mental health literature review example

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

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

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

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

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

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

Conclusions

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

Peer Review reports

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

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

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

Stage 1: identify the research question

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

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

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

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

Stage 2: identify the relevant studies

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

Stage 3: literature selection

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

PRISMA Flow Diagram

Stage 4: charting the data

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

Stage 5: collating, summarizing, and reporting the results

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

Characteristics of included literature

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

Number of sources by characteristics of included literature

Frequency of themes in literature ( n  = 91)

Mental health concerns and their prevalence in the literature

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

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

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

Causes of mental health concerns

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

Effects of mental health concerns on physicians and patients

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

Solutions and interventions

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

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

Barriers to seeking and providing care

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

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

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

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

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

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

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

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

Availability of data and materials

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

Abbreviations

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

United States of America

World Health Organization

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

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

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Our current understanding of the efficacy of psychological interventions in improving mental states of wellbeing is incomplete. This study aimed to overcome limitations of previous reviews by examining the efficacy of distinct types of psychological interventions, irrespective of their theoretical underpinning, and the impact of various moderators, in a unified systematic review and meta-analysis. Four-hundred-and-nineteen randomized controlled trials from clinical and non-clinical populations ( n  = 53,288) were identified for inclusion. Mindfulness-based and multi-component positive psychological interventions demonstrated the greatest efficacy in both clinical and non-clinical populations. Meta-analyses also found that singular positive psychological interventions, cognitive and behavioural therapy-based, acceptance and commitment therapy-based, and reminiscence interventions were impactful. Effect sizes were moderate at best, but differed according to target population and moderator, most notably intervention intensity. The evidence quality was generally low to moderate. While the evidence requires further advancement, the review provides insight into how psychological interventions can be designed to improve mental wellbeing.

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Acknowledgements

The authors thank colleagues at the South Australian Health and Medical Research Institute, Wellbeing and Resilience Centre, for their support during the creation of this review, S. Brown and N. May, for their help in crafting the search strategy. This work was supported by a grant by the James and Diana Ramsay Foundation. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

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van Agteren, J., Iasiello, M., Lo, L. et al. A systematic review and meta-analysis of psychological interventions to improve mental wellbeing. Nat Hum Behav 5 , 631–652 (2021). https://doi.org/10.1038/s41562-021-01093-w

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Peer Support in Mental Health: Literature Review

Authors of this article:

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

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

*all authors contributed equally

Corresponding Author:

Reham A Hameed Shalaby, MD

Department of Psychiatry

University of Alberta

1E1 Walter Mackenzie Health Sciences Centre

8440 112 St NW

Edmonton, AB, T6G 2B7

Phone: 1 4034702050

Email: [email protected]

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

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

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

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

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

Introduction

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

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

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

Definitions

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

Origin and Growth of Peer Support

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

Transformational Concepts in Peer Support Service

Intentional peer support: informal to formal peer support evolution.

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

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

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

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

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

The Transformation From Patient to Peer Support Providers

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

Effects of Peer Support Service in Different Contexts

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

Severe or Serious Mental Illness

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

Addiction and Drug Users

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

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

Forensic Peer Support Service

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

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

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

Youth and Adolescents

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

Medically and Socially Disadvantaged Subgroups

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

Persons With Disabilities

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

Peer Support for Families

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

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

Peer Support Service in Low- and Middle-Income Countries

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

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

The Conceptual Framework for the Effects of Peer Support Service

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

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

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

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

Peer Support Workers’ Satisfaction and Challenges

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

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

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

Novel Technology in Peer Support Service (Online and Telephone)

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

Future of Peer Support Services

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

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

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

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

Acknowledgments

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

Conflicts of Interest

None declared.

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Abbreviations

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

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

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

Clinical Mental Health Counseling

• Choosing a Topic
• Developing a Research Question
• Determine Keywords
• Find Articles
• Database Search Strategies
• Using Google Scholar
• Open Educational Resources (OERs)
• Evaluate Sources
• Cite Sources This link opens in a new window
• Annotated Bibliography
• Zotero This link opens in a new window

Writing a Literature Review

Synthesis visualization.

• Statistics & Assessment
• CMH Websites
• CMH Organizations

Literature Review Class Activity

Lit review matrix, lit review organizer, lit review worksheet 1, lit review worksheet 2, lit review worksheet 3, lit review template, click on the activity link above, select file > make a copy, complete the activity on  your copy, online resources.

Basics of a Literature Review (Merrimack College's Writing Center)

Library Guide to Capstone Literature Reviews: Role of the Literature Review

University of Toronto

This one is customized for Higher Education students, but may be helpful for others.

This page from Walden University gives examples of different types of literature review matrices. A matrix can be very helpful in taking notes and preparing sources for your literature review.

OWL's Literature Reviews

UW - Madison, Writing Center

UNC at Chapel Hill's Literature Reviews

What Is a Literature Review? 

A literature review is a survey of scholarly articles, books, or other sources that pertain to a specific topic, area of research, or theory. The literature review offers brief descriptions, summaries, and critical evaluations of each work, and does so in the form of a well-organized essay. Scholars often write literature reviews to provide an overview of the most significant recent literature published on a topic. They also use literature reviews to trace the evolution of certain debates or intellectual problems within a field. Even if a literature review is not a formal part of a research project, students should conduct an informal one so that they know what kind of scholarly work has been done previously on the topic that they have selected. 

How Is a Literature Review Different from a Research Paper? 

An academic research paper attempts to develop a new argument and typically has a literature review as one of its parts. In a research paper, the author uses the literature review to show how his or her new insights build upon and depart from existing scholarship. A literature review by itself does not try to make a new argument based on original research but rather summarizes, synthesizes, and critiques the arguments and ideas of others, and points to gaps in the current literature. Before writing a literature review, a student should look for a model from a relevant journal or ask the instructor to point to a good example. 

Organizing a Literature Review  

A successful literature review should have three parts that break down in the following way: 

INTRODUCTION 

• Defines and identifies the topic and establishes the reason for the literature review. 
• Points to general trends in what has been published about the topic. 
• Explains the criteria used in analyzing and comparing articles. 

BODY OF THE REVIEW 

• Groups articles into thematic clusters, or subtopics. Clusters may be grouped together chronologically, thematically, or methodologically (see below for more on this).
• Proceeds in a logical order from cluster to cluster. 
• Emphasizes the main findings or arguments of the articles in the student’s own words. Keeps quotations from sources to an absolute minimum. 

CONCLUSION 

• Summarizes the major themes that emerged in the review and identifies areas of controversy in the literature. 
• Pinpoints strengths and weaknesses among the articles (innovative methods used, gaps in research, problems with theoretical frameworks, etc.). 
• Concludes by formulating questions that need further research within the topic, and provides some insight into the relationship between that topic and the larger field of study or discipline. 

In the four examples of student writing below, only one shows a good example of synthesis: the fourth column, Student D. (Click on the image below to see larger)

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Recommendation 22 Literature Review Summary

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

Literature Review Findings

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

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

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

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

Implications for Practice 

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

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

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• Ghana Med J
• v.46(2 Suppl); 2012 Jun

Mental Health Research in Ghana: A Literature Review

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

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

Context/Background

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

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

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

Conclusions

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

Introduction

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

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

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

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

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

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

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

Papers excluded from the review

Reviewed papers by topic

Epidemiology

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

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

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

chizophrenia/psychosis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Suicide and self-harm

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

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

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

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

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

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

Substance misuse

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

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

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

Help-seeking

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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• Volume 5, Issue 1
• Systematic review of mental health and well-being outcomes following community-based obesity prevention interventions among adolescents
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• Erin Hoare 1 , 2 ,
• Matthew Fuller-Tyszkiewicz 3 ,
• Helen Skouteris 3 ,
• Lynne Millar 1 , 2 ,
• Melanie Nichols 2 ,
• Steven Allender 2
• 1 School of Health and Social Development, Deakin University , Geelong, Victoria , Australia
• 2 WHO Collaborating Centre for Obesity Prevention, Deakin University , Burwood, Victoria , Australia
• 3 School of Psychology, Deakin University , Burwood, Victoria , Australia
• Correspondence to Erin Hoare; ejhoa{at}deakin.edu.au

Objectives This paper aimed to systematically evaluate the mental health and well-being outcomes observed in previous community-based obesity prevention interventions in adolescent populations.

Setting Systematic review of literature from database inception to October 2014. Articles were sourced from CINAHL, Global Health, Health Source: Nursing and Academic Edition, MEDLINE, PsycARTICLES and PsycINFO, all of which were accessed through EBSCOhost. The Cochrane Database was also searched to identify all eligible articles. PRISMA guidelines were followed and search terms and search strategy ensured all possible studies were identified for review.

Participants Intervention studies were eligible for inclusion if they were: focused on overweight or obesity prevention, community-based, targeted adolescents (aged 10–19 years), reported a mental health or well-being measure, and included a comparison or control group. Studies that focused on specific adolescent groups or were treatment interventions were excluded from review. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines.

Primary and secondary outcome measures Primary outcomes were measures of mental health and well-being, including diagnostic and symptomatic measures. Secondary outcomes included adiposity or weight-related measures.

Results Seven studies met the inclusion criteria; one reported anxiety/depressive outcomes, two reported on self-perception well-being measures such as self-esteem and self-efficacy, and four studies reported outcomes of quality of life. Positive mental health outcomes demonstrated that following obesity prevention, interventions included a decrease in anxiety and improved health-related quality of life. Quality of evidence was graded as very low.

Conclusions Although positive outcomes for mental health and well-being do exist, controlled evaluations of community-based obesity prevention interventions have not often included mental health measures (n=7). It is recommended that future interventions incorporate mental health and well-being measures to identify any potential mechanisms influencing adolescent weight-related outcomes, and equally to ensure interventions are not causing harm to adolescent mental health.

• MENTAL HEALTH
• PUBLIC HEALTH
• PREVENTIVE MEDICINE

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

https://doi.org/10.1136/bmjopen-2014-006586

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Strengths and limitations of this study

This study was the first to systematically review mental health outcomes following community-based obesity prevention interventions among adolescents.

This study ensured rigorous methodology by following PRISMA guidelines and evaluated quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines to allow findings to be interpreted with respect to the quality of studies in which they are found.

A limitation of this review was that a meta-analysis was not possible due to study heterogeneity in differing components of the interventions and different measures of mental health outcomes at follow-up.

Study biases may be present due to interventions having the primary outcome of weight reduction; therefore, mental health measures at outcome may have been under-reported or not reported at all.

Adolescent obesity prevention remains a high priority given negative health consequences of overweight/obesity both during adolescence and later in life. It has been suggested that prevention efforts should be community-based to meet the complex and multidimensional nature of obesity. 1 , 2 Importantly, recent research also suggests that there is a high comorbidity between poor mental health and obesity and this may reflect some shared underlying mechanisms and common potentially modifiable risk factors. 3 , 4 Changes in physical activity and diet patterns have been linked to mental health outcomes and compelling evidence suggests that unhealthy weight-related risk factors are bi-directionally associated with common mental health disorders. 5 There is potential then that interventions aiming to promote healthy weight among adolescents may also impact on mental health and well-being outcomes.

Overweight and obesity treatment programmes appear to have positive psychological impacts for children and adolescents; a systematic review examining the impact of weight management programmes on self-esteem found that despite variance in methodology and treatment design, there were overall positive effects for self-esteem following weight treatment programmes in paediatric overweight populations. 6 This review highlighted the importance of considering both physical and emotional health outcomes from weight-based treatment for overweight adolescents. A second review examined the psychological outcomes of weight loss following behavioural and diet interventions in overweight/obese populations 7 finding that improvements in body image and health-related quality of life were consistently associated with weight loss.

Given weight-related stigma and particular sensitivity to body image concerns during adolescence, it is also important to ensure overweight/obesity focused programmes are not causing psychological harm to participants. O'Dea 8 identified the importance of prevention versus treatment for obesity, emphasising that prevention initiatives must encompass all the dimensions of a child's health and that other healthy behaviours should not be forfeited in place overweight and obesity prevention. Care must be taken to avoid further stigmatising overweight and obese young people, and to ensure the health messages delivered in obesity prevention interventions do not damage any other domains of health, such as normal eating behaviours, or self-esteem.

One systematic review 9 examined prevention of mental disorders in children, adolescents and adults, with studies included if they included interventions aimed at positively affecting mental health outcomes. Interventions were mostly based on cognitive behavioural therapy/counselling sessions, drug therapy or prosocial behaviour management programmes. This review did not examine obesity prevention interventions. One other review 10 examined mental health and wellness in relation to the prevention of childhood obesity in studies from January 2000 to January 2011. This review identified that psychosocial emotional health is one of the most neglected areas of study in childhood overweight/obesity and that many recommendations focus on physical outcomes such as body mass index, ignoring the impact on psychological or social well-being. Three systematic reviews have examined community-based obesity prevention studies in children and adolescents; however, none of these reviews investigated mental health and well-being outcomes either as intentional effects or side effects of the interventions. 11–13

Currently, our understanding of mental health outcomes in obesity prevention interventions is limited because existing systematic reviews are limited to specific high-risk groups such as individuals classified as overweight or obese, 7 , 10 individuals undergoing weight management 6 or mental health treatment programmes. 9 For community-based obesity prevention interventions, previous reviews have focused solely on weight status outcomes, and none have reported mental health and well-being outcomes. 11–13 It remains unknown whether positive mental health effects have been achieved following such interventions and whether obesity prevention interventions protect mental health and well-being to ensure no harm has been done.

Despite emerging empirical evidence highlighted above, there is not yet a clear synthesis of the literature relating to the effect of obesity prevention interventions on mental health outcomes. Without this understanding, efforts to target and protect mental health in such interventions are limited. The purpose of this systematic review is to evaluate the mental health outcomes following community-based obesity prevention interventions among adolescents, and develop a set of recommendations for future interventions. This review is limited to controlled studies.

The specific questions addressed in this review were:

What mental health and well-being outcomes have been examined in community-based obesity prevention interventions for adolescents and what do the findings reveal?

What limitations exist in the research to date and what recommendations can be made for future interventions?

Inclusion/exclusion criteria.

The search was designed to identify studies that were community-based obesity prevention interventions, targeting adolescent populations. Community-based interventions were defined as those that target a group of individuals or a geographic community but are not aimed at a single individual. This included cities, schools and community healthcare centres. It did not include clinical settings. Adolescence was defined as the period including and between 10–19 years as defined by the WHO. Studies that were randomised control trials (RCTs), quasi-experimental and natural experiments were eligible for selection. Inclusion criteria were (1) primary research; (2) overweight or obesity prevention interventions; (3) community-based; (4) targeted adolescent population; (5) mental health measure reported at baseline and follow-up; (6) included a comparison or control group and (7) were published through October 2014. Exclusion criteria were (1) obesity treatment/management interventions; (2) targeted children or adult populations and (3) focused on specific high risk (such as overweight/obese adolescents), or that were designed to suit specific demographics such those living in rural areas. Studies were not excluded based on ethnicity. This review was focused on interventions to prevent overweight and obesity, and therefore studies examining eating disorders and underweight management were not eligible for review. Exclusion criteria were set to ensure studies examining adolescents who were representative of the broader population were sourced.

Definitions of outcomes

Mental health and well-being outcomes included any diagnosed psychopathologies, or symptoms of psychopathologies (eg, depression or depressive symptoms). Given that obesity prevention interventions have rarely investigated psychological and cognitive mediators, 14 studies that included health-related quality of life, self-efficacy and other psychosocial factors were eligible for inclusion. Owing to outcome measures utilising different measurement tools, there were no principle summary measures set. The overall findings in relation to mental health and well-being were summarised individually and combined.

Search strategy

Articles for this review were sourced from CINAHL, Global Health, Health Source: Nursing and Academic Edition, MEDLINE, PsycARTICLES and PsycINFO, all of which were accessed through EBSCOhost. In addition, the same search was also performed on the Cochrane Database to ensure all relevant articles were screened for eligibility. The search was limited to peer-reviewed paper published from database inception through October 2014. A range of search terms was used to maximise the yield of the search for studies that conducted a community-based obesity prevention intervention among adolescents and included a mental health or well-being measure. Search terms were selected based on components of obesity prevention interventions, community settings and mental health/well-being outcomes. Mental health and well-being outcomes are described in more detail in the following section. The full search strategy including search terms can be found in figure 1 . The reference lists of selected articles and reference lists of other systematic reviews were screened by two independent authors to identify all relevant articles for potential study selection. Disagreements in study selection were resolved by a third reviewer. The studies included in the previously mentioned systematic reviews 10–13 examining community-based obesity preventions were scanned to determine whether they included adolescent samples, and if so, the original article was sourced and the full text was assessed for eligibility.

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Search terms and strategy used in CINAHL, Global Health, Health Source: Nursing and Academic Edition, MEDLINE, PsycARTICLES and PsycINFO, all of which were accessed through EBSCOhost. In addition, the same search was also performed on the Cochrane Database to ensure all relevant articles were screened for eligibility.

Data extraction and data synthesis

Two authors (EH and LM) screened titles, abstracts and reference lists for potential inclusion in this review. Forty-one articles were selected for full-text review to assess eligibility for inclusion. A standardised form for data extraction was created for study aim, characteristics, participants, intervention type, outcome measures and main findings ( table 1 ). Data were synthesised by categorising the components of the obesity prevention intervention and by the mental health outcome the study examined ( table 2 ). Mental health outcomes at follow-up were extracted and used as the main findings for this review. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system ( table 3 ). 15

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Interventions designed to prevent overweight/obesity that include mental health outcomes in adolescents

Mental health outcomes (shaded) and community-based obesity prevention components of reviewed studies

Assessment of quality of studies based on mental health and well-being outcome using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system

Summary of included studies

The search strategy yielded 621 abstracts through EBSCOhost and 140 studies through Cochrane Database which were screened by authors for possible inclusion. After screening, 46 full-text articles were selected and examined in detail to determine eligibility. A further 39 articles were excluded at this stage; 14 studies did not include mental health outcome measures, 23–36 14 studies sampled specific adolescent groups such as those at risk or already overweight/obese, 37–45 disadvantaged or sedentary adolescents, 46 , 47 or younger or older age groups, 48–50 six studies did not include an intervention design with a comparison or control group, 51–56 two studies failed to report mental health measures at follow-up, 29 , 57 two studies sampled from specific communities such a rural 58 or low-income schools, 59 and one study focused on disordered eating behaviours 60 leaving seven eligible studies for review. See figure 2 for flow chart process of article inclusion. A list of excluded studies with reasons for exclusion can be found in online supplementary table S1.

Flow diagram of studies that were identified using the search terms and strategy, articles screened for eligibility, included/excluded with reasons, following PRISMA guidelines.

Quality of evidence according to the GRADE rating system is summarised in table 3 . Owing to significant limitations in study design, inconsistency, lack of directness and sparse data for outcome of mental health disorders/symptoms the overall quality of evidence was very low. A full description of the GRADE rating system is described in Balshem et al 15

Two interventions took place in the USA, 17 , 19 and one each in France, 21 Australia, 20 Tonga, 16 Fiji 18 and New Zealand. 22 The details pertaining to study aim, intervention, design and outcomes are outlined in table 1 . The mental health domains measured in each study are summarised in table 2 . Six of the seven reviewed studies had samples consisting of close to half (40–55%) males. 16–18 , 20–22 One study had higher proportions of females at 72%. 19

Community-based obesity prevention interventions

Design methodology of the reviewed interventions included RCTs 17 , 19 , 21 and quasi-experimental studies. 16 , 18 , 20 , 22 Four of the reviewed studies had interventions that lasted 2–3 years, 16 , 18 , 20 , 22 and the other studies lasted 1 year, 17 6 months 21 and 9 weeks. 19 The interventions took place in schools 16 , 18–22 and in the general community 17 and shared similar specific intervention components; increased opportunities for adolescents to engage in physical activities and healthy eating behaviours; included educational sessions in relation to physical activity, nutrition and behaviours promoting healthy weight; targeted environmental aspects such as increased water fountains in school or improved canteen quality, and incorporated counselling or psychology sessions in relation to healthy living (see table 2 ). Community capacity building for obesity prevention was an explicit component in four of the reviewed studies. Four of the interventions 17–20 successfully reduced or prevented unhealthy weight in adolescents based on significant changes in weight from preintervention to postintervention. Two studies resulted in no significant effect in anthropometry postintervention. 16 , 22 One study 21 did not report anthropometric outcomes at follow-up.

Each of the seven interventions included a mental health measurement as an outcome, which fell into one or more of the following categories: mental health disorders (including depression and anxiety), health-related quality of life and self-perception referring to one's beliefs about oneself including self-concept, self-worth, self-esteem, body satisfaction and physical self-worth. Findings for each mental health outcome are discussed in detail below. Owing to heterogeneity in population characteristics, intervention components, outcome measures and duration of interventions, it was not possible to complete a meta-analysis.

Mental health outcomes measured in community-based obesity prevention interventions

Mental health disorders/symptoms.

Mental health disorders were examined as outcomes in one of the reviewed studies. 19 Melnyk et al 19 reported a moderate decrease in anxiety symptoms, as indicated by the Beck Youth Inventory ( BYI ) 61 from preintervention to postintervention (d=−0.56, p<0.05) in adolescents following a 9-week healthy lifestyles programme. The intervention consisted of 15 50 min sessions based on educational information on healthy lifestyles, strategies to build self-esteem, nutrition and physical activity. No significant mean difference was observed for depressive symptoms (Cohen's d=−0.32, p=0.11).

Health-related quality of life

All four of the Pacific Obesity Prevention in Communities (OPIC) studies 16 , 18 , 20 , 22 measured health-related quality of life by the Adolescent Quality of Life Inventory (AQoL) 62 and Pediatric Quality of Life Inventory (PedsQoL). 63 Fotu et al 16 found that health-related quality of life increased in the intervention group at follow-up according to one measure (PedsQoL), however, remained significantly lower in the intervention group compared with the comparison group (p<0.001). Similarly, Kremer et al 18 found the intervention group had smaller increase in health-related quality of life compared with the comparison group (p<0.05) following a 3-year comprehensive school-based obesity prevention project. The other two OPIC studies, set in Geelong, Australia, 20 and Auckland, New Zealand, 22 did not find significant changes in HRQoL from baseline to follow-up in either measure.

Self-perception

Two obesity prevention intervention studies among adolescents have included self-perception as an outcome measure. 17 , 21 Huang et al 17 assessed self-esteem using the Rosenberg Self-Esteem Scale 64 and found no significant differences between intervention and control groups following a 1-year intervention targeting physical activity, sedentary and diet behaviours. Simon et al 21 assessed self-efficacy with self-reported questions scored on a six-point Likert scale, and found no significant differences in self-efficacy between comparison and intervention groups following a 6-month programme aimed at preventing excessive weight gain by promoting physical activity.

What mental health and well-being outcomes have been examined in community-based obesity prevention interventions for adolescents and what do findings reveal?

An examination of the literature on obesity prevention interventions targeting adolescents in community settings reveals that the following mental health outcomes have been reported: anxiety and depressive symptoms, health-related quality of life, body image, self-worth and self-esteem. Obesity prevention interventions that have included mental health measures as outcomes have taken place most commonly in school settings (n=7) and have had the primary focus on anthropometry at follow-up. The GRADE quality of evidence assessment revealed very low quality of evidence for mental health disorders or symptoms, and low quality of evidence for health-related quality of life and self-perception.

Findings of mental health outcomes following community-based obesity prevention interventions were mixed. A significant decrease in anxiety symptoms was found in the intervention group compared with controls following a 9-week healthy lifestyle intervention; however, no significant differences were found in depressive symptoms. 19 Of the four studies that examined health-related quality of life, two 16 , 18 found significant increases postintervention; however, these increases were smaller than increases observed in the control groups. The other two studies 20 , 22 that examined health-related quality of life did not find any significant changes in health-related quality of life following 3-year obesity prevention interventions in school settings. Two studies found no significant differences in self-esteem or self-efficacy following a 1-year 17 and 6-month 21 intervention. Common characteristics across the interventions that demonstrated positive mental health outcomes were: inclusion of a physical exercise component, education components targeting healthy living behaviours (specifically healthy eating and physical activity), group-based sessions aimed at both healthy living and provision of opportunities for adolescents to engage in meaningful activities that promote personal development (such as mastery, friendships, leadership). Mechanisms contributing to significant findings are difficult to identify due to heterogeneity in interventions delivered to adolescents.

Interventions that included a cognitive behavioural component, or that were theoretically based on cognitive behavioural theory, 21 , 65 showed positive findings in promotion of mental health and well-being. Cognitive behavioural approach refers to the thoughts and beliefs in relation to behaviour, and this approach is widely accepted as a beneficial therapy for mental health disorders. 66–68 Research suggests that adolescents who have stronger beliefs/confidence about their ability to engage in healthy lifestyle behaviours and perceive them as less difficult to perform are more likely to engage in more healthy choices. 19 Similarly, opportunities for adolescents to participate in physical activity or diet-related activities provide mastery experience. Bandura 69 outlined mastery experience as key in the theory of self-efficacy as this experience builds beliefs about capabilities to produce behaviours that exercise influence over events that affect their lives. Adolescents with greater perceived self-efficacy may be better equipped to maintain healthy lifestyles and deal with adversity such as mental health problems.

Importantly, there were some findings that suggested that intervention groups experienced poorer mental health following obesity prevention interventions compared with control groups. 16 , 18 Authors in one study acknowledged a potential explanation being that the schools that made up the intervention sample were located in a more urbanised main island in Tonga. 16 These students may have been exposed to more pressure in terms of achieving high examination results and obtaining employment or overseas tertiary education, compared with the less-urbanised outer island that made up the comparison sample. This may have been a result of biases in sampling technique, however exposes the need for targeted interventions to suit the specific needs of communities, as previously identified as a priority in obesity prevention. 70 Additionally, these findings may reflect negative consequences of the obesity prevention interventions. Potential psychological harm due to obesity interventions has been raised in previous research. 8 These results demonstrate the need to assess mental health to ensure no harm is being done to adolescents, and also highlights the importance of incorporating explicit aims to protect mental health of participants involved in such interventions.

As identified in this review, there is evidence for positive mental health outcomes following community-based obesity prevention interventions; however, the number of interventions incorporating mental health measures is few (n=7). The findings of this systematic review demonstrate the dearth of evidence: there were 14 studies excluded from this review for not including a mental health measure, and two studies that included a measure but failed to report the mental health outcomes at follow-up. Given the comorbidity between overweight/obesity and obesogenic behaviours with mental and emotional health, 4 , 5 , 71 and the increased vulnerability to both unhealthy weight and mental health problems during adolescence, 72 , 73 future interventions should aim to include mental health measures to assess the impact such interventions are having on participant's mental health and well-being. In addition, the issue of directionality still remains in relation to changes in obesogenic behaviours and mental health, and risk factors that may be common to both conditions. Sample biases exist in the reviewed studies with majority of interventions taking place at school 16 , 18–22 and consequently overlooking those adolescents who do not attend school and may represent a population in need of mental health support. Additionally, two 16 , 22 of the seven reviewed studies did not find significant improvements in weight status postintervention, and therefore were not successful in meeting their primary obesity-related aims. The implications of these null findings are outside the scope of this review, however may limit the extent to which mental health can be evaluated as an outcome of the reviewed interventions, given that the effectiveness of interventions’ obesity prevention was varied.

Finally, the current review categorised mental health outcomes by disorders, health-related quality of life or self-perception. The extent to which results can be compared is limited by use of different mental health instruments. Mental disorders, for example, have been measured by diagnostic tools indicating presence of a disorder and also symptomatic measures that indicate suspected presence of disorder symptoms. Such differences affect findings as outcomes vary greatly depending on mental health measures being used.

This review has some limitations. As discussed in the GRADE quality of evidence assessment, many studies published have included less than optimal study designs and this may have biased the findings presented here. As the primary aim of obesity prevention interventions is to reduce or prevent weight gain, this may have led to mental health outcomes being under-reported or not reported at all. Eligible interventions may therefore have not been included in the analysis because of a lack of published data. A further limitation of this review was that a meta-analysis could not be performed due to heterogeneity in the reviewed studies.

This systematic review was also limited in focusing solely on obesity prevention interventions that were community-based. Studies conducted in clinical settings were excluded from this review and these studies may have provided important insight into the mental health and well-being. Previous research examining mental health in clinical settings have discussed psychosocial issues such as weight stigmatisation, and the negative impact this has on client's emotional health. 74 Within clinical settings, there also appears to be psychological benefits such as improved body image and health-related quality of life, however these issues have been under-reported due to being considered secondary to the primary aim of obesity prevention, 75 which reflects the findings found in the current review.

Despite limitations this study has a number of strengths. There was a range of obesity prevention interventions included in this review including differences in duration, components and country where the intervention took place. The review process was systematic and all studies included were assessed based on strict eligibility and exclusion criteria and robust review methods were used including the searching of multiple databases to ensure all relevant articles were included in this review. The inclusion of the GRADE quality of evidence assessment ensured that the findings presented here could be considered in relation to the quality of research in which they are found.

Future research needs to build on what is already known about the effect of community-based obesity prevention interventions on mental health outcomes in adolescents, as the mechanisms affecting these outcomes are yet to be clearly defined. Mental health is strongly recommended to become a primary outcome of obesity prevention interventions, as potential benefits do exist, however rarely have mental health measures been evaluated (or reported) in community-based interventions. Additionally, two of the reviewed interventions were not successful in reducing or preventing unhealthy weight gain and future research should evaluate the mental health and well-being of adolescents alongside the efficaciousness of obesity prevention initiatives, to highlight potential shared underlying mechanisms.

Conclusions

Comorbidity between poor mental health and poor physical health is well established 76 and evidence for successful community-based obesity prevention strategies among adolescents is growing. A focus now needs to be placed on mental health of adolescents in these interventions. It is recommended that obesity prevention interventions incorporate mental health measures to monitor the mental health and well-being of adolescents. This review supports a shift in thinking around mental health, from a secondary outcome of these interventions to a primary outcome alongside overweight and obesity, to ensure that the mechanisms leading to comorbidity can be identified and outcomes can be improved through these interventions. In addition, including such measures can allow care to be taken to ensure that community-based obesity prevention initiatives do not have adverse effects on adolescents’ mental health.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Files in this Data Supplement:

• Data supplement 1 - Online supplement

Contributors EH contributed to the conception and design of the study, performed the literature search, extracted and analysed data, and drafted and revised the manuscript. MF-T and HS contributed to the conception and design of the study, analysed data, critically revised the manuscript and approved the final draft. LM screened articles for eligibility for review. LM and MN were involved in drafting the manuscript, critically revising the piece and approved the final draft. SA critically revised the manuscript and approved the final draft for publication.

Funding SA is supported by funding from an Australian National Health and Medical Research Council/Australian National Heart Foundation Career Development Fellowship (APP1045836). SA is a researcher on the US National Institutes of Health grant titled Systems Science to Guide Whole-of-Community Childhood Obesity Interventions (1R01HL115485-01A1). SA is a researcher within a NHMRC Centre for Research Excellence in Obesity Policy and Food Systems (APP1041020).

Competing interests None.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

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