14.2%，但在2019年至2021年期间，这一下降趋势发生逆转，2020年和2021年分别增加了4.1%和7.2%5。其中，焦虑症和抑郁症的年龄标准化DALY率增幅最为显著，分别增加了16.7%和16.4%5。这表明COVID-19疫情对全球心理健康产生了持续且深远的不利影响。
1.2 地区差异与社会经济关联
全球抑郁症和相关心理问题的流行呈现显著的地区差异，并与社会经济发展水平（Socio-demographic Index, SDI）密切相关。一项关于产后抑郁症（PPD）的全球流行病学研究显示，PPD的全球患病率为17.22%，但发达国家或高收入国家的PPD发生率显著较低 6。这可能与这些地区更完善的心理健康服务可及性、更高的诊断率以及更强的社会支持系统有关。
然而，中低收入国家（LMICs）的心理健康挑战同样严峻，尽管其表面患病率可能因诊断不足、污名化和数据收集不足而显得较低。在这些地区，社会经济地位与精神健康状况之间存在复杂的关联。研究表明，社会经济劣势，包括年轻、女性、未婚、受教育程度较低、家庭收入较低以及失业等，都与创伤后应激障碍（PTSD）的终生风险增加相关 7。在低SDI地区，多种特定风险因素叠加，进一步加剧了心理健康问题。例如，在拉丁美洲的土著居民中，健康差异持续存在，反映出系统性不平等和历史性边缘化，这些因素加剧了传染病、营养不良以及慢性病的负担 8。在尼日利亚等中低收入国家，医学生面临着收入不平等、贫困、不安全感和政治不稳定等社会问题，这些都直接影响了他们的心理健康和福祉，导致精神疾病患病率较高，例如心理困扰（25.2%）、感知压力（60.5%）、抑郁（33.5%）和焦虑（28.8%） 9。
此外，社会隔离和缺乏社会支持也被证实是导致心理健康问题（如抑郁症状）的重要风险因素，尤其对于少数族裔、国际学生和低社会经济地位的学生群体 1011。亲密伴侣暴力（IPV）在不同收入水平国家中的流行率也存在显著差异，并与抑郁症、PTSD和自杀意念的发生风险增加密切相关，这在中低收入国家尤为突出 12。睡眠健康差异也是一个重要的考量因素，不同社会经济地位背景和少数族裔群体之间存在睡眠健康差异 13。这些因素共同表明，地区差异和社会经济关联是理解全球抑郁及相关心理问题流行模式不可或缺的维度。
2. 人群特异性流行特征
2.1 性别与年龄分布
抑郁及相关心理问题在全球范围内的流行呈现出显著的性别和年龄差异。研究普遍表明，女性患抑郁症的风险高于男性 141516。例如，有数据显示，女性在一生中经历精神障碍的累积风险（53.1%）高于男性（46.4%）16。这种性别差异在不同年龄段和特定情境下尤为突出。例如，在大学生群体中，女性在焦虑水平上显著高于男性，尤其是在大学前两年，尽管在平均抑郁和压力水平上没有显著的性别差异，但有更高比例的女性大学生存在超出正常阈值的焦虑，而男性大学生则表现出更高比例的抑郁问题 17。癌症患者的研究也显示，女性患者的焦虑和抑郁发生率更高，在某些癌症类型中，女性的患病率甚至是男性的两到三倍 18。这种差异可能与生理、心理和社会文化等多重因素有关，如女性特有的激素波动（如围绝经期和围产期抑郁）19、社会角色压力以及应对方式的不同等 1114。
年龄是影响心理问题流行的另一个关键因素。抑郁症和相关心理问题的发病年龄通常较早，大约一半的终生精神障碍病例在14岁前首次发病，四分之三在24岁前发病 2021。世界卫生组织（WHO）的调查数据显示，焦虑症和冲动控制障碍的中位发病年龄更早（7-15岁），而物质使用障碍和情绪障碍的发病中位年龄分别为20岁和30岁 20。
特别关注青少年群体（10-24岁），这是精神障碍发病率显著增加的时期。2019年全球疾病负担研究（GBD）的数据显示，全球5至24岁个体中，有2.93亿人患有至少一种精神障碍。精神障碍的患病率在10-14岁年龄组中为12.40%，在15-19岁年龄组中升至13.96%，在20-24岁年龄组中略有下降至13.63% 22。这表明青春期是精神健康问题，尤其是抑郁和焦虑障碍的高发阶段 1423。在青少年中，早发性抑郁症的特征可能包括应激、功能失调的应对方式、负面身体意象和不安全的依恋风格等 14。
对于老年群体而言，虽然某些精神障碍的首次发病率可能较低，但共病风险显著增加。例如，在老年人中，焦虑症状与骨折风险增加有关，尤其是男性，这可能提示了精神健康与躯体健康之间的复杂互动 24。慢性共病指数（CCI）与抑郁症风险之间存在正相关，且与全因死亡率增加相关，尤其是在CCI≥2且合并抑郁症的患者中，死亡风险显著升高 25。这凸显了在老年人群中，对抑郁症和共病情况进行综合评估和管理的必要性。
2.2 特殊群体的脆弱性
某些特定人群由于其独特的生理、社会或环境因素，在抑郁及相关心理问题方面表现出更高的脆弱性。
跨性别及非二元性别青年 是一个面临严重心理健康挑战的群体。研究显示，跨性别和非二元性别（TNB）青年因社会支持减少、污名化和歧视而承受着不成比例的心理健康负担 26。一项针对寻求性别肯定护理的TNB青年的研究发现，基线时有56.7%的个体存在中重度抑郁，50.0%存在中重度焦虑，43.3%报告有自残或自杀念头 26。尽管性别肯定医疗干预（如青春期阻滞剂或性别肯定激素）与12个月内抑郁和自杀率的降低相关（抑郁症的调整优势比为0.40，自杀率的调整优势比为0.27），但焦虑症的改善不显著 26。这表明，社会歧视、缺乏认同和内在化污名是导致这一群体心理困境的重要因素 2627。跨性别个体面临的压力不仅包括来自外界的歧视，还包括因不被社会接受而产生的心理负担，这可能导致高水平的焦虑和抑郁 28。此外，即使在接受性别肯定手术后，跨性别个体仍可能面临较高的抑郁、焦虑和自杀意念风险，这强调了持续且对性别敏感的心理健康支持的必要性 29。
孕妇 也是抑郁症高风险人群。围产期（包括孕期和产后）是一个女性生理和心理都经历剧烈变化的阶段，这使得她们对抑郁症的易感性增加。一项系统性回顾和荟萃分析显示，全球产前抑郁症（antenatal depression）的汇总患病率为20.7% 30。在低收入和中低收入国家，以及使用自评工具或2010年后进行的研究中，产前抑郁症的患病率更高 30。在埃塞俄比亚，产前抑郁症的汇总患病率高达25.33% 31。在中国大陆地区，围产期抑郁症的患病率为16.3%，其中产前抑郁为19.7%，产后抑郁为14.8% 32。孕产妇抑郁症的风险因素包括抑郁史、缺乏社会支持、单身/分居/离婚状态、意外怀孕、失业、遭受暴力以及孕前或孕期吸烟等 303133。这些风险因素往往与社会经济地位较低和缺乏资源支持相关 3234。
精英青少年运动员 同样面临独特的心理健康挑战。这项群体在追求卓越表现的同时，承受着巨大的训练、比赛和学业压力。一项针对精英青少年运动员的范围审查发现，他们心理健康症状和疾病的患病率需要更多关注 35。例如，在混合性别的样本中，抑郁症的患病率可达7%，而女性运动员的抑郁率甚至高达40% 35。另一项针对中国精英青少年运动员的研究显示，19%的运动员达到广泛性焦虑障碍的诊断阈值，抑郁症的比例也类似 36。与非运动员相比，运动员身份本身以及性别是心理健康问题常见的风险因素 3537。社会关系因素（如与教练、父母和同伴的关系）也对他们的心理健康产生影响 35。此外，伤病被发现是澳大利亚精英运动员抑郁症和广泛性焦虑障碍症状加剧的重要因素 37。职业生涯满意度与焦虑/抑郁和困扰的迹象显著相关，职业生涯不满意度是焦虑/抑郁和困扰迹象的显著独立预测因子 38。
3. 抑郁及相关心理问题的多维影响因素
3.1 社会环境因素
抑郁及相关心理问题的发生和发展受到复杂多样的社会环境因素影响，尤其在经历全球性公共卫生危机时，这些因素的作用更为凸显。COVID-19大流行期间，感染率、社会流动性下降、社会隔离以及经济压力等社会环境变化对个体心理健康产生了深远影响。
COVID-19相关因素的影响：疫情期间，病毒感染本身及其带来的健康不确定性是普遍的心理压力源。一项系统综述指出，超过半数的COVID-19康复者在感染后6个月甚至更长时间内出现感染后遗症（PASC），其中心理健康障碍是常见问题之一，广义焦虑症的患病率中位数达到29.6% 39。除了直接感染，与COVID-19相关的各种公共卫生措施，如封锁、隔离、学校停课等，都极大地改变了人们的日常生活模式，导致精神健康问题的增加 40。一项针对马来西亚大学生群体的研究显示，在疫情期间，压力、焦虑和抑郁的患病率分别高达56.5%、51.3%和29.4%，而对COVID-19的负面认知与这些心理问题的加剧密切相关 41。此外，对COVID-19的恐惧也与多种精神健康相关因素（如焦虑、压力、抑郁和睡眠问题）存在中等程度的关联 42。
社会隔离与孤独感：为了遏制病毒传播，各国政府普遍实施了限制社交互动、居家隔离等措施，导致社会隔离程度显著上升。人类对归属感有基本需求，社会孤立被视为对生物适应性的威胁 43。研究发现，疫情导致的社会隔离对儿童和青少年的心理健康产生了负面影响，特别是青少年时期对社会排斥的敏感性达到顶峰 43。远程学习模式的推广使得学生，特别是青少年，长期处于缺乏面对面社交互动的状态，加剧了孤独感、焦虑、悲伤和压力 4445。一项针对埃塞俄比亚高中学生的研究表明，虽然大多数学生在隔离期间建立了相似的日常学习习惯，但仍有16%的学生心理健康得分显示抑郁症状 45。进一步的研究也发现，疫情导致的社会隔离与儿童焦虑水平的线性增加相关，甚至导致焦虑症患病率增加四倍 46。对于有运动障碍的儿童及其照护者而言，疫情期间康复治疗中断进一步加剧了儿童和照护者的身体和心理健康困境，包括儿童压力增加、身体活动减少以及照护者压力增大等 47。
经济压力与不安全感：COVID-19大流行对全球经济造成冲击，导致失业、收入减少以及更广泛的经济不确定性，这些都转化为巨大的心理压力。经济压力，特别是粮食不安全，与父母和儿童的抑郁症患病率存在显著关联。例如，在肯尼亚西部，青少年母亲更容易面临贷款、粮食不安全以及健康和经济功能受损等问题，这些问题会持续到成年，并与其不良的心理健康状况相关 48。此外，在产妇群体中，物质和社会资源匮乏以及疫情期间就业相关的压力，都与围产期精神健康症状的增加有关，且这种影响在有色人种中更为显著 49。环境不公正也加剧了低社会经济地位边缘化人群的心理健康风险，他们更容易暴露于空气污染等环境危害，而这些危害会对其身心健康产生更大的负面影响，尤其是对儿童 50。这些证据表明，经济不稳定和资源不平等是加剧心理健康问题的重要社会决定因素。
3.2 生物与生理机制
抑郁及相关心理问题的发生发展与复杂的生物学和生理机制密切相关，涉及神经内分泌、肠道菌群以及躯体疾病等多个层面。
HPA轴异常：下丘脑-垂体-肾上腺（HPA）轴是应激反应的核心调节系统，其功能失调在抑郁症的病理生理学中扮演关键角色 51。HPA轴的过度激活或调节异常，特别是皮质醇水平的升高，已被广泛认为是抑郁症的生物学标志之一。在青少年群体中，HPA轴的功能尤其敏感。研究表明，青少年时期经历的应激可能会影响大脑成熟的轨迹，尤其是在边缘系统和皮层区域，从而导致焦虑和抑郁等心理疾病的增加 52。有证据指出，青少年晨间皮质醇水平的升高可能预示着抑郁症的发生 51。例如，HPA轴功能异常与青少年酒精滥用和自杀行为的病理生理学相关，其活动机制的改变甚至可能先于酒精使用障碍的发展 53。此外，HPA轴还与血清素能系统存在复杂的相互作用，两者异常的相互作用可能导致情绪失调，这在青少年自杀行为中发挥重要作用 51。尽管如此，针对青少年抑郁症的研究显示，HPA轴与下丘脑-垂体-甲状腺（HPT）轴之间的关系不如成人明确，提示了这种调节机制可能存在年龄相关的成熟调整 54。
肠道菌群失调：近年来，肠道菌群在抑郁症中的作用受到了广泛关注。肠道菌群通过肠-脑轴（gut-brain axis）与大脑进行双向交流，影响神经递质合成、免疫反应和神经炎症，进而影响情绪和行为 555657。肠道菌群的组成和功能改变，即生态失调（dysbiosis），被认为是抑郁症发生和进展的重要因素。菌群代谢产物，如短链脂肪酸（SCFAs）和色氨酸代谢产物，在调节肠-脑轴中发挥关键作用 5558。例如，色氨酸作为神经递质血清素的前体，其代谢过程受肠道微生物影响，进而影响情绪调节 5960。肠道菌群失调可能导致神经炎症，进一步加剧抑郁症状 57。针对微生物的疗法，如饮食干预、粪便微生物移植、益生菌、益生元等，被认为是治疗抑郁症的新兴策略 5558。
心血管共病：抑郁症与心血管疾病之间存在复杂的双向关系。高血压等心血管疾病不仅是抑郁症的风险因素，反之，抑郁症也会增加心血管疾病的风险并影响其管理 6162。这种共病关系增加了死亡风险，并可能降低干预措施的疗效 61。高血压与焦虑和抑郁之间的双向关联在美国年轻人中尤为明显，且在低收入人群、女性和少数族裔群体中影响更强 62。队列研究表明，抑郁症通过炎症和自主神经功能障碍途径促进高血压的发生，而高血压本身也会加剧心理困扰，形成恶性循环 62。此外，睡眠障碍与高血压、抑郁症和心血管疾病之间也存在显著的双向关系，提示了三者共病的复杂性 63。遗传学研究也揭示了抑郁症与心血管疾病（如冠状动脉疾病和高血压）之间存在因果关联，加重了阿尔茨海默病等其他疾病的风险 64。
3.3 心理与行为风险
除了社会环境和生物生理因素外，心理与行为模式在抑郁及相关心理问题的发生和维持中扮演着重要角色。其中，智能手机成瘾、情绪性进食以及负性认知模式（如反刍思维）是近年来受到广泛关注的几个关键领域。
智能手机成瘾（Smartphone Addiction）：随着智能手机的普及，过度使用已成为一个全球性的公共卫生问题，并与心理健康问题密切相关。研究表明，智能手机成瘾与抑郁、焦虑和压力之间存在显著关联 65666768。一项针对黎巴嫩年轻人的研究发现，智能手机成瘾与更高的无聊倾向、焦虑和孤独感显著相关 65。其中，焦虑在此关联中起到中介作用，即无聊倾向和孤独感通过焦虑间接影响智能手机成瘾 65。另一项针对大学生的研究也证实了焦虑（包括学术焦虑、社交焦虑和未来焦虑）通过元认知（metacognition）中介智能手机成瘾的机制 69。此外，智能手机成瘾还被发现与精神病性特征（schizotypal traits）相关，而抑郁、焦虑和压力在此关系中发挥中介作用，表明过度使用智能手机可能作为一种压力源，通过加剧心理困扰而间接促进精神病性倾向 66。在孕妇群体中，智能手机成瘾虽然不直接影响睡眠质量，但会增加抑郁水平，进而导致睡眠质量下降，提示了智能手机成瘾对特定脆弱群体心理健康的间接影响 70。此外，父母的“手机冷落”（parental phubbing）行为也被发现与青少年智能手机成瘾正相关，其中抑郁起部分中介作用，且这种关联在学校氛围更负面的青少年中更强 71。总体而言，高度或不断增长的成瘾性屏幕使用轨迹与青少年自杀行为、自杀意念以及更差的心理健康状况相关，而非仅仅是总屏幕时间 72。
情绪性进食（Emotional Eating）：情绪性进食是指个体为应对负面情绪（如抑郁、焦虑、压力）而摄入食物的行为。这种行为在青少年中尤为常见，并与抑郁症呈现中等强度的关联 7374。一项针对肥胖症手术候选者的研究显示，抑郁症状的严重程度与情绪性进食和外部性进食行为呈正相关，而与限制性进食行为呈负相关 75。这意味着，抑郁程度越高的个体，越倾向于通过食物来应对情绪，并更容易受到外部食物线索的影响。另一项针对青少年的研究发现，睡眠不足与情绪性进食（尤其是在应对焦虑、愤怒、沮丧和抑郁时进食）以及身体不满（body dissatisfaction）相关 73。在身体不满程度较高的青少年中，睡眠不足与情绪性进食的关联更加显著，提示优化睡眠可能有助于降低患有高度身体不满的青少年的饮食失调风险 73。抑郁症与情绪性进食之间可能存在复杂的通路，例如，抑郁可能通过述情障碍（alexithymia）和冲动性（impulsivity）间接促进情绪性进食，而与外部性进食的直接关联较弱 74。
认知模式（如反刍思维）：反刍思维（rumination）是一种重复性地思考自己的负面情绪、症状、原因和后果的认知模式，被认为是抑郁症的核心特征之一，并能维持和加剧抑郁症状 767778。反刍思维具有多重负面影响：它能放大和延长负面情绪状态，干扰问题解决和工具性行为，降低对情境变化的敏感性 76。作为一种跨诊断的精神健康脆弱性因素，反刍思维影响焦虑、抑郁、精神病、失眠和冲动行为 76。它还会干扰治疗效果，限制心理干预的效力，并加剧和维持生理应激反应 76。抑郁症患者通常表现出负性偏向的信息处理，影响注意力、记忆力以及对反馈的反应，且对避免负性情境有更强的动机，而接近积极目标的动机减弱 77。反刍思维的潜在机制包括习惯养成、执行控制功能障碍、抽象加工、目标差异和负性偏向（H-EX-A-GO-N模型），这些因素共同解释了反刍思维的发生和维持 76。此外，反刍思维与非自杀性自伤行为（NSSI）之间存在小到中等程度的正相关，且这种关联独立于反刍思维的亚型（如一般性反刍、抑郁性反刍、沉思性反刍、反思性反刍），提示其在情绪失调和应对策略中的核心作用 79。在经前期综合征（PMS）和经前烦躁障碍（PMDD）中，情绪失调，特别是反刍思维，也是预测经前症状严重程度的重要因素 78。
4. 全球健康负担与社会影响
4.1 疾病负担量化评估
抑郁症和焦虑症等精神障碍在全球范围内造成了巨大的疾病负担，这主要通过伤残调整生命年（DALYs）和健康生命年损失（YLDs）等指标进行量化评估。根据2019年全球疾病负担研究（GBD）的系统分析，精神障碍在全球疾病负担中占据突出位置，且自1990年以来，其负担并未在全球范围内显著减轻 1。
DALYs与YLDs的构成与占比：
DALYs是衡量疾病总负担的综合指标，由因早逝造成的生命年损失（YLLs）和因疾病或损伤造成的健康生命年损失（YLDs）两部分组成。对于精神障碍而言，其主要负担体现在YLDs上，因为大多数精神障碍直接导致长期残疾而非过早死亡（除饮食失调等少数情况外） 1。
- 总体精神障碍负担：在2019年，精神障碍导致的DALYs总计达1.253亿（95%不确定区间 [UI] 93.0-1.632亿），占全球总DALYs的4.9%（95% UI 3.9-6.1） 1。其中，YLDs在精神障碍总负担中占据绝大部分，2019年精神障碍导致的YLDs为1.253亿（95% UI 93.0-1.632亿），占全球总YLDs的14.6%（95% UI 12.2-16.8） 1。这使得精神和物质使用障碍成为全球YLDs的首要原因 80。
- 抑郁症与焦虑症的负担：抑郁症和焦虑症是其中贡献最大的两类精神障碍。2010年，抑郁症占精神和物质使用障碍所致DALYs的40.5%（31.7-49.2），而焦虑症占14.6%（11.2-18.4） 80。
- 工作年龄人口的负担：抑郁症对工作年龄人群（15-49岁）的健康和生产力影响尤为显著。2019年GBD数据显示，全球工作年龄人口的抑郁症患病率、发病率和DALYs均有所增加 81。
- 神经系统疾病的整体负担：2021年GBD研究显示，影响神经系统的37种疾病（包括多种精神障碍）合计成为全球DALYs的首要原因（4.43亿，95% UI 3.78-5.21亿），影响了全球43.1%的人口（34亿人） 82。虽然这些疾病的年龄标准化死亡率和DALYs率在1990年至2021年间有所下降，但年龄标准化患病率几乎保持稳定 82。
COVID-19大流行对疾病负担的影响：COVID-19大流行显著加重了全球疾病负担。2021年，COVID-19成为全球DALYs的首要原因（2.12亿，95% UI 1.98-2.345亿），其次是缺血性心脏病（1.883亿）和新生儿疾病（1.863亿） 5。值得注意的是，在2010年至2021年间，年龄标准化DALYs率增幅最大的三类疾病中，焦虑症（16.7%）和抑郁症（16.4%）位列其中，凸显了疫情对心理健康的巨大冲击 5。
与其他疾病的共病负担：抑郁症与其他躯体疾病的共病进一步加重了疾病负担。
- 精神障碍与躯体疾病的关联：精神障碍不仅独立造成健康损失，还通过增加罹患传染病和非传染性疾病的风险、促成非故意和故意伤害来间接影响健康。反之，许多躯体疾病也会增加精神障碍的风险，共病使得寻求帮助、诊断和治疗变得复杂，并影响预后 83。
- 糖尿病与抑郁症：糖尿病患者罹患抑郁症的风险显著高于普通人群。抑郁症会影响糖尿病的自我管理，如依从性差、生活方式不健康，进而导致糖尿病并发症的恶化，增加整体DALYs。
- 心血管疾病与抑郁症：抑郁症与心血管疾病存在双向关联。例如，抑郁症会增加缺血性心脏病和高血压的风险，反之，心血管疾病患者也更容易出现抑郁症状 84。抑郁症不仅作为独立因素导致DALYs，还通过增加自杀（1600万DALYs）和缺血性心脏病（近400万DALYs）的负担，使抑郁症的总DALYs占比从3.0%上升到3.8% 85。
- 神经系统疾病共病：精神障碍本身常与其他神经系统疾病共病，加剧了整体负担。例如，在西班牙，抑郁症、阿尔茨海默病、偏头痛、物质使用障碍和焦虑症是神经精神疾病DALYs的前五大原因，占这类疾病总DALYs的70.9% 86。
综上所述，抑郁症和相关心理问题是全球范围内导致YLDs的主要原因，其对DALYs的贡献持续且显著，并在COVID-19大流行期间进一步加剧。此外，精神障碍与其他躯体疾病的共病，特别是心血管疾病和糖尿病，形成了复杂的疾病交互网络，使得疾病负担进一步放大，强调了将精神健康融入整体健康框架的必要性。
4.2 社会经济成本
抑郁症及相关心理问题不仅造成巨大的疾病负担，还带来沉重的社会经济成本，主要体现在生产力损失、医疗资源消耗以及对教育系统的负面影响等方面。
生产力损失：抑郁症对个体工作能力和生产力造成显著损害，包括工作缺勤（absenteeism）和在职效率低下（presenteeism）。
- 工作缺勤：抑郁症患者因疾病发作或治疗而无法正常上班，导致直接的生产力损失。一项研究发现，患有重度抑郁症（MDD）的员工因缺勤和在职效率低下导致的生产力损失成本，平均占其年薪的33.4%，远高于对照组的2.5% 87。及时有效的精神科治疗（如8周的抗抑郁治疗）能显著减少缺勤和临床症状，并将自评工作表现提高31.8%，相当于每位员工每年节省7508美元的成本 87。
- 在职效率低下：即便抑郁症患者坚持上班，其认知功能、专注力、决策能力和工作效率也可能受到严重影响，导致“人在岗心不在”，即在职效率低下 8889。一项针对实习医生的研究显示，抑郁症状的严重程度与在职效率低下呈显著负相关，抑郁程度越高，工作表现越差 88。该研究估算，若能将因抑郁导致的在职效率低下水平恢复至基线水平，每年可为所有实习医生带来12亿美元的生产力收益 88。另一项研究也强调，抑郁症相关的生产力损失中，在职效率低下所占比例高于缺勤 89。这表明，雇主承担了抑郁症造成的大部分经济负担 89。
- 治疗抵抗性抑郁症（TRD）的更高成本：与非治疗抵抗性抑郁症（non-TRD）患者相比，TRD患者的经济负担显著更高，包括直接医疗成本和间接成本 9091。例如，在泰国的一项研究中，TRD患者的年化经济成本为每人276,059.97泰铢（约合7,668.33美元），显著高于非TRD患者的173,487.04泰铢（约合4,819.08美元） 90。另一项针对英国11万患者的纵向研究显示，TRD患者的医疗资源利用率更高，平均总医疗成本比MDD患者高出1.5倍 91。这些患者的精神和躯体共病风险也更高，例如焦虑、哮喘和酒精滥用等 91。
医疗资源消耗：抑郁症患者对医疗服务的需求显著增加，导致医疗系统资源的大量消耗。
- 初级医疗中的高就诊率：抑郁症在初级医疗环境中普遍存在，其患者倾向于频繁就诊，且医疗成本远高于非抑郁症患者 9293。即使在调整了躯体疾病共病因素后，抑郁症和焦虑症患者的医疗总成本仍显著更高，这主要体现在对普通医疗服务的利用增加，而非精神健康治疗成本的增加 9294。一项研究发现，重度抑郁症患者的年平均医疗费用比非重度抑郁症患者高出约三倍（19,838美元 vs. 6,268美元），尤其是在伴有中度至重度疼痛干扰的患者中，MDD患者的医疗费用是非MDD患者的2.33倍 94。
- 治疗依从性与成本：虽然抗抑郁药物治疗被证实能有效降低生产力损失，但初级医疗环境中MDD患者的治疗管理往往不规范，导致治疗依从性差和医疗资源利用率高 93。例如，超过75%的MDD患者在6个月内停用抗抑郁药物，这不仅影响治疗效果，也可能导致后续更多的医疗干预和更高的成本 93。然而，也有研究表明，抑郁症治疗的成本可能被因生产力提高（如减少工作日损失）所节省的成本完全抵消，尤其是在考虑其他未纳入分析的益处（如减少痛苦和提高在职效率）时 9596。例如，美国《平价医疗法案》（ACA）的实施，预计可使每位患者终生抑郁症治疗和生产力损失成本减少215美元，并增加0.01质量调整生命年（QALY），若推广至所有美国成年人，可节省473亿美元并增加220万QALYs 95。
对教育系统的影响：抑郁症及相关心理问题对学生，尤其是大学生，学业表现和整体福祉产生负面影响。
- 学业表现下降：大学生群体中普遍存在心理困扰，如抑郁、焦虑和压力 9798。一项针对大学生的研究显示，27.1%的学生存在心理困扰，7.3%存在职业倦怠 97。高水平的心理困扰和压力通常与学业成绩不佳相关 98。职业倦怠，特别是在护理专业的学生中，与学业成绩和心理健康状况呈负相关，影响学生的自我概念和学习投入 99。
- 大学入学初期的高风险：大学一年级是学生面临巨大挑战的时期，心理困扰的患病率较高 97。研究表明，大学一年级学生的心理困扰患病率为27.1%，即使职业倦怠的患病率较低（7.3%），也提示了早期预防和干预的必要性 97。在大学生中，学术表现、成功压力和毕业后规划是导致压力、焦虑和抑郁的主要担忧 98。
- 学生群体的脆弱性：转学生、高年级学生以及校外住宿的学生更容易出现压力、焦虑和抑郁症状 98。非健康科学专业的学生也显示出更大的抑郁风险 97。这些证据强调了高校需持续评估学生心理健康状况，并制定针对性的治疗和支持方案，以减轻心理问题对学业的负面影响 98。
5. 干预策略与未来方向
5.1 现有治疗与新兴疗法
抑郁症的治疗方法日益多样化，但传统疗法仍面临局限性，促使研究人员不断探索新兴疗法，以期提高治疗效果，特别是对于治疗抵抗性抑郁症（TRD）患者。
传统治疗的局限性与进展：
选择性血清素再摄取抑制剂（SSRIs）和认知行为疗法（CBT）是目前抑郁症和焦虑症的一线治疗方案。SSRI通过增加大脑中血清素的浓度来发挥作用，而CBT则通过改变患者的非适应性思维模式和行为来改善情绪。虽然这两种方法对多数患者有效，但仍有相当一部分患者（约30%）对至少两种一线抗抑郁药物治疗无效，被诊断为治疗抵抗性抑郁症（TRD）100101。针对儿童和青少年抑郁症和焦虑症的治疗研究显示，SSRI与CBT联合治疗的效果优于单一疗法，并且在症状改善方面更为显著102。然而，CBT的附加益处通常在治疗后期才显现102。对于TRD患者，现有策略包括锂盐、三碘甲状腺原氨酸和第二代抗精神病药物等药物增效方案，以及改变抗抑郁药物类别100。然而，这些方法的效果有限，且常伴有副作用。
新兴疗法：多维探索：
为了解决传统治疗的局限性，多种新兴疗法正在被积极研究和应用于临床：
赛洛西宾（Psilocybin）：这是一种天然存在的具有致幻作用的生物碱，在某些蘑菇中发现，作为血清素受体激动剂，尤其是在5-HT受体上发挥作用103。初步研究显示，赛洛西宾在治疗重度抑郁症，特别是TRD方面展现出巨大潜力103104。在一项针对TRD患者的二期双盲试验中，单次25毫克剂量的赛洛西宾在3周内显著降低了抑郁评分，且效果优于1毫克的对照组，但伴有头痛、恶心和头晕等不良反应105。另有研究探讨其在老年重度抑郁症患者中的应用潜力，认为赛洛西宾可能通过调节神经可塑性和神经炎症等机制发挥作用106。
经颅磁刺激（Transcranial Magnetic Stimulation, TMS）：TMS是一种非侵入性脑刺激技术，通过电磁感应调节大脑皮层活动，已获得美国FDA批准用于治疗重度抑郁症107。它特别适用于对药物反应不佳的TRD患者100。虽然TMS对年轻成人TRD的疗效已得到证实108，但其在老年抑郁症中的疗效仍在研究中，目前研究结果存在显著异质性108。对于青少年抑郁症，现有研究（主要是非对照研究）显示TMS可能有效，但大规模随机对照试验仍缺乏，且现有大型随机试验表明TMS不一定优于假刺激109。神经影像学技术正被用于优化TMS靶点，通过识别与深部边缘区（如扣带回下部）功能连接的额叶区域，以提高治疗效果110。
性腺激素释放激素类似物和性别肯定激素：对于跨性别和性别多样性（TGD）青年，性别肯定医疗（Gender-Affirming Care, GAC）被认为是“救命”的干预措施111。一项前瞻性队列研究发现，对于接受GAC的TNB青少年，启动青春期阻滞剂或性别肯定激素治疗与12个月内抑郁症和自杀率的降低显著相关26。虽然GAC在肯定性别认同方面具有益处，但有研究指出，即使在接受性别肯定手术后，跨性别个体仍可能面临较高的抑郁、焦虑和自杀意念风险29。这强调了在GAC过程中和之后，持续提供对性别敏感的心理健康支持的重要性29112。
其他新兴疗法：
这些新兴疗法的出现，为抑郁症，特别是TRD患者带来了新的希望。然而，多数疗法仍需大规模、长期的随机对照试验来进一步证实其长期疗效和安全性，并明确其在不同患者群体中的适用性。
5.2 预防与公共卫生措施
鉴于抑郁及相关心理问题日益增长的全球负担，有效的预防与公共卫生措施变得至关重要。这些措施应涵盖不同生命阶段和不同社会环境，通过多层级干预来促进心理健康，并减少精神疾病的发生率和严重程度。
学校心理健康项目：
学校作为青少年成长的重要场所，是实施心理健康预防和早期干预的关键阵地。全球多个国家已探索将心理健康服务融入学校系统。
- 早期筛查与转介：在学校环境中进行心理健康筛查是早期识别高危学生并及时提供支持的有效途径。例如，美国的一项合作倡议建议，通过分阶段评估流程，包括初级简短筛查和后续深入评估，来识别青少年（10-24岁）的心理健康问题，并将其转介至基于证据的护理服务 115。这种筛查机制有助于发现潜在的严重精神疾病，为早期干预赢得宝贵时间。
- 综合性支持服务：学校不仅仅是提供学术教育的场所，也应是提供全面支持服务的社区中心。例如，在美国达拉斯公立学校，其青年与家庭中心（Youth and Family Centers, YFCs）为学生及其家庭提供包括身体健康、心理健康及其他支持服务 116。这些中心配备持证心理健康专业人员，能够为学生提供个性化的心理咨询和支持，从而减少纪律问题、课程失败和缺勤率 116。
- 提升心理素养与抗逆力：学校还可以通过课程设置、工作坊等形式，提升学生的心理健康素养，教授应对压力、情绪管理和解决问题的技能，从而增强其心理抗逆力。对于临床精神病高危人群（Clinical High Risk for Psychosis, CHR-P）的服务，也延伸到公共卫生预防领域，通过学校、社区的宣传和教育，促进心理健康的普遍提升 117。
社区支持：
社区是个人生活的重要组成部分，强大的社区支持系统对心理健康具有显著的保护作用。
- 社会安全网与资源整合：社区可以建立多部门协作机制，整合社会福利、医疗、教育等资源，为弱势群体提供全面的支持。例如，学校供餐计划等社会福利项目，对改善弱势儿童的营养状况和心理健康具有积极作用。在COVID-19大流行期间，社区层面的社会支持和资源可及性对减轻民众的心理压力至关重要。
- 特定弱势群体的支持：对于无家可归或住房不稳定人群，由于其面临更高的精神疾病风险，加强案例管理和社区支持尤为重要。研究表明，强化案例管理（Intensive Case Management）能显著减少无家可归的时间，并改善物质使用状况 118。批判性时间干预（Critical Time Interventions）和积极社区治疗（Assertive Community Treatment）已被证明在减少再住院率和改善住房稳定性方面具有保护作用，并且积极社区治疗相对于标准案例管理具有成本效益 118。
- 移民与难民群体的心理支持：难民儿童在经历冲突、被迫移民和寻求安全的过程中，面临独特的创伤性经历 119。社区应提供文化敏感的心理支持服务，并关注家庭分散、严格的移民政策等负面经历，同时加强建设性育儿和社区支持等保护性因素 119。
工作场所干预：
工作场所是成年人花费大量时间的环境，其心理健康状况对个体乃至整个社会经济都具有深远影响。
- 改善工作条件：工作条件与心理健康状况之间存在关联，不良的工作条件可能会增加精神障碍的风险，例如抑郁症 120。特别是在高压行业，如医护人员，在危机时期和挑战性工作条件下，面临更高的压力、倦怠、道德伤害、抑郁及其他心理健康问题的风险 121。针对重症监护病房护士的研究发现，低工作满意度与高倦怠水平呈负相关，因此改善工作条件（如薪资、职业发展机会、心理健康支持）对降低倦怠至关重要 122。
- 组织层面干预：除了关注个人层面，工作场所干预应更多聚焦于组织层面的变革。例如，一项针对医院医护人员的调查发现，医护人员更倾向于改善管理干预措施，如解决护士人员不足、工作量控制以及改善工作环境，而非仅仅是个人层面的健康项目或抗逆力培训 123。组织应实施循证干预和组织措施，以保护和支持医护人员的心理健康和福祉 121。
- 支持性文化建设：创建支持性的工作文化，鼓励员工寻求心理帮助，消除污名化，提供灵活的工作安排，以及定期进行心理健康评估，都有助于构建健康的职场环境。系统性回顾发现，全系统健康工作场所干预措施，通过满足当地需求、全员参与、领导力支持等，能够改善员工的健康和福祉 124。
- 减少工作场所暴力：医护人员，特别是医生，在全球范围内普遍面临工作场所暴力问题 125。暴力不仅直接威胁医护人员人身安全，还导致其心理健康恶化、倦怠、创伤应激，甚至影响患者护理质量 125。因此，采取措施增强对工作场所暴力的理解、预防和管理，是保障医护人员心理健康的重要方面 125。
通过这些多维度、系统性的预防和公共卫生措施，我们可以更有效地应对抑郁及相关心理问题的挑战，提升全人群的心理健康水平。
5.3 政策与系统强化
为有效应对全球抑郁及相关心理问题的挑战，政策制定者和卫生系统管理者需采取多维度、系统性的强化措施，尤其关注低收入国家的服务可及性、心理与躯体健康的整合以及气候变化等长期社会风险。
加强低收入国家心理健康服务可及性：
全球范围内，尤其是低收入国家，精神障碍的治疗缺口巨大，高达76-85%的精神疾病患者未能获得治疗 126。这主要是由于财政资源有限、卫生组织效率低下、人力资源不足、药物匮乏以及患者面临精神病院路途遥远、自费支付和污名化等障碍 126。因此，强化低收入国家的心理健康服务可及性是当务之急。
- 培训基层医务人员：将心理健康服务整合到初级卫生保健中是提高可及性的有效策略。通过培训基层医生和其他初级卫生保健工作者识别、管理常见的精神疾病，可以显著扩大服务覆盖范围 127128。这不仅能够弥补精神科专家短缺的现状，还能降低患者就医成本，减少污名化，因为患者可以在熟悉的社区诊所而非专门的精神科机构寻求帮助。例如，世界卫生组织（WHO）的《精神卫生差距行动计划》（mhGAP）旨在通过非精神科卫生工作者提供基于证据的护理来扩大精神卫生服务的覆盖范围。
- 优化资源配置：低收入国家需要针对精神卫生投入有限的现实，优化现有资源的配置。例如，通过开发和实施适合当地需求的护理方案，并采取任务分担（task-shifting）的方法，让更多非专业人员参与到精神卫生服务中来 128。
- 社区参与和去污名化：在塞拉利昂等低收入国家，普遍存在的污名化和对精神疾病的传统观念严重阻碍了服务的利用 129。政策应支持社区参与，提高公众对精神疾病的认识，挑战负面刻板印象，从而促进精神卫生服务的采纳 127129。
整合心理与躯体健康管理：
精神疾病与躯体疾病常常共存，且相互影响，导致更高的发病率和死亡率 130。因此，将心理健康护理整合到初级保健中是提升整体健康水平的关键策略。
- 协同护理模式：整合行为健康和初级保健的模式，如协同护理（Collaborative Care Model, CoCM）或初级保健行为健康（Primary Care Behavioral Health, PCBH）模式，被认为是可操作且可持续的解决方案 131。这些模式旨在将行为健康专业知识引入医疗机构，以改善患者预后、增加治疗能力并减少污名 131。研究表明，整合护理模式在治疗共病障碍（如精神健康和物质使用障碍）方面比传统非整合模式更有效，能够减少物质使用障碍并改善患者的精神健康状况 132133。
- 筛查与早期干预：对于患有慢性躯体疾病（如糖尿病、心血管疾病）的患者，应常规进行抑郁和焦虑筛查。例如，心血管疾病患者更容易出现抑郁症状，对这部分人群进行早期筛查和干预，不仅可以改善心理健康，也可能对心血管疾病的预后产生积极影响 130。这种整合的护理方法有助于识别并解决未被发现的心理健康问题，从而提高整体治疗效果。
- 测量导向的护理（Measurement-Based Care, MBC）：MBC是有效整合护理的关键组成部分，它通过重复及时地使用经过验证的评估工具，为个体患者的医疗决策提供信息 131。MBC比其他复杂模型需要更少的财务、人员和IT投入，可以由初级医疗提供者独立实施，为解决行为健康危机提供了潜在方案 131。
应对气候变化等长期社会风险：
气候变化被认为是21世纪全球公共卫生的最大威胁之一，其对心理健康的影响日益凸显 134135。极端天气事件、环境退化以及相关的社会经济不稳定，都可能加剧心理健康问题。
- 政策整合：气候变化和心理健康的应对策略应纳入国家卫生政策和可持续发展规划中。政策制定者需认识到气候变化对精神健康的直接和间接影响，并制定相应的预防和干预措施 134136。例如，通过早期预警系统和社区韧性建设，减少极端天气事件对心理健康的冲击。
- 弱势群体保护：气候变化对低收入国家和弱势群体的影响尤为严重 134137。这些群体在面对气候灾害时，不仅身体健康受损，心理健康也更容易受到创伤。因此，政策应优先保护这些高危人群，提供适应性措施和心理支持服务。
- 多部门合作：应对气候变化对心理健康的影响需要跨部门合作，包括卫生、环境、农业、城市规划等部门。例如，城市绿地建设不仅有助于缓解热岛效应，改善空气质量，还能为居民提供休闲空间，促进心理健康 137。
- 可持续发展：加速向清洁能源转型，减少对化石燃料的依赖，不仅有助于减缓气候变化，还能带来空气质量改善、促进体育活动等健康协同效益，从而提升居民的身体和心理健康 137。
总之，政策与系统强化需要从全球视角出发，通过加强低收入国家的基础医疗服务、推动心理与躯体健康的整合以及前瞻性地应对气候变化等长期社会风险，构建一个更具韧性和包容性的全球心理健康支持体系。
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参考文献
1Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019.PubMed
Lancet Psychiatry. 2022 Feb;9(2):137-150. doi: 10.1016/S2215-0366(21)00395-3. Epub 2022 Jan 10.
BACKGROUND: The mental disorders included in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 were depressive disorders, anxiety disorders, bipolar disorder, schizophrenia, autism spectrum disorders, conduct disorder, attention-deficit hyperactivity disorder, eating disorders, idiopathic developmental intellectual disability, and a residual category of other mental disorders. We aimed to measure the global, regional, and national prevalence, disability-adjusted life-years (DALYS), years lived with disability (YLDs), and years of life lost (YLLs) for mental disorders from 1990 to 2019. METHODS: In this study, we assessed prevalence and burden estimates from GBD 2019 for 12 mental disorders, males and females, 23 age groups, 204 countries and territories, between 1990 and 2019. DALYs were estimated as the sum of YLDs and YLLs to premature mortality. We systematically reviewed PsycINFO, Embase, PubMed, and the Global Health Data Exchange to obtain data on prevalence, incidence, remission, duration, severity, and excess mortality for each mental disorder. These data informed a Bayesian meta-regression analysis to estimate prevalence by disorder, age, sex, year, and location. Prevalence was multiplied by corresponding disability weights to estimate YLDs. Cause-specific deaths were compiled from mortality surveillance databases. The Cause of Death Ensemble modelling strategy was used to estimate death rate by age, sex, year, and location. The death rates were multiplied by the years of life expected to be remaining at death based on a normative life expectancy to estimate YLLs. Deaths and YLLs could be calculated only for anorexia nervosa and bulimia nervosa, since these were the only mental disorders identified as underlying causes of death in GBD 2019. FINDINGS: Between 1990 and 2019, the global number of DALYs due to mental disorders increased from 80·8 million (95% uncertainty interval [UI] 59·5-105·9) to 125·3 million (93·0-163·2), and the proportion of global DALYs attributed to mental disorders increased from 3·1% (95% UI 2·4-3·9) to 4·9% (3·9-6·1). Age-standardised DALY rates remained largely consistent between 1990 (1581·2 DALYs [1170·9-2061·4] per 100 000 people) and 2019 (1566·2 DALYs [1160·1-2042·8] per 100 000 people). YLDs contributed to most of the mental disorder burden, with 125·3 million YLDs (95% UI 93·0-163·2; 14·6% [12·2-16·8] of global YLDs) in 2019 attributable to mental disorders. Eating disorders accounted for 17 361·5 YLLs (95% UI 15 518·5-21 459·8). Globally, the age-standardised DALY rate for mental disorders was 1426·5 (95% UI 1056·4-1869·5) per 100 000 population among males and 1703·3 (1261·5-2237·8) per 100 000 population among females. Age-standardised DALY rates were highest in Australasia, Tropical Latin America, and high-income North America. INTERPRETATION: GBD 2019 showed that mental disorders remained among the top ten leading causes of burden worldwide, with no evidence of global reduction in the burden since 1990. The estimated YLLs for mental disorders were extremely low and do not reflect premature mortality in individuals with mental disorders. Research to establish causal pathways between mental disorders and other fatal health outcomes is recommended so that this may be addressed within the GBD study. To reduce the burden of mental disorders, coordinated delivery of effective prevention and treatment programmes by governments and the global health community is imperative. FUNDING: Bill & Melinda Gates Foundation, Australian National Health and Medical Research Council, Queensland Department of Health, Australia.
2Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic.PubMed
Lancet. 2021 Nov 6;398(10312):1700-1712. doi: 10.1016/S0140-6736(21)02143-7. Epub 2021 Oct 8.
BACKGROUND: Before 2020, mental disorders were leading causes of the global health-related burden, with depressive and anxiety disorders being leading contributors to this burden. The emergence of the COVID-19 pandemic has created an environment where many determinants of poor mental health are exacerbated. The need for up-to-date information on the mental health impacts of COVID-19 in a way that informs health system responses is imperative. In this study, we aimed to quantify the impact of the COVID-19 pandemic on the prevalence and burden of major depressive disorder and anxiety disorders globally in 2020. METHODS: We conducted a systematic review of data reporting the prevalence of major depressive disorder and anxiety disorders during the COVID-19 pandemic and published between Jan 1, 2020, and Jan 29, 2021. We searched PubMed, Google Scholar, preprint servers, grey literature sources, and consulted experts. Eligible studies reported prevalence of depressive or anxiety disorders that were representative of the general population during the COVID-19 pandemic and had a pre-pandemic baseline. We used the assembled data in a meta-regression to estimate change in the prevalence of major depressive disorder and anxiety disorders between pre-pandemic and mid-pandemic (using periods as defined by each study) via COVID-19 impact indicators (human mobility, daily SARS-CoV-2 infection rate, and daily excess mortality rate). We then used this model to estimate the change from pre-pandemic prevalence (estimated using Disease Modelling Meta-Regression version 2.1 [known as DisMod-MR 2.1]) by age, sex, and location. We used final prevalence estimates and disability weights to estimate years lived with disability and disability-adjusted life-years (DALYs) for major depressive disorder and anxiety disorders. FINDINGS: We identified 5683 unique data sources, of which 48 met inclusion criteria (46 studies met criteria for major depressive disorder and 27 for anxiety disorders). Two COVID-19 impact indicators, specifically daily SARS-CoV-2 infection rates and reductions in human mobility, were associated with increased prevalence of major depressive disorder (regression coefficient [B] 0·9 [95% uncertainty interval 0·1 to 1·8; p=0·029] for human mobility, 18·1 [7·9 to 28·3; p=0·0005] for daily SARS-CoV-2 infection) and anxiety disorders (0·9 [0·1 to 1·7; p=0·022] and 13·8 [10·7 to 17·0; p<0·0001]. Females were affected more by the pandemic than males (B 0·1 [0·1 to 0·2; p=0·0001] for major depressive disorder, 0·1 [0·1 to 0·2; p=0·0001] for anxiety disorders) and younger age groups were more affected than older age groups (-0·007 [-0·009 to -0·006; p=0·0001] for major depressive disorder, -0·003 [-0·005 to -0·002; p=0·0001] for anxiety disorders). We estimated that the locations hit hardest by the pandemic in 2020, as measured with decreased human mobility and daily SARS-CoV-2 infection rate, had the greatest increases in prevalence of major depressive disorder and anxiety disorders. We estimated an additional 53·2 million (44·8 to 62·9) cases of major depressive disorder globally (an increase of 27·6% [25·1 to 30·3]) due to the COVID-19 pandemic, such that the total prevalence was 3152·9 cases (2722·5 to 3654·5) per 100 000 population. We also estimated an additional 76·2 million (64·3 to 90·6) cases of anxiety disorders globally (an increase of 25·6% [23·2 to 28·0]), such that the total prevalence was 4802·4 cases (4108·2 to 5588·6) per 100 000 population. Altogether, major depressive disorder caused 49·4 million (33·6 to 68·7) DALYs and anxiety disorders caused 44·5 million (30·2 to 62·5) DALYs globally in 2020. INTERPRETATION: This pandemic has created an increased urgency to strengthen mental health systems in most countries. Mitigation strategies could incorporate ways to promote mental wellbeing and target determinants of poor mental health and interventions to treat those with a mental disorder. Taking no action to address the burden of major depressive disorder and anxiety disorders should not be an option. FUNDING: Queensland Health, National Health and Medical Research Council, and the Bill and Melinda Gates Foundation.
3Prevalence of mental health symptoms in children and adolescents during the COVID-19 pandemic: A meta-analysis.PubMed
Jiawen Deng, Fangwen Zhou, Wenteng Hou, et al.
Ann N Y Acad Sci. 2023 Feb;1520(1):53-73. doi: 10.1111/nyas.14947. Epub 2022 Dec 20.
The COVID-19 pandemic and its accompanying infection control measures introduced sudden and significant disruptions to the lives of children and adolescents around the world. Given the potential for negative impacts on the mental health of youths as a result of these changes, we conducted a systematic review and meta-analysis to examine the prevalence of depressive symptoms, anxiety symptoms, and sleep disturbances in children and adolescents during the pandemic. We searched major literature databases for relevant cross-sectional or longitudinal studies that included primary and secondary school students or children and adolescents ≤18 years of age. Prevalence values were extracted, logit-transformed, and pooled. Based on 191 included studies with 1,389,447 children and adolescents, we found the pooled prevalence of depressive symptoms, anxiety symptoms, and sleep disturbances to be 31%, 31%, and 42%, respectively. Age, grade levels, education levels, gender, geographical regions, and electronics use were correlated with the prevalence of mental health symptoms. The prevalence of mental health symptoms also increased with time, although signs of recovery and stabilization were also observed. Overall, the results from this review demonstrate the need for increased mental health research, monitoring, and intervention for children and adolescents during the current and future pandemics.
4Prevalence of mental health problems during the COVID-19 pandemic: A systematic review and meta-analysis.PubMed
Tianchen Wu, Xiaoqian Jia, Huifeng Shi, et al.
J Affect Disord. 2021 Feb 15;281:91-98. doi: 10.1016/j.jad.2020.11.117. Epub 2020 Dec 3.
BACKGROUND: The global COVID-19 pandemic has generated major mental and psychological health problems worldwide. We conducted a meta-analysis to assess the prevalence of depression, anxiety, distress, and insomnia during the COVID-19 pandemic. METHODS: We searched online biomedical databases (PubMed, Embase, Web of Science, Ovid, CNKI, and Wanfang Data) and preprint databases (SSRN, bioRxiv, and MedRxiv) for observational studies from January 1, 2020 to March 16, 2020 investigating the prevalence of mental health problems during the COVID-19 pandemic. RESULTS: We retrieved 821 citations from the biomedical databases and 53 citations from the preprint databases: 66 studies with 221,970 participants were included in our meta-analysis. The overall pooled prevalence of depression, anxiety, distress, and insomnia was 31.4%, 31.9%, 41.1% and 37.9%, respectively. Noninfectious chronic disease patients, quarantined persons, and COVID-19 patients had a higher risk of depression (Q=26.73, p<0.01) and anxiety (Q=21.86, p<0.01) than other populations. The general population and non-medical staff had a lower risk of distress than other populations (Q=461.21, p< 0.01). Physicians, nurses, and non-medical staff showed a higher prevalence of insomnia (Q=196.64, p<0.01) than other populations. LIMITATIONS: All included studies were from the early phase of the global pandemic. Additional meta-analyses are needed to obtain more data in all phases of the pandemic. CONCLUSIONS: The COVID-19 pandemic increases the mental health problems of the global population, particularly health care workers, noninfectious chronic disease patients, COVID-19 patients, and quarantined persons. Interventions for mental health are urgently needed for preventing mental health problems.
5Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021.PubMed
Lancet. 2024 May 18;403(10440):2133-2161. doi: 10.1016/S0140-6736(24)00757-8. Epub 2024 Apr 17.
BACKGROUND: Detailed, comprehensive, and timely reporting on population health by underlying causes of disability and premature death is crucial to understanding and responding to complex patterns of disease and injury burden over time and across age groups, sexes, and locations. The availability of disease burden estimates can promote evidence-based interventions that enable public health researchers, policy makers, and other professionals to implement strategies that can mitigate diseases. It can also facilitate more rigorous monitoring of progress towards national and international health targets, such as the Sustainable Development Goals. For three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has filled that need. A global network of collaborators contributed to the production of GBD 2021 by providing, reviewing, and analysing all available data. GBD estimates are updated routinely with additional data and refined analytical methods. GBD 2021 presents, for the first time, estimates of health loss due to the COVID-19 pandemic. METHODS: The GBD 2021 disease and injury burden analysis estimated years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries using 100 983 data sources. Data were extracted from vital registration systems, verbal autopsies, censuses, household surveys, disease-specific registries, health service contact data, and other sources. YLDs were calculated by multiplying cause-age-sex-location-year-specific prevalence of sequelae by their respective disability weights, for each disease and injury. YLLs were calculated by multiplying cause-age-sex-location-year-specific deaths by the standard life expectancy at the age that death occurred. DALYs were calculated by summing YLDs and YLLs. HALE estimates were produced using YLDs per capita and age-specific mortality rates by location, age, sex, year, and cause. 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws. Uncertainty was propagated at each step of the estimation process. Counts and age-standardised rates were calculated globally, for seven super-regions, 21 regions, 204 countries and territories (including 21 countries with subnational locations), and 811 subnational locations, from 1990 to 2021. Here we report data for 2010 to 2021 to highlight trends in disease burden over the past decade and through the first 2 years of the COVID-19 pandemic. FINDINGS: Global DALYs increased from 2·63 billion (95% UI 2·44-2·85) in 2010 to 2·88 billion (2·64-3·15) in 2021 for all causes combined. Much of this increase in the number of DALYs was due to population growth and ageing, as indicated by a decrease in global age-standardised all-cause DALY rates of 14·2% (95% UI 10·7-17·3) between 2010 and 2019. Notably, however, this decrease in rates reversed during the first 2 years of the COVID-19 pandemic, with increases in global age-standardised all-cause DALY rates since 2019 of 4·1% (1·8-6·3) in 2020 and 7·2% (4·7-10·0) in 2021. In 2021, COVID-19 was the leading cause of DALYs globally (212·0 million [198·0-234·5] DALYs), followed by ischaemic heart disease (188·3 million [176·7-198·3]), neonatal disorders (186·3 million [162·3-214·9]), and stroke (160·4 million [148·0-171·7]). However, notable health gains were seen among other leading communicable, maternal, neonatal, and nutritional (CMNN) diseases. Globally between 2010 and 2021, the age-standardised DALY rates for HIV/AIDS decreased by 47·8% (43·3-51·7) and for diarrhoeal diseases decreased by 47·0% (39·9-52·9). Non-communicable diseases contributed 1·73 billion (95% UI 1·54-1·94) DALYs in 2021, with a decrease in age-standardised DALY rates since 2010 of 6·4% (95% UI 3·5-9·5). Between 2010 and 2021, among the 25 leading Level 3 causes, age-standardised DALY rates increased most substantially for anxiety disorders (16·7% [14·0-19·8]), depressive disorders (16·4% [11·9-21·3]), and diabetes (14·0% [10·0-17·4]). Age-standardised DALY rates due to injuries decreased globally by 24·0% (20·7-27·2) between 2010 and 2021, although improvements were not uniform across locations, ages, and sexes. Globally, HALE at birth improved slightly, from 61·3 years (58·6-63·6) in 2010 to 62·2 years (59·4-64·7) in 2021. However, despite this overall increase, HALE decreased by 2·2% (1·6-2·9) between 2019 and 2021. INTERPRETATION: Putting the COVID-19 pandemic in the context of a mutually exclusive and collectively exhaustive list of causes of health loss is crucial to understanding its impact and ensuring that health funding and policy address needs at both local and global levels through cost-effective and evidence-based interventions. A global epidemiological transition remains underway. Our findings suggest that prioritising non-communicable disease prevention and treatment policies, as well as strengthening health systems, continues to be crucially important. The progress on reducing the burden of CMNN diseases must not stall; although global trends are improving, the burden of CMNN diseases remains unacceptably high. Evidence-based interventions will help save the lives of young children and mothers and improve the overall health and economic conditions of societies across the world. Governments and multilateral organisations should prioritise pandemic preparedness planning alongside efforts to reduce the burden of diseases and injuries that will strain resources in the coming decades. FUNDING: Bill & Melinda Gates Foundation.
6Mapping global prevalence of depression among postpartum women.PubMed
Ziyi Wang, Jiaye Liu, Huan Shuai, et al.
Transl Psychiatry. 2021 Oct 20;11(1):543. doi: 10.1038/s41398-021-01663-6.
Postpartum depression (PPD) is the most common psychological condition following childbirth, and may have a detrimental effect on the social and cognitive health of spouses, infants, and children. The aim of this study was to complete a comprehensive overview of the current literature on the global epidemiology of PPD. A total of 565 studies from 80 different countries or regions were included in the final analysis. Postpartum depression was found in 17.22% (95% CI 16.00-18.51) of the world's population. Meta-regression analysis showed that study size, country or region development, and country or region income were the causes of heterogeneity. Multivariable meta-regression analysis found that study size and country or area development were the most important predictors. Varied prevalence rates were noted in geographic regions with the highest rate found in Southern Africa (39.96%). Of interested was a significantly lower rate of PPD in developed countries or high-income countries or areas. Furthermore, the findings showed that there was a substantial difference in rates of PPD when marital status, educational level, social support, spouse care, violence, gestational age, breast feeding, child mortality, pregnancy plan, financial difficulties, partnership, life stress, smoking, alcohol intake, and living conditions were considered in the pooled estimates. Our results indicated that one out of every five women experiences PPD which is linked to income and geographic development. It is triggered by a variety of causes that necessitate the attention and committed intervention of primary care providers, clinicians, health authorities, and the general population.
7Posttraumatic stress disorder in the World Mental Health Surveys.PubMed
K C Koenen, A Ratanatharathorn, L Ng, et al.
Psychol Med. 2017 Oct;47(13):2260-2274. doi: 10.1017/S0033291717000708. Epub 2017 Apr 7.
BACKGROUND: Traumatic events are common globally; however, comprehensive population-based cross-national data on the epidemiology of posttraumatic stress disorder (PTSD), the paradigmatic trauma-related mental disorder, are lacking. METHODS: Data were analyzed from 26 population surveys in the World Health Organization World Mental Health Surveys. A total of 71 083 respondents ages 18+ participated. The Composite International Diagnostic Interview assessed exposure to traumatic events as well as 30-day, 12-month, and lifetime PTSD. Respondents were also assessed for treatment in the 12 months preceding the survey. Age of onset distributions were examined by country income level. Associations of PTSD were examined with country income, world region, and respondent demographics. RESULTS: The cross-national lifetime prevalence of PTSD was 3.9% in the total sample and 5.6% among the trauma exposed. Half of respondents with PTSD reported persistent symptoms. Treatment seeking in high-income countries (53.5%) was roughly double that in low-lower middle income (22.8%) and upper-middle income (28.7%) countries. Social disadvantage, including younger age, female sex, being unmarried, being less educated, having lower household income, and being unemployed, was associated with increased risk of lifetime PTSD among the trauma exposed. CONCLUSIONS: PTSD is prevalent cross-nationally, with half of all global cases being persistent. Only half of those with severe PTSD report receiving any treatment and only a minority receive specialty mental health care. Striking disparities in PTSD treatment exist by country income level. Increasing access to effective treatment, especially in low- and middle-income countries, remains critical for reducing the population burden of PTSD.
8Health disparities among indigenous populations in Latin America: a scoping review.PubMed
Mariana Garza, Lucía Abascal Miguel
Int J Equity Health. 2025 Apr 30;24(1):119. doi: 10.1186/s12939-025-02495-2.
BACKGROUND: Health disparities persist among Indigenous populations in Latin America, reflecting systemic inequities and historical marginalization. These disparities span infectious diseases, malnutrition, and chronic conditions, necessitating a comprehensive understanding to inform equitable public health strategies. This scoping review aims to map health disparities affecting Indigenous populations in Latin America, identify research gaps, and inform policy recommendations. METHODS: Following PRISMA-ScR guidelines, we systematically searched PubMed, Embase, and Scielo for studies with data collected between May 2014 and May 2024. Studies were included if they examined health disparities among Indigenous populations in Latin America, contained a comparator related to disparities, and presented quantitative data. We excluded studies on oral health, risk factors, genetic disparities, health system access, and ecological studies, as well as non-research articles such as commentaries and letters to the editor. Data were synthesized narratively, summarizing key themes. RESULTS: Of 1,116 identified articles, 35 met inclusion criteria, spanning nine Latin American countries. Most studies were cross-sectional (n = 18) or cohort-based (n = 16). Infectious diseases and malnutrition were the most studied topics, consistently showing higher incidence and mortality rates among Indigenous populations. Many papers highlighted COVID-19 disparities, with Indigenous groups experiencing higher incidence and mortality. Malnutrition, particularly stunting and anemia, was significantly more prevalent among Indigenous children and women. Studies on overweight and obesity showed mixed results. Chronic diseases, including chronic kidney disease and cardiovascular issues, showed notable disparities, while mental health and cancer were underrepresented. CONCLUSION: Indigenous populations in Latin America face a dual burden of infectious and chronic diseases, compounded by structural barriers such as poverty, geographic isolation, and systemic discrimination. Addressing these disparities requires culturally tailored interventions, structural reforms, and policy prioritization. This scoping review is limited by database restrictions, search term variability, language and time frame constraints, the absence of a methodological quality assessment, inconsistencies in defining Indigenous status, exclusion of grey literature, and a focus on disease prevalence rather than disparities in risk factors, diagnosis, and treatment, which may result in an incomplete representation of Indigenous health disparities in Latin America. Future research should incorporate mental health outcomes to provide a more comprehensive understanding of Indigenous health disparities.
9Mental health and wellbeing of medical students in Nigeria: a systematic review.PubMed
Oluyomi Esan, Arinola Esan, Ayorinde Folasire, et al.
Int Rev Psychiatry. 2019 Nov-Dec;31(7-8):661-672. doi: 10.1080/09540261.2019.1677220. Epub 2019 Oct 24.
In addition to the stresses common to medical school training, medical students in Nigeria face additional peculiar contemporary social problems due to income inequality, poverty, insecurity and political instability. These have a direct impact on their mental health and wellbeing. The aim of this study was to systematically review articles reporting on the epidemiology of psychiatric disorders among medical students in Nigeria. Studies were identified using MEDLINE, HINARI, (AJOL) and Google Scholar databases using search terms encompassing psychiatric morbidity amongst medical students. No date restrictions were applied to the search. The pooled prevalence estimate was calculated for each disorder. Psychological distress was present in 25.2% of the students, perceived stress in 60.5%, depression in 33.5% and anxiety in 28.8%. The current use of at least one psychoactive substance was present in up to 44.2%, while 35.5% of all the respondents had experienced one or more forms of abuse during their training as medical students. The prevalence of psychiatric disorders among medical students in Nigeria is high. Positive coping mechanisms such as religiosity, positive reframing and resilience which were identified in this review should be optimized to reduce the burden.
10Social support and mental health among college students.PubMed
Jennifer Hefner, Daniel Eisenberg
Am J Orthopsychiatry. 2009 Oct;79(4):491-9. doi: 10.1037/a0016918.
This study is the first, to our knowledge, to evaluate the relationship between mental health and social support in a large, random sample of college students. A Web-based survey was administered at a large, public university, with 1,378 students completing the measures in this analysis (response rate = 57%). The results support our hypothesis that students with characteristics differing from most other students, such as minority race or ethnicity, international status, and low socioeconomic status, are at greater risk of social isolation. In addition, the authors found that students with lower quality social support, as measured by the Multidimensional Scale of Perceived Social Support, were more likely to experience mental health problems, including a sixfold risk of depressive symptoms relative to students with high quality social support. These results may help administrators and health providers to identify more effectively the population of students at high risk for mental illness and develop effective interventions to address this significant and growing public health issue.
11Social ties and mental health.PubMed
I Kawachi, L F Berkman
J Urban Health. 2001 Sep;78(3):458-67. doi: 10.1093/jurban/78.3.458.
It is generally agreed that social ties play a beneficial role in the maintenance of psychological well-being. In this targeted review, we highlight four sets of insights that emerge from the literature on social ties and mental health outcomes (defined as stress reactions, psychological well-being, and psychological distress, including depressive symptoms and anxiety). First, the pathways by which social networks and social supports influence mental health can be described by two alternative (although not mutually exclusive) causal models-the main effect model and the stress-buffering model. Second, the protective effects of social ties on mental health are not uniform across groups in society. Gender differences in support derived from social network participation may partly account for the higher prevalence of psychological distress among women compared to men. Social connections may paradoxically increase levels of mental illness symptoms among women with low resources, especially if such connections entail role strain associated with obligations to provide social support to others. Third, egocentric networks are nested within a broader structure of social relationships. The notion of social capital embraces the embeddedness of individual social ties within the broader social structure. Fourth, despite some successes reported in social support interventions to enhance mental health, further work is needed to deepen our understanding of the design, timing, and dose of interventions that work, as well as the characteristics of individuals who benefit the most.
12Global Prevalence and Mental Health Outcomes of Intimate Partner Violence Among Women: A Systematic Review and Meta-Analysis.PubMed
Sarah J White, Jacqueline Sin, Angela Sweeney, et al.
Trauma Violence Abuse. 2024 Jan;25(1):494-511. doi: 10.1177/15248380231155529. Epub 2023 Feb 24.
The aim of this systematic review was to assess the magnitude of the association between types of intimate partner violence (IPV) and mental health outcomes and shed light on the large variation in IPV prevalence rates between low- to middle-income countries and high-income countries. The study is a systematic review and meta-analysis. The following databases were searched for this study: Cochrane, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and the Applied Social Sciences Index and Abstracts. The inclusion criteria for this study are as follows: quantitative studies published from 2012 to 2020 on IPV exposure in women aged 16+, using validated measures. Random effects meta-analyses and subgroup analysis exploring heterogeneity across population groups in different economic contexts are used in this study. In all, 201 studies were included with 250,599 women, primarily from high-income countries. Higher prevalence rates were reported for women's lifetime IPV than past year IPV. Lifetime psychological violence was the most prevalent form of IPV. Women in the community reported the highest prevalence for physical, psychological, and sexual violence in the past year compared to clinical groups. Perinatal women were most likely to have experienced lifetime physical IPV. Prevalence rates differed significantly ( = .037 to <.001) for "any IPV" and all subtypes by income country level. Meta-analysis suggested increased odds for all mental health outcomes associated with IPV including depression (odds ratio [OR] = 2.04-3.14), posttraumatic stress disorder (PTSD) (OR = 2.15-2.66), and suicidality (OR = 2.17-5.52). Clinical and community populations were exposed to high prevalence of IPV and increased likelihood of depression, PTSD, and suicidality. Future research should seek to understand women's perspectives on service/support responses to IPV to address their mental health needs. Work with IPV survivors should be carried out to develop bespoke services to reduce IPV in groups most at risk such as pregnant and/or help-seeking women.
13Sleep Health Disparities.PubMed
Seyni Gueye-Ndiaye, Susan Redline
Annu Rev Med. 2025 Jan;76(1):403-415. doi: 10.1146/annurev-med-070323-103130. Epub 2025 Jan 16.
Sleep is an important and potentially modifiable determinant of many severe health outcomes. Sleep health disparities exist and are exemplified by reported differential rates of prevalence, severity, and outcomes among minority groups and low-socioeconomic-status backgrounds. In this review we highlight the concept of sleep health, review the evidence for disparities in sleep health, examine risk factors and consequences of poor sleep health, and discuss policy implications.
14[Depression in children and adolescents: prevalence, diagnosis, etiology, gender differences and therapeutic approaches].PubMed
Inge Seiffge-Krenke
Prax Kinderpsychol Kinderpsychiatr. 2007;56(3):185-205. doi: 10.13109/prkk.2007.56.3.185.
Prevalence rates of the different forms of depression (depressive mood, depressive syndromes and Major Depression) have increased during recent years. Similarily, gender differences have augmented. Stress, dysfunctional coping styles, a negative body image, and an insecure attachment style have been identified as factors contributing to the etiology of depression. Different therapeutic approaches were presented with psychonanalytic treatment being the most comprehensive.
15Epidemiology of depression and diabetes: a systematic review.PubMed
Tapash Roy, Cathy E Lloyd
J Affect Disord. 2012 Oct;142 Suppl:S8-21. doi: 10.1016/S0165-0327(12)70004-6.
BACKGROUND: Research suggests that co-morbid diabetes and depression is common; however, the implications for clinical practice remain unclear. This paper reviews the current epidemiological evidence on comorbid diabetes and depression, in order to identify the key publications which could both inform practice and identify gaps in knowledge and research. METHODS: A systematic review was conducted to identify published literature on the epidemiology of diabetes and depression. In order to review evidence on up-to-date knowledge of recent research and innovations in care literature searches for the last five years (August 2006-August 2011) were conducted. To identify relevant literature, electronic databases MEDLINE, Psych-INFO and EMBASE were searched for English language articles in peer-reviewed journals. RESULTS: High rates of co-morbidity of depression and diabetes have been reported. The prevalence rate of depression is more than three-times higher in people with type 1 diabetes (12%, range 5.8-43.3% vs. 3.2%, range 2.7-11.4%) and nearly twice as high in people with type 2 diabetes (19.1%, range 6.5-33% vs. 10.7%, range 3.8-19.4%) compared to those without. Women with diabetes and also women without diabetes experience a higher prevalence of depression than men. Reviewed studies provide support for a modest relationship between diabetes and depressive symptoms, but the exact direction of this relationship remains unclear. LIMITATIONS: Most studies reviewed were cross-sectional and this limits any conclusions about the causal nature and direction of the relationship between diabetes and depression. Variation in measurement methods, lack of longitudinal data and few studies outside Europe and America limit the generalizability of the findings of this review. CONCLUSIONS: Current research suggests that the risk of developing depression is increased in people with diabetes; however, further studies are required in order to establish the nature of the relationship between depression, glycaemic control and the development of diabetes complications, and make appropriate recommendations for treatment and to support self-management of diabetes.
16Age of onset and cumulative risk of mental disorders: a cross-national analysis of population surveys from 29 countries.PubMed
John J McGrath, Ali Al-Hamzawi, Jordi Alonso, et al.
Lancet Psychiatry. 2023 Sep;10(9):668-681. doi: 10.1016/S2215-0366(23)00193-1. Epub 2023 Jul 30.
BACKGROUND: Information on the frequency and timing of mental disorder onsets across the lifespan is of fundamental importance for public health planning. Broad, cross-national estimates of this information from coordinated general population surveys were last updated in 2007. We aimed to provide updated and improved estimates of age-of-onset distributions, lifetime prevalence, and morbid risk. METHODS: In this cross-national analysis, we analysed data from respondents aged 18 years or older to the World Mental Health surveys, a coordinated series of cross-sectional, face-to-face community epidemiological surveys administered between 2001 and 2022. In the surveys, the WHO Composite International Diagnostic Interview, a fully structured psychiatric diagnostic interview, was used to assess age of onset, lifetime prevalence, and morbid risk of 13 DSM-IV mental disorders until age 75 years across surveys by sex. We did not assess ethnicity. The surveys were geographically clustered and weighted to adjust for selection probability, and standard errors of incidence rates and cumulative incidence curves were calculated using the jackknife repeated replications simulation method, taking weighting and geographical clustering of data into account. FINDINGS: We included 156 331 respondents from 32 surveys in 29 countries, including 12 low-income and middle-income countries and 17 high-income countries, and including 85 308 (54·5%) female respondents and 71 023 (45·4%) male respondents. The lifetime prevalence of any mental disorder was 28·6% (95% CI 27·9-29·2) for male respondents and 29·8% (29·2-30·3) for female respondents. Morbid risk of any mental disorder by age 75 years was 46·4% (44·9-47·8) for male respondents and 53·1% (51·9-54·3) for female respondents. Conditional probabilities of first onset peaked at approximately age 15 years, with a median age of onset of 19 years (IQR 14-32) for male respondents and 20 years (12-36) for female respondents. The two most prevalent disorders were alcohol use disorder and major depressive disorder for male respondents and major depressive disorder and specific phobia for female respondents. INTERPRETATION: By age 75 years, approximately half the population can expect to develop one or more of the 13 mental disorders considered in this Article. These disorders typically first emerge in childhood, adolescence, or young adulthood. Services should have the capacity to detect and treat common mental disorders promptly and to optimise care that suits people at these crucial parts of the life course. FUNDING: None.
17Gender differences in depression, anxiety, and stress among college students: A longitudinal study from China.PubMed
Wenjuan Gao, Siqing Ping, Xinqiao Liu
J Affect Disord. 2020 Feb 15;263:292-300. doi: 10.1016/j.jad.2019.11.121. Epub 2019 Dec 4.
BACKGROUND: The objective of this longitudinal study was to examine the gender differences in college students' depression, anxiety, and stress over the four academic years, and to explore possible anxiety-related factors among first year students. METHODS: The study analyzed 1892 undergraduate students from 15 universities in China, with 898 females and 994 males. The students have been followed for four years and completed a survey containing the Depression Anxiety Stress Scale-21 questionnaire, students' socio-demographic information, and their educational background, etc. RESULTS: (1) On average, both female and male college students suffered from mild anxiety in the first three years. Female students scored significantly higher in anxiety than males in the first and second years, and there was no significant gender difference in students' average depression and stress levels. (2) A significantly larger proportion of female students experienced anxiety above the normal threshold, whereas a higher percentage of male students endured different degrees of depression; no significant gender differences were found in stress problems. (3) Anxiety had a significant positive correlation with introversion. Female freshmen's anxiety levels were also associated with their body image, drinking habits, and academic performance. LIMITATIONS: Response bias may exist considering that self-reported data was used. Due to data unavailability, we only explored the anxiety-related factors in freshman year, which cannot sufficiently reflect the consistency of correlations over time. CONCLUSIONS: Anxiety turned out to be the most prevalent and serious issue for college students, especially for female students; while a growing prevalence of depression was found among male students during college. It is of great significance to adopt collegiate policies reflecting the gender differentials.
18Anxiety and depression after cancer diagnosis: prevalence rates by cancer type, gender, and age.PubMed
Wolfgang Linden, Andrea Vodermaier, Regina Mackenzie, et al.
J Affect Disord. 2012 Dec 10;141(2-3):343-51. doi: 10.1016/j.jad.2012.03.025. Epub 2012 Jun 21.
BACKGROUND: Reported prevalence of emotional distress in cancer patients varies widely across studies. The present study determined prevalence of anxiety and depression (separated for presence of symptoms versus clinical levels) in a large, representative sample of cancer patients after diagnosis. METHOD: During the years 2004-2009, 10,153 consecutive patients were routinely screened with the Psychosocial Screen for Cancer questionnaire at two major cancer centers. RESULTS: Patients' mean age was 59 years and 45% were men. Across cancer types, 19.0% of patients showed clinical levels of anxiety and another 22.6% had subclinical symptoms. Further, 12.9% of patients reported clinical symptoms of depression and an additional 16.5% described subclinical symptoms. Analyses by cancer type revealed significant differences such that patients with lung, gynecological, or hematological cancer reported the highest levels of distress at the time point of cancer diagnosis. As expected, women showed higher rates of anxiety and depression, and for some cancer types the prevalence was two to three times higher than that seen for men. In some cancer types emotional distress was inversely related to age. Patients younger than 50 and women across all cancer types revealed either subclinical or clinical levels of anxiety in over 50% of cases. LIMITATIONS: Findings describe levels of emotional distress after diagnosis but cannot inform about trajectories of anxiety and depression over time. CONCLUSION: Given that levels of anxiety and depression varied widely by cancer type, gender, and age, these results inform which cancer patients are most likely in need of psychosocial support.
19Sex steroids and the female brain across the lifespan: insights into risk of depression and Alzheimer's disease.PubMed
Claudia Barth, Arielle Crestol, Ann-Marie G de Lange, et al.
Lancet Diabetes Endocrinol. 2023 Dec;11(12):926-941. doi: 10.1016/S2213-8587(23)00224-3. Epub 2023 Oct 18.
Despite widespread sex differences in prevalence and presentation of numerous illnesses affecting the human brain, there has been little focus on the effect of endocrine ageing. Most preclinical studies have focused on males only, and clinical studies often analyse data by covarying for sex, ignoring relevant differences between the sexes. This sex- (and gender)-neutral approach is biased and contributes to the absence of targeted treatments and services for all sexes (and genders). Female health has been historically understudied, with grave consequences for their wellbeing and health equity. In this Review, we spotlight female brain health across the lifespan by informing on the role of sex steroids, particularly oestradiol, on the female brain and on risk for diseases more prevalent in females, such as depression and Alzheimer's disease.
20Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication.PubMed
Ronald C Kessler, Patricia Berglund, Olga Demler, et al.
Arch Gen Psychiatry. 2005 Jun;62(6):593-602. doi: 10.1001/archpsyc.62.6.593.
CONTEXT: Little is known about lifetime prevalence or age of onset of DSM-IV disorders. OBJECTIVE: To estimate lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the recently completed National Comorbidity Survey Replication. DESIGN AND SETTING: Nationally representative face-to-face household survey conducted between February 2001 and April 2003 using the fully structured World Health Organization World Mental Health Survey version of the Composite International Diagnostic Interview. PARTICIPANTS: Nine thousand two hundred eighty-two English-speaking respondents aged 18 years and older. MAIN OUTCOME MEASURES: Lifetime DSM-IV anxiety, mood, impulse-control, and substance use disorders. RESULTS: Lifetime prevalence estimates are as follows: anxiety disorders, 28.8%; mood disorders, 20.8%; impulse-control disorders, 24.8%; substance use disorders, 14.6%; any disorder, 46.4%. Median age of onset is much earlier for anxiety (11 years) and impulse-control (11 years) disorders than for substance use (20 years) and mood (30 years) disorders. Half of all lifetime cases start by age 14 years and three fourths by age 24 years. Later onsets are mostly of comorbid conditions, with estimated lifetime risk of any disorder at age 75 years (50.8%) only slightly higher than observed lifetime prevalence (46.4%). Lifetime prevalence estimates are higher in recent cohorts than in earlier cohorts and have fairly stable intercohort differences across the life course that vary in substantively plausible ways among sociodemographic subgroups. CONCLUSIONS: About half of Americans will meet the criteria for a DSM-IV disorder sometime in their life, with first onset usually in childhood or adolescence. Interventions aimed at prevention or early treatment need to focus on youth.
21Age of onset of mental disorders: a review of recent literature.PubMed
Ronald C Kessler, G Paul Amminger, Sergio Aguilar-Gaxiola, et al.
Curr Opin Psychiatry. 2007 Jul;20(4):359-64. doi: 10.1097/YCO.0b013e32816ebc8c.
PURPOSE OF REVIEW: The aim of this article is to review recent epidemiological research on age-of-onset of mental disorders, focusing on the WHO World Mental Health surveys. RECENT FINDINGS: Median and inter-quartile range (IQR; 25th-75th percentiles) of age-of-onset is much earlier for phobias (7-14, IQR 4-20) and impulse-control disorders (7-15; IQR 4-35) than other anxiety disorders (25-53, IQR 15-75), mood disorders (25-45, IQR 17-65), and substance disorders (18-29, IQR 16-43). Although less data exist for nonaffective psychosis, available evidence suggests that median age-of-onset is in the range late teens through early 20s. Roughly half of all lifetime mental disorders in most studies start by the mid-teens and three quarters by the mid-20s. Later onsets are mostly secondary conditions. Severe disorders are typically preceded by less severe disorders that are seldom brought to clinical attention. SUMMARY: First onset of mental disorders usually occur in childhood or adolescence, although treatment typically does not occur until a number of years later. Although interventions with early incipient disorders might help reduce severity-persistence of primary disorders and prevent secondary disorders, additional research is needed on appropriate treatments for early incipient cases and on long-term evaluation of the effects of early intervention on secondary prevention.
22Worldwide Prevalence and Disability From Mental Disorders Across Childhood and Adolescence: Evidence From the Global Burden of Disease Study.PubMed
Christian Kieling, Claudia Buchweitz, Arthur Caye, et al.
JAMA Psychiatry. 2024 Apr 1;81(4):347-356. doi: 10.1001/jamapsychiatry.2023.5051.
IMPORTANCE: The period from childhood to early adulthood involves increased susceptibility to the onset of mental disorders, with implications for policy making that may be better appreciated by disaggregated analyses of narrow age groups. OBJECTIVE: To estimate the global prevalence and years lived with disability (YLDs) associated with mental disorders and substance use disorders (SUDs) across 4 age groups using data from the 2019 Global Burden of Disease (GBD) study. DESIGN, SETTING, AND PARTICIPANTS: Data from the 2019 GBD study were used for analysis of mental disorders and SUDs. Results were stratified by age group (age 5 to 9, 10 to 14, 15 to 19, and 20 to 24 years) and sex. Data for the 2019 GBD study were collected up to 2018, and data were analyzed for this article from April 2022 to September 2023. EXPOSURE: Age 5 to 9 years, 10 to 14 years, 15 to 19 years, and 20 to 24 years. MAIN OUTCOMES AND MEASURES: Prevalence rates with 95% uncertainty intervals (95% UIs) and number of YLDs. RESULTS: Globally in 2019, 293 million of 2516 million individuals aged 5 to 24 years had at least 1 mental disorder, and 31 million had an SUD. The mean prevalence was 11.63% for mental disorders and 1.22% for SUDs. For the narrower age groups, the prevalence of mental disorders was 6.80% (95% UI, 5.58-8.03) for those aged 5 to 9 years, 12.40% (95% UI, 10.62-14.59) for those aged 10 to 14 years, 13.96% (95% UI, 12.36-15.78) for those aged 15 to 19 years, and 13.63% (95% UI, 11.90-15.53) for those aged 20 to 24 years. The prevalence of each individual disorder also varied by age groups; sex-specific patterns varied to some extent by age. Mental disorders accounted for 31.14 million of 153.59 million YLDs (20.27% of YLDs from all causes). SUDs accounted for 4.30 million YLDs (2.80% of YLDs from all causes). Over the entire life course, 24.85% of all YLDs attributable to mental disorders were recorded before age 25 years. CONCLUSIONS AND RELEVANCE: An analytical framework that relies on stratified age groups should be adopted for examination of mental disorders and SUDs from childhood to early adulthood. Given the implications of the early onset and lifetime burden of mental disorders and SUDs, age-disaggregated data are essential for the understanding of vulnerability and effective prevention and intervention initiatives.
23Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A).PubMed
Kathleen Ries Merikangas, Jian-Ping He, Marcy Burstein, et al.
J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9. doi: 10.1016/j.jaac.2010.05.017. Epub 2010 Jul 31.
OBJECTIVE: To present estimates of the lifetime prevalence of DSM-IV mental disorders with and without severe impairment, their comorbidity across broad classes of disorder, and their sociodemographic correlates. METHOD: The National Comorbidity Survey-Adolescent Supplement NCS-A is a nationally representative face-to-face survey of 10,123 adolescents aged 13 to 18 years in the continental United States. DSM-IV mental disorders were assessed using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview. RESULTS: Anxiety disorders were the most common condition (31.9%), followed by behavior disorders (19.1%), mood disorders (14.3%), and substance use disorders (11.4%), with approximately 40% of participants with one class of disorder also meeting criteria for another class of lifetime disorder. The overall prevalence of disorders with severe impairment and/or distress was 22.2% (11.2% with mood disorders, 8.3% with anxiety disorders, and 9.6% behavior disorders). The median age of onset for disorder classes was earliest for anxiety (6 years), followed by 11 years for behavior, 13 years for mood, and 15 years for substance use disorders. CONCLUSIONS: These findings provide the first prevalence data on a broad range of mental disorders in a nationally representative sample of U.S. adolescents. Approximately one in every four to five youth in the U.S. meets criteria for a mental disorder with severe impairment across their lifetime. The likelihood that common mental disorders in adults first emerge in childhood and adolescence highlights the need for a transition from the common focus on treatment of U.S. youth to that of prevention and early intervention.
24Symptoms of anxiety or depression and risk of fracture in older people: the Hertfordshire Cohort Study.PubMed
Catharine R Gale, Elaine M Dennison, Mark Edwards, et al.
Arch Osteoporos. 2012;7(0):59-65. doi: 10.1007/s11657-012-0080-5. Epub 2012 Apr 12.
UNLABELLED: The aim of this study was to examine the prospective association between symptoms of anxiety and depression and risk of fracture in older people. Results showed that men, but not women, with probable anxiety at baseline had an increased risk of fracture. INTRODUCTION: The use of psychotropic drugs has been linked with an increased risk of fracture in older people, but there are indications that the conditions for which these drugs were prescribed may themselves influence fracture risk. The aim of this study was to investigate the relation between symptoms of anxiety and depression and risk of fracture in older people. The study design is a prospective cohort study. METHODS: One thousand eighty-seven men and 1,050 women aged 59-73 years completed the Hospital Anxiety and Depression Scale (HADS). Data on incident fracture during an average follow-up period of 5.6 years were collected through interview and a postal questionnaire. RESULTS: Compared to men with no or few symptoms of anxiety (score ≤7 on the HADS anxiety subscale), men with probable anxiety (score ≥11) had an increased risk of fracture: After adjustment for age and potential confounding factors, the odds ratio (OR) (95 % confidence interval) was 4.03 (1.55, 10.5). There were no associations between levels of anxiety and fracture risk in women. Few men or women had probable depression at baseline (score ≥11 on the HADS depression subscale). Amongst men with possible depression (score 8-10), there was an increased risk of fracture that was of borderline significance: multivariate-adjusted OR 3.57 (0.99, 12.9). There was no association between possible depression and fracture risk in women. CONCLUSIONS: High levels of anxiety in older men may increase their risk of fracture. Future research needs to replicate this finding in other populations and investigate the underlying mechanisms.
25Associations of the Charlson comorbidity index with depression and mortality among the U.S. adults.PubMed
Ying-Zhao Wang, Chun Xue, Chao Ma, et al.
Front Public Health. 2024 Nov 27;12:1404270. doi: 10.3389/fpubh.2024.1404270. eCollection 2024.
BACKGROUND: Chronic comorbidities are often associated with higher risks of depression and mortality. This study aims to explore the relationships between the Charlson Comorbidity Index (CCI) and depression, and their combined effect on mortality. METHODS: This study made use of data gathered in the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2018, including a collective of 23,927 adult participants. According to CCI score distribution, CCI was categorized into three groups (T1 with CCI = 0; T2 with CCI = 1; T3 with CCI ≥ 2). In the CCI ≥ 2 group, patients may have two or more chronic diseases. Multivariable logistic regression models were employed to explore the relationship between CCI and depression. The study utilized the Cox proportional hazards model to investigate the association between CCI, the combination of CCI and depression, and all-cause mortality. RESULTS: Our analysis revealed that after adjusting for potential confounders, a positive association was found between CCI and depression (OR = 1.25, 95% CI: 1.21, 1.29). Moreover, a greater CCI was found to be closely linked to higher mortality in individuals with depression (HR = 1.14, 95% CI 1.11, 1.18). Stratifying CCI into tertiles, higher tertiles of CCI (T2, T3 vs T1) also showed positive associations with depression and all-cause mortality. For patients with CCI ≥2 (T3) combined with depression, the risk of mortality was significantly elevated compared to those with CCI = 0 (T1) and non-depressed participants (HR = 2.01, 95% CI: 1.60, 2.52). CONCLUSION: The study findings demonstrate a positive correlation between CCI and the risk of depression, along with an association with increased all-cause mortality among depression patients. Hence, it is important to prioritize the clinical care of patients with a high CCI (≥2) and depression in order to lower the chances of mortality.
26Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care.PubMed
Diana M Tordoff, Jonathon W Wanta, Arin Collin, et al.
JAMA Netw Open. 2022 Feb 1;5(2):e220978. doi: 10.1001/jamanetworkopen.2022.0978.
IMPORTANCE: Transgender and nonbinary (TNB) youths are disproportionately burdened by poor mental health outcomes owing to decreased social support and increased stigma and discrimination. Although gender-affirming care is associated with decreased long-term adverse mental health outcomes among these youths, less is known about its association with mental health immediately after initiation of care. OBJECTIVE: To investigate changes in mental health over the first year of receiving gender-affirming care and whether initiation of puberty blockers (PBs) and gender-affirming hormones (GAHs) was associated with changes in depression, anxiety, and suicidality. DESIGN, SETTING, AND PARTICIPANTS: This prospective observational cohort study was conducted at an urban multidisciplinary gender clinic among TNB adolescents and young adults seeking gender-affirming care from August 2017 to June 2018. Data were analyzed from August 2020 through November 2021. EXPOSURES: Time since enrollment and receipt of PBs or GAHs. MAIN OUTCOMES AND MEASURES: Mental health outcomes of interest were assessed via the Patient Health Questionnaire 9-item (PHQ-9) and Generalized Anxiety Disorder 7-item (GAD-7) scales, which were dichotomized into measures of moderate or severe depression and anxiety (ie, scores ≥10), respectively. Any self-report of self-harm or suicidal thoughts over the previous 2 weeks was assessed using PHQ-9 question 9. Generalized estimating equations were used to assess change from baseline in each outcome at 3, 6, and 12 months of follow-up. Bivariate and multivariable logistic models were estimated to examine temporal trends and investigate associations between receipt of PBs or GAHs and each outcome. RESULTS: Among 104 youths aged 13 to 20 years (mean [SD] age, 15.8 [1.6] years) who participated in the study, there were 63 transmasculine individuals (60.6%), 27 transfeminine individuals (26.0%), 10 nonbinary or gender fluid individuals (9.6%), and 4 youths who responded "I don't know" or did not respond to the gender identity question (3.8%). At baseline, 59 individuals (56.7%) had moderate to severe depression, 52 individuals (50.0%) had moderate to severe anxiety, and 45 individuals (43.3%) reported self-harm or suicidal thoughts. By the end of the study, 69 youths (66.3%) had received PBs, GAHs, or both interventions, while 35 youths had not received either intervention (33.7%). After adjustment for temporal trends and potential confounders, we observed 60% lower odds of depression (adjusted odds ratio [aOR], 0.40; 95% CI, 0.17-0.95) and 73% lower odds of suicidality (aOR, 0.27; 95% CI, 0.11-0.65) among youths who had initiated PBs or GAHs compared with youths who had not. There was no association between PBs or GAHs and anxiety (aOR, 1.01; 95% CI, 0.41, 2.51). CONCLUSIONS AND RELEVANCE: This study found that gender-affirming medical interventions were associated with lower odds of depression and suicidality over 12 months. These data add to existing evidence suggesting that gender-affirming care may be associated with improved well-being among TNB youths over a short period, which is important given mental health disparities experienced by this population, particularly the high levels of self-harm and suicide.
27Endocrinology of Transgender Medicine.PubMed
Guy T'Sjoen, Jon Arcelus, Louis Gooren, et al.
Endocr Rev. 2019 Feb 1;40(1):97-117. doi: 10.1210/er.2018-00011.
Gender-affirming treatment of transgender people requires a multidisciplinary approach in which endocrinologists play a crucial role. The aim of this paper is to review recent data on hormonal treatment of this population and its effect on physical, psychological, and mental health. The Endocrine Society guidelines for transgender women include estrogens in combination with androgen-lowering medications. Feminizing treatment with estrogens and antiandrogens has desired physical changes, such as enhanced breast growth, reduction of facial and body hair growth, and fat redistribution in a female pattern. Possible side effects should be discussed with patients, particularly those at risk for venous thromboembolism. The Endocrine Society guidelines for transgender men include testosterone therapy for virilization with deepening of the voice, cessation of menses, and increases of muscle mass and facial and body hair. Owing to the lack of evidence, treatment of gender nonbinary people should be individualized. Young people may receive pubertal suspension, consisting of GnRH analogs, later followed by sex steroids. Options for fertility preservation should be discussed before any hormonal intervention. Morbidity and cardiovascular risk with cross-sex hormones is unchanged among transgender men and unclear among transgender women. Sex steroid-related malignancies can occur but are rare. Mental health problems such as depression and anxiety have been found to reduce considerably following hormonal treatment. Future studies should aim to explore the long-term outcome of hormonal treatment in transgender people and provide evidence as to the effect of gender-affirming treatment in the nonbinary population.
28Anxiety and depression in transgender individuals: the roles of transition status, loss, social support, and coping.PubMed
Stephanie L Budge, Jill L Adelson, Kimberly A S Howard
J Consult Clin Psychol. 2013 Jun;81(3):545-57. doi: 10.1037/a0031774. Epub 2013 Feb 11.
OBJECTIVE: The purpose of the current study was to examine facilitative and avoidant coping as mediators between distress and transition status, social support, and loss. METHOD: A total of 351 transgender individuals (n = 226 transgender women and n = 125 transgender men) participated in this study. Participants completed measures on transgender identity, family history of mental health concerns, perceptions of loss, coping, depression, and anxiety. RESULTS: The rates of depressive symptoms (51.4% for transgender women; 48.3% for transgender men) and anxiety (40.4% for transgender women; 47.5% for transgender men) within the current study far surpass the rates of those for the general population. Structural equation modeling (SEM) was used to analyze the data-2 separate models were hypothesized, based on reports of anxiety or depression. The SEM results suggest that the processes for transgender women and transgender men are primarily similar for depression and anxiety; avoidant coping served as a mediator between transition status and both distress variables. Social support was directly related to distress variables, as well as indirectly related through avoidant coping. CONCLUSION: Results suggest the need for practitioners to focus on interventions that reduce avoidant coping strategies, while simultaneously increasing social support, in order to improve mental health for transgender individuals. Individuals who are in the beginning stages of their transition will use different coping strategies than those who are in later stages; interventions should be adjusted on the basis of the transition status of transgender clients.
29Examining gender-specific mental health risks after gender-affirming surgery: a national database study.PubMed
Joshua E Lewis, Amani R Patterson, Maame A Effirim, et al.
J Sex Med. 2025 Apr 15;22(4):645-651. doi: 10.1093/jsxmed/qdaf026.
BACKGROUND: Transgender individuals face heightened psychological distress, including depression, anxiety, and suicidal ideation, partly due to stigma and lack of gender affirmation. AIM: To evaluate mental health outcomes in transgender individuals with gender dysphoria who have undergone gender-affirming surgery, stratified by gender and time since surgery. METHODS: This retrospective study utilized the TriNetX database, analyzing U.S. patients aged ≥18 with gender dysphoria (International Classification of Diseases, Tenth Revision [ICD-10] F64) between June 2014 and June 2024. Six cohorts were created based on gender and surgery status: Cohorts A-D included patients with or without surgery, and Cohorts E-F allowed for gender comparison among those with surgery. Propensity score matching controlled for age, race, and ethnicity. Mental health outcomes included depression, anxiety, suicidal ideation, substance use disorder, and body dysmorphic disorder, assessed over two years post-surgery using clinician-verified ICD-10 codes. Body dysmorphic disorder (BDD) was analyzed separately and not conflated with gender dysphoria cohorts to ensure the distinction between these conditions. Statistical analysis employed risk ratios, with P < 0.05 deemed significant. OUTCOMES: Primary outcomes were differences in mental health disorders, specifically depression, anxiety, suicidal ideation, body-dysmorphic disorder, and substance use disorder, among transgender individuals' post-surgery. RESULTS: From 107 583 patients, matched cohorts demonstrated that those undergoing surgery were at significantly higher risk for depression, anxiety, suicidal ideation, and substance use disorders than those without surgery. Males with surgery showed a higher prevalence of depression (25.4% vs. 11.5%, RR 2.203, P < 0.0001) and anxiety (12.8% vs. 2.6%, RR 4.882, P < 0.0001). Females exhibited similar trends, with elevated depression (22.9% vs. 14.6%, RR 1.563, P < 0.0001) and anxiety (10.5% vs. 7.1%, RR 1.478, P < 0.0001). Feminizing individuals demonstrated particularly high risk for depression (RR 1.783, P = 0.0298) and substance use disorders (RR 1.284, P < 0.0001). CLINICAL IMPLICATIONS: Findings suggest the necessity for gender-sensitive mental health support following gender-affirming surgery to address post-surgical psychological risks. STRENGTHS AND LIMITATIONS: By leveraging ICD-10 codes, we provide a more accurate representation of patient demographics and clinical outcomes, minimizing recall and reporting biases that often limit survey-based research. Limitations include the inability to account for unmeasured confounders such as social support. CONCLUSION: Gender-affirming surgery, while beneficial in affirming gender identity, is associated with increased risk of mental health issues, underscoring the need for ongoing, gender-sensitive mental health support for transgender individuals' post-surgery.
30Prevalence and associated factors of antenatal depression: Systematic reviews and meta-analyses.PubMed
Xiaoxv Yin, Na Sun, Nan Jiang, et al.
Clin Psychol Rev. 2021 Feb;83:101932. doi: 10.1016/j.cpr.2020.101932. Epub 2020 Oct 25.
To evaluate the global prevalence of antenatal depression and clarify its potential associated factors, we conducted two systematic reviews and meta-analyses, where appropriate. PubMed, Web of Science, and Embase were used to identify studies published up to Feb 28, 2019. The pooled prevalence of any antenatal depression across 173 studies with 182 reports was 20.7% (95% CI 19.4-21.9%, P = 0.000, I = 98.4%), and the pooled prevalence of major antenatal depression across 72 studies with 79 reports was 15.0% (95% CI 13.6-16.3%, P = 0.000, I = 97.8%). The prevalence of antenatal depression was higher in low- or lower-middle-income countries, and in studies using self-report instruments or conducted after the year 2010. History of depression, lack of social support, single/separated/divorced status, unplanned pregnancy, unemployment, experience of violence, and smoking before or during pregnancy were significantly associated with antenatal depression. The results of our study indicated that a significant number of pregnant women experience depression and verified some factors that are related to this disorder. As countermeasures, it is important to develop effective risk assessment strategies as well as prevention and intervention strategies for antenatal depression based on its associated factors.
31Prevalence and Risk Factors for Antenatal Depression in Ethiopia: Systematic Review.PubMed
Wondale Getinet, Tadele Amare, Berhanu Boru, et al.
Depress Res Treat. 2018 Jul 9;2018:3649269. doi: 10.1155/2018/3649269. eCollection 2018.
INTRODUCTION: Antenatal depression is a syndrome, in which women experience depressed mood, excessive anxiety, insomnia, and change in weight during the period of pregnancy. Maternal depression negatively influences child outcomes and maternal health. Antenatal depression was measured by different rating scales, namely, BDI, EPDS, and PHQ. The objective of this systematic review was to synthesize logical evidence about the prevalence and potential risk factors of antenatal depression in Ethiopia. METHODS: Our team explored multiple databases including PSYCHINFO, MEDLINE, Embase, Google Scholar, and Google Search to detect studies published with data on the prevalence of antenatal depression. We found 246 research papers on antenatal depression, of which 210 did not correspond to the title and 27 were duplicates. Subsequently, nine articles were used for synthesis prevalence, of which four studies were selected in the analysis of the effect of unplanned pregnancy on antenatal depression. Figures were extracted from published reports and grey literature, and any lost information was requested from investigators. Estimates were pooled using random-effects meta-analyses. RESULTS: The pooled prevalence of antenatal depression for five studies selected, which had used BDI, was 25.33 (20.74, 29.92). The other four studies that had included other screening tools (3 EPDS and 1 PHQ) had the prevalence decreased to 23.56 (19.04, 28.07), and the pooled effect of unplanned pregnancy on antenatal depression was 1.93 (1.81, 2.06). Factors such as age, marital status, income, occupation, history of the previous mental disorder, antenatal follow-up, unplanned pregnancy, complication during to pregnancy, age of mother during pregnancy, conflict, and social support were associated with antenatal depression. CONCLUSIONS: Antenatal depression is a common maternal problem; further attention should be given to the effect of unplanned pregnancy, social support, pregnancy-related complications, family conflicts, and violence on pregnant women. All these are possible risk factors for antenatal depression.
32Prevalence of perinatal depression and its determinants in Mainland China: A systematic review and meta-analysis.PubMed
Anum Nisar, Juan Yin, Ahmed Waqas, et al.
J Affect Disord. 2020 Dec 1;277:1022-1037. doi: 10.1016/j.jad.2020.07.046. Epub 2020 Jul 18.
BACKGROUND: Perinatal depression is a maternal mental health condition that is associated with various adverse health outcomes both for the mothers and the babies. The study aim was to estimate the prevalence of perinatal depression and its risks and determinants in Mainland China. METHODS: Systematic searches were conducted in 10 major databases and random effect meta-analysis was performed to achieve the pooled variance of perinatal depression. Subgroup analyses were conducted based on region, scale, methods of diagnosis and study design. Meta-regression was performed with the variables such as age, quality assessment score and gross domestic product (GDP) of the province. RESULTS: Pooled prevalence of perinatal depression was 16.3% (CI=95%; 14.7% to 18.2%, P < 0.001), with antenatal depression 19.7% (CI=95%; 15.8% to 24.2%, P < 0.001) and postnatal depression 14.8% (CI=95%; 13.1% to 16.6%, P < 0.001). Significant publication bias was found and heterogeneity was I= 98.13%. Lower socioeconomic status, poor physical health, anxiety about pregnancy and reduced social support were major risk factors while better living conditions and higher level of education were protective factors. The prevalence of perinatal depression showed a significant increasing trend in the last decade. LIMITATIONS: The review does not include studies with small sample size (n <250). Moreover a narrative review of risk and protective factors was done, these were not included in meta-analysis. CONCLUSION: The prevalence of perinatal depression in China is similar to low and middle-income countries. Urgent attention is needed to address this public health priority in China.
33Antenatal depression.PubMed
Angela Bowen, Nazeem Muhajarine
Can Nurse. 2006 Nov;102(9):26-30.
About 20 per cent of pregnant women experience antenatal depression (AD), which not only has deleterious effects on the woman and her baby but also increases the risk of developing postpartum depression. Nurses who understand the prevalence, signs and symptoms, and risk factors associated with AD can help to identify it and prevent the sequelae. The signs and symptoms of depression in pregnancy do not differ from depression at at any other time. However, AD may go undiagnosed because of a focus on maternal and fetal well-being and the attribution of complaints to the physical and hormonal changes associated with pregnancy. Risk factors include history of depression, lack of partner, marital difficulties, lack of social support, poverty, family violence, increased life stress, substance abuse, history of previous abortions, unplanned pregnancy, ambivalence toward the pregnancy and anxiety about the fetus. Most of the standard treatments for depression can be used in pregnant women, with the exception of some antidepressant medications. Supportive therapies--exercise, adequate nutrition, adequate sleep, and support from family and friends--are also indicated. Screening of women with known risk factors is crucial, but the authors suggest that the high overall prevalence of depressive symptoms during pregnancy indicates a need for universal screening.
34Health Equity and Perinatal Mental Health.PubMed
Michelle L Miller, Jessica Dupree, Mahogany A Monette, et al.
Curr Psychiatry Rep. 2024 Sep;26(9):460-469. doi: 10.1007/s11920-024-01521-4. Epub 2024 Jul 15.
PURPOSE OF REVIEW: Pregnancy and the postpartum period are vulnerable times to experience psychiatric symptoms. Our goal was to describe existing inequities in perinatal mental health, especially across populations, geography, and in the role of childbirth. RECENT FINDINGS: People of color are at an increased risk for perinatal mental health difficulties and more likely to experience neglect, poor communication, and racial discrimination. LGBTQ + individuals encounter unique challenges, implicating the role of heteronormativity, cisnormativity, and gender dysphoria through pregnancy-related processes. Rural-dwelling women are significantly less likely to seek care, be screened for, or receive treatment for perinatal mental health conditions. Trauma-informed, comprehensive mental health support must be provided to all patients during pregnancy, childbirth, and the postpartum period, especially for racially and ethnically minoritized individuals that have often been omitted from care. Future research needs to prioritize inclusion of perinatal populations not well represented in the literature, including rural-dwelling individuals.
35Mental health and well-being of elite youth athletes: a scoping review.PubMed
Kate Gwyther, Vita Pilkington, Alan P Bailey, et al.
Br J Sports Med. 2024 Sep 4;58(17):1011-1019. doi: 10.1136/bjsports-2024-108244.
BACKGROUND: There is increasing recognition of the prevalence and risk factors for mental health symptoms and disorders among adult elite athletes, with less research involving elite youth athletes. This scoping review aimed to characterise the mental health and well-being of elite youth athletes who travel internationally and compete for their sport. METHOD: Four databases were searched in March 2023. Inclusion criteria were studies with elite youth athlete populations (mean age 12-17 years) reporting mental health and well-being outcomes. Data from included studies were charted by outcome, and risk/protective factors identified. RESULTS: Searches retrieved 3088 records, of which 33 studies met inclusion criteria, encapsulating data from 5826 athletes (2538 males, 3288 females). The most frequently studied issue was disordered eating (k=16), followed by anxiety (k=7), depression (k=5) and mixed anxiety/depression (k=2). Caseness estimates (a symptom level where mental health treatment is typically indicated) for disordered eating were wide ranging (0%-14% for males; 11%-41% for females), whereas only two studies estimated caseness for depression (7% in a mixed-sex sample; 14% for males, 40% for females) and one for anxiety (8% for males, 28% for females). Common risk factors for mental ill-health included sex, athlete status (compared with non-athletes) and social/relationship factors (with coaches/parents/peers). Contradictory evidence was observed for elite/competition level, which was associated with higher and lower rates of disordered eating. CONCLUSION: Further representative research into the mental health and well-being of elite youth athletes is needed to enhance understanding and guide prevention and intervention measures.
36Elite youth athletes' mental health and its relationship with the talent development environment: A variable- and person-centred approach.PubMed
Xingni Cao, Russell Martindale, Heetae Cho, et al.
J Sports Sci. 2023 Jun;41(7):706-714. doi: 10.1080/02640414.2023.2235162. Epub 2023 Jul 15.
The present research sought to examine the prevalence of elite youth athletes' mental health and its relationship with talent development environments (TDEs). A sample of 248 Chinese elite youth athletes completed a self-report survey measuring demographic variables, TDE factors, and mental health outcomes including generalised anxiety disorder (GAD), depression, and athlete burnout. The results revealed moderate levels of burnout, with 19% of the participants meeting the diagnostic cut-off of GAD, and similar numbers for depression. The multiple regression analysis revealed alignment of expectations was the only TDE factor to significantly predict GAD and depression. Holistic quality preparation was the only significant TDE predictor of burnout. The results of cluster analysis suggested a three-cluster solution: cluster 1-"slightly below average TDE", cluster 2-"high TDE", and cluster 3-"very low TDE". Among the three clusters, cluster 2 had the lowest levels of GAD, depression, and burnout. Cluster 3 reported a higher burnout level than cluster 1, and the two clusters showed no differences in other two mental health outcomes. These findings suggest a need to manage mental health symptoms of elite youth athletes, and the roles of TDE could be considered in the management of mental health.
37The mental health of Australian elite athletes.PubMed
Amelia Gulliver, Kathleen M Griffiths, Andrew Mackinnon, et al.
J Sci Med Sport. 2015 May;18(3):255-61. doi: 10.1016/j.jsams.2014.04.006. Epub 2014 Apr 29.
OBJECTIVES: Currently, little is known about the prevalence of mental disorders in athletes. This study aims to investigate Australian elite athletes' symptoms of general psychological distress and common mental disorders. DESIGN: A cross-sectional survey design was employed to assess self-reported symptom prevalence. METHODS: A total of 224 elite athletes (118 female, 106 male) from national sporting organisations in Australia were administered a self-report internet-based survey comprising measures of demographic status and mental health symptoms. RESULTS: Overall, 46.4% of athletes were experiencing symptoms of at least one of the mental health problems assessed. Percentages meeting criteria for mental disorders were similar to previous epidemiological studies of both international athlete and community samples: depression (27.2%), eating disorder (22.8%), general psychological distress (16.5%), social anxiety (14.7%), generalised anxiety disorder (7.1%), and panic disorder (4.5%). Injured athletes had higher levels of both symptoms of depression (t=3.23, p=.001) and generalised anxiety disorder (t=2.26, p=.025). CONCLUSIONS: The level of symptoms of mental health problems reported by elite athletes appears similar to that observed in the community. However, caution must be exercised in interpreting the findings, as possible demographic differences between athletes and comparison population datasets may exist. Furthermore, self-selection of respondents in the present study may have reduced the representativeness of the sample and the validity of the comparisons. Athletes, particularly those currently injured, should be well-supported to seek help for mental disorders through access to mental health professionals.
38The mental health of elite athletes in the United Kingdom.PubMed
R L Foskett, F Longstaff
J Sci Med Sport. 2018 Aug;21(8):765-770. doi: 10.1016/j.jsams.2017.11.016. Epub 2017 Dec 15.
OBJECTIVES: The purpose of this study was to investigate the prevalence of signs of anxiety/depression and distress among a sample of elite athletes in the United Kingdom (UK). A secondary aim was to identify the variables associated with signs of anxiety/depression and distress in the same sample. DESIGN: A cross-sectional survey was distributed to a sample of elite athletes in the UK. METHODS: A total of 143 elite athletes completed an online survey that consisted of demographic questions, the Greenhaus Scale assessing career satisfaction, the 12-Item General Health Questionnaire assessing signs of anxiety/depression and a distress screener based on the Four-Dimensional Symptom Questionnaire. RESULTS: 47.8% of the overall sample met the cut-off for signs of anxiety/depression and 26.8% met the cut-off for signs of distress. A significant association was found between gender and signs of distress (x=8.64, df=1, p=0.003). Career dissatisfaction was a significant independent predictor of signs of anxiety/depression (OR=0.836, p=0.001) and distress (OR=0.849, p=0.003). CONCLUSIONS: The percentage of a sample of elite athletes in the UK showing signs of anxiety/depression and distress indicate that further cross-sectional research is required to understand the prevalence of mental health issues in the elite athlete population in the UK. Findings indicate that screening elite athletes for career dissatisfaction may support the early detection of signs of anxiety/depression and/or distress. Emphasis should be placed on understanding and improving the mental health of elite athletes in the UK.
39Short-term and Long-term Rates of Postacute Sequelae of SARS-CoV-2 Infection: A Systematic Review.PubMed
Destin Groff, Ashley Sun, Anna E Ssentongo, et al.
JAMA Netw Open. 2021 Oct 1;4(10):e2128568. doi: 10.1001/jamanetworkopen.2021.28568.
IMPORTANCE: Short-term and long-term persistent postacute sequelae of COVID-19 (PASC) have not been systematically evaluated. The incidence and evolution of PASC are dependent on time from infection, organ systems and tissue affected, vaccination status, variant of the virus, and geographic region. OBJECTIVE: To estimate organ system-specific frequency and evolution of PASC. EVIDENCE REVIEW: PubMed (MEDLINE), Scopus, the World Health Organization Global Literature on Coronavirus Disease, and CoronaCentral databases were searched from December 2019 through March 2021. A total of 2100 studies were identified from databases and through cited references. Studies providing data on PASC in children and adults were included. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for abstracting data were followed and performed independently by 2 reviewers. Quality was assessed using the Newcastle-Ottawa Scale for cohort studies. The main outcome was frequency of PASC diagnosed by (1) laboratory investigation, (2) radiologic pathology, and (3) clinical signs and symptoms. PASC were classified by organ system, ie, neurologic; cardiovascular; respiratory; digestive; dermatologic; and ear, nose, and throat as well as mental health, constitutional symptoms, and functional mobility. FINDINGS: From a total of 2100 studies identified, 57 studies with 250 351 survivors of COVID-19 met inclusion criteria. The mean (SD) age of survivors was 54.4 (8.9) years, 140 196 (56%) were male, and 197 777 (79%) were hospitalized during acute COVID-19. High-income countries contributed 45 studies (79%). The median (IQR) proportion of COVID-19 survivors experiencing at least 1 PASC was 54.0% (45.0%-69.0%; 13 studies) at 1 month (short-term), 55.0% (34.8%-65.5%; 38 studies) at 2 to 5 months (intermediate-term), and 54.0% (31.0%-67.0%; 9 studies) at 6 or more months (long-term). Most prevalent pulmonary sequelae, neurologic disorders, mental health disorders, functional mobility impairments, and general and constitutional symptoms were chest imaging abnormality (median [IQR], 62.2% [45.8%-76.5%]), difficulty concentrating (median [IQR], 23.8% [20.4%-25.9%]), generalized anxiety disorder (median [IQR], 29.6% [14.0%-44.0%]), general functional impairments (median [IQR], 44.0% [23.4%-62.6%]), and fatigue or muscle weakness (median [IQR], 37.5% [25.4%-54.5%]), respectively. Other frequently reported symptoms included cardiac, dermatologic, digestive, and ear, nose, and throat disorders. CONCLUSIONS AND RELEVANCE: In this systematic review, more than half of COVID-19 survivors experienced PASC 6 months after recovery. The most common PASC involved functional mobility impairments, pulmonary abnormalities, and mental health disorders. These long-term PASC effects occur on a scale that could overwhelm existing health care capacity, particularly in low- and middle-income countries.
40The impact of the COVID-19 pandemic on children and young people.PubMed
Konstantina Magklara, Marinos Kyriakopoulos
Psychiatriki. 2023 Dec 29;34(4):265-268. doi: 10.22365/jpsych.2023.024. Epub 2023 Nov 14.
In March 2020, the World Health Organization declared the spread of COVID-19 as a global pandemic, and youth worldwide were suddenly confronted with unprecedented consequences. The first line of concern was related to the direct effect of SARS-CoV-2 viral infection. While severe physical health symptomatology including death following infection was found to be less common in children than in adults,1 long-COVID has been identified in the pediatric population with the most prevalent manifestations involving mood symptoms, sleep difficulties, and fatigue.2 Secondly, the measures against COVID-19 carried their own set of risks. Many governments imposed national lockdowns, schools closed, remote learning started operating and social distancing measures prevented families from visiting public places or meeting people from other households. Isolation, disruption of everyday routines, and a sharp and dramatic decrease in physical activity and social interaction levels became the new reality experienced by children and adolescents of all age groups.3 Cross-sectional community studies on children and adolescents conducted early in the course of the pandemic indicated elevated levels of loneliness, anxiety, and behavioral problems in youth samples, even during the initial phases of the outbreak.4 Systematic reviews of mainly cross-sectional studies that followed indicated a significant rise in clinically significant anxiety and depression symptoms among children and adolescents compared to pre-pandemic levels5 and high prevalence estimates for depression, anxiety, posttraumatic stress symptomatology, and sleep disorders.6 A recent systematic review that included data from 55,000 children and adolescents from many countries of the world (mean age 11.3 years) reported that anxiety (range = 1.8–49.5%), depression (range = 2.2– 63.8%), irritability (range = 16.7–73.2%) and anger (range = 30.0–51.3%) were frequently reported by children and adolescents during the pandemic.7 However, the experience of the pandemic was not homogenous among all youth. Possible risk factors included the presence of mental health problems before the pandemic, excessive exposure to media, and high COVID-19 caseload in the community, while the presence of any kind of family routines and good parent-child communication were identified as protective factors.7 Females and older adolescents were also reported to be at greater risk for adverse mental health outcomes. In most countries, the spread of the infection, on one hand, and the enforcement of lockdowns and other containment measures, on the other, have put health care under tremendous pressure, leaving families with children with mental health disorders with minimal or inadequate support. Nevertheless, differences were also observed within the group of children with psychiatric or developmental disorders diagnosed before the pandemic. Numerous studies that have investigated the impact of the COVID-19 pandemic and related containment measures on children and adolescents with autism spectrum disorders reported a significant increase in parental stress, as well as high levels of anxiety, irritability, hyperactivity, stereotypical behavior, and other behavioral problems among children and adolescents.8 Further studies that investigated the issue of neurodevelopmental disorders showed that the COVID-19 pandemic has disproportionately and adversely affected children with attention-deficit/hyperactivity disorder (ADHD) with a recent meta-analysis pointing to a global increase in ADHD symptoms.9 Finally, early concerns about a possible significant increase in suicidality among youth during the pandemic were followed by contradicting findings from relevant studies. On the whole, though, it is suggested that during the pandemic, as previously, higher rates of suicidal ideation than of suicidal behaviors and suicide events were reported among children and adolescents.10 Similar patterns of mental health difficulties to those described above have also been identified in youth in Greece. During the early stages of the pandemic, one-third (35.1%) of the parents reported that their child’s psychological health was considerably affected,11 while a study of final-year high-school students found that the rates of severe depression and anxiety increased significantly during the lockdown.12 Among children and adolescents with pre-existing mental health problems from different parts of the country, no change was found in mood state scores pre- and post-pandemic onset, while several of their daily behaviors worsened during the lockdown, such as reduced sleep or time spent outdoors.13 Such research findings related to the effects of the COVID-19 pandemic and its containment measures should guide the follow-up of children and young people affected by it and inform the design of effective health strategies and policies in the post-pandemic era with the aim to prevent and mitigate further mental health crises.
41Perception towards E-learning and COVID-19 on the mental health status of university students in Malaysia.PubMed
Foong Ming Moy, Yit Han Ng
Sci Prog. 2021 Jul-Sep;104(3):368504211029812. doi: 10.1177/00368504211029812.
The COVID-19 pandemic has disrupted the lives of all including university students. With the preventive measures to reduce the transmission of COVID-19, all face-to-face teaching and learning are converted to e-learning. The COVID-19 pandemic and the implementation of e-learning may influence these students' mental conditions. This study aimed to determine the association of factors with mental health status (depression, anxiety and stress) among university students in Malaysia. Study participants were tertiary education students from both the private and public universities in Malaysia. Participants were recruited via university emails and social media. The survey was administered via the online REDCap platform, from April to June 2020, during the movement control order period in the country. The questionnaire captured data on socio-demographic characteristics, academic information, implementation of e-learning, perception towards e-learning and COVID-19; as well as DASS 21 to screen for depression, anxiety and stress. The levels of stress, anxiety and depression were 56.5% (95% CI: 50.7%, 62.1%), 51.3% (95% CI: 45.6%, 57.0%) and 29.4% (95% CI: 24.3%, 34.8%) respectively. Most participants had good perception towards e-learning but negative perception on COVID-19. From the multivariate analysis, participants with positive perception on COVID-19 were protective towards stress (aOR: 0.96; 95% CI: 0.92, 0.99), anxiety (aOR: 0.94, 95% CI: 0.90, 0.98) and depression (aOR: 0.95; 95% CI: 0.91, 0.99). Older students were 14% (aOR: 0.86, 95% CI: 0.79, 0.94) and 11% (aOR: 0.89: 95% CI: 0.80, 0.99) less likely for anxiety and depression, respectively. Students originated from the Malay ethnicity had higher odds (aOR: 1.93; 95% CI: 1.05, 3.56) for depression. These findings demonstrated that the mental status of university students was greatly affected during the COVID-19 pandemic. Timely and credible information should be disseminated to alleviate their negative perception towards COVID-19.
42Fear of COVID-19 and its association with mental health-related factors: systematic review and meta-analysis.PubMed
Zainab Alimoradi, Maurice M Ohayon, Mark D Griffiths, et al.
BJPsych Open. 2022 Mar 21;8(2):e73. doi: 10.1192/bjo.2022.26.
BACKGROUND: The severity of COVID-19 remains high worldwide. Therefore, millions of individuals are likely to suffer from fear of COVID-19 and related mental health factors. AIMS: The present systematic review and meta-analysis aimed to synthesize empirical evidence to understand fear of COVID-19 and its associations with mental health-related problems during this pandemic period. METHOD: Relevant studies were searched for on five databases (Scopus, ProQuest, EMBASE, PubMed Central, and ISI Web of Knowledge), using relevant terms (COVID-19-related fear, anxiety, depression, mental health-related factors, mental well-being and sleep problems). All studies were included for analyses irrespective of their methodological quality, and the impact of quality on pooled effect size was examined by subgroup analysis. RESULTS: The meta-analysis pooled data from 91 studies comprising 88 320 participants (mean age 38.88 years; 60.66% females) from 36 countries. The pooled estimated mean of fear of COVID-19 was 13.11 (out of 35), using the Fear of COVID-19 Scale. The associations between fear of COVID-19 and mental health-related factors were mostly moderate (Fisher's z = 0.56 for mental health-related factors; 0.54 for anxiety; 0.42 for stress; 0.40 for depression; 0.29 for sleep problems and -0.24 for mental well-being). Methodological quality did not affect these associations. CONCLUSIONS: Fear of COVID-19 has associations with various mental health-related factors. Therefore, programmes for reducing fear of COVID-19 and improving mental health are needed.
43Social determinants of mental health during a year of the COVID-19 pandemic.PubMed
Savannah Minihan, Amy Orben, Annabel Songco, et al.
Dev Psychopathol. 2023 Oct;35(4):1701-1713. doi: 10.1017/S0954579422000396. Epub 2022 Jul 7.
Belonging is a basic human need, with social isolation signaling a threat to biological fitness. Sensitivity to ostracism varies across individuals and the lifespan, peaking in adolescence. Government-imposed restrictions upon social interactions during COVID-19 may therefore be particularly detrimental to young people and those most sensitive to ostracism. Participants ( = 2367; 89.95% female, 11-100 years) from three countries with differing levels of government restrictions (Australia, UK, and USA) were surveyed thrice at three-month intervals (May 2020 - April 2021). Young people, and those living under the tightest government restrictions, reported the worst mental health, with these inequalities in mental health remaining constant throughout the study period. Further dissection of these results revealed that young people high on social rejection sensitivity reported the most mental health problems at the final assessment. These findings help account for the greater impact of enforced social isolation on young people's mental health, and open novel avenues for intervention.
44Psychosocial alterations during the COVID-19 pandemic and the global burden of anxiety and major depressive disorders in adolescents, 1990-2021: challenges in mental health amid socioeconomic disparities.PubMed
Soeun Kim, Jiyoung Hwang, Jun Hyuk Lee, et al.
World J Pediatr. 2024 Oct;20(10):1003-1016. doi: 10.1007/s12519-024-00837-8. Epub 2024 Aug 20.
BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic, a global health crisis, profoundly impacted all aspects of daily life. Adolescence, a pivotal stage of psychological and social development, is heavily influenced by the psychosocial and socio-cultural context. Hence, it is imperative to thoroughly understand the psychosocial changes adolescents experienced during the pandemic and implement effective management initiatives. DATA SOURCES: We examined the incidence rates of depressive and anxiety disorders among adolescents aged 10-19 years globally and regionally. We utilized data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 to compare pre-pandemic (2018-2019) and pandemic (2020-2021) periods. Our investigation covered 204 countries and territories across the six World Health Organization regions. We conducted a comprehensive literature search using databases including PubMed/MEDLINE, Scopus, and Google Scholar, employing search terms such as "psychosocial", "adolescent", "youth", "risk factors", "COVID-19 pandemic", "prevention", and "intervention". RESULTS: During the pandemic, the mental health outcomes of adolescents deteriorated, particularly in terms of depressive and anxiety disorders. According to GBD 2021, the incidence rate of anxiety disorders increased from 720.26 [95% uncertainty intervals (UI) = 548.90-929.19] before the COVID-19 pandemic (2018-2019) to 880.87 per 100,000 people (95% UI = 670.43-1132.58) during the COVID-19 pandemic (2020-2021). Similarly, the incidence rate of major depressive disorder increased from 2333.91 (95% UI = 1626.92-3138.55) before the COVID-19 pandemic to 3030.49 per 100,000 people (95% UI = 2096.73-4077.73) during the COVID-19 pandemic. This worsening was notably pronounced in high-income countries (HICs). Rapid environmental changes, including heightened social anxiety, school closures, economic crises, and exacerbated racism, have been shown to adversely affect the mental well-being of adolescents. CONCLUSIONS: The abrupt shift to remote learning and the absence of in-person social interactions heightened feelings of loneliness, anxiety, sadness, and stress among adolescents. This change magnified existing socioeconomic disparities, posing additional challenges. These complexities profoundly impact adolescents' well-being, especially vulnerable groups like those from HICs, females, and minorities. Acknowledging the underreporting bias in low- to middle-income countries highlights the importance of addressing these mental health alterations in assessments and interventions within these regions as well. Urgent interventions are crucial as the pandemic-induced mental stress may have lasting effects on adolescents' mental health.
45Remote-learning, time-use, and mental health of Ecuadorian high-school students during the COVID-19 quarantine.PubMed
Igor Asanov, Francisco Flores, David McKenzie, et al.
World Dev. 2021 Feb;138:105225. doi: 10.1016/j.worlddev.2020.105225. Epub 2020 Oct 22.
The COVID-19 pandemic has closed schools around the world, forcing school systems and students to quickly attempt remote learning. We conducted a rapid response phone survey of over 1500 high school students aged 14 to 18 in Ecuador to learn how students spend their time during the period of quarantine, examine their access to remote learning, and measure their mental health status. We find 59 percent of students have both an internet connection at home and a computer or tablet, 74 percent are engaging in some online or telelearning, and 86 percent have done some schoolwork on the last weekday. Detailed time-use data show most students have established similar daily routines around education, although gender and wealth differences emerge in time spent working and on household tasks. Closure of schools and social isolation are the two main problems students say they face, and while the majority are mostly happy, 16 percent have mental health scores that indicate depression.
46Pandemic Isolation and Mental Health Among Children.PubMed
Donald E Brannen, Sheryl Wynn, Jaime Shuster, et al.
Disaster Med Public Health Prep. 2023 Jan 11;17:e353. doi: 10.1017/dmp.2023.7.
OBJECTIVE: Mental health issues increased during the COVID - 19 pandemic, especially among children. Our past research efforts found that surveillance data can address a variety of health concerns; that personal psychological awareness impacted ability to cope, and mental health outcomes were improved when survivors were triaged to mental health countermeasures. To build upon our public health efforts, we wanted to see if increased screen time due to remote learning caused by the pandemic influenced school aged children's mental health. METHODS: With the hypothesis that excessive time spent isolated during remote learning increased the amount of mental health events in children, we conducted a public health surveillance project on actual diagnoses rather than just symptoms, controlling for historical mental health and emotional disorders. RESULTS: The entire cohort of children aged 6 to 17 years were studied over time before and during the pandemic for their medically diagnosed mental health and emotional outcomes by the amount of pandemic induced social isolation. CONCLUSIONS: After controlling for historical diagnoses and the rate of COVID - 19, the effect of pandemic - induced social isolation had a linear increase on the amount of anxiety, resulting in a 4-fold increase in pandemic social isolation - induced anxiety.
47Disrupted Access to Therapies and Impact on Well-Being During the COVID-19 Pandemic for Children With Motor Impairment and Their Caregivers.PubMed
Ellen N Sutter, Linda Smith Francis, Sunday M Francis, et al.
Am J Phys Med Rehabil. 2021 Sep 1;100(9):821-830. doi: 10.1097/PHM.0000000000001818.
OBJECTIVES: The aim of this study was to determine the impact of the COVID-19 pandemic on access to rehabilitation therapies and the impact of changes in therapy access on the physical and mental well-being of children with motor impairment and their caregivers. DESIGN: Caregivers of children younger than 18 yrs with childhood-onset motor impairment (primarily cerebral palsy) completed an anonymous survey through the online platform REDCap between May 5 and July 13, 2020. RESULTS: The survey was completed by 102 participants. Before the pandemic, 92 of 102 children (90%) were receiving one or more therapies; at the time surveyed, 55 children (54%) were receiving any therapies (P < 0.001). More than 40% of the sample reported increased child stress, decreased physical activity, and/or decline in mobility/movement. Participants who reported a decrease in number of therapies at the time surveyed more frequently reported lower satisfaction with treatment delivery (P < 0.001), a decline in child's mobility (P = 0.001), and increased caregiver stress (P = 0.004). Five qualitative themes were identified from open-ended question responses related to therapies and well-being. CONCLUSIONS: Access to pediatric rehabilitation therapies was disrupted during COVID-19. Disrupted access may be related to impact on physical and mental health. With the expansion of telehealth, caregiver and child feedback should be incorporated to optimize benefit.
48Teenage mothers report poor health and economic functioning in Western Kenya: A call to action.PubMed
Aleksandra Jakubowski, Elizabeth Nakiyingi, Jane Wamae, et al.
PLOS Glob Public Health. 2025 Jul 15;5(7):e0004732. doi: 10.1371/journal.pgph.0004732. eCollection 2025.
Teenage pregnancy remains a critical issue in Kenya, with 15% of girls aged 15-19 having been pregnant. Counties in western Kenya experience high teenage pregnancy rates (22-30%) along with high HIV prevalence and widespread poverty. Long-term consequences of teenage pregnancy have been documented in high-income countries, but evidence from the Global South is lacking. Here, we examined the association between teenage pregnancy and adult socio-economic functioning in western Kenya using cross-sectional survey data from Migori County, Kenya. We categorized women into three groups: adult mothers (first child ≥20 years), teenage mothers to 1 child (had 1 child before age 20), and teenage mothers to 2 + children (had 2 or more children before age 20). We then compared adult socioeconomic and health outcomes of these groups. We found that among 6,089 mothers, 45.2% had their first child during adolescence. Compared to adult mothers, teenage mothers were significantly less likely to complete primary education: a 12.2 percentage point (pp) reduction (95% CI: -14.9, -9.4) among teenage mothers to 1 child and 27.6 pp reduction (95% CI: -31.4, -23.8) among teenage mothers to 2 + children. Teenage mothers were also more likely to have loans and experience food insecurity. The risk of experiencing the death of a child increased from 3.4% among adult mothers to 15.3% among teenage mothers to 2 + children, a 4.5-fold increase (p < 0.001). Teenage mothers also reported short birth spacing and poor mental health. Our study highlights that teenage motherhood is associated with worse health and economic functioning that persists into adulthood. Urgent policy action is needed to address teenage pregnancy in Kenya to support the economic development of youth and reduce the risk of HIV infection.
49Social determinants of perinatal mental health during the COVID-19 pandemic.PubMed
Kodi Endres, Katherine Haigler, Marissa Sbrilli, et al.
Gen Hosp Psychiatry. 2023 Sep-Oct;84:39-43. doi: 10.1016/j.genhosppsych.2023.05.010. Epub 2023 May 23.
OBJECTIVE: We sought to clarify relevant social-structural determinants of perinatal mental health-material and social resources, as well as pandemic employment-related stressors, in White and BIPOC child-bearers-toward building comprehensive risk screening and prevention/intervention models that can alleviate health disparities. Each of these determinants was hypothesized to contribute to perinatal symptoms in ways that disproportionately benefit White child-bearers. METHOD: A community sample of Illinois child-bearers (n = 409 pregnant, 122 new parents) completed online questionnaires from May 2020-June 2021. Relations between composite measures of child-bearers' material resources, social resources, and pandemic employment-related stressors and mental health symptoms were tested in multiple regression models. Main effects of social determinant composites and moderated effects by race/ethnic identification were tested. RESULTS: All social determinants displayed significant unique associations with mental health in the sample, with social resources carrying the greatest weight. Although no moderated effects of composite resource measures were found, the relation between pandemic employment-related reduced resources and symptoms proved stronger in BIPOC compared to White child-bearers. CONCLUSIONS: Both stable social-structural determinants and acute crisis-related shifts contribute to perinatal mental health, with higher levels and/or impacts of resources helping to explain racial/ethnic disparities. These findings can inform more comprehensive screening and prevention protocols and policy recommendations that improve perinatal health outcomes.
50Impact of Environmental Injustice on Children's Health-Interaction between Air Pollution and Socioeconomic Status.PubMed
Sahana Mathiarasan, Anke Hüls
Int J Environ Res Public Health. 2021 Jan 19;18(2):795. doi: 10.3390/ijerph18020795.
Air pollution disproportionately affects marginalized populations of lower socioeconomic status. There is little literature on how socioeconomic status affects the risk of exposure to air pollution and associated health outcomes, particularly for children's health. The objective of this article was to review the existing literature on air pollution and children's health and discern how socioeconomic status affects this association. The concept of environmental injustice recognizes how underserved communities often suffer from higher air pollution concentrations in addition to other underlying risk factors for impaired health. This exposure then exerts larger effects on their health than it does in the average population, affecting the whole body, including the lungs and the brain. Children, whose organs and mind are still developing and who do not have the means of protecting themselves or creating change, are the most vulnerable to the detrimental effects of air pollution and environmental injustice. The adverse health effects of air pollution and environmental injustice can harm children well into adulthood and may even have transgenerational effects. There is an urgent need for action in order to ensure the health and safety of future generations, as social disparities are continuously increasing, due to social discrimination and climate change.
51Hypothalamic-pituitary-adrenal axis dysfunction as a neurobiological correlate of emotion dysregulation in adolescent suicide.PubMed
María Dolores Braquehais, María Dolores Picouto, Miquel Casas, et al.
World J Pediatr. 2012 Aug;8(3):197-206. doi: 10.1007/s12519-012-0358-0. Epub 2012 Aug 12.
BACKGROUND: Biological markers of vulnerability for current or future risk of suicide in adolescents could be important adjuncts to the treatment and prevention of this phenomenon. DATA SOURCES: We conducted a PubMed search of all English-language articles published between January 1990 and June 2011 using the following search terms: ("hypothalamic-pituitary-adrenal" OR "HPA") AND ("adolescence" OR "adolescent" OR "teenager") AND ("depression" OR "major depressive disorder" OR "suicidal behavior" OR "suicidal ideation" OR "suicidal thoughts" OR "deliberate self-harm" OR "suicidal attempt" OR "suicide"). RESULTS: HPA axis activity can be examined using different methods that do not have the same biological interpretation. An abnormal HPA axis functioning together with an anomalous interaction between HPA mechanisms and other systems such as the serotonergic system may be one of the neurobiological correlates of emotion dysregulation (ED). ED may play an important role in adolescent suicidal behavior. Some psychopathological conditions such as depression or childhood psychological trauma that increase suicidal risk in adolescents are also associated with HPA axis dysregulation. ED, a personality trait, can also be viewed as a predisposing factor that augments the vulnerability to suffer from psychiatric conditions. CONCLUSIONS: Correlating HPA axis dysfunction with psychological factors such as ED could lead to a better understanding of the role of HPA abnormalities in adolescent suicide and may enhance preventive and treatment strategies.
52Stress and the developing adolescent brain.PubMed
L Eiland, R D Romeo
Neuroscience. 2013 Sep 26;249:162-71. doi: 10.1016/j.neuroscience.2012.10.048. Epub 2012 Nov 2.
Adolescence is a time of continued brain maturation, particularly in limbic and cortical regions, which undoubtedly plays a role in the physiological and emotional changes coincident with adolescence. An emerging line of research has indicated that stressors experienced during this crucial developmental stage may affect the trajectory of this neural maturation and contribute to the increase in psychological morbidities, such as anxiety and depression, often observed during adolescence. In this review, we discuss the short- and long-term effects of periadolescent stress exposure on the structure and function of the brain. More specifically, we examine how stress at prepubertal and early adolescent stages of development affects the morphological plasticity of limbic and cortical brain regions, as well as the enduring effects of adolescent stress exposure on these brain regions in adulthood. We suggest that, due to a number of converging factors during this period of maturation, the adolescent brain may be particularly sensitive to stress-induced neurobehavioral dysfunctions with important consequences on an individual's immediate and long-term health and well-being.
53The role of the hypothalamic-pituitary-adrenal axis dysfunction in the pathophysiology of alcohol misuse and suicidal behavior in adolescents.PubMed
Leo Sher
Int J Adolesc Med Health. 2007 Jan-Mar;19(1):3-9. doi: 10.1515/ijamh.2007.19.1.3.
Alterations in the mechanisms that regulate hypothalamic-pituitary-adrenal (HPA) axis activity predate the development of alcohol use disorders. Human and animal studies indicate that chronic alcohol consumption induces a persistent impairment in the ability of the HPA axis to respond to stress. Therefore, HPA axis abnormalities may contribute to the development of alcohol use disorders and may be a result of alcohol misuse. HPA axis interacts with serotonergic mechanisms. Hippocampal function is modulated by serotonergic projections mostly from dorsal raphe nucleus in the midbrain. Glucocorticoids modulate the activity of this raphe-hippocampal system in various ways. These effects are mediated via central corticosteroid receptors, which include glucocorticoid and mineralocorticoid receptors located in the hippocampus and in other cortical structures. An association between suicidal behavior and hyperactivity of the HPA axis has been suggested. An abnormal interaction between the HPA mechanisms and serotonergic systems may substantially contribute to suicidal behavior in adolescents, because abnormalities in HPA and serotonin functions may be inherited and may manifest at young age. Vulnerability to alcohol use disorders and suicide is likely to be due to multiple interacting genetic loci of small to modest effects. The identification and treatment of adolescents at risk for suicide is one of the most critical issues in adolescent psychiatry. The identification of alcohol and drug misuse is critical to the proper assessment of suicide risk in adolescents. HPA dysregulation may contribute to both alcohol abuse and suicidal behavior in adolescents. Studies of HPA function in alcohol abusing adolescents may lead to the development of new diagnostic tests for predisposition to suicidal behavior. Furthermore, study of biological markers may help us towards an understanding of the neurophysiological substrates of severe dysphoric mood states, alcohol and substance abuse, and suicidal behavior in adolescents.
54Lack of Evidence for a Relationship Between the Hypothalamus-Pituitary-Adrenal and the Hypothalamus-Pituitary-Thyroid Axis in Adolescent Depression.PubMed
Raphael Hirtz, Lars Libuda, Anke Hinney, et al.
Front Endocrinol (Lausanne). 2021 May 24;12:662243. doi: 10.3389/fendo.2021.662243. eCollection 2021.
In adults with major depressive disorder (MDD), a dysfunction between the hypothalamus-pituitary-adrenal (HPA) and the hypothalamus-pituitary-thyroid (HPT) axis has been shown, but the interaction of both axes has not yet been studied in adolescent major depressive disorder (MDD). Data from 273 adolescents diagnosed with MDD from two single center cross-sectional studies were used for analysis. Serum levels of thyrotropin (TSH), free levothyroxine (fT4), and cortisol were determined as indicators of basal HPT and HPA axis functioning and compared to that of adolescent controls by t-tests. Quantile regression was employed in the sample of adolescents with MDD to investigate the relationship between both axes in the normal as well as the pathological range of cortisol levels, considering confounders of both axes. In adolescent MDD, cortisol levels and TSH levels were significantly elevated in comparison to controls ( = <.001, = 1.35, large effect size, and = <.001, = 0.79, moderate effect size, respectively). There was a positive linear relationship between TSH and cortisol ( = .003, = 0.25, small effect size) at the median of cortisol levels (50 percentile). However, no relationship between TSH and cortisol was found in hypercortisolemia (cortisol levels at the 97.5 percentile). These findings imply that HPT and HPA axis dysfunction is common in adolescents with MDD and that function of both axes is only loosely related. Moreover, the regulation of the HPA and HPT axis are likely subjected to age-related maturational adjustments since findings of this study differ from those reported in adults.
55Gut microbiota and its metabolites in depression: from pathogenesis to treatment.PubMed
Lanxiang Liu, Haiyang Wang, Xueyi Chen, et al.
EBioMedicine. 2023 Apr;90:104527. doi: 10.1016/j.ebiom.2023.104527. Epub 2023 Mar 22.
Major depressive disorder is one of the most disabling mental disorders worldwide. Increasing preclinical and clinical studies have highlighted that compositional and functional (e.g., metabolite) changes in gut microbiota, known as dysbiosis, are associated with the onset and progression of depression via regulating the gut-brain axis. However, the gut microbiota and their metabolites present a double-edged sword in depression. Dysbiosis is involved in the pathogenesis of depression while, at the same time, offering a novel therapeutic target. In this review, we describe the association between dysbiosis and depression, drug-microbiota interactions in antidepressant treatment, and the potential health benefits of microbial-targeted therapeutics in depression, including dietary interventions, fecal microbiota transplantation, probiotics, prebiotics, synbiotics, and postbiotics. With the emergence of microbial research, we describe a new direction for future research and clinical treatment of depression.
56Brain-gut-microbiota axis in depression: A historical overview and future directions.PubMed
Lijia Chang, Yan Wei, Kenji Hashimoto
Brain Res Bull. 2022 May;182:44-56. doi: 10.1016/j.brainresbull.2022.02.004. Epub 2022 Feb 11.
Depression is the most common mental disorder and a leading cause of disability worldwide. Despite abundant research, the precise mechanisms underlying the pathophysiology of depression remain elusive. Accumulating evidence from preclinical and clinical studies suggests that alterations in the gut microbiota, microbe-derived short-chain fatty acids, D-amino acids and metabolites play a key role in the pathophysiology of depression via the brain-gut-microbiota axis, including the neural and immune systems. Notably, the brain-gut-microbiota axis might play a crucial role in susceptibility versus resilience in rodents exposed to stress. Vagotomy is reported to block depression-like phenotypes in rodents after fecal microbiota transplantation of "depression-related" microbiome, suggesting that the vagus nerve influences depression through the brain-gut-microbiota axis. In this article, we review recent findings regarding the brain-gut-microbiota axis in depression and discuss its potential as a therapeutic target for depression.
57Neuroinflammation, Microbiota-Gut-Brain Axis, and Depression: The Vicious Circle.PubMed
Sandy Reyes-Martínez, Lorena Segura-Real, Ana Pamela Gómez-García, et al.
J Integr Neurosci. 2023 May 8;22(3):65. doi: 10.31083/j.jin2203065.
Depression is the leading cause of disability worldwide, contributing to the global disease burden. From above, it is a priority to investigate models that fully explain its physiopathology to develop new treatments. In the last decade, many studies have shown that gut microbiota (GM) dysbiosis influences brain functions and participate, in association with immunity, in the pathogenesis of depression. Thereby, GM modulation could be a novel therapeutic target for depression. This review aims to evidence how the GM and the immune system influence mental illness, particularly depression. Here, we focus on the communication mechanisms between the intestine and the brain and the impact on the development of neuroinflammation contributing to the development of Major Depressive Disorder (MDD). However, most of the current findings are in animal models, suggesting the need for studies in humans. In addition, more analysis of metabolites and cytokines are needed to identify new pathophysiological mechanisms improving anti-depression treatments.
58Prebiotic and Probiotic Modulation of the Microbiota-Gut-Brain Axis in Depression.PubMed
Daniel E Radford-Smith, Daniel C Anthony
Nutrients. 2023 Apr 13;15(8):1880. doi: 10.3390/nu15081880.
Emerging evidence demonstrates that alterations to the gut microbiota can affect mood, suggesting that the microbiota-gut-brain (MGB) axis contributes to the pathogenesis of depression. Many of these pathways overlap with the way in which the gut microbiota are thought to contribute to metabolic disease progression and obesity. In rodents, prebiotics and probiotics have been shown to modulate the composition and function of the gut microbiota. Together with germ-free rodent models, probiotics have provided compelling evidence for a causal relationship between microbes, microbial metabolites, and altered neurochemical signalling and inflammatory pathways in the brain. In humans, probiotic supplementation has demonstrated modest antidepressant effects in individuals with depressive symptoms, though more studies in clinically relevant populations are needed. This review critically discusses the role of the MGB axis in depression pathophysiology, integrating preclinical and clinical evidence, as well as the putative routes of communication between the microbiota-gut interface and the brain. A critical overview of the current approaches to investigating microbiome changes in depression is provided. To effectively translate preclinical breakthroughs in MGB axis research into novel therapies, rigorous placebo-controlled trials alongside a mechanistic and biochemical understanding of prebiotic and probiotic action are required from future research.
59On serotonin and experimental anxiety.PubMed
Frederico G Graeff
Psychopharmacology (Berl). 2002 Oct;163(3-4):467-76. doi: 10.1007/s00213-002-1112-4. Epub 2002 Jun 5.
BACKGROUND: This review describes the development of a research line on the role of serotonin (5-HT) in experimental anxiety that was initiated in 1969, in the laboratory founded by P.B. Dews, W.H. Morse and R.T. Kelleher at the Harvard Medical School, and has evolved until this date. RESULTS: Initially, it was found that two non-selective 5-HT receptor antagonists released punished responding in pigeons with a magnitude comparable to that of benzodiazepine anxiolytics. This result was one of the key evidences that led to the concept that 5-HT enhanced anxiety by acting both in the forebrain and in the periaqueductal gray matter (PAG). Further evidence supported this hypothesis regarding the forebrain, but results with electrical stimulation and intracerebral drug injection into the PAG indicated that 5-HT inhibited aversive behavior evoked from this area. As a result, it has been suggested that 5-HT has a dual role in the regulation of defense, namely enhancing learned responses to potential or distal threat through actions in the forebrain while inhibiting unconditioned responses to proximal threat by acting on the PAG. The former would be related to generalized anxiety and the latter to panic disorder. To test this hypothesis, a new animal model, named the elevated T-maze, has been designed. It consists of one arm enclosed by walls that is perpendicular to two open arms elevated from the floor. The same rat performs two tasks, namely inhibitory avoidance of the elevated open arms, representing conditioned anxiety and one-way escape from one of the open arms, representative of unconditioned fear. CONCLUSION: The differential effects of drugs acting on 5-HT observed in the two tasks of the ETM generally support the hypothesis under scrutiny.
60Tryptophan Metabolism and Gut-Brain Homeostasis.PubMed
William Roth, Kimia Zadeh, Rushi Vekariya, et al.
Int J Mol Sci. 2021 Mar 15;22(6):2973. doi: 10.3390/ijms22062973.
Tryptophan is an essential amino acid critical for protein synthesis in humans that has emerged as a key player in the microbiota-gut-brain axis. It is the only precursor for the neurotransmitter serotonin, which is vital for the processing of emotional regulation, hunger, sleep, and pain, as well as colonic motility and secretory activity in the gut. Tryptophan catabolites from the kynurenine degradation pathway also modulate neural activity and are active in the systemic inflammatory cascade. Additionally, tryptophan and its metabolites support the development of the central and enteric nervous systems. Accordingly, dysregulation of tryptophan metabolites plays a central role in the pathogenesis of many neurologic and psychiatric disorders. Gut microbes influence tryptophan metabolism directly and indirectly, with corresponding changes in behavior and cognition. The gut microbiome has thus garnered much attention as a therapeutic target for both neurologic and psychiatric disorders where tryptophan and its metabolites play a prominent role. In this review, we will touch upon some of these features and their involvement in health and disease.
61Understanding the Relationship between Depression and Chronic Diseases Such as Diabetes and Hypertension: A Grounded Theory Study.PubMed
Pablo Alberto Herrera, Solange Campos-Romero, Wilsa Szabo, et al.
Int J Environ Res Public Health. 2021 Nov 19;18(22):12130. doi: 10.3390/ijerph182212130.
There is a bi-directional relationship between depression and chronic illnesses such as diabetes and hypertension. This comorbidity is associated with higher mortality risk and diminishes the efficacy of interventions. The specific mechanisms of this mutual influence are still not fully understood, and most intervention protocols address these conditions separately. This study aims to improve our understanding of this relationship. We interviewed 18 patients and 24 health care professionals, focusing on understanding the different ways in which depression and chronic illness could influence each other. Our results show a common cyclical pattern and specific situations where the reported bi-directional relationship does not occur. We discuss the importance of opening a space for the patient's grief process after the chronic illness diagnosis, managing the demands and stress of the patient's treatment, and how to adjust the treatment to the different needs and possibilities of each person.
62Comorbidity of Anxiety and Depression With Hypertension Among Young Adults in the United States: A Systematic Review of Bidirectional Associations and Implications for Blood Pressure Control.PubMed
Benjamin O Akangbe, Folasade E Akinwumi, Damilola O Adekunle, et al.
Cureus. 2025 Jul 22;17(7):e88532. doi: 10.7759/cureus.88532. eCollection 2025 Jul.
Hypertension is a significant risk factor for cardiovascular diseases, while anxiety and depression are highly prevalent mental health disorders that may influence the development and management of hypertension. The bidirectional associations between these conditions remain understudied, particularly among adults in the United States. Understanding the interplay of mental health and hypertension is critical for improving clinical and public health interventions. This systematic review aims to examine the prevalence and bidirectional associations between anxiety, depression, and hypertension among US adults; identify clinical, behavioral, and sociodemographic factors influencing comorbidity; and explore implications for hypertension management. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search was conducted across multiple databases, including PsycINFO, Scopus, PubMed, Web of Science, ScienceDirect, and Google Scholar, covering literature from 2015 to 2024. Eligible studies included cross-sectional, cohort, and case-control designs focusing on US adults (≥18 years) and examining the association between anxiety, depression, and hypertension. Data extraction covered study characteristics, diagnostic criteria, statistical findings, and relevant confounders. The Newcastle-Ottawa Scale (NOS) was used for quality assessment. Eight studies met the inclusion criteria, comprising six cross-sectional and two cohort studies. Anxiety and depression were significantly associated with increased hypertension risk, with stronger effects observed among low-income populations, women, and minority groups. Cohort studies indicated that depression contributed to hypertension incidence via inflammatory and autonomic dysfunction pathways, while cross-sectional studies highlighted that hypertension itself exacerbated psychological distress, leading to a cyclical comorbid relationship. The review also found that individuals with comorbid anxiety or depression had poorer hypertension control and lower adherence to antihypertensive treatment. The findings underscore the need for integrated care approaches that address both mental health and hypertension, particularly in vulnerable populations. Routine mental health screenings should be incorporated into hypertension management strategies to improve adherence and outcomes. Future longitudinal research should explore causal mechanisms and assess intervention effectiveness in mitigating the adverse effects of comorbidity.
63Evidence-based recommendations for the assessment and management of sleep disorders in older persons.PubMed
Harrison G Bloom, Imran Ahmed, Cathy A Alessi, et al.
J Am Geriatr Soc. 2009 May;57(5):761-89. doi: 10.1111/j.1532-5415.2009.02220.x.
Sleep-related disorders are most prevalent in the older adult population. A high prevalence of medical and psychosocial comorbidities and the frequent use of multiple medications, rather than aging per se, are major reasons for this. A major concern, often underappreciated and underaddressed by clinicians, is the strong bidirectional relationship between sleep disorders and serious medical problems in older adults. Hypertension, depression, cardiovascular disease, and cerebrovascular disease are examples of diseases that are more likely to develop in individuals with sleep disorders. Conversely, individuals with any of these diseases are at a higher risk of developing sleep disorders. The goals of this article are to help guide clinicians in their general understanding of sleep problems in older persons, examine specific sleep disorders that occur in older persons, and suggest evidence- and expert-based recommendations for the assessment and treatment of sleep disorders in older persons. No such recommendations are available to help clinicians in their daily patient care practices. The four sections in the beginning of the article are titled, Background and Significance, General Review of Sleep, Recommendations Development, and General Approach to Detecting Sleep Disorders in an Ambulatory Setting. These are followed by overviews of specific sleep disorders: Insomnia, Sleep Apnea, Restless Legs Syndrome, Circadian Rhythm Sleep Disorders, Parasomnias, Hypersomnias, and Sleep Disorders in Long-Term Care Settings. Evidence- and expert- based recommendations, developed by a group of sleep and clinical experts, are presented after each sleep disorder.
64Evaluating the Bidirectional Causal Effects of Alzheimer's Disease Across Multiple Conditions: A Systematic Review and Meta-Analysis of Mendelian Randomization Studies.PubMed
Haoning Zhu, Huitong Ni, Qiuling Yang, et al.
Int J Mol Sci. 2025 Apr 10;26(8):3589. doi: 10.3390/ijms26083589.
This study systematically evaluates and meta-analyzes Mendelian randomization studies on the bidirectional causal relationship between Alzheimer's disease (AD) and systemic diseases. We searched five databases, assessed study quality, and extracted data. Diseases were classified using ICD-11, and the meta-analysis was performed with RevMan 5.4. A total of 56 studies identified genetic links between AD susceptibility and systemic diseases. Notably, genetic proxies for hip osteoarthritis (OR = 0.80; = 0.007) and rheumatoid arthritis (OR = 0.97; = 0.004) were inversely associated with AD risk, while gout (OR = 1.02; = 0.049) showed a positive association. Genetic liability to depression (OR = 1.03; = 0.001) elevated AD risk, and AD genetic risk increased susceptibility to delirium (OR = 1.32; = 0.0005). Cardiovascular traits, including coronary artery disease (OR = 1.07; = 0.021) and hypertension (OR = 4.30; = 0.044), were causally linked to a higher AD risk. Other conditions, such as insomnia, chronic periodontitis, migraine, and certain cancers, exhibited significant genetic correlations. Intriguingly, herpes zoster (OR = 0.87; = 0.005) and cataracts (OR = 0.96; = 0.012) demonstrated inverse genetic associations with AD. These findings suggest potential therapeutic targets and preventive strategies, emphasizing the need to address comorbid systemic diseases to reduce AD risk and progression.
65Boredom Proneness, Loneliness, and Smartphone Addiction Among Lebanese Young Adults: The Mediating Role of Depression, Anxiety, and Stress.PubMed
Diana Malaeb, Marwan Akel, Pascale Salameh, et al.
Prim Care Companion CNS Disord. 2022 Nov 8;24(6):21m03092. doi: 10.4088/PCC.21m03092.
To evaluate the association between boredom proneness, loneliness, and smartphone addiction among Lebanese young adults and examine the mediating role of depression, anxiety, and stress in this association. This cross-sectional study was conducted between August and September 2020 during the lockdown period of the coronavirus disease 2019 pandemic. An online survey was completed by 461 young adults aged 18 to 29 years. The results showed that 66 of 134 males (49.3%, scores ≥ 31) and 143 of 327 females (43.7%, scores ≥ 33) had smartphone addiction. Smartphone addiction was significantly associated with higher boredom proneness ( < .001), anxiety ( = .012), and loneliness ( = .025). Anxiety mediated the association between boredom proneness and smartphone addiction and between loneliness and smartphone addiction, whereas depression and stress did not mediate the association between boredom/loneliness and smartphone addiction. Smartphone addiction is highly associated with psychological disorders, and screening strategies are needed to minimize addiction. This study emphasizes the importance of investigating the relation between smartphone addiction and psychological disorders.
66The relationship between technology addictions and schizotypal traits: mediating roles of depression, anxiety, and stress.PubMed
Feten Fekih-Romdhane, Haitham Jahrami, Rami Away, et al.
BMC Psychiatry. 2023 Jan 25;23(1):67. doi: 10.1186/s12888-023-04563-9.
BACKGROUND: The way how technology addiction relates to psychosis remains inconclusive and uncertain. The present study aimed to test the hypothesis of a mediating role of depression, anxiety and stress in the association between three technology (behavioral) addictions (i.e., Addiction to the Internet, smartphones and Facebook) and psychosis proneness as estimated through schizotypal traits in emerging adults. METHODS: A cross-sectional study was performed among non-clinical Tunisian university students (67.6% females, mean age of 21.5 ± 2.5 years) using a paper-and-pencil self-administered questionnaire. RESULTS: Results for the Pearson correlation revealed that higher smartphone, Internet, and Facebook addictions' scores were significantly and positively correlated with each of the depression, anxiety and stress subscores; whereas depression (r = 0.474), anxiety (r = 0.499) and stress (r = 0.461) scores were positively correlated with higher schizotypal traits. The results of the mediation analysis found a significant mediating effect for depressive, anxiety and stress symptoms on the cross-sectional relationship between each facet of the TA and schizotypal traits. CONCLUSION: Our findings preliminarily suggest that an addictive use of smartphones, Internet and Facebook may act as a stressor that exacerbates psychosis proneness directly or indirectly through distress. Although future longitudinal research is needed to determine causality, we draw attention to the possibility that treating psychological distress may constitute an effective target of interventions to prevent psychosis in adolescents with technology addictions.
67Impact of mobile phones and wireless devices use on children and adolescents' mental health: a systematic review.PubMed
Braulio M Girela-Serrano, Alexander D V Spiers, Liu Ruotong, et al.
Eur Child Adolesc Psychiatry. 2024 Jun;33(6):1621-1651. doi: 10.1007/s00787-022-02012-8. Epub 2022 Jun 16.
Growing use of mobiles phones (MP) and other wireless devices (WD) has raised concerns about their possible effects on children and adolescents' wellbeing. Understanding whether these technologies affect children and adolescents' mental health in positive or detrimental ways has become more urgent following further increase in use since the COVID-19 outbreak. To review the empirical evidence on associations between use of MP/WD and mental health in children and adolescents. A systematic review of literature was carried out on Medline, Embase and PsycINFO for studies published prior to July 15th 2019, PROSPERO ID: CRD42019146750. 25 observational studies published between January 1st 2011 and 2019 were reviewed (ten were cohort studies, 15 were cross-sectional). Overall estimated participant mean age and proportion female were 14.6 years and 47%, respectively. Substantial between-study heterogeneity in design and measurement of MP/WD usage and mental health outcomes limited our ability to infer general conclusions. Observed effects differed depending on time and type of MP/WD usage. We found suggestive but limited evidence that greater use of MP/WD may be associated with poorer mental health in children and adolescents. Risk of bias was rated as 'high' for 16 studies, 'moderate' for five studies and 'low' for four studies. More high-quality longitudinal studies and mechanistic research are needed to clarify the role of sleep and of type of MP/WD use (e.g. social media) on mental health trajectories in children and adolescents.
68Prevalence of problematic smartphone usage and associated mental health outcomes amongst children and young people: a systematic review, meta-analysis and GRADE of the evidence.PubMed
Sei Yon Sohn, Philippa Rees, Bethany Wildridge, et al.
BMC Psychiatry. 2019 Nov 29;19(1):356. doi: 10.1186/s12888-019-2350-x.
BACKGROUND: Over the past decade, smartphone use has become widespread amongst today's children and young people (CYP) which parallels increases in poor mental health in this group. Simultaneously, media concern abounds about the existence of 'smartphone addiction' or problematic smartphone use. There has been much recent research concerning the prevalence of problematic smartphone use is in children and young people who use smartphones, and how this syndrome relates to mental health outcomes, but this has not been synthesized and critically evaluated. AIMS: To conduct a systematic review and meta-analysis to examine the prevalence of PSU and quantify the association with mental health harms. METHODS: A search strategy using Medical Subject Headings was developed and adapted for eight databases between January 1, 1st 2011 to October 15th 2017. No language restriction was applied. Of 924 studies identified, 41 were included in this review, three of which were cohort studies and 38 were cross sectional studies. The mental health outcomes were self-reported: depression; anxiety; stress; poor sleep quality; and decreased educational attainment, which were synthesized according to an a priori protocol. RESULTS: The studies included 41,871 CYP, and 55% were female. The median prevalence of PSU amongst CYP was 23.3% (14.0-31.2%). PSU was associated with an increased odds of depression (OR = 3.17;95%CI 2.30-4.37;I = 78%); increased anxiety (OR = 3.05 95%CI 2.64-3.53;I = 0%); higher perceived stress (OR = 1.86;95%CI 1.24-2.77;I = 65%); and poorer sleep quality (OR = 2.60; 95%CI; 1.39-4.85, I = 78%). CONCLUSIONS: PSU was reported in approximately one in every four CYP and accompanied by an increased odds of poorer mental health. PSU is an evolving public health concern that requires greater study to determine the boundary between helpful and harmful technology use. Policy guidance is needed to outline harm reduction strategies.
69Metacognition mediates the relationship between anxiety and smartphone addiction in university students.PubMed
Ziya Hua, Yan Ji, Xiuna Han
Sci Rep. 2025 Sep 29;15(1):33348. doi: 10.1038/s41598-025-14799-y.
This study aims to explore the influencing factors of smartphone addiction among university students and further examine the mediating role of metacognition in the relationship between anxiety elements and smartphone addiction. Researchers conducted a structured questionnaire survey on 736 university students from three universities(Hunan University of Science and Technology, Anhui University of Finance & Economics, and Hunan Normal University), measuring their self-reported responses on six constructs: academic anxiety, social anxiety, future anxiety, positive metacognition, negative metacognition, and smartphone addiction. The study interpreted the non-compensatory and non-linear relationships between predictors and smartphone addiction by applying the Structural Equation Modeling - Artificial Neural Network (SEM-ANN) method. The findings revealed that academic anxiety had no significant impact on smartphone addiction, nor did social and future anxiety on positive metacognition and social anxiety on negative metacognition. Furthermore, positive metacognition did not play a mediating role between anxiety and smartphone addiction, nor did negative metacognition between social anxiety and smartphone addiction. The remaining hypotheses were validated. Additionally, according to the normalized importance derived from the multilayer perceptron, the study identified the most critical predictive factor as negative metacognition (100%), followed by future anxiety (49.19%), social anxiety (29.52%), positive metacognition (16.51%), and academic anxiety (10.73%). Lastly, the study presents theoretical and practical implications regarding smartphone addiction among university students.
70The relationship between sleep quality, depression, and smartphone addiction in pregnant women: a mediation analysis.PubMed
Sibel Kiyak, Serap Batı
Women Health. 2024 Nov-Dec;64(10):839-847. doi: 10.1080/03630242.2024.2420215. Epub 2024 Oct 27.
In recent years, the prevalence of smartphone addiction has significantly increased. This situation has raised concerns about its potential impact on health aspects, such as sleep quality and mental health, particularly among vulnerable populations like pregnant women. This study aimed to identify the factors that determine sleep quality in pregnant women and examine the relationship between smartphone addiction, depression, and sleep quality. This descriptive correlational study included 257 pregnant women in their second and third trimesters who were registered at six family health centers between September 2022 and March 2023. Data were collected using a sociodemographic questionnaire, the Smartphone Addiction Scale Short Form, Edinburgh Postnatal Depression Scale, and Pittsburgh Sleep Quality Index. Regression and mediation analyses were performed for the data. Of the participants, 44.4 percent had poor sleep quality. Depression and third trimester were significant determinants of sleep quality. The bootstrapping results revealed that smartphone addiction led to an increase in the level of depression (β = 0.145; < .001). Depression worsened sleep quality (β = 0.262; < .001). The smartphone addiction did not significantly affect sleep quality (β = 0.020; = .279). Depression mediates the relationship between sleep quality and smartphone addiction (β = 0.038; 95 percent CI [0.018: 0.062]). The study highlights that while smartphone addiction does not directly impact sleep quality in pregnant women, it is associated with increased depression levels, which subsequently worsen sleep quality. It is recommended that healthcare providers monitor smartphone usage and mental health in pregnant women to mitigate the risk of sleep disturbances and improve overall well-being.
71Parental Phubbing and Adolescent Smartphone Addiction: Depression and Perceived School Climate Matter.PubMed
Yuan Tang, Jingyi Xu, Yunxin Zhao, et al.
Cyberpsychol Behav Soc Netw. 2024 Apr;27(4):287-293. doi: 10.1089/cyber.2023.0300. Epub 2024 Feb 26.
This study investigated the association between parental phubbing and adolescents' smartphone addiction, the mediating role of depression, and the moderating role of perceived school climate in the association. Seven hundred forty-two Chinese adolescents ( = 12.97, = 0.64, 45.55 percent female) were recruited and self-reported questionnaires were administered. Results indicated that parental phubbing was positively associated with adolescents' smartphone addiction. Depression partially mediated the above relation. Further, perceived school climate moderated the relation between parental phubbing and depression, such that the positive association between parental phubbing and depression was stronger among adolescents who perceived their school climate as more negative (vs. positive). The findings deepened our understanding of the relation between parenting behaviors and adolescents' smartphone addiction and implications for interventions and practices were discussed.
72Addictive Screen Use Trajectories and Suicidal Behaviors, Suicidal Ideation, and Mental Health in US Youths.PubMed
Yunyu Xiao, Yuan Meng, Timothy T Brown, et al.
JAMA. 2025 Jul 15;334(3):219-228. doi: 10.1001/jama.2025.7829.
IMPORTANCE: Increasing child and adolescent use of social media, video games, and mobile phones has raised concerns about potential links to youth mental health problems. Prior research has largely focused on total screen time rather than longitudinal addictive use trajectories. OBJECTIVES: To identify trajectories of addictive use of social media, mobile phones, and video games and to examine their associations with suicidal behaviors and ideation and mental health outcomes among youths. DESIGN, SETTING, AND PARTICIPANTS: Cohort study analyzing data from baseline through year 4 follow-up in the Adolescent Brain Cognitive Development Study (2016-2022), with population-based samples from 21 US sites. EXPOSURES: Addictive use of social media, mobile phones, and video games using validated child-reported measures from year 2, year 3, and year 4 follow-up surveys. MAIN OUTCOMES AND MEASURES: Suicidal behaviors and ideation assessed using child- and parent-reported information via the Kiddie Schedule for Affective Disorders and Schizophrenia. Internalizing and externalizing symptoms were assessed using the parent-reported Child Behavior Checklist. RESULTS: The analytic sample (n = 4285) had a mean age of 10.0 (SD, 0.6) years; 47.9% were female; and 9.9% were Black, 19.4% Hispanic, and 58.7% White. Latent class linear mixed models identified 3 addictive use trajectories for social media and mobile phones and 2 for video games. Nearly one-third of participants had an increasing addictive use trajectory for social media or mobile phones beginning at age 11 years. In adjusted models, increasing addictive use trajectories were associated with higher risks of suicide-related outcomes than low addictive use trajectories (eg, increasing addictive use of social media had a risk ratio of 2.14 [95% CI, 1.61-2.85] for suicidal behaviors). High addictive use trajectories for all screen types were associated with suicide-related outcomes (eg, high-peaking addictive use of social media had a risk ratio of 2.39 [95% CI, 1.66-3.43] for suicidal behaviors). The high video game addictive use trajectory showed the largest relative difference in internalizing symptoms (T score difference, 2.03 [95% CI, 1.45-2.61]), and the increasing social media addictive use trajectory for externalizing symptoms (T score difference, 1.05 [95% CI, 0.54-1.56]), compared with low addictive use trajectories. Total screen time at baseline was not associated with outcomes. CONCLUSIONS AND RELEVANCE: High or increasing trajectories of addictive use of social media, mobile phones, or video games were common in early adolescents. Both high and increasing addictive screen use trajectories were associated with suicidal behaviors and ideation and worse mental health.
73Associations Among Sleep, Emotional Eating, and Body Dissatisfaction in Adolescents.PubMed
Megan L White, Olivia M Triplett, Nuria Morales, et al.
Child Psychiatry Hum Dev. 2024 Apr 5. doi: 10.1007/s10578-024-01692-4.
The literature on adolescent sleep has shown a bidirectional relationship between sleep difficulties and altered eating habits, including emotional eating. However, it is unclear if this relationship is related to preexisting body concerns, or if poor sleep is the prime contributor to emotional eating patterns. This study therefore seeks to examine body dissatisfaction as a moderator of the sleep-emotional eating relationship in an at-risk sample. Adolescents (N = 106) presenting for overnight polysomnography self-reported on time-in-bed, insomnia, body dissatisfaction, and emotional eating. Less time-in-bed was correlated with a greater desire for thinness and greater insomnia severity was related to overall emotional eating and eating in response to anxiety, anger, and frustration and in response to depression. Moderation analyses revealed that the relationships between time-in-bed and eating in response to feeling unsettled (b = -.002, 95% CI[- .003, - .001], p < .005) and eating in response to anxiety, anger, and frustration (b = -.01, 95% CI[- .01, - .001], p < .05) were exacerbated by worse body dissatisfaction. Optimizing sleep may attenuate the risk for disordered eating, particularly for adolescents with high body dissatisfaction.
74Possible pathways between depression, emotional and external eating. A structural equation model.PubMed
Machteld A Ouwens, Tatjana van Strien, Jan F J van Leeuwe
Appetite. 2009 Oct;53(2):245-8. doi: 10.1016/j.appet.2009.06.001. Epub 2009 Jun 6.
Emotional and external eating appear to co-occur and both have been shown to correlate to neuroticism, especially depression. However, there is evidence suggesting that emotional and external eating are independent constructs. In this study we revisited the relation between depression, emotional, and external eating. Using structural equation modelling, we examined whether depression, emotional and external eating are directly related and also indirectly related through the intervening concepts alexithymia and impulsivity. Participants were 549 females concerned about their weight. They filled out instruments on emotional and external eating, depression, alexithymia, and impulse regulation. The relational structure between the model variables was explored for one half of the participants and this solution was checked using the other half. Our data showed a moderate relationship between emotional and external eating. Depression was positively and directly associated with emotional eating, but not with external eating. In addition, depression was indirectly related to emotional eating through both alexithymia and impulsivity. A significant relation was found between impulsivity and external eating. Results suggest potential mediating pathways between depression and emotional eating, while no relation appeared to exist between depression and external eating. Emotional and external eating would appear to be different constructs.
75Association between depression and eating behaviors among bariatric surgery candidates in a Turkish sample.PubMed
Güzin M Sevinçer, Numan Konuk, Derya İpekçioğlu, et al.
Eat Weight Disord. 2017 Mar;22(1):117-123. doi: 10.1007/s40519-016-0296-2. Epub 2016 Jun 24.
PURPOSE: The purpose of this study was to explore further whether depression is associated with problematic eating behaviors in a sample of Turkish bariatric surgery candidates. METHODS: This descriptive study included 168 consecutively seen bariatric surgery candidates in a university bariatric surgery outpatient. Participants were asked to complete the Dutch Eating Behavior Questionnaire (DEBQ), the Beck Depression Inventory (BDI) and surveys assessing sociodemographic and clinical variables. Correlations and linear regression analyses were performed to evaluate the relationship between clinical and demographic variables. RESULTS: Participants had a mean age 37.7 ± 11.3 years and BMI of 46.4 ± 6.7 kg/m (SD = 6.7). According to BDI scores, 75.5 % of the patients had mild, moderate, or severe depressive symptomatology. Lower levels of depressive symptoms were associated with higher levels of restrictive eating (r = -0.17; p = 0.04), whereas higher levels of depressive symptoms were associated with more frequent eating in response to both internal (r = 0.3; p = 0.002) and external (r = 0.2; p = 0.04) cues. The BDI scores were significantly associated with increased external eating (ß = 0.03, p < 0.02) and emotional eating (ß = 0.03, p < 0.002) scores. BMI (β = -0.02, p = 0.02 > 0.1) was not associated with DEBQ total scores. CONCLUSIONS: This research suggests that mild, moderate or severe depressive symptoms are observed in most of the bariatric surgical candidate patients. There is a positive correlation between severity of depression and emotional/external eating behaviors, and a negative correlation between severity of depression and restrictive eating behavior. Additional research is needed to determine whether treating depression preoperatively can assist with alleviating problematic eating behaviors.
76Reflecting on rumination: Consequences, causes, mechanisms and treatment of rumination.PubMed
Edward R Watkins, Henrietta Roberts
Behav Res Ther. 2020 Apr;127:103573. doi: 10.1016/j.brat.2020.103573. Epub 2020 Jan 31.
We review research showing that rumination has multiple negative consequences: (a) exacerbating psychopathology by magnifying and prolonging negative mood states, interfering with problem-solving and instrumental behaviour and reducing sensitivity to changing contingencies; (b) acting as a transdiagnostic mental health vulnerability impacting anxiety, depression, psychosis, insomnia, and impulsive behaviours; (c) interfering with therapy and limiting the efficacy of psychological interventions; (d) exacerbating and maintaining physiological stress responses. The mechanisms underlying rumination are examined, and a model (H-EX-A-GO-N - Habit development, EXecutive control, Abstract processing, GOal discrepancies, Negative bias) is proposed to account for the onset and maintenance of rumination. H-EX-A-GO-N outlines how rumination results from dwelling on problematic goals developing into a learnt habit that involves the tendency to process negative information in an abstract way, particularly in the context of poor executive control and negative information-processing biases. These proximal factors integrate experimental evidence to provide a partial answer to the critical question of what maintains rumination. They constitute a pathway by which more distal biological and environmental factors increase the likelihood of rumination developing. Treatments for rumination are reviewed, with preliminary trials suggesting that psychological interventions designed to specifically target these mechanisms may be effective at reducing rumination.
77[Depressed, biased, forgetful: The interaction of emotional and cognitive dysfunctions in depression].PubMed
Lorenz B Dehn, Thomas Beblo
Neuropsychiatr. 2019 Sep;33(3):123-130. doi: 10.1007/s40211-019-0307-4. Epub 2019 Mar 14.
Major depressive disorder is characterized by changes in the emotional state, e. g. the diminished experience of positive emotions, as well as cognitive impairments such as concentration and memory difficulties. These emotional and cognitive dysfunctions are closely interrelated and play a key role for the development and maintenance of depressive symptoms. For instance, patients with depression show negatively biased information processing that affects attention and memory as well as their reaction to feedback. In addition, there is an increased motivation to avoid negatively evaluated conditions and at the same time a reduced motivation to approach positive goals. Furthermore, depressed patients often show a specific style of thinking, called rumination, which involves repeated, intensive thinking about the causes, consequences and symptoms of one's own negative feelings. In this review, the different relationships between emotional, motivational and cognitive symptoms of depressive patients will be presented and the influence of their interaction on cognitive performance will be discussed. The highlighted clinical relevance of emotional-cognitive dysfunctions should be considered more often in therapeutic interventions for depressed patients.
78The role of emotion dysregulation and rumination in predicting premenstrual symptom severity in premenstrual disorders and elevated anxiety or depression.PubMed
Anagha M Kaluve, Bronwyn M Graham
J Affect Disord. 2025 Nov 15;389:119705. doi: 10.1016/j.jad.2025.119705. Epub 2025 Jun 18.
Premenstrual Dysphoric Disorder (PMDD) and Premenstrual Syndrome (PMS) are prevalent and cause significant distress, yet their psychological mechanisms remain poorly understood. Previous research has linked emotion dysregulation with premenstrual symptoms, but it has often relied on retrospective self-reports, which are prone to bias, and rarely compared PMDD with the milder PMS. Additionally, past studies have not differentiated the heightened emotion dysregulation seen in PMDD from that typically observed in other affective conditions. To address these gaps, we examined the association between emotion dysregulation and premenstrual symptoms in a sample of menstruating individuals meeting criteria for provisional PMDD (N = 39), PMS (N = 160), elevated depression or anxiety (DEPANX; N = 88), and controls (N = 172). All participants completed questionnaires on premenstrual symptom severity and trait global emotion dysregulation, rumination, reappraisal, and suppression. A subset of participants completed a sad mood induction task (PMDD/PMS combined: N = 104; DEPANX: N = 54; Control: N = 161) and reported in vivo use of emotion regulation strategies. Compared to controls, all groups reported greater in vivo and trait rumination, higher trait emotion dysregulation, and lower trait reappraisal. The PMDD group endorsed greater rumination and emotion dysregulation than both the PMS and DEPANX groups. Greater trait emotion dysregulation and rumination predicted higher premenstrual symptom severity across groups. Rumination was the strongest predictor of premenstrual symptom severity between groups, compared to other emotion dysregulation measures. These findings raise the possibility that emotion dysregulation, particularly rumination, plays a role in the aetiology and/or maintenance of impairing premenstrual symptoms, although longitudinal research is needed to further explore these relationships.
79Examining the relationship between subtypes of rumination and non-suicidal self-injury: A meta-analytic review.PubMed
Joey C Cheung, Kristen M Sorgi-Wilson, Nicole K Ciesinski, et al.
Suicide Life Threat Behav. 2024 Jun;54(3):528-555. doi: 10.1111/sltb.13051. Epub 2024 Feb 27.
INTRODUCTION: Non-suicidal self-injury (NSSI) is a highly prevalent maladaptive behavior, often used to cope with intense negative affect. Rumination is an emotion regulation strategy that leads to fixation on and exacerbation of (typically) negative affective states. However, studies examining the relationship between rumination and NSSI have yielded mixed results, showing high degrees of heterogeneity. METHODS: The present study conducted meta-analyses (k = 50) of the association between overall rumination and NSSI, and independent meta-analyses for each of four subtypes of rumination (general, depressive, brooding, reflection rumination). Potential moderators that may influence the magnitude of these relationships were also examined. RESULTS: A small-to-moderate positive association between rumination and NSSI was found independent of rumination subtype. Moderating effects included NSSI outcome measure and study design for overall rumination and general rumination, respectively. Race was found to moderate the relationships between both brooding and depressive rumination and NSSI, though in inverse directions. An analysis of effect heterogeneity across studies suggested that undetected moderators may be present. CONCLUSION: Results of this study support the relationships between rumination subtypes and NSSI and identify factors that may impact these relationships. Continued research is needed to understand this association, particularly in more varied subtypes of rumination and cognitive-affective moderators.
80Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010.PubMed
Harvey A Whiteford, Louisa Degenhardt, Jürgen Rehm, et al.
Lancet. 2013 Nov 9;382(9904):1575-86. doi: 10.1016/S0140-6736(13)61611-6. Epub 2013 Aug 29.
BACKGROUND: We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) to estimate the burden of disease attributable to mental and substance use disorders in terms of disability-adjusted life years (DALYs), years of life lost to premature mortality (YLLs), and years lived with disability (YLDs). METHODS: For each of the 20 mental and substance use disorders included in GBD 2010, we systematically reviewed epidemiological data and used a Bayesian meta-regression tool, DisMod-MR, to model prevalence by age, sex, country, region, and year. We obtained disability weights from representative community surveys and an internet-based survey to calculate YLDs. We calculated premature mortality as YLLs from cause of death estimates for 1980-2010 for 20 age groups, both sexes, and 187 countries. We derived DALYs from the sum of YLDs and YLLs. We adjusted burden estimates for comorbidity and present them with 95% uncertainty intervals. FINDINGS: In 2010, mental and substance use disorders accounted for 183·9 million DALYs (95% UI 153·5 million-216·7 million), or 7·4% (6·2-8·6) of all DALYs worldwide. Such disorders accounted for 8·6 million YLLs (6·5 million-12·1 million; 0·5% [0·4-0·7] of all YLLs) and 175·3 million YLDs (144·5 million-207·8 million; 22·9% [18·6-27·2] of all YLDs). Mental and substance use disorders were the leading cause of YLDs worldwide. Depressive disorders accounted for 40·5% (31·7-49·2) of DALYs caused by mental and substance use disorders, with anxiety disorders accounting for 14·6% (11·2-18·4), illicit drug use disorders for 10·9% (8·9-13·2), alcohol use disorders for 9·6% (7·7-11·8), schizophrenia for 7·4% (5·0-9·8), bipolar disorder for 7·0% (4·4-10·3), pervasive developmental disorders for 4·2% (3·2-5·3), childhood behavioural disorders for 3·4% (2·2-4·7), and eating disorders for 1·2% (0·9-1·5). DALYs varied by age and sex, with the highest proportion of total DALYs occurring in people aged 10-29 years. The burden of mental and substance use disorders increased by 37·6% between 1990 and 2010, which for most disorders was driven by population growth and ageing. INTERPRETATION: Despite the apparently small contribution of YLLs--with deaths in people with mental disorders coded to the physical cause of death and suicide coded to the category of injuries under self-harm--our findings show the striking and growing challenge that these disorders pose for health systems in developed and developing regions. In view of the magnitude of their contribution, improvement in population health is only possible if countries make the prevention and treatment of mental and substance use disorders a public health priority. FUNDING: Queensland Department of Health, National Health and Medical Research Council of Australia, National Drug and Alcohol Research Centre-University of New South Wales, Bill & Melinda Gates Foundation, University of Toronto, Technische Universität, Ontario Ministry of Health and Long Term Care, and the US National Institute of Alcohol Abuse and Alcoholism.
81Global, Regional, and National Epidemiology of Depression in Working-Age Individuals, 1990-2019.PubMed
Jin-Shuai Yang, Lu-Yu Zhang, Cheng-Hao Yang, et al.
Depress Anxiety. 2024 Aug 24;2024:4747449. doi: 10.1155/2024/4747449. eCollection 2024.
BACKGROUND: Depression is a disorder that can have a serious impact on functioning and quality of life. Understanding the global, regional, and national epidemiology of depression in working-age populations (15-49 years) is important for informing mental health policies and services. However, up-to-date data have been lacking, especially in developing regions. METHODS: This study delved into the prevalence of depression among individuals in the working-age group, specifically those between 15 and 49 years, by analyzing data from the 2019 Global Burden of Disease, Injuries, and Risk Factors Study (GBD). The comprehensive analysis aimed to determine the age-standardized prevalence, incidence, and disability-adjusted life years (DALYs) associated with depression across diverse groups. It considered factors such as geographical regions, age brackets, genders, and sociodemographic indices, spanning a time frame from 1990 to 2019. RESULTS: Globally, the estimated prevalent cases, incident cases, and DALYs for depression increased from 1990 to 2019. Regionally, certain regions like Central Latin America saw rapid increases in age-standardized prevalence and incidence rates over time. By sociodemographic regions, all tiers witnessed rises in incident cases, with high sociodemographic index (SDI) areas having the greatest burden in 2019. Nationally, countries such as India, China, and the United States had the highest total prevalence and incidence in 2019, while nations like Yemen and Angola reported exceptionally high age-standardized rates (ASRs). Peak prevalence risk occurred in the mid-to-late 40s age range. Period effects showed declining risks over time. Earlier birth cohorts, especially before the mid-1960s, faced higher risks than more recent generations. Population growth rather than epidemiological changes appeared to drive increases in disease burden. CONCLUSION: From 1990 to 2019, the overall trend of depression burden in working-age individuals presents regional and national variations and differs by age, sex, period, and cohort.
82Global, regional, and national burden of disorders affecting the nervous system, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021.PubMed
Lancet Neurol. 2024 Apr;23(4):344-381. doi: 10.1016/S1474-4422(24)00038-3. Epub 2024 Mar 14.
BACKGROUND: Disorders affecting the nervous system are diverse and include neurodevelopmental disorders, late-life neurodegeneration, and newly emergent conditions, such as cognitive impairment following COVID-19. Previous publications from the Global Burden of Disease, Injuries, and Risk Factor Study estimated the burden of 15 neurological conditions in 2015 and 2016, but these analyses did not include neurodevelopmental disorders, as defined by the International Classification of Diseases (ICD)-11, or a subset of cases of congenital, neonatal, and infectious conditions that cause neurological damage. Here, we estimate nervous system health loss caused by 37 unique conditions and their associated risk factors globally, regionally, and nationally from 1990 to 2021. METHODS: We estimated mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), with corresponding 95% uncertainty intervals (UIs), by age and sex in 204 countries and territories, from 1990 to 2021. We included morbidity and deaths due to neurological conditions, for which health loss is directly due to damage to the CNS or peripheral nervous system. We also isolated neurological health loss from conditions for which nervous system morbidity is a consequence, but not the primary feature, including a subset of congenital conditions (ie, chromosomal anomalies and congenital birth defects), neonatal conditions (ie, jaundice, preterm birth, and sepsis), infectious diseases (ie, COVID-19, cystic echinococcosis, malaria, syphilis, and Zika virus disease), and diabetic neuropathy. By conducting a sequela-level analysis of the health outcomes for these conditions, only cases where nervous system damage occurred were included, and YLDs were recalculated to isolate the non-fatal burden directly attributable to nervous system health loss. A comorbidity correction was used to calculate total prevalence of all conditions that affect the nervous system combined. FINDINGS: Globally, the 37 conditions affecting the nervous system were collectively ranked as the leading group cause of DALYs in 2021 (443 million, 95% UI 378-521), affecting 3·40 billion (3·20-3·62) individuals (43·1%, 40·5-45·9 of the global population); global DALY counts attributed to these conditions increased by 18·2% (8·7-26·7) between 1990 and 2021. Age-standardised rates of deaths per 100 000 people attributed to these conditions decreased from 1990 to 2021 by 33·6% (27·6-38·8), and age-standardised rates of DALYs attributed to these conditions decreased by 27·0% (21·5-32·4). Age-standardised prevalence was almost stable, with a change of 1·5% (0·7-2·4). The ten conditions with the highest age-standardised DALYs in 2021 were stroke, neonatal encephalopathy, migraine, Alzheimer's disease and other dementias, diabetic neuropathy, meningitis, epilepsy, neurological complications due to preterm birth, autism spectrum disorder, and nervous system cancer. INTERPRETATION: As the leading cause of overall disease burden in the world, with increasing global DALY counts, effective prevention, treatment, and rehabilitation strategies for disorders affecting the nervous system are needed. FUNDING: Bill & Melinda Gates Foundation.
83No health without mental health.PubMed
Martin Prince, Vikram Patel, Shekhar Saxena, et al.
Lancet. 2007 Sep 8;370(9590):859-77. doi: 10.1016/S0140-6736(07)61238-0.
About 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders, and psychoses. Such estimates have drawn attention to the importance of mental disorders for public health. However, because they stress the separate contributions of mental and physical disorders to disability and mortality, they might have entrenched the alienation of mental health from mainstream efforts to improve health and reduce poverty. The burden of mental disorders is likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions. Because these interactions are protean, there can be no health without mental health. Mental disorders increase risk for communicable and non-communicable diseases, and contribute to unintentional and intentional injury. Conversely, many health conditions increase the risk for mental disorder, and comorbidity complicates help-seeking, diagnosis, and treatment, and influences prognosis. Health services are not provided equitably to people with mental disorders, and the quality of care for both mental and physical health conditions for these people could be improved. We need to develop and evaluate psychosocial interventions that can be integrated into management of communicable and non-communicable diseases. Health-care systems should be strengthened to improve delivery of mental health care, by focusing on existing programmes and activities, such as those which address the prevention and treatment of HIV, tuberculosis, and malaria; gender-based violence; antenatal care; integrated management of childhood illnesses and child nutrition; and innovative management of chronic disease. An explicit mental health budget might need to be allocated for such activities. Mental health affects progress towards the achievement of several Millennium Development Goals, such as promotion of gender equality and empowerment of women, reduction of child mortality, improvement of maternal health, and reversal of the spread of HIV/AIDS. Mental health awareness needs to be integrated into all aspects of health and social policy, health-system planning, and delivery of primary and secondary general health care.
84Prevalence of depression and anxiety and correlations between depression, anxiety, family functioning, social support and coping styles among Chinese medical students.PubMed
Ruyue Shao, Ping He, Bin Ling, et al.
BMC Psychol. 2020 Apr 22;8(1):38. doi: 10.1186/s40359-020-00402-8.
BACKGROUND: Medical students experience depression and anxiety at a higher rate than the general population or students from other specialties. While there is a growing literature on the high prevalence of depression and anxiety symptoms and about potential risk factors to the prevalence of depression and anxiety symptoms among medical students, there is a paucity of evidence focused on the prevalence of depression and anxiety symptoms and associations with family function, social support and coping styles in Chinese vocational medicine students. This study aims to investigate the prevalence of depression and anxiety symptoms among Chinese medical students and assess the correlation between depression/anxiety symptoms and family function, social support and coping styles. METHODS: A sample of 2057 medical students from Chongqing Medical and Pharmaceutical College in China was investigated with a self-report questionnaire, which included demographic information, Zung self-rating depression scale, Zung Self-Rating Anxiety Scale, Family APGAR Index, Social Support Rating Scale and Trait Coping Style Questionnaire. RESULTS: The prevalence of depression and anxiety symptoms among the medical students was 57.5 and 30.8%, respectively. Older students(≥20 years) experienced higher levels of depression and anxiety. More depression and anxiety symptoms were exhibited among students with big financial burden, big study-induced stress and poor sleep quality. Students with large employment pressure showed more anxiety symptoms. Students who live alone or had bad relationship with their lovers or classmates or friends showed higher depression and anxiety scores. Depression and anxiety symptoms had highly significant correlations with family functioning, social support and coping style. CONCLUSIONS: Academic staffs should take measures to reduce depression and anxiety among medical students and to provide educational counseling and psychological support for students to cope with these problems.
85Burden of depressive disorders by country, sex, age, and year: findings from the global burden of disease study 2010.PubMed
Alize J Ferrari, Fiona J Charlson, Rosana E Norman, et al.
PLoS Med. 2013 Nov;10(11):e1001547. doi: 10.1371/journal.pmed.1001547. Epub 2013 Nov 5.
BACKGROUND: Depressive disorders were a leading cause of burden in the Global Burden of Disease (GBD) 1990 and 2000 studies. Here, we analyze the burden of depressive disorders in GBD 2010 and present severity proportions, burden by country, region, age, sex, and year, as well as burden of depressive disorders as a risk factor for suicide and ischemic heart disease. METHODS AND FINDINGS: Burden was calculated for major depressive disorder (MDD) and dysthymia. A systematic review of epidemiological data was conducted. The data were pooled using a Bayesian meta-regression. Disability weights from population survey data quantified the severity of health loss from depressive disorders. These weights were used to calculate years lived with disability (YLDs) and disability adjusted life years (DALYs). Separate DALYs were estimated for suicide and ischemic heart disease attributable to depressive disorders. Depressive disorders were the second leading cause of YLDs in 2010. MDD accounted for 8.2% (5.9%-10.8%) of global YLDs and dysthymia for 1.4% (0.9%-2.0%). Depressive disorders were a leading cause of DALYs even though no mortality was attributed to them as the underlying cause. MDD accounted for 2.5% (1.9%-3.2%) of global DALYs and dysthymia for 0.5% (0.3%-0.6%). There was more regional variation in burden for MDD than for dysthymia; with higher estimates in females, and adults of working age. Whilst burden increased by 37.5% between 1990 and 2010, this was due to population growth and ageing. MDD explained 16 million suicide DALYs and almost 4 million ischemic heart disease DALYs. This attributable burden would increase the overall burden of depressive disorders from 3.0% (2.2%-3.8%) to 3.8% (3.0%-4.7%) of global DALYs. CONCLUSIONS: GBD 2010 identified depressive disorders as a leading cause of burden. MDD was also a contributor of burden allocated to suicide and ischemic heart disease. These findings emphasize the importance of including depressive disorders as a public-health priority and implementing cost-effective interventions to reduce its burden. Please see later in the article for the Editors' Summary.
86The Spanish Burden of Disease 2010: Neurological, mental and substance use disorders.PubMed
Elvira Lara, Noé Garin, Alize J Ferrari, et al.
Rev Psiquiatr Salud Ment. 2015 Oct-Dec;8(4):207-17. doi: 10.1016/j.rpsm.2014.09.001. Epub 2014 Nov 27.
INTRODUCTION: We used data from the Global Burden of Disease, Injuries, and Risk Factors Study 2010 to report on the burden of neuropsychiatric disorders in Spain. MATERIALS AND METHODS: The summary measure of burden used in the study was the disability-adjusted life-year (DALY), which sums of the years of life lost due to premature mortality (YLLs) and the years lived with disability (YLDs). DALYs were adjusted for comorbidity and estimated with 95% uncertainty intervals. RESULTS: The burden of neuropsychiatric disorders accounted for 18.4% of total all-cause DALYs generated in Spain for 2010. Within this group, the top five leading causes of DALYs were: depressive disorders, Alzheimer's disease, migraine, substance-use disorders, and anxiety disorder, which accounted for 70.9% of all DALYs due to neuropsychiatric disorders. Neurological disorders represented 5.03% of total all cause YLLs, whereas mental and substance-use disorders accounted for 0.8%. Mental and substance-use disorders accounted for 22.4% of total YLDs, with depression being the most disabling disorder. Neurological disorders represented 8.3% of total YLDs. CONCLUSIONS: Neuropsychiatric disorders were one of the leading causes of disability in 2010. This finding contributes to our understanding of the burden of neuropsychiatric disorders in the Spanish population and highlights the importance of prioritising neuropsychiatric disorders in the Spanish public health system.
87Impact of depression on work productivity and its improvement after outpatient treatment with antidepressants.PubMed
Jong-Min Woo, Won Kim, Tae-Yeon Hwang, et al.
Value Health. 2011 Jun;14(4):475-82. doi: 10.1016/j.jval.2010.11.006. Epub 2011 Apr 22.
OBJECTIVE: Depressive disorders influence socioeconomic burden at both the individual and organizational levels. This study estimates the lost productive time (LPT) and its resulting cost among workers with major depressive disorder (MDD) compared with a comparison group. It also estimates the change in productivity after 8 weeks of outpatient psychiatric treatment with antidepressants. METHODS: Working patients diagnosed with MDD without other major physical or mental disorders were recruited (n = 102), along with age- and sex-matched healthy controls from the Seoul Metropolitan area (n = 91). The World Health Organization's Health and Work Performance Questionnaire and the Hamilton Rating Scale for Depression were utilized to measure productivity and severity of depression, respectively, at baseline and at 8 weeks of treatment. RESULTS: The LPT from absenteeism and presenteeism (reduced performance while present at work) was significantly higher among the MDD group. Workers with MDD averaged costs due to LPT at 33.4% of their average annual salary, whereas the comparison group averaged costs of 2.5% of annual salary. After 8 weeks of treatment, absenteeism and clinical symptoms of depression were significantly reduced and associated with significant improvement in self-rated job performance (31.8%) or cost savings of $7508 per employee per year. CONCLUSIONS: We confirmed that significant productivity loss arises from MDD and that this loss can be reduced with psychiatric intervention after a time period as short as 8 weeks. Mental health professionals should work with employers to devise a cost-effective system to provide workers with accessible quality care.
88The Cost of Depression-Related Presenteeism in Resident Physicians.PubMed
Tracey Rosen, Kara Zivin, Daniel Eisenberg, et al.
Acad Psychiatry. 2018 Feb;42(1):84-87. doi: 10.1007/s40596-017-0867-1. Epub 2017 Dec 18.
OBJECTIVE: The authors aimed to assess the level of presenteeism, defined as a worker being present but not functioning at full capacity, related to depression among interns and determine the associated economic cost. METHODS: Interns from 55 universities nationwide received an invitation to participate in a prospective longitudinal study. The authors assessed participants’ depressive symptoms before residency and at 12 months using the nine-item Patient Health Questionnaire (PHQ-9). They assessed performance associated with presenteeism at 12 months of residency using the Health and Work Performance Questionnaire. RESULTS: The study enrolled 3127 interns. Mean PHQ score increased significantly from 2.74 before residency to 5.33 at 12 months of residency (p=0.26, p<0.001). A PHQ score of 10 or above correlated significantly with presenteeism during residency (p=-1.00, p<0.0001). Mean performance levels decreased (i.e., presenteeism increased) as depression severity levels increased from minimal depression (74.8%) to mild (68.9%), moderate (64.8%), moderately severe (59.8%) and severe depression (56.3%). If depression severity levels were unchanged from baseline, the mean presenteeism would have been 3.5% lower during residency. With the annual productivity of residents estimated to have a value of $296,000, a 3.5% increase in productivity value would result in a $1.2 billion gain across all resident physicians practicing each year. CONCLUSIONS: The economic cost of presenteeism associated with depression caused by residency is substantial. As residency programs, institutions, and accrediting agencies weigh the costs and benefits of interventions and system changes to reduce depression in residency, they should consider the hidden productivity cost of depression.
89Promoting health and productivity for depressed patients in the workplace.PubMed
Sean Sullivan
J Manag Care Pharm. 2005 Apr;11(3 Suppl):S12-5. doi: 10.18553/jmcp.2005.11.3.S12.
OBJECTIVE: To discuss the impact of major disease states, including depression, in the loss of productivity in the workplace and how integration of health care can decrease cost to employers. SUMMARY: The majority of costs associated with depressive illness can be traced to lost productivity, and the employer, therefore, bears most of the economic burden. Efforts to improve employee health and productivity have been hampered by the compartmentalization of medical costs, pharmacy costs, behavioral health costs, and productivity measures. This situation can be rectified by "busting" these silos and promoting a reintegration of prospective costs and parties. Health risk assessments enable employers to identify illnesses that are suitable targets for integrated health and productivity management programs. In the case of depression, employers can act proactively to identify employees at risk, working to minimize risk factors such as stress before these individuals become heavy utilizers of company resources. For employees who are currently depressed, recent research evidence has demonstrated that pharmacotherapy can have a dramatic and positive effect on lost productivity, absenteeism, and presenteeism. The selection of antidepressants and subsequent follow-up must be improved, however, if the benefits of pharmacotherapy are to be optimized. CONCLUSION: Understanding the linkage of disease management and productivity in the workplace can result in dramatic decreases in absenteeism and presenteeism and increased cost savings to the employers.
90The prevalence and economic burden of treatment-resistant depression in Thailand.PubMed
Jirada Prasartpornsirichoke, Nuttorn Pityaratstian, Chayanit Poolvoralaks, et al.
BMC Public Health. 2023 Aug 12;23(1):1541. doi: 10.1186/s12889-023-16477-y.
BACKGROUND: The objectives of this study were to investigate the proportion of treatment-resistant depression (TRD) among patients with diagnosed major depressive disorder (MDD) and undergoing antidepressant treatment, to estimate the economic cost of MDD, TRD, and non-treatment-resistant depression (non-TRD), and to examine the differences between TRD and non-TRD MDD in a Thai public tertiary hospital. METHODS: This was a combined study between retrospective review of medical records and a cross-sectional survey. The sample size was 500 dyads of antidepressant-treated MDD patients and their unpaid caregivers. MDD patients' medical records, the concept of healthcare resource utilization, the Work Productivity and Activity Impairment Questionnaire: depression and mood & mental state versions (WPAI: D, MM), the Class Impairment Questionnaire (CIQ), and the Family Experiences Interview Schedule (FEIS) were applied as the tools of the study. Pearson Chi's square, Fisher's Exact test, and independent T-test were employed for statistical analysis. RESULTS: The proportion of TRD was 19.6% among antidepressant-treated MDD patients in a Thai tertiary public hospital. The results of the study indicated that several factors showed a statistically significant association with TRD criteria. These factors included younger age of MDD patients, a younger age of onset of MDD, lower body mass index (BMI), a history of suicide attempts and self-harm, as well as frequent smoking behavior. The annualized economic cost of TRD was 276,059.97 baht per person ($7,668.33), which was significantly higher than that of cost of non-TRD (173,487.04 baht or $4,819.08). The aggregated economic costs of MDD were 96.8 million baht annually ($2.69 M) if calculated from 500 MDD patients and unpaid caregivers. This contributed to the economic cost of TRD 27.05 million baht (98 respondents) and the economic cost of non-TRD 69.74 million baht (402 respondents). CONCLUSIONS: The economic burden associated with TRD was significantly higher compared to non-TRD among antidepressant-treated MDD patients. Specifically, both direct medical costs and indirect costs were notably elevated in the TRD group.
91Health-care utilisation and associated economic burden in major depressive disorder and treatment-resistant depression in a longitudinal population-based cohort study of 110.000 patients.PubMed
Sofia Pappa, Moulesh Shah, Sophie Young, et al.
J Psychiatr Res. 2024 Dec;180:511-518. doi: 10.1016/j.jpsychires.2024.11.022. Epub 2024 Nov 9.
Major depressive disorder (MDD), and particularly treatment-resistant depression (TRD), lead to high levels of health-care use and disease burden. The aim of this study was to evaluate and compare the health-care resource utilisation and associated costs in these patient groups. It was a population-wide, retrospective analysis of NHS health-care electronic records in northwest London using the Discover-NOW platform, one of the largest interlinked datasets in Europe hosted by Imperial College Health Partners, which contains coded emergency and routine, primary and secondary, physical and mental health data, covering a population of more than 2.5 million. Eligible patients were adults with a diagnosis of MDD who had been prescribed at least one antidepressant between 2015 and 2020. A total of 110,406 patients were included, 101,333 [92%] with MDD and 9073 [8%] with TRD. Mean duration of depression was 52.8 (SD 41.7) months for MDD and 70.8 (SD 37.8) months for TRD (p < 0.0001). Patients with TRD had significantly higher risks of both psychiatric and somatic comorbidities such as anxiety, asthma, and alcohol misuse (all p < 0.0001). They also demonstrated increased primary care and emergency attendance rates, more frequent and longer hospitalizations, and on average 1.5 times greater total healthcare costs compared to MDD patients. Primary care visits represented the largest proportion overall (TRD mean 162 [SD 96] vs. MDD 108 [90] visits per patient, p < 0.0001; cost per patient £17,348 [SD £33,040] vs. £12,011 [£25,588], p < 0.0001) during the study period. In secondary care, accident and emergency visits accounted for the highest use (TRD mean 5.5 [10.6] vs. MDD 3.54 [SD 6.0] visits per patient, p < 0.0001) while non-elective hospitalisations incurred the highest costs (mean £2518 [£8064] vs. £1909 [SD £6807], p < 0.0001). Demand increased with the duration of depression and the number of lines of treatment. The study highlights the substantial clinical and economic burden associated with MDD and especially TRD across different care settings.
92Health care costs associated with depressive and anxiety disorders in primary care.PubMed
G Simon, J Ormel, M VonKorff, et al.
Am J Psychiatry. 1995 Mar;152(3):352-7. doi: 10.1176/ajp.152.3.352.
OBJECTIVE: The authors examined the overall health care costs associated with depression and anxiety among primary care patients. METHOD: Of 2,110 consecutive primary care patients in a health maintenance organization, 1,962 were screened with the 12-item General Health Questionnaire. A stratified random sample of 615 patients were selected for further diagnostic assessment; 373 of these patients completed the Composite International Diagnostic Interview at baseline and 328 were reassessed 12 months later. Computerized cost records were used to calculate total health care costs for the 6-month period surrounding the baseline assessment and a similar period surrounding the follow-up assessment. Cost accounting data were available for 327 patients at baseline and for 206 patients at both assessments. RESULTS: Primary care patients with DSM-III-R anxiety or depressive disorders at baseline had markedly higher baseline costs ($2,390) than patients with subthreshold disorders ($1,098) and those with no anxiety or depressive disorder ($1,397). Large cost differences persisted after adjustment for medical morbidity. Cost differences reflected higher utilization of general medical services rather than higher mental health treatment costs. Although most patients with baseline anxiety or depressive disorders showed significant improvement, longitudinal analyses did not show any clear relationship between change in psychiatric diagnosis and change in health care cost. CONCLUSIONS: Among primary care patients, anxiety and depressive disorders are associated with markedly higher health care costs even after adjustment for medical comorbidity. In this small sample, improvement in depression over 1 year was not clearly associated with decreases in cost.
93Characterizing primary care for patients with major depressive disorder using electronic health records of a US-based healthcare provider.PubMed
Sharon Larson, Andrei Nemoianu, Debra F Lawrence, et al.
J Affect Disord. 2022 Mar 1;300:377-384. doi: 10.1016/j.jad.2021.12.096. Epub 2021 Dec 22.
BACKGROUND: Major depressive disorder (MDD) is predominantly managed in primary care. However, primary care providers (PCPs) may not consistently follow evidence-based treatment algorithms, leading to variable patient management that can impact outcomes. METHODS: We retrospectively analyzed adult patients with MDD seen at Geisinger, an integrated health system. Utilizing electronic health record (EHR) data, we classified patients as having MDD based on International Classification of Disease (ICD)-9/10 codes or a Patient Health Questionnaire (PHQ)-9 score ≥5. Outcomes assessed included time to first visit with a PCP or behavioral health specialist following diagnosis, antidepressant medication switching, persistence, healthcare resource utilization (HRU), and treatment costs. RESULTS: Among the 38,321 patients with MDD managed in primary care in this study, significant delays between diagnosis with antidepressant prescribing and follow-up PCP visits were observed. There was also considerable variation in care following diagnosis. Overall, 34.9% of patients with an ICD-9/10 diagnosis of MDD and 41.3% with a PHQ-9 score ≥15 switched antidepressants. An ICD-9/10 diagnosis, but not moderately severe to severe depression, was associated with higher costs and HRU. More than 75% of patients with MDD discontinued antidepressant medication within 6 months. LIMITATIONS: The study population was comparable with other real-world studies of MDD, but study limitations include its retrospective nature and reliance on the accuracy of EHRs. CONCLUSIONS: Management of patients with MDD in a primary care setting is variable. Addressing these gaps will have important implications for ensuring optimal patient management, which may reduce HRU and treatment medication costs, and improve treatment persistence.
94Major depressive disorder, somatic pain, and health care costs in an urban primary care practice.PubMed
Marc J Gameroff, Mark Olfson
J Clin Psychiatry. 2006 Aug;67(8):1232-9. doi: 10.4088/jcp.v67n0809.
OBJECTIVE: To evaluate the extent to which pain severity contributes to the increased medical care costs associated with depression in primary care. METHOD: A systematic sample of primary care patients (N = 1028) from an urban practice were assessed between April 1, 2002, and January 16, 2003, with the DSM-IV Primary Care Evaluation of Mental Disorders Patient Health Questionnaire, the Sheehan Disability Scale, a medical illness checklist, and the Medical Outcomes Study 12-Item Short Form Health Survey, which includes a measure of pain interference with daily activities. Medical charges for inpatient, outpatient, and emergency department services were assessed for the 6-month periods preceding and following the index medical visit. Patients with and without major depressive disorder (MDD) were first compared with respect to clinical characteristics and median medical charges. Mean predicted medical care charges were then compared among 4 patient groups: (1) No MDD/ Low Pain Interference, (2) No MDD/High Pain Interference, (3) MDD/Low Pain Interference, and (4) MDD/High Pain Interference. RESULTS: As compared to patients without MDD (N = 821), those with MDD (N = 207) had significantly higher predicted mean medical care charges (19,838 dollars vs. 6268 dollars; t = 3.3, p = .001) after controlling for age and gender and were significantly more likely to report at least moderate pain-related interference in daily activities (MDD: 69.1% vs. no MDD: 38.6%; chi 2 = 61.3, df = 1, p < .0001). Mean predicted medical care charges of patients with MDD and at least moderate pain-related interference were on average 2.33 times (95% CI = 1.34 to 4.05) as high as those for patients with MDD and little or no pain-related interference. Among patients with at least moderate pain-related interference, MDD was associated with significantly greater mean predicted charges (mean = 28,598 dollars/ year with MDD vs. 11,031 dollars/year without MDD). However, among patients with lower levels of pain-related interference, MDD was not associated with greater mean predicted medical charges (mean = 2306 dollars/year with MDD vs. 3560 dollars/year without MDD). CONCLUSION: In this urban primary care practice, major depressive disorder is associated with increased health care costs, but only among patients with moderate to extreme pain-related interference in daily activities.
95A Cost-effectiveness Study of the Impact of the Affordable Care Act on Depression Outcomes in the United States.PubMed
Babak Mohit
J Ment Health Policy Econ. 2018 Jun 1;21(2):71-78.
OBJECTIVE: Two separate changes in insurance regulation have altered mental health delivery to Americans: (i) the Mental Health Parity and Addiction Equity Act (MHPA 2008) and (ii) the Patient Protection and Affordable Care Act (ACA 2010). This study aims to model and provide estimates for the costs and effects of depression that are impacted by these regulations. METHOD: Literature exists on the effectiveness of insurance coverage in reducing the prevalence, the costs of treatment and lost productivity time, as well as the health related quality of life (HRQL) associated with depression. Data from this literature is employed in a Markov model to obtain costs and effects associated with depression under both the MHPA and the ACA regulations as compared to without either one. RESULTS: The implementation of these regulations may reduce the per capita lifetime costs of depression treatment and lost productivity by USD 215 and enhance life expectancy by 0.01 Quality Adjusted Life Years (QALY) per capita. CONCLUSIONS: If the savings of these regulations are expanded over the entire cohort of Americans adults, the potential cost savings from treated depression are estimated at USD 47.30 billion in addition to 2.2 million QALYs saved.
96A community study of depression treatment and employment earnings.PubMed
M Zhang, K M Rost, J C Fortney, et al.
Psychiatr Serv. 1999 Sep;50(9):1209-13. doi: 10.1176/ps.50.9.1209.
OBJECTIVE: Although treatment for major depression has been shown to reduce the costs of lost earnings resulting from lost work days, research has not demonstrated whether the reduction fully offsets the costs of treatment for the disorder. METHODS: A statewide cohort of community residents with recent major depression, dysthymia, or substantial depressive symptoms was recruited and interviewed at baseline and at six-month and 12-month follow-ups. The cost of lost earnings was measured by lost work days multiplied by subjects' wage rates. Cost of treatment for depression was approximated using charges abstracted from provider and insurance records. Net economic cost, defined as the sum of changes in lost earnings and depression treatment costs, was examined in multiple regression analyses. RESULTS: After the analyses controlled for sociodemographic characteristics, baseline severity of depression, and comorbidity, no statistically significant effect of depression treatment on net economic cost was found. This finding suggests that the cost of depression treatment was fully offset by savings from reduction in lost work days. Results from sensitivity analyses in multiple alternative scenarios support the same conclusion. CONCLUSIONS: The finding of a full offset of depression treatment cost is conservative because other benefits, such as reduced pain and suffering and increased productivity while at work, were not included in the analyses. Employers who bear the cost from lost work days should encourage their employees with depressive disorders to seek treatment, even if it means paying for the entire treatment cost. Self-employed individuals with depression also will benefit even if they pay for the treatment costs themselves.
97Psychological Distress, Burnout, and Academic Performance in First Year College Students.PubMed
Jaume-Miquel March-Amengual, Irene Cambra Badii, Joan-Carles Casas-Baroy, et al.
Int J Environ Res Public Health. 2022 Mar 12;19(6):3356. doi: 10.3390/ijerph19063356.
BACKGROUND: The first years of university can be very challenging for students. Previous research has focused on the study of the prevalence of burnout and of psychological distress in medical students. The aim of this study was to investigate the prevalence of psychological symptoms and burnout reported by first-year students, the relationship between these variables and their academic performance, and the differences between health and non-health sciences students. METHODS: An observational study with a cross-sectional design was performed. Students of health sciences (medicine, nursing, physiotherapy, psychology), and non-health sciences (biology, social sciences, business management, and engineering) undergraduate programs completed the Brief Symptom Inventory (BSI-18) and the Maslach Burnout Inventory-Student Survey (MBI-SS). Students' grades for the first semester were collected. RESULTS: A sample of 506 students participated. Prevalence of psychological distress was 27.1% and burnout was 7.3%. Academic performance was unaffected in relation to either psychological distress or burnout. Non-health sciences students showed a greater risk of depression. CONCLUSIONS: This study provides evidence of the high prevalence of psychological distress in the first year of college. Even when burnout prevalence was low, the results suggest the need to introduce prevention programs to improve the psychological wellbeing of these students.
98The prevalence and correlates of depression, anxiety, and stress in a sample of college students.PubMed
R Beiter, R Nash, M McCrady, et al.
J Affect Disord. 2015 Mar 1;173:90-6. doi: 10.1016/j.jad.2014.10.054. Epub 2014 Nov 8.
BACKGROUND: Over the past four years, the Franciscan University Counseling Center has reported a 231% increase in yearly visits, as well as a 173% increase in total yearly clients. This trend has been observed at many universities as mental health issues pose significant problems for many college students. The objective of this study was to investigate potential correlates of depression, anxiety, and stress in a sample of college students. METHODS: The final analyzed sample consisted of 374 undergraduate students between the ages of 18 and 24 attending Franciscan University, Steubenville, Ohio. Subjects completed a survey consisting of demographic questions, a section instructing participants to rate the level of concern associated with challenges pertinent to daily life (e.g. academics, family, sleep), and the 21 question version of the Depression Anxiety Stress Scale (DASS21). RESULTS: The results indicated that the top three concerns were academic performance, pressure to succeed, and post-graduation plans. Demographically, the most stressed, anxious, and depressed students were transfers, upperclassmen, and those living off-campus. CONCLUSIONS: With the propensity for mental health issues to hinder the success of college students, it is vital that colleges continually evaluate the mental health of their students and tailor treatment programs to specifically target their needs.
99Impacts of Nursing Student Burnout on Psychological Well-Being and Academic Achievement.PubMed
Holly Wei, Alexandra Dorn, Hailey Hutto, et al.
J Nurs Educ. 2021 Jul;60(7):369-376. doi: 10.3928/01484834-20210616-02. Epub 2021 Jul 1.
BACKGROUND: Burnout, depression, and suicide among health care professionals and learners have reached a rampant level. This systematic review aimed to synthesize literature findings of nursing student burnout and its impact on psychological well-being and academic performance. METHOD: This systematic review followed PRISMA guidelines and included data-based studies on nursing student burnout published in peer-reviewed journals between January 2015 and January 2020. RESULTS: This review included 17 articles. Four major themes were identified: 1) a negative relationship between burnout and student self-concept, 2) a negative association between burnout and student engagement, 3) risk factors contributing to student burnout, and 4) interventions to mitigate student burnout. Promoting positive self-concept, engagement, and resilience may alleviate student academic burnout. CONCLUSION: Student burnout has negative influences on health and academics, and interventions to mitigate burnout should be considered early in nursing programs. Nurse educators can create an engaging learning environment to build resilience and reduce burnout. .
100Management of Treatment-Resistant Depression: Challenges and Strategies.PubMed
Daphne Voineskos, Zafiris J Daskalakis, Daniel M Blumberger
Neuropsychiatr Dis Treat. 2020 Jan 21;16:221-234. doi: 10.2147/NDT.S198774. eCollection 2020.
Treatment-resistant depression (TRD) is a subset of Major Depressive Disorder which does not respond to traditional and first-line therapeutic options. There are several definitions and staging models of TRD and a consensus for each has not yet been established. However, in common for each model is the inadequate response to at least 2 trials of antidepressant pharmacotherapy. In this review, a comprehensive analysis of existing literature regarding the challenges and management of TRD has been compiled. A PubMed search was performed to assemble meta-analyses, trials and reviews on the topic of TRD. First, we address the confounds in the definitions and staging models of TRD, and subsequently the difficulties inherent in assessing the illness. Pharmacological augmentation strategies including lithium, triiodothyronine and second-generation antipsychotics are reviewed, as is switching of antidepressant class. Somatic therapies, including several modalities of brain stimulation (electroconvulsive therapy, repetitive transcranial magnetic stimulation, magnetic seizure therapy and deep brain stimulation) are detailed, psychotherapeutic strategies and subsequently novel therapeutics including ketamine, psilocybin, anti-inflammatories and new directions are reviewed in this manuscript. Our review of the evidence suggests that further large-scale work is necessary to understand the appropriate treatment pathways for TRD and to prescribe effective therapeutic options for patients suffering from TRD.
101Treatment-Resistant Depression: Approaches to Treatment.PubMed
Karan S Kverno, Emma Mangano
J Psychosoc Nurs Ment Health Serv. 2021 Sep;59(9):7-11. doi: 10.3928/02793695-20210816-01. Epub 2021 Sep 1.
Approximately 30% of people treated for a major depressive episode will not achieve remission after two or more treatment trials of first-line antidepressants and are considered to have treatment-resistant depression (TRD). Because the odds of remission decrease with every subsequent medication trial, it is important for clinicians to understand the characteristics and risk factors for TRD, subtypes of major depressive disorder that are more likely to be less responsive to first-line anti-depressants, and the available treatment options. In the current article, we review the approved treatments for TRD, including esketamine, and the evidence for psilocybin and pramipexole. Although limited in specificity, guidelines to help prescribers identify person-centered treatments for TRD are available. [(9), 7-11.].
102Combining selective serotonin reuptake inhibitors and cognitive behavioral therapy in youth with depression and anxiety.PubMed
Jeffrey R Strawn, Jeffrey A Mills, Vikram Suresh, et al.
J Affect Disord. 2022 Feb 1;298(Pt A):292-300. doi: 10.1016/j.jad.2021.10.047. Epub 2021 Oct 31.
BACKGROUND: Treatment studies of children and adolescents with internalizing disorders suggest that the combination of a selective serotonin reuptake inhibitor (SSRI) and cognitive behavioral therapy (CBT) consistently produces greater improvement than either treatment alone. We sought to determine how response to combined treatment varies across disorders (anxiety versus depression), and by specific patient characteristics. METHODS: Three large National Institutes of Health-funded trials of children and adolescents with major depression (n = 2) and anxiety disorders (n = 1) were evaluated, each comparing CBT + SSRI to SSRI only, Bayesian Hierarchical Models (BHMs) were used, for endpoint response, time course of response and predictors of response in participants who received SSRI or SSRI+CBT. RESULTS: SSRI+CBT significantly decreased symptoms by week 4 (p<0.001) across disorders. This improvement continued at week 8 and 12 (p<0.001); however, the additive benefit of CBT over SSRI monotherapy was not statistically significant until week 12 (p<0.001). The fastest response to SSRI+CBT was for patients who were younger, with milder baseline anxiety/depression symptoms and depressive disorders. The slowest response for SSRI+CBT was for boys, adolescents, minoritized children, those with severe symptoms and externalizing disorders. LIMITATIONS: Limitations included inconsistent moderators, variation in the number of observations over time and a lack of genetic or pharmacokinetic variables related to SSRI exposure across studies. CONCLUSIONS: The superiority of SSRI+CBT for youth with depression and anxiety is further supported. For purposes of rapid and greater relief, combination treatment is the superior approach across anxiety and depression and is robust to a range of participant characteristics. However, the added value of CBT (with an SSRI) occurs late in treatment. These findings represent a step towards understanding heterogeneity of treatment response and raise the possibility that interventions could be better tailored or adapted based on patient characteristics.
103Molecular Mechanisms of Psilocybin and Implications for the Treatment of Depression.PubMed
Susan Ling, Felicia Ceban, Leanna M W Lui, et al.
CNS Drugs. 2022 Jan;36(1):17-30. doi: 10.1007/s40263-021-00877-y. Epub 2021 Nov 17.
Therapeutic deficiencies with monoaminergic antidepressants invites the need to identify and develop novel rapid-acting antidepressants. Hitherto, ketamine and esketamine are identified as safe, well-tolerated rapid-acting antidepressants in adults with treatment-resistant depression, and also mitigate measures of suicidality. Psilocybin is a naturally occurring psychoactive alkaloid and non-selective agonist at many serotonin receptors, especially at serotonin 5-HT receptors, and is found in the Psilocybe genus of mushrooms. Preliminary studies with psilocybin have shown therapeutic promise across diverse populations including major depressive disorder. The pharmacodynamic mechanisms mediating the antidepressant and psychedelic effects of psilocybin are currently unknown but are thought to involve the modulation of the serotonergic system, primarily through agonism at the 5-HT receptors and downstream changes in gene expression. It is also established that indirect effects on dopaminergic and glutamatergic systems are contributory, as well as effects at other lower affinity targets. Along with the direct effects on neurochemical systems, psilocybin alters neural circuitry and key brain regions previously implicated in depression, including the default mode network and amygdala. The aim of this review is to synthesize the current understanding of the receptor pharmacology and neuronal mechanisms underlying the psychedelic and putative antidepressant properties of psilocybin.
104Psilocybin with psychological support for treatment-resistant depression: an open-label feasibility study.PubMed
Robin L Carhart-Harris, Mark Bolstridge, James Rucker, et al.
Lancet Psychiatry. 2016 Jul;3(7):619-27. doi: 10.1016/S2215-0366(16)30065-7. Epub 2016 May 17.
BACKGROUND: Psilocybin is a serotonin receptor agonist that occurs naturally in some mushroom species. Recent studies have assessed the therapeutic potential of psilocybin for various conditions, including end-of-life anxiety, obsessive-compulsive disorder, and smoking and alcohol dependence, with promising preliminary results. Here, we aimed to investigate the feasibility, safety, and efficacy of psilocybin in patients with unipolar treatment-resistant depression. METHODS: In this open-label feasibility trial, 12 patients (six men, six women) with moderate-to-severe, unipolar, treatment-resistant major depression received two oral doses of psilocybin (10 mg and 25 mg, 7 days apart) in a supportive setting. There was no control group. Psychological support was provided before, during, and after each session. The primary outcome measure for feasibility was patient-reported intensity of psilocybin's effects. Patients were monitored for adverse reactions during the dosing sessions and subsequent clinic and remote follow-up. Depressive symptoms were assessed with standard assessments from 1 week to 3 months after treatment, with the 16-item Quick Inventory of Depressive Symptoms (QIDS) serving as the primary efficacy outcome. This trial is registered with ISRCTN, number ISRCTN14426797. FINDINGS: Psilocybin's acute psychedelic effects typically became detectable 30-60 min after dosing, peaked 2-3 h after dosing, and subsided to negligible levels at least 6 h after dosing. Mean self-rated intensity (on a 0-1 scale) was 0·51 (SD 0·36) for the low-dose session and 0·75 (SD 0·27) for the high-dose session. Psilocybin was well tolerated by all of the patients, and no serious or unexpected adverse events occurred. The adverse reactions we noted were transient anxiety during drug onset (all patients), transient confusion or thought disorder (nine patients), mild and transient nausea (four patients), and transient headache (four patients). Relative to baseline, depressive symptoms were markedly reduced 1 week (mean QIDS difference -11·8, 95% CI -9·15 to -14·35, p=0·002, Hedges' g=3·1) and 3 months (-9·2, 95% CI -5·69 to -12·71, p=0·003, Hedges' g=2) after high-dose treatment. Marked and sustained improvements in anxiety and anhedonia were also noted. INTERPRETATION: This study provides preliminary support for the safety and efficacy of psilocybin for treatment-resistant depression and motivates further trials, with more rigorous designs, to better examine the therapeutic potential of this approach. FUNDING: Medical Research Council.
105Single-Dose Psilocybin for a Treatment-Resistant Episode of Major Depression.PubMed
Guy M Goodwin, Scott T Aaronson, Oscar Alvarez, et al.
N Engl J Med. 2022 Nov 3;387(18):1637-1648. doi: 10.1056/NEJMoa2206443.
BACKGROUND: Psilocybin is being studied for use in treatment-resistant depression. METHODS: In this phase 2 double-blind trial, we randomly assigned adults with treatment-resistant depression to receive a single dose of a proprietary, synthetic formulation of psilocybin at a dose of 25 mg, 10 mg, or 1 mg (control), along with psychological support. The primary end point was the change from baseline to week 3 in the total score on the Montgomery-Åsberg Depression Rating Scale (MADRS; range, 0 to 60, with higher scores indicating more severe depression). Secondary end points included response at week 3 (≥50% decrease from baseline in the MADRS total score), remission at week 3 (MADRS total score ≤10), and sustained response at 12 weeks (meeting response criteria at week 3 and all subsequent visits). RESULTS: A total of 79 participants were in the 25-mg group, 75 in the 10-mg group, and 79 in the 1-mg group. The mean MADRS total score at baseline was 32 or 33 in each group. Least-squares mean changes from baseline to week 3 in the score were -12.0 for 25 mg, -7.9 for 10 mg, and -5.4 for 1 mg; the difference between the 25-mg group and 1-mg group was -6.6 (95% confidence interval [CI], -10.2 to -2.9; P<0.001) and between the 10-mg group and 1-mg group was -2.5 (95% CI, -6.2 to 1.2; P = 0.18). In the 25-mg group, the incidences of response and remission at 3 weeks, but not sustained response at 12 weeks, were generally supportive of the primary results. Adverse events occurred in 179 of 233 participants (77%) and included headache, nausea, and dizziness. Suicidal ideation or behavior or self-injury occurred in all dose groups. CONCLUSIONS: In this phase 2 trial involving participants with treatment-resistant depression, psilocybin at a single dose of 25 mg, but not 10 mg, reduced depression scores significantly more than a 1-mg dose over a period of 3 weeks but was associated with adverse effects. Larger and longer trials, including comparison with existing treatments, are required to determine the efficacy and safety of psilocybin for this disorder. (Funded by COMPASS Pathfinder; EudraCT number, 2017-003288-36; ClinicalTrials.gov number, NCT03775200.).
106Psychedelic interventions for major depressive disorder in the elderly: Exploring novel therapies, promise and potential.PubMed
Ivona-Maria Tudorancea, Gabriela-Dumitrita Stanciu, Carla Torrent, et al.
Dialogues Clin Neurosci. 2025 Dec;27(1):98-111. doi: 10.1080/19585969.2025.2499458. Epub 2025 May 6.
The global population is ageing rapidly, with the number of individuals aged 60 and older reaching 1 billion in 2019 and expected to double by 2050. As people age, neuropsychological health often deteriorates, leading to a higher prevalence of age-related depression. Symptoms may include anxiety, apathy, mood instability, sadness, and, in severe cases, suicidal thoughts. Depression in the elderly is a widespread concern, and conventional treatments such as antidepressants are often limited by side effects, reduced efficacy, and complications arising from polypharmacy. In response, novel therapeutic approaches are being explored, including psychedelic interventions. Recent clinical and preclinical studies suggest that psychedelics could offer a promising treatment for major depressive disorder (MDD) in older adults. These compounds, known for their profound neurobiological effects, have gained attention for their potential to address depression where traditional therapies fall short. This review aims to examine the therapeutic promise of psychedelic substances, focusing on those that show potential for treating MDD in the elderly. We also explore the underlying mechanisms through which psychedelics may exert their effects and highlight the preclinical models that support their use. Finally, we address safety considerations and propose strategies to enhance the effectiveness and safety of psychedelics in future clinical trials, offering new hope for treating age-related depressive disorders.
107Advances in transcranial magnetic stimulation (TMS) and its applications in resistant depression.PubMed
Theodoros Koutsomitros, Olympia Evagorou, Teresa Schuhmann, et al.
Psychiatriki. 2021 Dec;32(Supplement I):90-98. doi: 10.22365/jpsych.2021.054.
Transcranial magnetic stimulation (TMS) is a non-invasive method of brain stimulation that is receiving increasingly attentionTranscranial magnetic stimulation (TMS) is a non-invasive method of brain stimulation that is receiving increasingly attentionfor new clinical applications. Through electromagnetic induction cortical activity can be modulated and therapeuticeffects can be achieved in a variety of psychiatric and neurological conditions. According to the World Health Organization(WHO) depression is the most disabling disease in the world and 350 million people suffer from depression globally. Majordepression is the most common disorder to be treated with TMS and the first mental disorder for which TMS received approvalfrom the US Food and Drug Administration (FDA). We here introduce the basic principles of TMS, discuss the latestdata on safety and side effects, and present various TMS treatment protocols as well as treatment response predictors inmajor depressive disorder.
108Transcranial magnetic stimulation (TMS) for geriatric depression.PubMed
Davide Cappon, Tim den Boer, Caleb Jordan, et al.
Ageing Res Rev. 2022 Feb;74:101531. doi: 10.1016/j.arr.2021.101531. Epub 2021 Nov 25.
BACKGROUND: The prevalence of treatment-resistant geriatric depression (GD) highlights the need for treatments that preserve cognitive functions and recognize polypharmacy in elderly, yet effectively reduce symptom burden. Transcranial magnetic stimulation (TMS) is a proven intervention for treatment-resistant depression in younger adults but the efficacy of TMS to treat depressed older adults is still unclear. This review provides an updated view on the efficacy of TMS treatment for GD, discusses methodological differences between trials in TMS application, and explores avenues for optimization of TMS treatment in the context of the ageing brain. METHODS: A systematic review was conducted to identify published literature on the antidepressant efficacy of TMS for GD. Databases PubMed, Embase, and PsycINFO were searched for English language articles in peer-reviewed journals in March 2021. RESULTS: Seven randomized controlled trials (RCTs) (total n = 260, active n = 148, control n = 112) and seven uncontrolled trials (total n = 160) were included. Overall, we found substantial variability in the clinical response, ranging from 6.7% to 54.3%. CONCLUSIONS: The reviewed literature highlights large heterogeneity among studies both in terms of the employed TMS dosage and the observed clinical efficacy. This highlights the need for optimizing TMS dosage by recognizing the unique clinical features of GD. We showcase a set of novel approaches for the optimization of the TMS protocol for depression and discuss the possibility for a standardized TMS protocol tailored for the treatment of GD.
109Transcranial magnetic stimulation in the treatment of adolescent depression: a systematic review and meta-analysis of aggregated and individual-patient data from uncontrolled studies.PubMed
Christine Sigrist, Jasper Vöckel, Frank P MacMaster, et al.
Eur Child Adolesc Psychiatry. 2022 Oct;31(10):1501-1525. doi: 10.1007/s00787-022-02021-7. Epub 2022 Jun 24.
Transcranial magnetic stimulation (TMS) is a non-invasive treatment for adolescent major depressive disorder (MDD). Existing evidence on the efficacy of TMS in adolescent MDD awaits quantitative synthesis. A systematic literature search was conducted, and data from eligible studies were synthesized using random-effects models. Treatment-covariate interactions were examined in exploratory analyses of individual-patient data (IPD). Systematic search of the literature yielded 1264 hits, of which 10 individual studies (2 randomized trials) were included for quantitative synthesis of mainly uncontrolled studies. Individual patient data (IPD) were available from five trials (all uncontrolled studies). Quantitative synthesis of aggregated data revealed a statistically significant negative overall standardized mean change (pooled SMCC = 2.04, 95% CI [1.46; 2.61], SE = 0.29, p < .001), as well as a significant overall treatment response rate (Transformed Proportion = 41.30%, 95% CI [31.03; 51.57], SE = 0.05; p < 0.001), considering data from baseline to post-treatment. Exploratory IPD analyses suggests TMS might be more effective in younger individuals and individuals with more severe depression, and efficacy might be enhanced with certain treatment modality settings, including higher number of TMS sessions, longer treatment durations, and unilateral and not bilateral stimulation. Existing studies exhibit methodological shortcomings, including small-study effects and lack of control group, blinding, and randomization-compromising the credibility of the present results. To date, two randomized controlled trials on TMS in adolescent depression have been published, and the only large-scale randomized trial suggests TMS is not more effective than sham stimulation. Future large-scale, randomized, and sham-controlled trials are warranted. Future trials should ensure appropriate selection of patients for TMS treatment and guide precision medicine approaches for stimulation protocols.
110Using Brain Imaging to Improve Spatial Targeting of Transcranial Magnetic Stimulation for Depression.PubMed
Robin F H Cash, Anne Weigand, Andrew Zalesky, et al.
Biol Psychiatry. 2021 Nov 15;90(10):689-700. doi: 10.1016/j.biopsych.2020.05.033. Epub 2020 Jun 7.
Transcranial magnetic stimulation (TMS) is an effective treatment for depression but is limited in that the optimal therapeutic target remains unknown. Early TMS trials lacked a focal target and thus positioned the TMS coil over the prefrontal cortex using scalp measurements. Over time, it became clear that this method leads to variation in the stimulation site and that this could contribute to heterogeneity in antidepressant response. Newer methods allow for precise positioning of the TMS coil over a specific brain location, but leveraging these precise methods requires a more precise therapeutic target. We review how neuroimaging is being used to identify a more focal therapeutic target for depression. We highlight recent studies showing that more effective TMS targets in the frontal cortex are functionally connected to deep limbic regions such as the subgenual cingulate cortex. We review how connectivity might be used to identify an optimal TMS target for use in all patients and potentially even a personalized target for each individual patient. We address the clinical implications of this emerging field and highlight critical questions for future research.
111Gender-Affirming Care of Transgender and Gender-Diverse Youth: Current Concepts.PubMed
Janet Y Lee, Stephen M Rosenthal
Annu Rev Med. 2023 Jan 27;74:107-116. doi: 10.1146/annurev-med-043021-032007. Epub 2022 Oct 19.
Increasing numbers of transgender and gender-diverse (TGD) youth, from early puberty through late adolescence, are seeking medical services to bring their physical sex characteristics into alignment with their gender identity-their inner sense of self as male or female or elsewhere on the gender spectrum. Numerous studies, primarily of short- and medium-term duration (up to 6 years), demonstrate the clearly beneficial-even lifesaving-mental health impact of gender-affirming medical care in TGD youth. However, there are significant gaps in knowledge and challenges to such care. Long-term safety and efficacy studies are needed to optimize medical care for TGD youth.
112Gender-Affirming Mental Health Care for Transgender and Gender Diverse Youth on Pediatric Inpatient Psychiatry Units.PubMed
John L McKenna, Ethan T Anglemyer, Kerry McGregor
J Am Acad Child Adolesc Psychiatry. 2024 Jun;63(6):576-580. doi: 10.1016/j.jaac.2023.05.021. Epub 2023 Jun 24.
Transgender and gender diverse (TGD) youth, individuals whose gender identity is different from the sex that was assigned at birth, report higher rates of mental health and emotional challenges and are approximately twice as likely to access psychiatric inpatient services compared with cisgender peers. Existing research has suggested that the minority stress that TGD youth face from having to navigate transphobic cultural contexts and systems (eg, unsupportive parents/caregivers, school staff, peers) may play a key factor in mental health disparities, such as increased risk of depression, anxiety, suicidal ideation, suicide attempts, and nonsuicidal self-harm. These higher rates of mental health challenges among TGD youth offer an explanation as to why these youth access inpatient services significantly more frequently than cisgender peers. Research has found that TGD youth often experience discrimination during psychiatric inpatient admissions (eg, being misgendered during admission intake, facing stigmatization for an evolving gender identity, and receiving care from staff who have not been trained to provide gender-affirming care), despite professional organizations, such as the American Academy of Child and Adolescent Psychiatry, underscoring the importance of TGD youth receiving psychiatric care that is inclusive and affirming. Given that the inpatient setting offers a unique opportunity to facilitate positive and affirming changes for TGD youth, it is essential for providers to have a strong understanding of what affirmative care looks like within this context to best support this vulnerable patient population and reduce experiences of discrimination.
113Clinical use of Hypericum perforatum (St John's wort) in depression: A meta-analysis.PubMed
Qin Xiang Ng, Nandini Venkatanarayanan, Collin Yih Xian Ho
J Affect Disord. 2017 Mar 1;210:211-221. doi: 10.1016/j.jad.2016.12.048. Epub 2017 Jan 3.
INTRODUCTION: St John's wort is a popular herbal remedy recommended by Traditional Chinese Medicine (TCM) practitioners and licensed and widely prescribed for depression in many European countries. However, conflicting data regarding its benefits and risks exist, and the last large meta-analysis on St John's wort use for depression was done in 2008, with no updated meta-analysis available. METHODS: Using the keywords [St John's Wort OR Hypericum perforatum OR hypericin OR hyperforin OR johanniskraut OR] AND [depression OR antidepressant OR SSRI], a preliminary search (without language restriction) on the PubMed, Ovid, Clinical Trials Register of the Cochrane Collaboration Depression, Anxiety and Neurosis Group, Cochrane Field for Complementary Medicine, China National Knowledge Infrastructure and WanFang database yielded 5428 papers between 1-Jan-1960 and 1-May-2016. RESULTS: 27 clinical trials with a total of 3808 patients were reviewed, comparing the use of St John's wort and SSRI. In patients with depression, St John's wort demonstrated comparable response (pooled RR 0.983, 95% CI 0.924-1.042, p<0.001) and remission (pooled RR 1.013, 95% CI 0.892-1.134, p<0.001) rate, and significantly lower discontinuation/dropout (pooled OR 0.587, 95% CI 0.478-0.697, p<0.001) rate compared to standard SSRIs. The pooled SMD from baseline HAM-D scores (pooled SMD -0.068, 95% CI -0.127 to 0.021, p<0.001) also support its significant clinical efficacy in ameliorating depressive symptoms. LIMITATIONS: Evidence on the long-term efficacy and safety of St. John's wort is limited as the duration of all available studies ranged from 4 to 12 weeks. It is also unclear if St John's wort would be beneficial for patients with severe depression, high suicidality or suicide risk. CONCLUSION: For patients with mild-to-moderate depression, St John's wort has comparable efficacy and safety when compared to SSRIs. Follow-up studies carried out over a longer duration should be planned to ascertain its benefits.
114Progress in the relationship between GDF11 and depression.PubMed
Xiang Jin, Wei Guan
Life Sci. 2024 Mar 15;341:122507. doi: 10.1016/j.lfs.2024.122507. Epub 2024 Feb 18.
Annually, the frequency of morbidity in depression has increased progressively in response to life stressors, and there is an increasing trend toward younger morbidity. The pathogenesis of depression is complicated and includes factors such as genetic inheritance and variations in physiological functions induced by various environmental factors. Currently, drug therapy has wide adaptability in clinical practice and plays an important role in the treatment of patients with mild depression. However, the therapeutic effects of most antidepressants are typically not significant and are associated with considerable adverse effects and addiction. Therefore, it is imperative to identify the deeper mechanisms of depression and search for alternative drug targets. Growth differentiation factor 11 (GDF11) is described as an anti-ageing molecule that belongs to a member of the transforming growth factor β family. Additionally, the latest research findings suggested that GDF11 positively regulates neurogenesis and enhances neuronal activity, thereby attenuating depression-like behaviours. Although an increasing number of studies have focused on the multiple functions of GDF11 in skeletal dysplasia and carcinogenesis, its precise mechanism of action in depression remains unknown. Thus, in this review, we discuss the role of GDF11 and its mechanistic pathways in the pathogenesis of depression to develop novel therapies for depression.
115Youth Mental Health Screening and Linkage to Care.PubMed
Nicole R Karcher, Ramona Hicks, Jason Schiffman, et al.
Psychiatr Serv. 2023 Jul 1;74(7):727-736. doi: 10.1176/appi.ps.202200008. Epub 2023 Jan 25.
One Mind, in partnership with Meadows Mental Health Policy Institute, convened several virtual meetings of mental health researchers, clinicians, and other stakeholders in 2020 to identify first steps toward creating an initiative for early screening and linkage to care for youths (individuals in early adolescence through early adulthood, ages 10-24 years) with mental health difficulties, including serious mental illness, in the United States. This article synthesizes and builds on discussions from those meetings by outlining and recommending potential steps and considerations for the development and integration of a novel measurement-based screening process in youth-facing school and medical settings to increase early identification of mental health needs and linkage to evidence-based care. Meeting attendees agreed on an initiative incorporating a staged assessment process that includes a first-stage brief screener for several domains of psychopathology. Individuals who meet threshold criteria on the first-stage screener would then complete an interview, a second-stage in-depth screening, or both. Screening must be followed by recommendations and linkage to an appropriate level of evidence-based care based on acuity of symptoms endorsed during the staged assessment. Meeting attendees proposed steps and discussed additional considerations for creating the first nationwide initiative for screening and linkage to care, an initiative that could transform access of youths to mental health screening and care.
116Implementing and maintaining school-based mental health services in a large, urban school district.PubMed
J Jennings, G Pearson, M Harris
J Sch Health. 2000 May;70(5):201-5. doi: 10.1111/j.1746-1561.2000.tb06473.x.
The Dallas (Texas) Public Schools established the first school-based health center in the United States in 1969. In 1993 a partnership between two school principals, a school mental health professional, and the medical director of the county mental health center was the impetus for the first comprehensive school-based mental health center in Texas. In 1995 the programs joined together as Youth and Family Centers (YFCs) to provide physical health, mental health, and other support services to students and their families. The 10 strategically located school-based centers are directed by licensed mental health professionals employed by the district who lead a multidisciplinary team of physical health and mental health providers. Students served by the YFCs have fewer discipline problems, course failures, and school absences.
117Public health primary prevention implemented by clinical high-risk services for psychosis.PubMed
Andrés Estradé, Gonzalo Salazar de Pablo, Alice Zanotti, et al.
Transl Psychiatry. 2022 Jan 28;12(1):43. doi: 10.1038/s41398-022-01805-4.
Clinical High Risk for Psychosis (CHR-P) services have been primarily developed to support young people with attenuated symptoms (indicated prevention). No evidence-based appraisal has systematically investigated to what extent these clinics may implement other preventive approaches. PRISMA 2020-compliant systematic review of Web of Science, Cochrane Central Register of Reviews, and Ovid/PsychINFO, from inception until 14th June 2021, identifying original studies describing public health strategies: (a) service characteristics (configuration of mental health service, outreach, pathways to care); (b) universal interventions (general population); (c) selective interventions targeting CHR-P service-users or family/carers. Public health preventive initiatives were systematically stratified according to core social determinants of mental disorders associated with the 2030 Sustainable Development Goals promoted by the United Nations Member States (UN 2030 SDG) and good mental health outcomes. A total of 66 publications were included, providing data on 13 standalone, 40 integrated, three networks, and six regional or international surveys of CHR-P services across Europe, Asia, Oceania, Africa, North and South America, providing care to >28 M people. CHR-P services implement numerous public health initiatives targeting social and cultural (16 initiatives), economic (seven initiatives), demographic (six initiatives), environmental events (four initiatives) and neighbourhood (three initiatives) UN 2030 SGD determinants of mental disorders. There is additional evidence for CHR-P services promoting good mental health. The main barriers were the lack of resources for expanding public health prevention at a large scale. CHR-P services implement numerous public health prevention initiatives and promotion of good mental health beyond indicated prevention of psychosis.
118The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review.PubMed
David Ponka, Eric Agbata, Claire Kendall, et al.
PLoS One. 2020 Apr 9;15(4):e0230896. doi: 10.1371/journal.pone.0230896. eCollection 2020.
BACKGROUND: Individuals who are homeless or vulnerably housed are at an increased risk for mental illness, other morbidities and premature death. Standard case management interventions as well as more intensive models with practitioner support, such as assertive community treatment, critical time interventions, and intensive case management, may improve healthcare navigation and outcomes. However, the definitions of these models as well as the fidelity and adaptations in real world interventions are highly variable. We conducted a systematic review to examine the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations. METHODS AND FINDINGS: We searched Medline, Embase and 7 other electronic databases for trials on case management or care coordination, from the inception of these databases to July 2019. We sought outcomes on housing stability, mental health, quality of life, substance use, hospitalization, income and employment, and cost-effectiveness. We calculated pooled random effects estimates and assessed the certainty of the evidence using the GRADE approach. Our search identified 13,811 citations; and 56 primary studies met our full inclusion criteria. Standard case management had both limited and short-term effects on substance use and housing outcomes and showed potential to increase hostility and depression. Intensive case management substantially reduced the number of days spent homeless (SMD -0.22 95% CI -0.40 to -0.03), as well as substance and alcohol use. Critical time interventions and assertive community treatment were found to have a protective effect in terms of rehospitalizations and a promising effect on housing stability. Assertive community treatment was found to be cost-effective compared to standard case management. CONCLUSIONS: Case management approaches were found to improve some if not all of the health and social outcomes that were examined in this study. The important factors were likely delivery intensity, the number and type of caseloads, hospital versus community programs and varying levels of participant needs. More research is needed to fully understand how to continue to obtain the increased benefits inherent in intensive case management, even in community settings where feasibility considerations lead to larger caseloads and less-intensive follow-up.
119Negative and protective experiences influencing the well-being of refugee children resettling in Germany: a qualitative study.PubMed
Shaymaa Abdelhamid, Jutta Lindert, Joachim Fischer, et al.
BMJ Open. 2023 Apr 19;13(4):e067332. doi: 10.1136/bmjopen-2022-067332.
OBJECTIVE: Conflict, forced migration and searching for safety in a foreign land are all experiences common to refugee children. They experience potentially traumatic events that are distinct from the general population, yet current adverse childhood experience (ACE) studies do not cover these events. Studies that do examine refugee children's experiences typically focus on a single stage of migration or adversities from the community, offering insight into only a fraction of their realities. This study aimed to identify potentially traumatising and protective experiences subjectively perceived as influencing refugee children's well-being from all stages of migration and all socio-ecological levels. DESIGN: Qualitative study with thematic analysis of semi-structured individual and group interviews. Themes were organised within a socio-ecological model. SETTING: Non-profit organisations, youth welfare facilities and societies that organise civic engagement for refugee families in the Rhine-Neckar region in Germany provided rooms where interviews could be conducted. PARTICIPANTS: Refugee parents and children who spoke one of the four most common languages of those seeking asylum in Germany in 2018 were included. This study excluded refugees who were not fleeing a conflict area. Forty-seven refugee parents and 11 children (aged 8-17 years) from Syria, Iraq, Palestine, Afghanistan and Eritrea participated. RESULTS: Eight major themes emerged from interviews including six reflecting potentially negative experiences and two potentially protective themes. These themes evolved from experiences such as family dispersion, displacement, rigorous immigration and national policies, as well as constructive parenting and community support. CONCLUSION: It is increasingly important to identify these diverse experiences as the refugee population continues to grow, and the increased prevalence of poor health outcomes in refugee children continues to be widely documented. Identifying ACEs specifically relevant to refugee children could contribute to understanding potential pathways and could further serve as a starting point for tailored interventions.
120Work-related causes of mental health conditions and interventions for their improvement in workplaces.PubMed
Reiner Rugulies, Birgit Aust, Birgit A Greiner, et al.
Lancet. 2023 Oct 14;402(10410):1368-1381. doi: 10.1016/S0140-6736(23)00869-3.
Mental health problems and disorders are common among working people and are costly for the affected individuals, employers, and whole of society. This discussion paper provides an overview of the current state of knowledge on the relationship between work and mental health to inform research, policy, and practice. We synthesise available evidence, examining both the role of working conditions in the development of mental disorders, and what can be done to protect and promote mental health in the workplace. We show that exposure to some working conditions is associated with an increased risk of the onset of depressive disorders, the most studied mental disorders. The causality of the association, however, is still debated. Causal inference should be supported by more research with stronger linkage to theory, better exposure assessment, better understanding of biopsychosocial mechanisms, use of innovative analytical methods, a life-course perspective, and better understanding of the role of context, including the role of societal structures in the development of mental disorders. There is growing evidence for the effectiveness of interventions to protect and promote mental health and wellbeing in the workplace; however, there is a disproportionate focus on interventions directed towards individual workers and illnesses, compared with interventions for improving working conditions and enhancing mental health. Moreover, research on work and mental health is mainly done in high-income countries, and often does not address workers in lower socioeconomic positions. Flexible and innovative approaches tailored to local conditions are needed in implementation research on workplace mental health to complement experimental studies. Improvements in translating workplace mental health research to policy and practice, such as through workplace-oriented concrete guidance for interventions, and by national policies and programmes focusing on the people most in need, could capitalise on the growing interest in workplace mental health, possibly yielding important mental health gains in working populations.
121Prioritizing the Mental Health and Well-Being of Healthcare Workers: An Urgent Global Public Health Priority.PubMed
Lene E Søvold, John A Naslund, Antonis A Kousoulis, et al.
Front Public Health. 2021 May 7;9:679397. doi: 10.3389/fpubh.2021.679397. eCollection 2021.
The COVID-19 pandemic has had an unprecedented impact on health systems in most countries, and in particular, on the mental health and well-being of health workers on the frontlines of pandemic response efforts. The purpose of this article is to provide an evidence-based overview of the adverse mental health impacts on healthcare workers during times of crisis and other challenging working conditions and to highlight the importance of prioritizing and protecting the mental health and well-being of the healthcare workforce, particularly in the context of the COVID-19 pandemic. First, we provide a broad overview of the elevated risk of stress, burnout, moral injury, depression, trauma, and other mental health challenges among healthcare workers. Second, we consider how public health emergencies exacerbate these concerns, as reflected in emerging research on the negative mental health impacts of the COVID-19 pandemic on healthcare workers. Further, we consider potential approaches for overcoming these threats to mental health by exploring the value of practicing self-care strategies, and implementing evidence based interventions and organizational measures to help protect and support the mental health and well-being of the healthcare workforce. Lastly, we highlight systemic changes to empower healthcare workers and protect their mental health and well-being in the long run, and propose policy recommendations to guide healthcare leaders and health systems in this endeavor. This paper acknowledges the stressors, burdens, and psychological needs of the healthcare workforce across health systems and disciplines, and calls for renewed efforts to mitigate these challenges among those working on the frontlines during public health emergencies such as the COVID-19 pandemic.
122Job satisfaction and burnout syndrome among intensive-care unit nurses: A systematic review and meta-analysis.PubMed
Carmen Quesada-Puga, Francisco José Izquierdo-Espin, María José Membrive-Jiménez, et al.
Intensive Crit Care Nurs. 2024 Jun;82:103660. doi: 10.1016/j.iccn.2024.103660. Epub 2024 Feb 22.
INTRODUCTION: The severe conditions often experienced in an intensive care unit, combined with poor working conditions, increase stress and therefore decrease job satisfaction. Sustained stress in the workplace leads to the development of burnout, a syndrome characterised by three dimensions: emotional exhaustion, depersonalisation and perceived lack of personal fulfilment. OBJECTIVE: To analyse the relationship between burnout syndrome and job satisfaction among ICU personnel. DATA SOURCES: The PubMed, CINAHL and Scopus databases were used. STUDY DESIGN: A systematic review and meta-analysis. The study sample consisted of 18 quantitative primary studies conducted in the last five years. Validated questionnaires were used to assess burnout in ICU healthcare workers, the most commonly used being the Maslach Burnout Inventory. EXTRACTION METHODS: The search equation applied was: "job satisfaction AND nurs* AND burnout AND (ICU OR intensive care units)". The search was performed in October 2022. PRINCIPAL FINDINGS: The search returned 514 results. Only 73 articles met the eligibility criteria. After reading the title and abstract, 20 articles were selected. After reading the full texts, 12 articles remained and after the reverse search, 18 articles were finally selected. The studies reported a 50% prevalence of burnout, all three dimensions of which were heightened by the COVID-19 pandemic. Analysis of the study findings revealed an inverse association between burnout and job satisfaction. CONCLUSIONS: Job dissatisfaction of ICU nurses depends on lack of experience, working conditions or working environment among others. ICU nurses with lower job satisfaction have higher levels of burnout. IMPLICATIONS FOR CLINICAL PRACTICE: This meta-analysis shows the potential value of job satisfaction on improving health outcomes related to burnout syndrome for nursing professional in Intensive Care Units. Different factors that could increase job satisfaction and consequently protect them from suffering high levels of burnout, such as salary, permanence in the service, mental health care are the responsibility of the hospital supervisor and, finally, of the own Health System. Knowledge of a risk profile based on the factors influencing job dissatisfaction would enable the implementation of effective workplace interventions to reduce or prevent the risk of burnout. Health policies should focus on protecting the worker, so in addition to improving working conditions, it would be interesting to promote coping skills in order to improve the quality of care and patient safety.
123Physician and Nurse Well-Being and Preferred Interventions to Address Burnout in Hospital Practice: Factors Associated With Turnover, Outcomes, and Patient Safety.PubMed
Linda H Aiken, Karen B Lasater, Douglas M Sloane, et al.
JAMA Health Forum. 2023 Jul 7;4(7):e231809. doi: 10.1001/jamahealthforum.2023.1809.
IMPORTANCE: Disruptions in the hospital clinical workforce threaten quality and safety of care and retention of health professionals. It is important to understand which interventions would be well received by clinicians to address the factors associated with turnover. OBJECTIVES: To determine well-being and turnover rates of physicians and nurses in hospital practice, and to identify actionable factors associated with adverse clinician outcomes, patient safety, and clinicians' preferences for interventions. DESIGN, SETTING, AND PARTICIPANTS: This was a cross-sectional multicenter survey study conducted in 2021 with 21 050 physicians and nurses at 60 nationally distributed US Magnet hospitals. Respondents described their mental health and well-being, associations between modifiable work environment factors and physician and nurse burnout, mental health, hospital staff turnover, and patient safety. Data were analyzed from February 21, 2022, to March 28, 2023. MAIN OUTCOMES AND MEASURES: Clinician outcomes (burnout, job dissatisfaction, intent to leave, turnover), well-being (depression, anxiety, work-life balance, health), patient safety, resources and work environment adequacy, and clinicians' preferences for interventions to improve their well-being. RESULTS: The study sample comprised responses from 15 738 nurses (mean [SD] age, 38.4 [11.7] years; 10 887 (69%) women; 8404 [53%] White individuals) practicing in 60 hospitals, and 5312 physicians (mean [SD] age, 44.7 [12.0] years; 2362 [45%] men; 2768 [52%] White individuals) practicing in 53 of the same hospitals, with an average of 100 physicians and 262 nurses per hospital and an overall clinician response rate of 26%. High burnout was common among hospital physicians (32%) and nurses (47%). Nurse burnout was associated with higher turnover of both nurses and physicians. Many physicians (12%) and nurses (26%) rated their hospitals unfavorably on patient safety, reported having too few nurses (28% and 54%, respectively), reported having a poor work environment (20% and 34%, respectively), and lacked confidence in management (42% and 46%, respectively). Fewer than 10% of clinicians described their workplace as joyful. Both physicians and nurses rated management interventions to improve care delivery as more important to their mental health and well-being than interventions directed at improving clinicians' mental health. Improving nurse staffing was ranked highest among interventions (87% of nurses and 45% of physicians). CONCLUSIONS AND RELEVANCE: This cross-sectional survey study of physicians and nurses practicing in US Magnet hospitals found that hospitals characterized as having too few nurses and unfavorable work environments had higher rates of clinician burnout, turnover, and unfavorable patient safety ratings. Clinicians wanted action by management to address insufficient nurse staffing, insufficient clinician control over workload, and poor work environments; they were less interested in wellness programs and resilience training.
124Whole-system approaches to improving the health and wellbeing of healthcare workers: A systematic review.PubMed
Sarah L Brand, Jo Thompson Coon, Lora E Fleming, et al.
PLoS One. 2017 Dec 4;12(12):e0188418. doi: 10.1371/journal.pone.0188418. eCollection 2017.
BACKGROUND: Healthcare professionals throughout the developed world report higher levels of sickness absence, dissatisfaction, distress, and "burnout" at work than staff in other sectors. There is a growing call for the 'triple aim' of healthcare delivery (improving patient experience and outcomes and reducing costs; to include a fourth aim: improving healthcare staff experience of healthcare delivery. A systematic review commissioned by the United Kingdom's (UK) Department of Health reviewed a large number of international healthy workplace interventions and recommended five whole-system changes to improve healthcare staff health and wellbeing: identification and response to local need, engagement of staff at all levels, and the involvement, visible leadership from, and up-skilling of, management and board-level staff. OBJECTIVES: This systematic review aims to identify whole-system healthy workplace interventions in healthcare settings that incorporate (combinations of) these recommendations and determine whether they improve staff health and wellbeing. METHODS: A comprehensive and systematic search of medical, education, exercise science, and social science databases was undertaken. Studies were included if they reported the results of interventions that included all healthcare staff within a healthcare setting (e.g. whole hospital; whole unit, e.g. ward) in collective activities to improve physical or mental health or promote healthy behaviours. RESULTS: Eleven studies were identified which incorporated at least one of the whole-system recommendations. Interventions that incorporated recommendations to address local need and engage the whole workforce fell in to four broad types: 1) pre-determined (one-size-fits-all) and no choice of activities (two studies); or 2) pre-determined and some choice of activities (one study); 3) A wide choice of a range of activities and some adaptation to local needs (five studies); or, 3) a participatory approach to creating programmes responsive and adaptive to local staff needs that have extensive choice of activities to participate in (three studies). Only five of the interventions included substantial involvement and engagement of leadership and efforts aimed at up-skilling the leadership of staff to support staff health and wellbeing. Incorporation of more of the recommendations did not appear to be related to effectiveness. The heterogeneity of study designs, populations and outcomes excluded a meta-analysis. All studies were deemed by their authors to be at least partly effective. Two studies reported statistically significant improvement in objectively measured physical health (BMI) and eight in subjective mental health. Six studies reported statistically significant positive changes in subjectively assessed health behaviours. CONCLUSIONS: This systematic review identified 11 studies which incorporate at least one of the Boorman recommendations and provides evidence that whole-system healthy workplace interventions can improve health and wellbeing and promote healthier behaviours in healthcare staff.
125Violence Against Physicians in the Workplace: Trends, Causes, Consequences, and Strategies for Intervention.PubMed
Rosangela Caruso, Tommaso Toffanin, Federica Folesani, et al.
Curr Psychiatry Rep. 2022 Dec;24(12):911-924. doi: 10.1007/s11920-022-01398-1. Epub 2022 Nov 29.
PURPOSE: Violence against healthcare professionals has become an emergency in many countries. Literature in this area has mainly focused on nurses while there are less studies on physicians, whose alterations in mental health and burnout have been linked to higher rates of medical errors and poorer quality of care. We summarized peer-reviewed literature and examined the epidemiology, main causes, consequences, and areas of intervention associated with workplace violence perpetrated against physicians. RECENT FINDINGS: We performed a review utilizing several databases, by including the most relevant studies in full journal articles investigating the problem. Workplace violence against doctors is a widespread phenomenon, present all over the world and related to a number of variables, including individual, socio-cultural, and contextual variables. During the COVID-19 pandemic, incidence of violence has increased. Data also show the possible consequences in physicians' deterioration of quality of life, burnout, and traumatic stress which are linked to physical and mental health problems, which, in a domino effect, fall on patients' quality of care. Violence against doctors is an urgent global problem with consequences on an individual and societal level. This review highlights the need to undertake initiatives aimed at enhancing understanding, prevention, and management of workplace violence in healthcare settings.
126[Huge barriers to the treatment of mental disorders in low-income countries].PubMed
Carina Winkler Sørensen, Ole Bæk, Jessica Carlsson, et al.
Ugeskr Laeger. 2015 Aug 3;177(32):V09140514.
In low-income countries 76-85% of people living with mental disorders do not receive treatment. To reduce the treatment gap many challenges need to be addressed. On a health political level this includes limited financial resources and ineffective health organization. Human resources are inadequate, and often drugs are not available. Individuals face long distances to psychiatric hospitals, out-of-pocket payment and stigma. There is a great need for research in how to enhance prevention and treatment of mental disorders in low-income countries.
127Challenges and Opportunities in Global Mental Health: a Research-to-Practice Perspective.PubMed
Milton L Wainberg, Pamela Scorza, James M Shultz, et al.
Curr Psychiatry Rep. 2017 May;19(5):28. doi: 10.1007/s11920-017-0780-z.
PURPOSE OF REVIEW: Globally, the majority of those who need mental health care worldwide lack access to high-quality mental health services. Stigma, human resource shortages, fragmented service delivery models, and lack of research capacity for implementation and policy change contribute to the current mental health treatment gap. In this review, we describe how health systems in low- and middle-income countries (LMICs) are addressing the mental health gap and further identify challenges and priority areas for future research. RECENT FINDINGS: Common mental disorders are responsible for the largest proportion of the global burden of disease; yet, there is sound evidence that these disorders, as well as severe mental disorders, can be successfully treated using evidence-based interventions delivered by trained lay health workers in low-resource community or primary care settings. Stigma is a barrier to service uptake. Prevention, though necessary to address the mental health gap, has not solidified as a research or programmatic focus. Research-to-practice implementation studies are required to inform policies and scale-up services. Four priority areas are identified for focused attention to diminish the mental health treatment gap and to improve access to high-quality mental health services globally: diminishing pervasive stigma, building mental health system treatment and research capacity, implementing prevention programs to decrease the incidence of mental disorders, and establishing sustainable scale up of public health systems to improve access to mental health treatment using evidence-based interventions.
128Implementing the World Health Report 2001 recommendations for integrating mental health into primary health care: a situation analysis of three African countries: Ghana, South Africa and Uganda.PubMed
Arvin Bhana, Inge Petersen, Kim L Baillie, et al.
Int Rev Psychiatry. 2010;22(6):599-610. doi: 10.3109/09540261.2010.536152.
Integrating mental health into primary health care is widely promoted for a host of reasons, chief among which is providing a more comprehensive health care service. However, only a few countries have adequate mental health resources to undertake the integration of mental health into primary health care in a uniform manner, with wide variations among countries. This paper examines the extent to which two low-income countries (Ghana and Uganda) and one middle-income country (South Africa) are managing the integration of mental health into primary health care using the recommendations of the WHO World Health Report, 2001. Primary and secondary data sources from a situational analysis of mental health services in the three countries were analysed. The findings indicate that significant challenges remain in integrating mental health care into primary health care. Poor or uneven implementation of policy, inadequate access to essential drugs and lack of mental health specialists are some of the reasons advanced. Aside from better human resource planning for mental health, integration may be advanced by the development of packages of care which adopt a task-shifting approach suited to a country's needs.
129Strengthening mental health services in Sierra Leone: perspectives from within the health system.PubMed
Jessica J Fitts, Fatmata Gegbe, Mark S Aber, et al.
Health Policy Plan. 2020 Jul 1;35(6):657-664. doi: 10.1093/heapol/czaa029.
Though mental and substance use disorders are a leading cause of disability worldwide, mental health systems are vastly under-resourced in most low- and middle-income countries and the majority of people with serious mental health needs receives no formal treatment. Despite international calls for the integration of mental health into routine care, availability of outpatient mental health services and integration of mental health into the broader healthcare system remain weak in many countries. Efforts to strengthen mental healthcare systems must be informed by the local context, with attention to key health system components. The current study is a qualitative analysis of stakeholder perspectives on mental health system strengthening in one low-income country, Sierra Leone. It utilizes locally grounded knowledge from frontline healthcare providers to identify constraints and opportunities for strengthening mental health care within each component of the health system. In-depth semi-structured interviews were conducted with 43 participants including doctors, nurses, community health workers, mental health advocates, mental health specialists, and traditional healers recruited from the Bo, Moyamba and Western Area Urban Districts. Interview transcripts were content-coded in NVivo using both a priori and emergent codes and aggregated into broader themes, utilizing the World Health Organization Health Systems Framework. Participants described an extremely limited system of mental health care, with constraints and obstacles within each health system component. Participants identified potential strategies to help overcome these constraints. Findings reinforce the importance of factors outside of the healthcare system that shape the implementation of mental health initiatives, including pervasive stigma towards mental illness, local conceptualizations of mental illness and an emphasis on traditional treatment approaches. Implications for mental health initiatives in Sierra Leone and other low-income countries include a need for investment in primary care clinics to support integrated mental health services and the importance of engaging communities to promote the utilization of mental health services.
130Evolving Models of Integrated Behavioral Health and Primary Care.PubMed
Parashar Ramanuj, Erin Ferenchik, Mary Docherty, et al.
Curr Psychiatry Rep. 2019 Jan 19;21(1):4. doi: 10.1007/s11920-019-0985-4.
PURPOSE OF REVIEW: Mental and physical disorders commonly co-occur leading to higher morbidity and mortality in people with mental and substance use disorders (collectively called behavioral health disorders). Models to integrate primary and behavioral health care for this population have not yet been implemented widely across health systems, leading to efforts to adapt models for specific subpopulations and mechanisms to facilitate more widespread adoption. RECENT FINDINGS: Using examples from the UK and USA, we describe recent advances to integrate behavioral and primary care for new target populations including people with serious mental illness, people at the extremes of life, and for people with substance use disorders. We summarize mechanisms to incentivize integration efforts and to stimulate new integration between health and social services in primary care. We then present an outline of recent enablers for integration, concentrating on changes to funding mechanisms, developments in quality outcome measurements to promote collaborative working, and pragmatic guidance aimed at primary care providers wishing to enhance provision of behavioral care. Integrating care between primary care and behavioral health services is a complex process. Established models of integrated care are now being tailored to target specific patient populations and policy initiatives developed to encourage adoption in particular settings. Wholly novel approaches to integrate care are significantly less common. Future efforts to integrate care should allow for flexibility and innovation around implementation, payment models that support delivery of high value care, and the development of outcome measures that incentivize collaborative working practices.
131Measurement-Based Care: A Practical Strategy Toward Improving Behavioral Health Through Primary Care.PubMed
Andrew D Carlo, Kelli S Scott, Clare McNutt, et al.
J Gen Intern Med. 2025 Feb;40(3):677-681. doi: 10.1007/s11606-024-08877-6. Epub 2024 Oct 8.
Behavioral health care access is inadequate and new primary care-based strategies are needed to meet the rising demand. Behavioral health integration (BHI) models, such as collaborative care (CoCM) or the primary care behavioral health (PCBH) model, are often touted as actionable and sustainable solutions. The intent of such models is to bring behavioral health expertise into medical settings with the aims of improving outcomes, increasing treatment capacity, and reducing stigma. BHI models differ across several parameters, though measurement-based care (MBC) is a key component of virtually all effective approaches. MBC employs the repeated and timely use of validated instruments to inform medical decision-making for individual patients at the point of care and has a demonstrated association with improved outcomes. MBC generally has more flexibility for workflow development and fewer financial, staffing, and IT requirements than CoCM, PCBH, or other models. It can also be implemented by primary medical providers independently. Recent encouraging developments include technical assistance opportunities for MBC implementation and emerging payment models that emphasize MBC. However, concerns remain surrounding the limitations of existing MBC billing codes. Ultimately, with continued advocacy and thoughtful policy decision-making, MBC has the potential to be a solution to the current behavioral health crisis.
132A Review of Integrated Care for Concurrent Disorders: Cost Effectiveness and Clinical Outcomes.PubMed
Venu Karapareddy
J Dual Diagn. 2019 Jan-Mar;15(1):56-66. doi: 10.1080/15504263.2018.1518553. Epub 2019 Feb 26.
The recognition of concurrent disorders (combined mental health and substance use disorders) has increased substantially over the last three decades, leading to greater numbers of people with these diagnoses and a subsequent greater financial burden on the health care system, yet establishing effective modes of management remains a challenge. Further, there is little evidence on which to base recommendations for a particular mode of health service delivery. This paper will further summarize the existing treatment models for a comprehensive overview. The objectives of this study are to determine whether existing service models are effective in treating combined mental health and substance use disorders and to examine whether an integrated model of service delivery should be recommended to policy makers. The following two research questions are the focus of this paper: (1) Are the existing service models effective at treating mental health and substance use disorders? (2) How are existing service models effective at treating mental health and substance use disorders? We used various databases to systematically review the effectiveness of service delivery models to treat concurrent disorders. Models were considered effective if they are found to be cost-effective and significantly improve clinical and social outcomes. This systematic review revealed that integrated models of care are more effective than conventional, nonintegrated models. Integrated models demonstrated superiority to standard care models through reductions in substance use disorders and improvement of mental health in patients who had diagnoses of concurrent disorders. Our meta-analysis revealed similar findings, indicating that the integrated model is more cost-effective than standard care. Given the limited number of studies in relation to service delivery for concurrent disorders, it is too early to make a strong evidence-based recommendation to policy makers and service providers as to the superiority of one approach over the others. However, the available evidence suggests that integrated care models for concurrent disorders are the most effective models for patient care. More research is needed, especially around the translation of research findings to policy development and, vice versa, around the translation from the policy level to the patients' level.
133Dual diagnosis: A systematic review of the organization of community health services.PubMed
Claudia Fantuzzi, Roberto Mezzina
Int J Soc Psychiatry. 2020 May;66(3):300-310. doi: 10.1177/0020764019899975. Epub 2020 Jan 20.
BACKGROUND: Dual diagnosis (DD), as the co-occurrence of a substance use disorder and a psychiatric disorder, is underestimated, under-diagnosed and often poorly treated throughout the world, although it is highly prevalent in people suffering from a mental disorder. AIMS AND METHODS: This review analyzed 48 studies from a PubMed and PsycINFO databases search, in order to verify the state of the art regarding the organization of community health services for DD treatment. RESULTS: Four macro-themes have been identified: service organization, critical issues, assessment tools and evidence-based interventions. An effective service recognizes the complexity of DD, promotes a common staff culture, and tailors the organization to local needs. The main critical issues in its implementation include the lack of specific staff training, the poor management of resources and the need for greater personalization of care plans, with attention to psychosocial interventions. Integrated service assessment tools can be used as a benchmark measure at the program level for implementation planning and at the national level to affect policy change. The integrated treatment model for DD should also aim to improve access to care and offer treatments based on scientific evidence. It is also evident that the integration of services can improve outcomes but it is not a guarantee for it. CONCLUSION: There is an urgent need to improve networking between mental health and addiction services in order to deal with DD and create new integrated intervention models, paying attention to an approach to the whole person, seen in his/her absolute uniqueness.
134Climate change and mental health: a causal pathways framework.PubMed
Helen Louise Berry, Kathryn Bowen, Tord Kjellstrom
Int J Public Health. 2010 Apr;55(2):123-32. doi: 10.1007/s00038-009-0112-0. Epub 2009 Dec 22.
OBJECTIVES: Climate change will bring more frequent, long lasting and severe adverse weather events and these changes will affect mental health. We propose an explanatory framework to enhance consideration of how these effects may operate and to encourage debate about this important aspect of the health impacts of climate change. METHODS: Literature review. RESULTS: Climate change may affect mental health directly by exposing people to trauma. It may also affect mental health indirectly, by affecting (1) physical health (for example, extreme heat exposure causes heat exhaustion in vulnerable people, and associated mental health consequences) and (2) community wellbeing. Within community, wellbeing is a sub-process in which climate change erodes physical environments which, in turn, damage social environments. Vulnerable people and places, especially in low-income countries, will be particularly badly affected. CONCLUSIONS: Different aspects of climate change may affect mental health through direct and indirect pathways, leading to serious mental health problems, possibly including increased suicide mortality. We propose that it is helpful to integrate these pathways in an explanatory framework, which may assist in developing public health policy, practice and research.
135Climate Change and Mental Health: Implications for the Psychiatric Workforce.PubMed
Alison R Hwong, Emily A Kuhl, Wilson M Compton, et al.
Psychiatr Serv. 2022 May;73(5):592-595. doi: 10.1176/appi.ps.202100227. Epub 2021 Aug 9.
Climate change is a major global public mental health crisis that is expected to increase the need for mental health services. Psychiatrists and other mental health care providers must address workforce needs through recruitment, training and education, prevention and intervention, public policy and advocacy, and direct efforts to reduce climate change. This column discusses concrete steps for the psychiatric workforce to take to prepare for growing mental health needs associated with climate change.
136Mental health and climate change in Bangladesh.PubMed
Nazish Arman, Salowa Salam Shaoli, Saima Hossain
Int Rev Psychiatry. 2022 Aug;34(5):513-515. doi: 10.1080/09540261.2022.2093100.
Climate change adversely impacts the health and well-being of billions of people worldwide and will increasingly do so over the next few decades. Although all populations are at risk, some are more vulnerable than others. It is therefore critical to increase resilience to climate-related risks and build the capacity of national health systems by considering climate risks in health policy and decision making, strengthening leadership and governance to address impacts, and implementing strategies to build climate-resilient health care systems.
137The 2022 report of the Lancet Countdown on health and climate change: health at the mercy of fossil fuels.PubMed
Marina Romanello, Claudia Di Napoli, Paul Drummond, et al.
Lancet. 2022 Nov 5;400(10363):1619-1654. doi: 10.1016/S0140-6736(22)01540-9. Epub 2022 Oct 25.
UNLABELLED: The 2022 report of the Countdown is published as the world confronts profound and concurrent systemic shocks. Countries and health systems continue to contend with the health, social, and economic impacts of the COVID-19 pandemic, while Russia’s invasion of Ukraine and a persistent fossil fuel overdependence has pushed the world into global energy and cost-of-living crises. As these crises unfold, climate change escalates unabated. Its worsening impacts are increasingly affecting the foundations of human health and wellbeing, exacerbating the vulnerability of the world’s populations to concurrent health threats. During 2021 and 2022, extreme weather events caused devastation across every continent, adding further pressure to health services already grappling with the impacts of the COVID-19 pandemic. Floods in Australia, Brazil, China, western Europe, Malaysia, Pakistan, South Africa, and South Sudan caused thousands of deaths, displaced hundreds of thousands of people, and caused billions of dollars in economic losses. Wildfires caused devastation in Canada, the USA, Greece, Algeria, Italy, Spain, and Türkiye, and record temperatures were recorded in many countries, including Australia, Canada, India, Italy, Oman, Türkiye, Pakistan, and the UK. With advancements in the science of detection and attribution studies, the influence of climate change over many events has now been quantified. Because of the rapidly increasing temperatures, vulnerable populations (adults older than 65 years, and children younger than one year of age) were exposed to 3·7 billion more heatwave days in 2021 than annually in 1986–2005 (indicator 1.1.2), and heat-related deaths increased by 68% between 2000–04 and 2017–21 (indicator 1.1.5), a death toll that was significantly exacerbated by the confluence of the COVID-19 pandemic. Simultaneously, the changing climate is affecting the spread of infectious diseases, putting populations at higher risk of emerging diseases and co-epidemics. Coastal waters are becoming more suitable for the transmission of Vibrio pathogens; the number of months suitable for malaria transmission increased by 31·3% in the highland areas of the Americas and 13·8% in the highland areas of Africa from 1951–60 to 2012–21, and the likelihood of dengue transmission rose by 12% in the same period (indicator 1.3.1). The coexistence of dengue outbreaks with the COVID-19 pandemic led to aggravated pressure on health systems, misdiagnosis, and difficulties in management of both diseases in many regions of South America, Asia, and Africa. The economic losses associated with climate change impacts are also increasing pressure on families and economies already challenged with the synergistic effects of the COVID-19 pandemic and the international cost-of-living and energy crises, further undermining the socioeconomic determinants that good health depends on. Heat exposure led to 470 billion potential labour hours lost globally in 2021 (indicator 1.1.4), with potential income losses equivalent to 0·72% of the global economic output, increasing to 5·6% of the GDP in low Human Development Index (HDI) countries, where workers are most vulnerable to the effects of financial fluctuations (indicator 4.1.3). Meanwhile, extreme weather events caused damage worth US$253 billion in 2021, particularly burdening people in low HDI countries in which almost none of the losses were insured (indicator 4.1.1). Through multiple and interconnected pathways, every dimension of food security is being affected by climate change, aggravating the impacts of other coexisting crises. The higher temperatures threaten crop yields directly, with the growth seasons of maize on average 9 days shorter in 2020, and the growth seasons of winter wheat and spring wheat 6 days shorter than for 1981–2010 globally (indicator 1.4). The threat to crop yields adds to the rising impact of extreme weather on supply chains, socioeconomic pressures, and the risk of infectious disease transmission, undermining food availability, access, stability, and utilisation. New analysis suggests that extreme heat was associated with 98 million more people reporting moderate to severe food insecurity in 2020 than annually in 1981–2010, in 103 countries analysed (indicator 1.4). The increasingly extreme weather worsens the stability of global food systems, acting in synergy with other concurrent crises to reverse progress towards hunger eradication. Indeed, the prevalence of undernourishment increased during the COVID-19 pandemic, and up to 161 million more people faced hunger during the COVID-19 pandemic in 2020 than in 2019. This situation is now worsened by Russia’s invasion of Ukraine and the energy and cost-of-living crises, with impacts on international agricultural production and supply chains threatening to result in 13 million additional people facing undernutrition in 2022. A DEBILITATED FIRST LINE OF DEFENCE: With the worsening health impacts of climate change compounding other coexisting crises, populations worldwide increasingly rely on health systems as their first line of defence. However, just as the need for healthcare rises, health systems worldwide are debilitated by the effects of the COVID-19 pandemic and the energy and cost-of-living crises. Urgent action is therefore needed to strengthen health-system resilience and to prevent a rapidly escalating loss of lives and to prevent suffering in a changing climate. However, only 48 (51%) of 95 countries reported having assessed their climate change adaptation needs (indicator 2.1.1) and, even after the profound impacts of COVID-19, only 60 (63%) countries reported a high to very high implementation status for health emergency management in 2021 (indicator 2.2.4). The scarcity of proactive adaptation is shown in the response to extreme heat. Despite the local cooling and overall health benefits of urban greenspaces, only 277 (27%) of 1038 global urban centres were at least moderately green in 2021 (indicator 2.2.3), and the number of households with air conditioning increased by 66% from 2000 to 2020, a maladaptive response that worsens the energy crisis and further increases urban heat, air pollution, and greenhouse gas emissions. As converging crises further threaten the world’s life-supporting systems, rapid, decisive, and coherent intersectoral action is essential to protect human health from the hazards of the rapidly changing climate. HEALTH AT THE MERCY OF FOSSIL FUELS: The year 2022 marks the 30th anniversary of the signing of the UN Framework Convention on Climate Change, in which countries agreed to prevent dangerous anthropogenic climate change and its deleterious effects on human health and welfare. However, little meaningful action has since followed. The carbon intensity of the global energy system has decreased by less than 1% since the UNFCCC was established, and global electricity generation is still dominated by fossil fuels, with renewable energy contributing to only 8·2% of the global total (indicator 3.1). Simultaneously, the total energy demand has risen by 59%, increasing energy-related emissions to a historical high in 2021. Current policies put the world on track to a catastrophic 2·7°C increase by the end of the century. Even with the commitments that countries set in the Nationally Determined Contributions (NDCs) updated up until November 2021, global emissions could be 13·7% above 2010 levels by 2030—far from the 43% decrease from current levels required to meet Paris Agreement goals and keep temperatures within the limits of adaptation. Fossil fuel dependence is not only undermining global health through increased climate change impacts, but also affects human health and wellbeing directly, through volatile and unpredictable fossil fuel markets, frail supply chains, and geopolitical conflicts. As a result, millions of people do not have access to the energy needed to keep their homes at healthy temperatures, preserve food and medication, and meet the seventh Sustainable Development Goal (to ensure access to affordable, reliable, sustainable, and modern energy for all). Without sufficient support, access to clean energy has been particularly slow in low HDI countries, and only 1·4% of their electricity came from modern renewables (mostly wind and solar power) in 2020 (indicator 3.1). An estimated 59% of healthcare facilities in low and middle-income countries still do not have access to the reliable electricity needed to provide basic care. Meanwhile, biomass accounts for as much as 31% of the energy consumed in the domestic sector globally, mostly from traditional sources—a proportion that increases to 96% in low HDI countries (indicator 3.2). The associated burden of disease is substantial, with the air in people’s homes exceeding WHO guidelines for safe concentrations of small particulate air pollution (PM) in 2020 by 30-fold on average in the 62 countries assessed (indicator 3.2). After 6 years of improvement, the number of people without access to electricity increased in 2020 as a result of the socioeconomic pressures of the COVID-19 pandemic. The current energy and cost-of-living crises now threaten to reverse progress toward affordable, reliable, and sustainable energy, further undermining the socioeconomic determinants of health. Simultaneously, oil and gas companies are registering record profits, while their production strategies continue to undermine people’s lives and wellbeing. An analysis of the production strategies of 15 of the world’s largest oil and gas companies, as of February 2022, revealed they exceed their share of emissions consistent with 1·5°C of global heating (indicator 4.2.6) by 37% in 2030 and 103% in 2040, continuing to undermine efforts to deliver a low carbon, healthy, liveable future. Aggravating this situation even further, governments continue to incentivise fossil fuel production and consumption: 69 (80%) of 86 countries reviewed had net-negative carbon prices (ie, provided a net subsidy to fossil fuels) for a net total of US$400 billion in 2019, allocating amounts often comparable with or even exceeding their total health budgets (indicator 4.2.4). Simultaneously, wealthier countries failed to meet their commitment of mobilising the considerably lower sum of $100 billion annually by 2020 as agreed at the 2009 Copenhagen Accord to support climate action in “developing countries”, and climate efforts are being undercut by a profound scarcity of funding (indicator 2.1.1). The impacts of climate change on global economies, together with the recession triggered by COVID-19 and worsened by geopolitical instability, could paradoxically further reduce the willingness of countries to allocate the funds needed to enable a just climate transition. A HEALTH-CENTRED RESPONSE FOR A THRIVING FUTURE: The world is at a critical juncture. With countries facing concurrent crises, the implementation of long-term emissions-reduction policies risks being deflected or defeated by challenges wrongly perceived as more immediate. Addressing each of the concurrent crises in isolation risks alleviating one, while worsening another. Such a situation is emerging from the response to COVID-19, which has so far has not delivered the green recovery that the health community proposed, and, on the contrary, is aggravating climate change-related health risks. Less than one third of $3·11 trillion allocated to COVID-19 economic recovery is likely to reduce greenhouse gas emissions or air pollution, with the net effect likely to increase emissions. The COVID-19 pandemic affected climate action at the city level, and 239 (30%) of 798 cities reported that COVID-19 reduced financing available for climate action (indicator 2.1.3). As countries search for alternatives to Russian oil and gas, many continue to favour the burning of fossil fuels, with some even turning back to coal. Shifts in global energy supplies threaten to increase fossil fuel production. Even if implemented as a temporary transition, these responses could reverse progress on air quality improvement, irreversibly push the world off track from meeting the commitments set out in the Paris Agreement, and guarantee a future of accelerated climate change that threatens human survival. On the contrary, in this pivotal moment, a health-centred response to the current crises would still provide the opportunity for a low-carbon, resilient future, which not only avoids the health harms of accelerated climate change, but also delivers improved health and wellbeing through the associated co-benefits of climate action. Such response would see countries promptly shifting away from fossil fuels, reducing their dependence on fragile international oil and gas markets, and accelerating a just transition to clean energy sources. A health-centred response would reduce the likelihood of the most catastrophic climate change impacts, while improving energy security, creating an opportunity for economic recovery, and offering immediate health benefits. Improvements in air quality would help to prevent the 1·2 million deaths resulting from exposure to fossil fuel-derived ambient PM in 2020 alone (indicator 3.3), and a health-centred energy transition would enhance low-carbon travel and increase urban green spaces, promoting physical activity, and improving physical and mental health. In the food sector, an accelerated transition to balanced and more plant-based diets would not only help reduce the 55% of agricultural sector emissions coming from red meat and milk production (indicator 3.5.1), but also prevent up to 11·5 million diet-related deaths annually (indicator 3.5.2), and substantially reduce the risk of zoonotic diseases. These health-focused shifts would reduce the burden of communicable and non-communicable diseases, reducing the strain on overwhelmed health-care providers. Importantly, accelerating climate change adaptation would lead to more robust health systems, minimising the negative impacts of future infectious disease outbreaks and geopolitical conflicts, and restoring the first line of defence of global populations. EMERGING GLIMMERS OF HOPE: Despite decades of insufficient action, emerging, albeit few, signs of change provide some hope that a health-centred response might be starting to emerge. Individual engagement with the health dimensions of climate change, essential to drive and enable an accelerated response, increased from 2020 to 2021 (indicator 5.2), and coverage of health and climate change in the media reached a new record high in 2021, with a 27% increase from 2020 (indicator 5.1). This engagement is also reflected by country leaders, with a record 60% of 194 countries focusing their attention on the links between climate change and health in the 2021 UN General Debate, and with 86% of national updated or new NDCs making references to health (indicator 5.4). At the city level, local authorities are progressively identifying risks of climate change on the health of their populations (indicator 2.1.3), a first step to delivering a tailored response that strengthens local health systems. Although the health sector is responsible for 5·2% of all global emissions (indicator 3.6), it has shown impressive climate leadership, and 60 countries had committed to transitioning to climate-resilient and/or low-carbon or net-zero carbon health systems as part of the COP26 Health Programme, as of July, 2022. Signs of change are also emerging in the energy sector. Although total clean energy generation remains grossly insufficient, record high levels were reached in 2020 (indicator 3.1). Zero-carbon sources accounted for 80% of investment in electricity generation in 2021 (indicator 4.2.1), and renewable energies have reached cost parity with fossil fuel energies. As some of the highest emitting countries attempt to cut their dependence on oil and gas in response to the war in Ukraine and soaring energy prices, many are focusing on increasing renewable energy generation, raising hopes for a health-centred response. However, increased awareness and commitments should be urgently translated into action for hope to turn into reality. A CALL TO ACTION: After 30 years of UNFCCC negotiations, the Countdown indicators show that countries and companies continue to make choices that threaten the health and survival of people in every part of the world. As countries devise ways to recover from the coexisting crises, the evidence is unequivocal. At this critical juncture, an immediate, health-centred response can still secure a future in which world populations can not only survive, but thrive.