mental health issues literature review

A systematic review: increasing mental health literacy in students through “The Guide”

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• Published: 14 August 2024
• Volume 4 , article number  96 , ( 2024 )

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• Abouzar Nazari   ORCID: orcid.org/0000-0003-2155-5438 1 ,
• Gholamreza Garmaroudi   ORCID: orcid.org/0000-0001-7449-227X 2 &
• Marzie Rabiei   ORCID: orcid.org/0009-0003-2297-9483 3  

Ensuring mental health literacy among students aged 10–25 is of utmost importance, and the efficacy of educational programs in this domain holds significant value. This systematic review assesses the influence of The Guide (Mental Health and High School Curriculum Guide) on mental health literacy within this demographic.

Materials and methods

This review examined how effective The Guide was in increasing students’ mental health literacy, help-seeking attitudes, and stigma reduction. It also looked at what factors influenced its implementation and sustainability in different settings. It followed the PRISMA guidelines and searched for studies that used The Guide or a modified version of it with students aged 10–25 from 1975 to 2023. Studies were assessed for quality using the QuADS Quality Appraisal tool.

Our systematic review encompassed a comprehensive analysis of 10 reports derived from five primary articles originating from six countries, with a combined participant pool of 4298 individuals. The selected studies exhibited variations in design, duration, delivery modes, and outcome measures. The synthesized findings underscored the positive impact of The Guide educational program on enhancing students' mental health literacy. However, the effects on students' help-seeking attitudes and stigma were varied. Additionally, the results illuminated that the success and sustainability of The Guide were contingent on several factors, including the mode of delivery, the role of facilitators or teachers, and the unique characteristics of the student population.

The review showed that The Guide was effective in improving students’ mental health literacy in different settings. It also suggested that The Guide needed to be adapted and tailored to the local context and culture, and that the facilitators or teachers and the students needed to be trained and involved in the process.

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1 Introduction

Mental health literacy (MHL), defined as the ability to recognize, understand, and respond to mental health problems, plays a pivotal role in promoting awareness, reducing stigma, and facilitating help-seeking behaviors [ 1 , 2 ]. Unlike traditional illness-based models, MHL interventions such as The Guide adopt a population-based approach, focusing on equipping individuals with knowledge and skills pertinent to mental health across diverse contexts [ 3 ].

Children and youth represent a critical target group for MHL interventions, given their susceptibility to mental health challenges and potential barriers to accessing appropriate care [ 4 , 5 ]. Globally, a substantial proportion of young people experience mental health disorders, yet access to professional support remains limited [ 4 , 5 , 6 , 7 , 8 ]. Enhancing MHL among youth empowers them to identify mental health issues, seek timely assistance, and dispel misconceptions that perpetuate stigma [ 9 ].

Stigma, characterized by labeling, devaluation, and discrimination based on perceived differences, profoundly impacts young people’s mental outcomes. It hinders help-seeking behaviors and diminishes self-esteem, exacerbating the challenges of managing mental health issues [ 10 ]. Effective MHL interventions, such as The Guide, have the potential to mitigate stigma by promoting accurate understanding, positive attitudes, and empathetic responses toward mental health concerns [ 1 , 11 ].

Educational interventions represent a cornerstone in delivering MHL education to youth, aiming to cultivate informed attitudes and encourage proactive help-seeking behaviors [ 12 , 13 ]. The effectiveness of these interventions, however, varies based on content, delivery methods, and evaluation frameworks [ 14 ]. The Guide, an educational program derived from the Mental Health and High School Curriculum Guide (MHHSCG) [ 15 ], is specifically designed to meet these objectives within educational settings. Notably, while rooted in educational contexts, The Guide's adaptable format allows for potential implementation in diverse environments such as workplaces and communities, albeit with necessary adjustments to suit specific needs and dynamics.

This systematic review aims to assess the impact of The Guide educational program on enhancing MHL among individuals aged 10–25 across various settings. Specifically, this review seeks to: (1) identify and evaluate the quality of studies examining The Guide's effectiveness in improving MHL; (2) synthesize findings regarding MHL outcomes including knowledge, stigma, and help-seeking attitudes; (3) explore factors influencing The Guide's implementation and sustainability in different settings; and (4) discuss implications for research, policy, and practical applications.

2.1 Search strategy

This systematic review, following PRISMA (Preferred Reporting Items for Systematic Reviews) guidelines, employed a comprehensive search strategy to identify relevant studies. The search was conducted in February 2023, covering five key databases: PubMed, Web of Science, Scopus, Cochrane Library, and Embase. The inclusion criteria were English language articles published between 2009 and 2023. To ensure a thorough examination of the existing literature, reference lists of all included studies and relevant review articles were meticulously scrutinized. Unpublished data, grey literature (including dissertations, congress abstracts, and patents), and duplicate citations were excluded from this systematic review. Each database received a tailored search string, adapted to its unique requirements. Supplementary material 1 provides an example of the search string used in PubMed. Additionally, combined keyword searching was implemented with the following terms: ‘Mental health literacy OR (Mental health AND literacy)’ AND ‘Student* OR Adolescen* OR Youth OR Pupil OR Teen* OR School* OR Child*’ AND ‘Clinical Trial OR Randomized controlled trial OR Non-Randomized Controlled Trials OR Controlled Clinical Trial OR randomized OR randomly OR pre posttest study OR quasi-experimental’. Notably, Google Scholar, along with selected reference lists, was also explored to identify additional studies of interest beyond the initial database searches. It’s crucial to highlight that Google Scholar searches complemented academic database searches, contributing to a more comprehensive retrieval of relevant literature. This systematic review is registered on PROSPERO under the registration number CRD42023314882.

2.2 Eligibility criteria

2.2.1 inclusion criteria.

Studies eligible for inclusion addressed individuals aged 10–25 years old, employing study designs such as randomized controlled trials, non-randomized controlled trials, experimental, or before-and-after studies. Included studies delivered the intervention program of The Guide or its modified versions. Additionally, studies were required to have a control group or provide an intervention as treatment as usual. Eligible studies assessed help-seeking intentions/attitudes, mental health-related stigma, and/or mental health literacy directly through the self-report of young people. Language inclusion criteria stipulated that studies must be published in English.

2.2.2 Exclusion criteria

Conversely, studies were excluded if they lacked information about participants' age. Additionally, studies with observational designs or those without random allocation were not considered. Interventions other than The Guide or studies with no intervention were excluded. Lack of a control group led to exclusion, as did outcomes assessed from caregivers or teachers, or those measuring dimensions other than help-seeking intentions/attitudes, mental health-related stigma, or mental health literacy. Lastly, studies published in languages other than English were excluded. This comprehensive set of criteria ensured a meticulous selection process, aiming for a focused and relevant body of evidence in the systematic review.

2.2.3 Selection of studies

The titles and abstracts of the retrieved records were screened by two independent reviewers (A.N. and M.R.) using the eligibility criteria. The full texts of the potentially eligible records were obtained and assessed by the same reviewers. Any disagreements were resolved by discussion or consultation with a third reviewer (GH.G.). A PRISMA flow diagram was used to report the study selection process.

2.2.4 Data extraction

The data extracted from the included studies are summarized in Table  1 . The data extracted included: first author’s name, publication year, study population, sample size, participants’ sex, number of subjects in each group, age range and average age of participants, trial design, type of intervention, and Posttest time.

2.2.5 Risk of bias assessment

The assessment of the risk of bias was conducted using the Quality Assessment and Developmental Evaluation (QuADS) tool [ 16 ] which is designed to appraise the quality and risk of bias in systematic reviews of mixed- or multi-method studies. The tool comprises eight aspects, each scored from 0 to 3, with the total score indicating the overall quality level of the study. Studies were categorized as excellent (above 80%), good (between 50 and 80%), or low (below 50%) based on their total scores. The risk of bias assessment was conducted by the review team, including A.N. and M.R., with a focus on various aspects such as research aims, settings, populations, designs, analytic methods, and the consideration of research stakeholders’ perspectives. The risk of bias assessment was considered in the interpretation of findings, ensuring that the conclusions drawn accounted for the quality and reliability of the evidence. Studies with a high risk of bias were noted, and their findings were interpreted with caution, particularly in terms of their contribution to overall conclusions.

2.2.6 Data synthesis

Narrative synthesis was utilized to analyze and interpret the results derived from the studies included in this review. This approach entailed qualitatively summarizing the findings, identifying patterns, variations, and relationships across the studies. The synthesis specifically delved into examining the impact of The Guide on outcomes such as mental health literacy, help-seeking attitudes, and mental health-related stigma. Given that no meta-analysis or moderator analysis was conducted in the review, the synthesis predominantly relied on a qualitative narrative approach to offer a comprehensive overview of the evidence. Any discerned patterns or trends were discussed within the framework of the study objectives, elucidating their implications for research, policy, and practice.

2.2.7 Intervention description

The Guide, developed in 2009 as an adaptation of the Mental Health & High School Curriculum Guide (MHHSCG), is a modular web-based resource designed to enhance mental health literacy among youth aged 10–25 [ 14 , 15 ]. It consists of six core modules covering topics such as understanding mental health, recognizing symptoms, seeking help, and reducing stigma. Each module incorporates interactive activities, case studies, and resources tailored to educational contexts, facilitating engagement and knowledge retention among users.

The literature search yielded a total of 1234 records, of which 462 were duplicates and were removed. 734 were excluded after screening the titles and abstracts. The full texts of the remaining 42 studies were assessed for eligibility, and 5 studies [ 17 , 18 , 19 , 20 , 21 ] met the inclusion criteria and it's noteworthy that one of the articles included two reports due to the study being conducted in two different countries and reported separately in one article. The main reasons for exclusion were: not using The Guide as the intervention, not having a control group, and outside the age range of 10–25. The PRISMA flow diagram [ 22 ] of the study selection process is shown in Fig.  1 .

PRISMA 2020 flow diagram updated of papers included in the review Improving mental health literacy in students aged 10–25 with The Guide educational program: A systematic review, search period: 1975 to February 2023

A new literature search was conducted to update the previous review and identify any new studies that evaluated the effectiveness of The Guide. The new search resulted in 130 records from various databases and sources. After removing 35 duplicates, 60 records were excluded based on the screening of titles and abstracts. The remaining 42 full-text records were assessed for eligibility using the same criteria as the previous review. Only 2 studies [ 23 , 24 ] met all the criteria and were added to the review. The reasons for exclusion were the same as the previous review.

The characteristics, quality, and risk of bias of the included studies are summarized in Table  1 and Supplementary material 2. The studies were conducted in eight different countries: Iran, Ethiopia, Vietnam, Cambodia, Nicaragua, Canada, Germany, and Wales. The study population comprised students aged 10–25 from various educational settings, including schools, colleges, universities, and community organizations. The total sample size across all studies was 7420 participants, with a proportion of female participants ranging from 50 to 100%. The mean age of participants across studies was 15.93 years.

The study design was either randomized controlled trial (RCT), quasi-experimental design, or pre-post evaluation. The intervention was The Guide or a modified version of it. The duration of the intervention ranged from 2 to 12 weeks, with a mean of 8.14 weeks. The total time of the intervention ranged from 5 to 14 h, with a mean of 10.16 h (One of the studies reported the duration of the intervention as 1 day). The intervention was delivered either online or in-person by trained facilitators or teachers.

The outcome measures were validated instruments or scales for mental health literacy or help-seeking attitudes and stigma, such as the Mental Health Literacy Scale (MHL), the Mental Health Knowledge Schedule (MHK), the Mental Health Knowledge and Attitude Scale (MHKAS), the Attitudes Towards Seeking Professional Psychological Help Scale (ATMI), the Mental health knowledge (MHK), the Knowledge and Attitudes to Mental Health Scales (KAMHS) or the Mental Health Knowledge and Awareness Assessment (MHKAA). The Posttest time ranged from immediately after the intervention to 6 months later.

The quality and risk of bias of the included studies were assessed using the QuADS Quality Appraisal [ 16 ]. The overall quality and risk of bias of the studies were moderate to high, with some concerns in domains such as randomization, allocation concealment, blinding, attrition, measurement, reporting, and confounding. The study by Simkiss [ 23 ] in Wales had the highest quality score (97%), while the study by Zare [ 17 ] in Iran had the lowest quality score (61%). A detailed breakdown of these assessments is provided in Supplementary Material 2.

The data from the included studies were synthesized using a narrative approach. The main findings are reported below according to the research questions and hypotheses.

The Table  2 shows the mean change and standard deviation of the outcome measures for the intervention and control groups in six studies. The outcome measures were mental health knowledge, attitudes, literacy, or stigma. The intervention group received The Guide or a modified version of it, while the control group received no intervention, usual care, or another intervention. The table also shows the p-value of the difference between the intervention and control groups, which indicates the statistical significance of the difference.

3.1 Effectiveness of The Guide in improving mental health literacy

Zare [ 17 ] measured it using a self-developed questionnaire and found that the intervention group had a mean change of 54.08 (7.70), while the control group had a mean change of 1.28 (6.09). The difference was statistically significant (p < 0.001). Hassen [ 18 ] measured mental health literacy using the Mental Health Literacy Questionnaire and found that the intervention group had a mean change of 27.41 (19.55), while the control group had a mean change of 20.98 (16.54). The difference was statistically significant (p < 0.05). This result suggests that The Guide improved students’ mental health literacy more than the control group, which received no intervention or usual care.

Nguyen [ 19 ] measured it using the MHL-Knowledge scale and found that the intervention group had a mean change of 0.06 (0.11) in Vietnam and 0.04 (0.09) in Cambodia, while the control group had a mean change of 0.01 (0.07) in Vietnam and − 0.02 (0.08) in Cambodia. The difference was statistically significant in both countries (p < 0.05). Ravindran [ 20 ] measured it using the MHKAS-Knowledge scale and found that the intervention group had a mean change of 2.23 (2.84), while the control group had a mean change of − 1.43 (4.52). The difference was statistically significant (p < 0.001). Milin [ 21 ] measured it using a self-developed scale and found that the intervention group had a mean change of 0.7 (1.47), while the control group had a mean change of − 0.18 (1.48). The difference was statistically significant (p < 0.001). These results suggest that The Guide improved students’ mental health literacy compared to no intervention or usual care.

Simkiss [ 23 ] measured mental health literacy using the Knowledge and Attitudes about Mental Health Scale (KAMHS) and found that the intervention group had a mean change of 0.09 (0.09), while the control group had a mean change of − 0.01 (0.09). The difference was statistically significant (p < 0.05). This result suggests that The Guide improved students’ mental health literacy more than the control group, which received usual care. Freţian [ 24 ] conducted a quasi-experimental pre-post study in Germany with students aged 14–17. The intervention involved The Guide and the Mental Health Knowledge (MHK) scale over a single day. The intervention group displayed a statistically significant mean change in mental health knowledge (p < 0.05).

3.2 Effectiveness of The Guide in improving help-seeking attitudes and stigma

Nguyen [ 19 ] measured them using the Stigma scale and found that the intervention group had a mean change of − 0.09 (0.37) in Vietnam and − 0.66 (0.50) in Cambodia, while the control group had a mean change of − 0.03 (0.39) in Vietnam and − 0.08 (0.52) in Cambodia. The difference was not statistically significant in both countries (p > 0.05). Ravindran [ 20 ] measured them using the MHKAS-Attitudes scale and found that the intervention group had a mean change of 0.54 (1.87), while the control group had a mean change of − 0.28 (1.79). The difference was statistically significant (p < 0.001). Milin [ 21 ] measured them using the Attitudes Towards Mental Illness scale and found that the intervention group had a mean change of 1.3 (2.46), while the control group had a mean change of − 1.17 (2.63). The difference was statistically significant (p < 0.001). These results suggest that The Guide had a mixed effect on improving students’ attitudes and reducing their stigma compared to no intervention or usual care.

3.3 Factors influencing the implementation and sustainability of The Guide

Some studies reported on the factors that influenced the implementation and sustainability of The Guide in different contexts. These factors included:

Mode of delivery The Guide was delivered either online or in-person by trained facilitators or teachers. The mode of delivery affected the accessibility, engagement, and interaction of the students with the program. For example, Nguyen [ 19 ] found that online delivery was more convenient and flexible for the students, but also posed some challenges such as technical issues, low attendance, and limited feedback. Milin [ 21 ] found that online delivery was more effective than in-person delivery in improving mental health knowledge and attitudes, but also required more support and guidance from the teachers. Simkiss [ 23 ] found that online delivery was more acceptable and feasible for the students and the schools, but also needed more resources and infrastructure to ensure the quality and fidelity of the program.

Duration and frequency of the sessions The total number of sessions varied across interventions in different studies, ranging from 2 to 12 weeks (with a mean duration of 7.1 weeks) and from 1 to 14 h (with a mean of 8.9 h). The duration and frequency of the sessions affected the retention, completion, and satisfaction of the students with the program. For example, Zare [ 17 ] found that a shorter duration (6 weeks) and a longer time (9 h) of the sessions resulted in a higher retention rate (95%) and a higher completion rate (90%) than a longer duration (12 weeks) and a shorter time (6 h) of the sessions in another study. Ravindran [ 20 ] found that a longer duration (6 weeks) and a longer time (12 h) of the sessions resulted in a higher satisfaction rate (90%) than a shorter duration (5 weeks) and a shorter time (7.5 h) of the sessions in another study. Freţian [ 24 ] found that a shorter duration (2 weeks) and a shorter time (1 h) of the sessions resulted in a lower dropout rate (5%) and a higher satisfaction rate (95%) than a longer duration (6 weeks) and a longer time (6 h) of the sessions in another study.

Characteristics of the facilitators or teachers The facilitators or teachers who delivered The Guide were either trained professionals or peers who had received training on the program content and methods. The characteristics of the facilitators or teachers affected the quality, fidelity, and effectiveness of the program delivery. For example, Hassen [ 18 ] found that peer educators were more relatable, credible, and engaging for the students than professionals, but also faced some challenges such as lack of confidence, experience, and supervision. Milin [ 21 ] found that teachers who delivered The Guide had more positive attitudes towards mental health than those who did not, but also needed more training and support to deliver the program effectively. Simkiss [ 23 ] found that facilitators who delivered The Guide had more knowledge and skills in mental health than those who did not, but also required more monitoring and feedback to ensure the consistency and quality of the program.

Characteristics of the students The students who participated in The Guide were aged 10–25 from various educational settings and cultural backgrounds. The diverse characteristics of students played a significant role in shaping their engagement with the program, influencing motivation, participation, and subsequent learning outcomes. Nguyen [ 19 ] highlighted this by illustrating that students from Vietnam and Cambodia exhibited varying levels of mental health knowledge, attitudes, and stigma both before and after the program. These differences were closely tied to the distinct cultural values and beliefs surrounding mental health in each region. Milin [ 21 ] found that students who had higher levels of mental health knowledge and lower levels of stigma before the program benefited more from the program than those who had lower levels of knowledge and higher levels of stigma. Freţian [ 24 ] found that students who had lower levels of mental health knowledge and higher levels of stigma before the program showed more improvement in their knowledge and attitudes than those who had higher levels of knowledge and lower levels of stigma.

4 Discussion

The primary objective of this systematic review was to assess the effectiveness of The Guide, a school-based program aimed at enhancing mental health literacy, improving attitudes, and reducing stigma among students aged 10–25. The study followed the PRISMA guidelines and examined ten studies from eight countries, encompassing a diverse range of participants and methodologies.

The review found that The Guide had a positive impact on mental health literacy and a mixed impact on help-seeking attitudes and stigma compared to no intervention or usual care [ 25 ]. The magnitude of the impact varied from small to large, depending on the instrument or scale used and the post-test time. These findings are consistent with previous reviews that have shown that mental health literacy interventions can improve mental health knowledge, attitudes, and behaviors among young people [ 26 , 27 , 28 ]. Mental health literacy is considered a key strategy to facilitate early intervention and prevention of mental disorders, as well as to promote mental health and well-being among young people [ 9 , 29 ]. By improving mental health literacy, young people can enhance their awareness, understanding, and skills related to mental health, reduce stigma and discrimination towards people with mental disorders, and increase their help-seeking efficacy and use of appropriate services [ 9 , 29 , 30 ]. The overall impact of The Guide on mental health literacy outcomes across all studies was moderate, indicating a noticeable improvement in mental health literacy after participating in The Guide.

The review also found that The Guide had a mixed impact on help-seeking attitudes and stigma among students aged 10–25. Help-seeking attitudes, representing the willingness to seek help for mental issues, and stigma, encompassing negative stereotypes and prejudices, are interconnected. The results of this review indicate that The Guide can improve help-seeking attitudes and reduce stigma among some groups of students, but not among others [ 19 , 20 , 21 ]. The overall impact of The Guide on help-seeking attitudes and stigma outcomes across all studies was small, indicating a slight improvement in help-seeking attitudes and a slight reduction in stigma after participating in The Guide. Research exploring why these outcomes vary among students is limited but crucial. Potential factors include cultural and contextual differences influencing perceptions of mental health interventions [ 31 , 32 , 33 ], perceived barriers to seeking help such as stigma and confidentiality concerns [ 34 , 35 ], variability in program implementation quality [ 31 ], and individual differences in developmental stages and personal experiences with mental health [ 31 , 34 ]. These factors suggest the need for further qualitative exploration of students’ perspectives and experiences to optimize the effectiveness of future MHL interventions like The Guide in promoting mental health awareness and reducing stigma among youth.

However, the review also found that the impact of The Guide may vary depending on the context, culture, and characteristics of the students and the facilitators or teachers. The review identified four main factors that influenced the implementation and sustainability of The Guide in different contexts: mode of delivery, duration and frequency of the sessions, characteristics of the facilitators or teachers, and characteristics of the students [ 31 , 32 , 33 , 34 ]. These factors affected the accessibility, engagement, interaction, retention, completion, satisfaction, quality, fidelity, and effectiveness of the program delivery [ 35 ]. The review suggested that The Guide needed to be adapted and tailored to the local context and culture, and that the facilitators or teachers and the students needed to be trained and involved in the planning, delivery, and evaluation of The Guide.

4.1 Limitations

The review has some limitations that should be acknowledged. First, the quality and risk of bias of the included studies were variable, which may affect the validity and reliability of the findings. Second, the heterogeneity of the studies in terms of population, intervention, comparison, outcome, and study design limited the possibility of conducting a meta-analysis or a subgroup analysis. Third, the review only included studies published in English, which may exclude relevant studies published in other languages. Fourth, the review only focused on The Guide or a modified version of it as an intervention, which may not capture other types of mental health literacy interventions that may be effective for young people.

4.2 Implications for practice and research

The systematic review underscores several implications for both practice and research. For practice, The Guide emerges as a valuable tool for advancing mental health education and awareness among young people, while also fostering reductions in stigma and improvements in help-seeking behavior. However, successful adoption and implementation of The Guide necessitate careful consideration of potential barriers and facilitators, including resource availability, participant readiness, alignment with local cultural norms, and robust evaluation mechanisms. Moreover, adequate training and ongoing support for facilitators and teachers are crucial, alongside active engagement of students and stakeholders in all stages of planning, delivery, and evaluation. In terms of research, there is a clear need for more high-quality studies to assess the long-term effects of The Guide on mental health outcomes across diverse demographic backgrounds and settings. Furthermore, future research should explore effective strategies for integrating The Guide into existing educational curricula or policies to ensure sustainability and scalability. Methodologically, there is a call for studies that delve deeper into the mechanisms and moderators influencing The Guide's impact on various mental health outcomes, utilizing more rigorous and standardized methods and measures. Additionally, comparative research that contrasts The Guide with other mental health literacy interventions or control conditions would provide valuable insights into its unique contributions.

5 Conclusion

The systematic review of The Guide, a mental health intervention targeting young people aged 10–25, underscores its positive impact on enhancing mental health literacy and help-seeking attitudes, though effect sizes vary across studies. Factors influencing its implementation and sustainability include delivery mode, session frequency, facilitator characteristics, and student demographics. While this review contributes valuable insights, limitations such as variability in study quality, number, and data heterogeneity highlight the necessity for more robust research efforts. Implications for practice include recognizing The Guide's potential across diverse educational and cultural settings, contingent upon addressing implementation barriers and optimizing facilitator training. Future research should prioritize enhancing measurement validity, exploring long-term effects, and assessing implementation costs to advance both understanding and application of The Guide. Expanding on the potential long-term impacts of The Guide and its scalability in various educational contexts could enrich the conclusion, offering a forward-looking perspective on its sustained effectiveness and broader implications for mental health interventions among young populations.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. No datasets were generated or analysed during the current study.

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Acknowledgements

We are grateful to Golbarg Andaji Garmaroudi for her help in translating this manuscript into English.

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Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

Abouzar Nazari

Gholamreza Garmaroudi

Department of Psychology, Faculty of Psychology, Khomeini Shahr Azad University, Isfahan, Iran

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All authors designed the study and wrote the manuscript. A.N. and M.R. searched, screened, and extracted the literature. GH.G. supervised the analysis and resolved any conflicts. All authors approved the final version.

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Nazari, A., Garmaroudi, G. & Rabiei, M. A systematic review: increasing mental health literacy in students through “The Guide”. Discov Psychol 4 , 96 (2024). https://doi.org/10.1007/s44202-024-00219-1

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Rethinking mental wellness among adolescents: an integrative review protocol of mental health components

• Zaida Orth   ORCID: orcid.org/0000-0002-2895-0417 1 &
• Brian van Wyk   ORCID: orcid.org/0000-0003-1032-1847 1  

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Adolescents have been overlooked in global public health initiatives as this period is generally considered to be the healthiest in an individual’s life course. However, the growth of the global adolescent population and their changing health profiles have called attention to the diverse health needs of adolescents. The increased attention toward adolescent health has accentuated existing gaps as global health reports have emphasised that there is a continued need for valid and reliable health data. In this context, evidence has shown that mental health issues constitute one of the greatest burdens of disease for adolescents. This integrative review aims to unpack the meaning of mental wellness among adolescents and its associated constructs by analysing and synthesising empirical and theoretical research on adolescent mental wellness. In doing this, we will develop a working definition of adolescent mental wellness that can be used to develop an instrument aimed at measuring adolescent mental wellness.

The integrative review is guided by the five steps described by Whittemore and Knafl. A comprehensive search strategy which will include carefully selected terms that correspond to the domains of interest (positive mental health/mental wellness) will be used to search for relevant literature on electronic databases, grey literature and government or non-governmental organisations (NGO) websites. Studies will be included if they describe and/or define general mental wellness in adolescent populations aged 10–19. The screening and reporting of the review will be conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data from the integrative review will be analysed using narrative framework synthesis for qualitative and quantitative studies.

This integrative review aims to search for and synthesise current research regarding adolescent mental wellness to identify how wellness is being described and conceptualised. We aim to identify gaps and to contribute to a more comprehensive definition of mental wellness which can aid in the development of an age- and culturally appropriate measure of adolescent mental wellness.

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In 2016, adolescents (10–19 years) were estimated at 1.2 billion (18%) of the world population, making them the largest population of adolescents in history [ 1 , 2 ]. Adolescents have been largely overlooked in global health and social policies, because this period is generally considered to be the healthiest in an individual’s life-course [ 2 ], and the unique health problems associated with adolescence have been misconstrued or ignored in favour of more pressing public health concerns [ 3 ]. However, changing health profiles of adolescents in both developed and developing countries have called attention to the diverse health needs of adolescents [ 1 ]. According to the World Health Organization (WHO), more than 1.1 million adolescents died in 2016—mostly from preventable or treatable causes [ 4 ]. Therefore, the considerable gains from global investments in child and maternal health programmes would yield fewer long term benefits without simultaneous investments in adolescent health [ 5 , 6 ].

According to the life course approach, all stages of an individual’s life are intricately intertwined and interconnected with each other, and other people in society including past, present and future generations of their families [ 7 ]. In other words, evidence has shown that early life experiences, including events experienced in the  pre-conception phase, play a role in determining the developmental origins and trajectories of health and wellness or disease across an individual’s life course [ 7 ]. From this perspective, it is understood that the health and wellness of individuals, as well as communities, depend on interactions oscillating between multiple risk and protective factors throughout one’s life. Based on this, early and appropriate interventions during child and adolescent years are shown to be the most effective prevention strategies to promote optimal public health and human development [ 5 , 6 , 8 ]. Additionally, following the life course approach, it is argued that these early investments in child and adolescent health will yield a triple dividend as they will grow into healthier adults who can contribute positively to society, as well as the health and development of the next generation [ 2 , 9 ].

Globally, mental health issues constitute one of the greatest burdens of disease for adolescents. According to the WHO, in 2016 mental health conditions accounted for 16% of the global burden of disease and injury for adolescents, with depression being identified as one of the leading causes of illness and disability, followed by suicide as the second leading cause of death in adolescents and self-harm the third [ 4 , 9 ]. UNICEF propagates that half of all lifetime mental disorders have onset during adolescence [ 10 ]. The recent inclusion of adolescents on the global health agenda as a target group for intervention represents a key step toward reducing the global burden of disease attributed to mental health disorders and reducing preventable deaths [ 2 , 10 , 11 , 12 , 13 ]. However, due to the previous neglect of mental health as a public health issue, efforts to address adolescent mental health are met with various challenges.

Currently, there is a lack of data concerning mental health conditions among adolescents, especially those living in low- and middle-income countries (LMICs) [ 11 ]. The lack of a body of quality evidence can affect the way adolescents are represented in national policies, as well as the ways in which government and healthcare officials respond to treatment and prevention [ 2 , 14 ]. According to WHO, a 2014 review of health policy documents from 109 countries showed that 84% have given some attention to adolescents, with three-quarters of them addressing sexual and reproductive health; one-third addressing tobacco and alcohol use, and one-quarter focusing on mental health [ 1 ]. In LMICs, efforts to improve child and adolescent mental health services (CAMHS) are hindered by a lack of specific CAMHS policies, resources and, fewer child and adolescent psychiatrists and other mental health professionals [ 12 , 13 ]. Furthermore, studies from developed countries have suggested that while CAMHS and policies are in place, there is a lack of mental health service uptake among children and adolescents due to various attitudinal, stigma-related, and structural barriers to accessing mental health services [ 14 ]. These challenges and barriers to CAMHS in both LMICs and higher-income countries are particularly apparent among adolescents living with a chronic disorder or disease [ 15 , 16 ]. Mental health conditions are increasingly recognised in children and adolescents with chronic disorders. Studies have shown that living with a chronic health condition is associated with increased risk of developing comorbid physical and mental health problems, which in turn influence treatment adherence and quality of life [ 16 , 17 , 18 ].

Another recurring obstacle for integrating mental health into global public health initiatives and frameworks is the lack of consensus of a definition of mental health [ 19 ]. Despite the growth of mental health and wellness research in recent decades, the question of how mental wellness should be defined remains largely unresolved [ 20 ]. This has given rise to broad and ambiguous definitions which, consequently, result in concepts such as mental health, mental wellness and mental wellbeing being used interchangeably. Currently, the term ‘mental health’ is often used as a euphemism to refer to mental illness, referring to conditions that adversely affect cognition, emotion and behaviour (i.e. depression and anxiety) [ 21 ]. This use reflects in the literature as the majority of adolescent mental health research adopts the dominant pathological view of health by focusing on mental health disorders such as psychiatric disorders, general mental health disorders, emotional and behavioural problems and psychological distress [ 22 , 23 ]. Similarly, global health initiatives such as AAH-HA! focus majorly on the burden of disease of mental disorders by reporting on self-harm, depressive disorders, childhood behavioural disorders and anxiety [ 3 ]. This dominant pathological view of mental health persists despite the contributions of positive health and wellbeing research which argues that wellness and illness are not two ends of the same continuum as previously thought, rather these constructs represent two independent continua [ 19 , 23 ]. In other words, the absence of mental illness does not necessarily indicate a state of mental health/wellness [ 1 , 23 , 24 ]. Therefore, it is imperative to consider both mental wellness and mental illness in research, and to move away from the previous ‘absence of disease’ model to one that emphasises positive psychological functioning for mental health [ 23 , 24 ]. In this model, wellness refers to the degree one feels positive about life, and one’s capacity to manage one’s feelings, behaviours, and limitations [ 23 ]. From this model, addressing adolescent mental wellness is seen as more than treating and mitigating the burden of disease of mental illness, rather it is also useful in maintaining lifelong mental and physical wellness and preventing the development of mental disorders [ 23 ]. Adolescents in particular experience multiple physical, social, and emotional changes, which can positively or negatively impact on their mental wellness. Therefore, interventions at this stage are crucial as research shows that providing psychosocial support and mental health promotion, such as psycho-education and community empowerment, facilitates the development of mental wellness (positive mental health) which is protective against psychopathology (mental illness) [ 9 , 24 ].

There is a need to develop accurate and culturally appropriate measures of mental wellness to support research endeavours that aim to improve adolescent mental health. Therefore, there is a greater necessity to clarify what is being measured, and how the resulting data from the measure should be interpreted to undertake fair and valid assessments. As such, developing a definition of mental wellness should encompass more than the description of wellness itself (as is the case with current definitions) to a clear and definite statement of the exact meaning of the construct.

To this end, this integrative review forms part of a larger study which aims to unpack the meaning of mental wellness among adolescents and its associated constructs by analysing and synthesising relevant literature and empirical and theoretical research on adolescent mental wellness. In doing this, we aim to use this information to develop and conceptualise adolescent mental wellness as a construct. Additionally, by focusing on conceptualising mental wellness, we hope to provide clarity regarding the way concepts such as mental wellness are used in the literature by clearly distinguishing between mental health (as a euphemism for mental illness) and mental wellness as a positive state of mental health. We aim to develop an instrument which can measure mental wellness as an indicator of general mental health and wellness among adolescents.

Methodology

The integrative review has been identified as a unique tool in healthcare for synthesising investigations available on a given topic or phenomena and for directing practise based on scientific knowledge [ 25 ]. The existing body of literature on mental health among adolescents is varied and complex as there are many concepts associated with mental health research ranging from positive aspects such as ‘resilience’ and ‘self-efficacy’ to negative aspects such as ‘depression’ and ‘anxiety’. As such, it is not possible for one study to capture all the dimensions associated with mental health. However, by adopting the integrative review method, we will be able to include the various sources and methodologies used in research to summarise existing empirical and theoretical literature associated with [positive] mental wellness concepts to better understand and conceptualise mental wellness among adolescents. The integrative review method proposed by Whittemore and Knafl [ 26 ] will be used: (1) problem identification, (2) literature search, (3) data evaluation, (4) data analysis, and (5) presentation of the integrative review.

Problem identification

The problem identification stage is a crucial first step in an integrative review. Therefore, we aim to approach this as a phase in itself. This means, going beyond the initial research questions to fully develop a framework of the problem and all its related variables. In this section, we describe some approaches we will use to identify the problem which the integrative review will address. As previously mentioned, our interest lies in understanding how mental wellness is conceptualised among adolescents, to aid in the conceptualisation and development of a mental wellness instrument for adolescent populations. Based on our initial reading of the literature, we have identified two recurring issues in this regard: firstly, there is a lack of validated mental wellness instruments for adolescents; and secondly, despite a growing body of research, the question of how mental wellness should be defined remains largely unresolved. Based on this, we have proposed to follow two research questions to aid us in identifying the problem.

How is the concept of mental wellness defined in research involving adolescents?

What indicators of mental wellness are being explored/investigated in research?

These two questions allow us to investigate how research has approached the study of mental wellness, what variables were of interest and how these were defined. To answer these questions, we will follow an iterative approach to gather and assess the available information to present a clear identification of the problem and all the variables of interest. To this end, we are currently conducting a systematic review of mental health instruments used in research with adolescent populations [ 21 ].

Understanding how mental wellness has been defined in research is an important part of our problem identification, as it will show us what theories and/or definitions of mental wellness are dominant, and which are missing. As Dodge et al. [ 20 ] argued, current definitions of wellness are more descriptive in the sense that they describe aspects of wellness rather than the construct itself. This lack of definition poses a problem in measurement development as the definition of a construct ultimately influences how it is being measured and how the resulting data should be interpreted. Therefore, to further aid our problem identification, we will compare the data from the systematic review with data from qualitative interviews exploring mental wellness among adolescents living with HIV (ALHIV). As previously mentioned, this review forms part of a larger study aimed at developing an instrument to measure mental wellness among adolescents. We have chosen to include the interviews with ALHIV for the problem identification stage as we want to develop an instrument that can measure mental wellness among healthy populations and those living with a chronic illness such as HIV. This is necessary as Manderscheid et al. [ 23 ] argue that a dual emphasis on mental and physical health is essential as studies have shown that positive health may influence biological functioning. This information will be used to identify the problem of the integrative review (Fig. 1 ). Using the information from the problem identification phase, we will move on to the second phase to conduct a literature search of mental health concepts used in research with adolescent populations.

Steps followed to identify the problem for an integrative review

Literature search

A comprehensive search strategy which will include carefully selected terms that correspond to the domains of interest (mental health/mental wellness) will be used to search for relevant literature on electronic databases, grey literature and government or non-governmental organisations (NGO) websites. A systematic database search will be performed using Ebscohost (Psycharticles, Academic Search Premier, SocIndex), Educational Resource Information Center (ERIC), Medical Literature Analysis Retrieval System Online (MEDLINE) and Sabinet. A list of initial keywords has been identified for the search strategy: ((adolescen* OR teenage* OR young people OR youth) [AND] (“psychological wellbeing” OR “mental health wellbeing” OR “mental wellness” OR “mental health”). As the integrative review allows for a more iterative process, the list of keywords will be modified as the initial search reveals more relevant and refined search terms.

Inclusion and exclusion criteria

Studies will be included if they describe and/or define mental wellness in adolescent populations. As the interest lies in conceptualising mental wellness for adolescents, only studies dealing with general mental health, wellbeing and wellness will be included. In other words, studies focused on mental disorders or mental illnesses among adolescents will be excluded. For this review, studies will be included for all adolescents aged 10–19 who have not been diagnosed with a mental illness or disorder. Eligible studies will include qualitative, quantitative, and mixed-method studies published from 2000 to 2022. The time period of the search strategy was chosen due to the paucity of research in this area [ 3 , 22 , 27 ]. Furthermore, the prioritization of adolescent health and the focus on adolescent-friendly services occurred after 2000 [ 28 ].

Screening and selection process

Study selection.

The PICOT mnemonics (Table 1 ) for reviews will be used to guide study selection.

The above-mentioned criteria and search strategy will be used to search the databases. The screening and reporting of the review will be conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline and checklist [ 29 ]. The number of hits for each database will be recorded and the citations will be exported to Mendeley citation software. Following this, two reviewers will screen all the titles and abstracts to assess which articles are appropriate for inclusion. The full-text articles of the included abstracts will be downloaded and reviewed again to determine which articles should be included for the final assessment [ 30 ]. Any discrepancies between the two reviewers will be resolved by a third party. Additionally, based on the information retrieved from the screening, the researcher may modify the search to include other relevant sources.

Data evaluation

In this integrative review, the primary sources will include both empirical and theoretical literature - which increases the complexity of evaluating the quality of the included sources [ 26 ]. According to Whittmore and Knafl [ 26 ], integrative reviews using diverse sampling frames may adopt an approach to data evaluation that is similarly used in historical research. In this case, the authenticity, methodological quality, informational value, and representativeness of the available sources should be discussed in the final report. To minimise bias, the two reviewers will utilise two existing quality criteria instruments to evaluate the different types of data [ 26 ]. Firstly, the Mixed Methods Appraisal Tool (MMAT) (Additional file 1 : Appendix A) will be used to assess the methodological quality of the studies as it allows for summarising the overall quality across a range of study designs [ 31 ]. Secondly, the SFS scoring system version E (Additional file 1 : Appendix B) will be used to assess the quality of the methodologies of the included articles [ 32 ]. The SFS scoring system version E is appropriate as it allows for screening of both quantitative and qualitative research and allows for the appraisal of the definitions of constructs being investigated [ 32 ].

Data analysis

Once the selection of included articles has been finalised, we will extract the relevant data into a Microsoft Excel document to organise the information and prepare for the data synthesis. The Excel sheet will include information regarding the purpose of the study, study characteristics, results, and appraisal of the study as well as any other supporting information. All data will be cross-checked for quality purposes.

Data from the integrative review will be analysed using narrative framework synthesis for qualitative and quantitative studies. Framework synthesis begins with a tentative framework that can either be borrowed from previous studies or can be developed from key concepts [ 26 , 33 ]. With framework synthesis, the included studies are coded according to the developing framework in an iterative process until the body of evidence can be presented coherently.

In the final stage, the findings from the review will be discussed and presented in either tabular or diagrammatic form. Additionally, the limitations of the review will be discussed as well as recommendations for future research.

This integrative review aims to synthesise current literature on adolescent mental wellness to identify the ways in which this is being described and applied in research. The purpose of this is to identify gaps and to contribute to the conceptualisation of a more comprehensive definition of mental wellness which can aid in the development of an age- and culturally appropriate measure of adolescent mental wellness. Such measures are much needed in adolescent health research as it may be used to better understand the mental wellness needs of adolescents and contribute to the development of interventions and programmes aimed at improving psychological wellbeing and/or mental wellness of adolescents.

Strengths and limitations

According to our knowledge, this protocol describes the first integrative review to investigate and describe how mental wellness is defined in research among adolescents. Understanding how mental wellness among adolescents has been conceptualised is necessary to identify what are the strengths and limitations of such definitions. This will allow researchers to rethink what mental wellness means to adolescents and how this can and should be measured in research. A limitation of this study is related to the search strategy, notably around the time span (2000–2022) and the identification of grey literature, as not all possible sources of literature may be accessed.

Availability of data and materials

Not applicable.

Abbreviations

Adolescents living with HIV

Antiretroviral therapy

Child and Adolescent Mental Health

Low- and middle-income countries

Mixed Methods Appraisal Tool

SFS Scoring System

United Nations International Children’s Emergency Fund

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Acknowledgements

ZO is supported by the National Research Foundation, grant number (118160). Additionally, the authors would like to acknowledge funding form the Belgian Development Cooperation, through the Institute of Tropical Medicine Antwerp. Any opinion, finding and conclusion or recommendation expressed in this material is that of the authors and not the funders.

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ZO conceived the idea, developed the research question and study methods, and contributed meaningfully to the drafting and editing; she also approved the final manuscript. BvW aided in developing the research question and study methods, contributed meaningfully to the drafting and editing, and approved the final manuscript.

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Additional file 1: appendix a..

Mixed Methods Appraisal Tool (MMAT). Appendix B. SFS Scoring System (Version E). Appendix C. PRISMA-P Checklist.

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Orth, Z., van Wyk, B. Rethinking mental wellness among adolescents: an integrative review protocol of mental health components. Syst Rev 11 , 83 (2022). https://doi.org/10.1186/s13643-022-01961-0

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

Peer Support in Mental Health: Literature Review

Authors of this article:

• 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.

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• Published: 20 September 2022

Factors that influence mental health of university and college students in the UK: a systematic review

• Fiona Campbell 1 ,
• Lindsay Blank 1 ,
• Anna Cantrell 1 ,
• Susan Baxter 1 ,
• Christopher Blackmore 1 ,
• Jan Dixon 1 &
• Elizabeth Goyder 1  

BMC Public Health volume  22 , Article number:  1778 ( 2022 ) Cite this article

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Worsening mental health of students in higher education is a public policy concern and the impact of measures to reduce transmission of COVID-19 has heightened awareness of this issue. Preventing poor mental health and supporting positive mental wellbeing needs to be based on an evidence informed understanding what factors influence the mental health of students.

To identify factors associated with mental health of students in higher education.

We undertook a systematic review of observational studies that measured factors associated with student mental wellbeing and poor mental health. Extensive searches were undertaken across five databases. We included studies undertaken in the UK and published within the last decade (2010–2020). Due to heterogeneity of factors, and diversity of outcomes used to measure wellbeing and poor mental health the findings were analysed and described narratively.

We included 31 studies, most of which were cross sectional in design. Those factors most strongly and consistently associated with increased risk of developing poor mental health included students with experiences of trauma in childhood, those that identify as LGBTQ and students with autism. Factors that promote wellbeing include developing strong and supportive social networks. Students who are prepared and able to adjust to the changes that moving into higher education presents also experience better mental health. Some behaviours that are associated with poor mental health include lack of engagement both with learning and leisure activities and poor mental health literacy.

Improved knowledge of factors associated with poor mental health and also those that increase mental wellbeing can provide a foundation for designing strategies and specific interventions that can prevent poor mental health and ensuring targeted support is available for students at increased risk.

Peer Review reports

Poor mental health of students in further and higher education is an increasing concern for public health and policy [ 1 , 2 , 3 , 4 ]. A 2020 Insight Network survey of students from 10 universities suggests that “1 in 5 students has a current mental health diagnosis” and that “almost half have experienced a serious psychological issue for which they felt they needed professional help”—an increase from 1 in 3 in the same survey conducted in 2018 [ 5 ]. A review of 105 Further Education (FE) colleges in England found that over a three-year period, 85% of colleges reported an increase in mental health difficulties [ 1 ]. Depression and anxiety were both prevalent and widespread in students; all colleges reported students experiencing depression and 99% reported students experiencing severe anxiety [ 5 , 6 ]. A UK cohort study found that levels of psychological distress increase on entering university [ 7 ], and recent evidence suggests that the prevalence of mental health problems among university students, including self-harm and suicide, is rising, [ 3 , 4 ] with increases in demand for services to support student mental health and reports of some universities finding a doubling of the number of students accessing support [ 8 ]. These common mental health difficulties clearly present considerable threat to the mental health and wellbeing of students but their impact also has educational, social and economic consequences such as academic underperformance and increased risk of dropping out of university [ 9 , 10 ].

Policy changes may have had an influence on the student experience, and on the levels of mental health problems seen in the student population; the biggest change has arguably been the move to widen higher education participation and to enable a more diverse demographic to access University education. The trend for widening participation has been continually rising since the late 1960s [ 11 ] but gained impetus in the 2000s through the work of the Higher Education Funding Council for England (HEFCE). Macaskill (2013) [ 12 ] suggests that the increased access to higher education will have resulted in more students attending university from minority groups and less affluent backgrounds, meaning that more students may be vulnerable to mental health problems, and these students may also experience greater challenges in making the transition to higher education.

Another significant change has been the introduction of tuition fees in 1998, which required students to self fund up to £1,000 per academic year. Since then, tuition fees have increased significantly for many students. With the abolition of maintenance grants, around 96% of government support for students now comes in the form of student loans [ 13 ]. It is estimated that in 2017, UK students were graduating with average debts of £50,000, and this figure was even higher for the poorest students [ 13 ]. There is a clear association between a student’s mental health and financial well-being [ 14 ], with “increased financial concern being consistently associated with worse health” [ 15 ].

The extent to which the increase in poor mental health is also being seen amongst non-students of a similar age is not well understood and warrants further study. However, the increase in poor mental health specifically within students in higher education highlights a need to understand what the risk factors are and what might be done within these settings to ensure young people are learning and developing and transitioning into adulthood in environments that promote mental wellbeing.

Commencing higher education represents a key transition point in a young person’s life. It is a stage often accompanied by significant change combined with high expectations of high expectations from students of what university life will be like, and also high expectations from themselves and others around their own academic performance. Relevant factors include moving away from home, learning to live independently, developing new social networks, adjusting to new ways of learning, and now also dealing with the additional greater financial burdens that students now face.

The recent global COVID-19 pandemic has had considerable impact on mental health across society, and there is concern that younger people (ages 18–25) have been particularly affected. Data from Canada [ 16 ] indicate that among survey respondents, “almost two-thirds (64%) of those aged 15 to 24 reported a negative impact on their mental health, while just over one-third (35%) of those aged 65 and older reported a negative impact on their mental health since physical distancing began” (ibid, p.4). This suggests that older adults are more prepared for the kind of social isolation which has been brought about through the response to COVID-19, whereas young adults have found this more difficult to cope with. UK data from the National Union of Students reports that for over half of UK students, their mental health is worse than before the pandemic [ 17 ]. Before COVID-19, students were already reporting increasing levels of mental health problems [ 2 ], but the COVID-19 pandemic has added a layer of “chronic and unpredictable” stress, creating the perfect conditions for a mental health crisis [ 18 ]. An example of this is the referrals (both urgent and routine) of young people with eating disorders for treatment in the NHS which almost doubled in number from 2019 to 2020 [ 19 ]. The travel restrictions enforced during the pandemic have also impacted on student mental health, particularly for international students who may have been unable to commence studies or go home to see friends and family during holidays [ 20 ].

With the increasing awareness and concern in the higher education sector and national bodies regarding student mental health has come increasing focus on how to respond. Various guidelines and best practice have been developed, e.g. ‘Degrees of Disturbance’ [ 21 ], ‘Good Practice Guide on Responding to Student Mental Health Issues: Duty of Care Responsibilities for Student Services in Higher Education’ [ 22 ] and the recent ‘The University Mental Health Charter’ [ 2 ]. Universities UK produced a Good Practice Guide in 2015 called “Student mental wellbeing in higher education” [ 23 ]. An increasing number of initiatives have emerged that are either student-led or jointly developed with students, and which reflect the increasing emphasis students and student bodies place on mental health and well-being and the increased demand for mental health support: Examples include: Nightline— www.nightline.ac.uk , Students Against Depression— www.studentsagainstdepression.org , Student Minds— www.studentminds.org.uk/student-minds-and-mental-wealth.html and The Alliance for Student-Led Wellbeing— www.alliancestudentwellbeing.weebly.com/ .

Although requests for professional support have increased substantially [ 24 ] only a third of students with mental health problems seek support from counselling services in the UK [ 12 ]. Many students encounter barriers to seeking help such as stigma or lack of awareness of services [ 25 ], and without formal support or intervention, there is a risk of deterioration. FE colleges and universities have identified the need to move beyond traditional forms of support and provide alternative, more accessible interventions aimed at improving mental health and well-being. Higher education institutions have a unique opportunity to identify, prevent, and treat mental health problems because they provide support in multiple aspects of students’ lives including academic studies, recreational activities, pastoral and counselling services, and residential accommodation.

In order to develop services that better meet the needs of students and design environments that are supportive of developing mental wellbeing it is necessary to explore and better understand the factors that lead to poor mental health in students.

Research objectives

The overall aim of this review was to identify, appraise and synthesise existing research evidence that explores the aetiology of poor mental health and mental wellbeing amongst students in tertiary level education. We aimed to gain a better understanding of the mechanisms that lead to poor mental health amongst tertiary level students and, in so doing, make evidence-based recommendations for policy, practice and future research priorities. Specific objectives in line with the project brief were to:

To co-produce with stakeholders a conceptual framework for exploring the factors associated with poorer mental health in students in tertiary settings. The factors may be both predictive, identifying students at risk, or causal, explaining why they are at risk. They may also be protective, promoting mental wellbeing.

To conduct a review drawing on qualitative studies, observational studies and surveys to explore the aetiology of poor mental health in students in university and college settings and identify factors which promote mental wellbeing amongst students.

To identify evidence-based recommendations for policy, service provision and future research that focus on prevention and early identification of poor mental health

Methodology

Identification of relevant evidence.

The following inclusion criteria were used to guide the development of the search strategy and the selection of studies.

We included students from a variety of further education settings (16 yrs + or 18 yrs + , including mature students, international students, distance learning students, students at specific transition points).

Universities and colleges in the UK. We were also interested in the context prior to the beginning of tertiary education, including factors during transition from home and secondary education or existing employment to tertiary education.

Any factor shown to be associated with mental health of students in tertiary level education. This included clinical indicators such as diagnosis and treatment and/or referral for depression and anxiety. Self-reported measures of wellbeing, happiness, stress, anxiety and depression were included. We did not include measures of academic achievement or engagement with learning as indicators of mental wellbeing.

Study design

We included cross-sectional and longitudinal studies that looked at factors associated with mental health outcomes in Table 5 .

Data extraction and quality appraisal

We extracted and tabulated key data from the included papers. Data extraction was undertaken by one reviewer, with a 10% sample checked for accuracy and consistency The quality of the included studies were evaluated using the Newcastle-Ottawa Scale [ 26 ] and the findings of the quality appraisal used in weighting the strength of associations and also identifying gaps for future high quality research.

Involvement of stakeholders

We recruited students, ex-students and parents of students to a public involvement group which met on-line three times during the process of the review and following the completion of the review. During a workshop meeting we asked for members of the group to draw on their personal experiences to suggest factors which were not mentioned in the literature.

Methods of synthesis

We undertook a narrative synthesis [ 27 ] due to the heterogeneity in the exposures and outcomes that were measured across the studies. Data showing the direction of effects and the strength of the association (correlation coefficients) were recorded and tabulated to aid comparison between studies.

Search strategy

Searches were conducted in the following electronic databases: Medline, Applied Social Sciences Index and Abstracts (ASSIA), International Bibliography of Social Sciences (IBSS), Science,PsycINFO and Science and Social Sciences Ciatation Indexes. Additional searches of grey literature, and reference lists of included studies were also undertaken.

The search strategy combined a number of terms relating to students and mental health and risk factors. The search terms included both subject (MeSH) and free-text searches. The searches were limited to papers about humans in English, published from 2010 to June 2020. The flow of studies through the review process is summarised in Fig.  1 .

Flow diagram

The full search strategy for Medline is provided in Appendix 1 .

Thirty-one quantitative, observational studies (39 papers) met the inclusion criteria. The total number of students that participated in the quantitative studies was 17,476, with studies ranging in size from 57 to 3706. Eighteen studies recruited student participants from only one university; five studies (10 publications) [ 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 ] included seven or more universities. Six studies (7 publications) [ 35 , 36 , 37 , 38 , 39 , 40 , 41 ] only recruited first year students, while the majority of studies recruited students from a range of year groups. Five studies [ 39 , 42 , 43 , 44 , 45 ] recruited only, or mainly, psychology students which may impact on the generalisability of findings. A number of studies focused on students studying particular subjects including: nursing [ 46 ] medicine [ 47 ], business [ 48 ], sports science [ 49 ]. One study [ 50 ] recruited LGBTQ (lesbian, gay, bisexual, transgender, intersex, queer/questioning) students, and one [ 51 ] recruited students who had attended hospital having self-harmed. In 27 of the studies, there were more female than male participants. The mean age of the participants ranged from 19 to 28 years. Ethnicity was not reported in 19 of the studies. Where ethnicity was reported, the proportion that were ‘white British’ ranged from 71 – 90%. See Table 1 for a summary of the characteristics of the included studies and the participants.

Design and quality appraisal of the included studies

The majority of included studies ( n  = 22) were cross-sectional surveys. Nine studies (10 publications) [ 35 , 36 , 39 , 41 , 43 , 50 , 51 , 52 , 53 , 62 ] were longitudinal in design, recording survey data at different time points to explore changes in the variables being measured. The duration of time that these studies covered ranged from 19 weeks to 12 years. Most of the studies ( n  = 22) only recruited participants from a single university. The use of one university setting and the large number of studies that recruited only psychology students weakens the wider applicability of the included studies.

Quantitative variables

Included studies ( n  = 31) measured a wide range of variables and explored their association with poor mental health and wellbeing. These included individual level factors: age, gender, sexual orientation, ethnicity and a range of psychological variables. They also included factors that related to mental health variables (family history, personal history and mental health literacy), pre-university factors (childhood trauma and parenting behaviour. University level factors including social isolation, adjustment and engagement with learning. Their association was measured against different measures of positive mental health and poor mental health.

Measurement of association and the strength of that association has some limitations in addressing our research question. It cannot prove causality, and nor can it capture fully the complexity of the inter-relationship and compounding aspect of the variables. For example, the stress of adjustment may be manageable, until it is combined with feeling isolated and out of place. Measurement itself may also be misleading, only capturing what is measureable, and may miss variables that are important but not known. We included both qualitative and PPI input to identify missed but important variables.

The wide range of variables and different outcomes, with few studies measuring the same variable and outcomes, prevented meta-analyses of findings which are therefore described narratively.

The variables described were categorised during the analyses into the following categories:

Vulnerabilities – factors that are associated with poor mental health

Individual level factors including; age, ethnicity, gender and a range of psychological variables were all measured against different mental health outcomes including depression, anxiety, paranoia, and suicidal behaviour, self-harm, coping and emotional intelligence.

Six studies [ 40 , 42 , 47 , 50 , 60 , 63 ] examined a student’s ages and association with mental health. There was inconsistency in the study findings, with studies finding that age (21 or older) was associated with fewer depressive symptoms, lower likelihood of suicide ideation and attempt, self-harm, and positively associated with better coping skills and mental wellbeing. This finding was not however consistent across studies and the association was weak. Theoretical models that seek to explain this mechanism have suggested that older age groups may cope better due to emotion-regulation strategies improving with age [ 67 ]. However, those over 30 experienced greater financial stress than those aged 17-19 in another study [ 63 ].

Sexual orientation

Four studies [ 33 , 40 , 64 , 68 ] examined the association between poor mental health and sexual orientation status. In all of the studies LGBTQ students were at significantly greater risk of mental health problems including depression [ 40 ], anxiety [ 40 ], suicidal behaviour [ 33 , 40 , 64 ], self harm [ 33 , 40 , 64 ], use of mental health services [ 33 ] and low levels of wellbeing [ 68 ]. The risk of mental health problems in these students compared with heterosexual students, ranged from OR 1.4 to 4.5. This elevated risk may reflect the greater levels of isolation and discrimination commonly experienced by minority groups.

Nine studies [ 33 , 38 , 39 , 40 , 42 , 47 , 50 , 60 , 63 ] examined whether gender was associated mental health variables. Two studies [ 33 , 47 ] found that being female was statistically significantly associated with use of mental health services, having a current mental health problem, suicide risk, self harm [ 33 ] and depression [ 47 ]. The results were not consistent, with another study [ 60 ] finding the association was not significant. Three studies [ 39 , 40 , 42 ] that considered mediating variables such as adaptability and coping found no difference or very weak associations.

Two studies [ 47 , 60 ] examined the extent to which ethnicity was associated with mental health One study [ 47 ] reported that the risks of depression were significantly greater for those who categorised themselves as non-white (OR 8.36 p = 0.004). Non-white ethnicity was also associated with poorer mental health in another cross-sectional study [ 63 ]. There was no significant difference in the McIntyre et al. (2018) study [ 60 ]. The small number of participants from ethnic minority groups represented across the studies means that this data is very limited.

Family factors

Six studies [ 33 , 40 , 42 , 50 , 60 ] explored the association of a concept that related to a student’s experiences in childhood and before going to university. Three studies [ 40 , 50 , 60 ] explored the impact of ACEs (Adverse Childhood Experiences) assessed using the same scale by Feletti (2009) [ 69 ] and another explored the impact of abuse in childhood [ 46 ]. Two studies examined the impact of attachment anxiety and avoidance [ 42 ], and parental acceptance [ 46 , 59 ]. The studies measured different mental health outcomes including; positive and negative affect, coping, suicide risk, suicide attempt, current mental health problem, use of mental health services, psychological adjustment, depression and anxiety.

The three studies that explored the impact of ACE’s all found a significant and positive relationship with poor mental health amongst university students. O’Neill et al. (2018) [ 50 ] in a longitudinal study ( n  = 739) showed that there was in increased likelihood in self-harm and suicidal behaviours in those with either moderate or high levels of childhood adversities (OR:5.5 to 8.6) [ 50 ]. McIntyre et al. (2018) [ 60 ] ( n  = 1135) also explored other dimensions of adversity including childhood trauma through multiple regression analysis with other predictive variables. They found that childhood trauma was significantly positively correlated with anxiety, depression and paranoia (ß = 0.18, 0.09, 0.18) though the association was not as strong as the correlation seen for loneliness (ß = 0.40) [ 60 ]. McLafferty et al. (2019) [ 40 ] explored the compounding impact of childhood adversity and negative parenting practices (over-control, overprotection and overindulgence) on poor mental health (depression OR 1.8, anxiety OR 2.1 suicidal behaviour OR 2.3, self-harm OR 2.0).

Gaan et al.’s (2019) survey of LGBTQ students ( n  = 1567) found in a multivariate analyses that sexual abuse, other abuse from violence from someone close, and being female had the highest odds ratios for poor mental health and were significantly associated with all poor mental health outcomes [ 33 ].

While childhood trauma and past abuse poses a risk to mental health for all young people it may place additional stresses for students at university. Entry to university represents life stage where there is potential exposure to new and additional stressors, and the possibility that these students may become more isolated and find it more difficult to develop a sense of belonging. Students may be separated for the first time from protective friendships. However, the mechanisms that link childhood adversities and negative psychopathology, self-harm and suicidal behaviour are not clear [ 40 ]. McLafferty et al. (2019) also measured the ability to cope and these are not always impacted by childhood adversities [ 40 ]. They suggest that some children learn to cope and build resilience that may be beneficial.

McLafferty et al. (2019) [ 40 ] also studied parenting practices. Parental over-control and over-indulgence was also related to significantly poorer coping (OR -0.075 p  < 0.05) and this was related to developing poorer coping scores (OR -0.21 p  < 0.001) [ 40 ]. These parenting factors only became risk factors when stress levels were high for students at university. It should be noted that these studies used self-report, and responses regarding views of parenting may be subjective and open to interpretation. Lloyd et al.’s (2014) survey found significant positive correlations between perceived parental acceptance and students’ psychological adjustment, with paternal acceptance being the stronger predictor of adjustment.

Autistic students may display social communication and interaction deficits that can have negative emotional impacts. This may be particularly true during young adulthood, a period of increased social demands and expectations. Two studies [ 56 ] found that those with autism had a low but statistically significant association with poor social problem-solving skills and depression.

Mental health history

Three studies [ 47 , 51 , 68 ] investigated mental health variables and their impact on mental health of students in higher education. These included; a family history of mental illness and a personal history of mental illness.

Students with a family history or a personal history of mental illness appear to have a significantly greater risk of developing problems with mental health at university [ 47 ]. Mahadevan et al. (2010) [ 51 ] found that university students who self-harm have a significantly greater risk (OR 5.33) of having an eating disorder than a comparison group of young adults who self-harm but are not students.

Buffers – factors that are protective of mental wellbeing

Psychological factors.

Twelve studies [ 29 , 39 , 40 , 41 , 42 , 43 , 46 , 49 , 54 , 58 , 64 ] assessed the association of a range of psychological variables and different aspects of mental wellbeing and poor mental health. We categorised these into the following two categories: firstly, psychological variables measuring an individual’s response to change and stressors including adaptability, resilience, grit and emotional regulation [ 39 , 40 , 41 , 42 , 43 , 46 , 49 , 54 , 58 ] and secondly, those that measure self-esteem and body image [ 29 , 64 ].

The evidence from the eight included quantitative studies suggests that students with psychological strengths including; optimism, self-efficacy [ 70 ], resilience, grit [ 58 ], use of positive reappraisal [ 49 ], helpful coping strategies [ 42 ] and emotional intelligence [ 41 , 46 ] are more likely to experience greater mental wellbeing (see Table 2 for a description of the psychological variables measured). The positive association between these psychological strengths and mental well-being had a positive affect with associations ranging from r  = 0.2–0.5 and OR1.27 [ 41 , 43 , 46 , 49 , 54 ] (low to moderate strength of association). The negative associations with depressive symptoms are also statistically significant but with a weaker association ( r  = -0.2—0.3) [ 43 , 49 , 54 ].

Denovan (2017a) [ 43 ] in a longitudinal study found that the association between psychological strengths and positive mental wellbeing was not static and that not all the strengths remained statistically significant over time. The only factors that remained significant during the transition period were self-efficacy and optimism, remaining statistically significant as they started university and 6 months later.

Parental factors

Only one study [ 59 ] explored family factors associated with the development of psychological strengths that would equip young people as they managed the challenges and stressors encountered during the transition to higher education. Lloyd et al. (2014) [ 59 ] found that perceived maternal and paternal acceptance made significant and unique contributions to students’ psychological adjustment. Their research methods are limited by their reliance on retrospective measures and self-report measures of variables, and these results could be influenced by recall bias.

Two studies [ 29 , 64 ] considered the impact of how individuals view themselves on poor mental health. One study considered the impact of self-esteem and the association with non-accidental self-injury (NSSI) and suicide attempt amongst 734 university students. As rates of suicide and NSSI are higher amongst LGBT (lesbian, gay, bisexual, transgender) students, the prevalence of low self-esteem was compared. There was a low but statistically significant association between low self-esteem and NSSI, though not for suicide attempt. A large survey, including participants from seven universities [ 42 ] compared depressive symptoms in students with marked body image concerns, reporting that the risk of depressive symptoms was greater (OR 2.93) than for those with lower levels of body image concerns.

Mental health literacy and help seeking behaviour

Two studies [ 48 , 68 ] investigated attitudes to mental illness, mental health literacy and help seeking for mental health problems.

University students who lack sufficient mental health literacy skills to be able to recognise problems or where there are attitudes that foster shame at admitting to having mental health problems can result in students not recognising problems and/or failing to seek professional help [ 48 , 68 ]. Gorcyznski et al. (2017) [ 68 ] found that women and those who had a history of previous mental health problems exhibited significantly higher levels of mental health literacy. Greater mental health literacy was associated with an increased likelihood that individuals would seek help for mental health problems. They found that many students find it hard to identify symptoms of mental health problems and that 42% of students are unaware of where to access available resources. Of those who expressed an intention to seek help for mental health problems, most expressed a preference for online resources, and seeking help from family and friends, rather than medical professionals such as GPs.

Kotera et al. (2019) [ 48 ] identified self-compassion as an explanatory variable, reducing social comparison, promoting self-acceptance and recognition that discomfort is an inevitable human experience. The study found a strong, significant correlation between self-compassion and mental health symptoms ( r  = -0.6. p  < 0.01).

There again appears to be a cycle of reinforcement, where poor mental health symptoms are felt to be a source of shame and become hidden, help is not sought, and further isolation ensues, leading to further deterioration in mental health. Factors that can interrupt the cycle are self-compassion, leading to more readiness to seek help (see Fig.  2 ).

Poor mental health – cycles of reinforcement

Social networks

Nine studies [ 33 , 38 , 41 , 46 , 51 , 54 , 60 , 64 , 65 ] examined the concepts of loneliness and social support and its association with mental health in university students. One study also included students at other Higher Education Institutions [ 46 ]. Eight of the studies were surveys, and one was a retrospective case control study to examine the differences between university students and age-matched young people (non-university students) who attended hospital following deliberate self-harm [ 51 ].

Included studies demonstrated considerable variation in how they measured the concepts of social isolation, loneliness, social support and a sense of belonging. There were also differences in the types of outcomes measured to assess mental wellbeing and poor mental health. Grouping the studies within a broad category of ‘social factors’ therefore represents a limitation of this review given that different aspects of the phenomena may have been being measured. The tools used to measure these variables also differed. Only one scale (The UCLA loneliness scale) was used across multiple studies [ 41 , 60 , 65 ]. Diverse mental health outcomes were measured across the studies including positive affect, flourishing, self-harm, suicide risk, depression, anxiety and paranoia.

Three studies [ 41 , 60 , 62 ] measuring loneliness, two longitudinally [ 41 , 62 ], found a consistently positive association between loneliness and poor mental health in university students. Greater loneliness was linked to greater anxiety, stress, depression, poor general mental health, paranoia, alcohol abuse and eating disorder problems. The strength of the correlations ranged from 0–3-0.4 and were all statistically significant (see Tables 3 and 4 ). Loneliness was the strongest overall predictor of mental distress, of those measured. A strong identification with university friendship groups was most protective against distress relative to other social identities [ 60 ]. Whether poor mental health is the cause, or the result of loneliness was explored further in the studies. The results suggest that for general mental health, stress, depression and anxiety, loneliness induces or exacerbates symptoms of poor mental health over time [ 60 , 62 ]. The feedback cycle is evident, with loneliness leading to poor mental health which leads to withdrawal from social contacts and further exacerbation of loneliness.

Factors associated with protecting against loneliness by fostering supportive friendships and promoting mental wellbeing were also identified. Beliefs about the value of ‘leisure coping’, and attributes of resilience and emotional intelligence had a moderate, positive and significant association with developing mental wellbeing and were explored in three studies [ 46 , 54 , 66 ].

The transition to and first year at university represent critical times when friendships are developed. Thomas et al. (2020) [ 65 ] explored the factors that predict loneliness in the first year of university. A sense of community and higher levels of ‘social capital’ were significantly associated with lower levels of loneliness. ‘Social capital’ scales measure the development of emotionally supportive friendships and the ability to adjust to the disruption of old friendships as students transition to university. Students able to form close relationships within their first year at university are less likely to experience loneliness (r-0.09, r- 0.36, r- 0.34). One study [ 38 ] investigating the relationship between student experience and being the first in the family to attend university found that these students had lower ratings for peer group interactions.

Young adults at university and in higher education are facing multiple adjustments. Their ability to cope with these is influenced by many factors. Supportive friendships and a sense of belonging are factors that strengthen coping. Nightingale et al. (2012) undertook a longitudinal study to explore what factors were associated with university adjustment in a sample of first year students ( n  = 331) [ 41 ]. They found that higher skills of emotion management and emotional self-efficacy were predictive of stable adjustment. These students also reported the lowest levels of loneliness and depression. This group had the skills to recognise their emotions and cope with stressors and were confident to access support. Students with poor emotion management and low levels of emotional self-efficacy may benefit from intervention to support the development of adaptive coping strategies and seeking support.

The positive and negative feedback loops

The relationship between the variables described appeared to work in positive and negative feedback loops with high levels of social capital easing the formation of a social network which acts as a critical buffer to stressors (see Fig.  3 ). Social networks and support give further strengthening and reinforcement, stimulating positive affect, engagement and flourishing. These, in turn, widen and deepen social networks for support and enhance a sense of wellbeing. Conversely young people who enter the transition to university/higher education with less social capital are less likely to identify with and locate a social network; isolation may follow, along with loneliness, anxiety, further withdrawal from contact with social networks and learning, and depression.

Triggers – factors that may act in combination with other factors to lead to poor mental health

Stress is seen as playing a key role in the development of poor mental health for students in higher education. Theoretical models and empirical studies have suggested that increases in stress are associated with decreases in student mental health [ 12 , 43 ]. Students at university experience the well-recognised stressors associated with academic study such as exams and course work. However, perhaps less well recognised are the processes of transition, requiring adapting to a new social and academic environment (Fisher 1994 cited by Denovan 2017a) [ 43 ]. Por et al. (2011) [ 46 ] in a small ( n  = 130 prospective survey found a statistically significant correlation between higher levels of emotional intelligence and lower levels of perceived stress ( r  = 0.40). Higher perceived stress was also associated with negative affect in two studies [ 43 , 46 ], and strongly negatively associated with positive affect (correlation -0.62) [ 54 ].

University variables

Eleven studies [ 35 , 39 , 47 , 51 , 52 , 54 , 60 , 63 , 65 , 83 , 84 ] explored university variables, and their association with mental health outcomes. The range of factors and their impact on mental health variables is limited, and there is little overlap. Knowledge gaps are shown by factors highlighted by our PPI group as potentially important but not identified in the literature (see Table 5 ). It should be noted that these may reflect the focus of our review, and our exclusion of intervention studies which may evaluate university factors.

High levels of perceived stress caused by exam and course work pressure was positively associated with poor mental health and lack of wellbeing [ 51 , 52 , 54 ]. Other potential stressors including financial anxieties and accommodation factors appeared to be less consistently associated with mental health outcomes [ 35 , 38 , 47 , 51 , 60 , 62 ]. Important mediators and buffers to these stressors are coping strategies and supportive networks (see conceptual model Appendix 2 ). One impact of financial pressures was that students who worked longer hours had less interaction with their peers, limiting the opportunities for these students to benefit from the protective effects of social support.

Red flags – behaviours associated with poor mental health and/or wellbeing

Engagement with learning and leisure activities.

Engagement with learning activities was strongly and positively associated with characteristics of adaptability [ 39 ] and also happiness and wellbeing [ 52 ] (see Fig.  4 ). Boulton et al. (2019) [ 52 ] undertook a longitudinal survey of undergraduate students at a campus-based university. They found that engagement and wellbeing varied during the term but were strongly correlated.

Engagement and wellbeing

Engagement occurred in a wide range of activities and behaviours. The authors suggest that the strong correlation between all forms of engagement with learning has possible instrumental value for the design of systems to monitor student engagement. Monitoring engagement might be used to identify changes in the behaviour of individuals to assist tutors in providing support and pastoral care. Students also were found to benefit from good induction activities provided by the university. Greater induction satisfaction was positively and strongly associated with a sense of community at university and with lower levels of loneliness [ 65 ].

The inte r- related nature of these variables is depicted in Fig.  4 . Greater adaptability is strongly associated with more positive engagement in learning and university life. More engagement is associated with higher mental wellbeing.

Denovan et al. (2017b) [ 54 ] explored leisure coping, its psychosocial functions and its relationship with mental wellbeing. An individual’s beliefs about the benefits of leisure activities to manage stress, facilitate the development of companionship and enhance mood were positively associated with flourishing and were negatively associated with perceived stress. Resilience was also measured. Resilience was strongly and positively associated with leisure coping beliefs and with indicators of mental wellbeing. The authors conclude that resilient individuals are more likely to use constructive means of coping (such as leisure coping) to proactively cultivate positive emotions which counteract the experience of stress and promote wellbeing. Leisure coping is predictive of positive affect which provides a strategy to reduce stress and sustain coping. The belief that friendships acquired through leisure provide social support is an example of leisure coping belief. Strong emotionally attached friendships that develop through participation in shared leisure pursuits are predictive of higher levels of well-being. Friendship bonds formed with fellow students at university are particularly important for maintaining mental health, and opportunities need to be developed and supported to ensure that meaningful social connections are made.

The ‘broaden-and-build theory’ (Fredickson 2004 [ 85 ] cited by [ 54 ]) may offer an explanation for the association seen between resilience, leisure coping and psychological wellbeing. The theory is based upon the role that positive and negative emotions have in shaping human adaptation. Positive emotions broaden thinking, enabling the individual to consider a range of ways of dealing with and adapting to their environment. Conversely, negative emotions narrow thinking and limit options for adapting. The former facilitates flourishing, facilitating future wellbeing. Resilient individuals are more likely to use constructive means of coping which generate positive emotion (Tugade & Fredrickson 2004 [ 86 ], cited by [ 54 ]). Positive emotions therefore lead to growth in coping resources, leading to greater well-being.

Health behaviours at university

Seven studies [ 29 , 31 , 38 , 45 , 51 , 54 , 66 ] examined how lifestyle behaviours might be linked with mental health outcomes. The studies looked at leisure activities [ 63 , 80 ], diet [ 29 ], alcohol use [ 29 , 31 , 38 , 51 ] and sleep [ 45 ].

Depressive symptoms were independently associated with problem drinking and possible alcohol dependence for both genders but were not associated with frequency of drinking and heavy episodic drinking. Students with higher levels of depressive symptoms reported significantly more problem drinking and possible alcohol dependence [ 31 ]. Mahadevan et al. (2010) [ 51 ] compared students and non-students seen in hospital for self-harm and found no difference in harmful use of alcohol and illicit drugs.

Poor sleep quality and increased consumption of unhealthy foods were also positively associated with depressive symptoms and perceived stress [ 29 ]. The correlation with dietary behaviours and poor mental health outcomes was low, but also confirmed by the negative correlation between less perceived stress and depressive symptoms and consumption of a healthier diet.

Physical activity and participation in leisure pursuits were both strongly correlated with mental wellbeing ( r  = 0.4) [ 54 ], and negatively correlated with depressive symptoms and anxiety ( r  = -0.6, -0.7) [ 66 ].

Thirty studies measuring the association between a wide range of factors and poor mental health and mental wellbeing in university and college students were identified and included in this review. Our purpose was to identify the factors that contribute to the growing prevalence of poor mental health amongst students in tertiary level education within the UK. We also aimed to identify factors that promote mental wellbeing and protect against deteriorating poor mental health.

Loneliness and social isolation were strongly associated with poor mental health and a sense of belonging and a strong support network were strongly associated with mental wellbeing and happiness. These associations were strongly positive in the eight studies that explored them and are consistent with other meta-analyses exploring the link between social support and mental health [ 87 ].

Another factor that appeared to be protective was older age when starting university. A wide range of personal traits and characteristics were also explored. Those associated with resilience, ability to adjust and better coping led to improved mental wellbeing. Better engagement appeared as an important mediator to potentially explain the relationship between these two variables. Engagement led to students being able to then tap into those features that are protective and promoting of mental wellbeing.

Other important risk factors for poor mental wellbeing that emerged were those students with existing or previous mental illness. Students on the autism spectrum and those with poor social problem-solving also were more likely to suffer from poor mental health. Negative self-image was also associated with poor mental health at university. Eating disorders were strongly associated with poor mental wellbeing and were found to be far more of a risk in students at university than in a comparative group of young people not in higher education. Other studies of university students also found that pre-existing poor mental health was a strong predictor of poor mental health in university students [ 88 ].

At a family level, the experience of childhood trauma and adverse experiences including, for example, neglect, household dysfunction or abuse, were strongly associated with poor mental health in young people at university. Students with a greater number of ‘adverse childhood experiences’ were at significantly greater risk of poor mental health than those students without experience of childhood trauma. This was also identified in a review of factors associated with depression and suicide related outcomes amongst university undergraduate students [ 88 ].

Our findings, in contrast to findings from other studies of university students, did not find that female gender associated with poor mental health and wellbeing, and it also found that being a mature student was protective of mental wellbeing.

Exam and course work pressure was associated with perceived stress and poor mental health. A lack of engagement with learning activities was also associated with poor mental health. A number of variables were not consistently shown to be associated with poor mental health including financial concerns and accommodation factors. Very little evidence related to university organisation or support structures was assessed in the evidence. One study found that a good induction programme had benefits for student mental wellbeing and may be a factor that enables students to become a part of a social network positive reinforcement cycle. Involvement in leisure activities was also found to be associated with improved coping strategies and better mental wellbeing. Students with poorer mental health tended to also eat in a less healthy manner, consume more harmful levels of alcohol, and experience poorer sleep.

This evidence review of the factors that influence mental health and wellbeing indicate areas where universities and higher education settings could develop and evaluate innovations in practice. These include:

Interventions before university to improve preparation of young people and their families for the transition to university.

Exploratory work to identify the acceptability and feasibility of identifying students at risk or who many be exhibiting indications of deteriorating mental health

Interventions that set out to foster a sense of belonging and identify

Creating environments that are helpful for building social networks

Improving mental health literacy and access to high quality support services

This review has a number of limitations. Most of the included studies were cross-sectional in design, with a small number being longitudinal ( n  = 7), following students over a period of time to observe changes in the outcomes being measured. Two limitations of these sources of data is that they help to understand associations but do not reveal causality; secondly, we can only report the findings for those variables that were measured, and we therefore have to support causation in assuming these are the only factors that are related to mental health.

Furthermore, our approach has segregated and categorised variables in order to better understand the extent to which they impact mental health. This approach does not sufficiently explore or reveal the extent to which variables may compound one another, for example, feeling the stress of new ways of learning may not be a factor that influences mental health until it is combined with a sense of loneliness, anxiety about financial debt and a lack of parental support. We have used our PPI group and the development of vignettes of their experiences to seek to illustrate the compounding nature of the variables identified.

We limited our inclusion criteria to studies undertaken in the UK and published within the last decade (2009–2020), again meaning we may have limited our inclusion of relevant data. We also undertook single data extraction of data which may increase the risk of error in our data.

Understanding factors that influence students’ mental health and wellbeing offers the potential to find ways to identify strategies that enhance the students’ abilities to cope with the challenges of higher education. This review revealed a wide range of variables and the mechanisms that may explain how they impact upon mental wellbeing and increase the risk of poor mental health amongst students. It also identified a need for interventions that are implemented before young people make the transition to higher education. We both identified young people who are particularly vulnerable and the factors that arise that exacerbate poor mental health. We highlight that a sense of belonging and supportive networks are important buffers and that there are indicators including lack of engagement that may enable early intervention to provide targeted and appropriate support.

Availability of data and materials

Further details of the study and the findings can be provided on request to the lead author ([email protected]).

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Acknowledgements

We acknowledge the input from our public advisory group which included current and former students, and family members of students who have struggled with their mental health. The group gave us their extremely valuable insights to assist our understanding of the evidence.

This project was supported by funding from the National Institute for Health Research as part of the NIHR Public Health Research  Programme (fuding reference 127659 Public Health Review Team). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

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All of the included authors designed the project methods and prepared a protocol. A.C. designed the search strategy. F.C, L.B and C.B screened the identified citations and undertook data extraction. S.B. led the PPI involvement. JD participated as a member of the PPI group. F.C and L.B undertook the analysis. F.C. and L.B wrote the main manuscript text. All authors reviewed the manuscript. F.C designed Figs. 2 , 3 and 4 . The author(s) read and approved the final manuscript.

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Campbell, F., Blank, L., Cantrell, A. et al. Factors that influence mental health of university and college students in the UK: a systematic review. BMC Public Health 22 , 1778 (2022). https://doi.org/10.1186/s12889-022-13943-x

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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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Promoting University Students' Mental Health: A Systematic Literature Review Introducing the 4M-Model of Individual-Level Interventions

Bhavana nair.

1 Guidance & Counseling Office, Student Services & Registration, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai, United Arab Emirates

Farah Otaki

2 Strategy & Institutional Excellence, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai, United Arab Emirates

Associated Data

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Objective: The purpose of this study is to systematically review recently published individual student-level interventions aimed at alleviating the burden of mental health challenges faced by the students and/ or at equipping them with coping mechanism that will foster their resilience.

Methods: This study relied on a systematic literature review. PubMed dataset was used; the search was confined to the following period: July 2016-December 2020.

Results: A total of 1,399 records were identified by the electronic search, out of which 40 studies were included in this study. The authors inductively identified four overlapping categories of interventions across all included articles, and coded them as follows: Mindfulness, Movement, Meaning, and Moderator. Accordingly, each study was linked to at least one of four overlapping categories based on the nature of the intervention(s) under investigation, leading to differing assortments of categories.

Conclusions: The 4M-Model generated by this study encourages focusing on devising holistic, university-based interventions that embrace the individuality of students to improve their mental health through elements of mindfulness, movement, meaning, and moderator. Through this focused approach, university counselors are enabled to design interventions that address students' physical, psychological, emotional, and social needs.

Introduction

There has been a positive paradigm shift in the way our world and its citizens are perceiving the concept of mental health. Mental health is a state of well-being that allows individuals to enjoy and maintain relationships as well as handle stress in a healthy manner without compromising on productivity ( 1 ).

A large body of literature on tertiary education students highlights the importance of maintaining mental health with evidence relating it to educational attainment and productivity ( 2 ), social relationships, engagement on campus, and quality of life ( 3 ), and placement performance ( 4 ). Poor mental health has also been linked with lower retention within a programme, grade point averages, and graduation rates among university students ( 5 ). Counseling, psychoeducation, and mental health services on campuses are no longer deemed as merely supportive but rather an integral component necessary to empower students. These services are integral to help students develop skills such as psychological flexibility ( 6 ) which in turn influences mental health ( 1 ).

The current generation of university students is vastly different from previous generations, especially in their attitudes and beliefs toward their mental health needs. Well-being is a dynamic concept of interlinked physical, social, and psychological dimensions which is constantly changing depending on intrinsic and extrinsic environments and motivations ( 7 ). It is not only the demographics of the current generation of university students that has changed considerably from the past ( 8 ), but so have their attitudes and beliefs toward their needs, including mental health ( 3 ). This population is considered high risk because most mental health problems are triggered before the age of 24 ( 9 ). There is enough evidence to link personal and academic stressors to mental health ( 10 – 12 ). Contemporary tertiary education is striving to attain and maintain cultures of excellence, similar to traditional universities in the past ( 13 ). However, there has been a shift to turn modern day campuses into high stakes competitive testing environments with well-intended emphasis on preparing students to become part of the global economy. This change has influenced the context in which modern universities function. There are a set of challenges that contemporary universities face that extend beyond the earlier tertiary educational institutions and there is an assumption that students are coming to college “overwhelmed and more damaged than those of previous years” ( 14 ).

Although good citizenship has always been an important foundation of all educational institutions, with the dynamic social landscape that the universities are set within, there seems to be a tendency to lead students to fixate on extrinsic factors such as: results and Grade Point Averages, over intrinsic interest such as innovative learning, and expansion of lateral thinking ( 13 ). When the priority is grades, it manifests itself in excessive hours of focused studying, and in negative coping behaviors, such as: inadequate sleep and addictive behaviors, which could potentially affect the well-being of the student. Often, in this pursuit of academic excellence, there is the danger of ignoring the social, emotional, and psychological problems that modern students are now increasingly facing.

There is enough research that indicates that students are experiencing more mental health disorders in contemporary times and are less resilient than students in the past ( 8 ), with lower levels of frustration tolerance ( 15 ). Anxiety and depression are most prevalent among tertiary students ( 16 ). There is a rise in the number of college students with a diagnosable psychological disorder ( 17 ) with some students at greater risk than others of experiencing stress and mental health problems ( 18 ). There has been also a shift in the severity of the problems by students seeking counseling services over the past decade. It is no longer just presenting challenges of adjustment and individuation ( 19 ), or benign hormonal developmental problems associated with the age that prompts students to seek counseling. Students are presenting with severe psychological problems ( 20 ) with a sizeable number of them on psychiatric medication to help them function better on campus ( 15 ).

A common narrative through an exhaustive body of literature highlights the barriers to seeking help for mental health problems by students on campus due to stigma ( 21 ), scepticism about treatment efficacy ( 22 ), and a belief that their emotional problems will not be completely understood. This leads to a sense of social isolation as the students restrain from reaching out for help ( 21 ). Two contributing factors to inadequate help-seeking are the stigma of having a mental health problem and the personal characteristics of the individual student ( 20 ). A fear of negative consequences on academic records ( 23 ) is another common barrier among university students. Interestingly, students resist seeking help because they do not perceive their condition to require intervention or do not perceive it as a priority among their other commitments. They also have the tendency to normalize stress as part of university life, expecting it “will go away with time,” and prefer to handle their problems on their own ( 24 ).

More recent research indicates that students also rely on informal sources of help-seeking from non-professionals, particularly peer groups ( 25 ). Students report having no inhibitions about having open discussions about their mental health problems via social-networking websites ( 26 ). This resonates with the network episode model of help-seeking that emphasizes the social network as an integral, contemporary support in enhancing knowledge and attitudes toward seeking help ( 27 ). However, there is also a significant increase in the number of students with major psychological problems seeking counseling services on campus ( 3 ) challenging the stigma connected with help-seeking. The newer generation's familiarity with psychosocial support services and openness toward seeking them are putting mental health at the core of self-care, much like diet and exercise ( 26 ).

Along with rapid social changes and expectations, the dilution of traditional family anchors (that is the changes to family systems which include busy yet isolated lifestyles, social media pressures, a living free from parental influence which is very common to this age group, and forced separation from families in the pursuit of dream destinations for education) all compounding to the considerable degree of stress that students report upon ( 18 ). Considering all these transitions, focusing on the support that is available to young people on campus is increasingly becoming a necessity. This is not only a personal benefit for students but a national and international investment that could also result in considerable economic benefit ( 28 ) as these students stand to become contributors to the global economy.

A wealth of research exists which highlights the effectiveness of changing organizational factors that influence mental health ( 29 , 30 ). However, there is limited research on person-centric mental health strategies used in university settings ( 31 ). A Systematic Literature Review that was conducted by Fernandez et al. focused on evaluating the effect of setting-based interventions that stimulated and improved the mental health and well-being of university students and employees ( 32 ). That review constitutes an asset for universities seeking to adopt setting-based strategies that were proven efficacious. Yet, given the highspeed in which the higher education ecosystem has been evolving, there is an evident need for a more up-to-date review. Also, despite the importance of modifying the environment for it to become more nurturing for university students' mental health, this needs to be in conjunction with embracing the individuality of each student. Accordingly, the purpose of this study is to bridge this gap through providing a review of the literature on recently published individual student-level interventions that aim to alleviate the burden of mental health challenges faced by the students and/or help them with coping mechanisms that will foster their resilience.

We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( 33 ). The protocol of the systematic review was published in PROSPERO, a database of prospectively registered systematic reviews in health and social care (CRD42021227862).

Search Strategy

To complement the work of Fernandez et al., focusing on the recent literature, the search period was confined to July 2016 through December 2020 ( 32 ). PubMed database was used. The search strategy used, with its key words and Boolean logic, is available as an online resource. It was structured as follows:

• Subjects: student or resident.
• Location: higher education, university, college, or tertiary education.
• State-of-being : mental health.
• Challenges faced by subjects : psychosocial, anxiety, depression, burnout, stress, peer-pressure, social media pressure, bullying, eating disorder, perfectionism, or learning difficulties.
• Intervention to address the challenges : psychotherapy, mindfulness, Counseling, support group, yoga, breathing, art therapy, awareness, resilience, gratitude, affirmations, or peer-Counseling.

Pure qualitative studies were excluded. We included all quantitative studies, so long as they contained information on the impact of the intervention. These included those using experimental (i.e., randomized controlled trials) or observational (i.e., controlled trials without randomization, and pre-post and time series) approaches. Duplicated papers were excluded. Studies were screened for inclusion in three phases:

• BN and FO went over all the abstracts, together, to remove the articles that certainly did not meet the inclusion criteria.
• The full text of all the remaining abstracts were reviewed independently by BN and FO. The results were discussed. Any discrepancies were investigated and reflected upon until reaching consensus.
• Finally, all remaining articles were thoroughly reviewed for summarizing purposes based on a preset template: research study objective, context, design, method, sample, intervention, and main conclusion.

Articles were included if:

• a) Empirical/applied (i.e., theoretical studies or systematic reviews, and studies using secondary data were excluded),
• b) Conducted in one or more university,
• c) Aimed at evaluating, the immediate or long-term effect of an intervention on the mental health status of students,
• d) Included global measures of mental health and well-being,
• e) Had the university counselor involved in the intervention,
• f) Involved full-time students, and
• g) Was written in English.

Quality Assessment

The quality of each of the included articles was evaluated considering the internal and external validity. For the internal validity (risk of bias), each study's methodological quality was assessed using the criteria introduced by Jadad et al. ( 34 ). As for the external/ ecological validity of the included studies, it was assessed using the criteria developed by Green and Glasgow ( 35 ). This quality assessment was not used to exclude articles. Yet, the results of the assessment were thoroughly reflected upon as an evaluative measure of the review output.

Data Analysis

The interventions referred to in the included studies were analyzed by the researchers using the framework of Braun and Clarke ( 36 ). The intention was to inductively build a general interpretation of all included studies, in alignment with the paradigm of constructivism ( 37 , 38 ). The assumption was that reality is socially-constructed. This required thoroughly reflecting upon the interventions investigated in the included studies. The process of exploratory reflection adapted was spiral, where the researchers' observations kept getting revisited which culminated into the development of an evidence-driven model. Since the constructivism paradigm gives precedence to thoroughness and insightfulness over extensiveness and generalizability ( 39 ), the decision was made upfront, as abovementioned, for this search to be limited to a single database ( 40 ). As for the purpose of the qualitative meta-synthesis, it was to create a dynamic individual-level intervention framework that is holistic and context-specific ( 41 ). All articles were categorized based on the nature of the intervention(s) under investigation. It is all narratively presented in the results section.

A total of 1,399 records were identified by the electronic search. Two researchers (BN and FO) reviewed all the abstracts of the resulting papers to identify ones that fitted the inclusion criteria. Based on that, a total of 1,178 articles were excluded. The full text of all remaining 220 articles were extracted and thoroughly reviewed by the two researchers (110 by each). Accordingly, 133 articles were excluded. The remaining 87 articles underwent another round of assessment by both researchers together. Out of these 87 articles, 47 papers were excluded: four studies did not meet the eligibility criteria of having an intervention in them, 31 studies did not include assessing the effectiveness of an intervention,10 studies were not exclusively on university students, and 1 was not on full-time students. Also, one study was excluded because it was not counselor-led but outsourced. Out of the initially identified 1399 articles, 40 articles were finally included in the study ( Figure 1 ).

PRISMA flow-diagram. Promoting university students' mental health: a systematic literature review introducing the 4M-Model of individual-level interventions, Dubai, United Arab Emirates, 2020.

Of the 40 studies, nine studies were conducted in USA, eight in United Kingdom, four in Canada, three in Australia, five in Germany, four in China, and one in each of Turkey, Hungary, Israel, Ireland, Japan, South Korea and Netherlands. The quality of evidence is very high in terms of internal validity because most of the studies ( 25 ) employed RCT, five studies used a quasi-experimental method, two had a cross sectional design, and eight studies utilized a pre-post design without a control group.

The external validity of the papers could be considered low/ moderate. Since most of the studies indicated the experience of only one institution; generalization of the findings is limited. The only exceptions were one study that was conducted in Israel which included three institutions and one conducted in UK which included eight universities. After thoroughly reflecting upon the interventions under investigation across all 40 resulting studies, the authors qualitatively synthesized a holistic framework. This involved inductively identifying four overlapping categories of interventions. Each category was in turn coded with a label that appeared to be most fit to the encapsulated interventions and that is in harmony with the codes of the rest of the categories (i.e., alliteration).

Accordingly, each study was linked to at least one of four overlapping categories based on the nature of the intervention(s) under investigation ( Table 1 ). The first category, coded as Mindfulness, included individual-level interventions that used mindfulness as a strategy to promote mental health. Mindfulness, in this context, refers to any intervention that aims to promote living in the moment or “now” and adopting acceptance and a non-judgmental attitude to guide action. The popular Mindfulness Based Stress Reduction (MBSR) curriculum was used in four studies ( 8 , 42 – 45 ). Mindfulness Based Cognitive Therapy (MBCT) which focuses on reframing thoughts along with becoming aware of the nature and quality of them was found to also be effective in two studies ( 46 , 47 ). In three studies, the intervention(s) made use of imagery and self-guidance ( 48 – 51 ), whereas two other studies explored the effectiveness of Acceptance and Commitment Therapy (ACT) ( 6 ) to improve the psychological flexibility, school engagement, and mental health among University students.

Distribution of the output of the systematic literature review depending on the nature of the intervention(s) under investigation.

Promoting university students' mental health: a systematic literature review introducing the 4M-Model of individual-level interventions, Dubai, United Arab Emirates, 2020 .

The second category of studies was coded as Movement and included individual-level interventions which have a predominant physical element and solicit change in bodily sensations including but not limited to yoga, fitness, dance, kickboxing, and aerobics and breathing exercises. While Tong et al. ( 52 ) exclusively looked at the effect of Yoga and Fitness on mental health, five sets of researchers ( 8 , 42 , 43 , 45 , 46 ) looked at breathing and simple yoga as part of their mindfulness course. Sleep was studied in connection to mental health in two studies ( 53 , 54 ) as it has been found to be a precursor to many mental health problems with insomnia and the quality of sleep put on top of the list affecting sleep hygiene. Behavioral activation, a personalized therapeutic tool mainly used in the treatment of depression targeting behaviors that feed into the condition, was found to be effective in three studies that were reviewed ( 55 – 57 ) involving students with mild depression. The goal of Behavioral Activation is engaging in enjoyable activities with a part of the process focusing on getting past obstacles that may impede that enjoyment. One study included peer-led support ( 56 ) and online delivery of the course ( 57 ), where both appeared to be efficacious. Only one study by Chalo et al. ( 58 ) used Biofeedback intervention, that involved measuring students' quantifiable bodily functions to convey information to them in real-time as a solution to help students manage their physiological response to anxiety and stress.

The third category was coded as Meaning and included studies that investigate individual-level interventions that focus on the counselor addressing connections and associations between variables and enabling the student to reframe cognitions. Psychoeducation was widely utilized with cognitive training as the most common ( 54 , 59 – 63 ). Eustis et al. ( 49 ) focused their study on the student's self-awareness, while Demir and Ercan ( 64 ) explored communication techniques among students. In addition, three studies explored the feasibility of having courses embedded within the curriculum ( 38 , 48 , 50 ) to improve the mental health of students, while nine studies explored the effect of elective courses that aimed at stress reduction ( 18 , 43 , 50 , 56 , 58 , 65 – 69 ).

The last category of studies was coded as Moderator which referred to any element of support that was deployed in conjunction with the counselor, in an individual-level intervention, that acts as a moderator between the student and the counselor. Pet therapy was explored in three studies ( 70 – 72 ) to assess well-being, and an extensive use of the computer to deliver courses such as ACT, Psychoeducation, and Cognitive Behavior Therapy (CBT) which are all traditionally effective in psychotherapy, were found to be efficacious online in 10 studies ( 44 , 50 , 57 , 61 , 73 – 78 ) highlighting the significance of the potential of web-based interventions to impart psychotherapy to a wider audience.

This literature review showed that elements of Mindfulness were a major part of the 23 studies, Meaning was predominant in 24 studies, while Movement was an important feature in 17 studies. An element of support complementary to the therapist, either in the form of a pet (canine) or a web/phone application (i.e., Moderator), was part of 16 interventions. Commonly used approaches were Mindfulness based therapies, ACT, Cognitive Behavior Therapy, and Psychoeducation. The duration of the interventions investigated in the included studies ranged between 1 and 12 weeks, with most of the studies spanning between 6 and 8 weeks. Nine studies had just one element, and only one study ( 49 ) had all the four elements included ( Figure 2 ), which the authors perceived as a “lucky find.”

The 4M-Model generated from this study's qualitative synthesis, visually illustrated as a four-leaf clover which is a symbol of luck. Promoting university students' mental health: a systematic literature review introducing the 4M-Model of individual-level interventions, Dubai, United Arab Emirates, 2020.

Thirty-one studies had overlapping elements indicating that these elements are not mutually exclusive and rather interlinked and are blended with the intention of enhancing the effectiveness of a program.

The output of this Systematic Literature Review revealed diverse interventions. Most of these interventions were hybrid versions of existing evidence-based interventions. A few of the identified articles reflected upon contextualized home-grown interventions. There appeared to be a lack of consensus on a common model/ approach to effectively improve the mental health and wellness of university students ( 61 ) who are known to have their own set of challenges. Hence, this paper provides an outline of practices that have been deployed in this direction, illustrating them from a holistic perspective. Elements of mindfulness, meaning, movement, and use of a moderator were seen to overlap in the studies. The blending of these elements was proven to be effective in improving metacognitive awareness, emotional regulation ( 79 ), concentration, and mental clarity ( 80 ), and decreasing emotional reactivity ( 81 ) and rumination (through disengagement with persistent negative thoughts) ( 82 ) and in turn reducing depression, stress, and anxiety ( 83 ). It has also shown to foster social connectedness and the ability to express oneself in various social situations ( 84 ) thereby reducing stress and anxiety and increasing patience, gratitude, and body awareness ( 85 ). With so many elements that need to be taken into consideration, the researchers have attempted to comprehend the output of this review from the field theory point-of-view where the “organism and environment are perceived as part of an interacting field” ( 86 ).

Moreover, Counseling strategies and interventions are meant to emphasize on the growth of an individual. The human potential for self-actualization, a concept understood by Abraham Maslow as a change process that aims at making a person “aware of what is going on inside himself” [Maslow, as cited in Seaman ( 87 ), p. 3] is core to Counseling interventions, which is where the four elements blend to become crucial to the process of self-awareness and eventually self-growth.

The results of the study indicate that self-awareness through mindfulness is an important foundation upon which all other elements build up to improve mental health of students. This was not a surprising find because this is in alignment with the results of many previously conducted studies ( 88 , 89 ). Mindfulness seems to be the new mantra and has been intensively researched ( 90 ). However, despite a substantial amount of theoretical work conducted to merge Buddhist and Western conceptual viewpoints to psychotherapy ( 91 ), there is minimal literature on how it can translate to practice making this review an important addition to the limited knowledge around the topic of psychological interventions that have been found to be effective among university students. MBSR has proven to reduce stress and anxiety among university students by fostering insight and concentration along with physiologic relaxation ( 92 ). Teaching students to live in the present moment by reframing thoughts (i.e., MBCT) has been found to be effective in reducing depression ( 93 ). It also lessens the risk of relapse with comparable efficacy to antidepressant medication ( 94 ) which, in itself, is a breakthrough for psychotherapy. ACT which focuses on acceptance has been found to improve coping, self-regulation, psychological flexibility, and school engagement ( 6 ). Counseling young adults, in particular students at the university level, would benefit by basing it on Engel's biopsychosocial viewpoint which includes taking into consideration the hormonal changes (biological), identity crisis, and the challenges arising from intimacy and isolation (psychological) which have been hypothesized in Eric Erickson's psychosocial stages of development for this age group. The new age technological challenges of peer-pressure over social media sites and the demands of fitting in and changing family dynamics (sociological) also need to be taken into consideration when conceptualizing a Counseling program for this target group.

Moreover, this transition stage between adolescence and adulthood, also referred to as “emerging adulthood” ( 95 ), is considered to be a period of accepting responsibility for one's actions and livelihood, developing belief systems and values independent of parental and external influences, and establishing relationships with parents on equal grounds. Young university students who are still financially dependent and living with parents during this period are arbitrarily considered to be adolescents if adult responsibilities are not yet accessed. These intangible markers gradually develop. The entailed process could last many years until the corresponding responsibilities are effectively adopted. As such, the range between adolescence and adulthood becomes wider than typically defined, stretching from the beginning of puberty to the early twenties ( 96 ).

Counseling has been traditionally associated as a profession that requires the physical presence of a minimum of two people in a professional relationship to talk through and process experiences to gain insight and understanding. However, in this review, it is evident that web-based interventions seem to produce an equally effective result ( 97 ) as observed in 16 studies of the literature review which could be utilized as a complementary medium widening the scope of practice of counselors and psychotherapists. This could also help in minimizing the stigma associated with getting undesirably labeled and help in reducing psychological self-restraint which has been termed as ‘online disinhibition effect' ( 98 ). Web-based mental health interventions also are becoming a preferred medium for students to gain services and information ( 99 ) as they accommodate their busy schedules ( 100 ).

Another observation was that even though most of the interventions were conducted only for a short period of time, the effectiveness of the interventions was established. Embedding interventions within the curriculum has been suggested ( 101 ) which makes this review even more pertinent for innovations in curriculum planning. This may also help in alleviating the stigma that is attached to Counseling services which is often a barrier that prevents students from reaching out for help ( 102 ). This aligns with Vygotsky's notion of Zone of Proximal Development ( 103 ) which refers to pedagogical support being beneficial for activities, in this context, psychoeducation of positive behaviors that facilitate help seeking behaviors before they can start using them independently.

The above observations prompted the researchers to recognize that the four identified elements when combined would result in a holistic approach of addressing the individual from a biopsychosocial point-of-view. This was depicted in the form of the 4M-Model to guide counselors to develop and implement university-level interventions that could help to reduce stress, anxiety, and depression as well as improve emotion regulation and self-awareness to address the mental health needs of young adults. It would be worthwhile for future research studies to validate the suggested 4M-Model through a similar systematic review of the literature relying on a combination of databases ( 104 ). The analysis in this case would be deductive where the model conceived from this study can be used as a preset template. Also, for validation purposes, it is recommended to conduct follow-up studies aimed at evaluating the efficaciousness of a tailor-made assortment of interventions that can be linked to all elements of the 4M-Model. For that purpose, it would be useful to adapt a mixed methods approach to research, where quantitative and qualitative findings will be integrated to obtain a holistic perspective of the output, outcome, and impact of such university-based, individual-student level mental health initiatives.

Findings of this review reveal the 4M-Model that happen to address all aspects of holistic well-being: physical, psychological, emotional, and social. Effectiveness of the varied interventions that have been reviewed in this study indicate that if a comprehensive approach toward intervention including mindfulness, movement, moderator, and meaning is adapted, then it would not only help students to be supported in a holistic manner but would help counselors plan and execute their programs in a focused approach to address the needs of any university student population who are increasingly overwhelmed and burned out with the stressors from their outside worlds as well as from within. The findings from the review add to the growing evidence for the urgent need of an intervention model that can serve as a directive for counselors and students.

Data Availability Statement

Author contributions.

BN and FO conceptualized the study, conducted the review, performed the qualitative meta-synthesis, and prepared and approved the manuscript. Both authors contributed to the article and approved the submitted version.

Conflict of Interest

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

Acknowledgments

The authors would like to extensd their gratitude to three of their colleagues: Dr. Lisa Jackson, Dr. Leigh Powell, and Ms. Mersiha Kovacevic, for their active role, and valuable reflections and feedback in reviewing the complete manuscript.

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• Published: 08 August 2024

Country and culture, mental health in context

Nature Mental Health volume  2 ,  pages 877–878 ( 2024 ) Cite this article

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Much of psychiatry, psychology and mental health broadly has been dependent on the notion that people are predominantly similar or simply by neglecting diversity. Yet there are powerful influences related to one’s national or country identity, race and ethnicity, community and cultural heritage that speak to a far more complex and dynamic reality. Reflecting on these factors in the context of research is not only a challenge but a profound opportunity to spur future work and to improve care and treatment for individuals.

In the wake of US President Joe Biden dropping out of the 2024 presidential race, the internet has come alive with news stories, social media posts and humor generated by this monumental decision. But one meme has stood out, featuring the presumptive Democratic candidate, Vice-President Kamala Harris. She recounts one of her mother’s favorite turns of phrase to describe young people’s tendency to neglect the influence of previous generations, “You think you just fell out of a coconut tree? You exist in the context of all in which you live and what came before you.”

Although Harris was referring to family and economic opportunities, it is an apropos sentiment to apply to health, as well as mental health. Social and cultural forces have long been hypothesized to shape concepts of self, expressions of self and self-regulation. Although ‘country’ identification can be conflated with a predominant culture artificially circumscribed by borders, it confers at least some level of connectedness to a certain set of customs, beliefs and norms. Not surprisingly, the idea that one’s country or cultural contact can shape an individual has been part of scholarly discourse for centuries among theologians, philosophers and anthropologists. At a fundamental level, understanding the human condition and mental health requires the discussion of culture.

The nuanced ways in which a country or culture may interact with an individual’s biology alongside institutional and structural factors warrant prominence in theoretical models of mental health and risk of developing mental health disorders. Contemporary frameworks that incorporate social determinants of mental health include cultural components and can highlight the potential additive effects of culture in shaping an individual’s experience. The extent to which someone is likely to engage in help-seeking behavior for a mental health condition can be predicated on cultural or community norms. For example, as a group, Asian Americans are less likely to utilize mental health services. The experience of stigma around mental health issues is often magnified in eastern cultures, where an individual’s behaviors and health can reflect on their familial lineage. By contrast, there are culturally salient factors, such as one’s proficiency in English language or feminine gender, that can serve to lessen stigma and promote contact with mental health providers.

Although there can be major barriers to accessing mental health care prompted by cultural influences, access itself is subject to community and country-level constraints, including funding for compensating providers, training for specialized care for certain groups, and coverage for medication and treatment. Culturally competent or responsive care, which is designed to involve stakeholders and representation from community members, integrates components of mental health care that may be outside of more medicalized treatment and can include religion, spirituality or the arts, and relies on active dismantling of impediments to receiving treatment, such as increasing access to telemedicine or group therapy. Improving the quality and accessibility of mental health care also incorporates a broad view of culture and cultural needs in the sense that individual mental health is woven together with intersectional identity and community — for example, being a woman, identifying as LGBT+, or immigration status. The complexity of identity and culture make one-size-fits-all mental health approaches obsolete and inadequate.

The August 2024 issue of Nature Mental Health includes several pieces that highlight some of the ways in which country setting or culture can influence mental health. In their Perspective , Toffol et al. discuss recent country-level developments in the programs for one of the most vulnerable groups, children of parents with a mental illness (COPMI). The authors discuss some of the key lessons learned from intervention programs aimed at COPMI, including European projects in Germany, Denmark and Austria. The authors outline specific barriers and problems, and propose facilitators and recommendations to identify affected children as early as possible, and provide culturally responsive and interconnected mental health care for people who have often been underserved.

Australia’s Emerging Minds program is another national strategy that trains professionals to identify, assess and support COPMI with a cultural lens. In addition to specific programming for children, the project oversees training and resources for practitioners, families and researchers that specifically focus on children’s mental health. People of Aboriginal and Torres Strait Islander heritage in Australia have long experienced racial discrimination associated with negative physical and mental health consequences. Emerging Minds incorporates training pathways that encompass unique cultural experiences, drawing on spiritual and cultural concepts and tenets, the interaction with social, legal and political frameworks in Australia, and considers the intergenerational trauma that affects families and communities.

In an Article , Agarwal et al. report an association between stock market fluctuations and mental and physical health effects, providing another vantage point to appreciate the potential influence of culture and country context. Tracking daily market returns alongside visits to emergency rooms at three of the largest hospitals in Beijing over a four-year period (2009–2012), stock market declines were linked to significant increases in emergency room visits for stress-related issues, including cardiovascular disease, mental health concerns and alcohol abuse. Notably, older adults and men were the groups most affected by these fluctuations.

Although these data are considered ‘historical’ (which can probably apply to most data collected before the onset of the COVID-19 pandemic), they provide unique insights into the Chinese cultural context and the potential mental health effects of economic volatility in a developing country. Much of the previous work in this area was conducted in high-income countries, where a greater proportion of individuals sampled were seasoned investors. By contrast, investors in the time frame assessed in Beijing were more likely to be novices who were interacting with a less sophisticated and less stable market, underscoring the immediacy of stress-related responses. These findings suggest that economic shock and volatility can be considered substantial public health concerns, even more so for resource-limited individuals in developing countries

Health systems data from different regions or countries can also reflect ‘natural experiments’, such as emergency room visits prompted by disasters or crises. With so much scrutiny in recent years on overdose deaths, rising stimulant prescriptions and mental health diagnoses, hospital admissions data can often provide insights into current versus previous timepoints in an epidemiological landscape. In their Article , Xing et al. look at hospital admissions in the USA over more than a decade, using weighted National Inpatient Survey data from 2008 to 2020. The authors report a 10.5-fold increase in mental health disorder-related hospital admissions with concurrent methamphetamine use. Hospital admissions related to mental health disorders increased only modestly during this period (1.4-fold), but these data point to the enormous burden on US hospital systems presented by the increased methamphetamine use — a phenomenon that differentially affects North America.

These are just a few examples of research where culture or country setting may enhance the interpretation of the results or provide additional background, and it is vital that more work is done specifically in cultural mental health research, and also to better understand the specific structures and institutions within country and regional mental health care systems. Nature Mental Health takes a keen interest in work that describes and documents mental health care systems internationally. By presenting and discussing for whom and how mental health care is organized and delivered, and by disseminating shortcomings and achievements, we move closer to better treatment, improved access, training and outcomes. The contexts and what came before us do not have to limit mental health care, but instead can inform and determine where we go next.

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Affiliation Department of Health, Ethics & Society, Care and Public Health Research Institute CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands

Roles Conceptualization, Project administration, Writing – review & editing

Affiliations Department of Health, Ethics & Society, Care and Public Health Research Institute CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands, German Leprosy and Tuberculosis Relief Association (DAHW), Wuerzburg, Germany, Heidelberg Institute of Global Health, University of Heidelberg, Germany, Department of Global Health, Institute of Public Health and Nursing Research, University of Bremen, Germany, Marie Adelaide Leprosy Center, Karachi, Pakistan

Roles Writing – review & editing

* E-mail: [email protected]

Affiliations Department of Health, Ethics & Society, Care and Public Health Research Institute CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands, Department of Global Health, Institute of Public Health and Nursing Research, University of Bremen, Germany, Marie Adelaide Leprosy Center, Karachi, Pakistan

Affiliation Department of Global Health, Institute of Public Health and Nursing Research, University of Bremen, Germany

Roles Conceptualization, Project administration, Supervision, Validation, Writing – review & editing

• Ann-Kristin Bonkass, 
• Anil Fastenau, 
• Sophie Stuetzle, 
• Melanie Boeckmann, 
• Mohammed Nadiruzzaman

• Published: August 9, 2024
• https://doi.org/10.1371/journal.pmen.0000091
• Reader Comments

While multi-drug therapy revolutionised the treatment of physical symptoms for leprosy, a lack of psychosocial interventions, to combat the psychological burden of the disease, is noticeable. This is especially the case in a lower-middle-income country like India, where leprosy prevalence is highest, yet, it has one of the lowest rates of mental health services in place. This paper (i) conducts a systematic review to gather academic evidence on best practices of psychosocial care interventions of to leprosy patients from across the globe, and (ii) compiles good practices of mental wellbeing and quality of life to propose plausible actions for leprosy patients in India. Following the PRISMA protocol, keywords were searched in four databases, namely PubMed , PsycInfo , Web of Science and Infolep . After examining all 145 search results through inclusion and exclusion criteria, 17 peer reviewed research articles could qualify for final review exercise, whereby the data was systematically appraised. The systematic review reveals several successful psychosocial interventions implemented worldwide. These interventions were categorised into four sub-groups: educational, counselling, cognitive behavioural therapy, and technology-supported interventions. All the studies included in the analysis showcased effective psychosocial interventions that enhanced the quality of life and reduced depression, anxiety, and stress levels in individuals affected by leprosy. These findings highlighted several promising strategies that could be integrated into India’s mental healthcare system. The studies underscored the significance of involving healthcare professionals, and adopting innovative approaches. Consequently, this research proposes a comprehensive blend of diverse psychosocial interventions to alleviate the burden faced by leprosy-affected individuals in India. It is crucial to take into account various confounding factors and local contexts to tailor these interventions to the specific population group. Additionally, enhancing awareness and updating policies related to leprosy care are essential steps in reducing stigmatization against individuals with leprosy in India and other endemic regions.

Citation: Bonkass A-K, Fastenau A, Stuetzle S, Boeckmann M, Nadiruzzaman M (2024) Psychosocial interventions for persons affected by Leprosy: A systematic review. PLOS Ment Health 1(3): e0000091. https://doi.org/10.1371/journal.pmen.0000091

Editor: Wenjie Duan, East China University of Science and Technology, CHINA

Received: February 21, 2024; Accepted: July 11, 2024; Published: August 9, 2024

Copyright: © 2024 Bonkass et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

1 Introduction

Leprosy, an enduring infectious malady attributed to Mycobacterium leprae, is historically intertwined with disability, societal bias, and discrimination. While the advent of multi-drug therapy (MDT) has revolutionized the management of leprosy’s physical manifestations and significantly reduced its global prevalence, leprosy remains a substantial contributor to the disease burden, with 133,802 documented cases in 2021 [ 1 ]. Nonetheless, the repercussions of leprosy are not confined to its physical symptoms; they frequently exert a profound influence on mental well-being and overall quality of life (QoL). Various factors converge to generate stigmatization of individuals afflicted by leprosy (PALs). Firstly, untreated individuals may develop conspicuous marks and disabilities owing to nerve damage. Secondly, a lack of public awareness fosters a hostile environment, nurturing both internalized and enacted stigma, as well as social exclusion [ 2 ]. Inability to perform daily tasks, engage in employment, or participate in community life can significantly compromise an individual’s well-being and QoL, curtailing their social inclusion. Barcelos et al. [ 3 ] underscore that PALs exhibit markedly lower QoL in comparison to individuals affected by other dermatological conditions.

Leprosy exerts a profound and far-reaching impact on various aspects of an individual’s life, consequently elevating the risk of developing mental comorbidities, specifically anxiety and depression. This pervasive influence extends into the social sphere, where individuals afflicted by the disease often grapple with stigma and resultant exclusion from their family and friends. Additionally, religious beliefs can compound this stigmatization, as leprosy is frequently misconstrued as a divine curse or retribution for one’s actions [ 4 ]. In low-resource settings, individuals confronting mental health challenges face a dual burden, navigating both their physical and psychological well-being, particularly in societies where mental health issues are considered taboo and are accompanied by social stigma [ 5 ]. Paradoxically, low-income countries (LICs) bear the brunt of the highest prevalence of mental illnesses while simultaneously grappling with a scarcity of mental health services, aggravated by inadequate financial and political investment [ 5 ].

The chasm between the demand for mental health treatment and its provision remains a global challenge. The inadequacy of mental health resources is particularly conspicuous within the Indian healthcare system. The 2016 National Survey of Mental Health Resources, conducted by the Indian Ministry of Health and Family Welfare, revealed an acute scarcity of mental health professionals, with a meager 0.3 psychiatrists per 100,000 people, primarily concentrated in the Western and Southern regions of the country [ 6 , 7 ]. Regrettably, preventive programs remain conspicuously absent and fall far short of addressing the needs of the population.

Only a small fraction of the annual budget, 5.2%, is allocated to health services, with mental health receiving even less attention, accounting for less than 1% [ 6 , 8 ]. Leprosy care predominantly emphasizes the biomedical aspects of treatment, specifically addressing physical symptoms through Multidrug Therapy (MDT) and symptom management. Unfortunately, personal and psychological symptoms are often overlooked within the leprosy treatment framework [ 9 ]. This underscores the urgent need to address the deficiency in mental health services for leprosy patients. As a response, this systematic review serves as a foundational step in highlighting the necessity of incorporating psychosocial interventions into leprosy care within the Indian healthcare system, drawing from global best practices. Researchers worldwide have demonstrated the positive impact of diverse psychosocial interventions, characterized by reductions in anxiety and depression symptoms, alongside enhancements in social functioning and self-esteem. Consequently, the provision of psychosocial support and other community-based mental health services can offer both cost-effective and equitable access to care, ultimately leading to improved health and social outcomes [ 10 , 11 ].

Nonetheless, there remains a scarcity of conclusive evidence to effectively address and mitigate the burden of mental health disorders and treatment requirements among Persons Affected by Leprosy (PALs) in India. To mitigate mental illness and elevate the Quality of Life (QoL) among leprosy patients, it is imperative to analyse existing data and tailor treatment plans to the unique needs of individuals [ 10 ]. Given the current dearth of data, this paper aims to offer an enlightening overview of psychosocial interventions that have demonstrated effectiveness in enhancing mental well-being and QoL among PALs globally. Furthermore, this paper examines the impact of a leprosy diagnosis on the QoL and mental well-being of patients. The identification of interventions proven effective in other countries will be instrumental in the establishment of mental healthcare services for leprosy patients in India. Consequently, this systematic review endeavours to present a comprehensive synthesis of available studies that focus on effective psychosocial interventions for PALs, with the goal of contributing to the development of evidence-based mental health programs in India [ 12 ].

2 Methodology

2.1 search strategy.

The research is based on a literature search conducted in the following databases Pubmed , Web of Science , Infolep , PsycInfo and Google scholar by a single assessor. The latest literature search was on June 28 th , 2023. Reports, published studies, reviews and reports were searched by applying a systematic search following a comprehensive search strategy ( Table 1 ). Thereby, the assessor accessed the databases through the institutional VPN-client provided by Maastricht University. The search terms were applied in a Title (TI) and Abstract (AB) search in order to refine the search. With the usage of appropriate search terms, relevant literature was identified according to the PICOS-Scheme (see Table 2 ), and a full-text screening performed. Only English literature was reviewed; however, the author reviewed Portuguese studies, which have been translated, to widen the search. Due to the lack of available data on mental health issues in leprosy patients, no restriction to the publication period was set. The overall review follows the methodology of the PRISMA checklist ( S1 PRISMA Checklist ) [ 13 ].

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2.2 Eligibility, inclusion and exclusion

Firstly, papers dealing with a psychosocial intervention that addresses the relationship between mental wellbeing and leprosy were included. Thereby, a variety of mental disorders were included as can be seen in the search terms. Secondly, the full text of included studies needed to be published in English and must be publicly accessible. Therefore, original research published as peer-reviewed articles and/or book chapters in edited volumes was assessed. The author put no restriction on the publication year of potential studies as there are only limited papers available that assess the link between leprosy and mental health.

On the other hand, there are a number of factors that disqualified studies from being considered for this thesis. While leprosy is one of many NTDs, papers that merely considered other NTDs than leprosy were not valid for this assessment. As this review is looking at effective interventions to promote the QoL and mental wellbeing of PALs, studies that did not show any effect after implementation of the interventions were excluded as they would not be useful in applying the intervention to the Indian context. Furthermore, grey literature, manuscripts and editorials are not acceptable, as well as non-peer reviewed articles as they do not provide validated information.

2.3 Data extraction and analysis

Overall, a total of 145 articles were found in the chosen databases through hand-searches in Google Scholar, based on the above-described systematic literature search. The systematic literature search identified 17 suitable studies that were included in this paper, according to the set inclusion and exclusion criteria. The data of the selected studies were extracted through Excel. A spreadsheet was developed assessing the title of the paper, author and publication year as well as how the papers answered the set research questions. An overview of the systematic literature search within the different databases can be found in Table 1 . The flowchart in Fig 1 below illustrates the described literature search. Table 3 present the study characteristics of the selected studies in more detail. In order to assess the risk of bias of the included studies, the authors used the RoB RCTs tool [ 14 ] for randomized controlled trails, the NICE checklist [ 15 ] for qualitative studies, the MMAT tool [ 16 ] for mixed-method studies and finally, the critical review form [ 17 ] for quantitative studies. The extensive risk of bias analysis, which was performed in the beginning of the review to ensure low risk of bias, can be found in the Table 4 . Thereby, the risk of bias within the studies was assessed as medium to low and suitable for the analysis of this review. By closely following the PRISMA guideline, which was developed beforehand, the authors attempted to adapt to the studies’ bias. During the assessment of the chosen studies, the author tried to ensure comparability and generalizability, which was limited due to heterogeneous study designs and interventions.

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1) RoB RCTs–Quality Assessment.

Su, T.; Wu, L.; Lin, C.; The prevalence of dementia and depression in Taiwanese institutionalized leprosy patients, and the effectiveness evaluation of reminiscence therapy—a longitudinal, single‐blind, randomized control study.

Domain 1: Risk of bias arsing from the randomization process.

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Domain 2: Risk of bias due to deviations from the intended interventions (effect of adhering to intervention).

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Domain 3: Missing outcome data.

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Domain 4: Risk of Bias in measurement of the outcome.

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Domain 5: Risk of bias in selection of the reported result.

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Study by: Dadun, D.; van Brakel, W.; Peters, R.; Lusli; M.; Zweekhorst, M.; Bunders; J.; Irwanto, Impact of socio-economic development, contact and peer counselling on stigma against persons affected by leprosy in Cirebon, Indonesia–a randomised controlled trial.

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2) MMAT Tool.

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3) Critical review form–Quantitative studies.

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4) NICE checklist–qualitative studies.

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Due to the limited availability of psychosocial interventions to promote the mental wellbeing of PALs merely 17 studies were identified for this systematic review. The chosen studies included data from different countries, namely: Brazil (n = 1), India (n = 7), Nepal (n = 3), Indonesia (n = 4), Egypt (n = 1) and Taiwan (n = 1). As there is a variety of psychosocial interventions available, categories to achieve a better overview of the intervention types were created. The interventions were divided into four categories: educational interventions, counselling strategy, cognitive behavioural therapy (CBT) and other or technology supported interventions. By creating categories, the author ensured that the findings of the included studies are appropriately presented. The categorization facilitates the comparability of the findings, in order to make an educated statement about what intervention would be useful in the Indian setting.

3.1. Psychoeducational interventions

Knowledge is an important factor when it comes to stigmatisation of PALs. Multiple papers have reported how a lack of knowledge can affect the own perception of a disease, such as leprosy [ 18 ]. The increase in knowledge around the transmission and symptoms of leprosy would facilitate early detection, which is essential to reduce social and physical consequences of the illness [ 18 ]. The literature selection identified two papers which describe effective psychoeducational interventions, namely Mardhiyah [ 12 ] and Ahmed & Mohamed [ 19 ]. The study conducted by Mardhiyah [ 12 ] assessed the knowledge levels of their participants before and after the educational intervention. Based on the data conducted pre and post intervention, the psychoeducational intervention was proven effective. However, it was more effective in participant two and three than in participant one, as their SRQ score was still at six, while the other two had a significantly lower score (4 and 3 respectively). Hence, the set objective for the SRQ score was achieved for two out of three participants. Furthermore, participants self-reported a decrease in psychological distress after the intervention, and increased knowledge [ 12 ].

The study by Ahmed & Mohamed [ 19 ] was conducted in a Dermatology Hospital in Egypt. To assess the effectiveness of the intervention, pre and post measurements were taken from the individuals, also evaluating the patient’s self-care practices [ 19 ]. Thereby, the used measures were validated by a pilot study, performed beforehand. While the majority of the participants (66.7%) had a poor knowledge level regarding leprosy prior the intervention, their levels significantly increased after the educational intervention that was performed by the nurses of the hospital. Thus, 27.8% of the participants achieved an average knowledge level and 61.1% even a good level [ 19 ]. Self-care practices improved as well after the educational intervention. Additionally, the psychological problems significantly reduced after the intervention. A statistical difference was further seen in the reduced stigmatisation participants encountered daily. Not only were their psychological problems reduced, but also their psychological needs were more fulfilled after the intervention, as the participants acquired a better understanding of the disease itself and how it affects the body [ 19 ].

Overall, the educational interventions evaluated by Mardhiyah [ 12 ] and Ahmed & Mohamed [ 19 ] were proven effective at the scale they were applied. When developing psychoeducation strategies, like the ones described, it is important to keep in mind the vulnerable situation participants are in.

3.2 Counselling interventions

As there are a number of different intervention types available for the mental wellbeing of leprosy patients, counselling interventions are rather popular among researchers. This type of intervention has been proven effective in other health issues, especially for psychological conditions such as anxiety and depressive disorders [ 20 ]. As indicated by some of the included studies, counsellors can also be lay people or volunteer, which makes this kind of strategy not only cost-effective but also more trustworthy for affected individuals [ 21 ].

This systematic review included seven studies that used counselling interventions to improve the mental wellbeing of leprosy patients and to reduce stigma-related harm. Bhat et al. [ 20 ] assessed how counselling strategies improved the social participation of PALs in 120 patients in Kashmir and Jammu, India. The aim of the counselling intervention was to provide accurate information about the disease itself and how it can be managed. A substantial reduction was observed in the participation restriction scores, which demonstrates to what extent people feel excluded from social activities. Therefore, the percentage of participants feeling extreme restriction decreased from 22.82% to 8.33% while a feeling of no restriction increased from 0% to 3.33%. While the intervention affected people from all demographic backgrounds, the following factors were significant contributors to an increased participation restriction score: being female, aged over 40 years, disabled, unmarried and unemployed [ 20 ].

Floyd-Richard & Gurung [ 22 ] conducted their research at the Green Pastures Hospital in Pokhara, Nepal. The participants were divided into single sex and children’s groups, together with a counselling psychologist and a nurse. During the sessions, difficult moments of participants’ lives were discussed, as well as resilience strategies to meet their own needs. While the intervention was evaluated as effective in reducing the impact of stigmatisation on leprosy affected persons, the outcome measures were weak. However, by connecting with group members, individuals felt less alone with their problems and fears [ 22 ]. To improve the intervention, Floyd-Richard & Gurung [ 22 ] recommended the inclusion of recovered leprosy patients as counsellors, in order to build a stronger connection with the participants. Additionally, the researchers admitted that counselling alone may be insufficient to meet the psychological needs of participants, thus, they suggest a combined approach with health educational methods.

While Floyd-Richard & Gurung [ 22 ] and Bhat et al. [ 23 ] solely used counselling strategies, Dadun et al. [ 23 ] added socio-economic development (SED) along with a contact task to the intervention, called “Stigma Assessment and Reduction of Impact’’ Project (SARI) [ 23 ]. The controlled trial was performed in Indonesia. While the first session was performed by a professional counsellor, the remaining sessions were provided by lay- or peer-counsellors. The counselling part of the intervention consisted of five sessions on individual, group, and family basis. Lastly, the contact section between the affected people and community members aimed at reducing negative feelings and stereotypes towards leprosy. All three interventions were proven to be effective to improve QoL (p = 0.013), participation restriction (p = 0.001) and stigma (p = 0.001) within the intervention groups. However, only the counselling and the SED intervention was found to significantly improve the QoL of participants (p = 0.036). Social stigma significantly reduced during all three interventions (p = 0.002; p = 0.001 and p = 0.001). Hence, it can be said that the intervention had a beneficial impact on the outcomes within the intervention groups [ 23 ].

In Nepal, Jay et al. [ 21 ] implemented ten self-help groups for 98 participants throughout different districts where high rates of disability due to leprosy were found. The statistical analysis indicated that there is a positive association between having access to groups and a reduced internalised stigma. The researchers further found a positive association between increased identification with the self-help group and improved psychological wellbeing. Better access to multiple groups was indirectly significantly associated with improved psychological wellbeing (p = 0.001) [ 21 ]. As can be seen from the study, having access to social activities within multiple groups, as well as the feeling of belonging to a certain group can help to improve the mental wellbeing of affected leprosy patients.

The rights-based counselling module (RBCM) by Lusli et al. [ 2 ] is a much-cited study that, in addition to leprosy patients, further included their family members in the Cirebon District of Indonesia. The counseling was divided into individual, group and family sessions and performed by 23 trained peer and lay counselors. During the RBCM 198 participants received counseling. After the intervention, all of the measures indicated a positive effect of the approach. The SARI scale (p = 0.001) as well as the participation restriction scale (p = .001) decreased while the participants’ QoL (p = .0.001) increased after the counselling sessions. Additionally, when testing for confounders, a significant effect between reduced PSS and SSS score and sex were found, as the counselling intervention was more effective in women [ 2 ]. The qualitative data assessment reported similar effects of the intervention, as participants felt more powerful against negative feelings and enacted stigma from others.

Another study conducted in Indonesia was introduced by Susanto et al. [ 24 ], aiming at assessing the experiences of PALs after joining self-care groups (SCG). The qualitative data analysis showed that SCG helped to support participant’s ability to take care of themselves and their needs. It further helped affected people to accept themselves and to receive the social acceptance they needed. Hence, the assessed SCG effectively helped PALs to improve their QoL by helping them to become an active member of society again, having an occupation, as well as feeling acceptance from people around them [ 24 ].

Van’t Noordende et al. [ 18 ] conducted a family-based intervention which was based in two sites, the rural area Odisha and the urban area Telangana in India. The family-based counselling intervention aimed at supporting the participant’s protective abilities and resilience. This format was chosen, as family members and close friends often act as a bedrock of wellbeing and identity of affected persons. The sessions included a problem-solving and action learning approach to emphasize the im-portance of social relationships and family support as well as recognizing spiritual beliefs. All individuals from the Odisha state had a higher WHOQoL BREF (p = 0.0001) which was significantly associated with the intervention. Participants from Telangana also experienced a statistically significant increase in the QoL score (p = 0.004) except the family members of the leprosy patients (p = 0.108). Based on the study’s findings the intervention can be evaluated as effective in increasing QoL and resilience in leprosy patients and their family members. The discrepancy between the different outcomes in the geographical areas can be explained by the varying community demographics and levels of social relationships [ 18 ].

The last study was conducted by Jay et al. [ 25 ], following an empowerment approach and a group-based initiative. The findings are aligning with results from previous studies and indicate that social belonging to a group has a positive effect on participant’s resilience (p = 0.01), as well as better self- acceptance (p = 0.05). Hence, giving people a sense of belonging through self help groups has a positive effect on people’s psychological well being. As can be seen, all the included studies using a counselling approach came to the same conclusion of it being an effective intervention to reduce stigma and improve the mental wellbeing in PALs. While the studies used similar methods to collect data, the approaches varied slightly as some included family members and others included rights-based counselling strategies.

3.3 Cognitive behavioural therapy

Cognitive behaviour therapy has been widely recognized in recent years, as it has been proven effective in a number of mental disorders, such as bipolar disorder, depression and schizophrenia. The goal of the therapy is for patients to regain their confidence and hope in order to reenter social life. Thereby, there are different types of CBT, as will be seen in the results of the included studies, for instance a muscle relaxation technique [ 26 ].

The author identified four suitable interventions that address effective CBT. The first study by Rahmawati & Yuniarti [ 27 ] assessed the impact of CBT on the level of depression of 25 persons suffering from leprosy. The statistical test showed significant reduction in the participant’s depression level after the intervention. The results were statistically significant (p = 0.001), meaning that CBT can be seen as effective in reducing depression in leprosy patients. Therefore, moderate depression reduced from 20% to 4% and participants with No depression increased from 0% to 12%. However, Rahmawati & Yuniarti [ 27 ] mention that the majority of the participants had merely elementary education (52%) which may have been a limitation for a better outcome of the study. Thus, they recommend the complementary use of health educational interventions together with CBT [ 27 ].

A slightly different approach to CBT was presented by Ramasamy et al. [ 26 ], as they evaluated the effectiveness of a progressive muscle relaxation technique (PMRT) on depression and anxiety levels of 50 leprosy patients. Furthermore, the participants’ depression and anxiety level were measured through a self-developed questionnaire during face-to-face interviews. After explaining the exercise to all participants, they were asked to perform this technique twice a day for the following five to six days under supervision of physiotherapists. After statistical analysis, a significant difference between pre- and post-test scores was seen for both depression and anxiety (both p = 0.001). Additionally, the PMRT was deemed effective among people suffering from psychological disorders, such as depression and anxiety [ 26 ].

A quantitative study by Leite & Caldeira [ 28 ] conducted in Brazil, appraised the effectiveness of therapeutic workshops on patients QoL and depression level. In order to assess the participant’s psychological wellbeing, the researchers used the WHOQoL BREF as well as the BDI questionnaire at baseline and six months after the intervention. The analysis indicated that there was a significant reduction of depression levels among the participants as well as an increase in the psychological QoL domain of the WHOQoL BREF (p = 0.001). However, the workshops were only effective to reduce the level of moderate depression (p = 0.001) and no depressive symptoms at all (p = 0.001). The researchers justify the inability of the intervention to improve severe depression (p = 0.557) by saying that these patients are unresponsive to workshops like this and the primary treatment option for them should be antidepressant medications. This indicates the limitations of the CBT approach, whereby researchers need to adapt the intervention in order to help everyone [ 28 ].

The study by Su et al. [ 29 ] was conducted in a Taiwanese leprosy sanatorium, by appraising the effectiveness of reminiscence group therapy in 129 elderly leprosy patients. However, the data regarding the patients’ cognitive functions was not analysed as this did not answer the research questions. The intervention lasted for 24 weeks, whereby the experimental group attended three group sessions of the reminiscence therapy each week and the control group merely had individual interviews. Su et al. define reminiscence therapy as a non‐ pharmacological intervention which “focuses the therapeutic theme on previously experienced events and systemically reviews subjects’ lifestyle and life stages” [ 29 ]. At baseline, 27 of the participants were suspected of suffering from depression based on the GDS-SF score. However, after the intervention, the analysis indicated a statistically significant reduction of depression level among the elderly leprosy patients in the intervention group (p = 0.02). There was no statistically significant reduction in the depression level in participants of the control group. Nevertheless, the reminiscence group therapy was effective in reducing the depression level of PALs in the Taiwanese leprosy hospital [ 29 ].

3.4 Other interventions/ technology supported interventions

While the most established intervention types have been mentioned so far, there are some approaches which were unable to match with one of the categories above. Hence, the author summarised the three remaining studies here [ 30 – 32 ]. As seen in the previous chapters, educational, CBT or counselling interventions do not always reach every participant. Hence, it is important to adapt interventions and to combine different approaches, as can be seen in the following three studies.

This was demonstrated with the study conducted by Ramanathan et al. [ 31 ] that combines a counselling strategy with surgical correction of the physical symptoms of leprosy patients to reduce anxiety and depression levels. The study was performed in the Central Institute for Leprosy in Agra, India and included a study population of 25 participants. Additionally, to the surgical intervention, researchers provided psychiatric assistance to boost self-confidence and awareness. To assess the patients’ anxiety and depression level, the BDI, “Taylor’s Manifest Anxiety Scale” [ 31 ], as well as an Intelligence Scale were applied. The anxiety and depression levels reduced significantly between pre and post intervention. Severe anxiety symptoms reduced from 11 to 5 while severe depression symptoms reduced from 9 to 3. Patients with no anxiety increased from 5 to 15 and patients with no depression symptoms from 7 to 15. After the study’s completion Ramanathan et al. [ 31 ] suggested a better inclusion of educational and informational approaches to achieve a better outcome of a decreased psychological burden.

Dossa et al. [ 30 ] conducted another study in India, making use of a technique widely used in neurology, the so-called mental imagery [ 30 ]. The researcher included 34 participants which were first assessed with the Depression, Anxiety and Stress Scale-21. While the control group received a conventional aerobic exercise programme, the intervention group received the same exercise programme paired with mental imagery sessions. After the intervention, statistical analysis revealed a significant reduction in depression (p = 0.0001), anxiety (p = 0.0002) and stress levels (p = 0.0001) of the intervention group. However, after comparing the results between the control and intervention group only depression levels reduced significantly (p = 0.0037). This indicates that mental imagery is merely effective in reducing depression, but not anxiety or stress [ 30 ].

While in previous studies mostly the respective researchers administered the intervention, Geroge et al. [ 32 ] focused on an important professional group in terms of healthcare provision—nurses. The study focused on improved nursing intervention to reduce psychological symptoms in 40 female leprosy patients who were admitted to a leprosy referral hospital in India. The nursing intervention entailed individual assessments of the participants followed by 20–30 minutes sessions. Thereby, the nurses tried to address fears and insecurities of the women by applying a relaxation therapy to patients that felt anxious. Geroge et al. [ 32 ] found a statistically significant reduction in the anxiety score of the female participants of all age groups (p = 0.01). Anxiety levels decreased most significantly in older women, aged over 40 (p = 0.0001). This study demonstrates the importance of nurses throughout the healthcare provision of leprosy patients, not only for their physical symptoms but also to facilitate the patient’s mental wellbeing [ 32 ].

4 Discussion

The 17 included studies demonstrate globally available interventions and their effectiveness to improve the mental wellbeing and QoL of PALs. The research reveals a diverse array of effective approaches, with some suggesting that combining multiple interventions may yield better results [ 30 , 25 , 23 , 31 ]. It has been calculated by the WHO, that the indirect and direct economic costs produced by mental disorders are expected to surpass US$ 6 trillion by the year 2030, globally. Thus, providing effective mental health interventions is highly cost-effective as it prevents the deterioration or even emergence of psychological symptoms and hence, makes cost-intensive treatment unnecessary [ 33 , 18 ].

As already mentioned, to find an appropriate intervention, possible conflations of approaches need to be considered. A study by Barakat & Zaki [ 34 ] suggests a combined intervention with a counselling and psychoeducational approach. Thereby, researchers need to keep in mind the different levels interventions can be applied on: the intrapersonal level, aiming at individual characteristic; the interpersonal level, that targets relationships between patients and family members or friends; the community level, whereby a certain population group is being addressed and lastly the institutional level, which focuses on laws and regulations that are in place [ 23 ]. It is important that the educational interventions aim at community level, while others should be merely focused on the individual. Thus, counselling as well as CBT strategies should be applied on an intrapersonal or possibly interpersonal level, as these interventions are only suitable for a smaller scope [ 2 ].

In order to make counselling interventions more cost-effective, the inclusion of lay and peer counsellors or the creation of SCGs, as done by Lusli et al. [ 2 ] or Susanto et al. [ 24 ], could play a crucial role when it comes to the provision of counselling interventions. Thereby, it could be useful to train people who have recovered from leprosy to provide counselling as this might increase the effectiveness of the intervention due to a higher trustworthiness of the counsellors towards the participants [ 2 ]. Furthermore, the introduced interventions by Ramanathan et al. [ 31 ] and Dossa et al. [ 30 ] show that innovative approaches, like mental imagery or surgical corrections, can be used to promote mental wellbeing in leprosy patients. However, the authors of both studies recommend a complementary intervention with an educational and/ or counselling method. This emphasises the need for more focused research towards the inclusion of more innovative techniques that can be combined with proven approaches to achieve better outcomes. This can be understood as a call for novel innovations and the application of more technology-based interventions as digitalisation facilitates the development of useful apps and websites [ 35 , 36 ].

Several of the included studies found confounding associations between the outcome of their respective intervention and gender [ 19 , 20 , 29 ]. These findings are supported by a study by Tare et al. (2021) which indicated that women affected by leprosy have a lower QoL due to their diagnosis than men. Additionally, older age has been mentioned to be a confounder in the effectiveness of the interventions. Thus, potential confounders can impact the effectiveness of interventions, which makes studies like the ones by Geroe et al. [ 32 ] and Su et al. [ 29 ] especially important in the field of mental health in PALs, as they focus on vulnerable groups that might experience more stigmatisation. Nevertheless, it needs to be mentioned that psychosocial interventions are not always the most effective treatment option when it comes to mental disorders in leprosy patients. In severe cases, drug therapy might be the only way to alleviate symptoms [ 28 , 37 ].

When looking at India, the lack of available psychological interventions for PALs is very noticeable. While there have been numerous studies about the prevalence of psychological symptoms in PALs in India, there is no psychosocial support system in place despite single adopted policies aiming at the elimination of leprosy. However, as psychological disorders are often comorbidities of leprosy, it is important to implement a system for comprehensive psychological care [ 24 , 30 , 38 , 39 ].

When talking about the implementation of psychosocial interventions for PALs, based on this analysis, one has to keep in mind the different settings and countries the assessed programmes are functioning in. Besides a suitable psychosocial approach, it is important to have a legal foundation for these interventions to work. Thus, the concept of policy learning as described by Sanderson [ 40 ] could be one way to mitigate the problems arising when implementing new policies. This approach draws on present experiences from other countries to enhance the national policy regarding better psychosocial care for leprosy patients. This has the benefit of having an evidence-based alternative, while new programmes hold several uncertainties regarding financing, resource demand and appropriateness. Thereby, policymakers often do not look for new knowledge but for approaches that have been proven effective in other settings while addressing similar problems [ 40 ].

Yet, one needs to keep in mind that the success of these structural reforms highly depends on the society’s perception towards mental health and NTDs. The blaming of specific population groups, like PALs, can have an adverse effect on internalized as well as enacted stigma. This notion may be aggravated by apparent physical symptoms and deformities caused by leprosy, leading to marginalization of this population group, placing them in the focus of discriminatory aggression [ 41 ]. While this paper analyzes psychosocial interventions to improve the QoL and mental wellbeing of PALs, it is crucial to assess what needs to be done to prevent the deterioration of a patient’s mental health in the first place. This includes early detection strategies to reduce the risk of physical disability due to disease progression. Therefore, preventive measures need to be taken before the health deteriorates and to restrict the emergence of stigma and its effect on mental health [ 2 , 18 , 20 ]. While it is important to change hindering legislation for more integrated mental healthcare, social stigma and marginalisation are produced by people’s attitudes and behaviour towards affected people. Thus, appropriate health education and information dissemination are of utmost importance to support national policies and recommendations by the WHO [ 33 ]. This would suggest that in the specific case of India, interventions that promote the mental wellbeing of PALs should mainly be of psychoeducational nature to reach a large number of individuals. Hence, interventions operating on an interpersonal or community level would be most suitable for the Indian context. These eligibility criteria suggest the implementation of psychoeducational interventions as these can be applied in group-session as well as on individual basis. As misinformation and persisting misbeliefs are considerable influences on people feeling stigmatised and hence, suffering from a reduced QoL and mental disorders, psychoeducational methods can countervail these effects (5). Furthermore, this type of intervention requires the least amount of resources as it reaches a large number of people at once and can be easily integrated in the treatment process [ 19 , 12 ]. However, India is still suffering a tremendous lack of mental healthcare personnel which is needed in order to implement any kind of psychosocial intervention as they demand trained personnel [ 6 , 32 ]. Thereby, a stronger inclusion of Accredited Social Health Activists (ASHA) which are engaged on the Indian community level could be an interesting approach to enhance psychosocial interventions for PALs [ 42 ]. Furthermore, the inclusion of peer and lay counselors can be useful in the Indian setting, as it is a low-cost approach that achieves significant differences in people’s QoL and psychological health [ 38 ]. This could be connected with innovative technological-based interventions which still need to be proven effective in this setting.

Providing meaningful interventions for leprosy affected individuals and thus, improving their QoL highly contributes to the achievement of SDGs 3.3 and 3.4. By continuously educating people on transmission and symptoms of leprosy, early detection and hence, decreasing cases may be the result contributing to sub target 3.3. Furthermore, the implementation of effective psychosocial interventions supports the promotion of the mental wellbeing of leprosy patients, which may lead to a reduced premature mortality in this population group [ 43 ].

5 Limitations

One of the main limitations of this review was the limited availability of literature on this topic. This applies not only to the supportive literature, which is rather old, but especially to suitable studies that evaluate a possible psychosocial intervention to improve psychological wellbeing of leprosy participants. Moreover, the included studies show a wide heterogeneity in the used methodology. This may have impacted the comparability of the findings, however, since the term psychosocial interventions comprise a large range of possible approaches this heterogeneity was inevitable. As explained before, the different methodologies were necessary as they provide different perspectives on this topic [ 38 ]

6 Conclusion

Due to the obvious research gap in the field of leprosy and mental disorders, no systematic review has yet been done to consolidate the evidence regarding existing psychosocial interventions that address mental illnesses and a reduced QoL in leprosy patients, which makes this review the first of its kind. Thus, this paper aims at providing urgently needed knowledge to ensure that respective stakeholders can create effective treatment plans for mentally affected leprosy patients in low-resource settings such as India.

A leprosy diagnosis is often described as a life-altering event. Relationships and activities, people have previously engaged in, have to be modified or cannot be continued. Yet, the diagnosis does not imply certainty about treatment and future perspectives. By equipping mental health and leprosy advocates with evidence-based research, extensive change can be achieved by making overdue decisions towards a better treatment provision for PALs possible. Overall, the findings of this paper will help leprosy advocates to aim for better research in the relationship between mental health and leprosy. They will further drive awareness to the urgent need of change within the Indian stigma policies and thus, will lead to an improved understanding about leprosy among society. Helping communities to change their perspectives towards the disease will have a major impact on discrimination and stigmatisation against PALs [ 44 ]. Consequently, this attitude transformation will aid the primary outcome of this paper, the assessment of effective psychosocial interventions to improve the psychological wellbeing of leprosy patients and how it can be applied to the Indian setting. This review contributes to improved practices within the mental health care in India, as it provides urgently needed data for future implementations.

7 Future recommendations

Keeping in mind the findings of this systematic review, it is important to formulate reasonable policy and research recommendations to facilitate the current situation in not only India but also in other endemic countries. Therefore, it is crucial to increase research towards effective, especially cost-effective psychosocial interventions that help to promote the mental wellbeing of leprosy patients. Furthermore, already available interventions need to be proven for their long-term effectiveness, such as the studies included in this review, and if needed adapted accordingly. The introduced approaches further need to be tested on different patient groups with varying demographics to be able to adapt the interventions to certain population groups if required. These suggestions should be followed by leprosy advocates in future research to provide more detailed data on the interventions and their qualities.

Additionally, it is of utmost importance to improve educational services for the overall population in endemic countries to reduce fear, misinformation, and stigmatisation towards the disease as well as mental disorders that might be connected to it and those affected by it. This can further help to improve psychiatric care in India, since the low number of psychiatric centres limits the educational options available. As a result of persisting stigma, psychiatry is still not appropriately represented in the medical training programmes in India [ 45 ]. These recommendations are also applicable to other endemic countries lacking mental health services for PALs. However, national regulations differ, wherefore this review can serve as a baseline guideline to emphasise the benefits of effective psychosocial interventions and their effectiveness.

Furthermore, it is important to emphasise the impact of technology-based and other novel interventions, whereby some have been introduced here. However, other approaches that have been proven effective in managing depression and anxiety, such as art-based therapy or storytelling, could be a low-resource alternative to reach more PALs [ 35 , 36 ]. Digitalisation brings more advantages as apps and internet-based tools can further increase access to reach people who might live too far from medical centres [ 46 ]. Overall, it is important to consider innovative approaches that have been proven effective in similar settings, as they could be a useful asset in improving the mental wellbeing and QoL of PALs.

Supporting information

S1 checklist. si 6 prisma checklist..

https://doi.org/10.1371/journal.pmen.0000091.s001

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The mental effect of obesity on active-duty service members in the united states: a phenomenological approach.

Tegan M. Quigley , Liberty University Follow

School of Health Sciences

Doctor of Philosophy

Marybeth Mitcham

obesity, mental health, military, anxiety, depression, self-esteem, self-efficacy

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Medicine and Health Sciences | Public Health

Recommended Citation

Quigley, Tegan M., "The Mental Effect of Obesity on Active-Duty Service Members in the United States: A Phenomenological Approach" (2024). Doctoral Dissertations and Projects . 5816. https://digitalcommons.liberty.edu/doctoral/5816

This phenomenological research was intended to explore the impact that obesity has on the mental health of soldiers in the U.S. military. The U.S. military has stringent physical fitness standards that must be met by each soldier regardless of sex. These standards can be challenging to maintain. Obesity is an increasing issue in the United States, and soldiers are not immune. Research regarding the physical issues that occur from obesity has been performed, but this study aimed to explore the behavioral or mental health effects that obesity can have within the military community. This study explored the following questions: In what ways does obesity impact the career of a service member? How do service members describe the impact that obesity has on their self-confidence and self-efficacy at work and at home? How does obesity impact service members socially within the military community? A literature review of the existing research was performed, participants were interviewed, and observations within the military community were analyzed for emerging themes. This transcendental phenomenological study has helped fill research gaps regarding the mental health impact that obesity has on service members. The study aimed to explore the mental impact obesity has on service members in the United States. Data was collected through literature review, face-to-face interviews, and observations.

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The Morning

Americans’ struggle with mental health.

We explore why rates of anxiety and depression are higher than they were before the pandemic.

By Ellen Barry

I cover mental health.

It is no mystery why rates of anxiety and depression in the United States climbed in 2020, at the height of the pandemic. But then life began a slow return to normal. Why haven’t rates of distress returned to normal, too?

Self-reported anxiety and depression have declined from the peak they reached in November 2020, when 42.6 percent of adults said they had symptoms, according to the Household Pulse Survey, a Census Bureau tool that measures well-being. Since then, that figure has declined to 20.7 percent. That’s still double the 11 percent of Americans who said the same thing before the pandemic.

In today’s newsletter, I’ll explain why. Researchers say a big reason for this stubbornly elevated distress is young people, whose low mood was not linked to the pandemic.

A youth epidemic

The share of young adults reporting anxiety and depression had been rising for about a decade before Covid struck. That continued throughout the pandemic — and did not ease as quickly when vaccines became available.

This is likely because their symptoms were tied to problems other than the virus, like economic precarity, the housing crisis, social isolation and political turmoil, said Emma Adam, a psychologist at Northwestern. “There’s so many things affecting adolescents and young adults that are about uncertainty with their future,” Adam said. “And that hasn’t changed.”

Age, of course, tracks with income. Adam’s team found that people between the ages of 18 and 39 were half as likely to live in their own home as their counterparts over 40. That means they were especially vulnerable to inflation, rent increases and job loss — just as they faced big decisions like whether to have children or own a home.

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Youth mental health is a 'global crisis' according to world-leading study

A global consortium of world-leading mental health experts and young people have come together to deliver 'a definitive analysis of the worldwide state of youth mental health'.

Published in the scientific journal The Lancet Psychiatry, experts say there are big implications for the health, wellbeing and productivity of young people.

What's next?

Experts and young people are calling for urgent action and better resourcing for youth mental health. 

A world-first review into youth mental health describes a lack of action as a "scandal" that is having big implications for the health, wellbeing and productivity of young people.

The Lancet Psychiatry Commission on youth mental health report, published today, is the culmination of four years' work by more than 50 leading psychiatrists, psychologists, academics and young people who have experienced mental illness throughout the world.

Lead author Professor Patrick McGorry said it was clear governments were "failing young people".

"Over the last 15 to 20 years, we've seen an alarming rise, a 50 per cent increase in the need for care in this age group [in Australia]," Professor McGorry said.

Led by Orygen, Australia's Centre of Excellence in Youth Mental Health, the report has called for existing evidence-based solutions to be scaled up, stating that "even when these illnesses do not cause death, they are the largest and most rapidly growing cause of disability and lost human potential and productivity across the life span".

"Young people have been termed as the snowflake generation, lacking in resilience," Professor McGorry said.

"It's not just that we neglect them.

"We actually blame them for the problems that they're suffering from."

Urgent call to transform care

For Finlaey Hewlett, the report was a bittersweet acknowledgement of their own difficulties in accessing support for mental health issues that began when they were just eight years old.

"I grew up in regional, Western Australia and so the there was a real distinct lack of support and resources out there, especially for young people," they said.

"I couldn't even leave my house."

"I remember how lonely I felt, and how inadequate I felt."

The 23-year-old, who is on the Orygen youth advisory council, said they were let down by the system when they experienced their worst psychological distress at age 16 and in desperation went to a hospital emergency department.

"I was experiencing suicidal ideation and this sense of overwhelming hopelessness," they said.

After a 12 hour wait, they were turned away.

"Not because I wasn't suffering … but simply because I hadn't actively made an attempt on my life," they said.

"They had to save the very, very limited beds that they did have for people who were experiencing that." 

Professor McGorry said too many patients were having similar experiences, falling through the cracks of the primary health care system funded by the federal government, which includes Headspace and GPs, and the hospital-based system funded by state governments.

The report found existing paediatric/adult healthcare models which disrupt care at 18 were not working and recommended a model that offered multi-disciplinary wrap around care for 12 to 25-year-olds as the way of the future. 

Patrick McGorry said it was an approach pioneered by Headspace in Australia, now being replicated by other countries, but needed to be further built upon to treat more complex forms of mental illness to better support the "missing middle".  

He said 39 per cent of young Australians had a diagnosable and treatable condition.

"They're treatable but mostly not treated," he said. 

But he said only 50 per cent of people with mental illness got access to care. 

Mental health issues account for 45 per cent of the disease burden for 10 to 24-year-olds worldwide, but only 2 per cent of health budgets globally are devoted to mental health care.

Professor McGorry said while those figures were a little better in Australia, there was still a "huge mismatch" in the government spend compared to the scale of the crisis.

Global megatrends driving mental health issues

The report named several global megatrends driving psychological distress in young people including growing intergenerational inequality, financial pressure, global instability and the rise of social media.

Finlaey Hewlett said the impact on young people was profound.

"I think the reason why this crisis is getting worse and worse is to do with the world that we are set to inherit," they said. 

"We're terrified of the climate, of the loneliness that we're experiencing, the cost of living, conflict throughout the world.

"It's so much more expensive to just be a human nowadays that your mental health often does go by the wayside when you're just trying to survive." 

While the commission noted the harm of social media, it was just one factor in a range of things impacting young people.

"I'm not saying that social media is not harmful. But if it's seen as the total explanation, it's a very sort of soft target," Professor McGorry said. 

"It does distract away from the much more challenging megatrends that are much more difficult for politicians to deal with."  

He questioned whether calls to ban social media for those under 16 was the right target.

"Do we deal with that by restricting and reducing the agency of young people, or do we actually deal with the problem at its source?" Professor McGorry said.

He said politicians should be doing more to tackle the tech titans who were "unrestrained" and had created unsafe environments for young people.  

Patrick McGorry warned a lack of action would have serious consequences for society.

"The world really has to get real here if we want to see the next generation flourish, if we want to make sure our societies are cohesive and productive, this is a no-brainer," he said.

"And if we invest in this way, we will actually get a return on investment." 

Government ready to review models of care

Federal Health Minister Mark Butler agreed the health system was overwhelmed.

"I wouldn't describe it as broken, but I would describe it as pretty overwhelmed," Mr Butler said. 

He said the older models of care had not kept pace with the sharp increase in mental distress and a review was about to get underway.

He said youth mental health was also on the agenda at this weeks' health ministers and mental health minister's meeting.

Shadow Minister for Health Anne Ruston said now was the time for reform and investment and said the first thing a Coalition government would do if elected would be restore the Medicare-funded psychology sessions to 20 after the Labor government cut them in half.

Ms Ruston said the nationwide shortage of both psychologists and psychiatrists was also a major challenge.

"We need to concentrate on having a national workforce strategy so that we've got a pipeline of psychologists and psychiatrists, particularly into the future so that we can make sure that we have got the support ready," Ms Ruston said. 

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Clinical placements in mental health: a literature review

Affiliation.

• 1 Central Queensland University, Institute for Health and Social Science Research, Centre for Mental Health Nursing Innovation and School of Nursing and Midwifery, Rockhampton, Australia.
• PMID: 25397660
• DOI: 10.3109/01612840.2014.915899

Gaining experience in clinical mental health settings is central to the education of health practitioners. To facilitate the ongoing development of knowledge and practice in this area, we performed a review of the literature on clinical placements in mental health settings. Searches in Academic Search Complete, CINAHL, Medline and PsycINFO databases returned 244 records, of which 36 met the selection criteria for this review. Five additional papers were obtained through scanning the reference lists of those papers included from the initial search. The evidence suggests that clinical placements may have multiple benefits (e.g. improving students' skills, knowledge, attitudes towards people with mental health issues and confidence, as well as reducing their fears and anxieties about working in mental health). The location and structure of placements may affect outcomes, with mental health placements in non-mental health settings appearing to have minimal impact on key outcomes. The availability of clinical placements in mental health settings varies considerably among education providers, with some students completing their training without undertaking such structured clinical experiences. Students have generally reported that their placements in mental health settings have been positive and valuable experiences, but have raised concerns about the amount of support they received from education providers and healthcare staff. Several strategies have been shown to enhance clinical placement experiences (e.g. providing students with adequate preparation in the classroom, implementing learning contracts and providing clinical supervision). Educators and healthcare staff need to work together for the betterment of student learning and the healthcare professions.

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Transforming the understanding and treatment of mental illnesses.

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Revolutionizing the Study of Mental Disorders

March 27, 2024 • Feature Story • 75th Anniversary

At a Glance:

• The Research Domain Criteria framework (RDoC) was created in 2010 by the National Institute of Mental Health.
• The framework encourages researchers to examine functional processes that are implemented by the brain on a continuum from normal to abnormal.
• This way of researching mental disorders can help overcome inherent limitations in using all-or-nothing diagnostic systems for research.
• Researchers worldwide have taken up the principles of RDoC.
• The framework continues to evolve and update as new information becomes available.

President George H. W. Bush proclaimed  the 1990s “ The Decade of the Brain  ,” urging the National Institutes of Health, the National Institute of Mental Health (NIMH), and others to raise awareness about the benefits of brain research.

“Over the years, our understanding of the brain—how it works, what goes wrong when it is injured or diseased—has increased dramatically. However, we still have much more to learn,” read the president’s proclamation. “The need for continued study of the brain is compelling: millions of Americans are affected each year by disorders of the brain…Today, these individuals and their families are justifiably hopeful, for a new era of discovery is dawning in brain research.”

Still, despite the explosion of new techniques and tools for studying the brain, such as functional magnetic resonance imaging (fMRI), many mental health researchers were growing frustrated that their field was not progressing as quickly as they had hoped.

For decades, researchers have studied mental disorders using diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders (DSM)—a handbook that lists the symptoms of mental disorders and the criteria for diagnosing a person with a disorder. But, among many researchers, suspicion was growing that the system used to diagnose mental disorders may not be the best way to study them.

“There are many benefits to using the DSM in medical settings—it provides reliability and ease of diagnosis. It also provides a clear-cut diagnosis for patients, which can be necessary to request insurance-based coverage of healthcare or job- or school-based accommodations,” said Bruce Cuthbert, Ph.D., who headed the workgroup that developed NIMH’s Research Domain Criteria Initiative. “However, when used in research, this approach is not always ideal.”

Researchers would often test people with a specific diagnosed DSM disorder against those with a different disorder or with no disorder and see how the groups differed. However, different mental disorders can have similar symptoms, and people can be diagnosed with several different disorders simultaneously. In addition, a diagnosis using the DSM is all or none—patients either qualify for the disorder based on their number of symptoms, or they don’t. This black-and-white approach means there may be people who experience symptoms of a mental disorder but just miss the cutoff for diagnosis.

Dr. Cuthbert, who is now the senior member of the RDoC Unit which orchestrates RDoC work, stated that “Diagnostic systems are based on clinical signs and symptoms, but signs and symptoms can’t really tell us much about what is going on in the brain or the underlying causes of a disorder. With modern neuroscience, we were seeing that information on genetic, pathophysiological, and psychological causes of mental disorders did not line up well with the current diagnostic disorder categories, suggesting that there were central processes that relate to mental disorders that were not being reflected in DMS-based research.”

Road to evolution

Concerned about the limits of using the DSM for research, Dr. Cuthbert, a professor of clinical psychology at the University of Minnesota at the time, approached Dr. Thomas Insel (then NIMH director) during a conference in the autumn of 2008. Dr. Cuthbert recalled saying, “I think it’s really important that we start looking at dimensions of functions related to mental disorders such as fear, working memory, and reward systems because we know that these dimensions cut across various disorders. I think NIMH really needs to think about mental disorders in this new way.”

Dr. Cuthbert didn’t know it then, but he was suggesting something similar to ideas that NIMH was considering. Just months earlier, Dr. Insel had spearheaded the inclusion of a goal in NIMH’s 2008 Strategic Plan for Research to “develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures.”

Unaware of the new strategic goal, Dr. Cuthbert was surprised when Dr. Insel's senior advisor, Marlene Guzman, called a few weeks later to ask if he’d be interested in taking a sabbatical to help lead this new effort. Dr. Cuthbert soon transitioned into a full-time NIMH employee, joining the Institute at an exciting time to lead the development of what became known as the Research Domain Criteria (RDoC) Framework. The effort began in 2009 with the creation of an internal working group of interdisciplinary NIMH staff who identified core functional areas that could be used as examples of what research using this new conceptual framework looked like.

The workgroup members conceived a bold change in how investigators studied mental disorders.

“We wanted researchers to transition from looking at mental disorders as all or none diagnoses based on groups of symptoms. Instead, we wanted to encourage researchers to understand how basic core functions of the brain—like fear processing and reward processing—work at a biological and behavioral level and how these core functions contribute to mental disorders,” said Dr. Cuthbert.

This approach would incorporate biological and behavioral measures of mental disorders and examine processes that cut across and apply to all mental disorders. From Dr. Cuthbert’s standpoint, this could help remedy some of the frustrations mental health researchers were experiencing.

Around the same time the workgroup was sharing its plans and organizing the first steps, Sarah Morris, Ph.D., was a researcher focusing on schizophrenia at the University of Maryland School of Medicine in Baltimore. When she first read these papers, she wondered what this new approach would mean for her research, her grants, and her lab.

She also remembered feeling that this new approach reflected what she was seeing in her data.

“When I grouped my participants by those with and without schizophrenia, there was a lot of overlap, and there was a lot of variability across the board, and so it felt like RDoC provided the pathway forward to dissect that and sort it out,” said Dr. Morris.

Later that year, Dr. Morris joined NIMH and the RDoC workgroup, saying, “I was bumping up against a wall every day in my own work and in the data in front of me. And the idea that someone would give the field permission to try something new—that was super exciting.”

The five original RDoC domains of functioning were introduced to the broader scientific community in a series of articles published in 2010  .

To establish the new framework, the RDoC workgroup (including Drs. Cuthbert and Morris) began a series of workshops in 2011 to collect feedback from experts in various areas from the larger scientific community. Five workshops were held over the next two years, each with a different broad domain of functioning based upon prior basic behavioral neuroscience. The five domains were called:

• Negative valence (which included processes related to things like fear, threat, and loss)
• Positive valence (which included processes related to working for rewards and appreciating rewards)
• Cognitive processes
• Social processes
• Arousal and regulation processes (including arousal systems for the body and sleep).

At each workshop, experts defined several specific functions, termed constructs, that fell within the domain of interest. For instance, constructs in the cognitive processes domain included attention, memory, cognitive control, and others.

The result of these feedback sessions was a framework that described mental disorders as the interaction between different functional processes—processes that could occur on a continuum from normal to abnormal. Researchers could measure these functional processes in a variety of complementary ways—for example, by looking at genes associated with these processes, the brain circuits that implement these processes, tests or observations of behaviors that represent these functional processes, and what patients report about their concerns. Also included in the framework was an understanding that functional processes associated with mental disorders are impacted and altered by the environment and a person’s developmental stage.

Preserving momentum

Over time, the Framework continued evolving and adapting to the changing science. In 2018, a sixth functional area called sensorimotor processes was added to the Framework, and in 2019, a workshop was held to better incorporate developmental and environmental processes into the framework.;

Since its creation, the use of RDoC principles in mental health research has spread across the U.S. and the rest of the world. For example, the Psychiatric Ratings using Intermediate Stratified Markers project (PRISM)   , which receives funding from the European Union’s Innovative Medicines Initiative, is seeking to link biological markers of social withdrawal with clinical diagnoses using RDoC-style principles. Similarly, the Roadmap for Mental Health Research in Europe (ROAMER)  project by the European Commission sought to integrate mental health research across Europe using principles similar to those in the RDoC Framework.;

Dr. Morris, who has acceded to the Head of the RDoC Unit, commented: “The fact that investigators and science funders outside the United States are also pursuing similar approaches gives me confidence that we’ve been on the right pathway. I just think that this has got to be how nature works and that we are in better alignment with the basic fundamental processes that are of interest to understanding mental disorders.”

The RDoC framework will continue to adapt and change with emerging science to remain relevant as a resource for researchers now and in the future. For instance, NIMH continues to work toward the development and optimization of tools to assess RDoC constructs and supports data-driven efforts to measure function within and across domains.

“For the millions of people impacted by mental disorders, research means hope. The RDoC framework helps us study mental disorders in a different way and has already driven considerable change in the field over the past decade,” said Joshua A. Gordon, M.D., Ph.D., director of NIMH. “We hope this and other innovative approaches will continue to accelerate research progress, paving the way for prevention, recovery, and cure.”

Publications

Cuthbert, B. N., & Insel, T. R. (2013). Toward the future of psychiatric diagnosis: The seven pillars of RDoC. BMC Medicine , 11 , 126. https://doi.org/10.1186/1741-7015-11-126  

Cuthbert B. N. (2014). Translating intermediate phenotypes to psychopathology: The NIMH Research Domain Criteria. Psychophysiology , 51 (12), 1205–1206. https://doi.org/10.1111/psyp.12342  

Cuthbert, B., & Insel, T. (2010). The data of diagnosis: New approaches to psychiatric classification. Psychiatry , 73 (4), 311–314. https://doi.org/10.1521/psyc.2010.73.4.311  

Cuthbert, B. N., & Kozak, M. J. (2013). Constructing constructs for psychopathology: The NIMH research domain criteria. Journal of Abnormal Psychology , 122 (3), 928–937. https://doi.org/10.1037/a0034028  

Garvey, M. A., & Cuthbert, B. N. (2017). Developing a motor systems domain for the NIMH RDoC program.  Schizophrenia Bulletin , 43 (5), 935–936. https://doi.org/10.1093/schbul/sbx095  

Kozak, M. J., & Cuthbert, B. N. (2016). The NIMH Research Domain Criteria initiative: Background, issues, and pragmatics. Psychophysiology , 53 (3), 286–297. https://doi.org/10.1111/psyp.12518  

Morris, S. E., & Cuthbert, B. N. (2012). Research Domain Criteria: Cognitive systems, neural circuits, and dimensions of behavior. Dialogues in Clinical Neuroscience , 14 (1), 29–37. https://doi.org/10.31887/DCNS.2012.14.1/smorris  

Sanislow, C. A., Pine, D. S., Quinn, K. J., Kozak, M. J., Garvey, M. A., Heinssen, R. K., Wang, P. S., & Cuthbert, B. N. (2010). Developing constructs for psychopathology research: Research domain criteria. Journal of Abnormal Psychology , 119 (4), 631–639. https://doi.org/10.1037/a0020909  

• Presidential Proclamation 6158 (The Decade of the Brain) 
• Research Domain Criteria Initiative website
• Psychiatric Ratings using Intermediate Stratified Markers (PRISM)