• Research article
  • Open access
  • Published: 13 August 2019

An assessment of awareness of mental health conditions and its association with socio-demographic characteristics: a cross-sectional study in a rural district in Bangladesh

  • Mohammed Nazim Uddin   ORCID: orcid.org/0000-0001-8363-7207 1 ,
  • Sunil Bhar 2 &
  • Fakir M Amirul Islam 1 , 3  

BMC Health Services Research volume  19 , Article number:  562 ( 2019 ) Cite this article

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To assess the level of awareness, knowledge and help-seeking attitudes and behaviours in relation to mental health conditions (MHCs) and associations with socio-demographic characteristics of a rural district of Bangladesh.

We recruited 2425 adult samples (18–90 years) from a Cross-sectional study in Narial district of Bangladesh. Data on awareness, knowledge, help-seeking attitudes and practice in relation to six MHCs were collected. The MHCs were classified as common (depression, anxiety and drug addiction), and severe (psychosis, dementia and bipolar disorder). Associations of MHCs with socio-demographic characteristics were assessed using Chi-square tests. Rasch analysis was performed to transform the latent attribute (awareness) of MHCs from ordinal to interval scale. Multiple regression analysis was performed to determine how the socio-demographic characteristics contribute to the combined awareness score of MHCs.

Of 2425 participants, 17 (0.7%) were cognizant of all the awareness construct of MHCs, and 1365 (56.28%) were not aware of any of MHCs. The prevalence of awareness of MHCs such as depression (8.5%), anxiety (6.2%), psychosis (3.5%), and bipolar disorder (3.3%), was found to be very low. Awareness was significantly lower in older adults, and in women. Higher levels of education (β 1.77, 95% confidence interval (CI): 1.58–1.97) associated with common MHCs and (β 0.81, 95% CI: 0.67–0.95) those associated with severe MHCs contributed significantly to increased awareness as opposed to having no or primary level of education. Availability of sufficient funds when applied to common MHCs (β 0.43, 95% CI: 0.26–0.61) and severe MHCs (β 0.25, 95% CI: 0.13–0.38) appeared to be more effective in boosting awareness compared to unstable financial situations. Almost 100% of the participants who were aware of the MHCs demonstrated positive attitudes towards seeking medical or psychological counselling.

Conclusions

Awareness of MHCs appeared to be very limited. However, knowledgeable participants were found to be very receptive to medical or psychological counselling. For improving awareness of MHCs need to conduct various intervention programs in particular those campaigns that focus on women, older adults, low SES and people up to the primary levels of education.

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Approximately 7.3% of the global burden of disease has been attributed to mental and behavioural disorders. Most of this burden is related to unipolar depressive disorders and other mental health conditions (MHCs) including anxiety, psychosis and substance use [ 1 ]. Currently, approximately 450 million people suffer from such conditions, and it is projected that one in four individuals in the world will be affected by MHCs at some point in their lifetimes. MHCs are amongst the leading causes of ill-health and disability worldwide [ 2 ]. Globally, approximately 20% of the adults have MHCs, and low and middle-income countries have only one psychiatrist for every 1 to 4 million people [ 3 , 4 ]. People with MHCs experience disproportionately higher rates of disability and mortality [ 5 ]. Individuals with major depressive disorders and schizophrenia had 40 to 60% greater chance of dying prematurely than the general population [ 6 ].

Mental health literacy (MHL), defined as “knowledge and attitudes about MHCs which aid their recognition, management and prevention” is low worldwide, but specifically low in developing countries [ 7 ]. In such societies, MHCs are believed to be consequences of familial imperfection and evil spirits [ 8 ]. Such beliefs have been purported to lead to poor utilisation and negative stigma about mental health services and treatment [ 9 ]. Unsurprisingly, poor health literacy is associated with negative disease outcomes, especially in developing countries [ 10 , 11 , 12 , 13 ].

The importance of health literacy on physical health is widely acknowledged in the world [ 14 ]. However, the literacy about MHCs has been neglected in both developed and developing countries [ 15 ]. The common myths in developing and developed countries are that the MHCs are not curable, caused by personal weakness, and that people with MHCs are usually violent or unstable [ 16 ]. A study from Germany reported that people were more reluctant to discuss MHCs than physical disorders with relatives and friends [ 17 ]. In the USA, many public servants did not seek treatments because they feared that MHCs would create the negative impact on their employment [ 18 ]. In developing countries, utilising services for MHCs are further blocked by stigma and beliefs about MHCs being due to sorcery or spiritual punishment, possessions by spirits and demons, genetic or family inheritance, social or moral disobediences towards ancestors or wraths of Gods [ 19 ]. A study from Nigeria showed that women in the community would be afraid to have a conversation with someone known to have mental disorders [ 20 ]. In the United Arab Emirates (UAE), women were ashamed to mention that they had a family member with mental illness, but this attitude was lower in men [ 21 ]. Moreover, a study from India reported that women thought that MHCs were family matters and should not be disclosed to other people [ 22 ]. However, in developing countries including Bangladesh and India, visiting a traditional healer for emotional problems was more common in women than in men [ 23 ]. A study revealed that in Qatar men possessed better knowledge, beliefs, and attitudes towards mental illness than women [ 21 ].

Despite the association between MHL and diseases outcomes, levels of MHL in rural regions of Bangladesh are unknown. Studies are needed to understand the level of MHL in the population and to develop targeted programs to address such levels. In the last decade, several studies have reported the prevalence of and contributing factors for depression and anxiety both in urban and rural areas in Bangladesh [ 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ]. However, no study has assessed awareness, knowledge, and attitudes of seeking medical treatment regarding MHCs in Bangladesh. Rural areas in Bangladesh are characterised by traditional healing practices and an absence of mental health facilities and care. Therefore, studies on MHL are imperative to gauge and increase the level of awareness of MHCs in rural populations in Bangladesh.

The current study had two aims. First, it aimed to estimate the level of MHL in a typical rural district of Bangladesh. Second, it aimed to identify socio-demographic characteristics associated with MHL in order to identify the factors that affect rural communities and therefore inform potential interventions for improving MHL.

Study sample

Bangladesh is a country of 163 million people divided into 64 districts. Participants were recruited from the Narail district, which is located approximately 200 km south-west of Dhaka, the capital city of Bangladesh. The population of Narail district is 272,872, with approximately 40% of residents aged between 18 and 59 years and 19,000 (about 7%) of residents aged between 60 and 90 years. The study location was selected as it was reflective of typical rural demography in Bangladesh. The Narail district with an estimated population density of 722 people was comparable to the national rural population density of 873 people per square kilometre. Narail is not at the extremity of remote locations nor is it a catchment of a metropolis such as Dhaka [ 33 ]. The area of Narail is 381.76 km2, located in between 23°02′ and 23°17′ north latitudes and in between 89°23’and 89°37′ east longitudes. The district is surrounded by Lohagara and Salikha upazilas on the north, Kalia and Abhaynagar upazilas on the south, Lohagara upazila on the east, and Bagherpara and Jessore Sadar upazilas on the west. The ratio of male to female (48.5 to 51.5) resembled quite well with that of Bangladesh (48.9 to 51.1) [ 34 ]. 72.3% of sample data attained primary education or above as opposed to 72.9% [ 35 ] of the national population, while 27.7% of it had no education, which was comparable to the national 27.1% [ 35 ]. In the make-up of the population with respect to marital status, the Married group of Narial sample data (79.9%) was fairly proximate to the national level (80.01%) [ 36 ]. With respect to the availability of funds, a determinant for socio-economic condition, the sample population having insufficient funds some / most of the time accounted for 32.2 and 23.2% [ 37 ] in Bangladesh. In summary, the socio-demographic make-up of the Narail district delineated well the typical characteristics of a rural district of Bangladesh. Moreover, researchers carried out studies [ 32 , 38 , 39 ] in Narail district earlier and motived to advance further studies based on the population of Narail district.

Sample size and statistical power

The sample comprised 2425 participants, aged between 18 to 90 years from the Narail district. The sample including 1147 older adults and 1278 adults. Prior data indicate that the prevalence of severe depression was 21% in older adults aged 60 years or above, and 6.5% in adults aged between 18 and 60 years [ 40 ]. We assumed a margin of error of 5% in prevalence rates for older adults, and of 3% for adults when estimating the true prevalence of severe depression for each cohort in this rural area [ 40 ]. Using a significance level of 0.05 and statistical power above 80%, a required sample size of 1128 was needed for the older adult cohort and 1283 for the adult group.

The sample size of 2425 was sufficiently large enough to detect a minimum 5% difference in proportion of attaining awareness or knowledge of MHCs related items between men and women; no schooling and primary or secondary level of education; have sufficient funds most of the time and insufficient funds some of the time (statistical power 90%, p  = 0.05).

Sampling frame

A multi-stage cluster random sampling technique was used for this study. Three unions from a total of 13 and one ward from a total of 9 wards of Narail upazilla were randomly selected at level 1. Two to three villages or mohalla from each selected union or ward were randomly selected at the level 2. About 120 older adults and 150 adults were interviewed from each of the villages. Recruitment strategy and quality assurance in data collection were described in details previously [ 38 ]. In brief, all team members participated in an intensive 2-day training programme in Narail before the commencement of the survey. The purpose of the training was to outline the rationale of the study, and the procedures and potential difficulties associated with data collection. The interviewers were instructed to visit every household within the randomly selected villages and to interview one household member of an older adult first. If none were available in this subgroup, the interviewers were approached an adult person of that household. If there was more than one male or female adult in the same household, one individual was selected, based on who was born closer to January. However, to maintain an approximately equal number of males and female participants, one female was interviewed immediately after a male participant. The recruitment started from a corner of a village and continued until the recruitment of a maximum of 250 participants was reached for a large village where the number of eligible participants were greater than 250. In case of fewer than 250 households in a village, the requirement continued to the adjacent village to reach the number to 250.

MHCs measures

Given the relative lack of validated MHL data, the specific items measuring MHL were sourced from the National Survey of Mental Health Literacy and Stigma in Australia [ 41 ]. A questionnaire comprising these items assessed participants’ awareness of six MHCs (depression, bipolar disorder, anxiety, psychosis, dementia, and drug addiction) by asking if they had ever heard of these conditions with a possible response of “yes” or “no”. Based on their responses, they were asked to list at least one symptom of these conditions, this provided insight into the level of knowledge they possessed. Attitudes towards the use of treatment was assessed by asking the question “do they or their relatives need treatment?” with a possible response of “yes” or “no”. Participants were also asked if they or their relatives had ever experienced any MHCs, and if so, if they had undertaken treatment from a “medical doctor”, “psychologist” or others such as “spiritual persons”.

Outcome variables

The outcome variables were determined by the level of awareness of MHCs divided into two groups, common (depression, anxiety and drug addiction) and severe (psychosis, dementia, and bipolar disorder) MHCs. Knowledge was measured based on whether the participants could identify at least one symptoms of the MHCs given that they were aware of the conditions. Attitudes were defined as positive if the participants who were aware of the MHCs were in favour of taking medical treatment or psychological counselling. Practice was defined based on whether participants’ themselves or their relatives with MHCs had undertaken medical treatment or psychological counselling.

Socio-demographic covariates

Demographic details for age was categorised into adult (18 to 59 years) and older adult (60 to 90 years) groups. Level of education was categorised into five categories: no schooling, primary school level of education (grade 1 to 5), secondary school level of education (grade 6 to 10), school secondary certificate (SSC) or higher secondary certificate (HSC), bachelor’s degree or above. SES was assessed according to Cheng et al. [ 42 ] asking whether “over the last twelve months, concerning household food consumption, how would you classify your socioeconomic status?” The possible answers were: (i) insufficient funds for the whole year; (ii) insufficient funds some of the time; (iii) neither a deficit nor surplus (balance); and (iv) sufficient funds most of the time. Occupation was categorised as students, housewives, landowners, labourers, business men or women, government or non-government employees and retired persons.

Statistical analyses

Participant’s sociodemographic characteristics including age, gender, level of education, occupation and SES were reported using descriptive statistics. Association of MHCs with gender, levels of education and other categorical factors were evaluated using Chi-square tests. The linear-by-linear association option in Chi-square test was used to report trends for ordinal categorical variables. Rasch Analysis is a unique approach of mathematical modelling based upon a latent trait and accomplishes stochastic (probabilistic) conjoint additivity (conjoint means measurement of persons and items on the same scale and additivity is the equal-interval property of the scale) [ 43 ]. Rasch models are used when a set of questionnaire items are intended to be summed together to provide a total score. In this study, Rasch analysis [ 44 ] was performed to compute the person measures based on the awareness for common and severe MHCs on a logarithmic scale and termed as “awareness score”. The negative value of an awareness score indicates the person has below average awareness, zero value indicates average and positive value indicates above average level of awareness of the items. Differentials of the measures of awareness and help-seeking attitudes and behaviour in relation to MHCs were evaluated across different major categories of age, gender, the level of education and other socioeconomic factors using Pearson Chi-square tests of independence. Multiple regression analysis techniques were used to evaluate the direction and strength of the effects of socio-economic factors gender, age, SES and education in predicting awareness of underlying MHCs. Data were analysed using RUMM2030 [ 45 ] and SPSS 24.0 [ 46 ].

Mean (SD, range) age of the participants was 52.0 years (17, 18–90). The demographic makeup of the total participants was 48.5% men and 51.5% women. As to the educational attainment, a considerably large proportion (66.6%) of population’s highest level of education was very modest, where 27.6% did not have any formal education and 39% completed primary education. About 14 and 16% of participants earned secondary and SSC/HSC degree respectively, while only 4% had their highest level of degree bachelor or above. The disparity between the educational distribution of adults and older adults is evident from the fact that older adults have relatively more percentage of people without education and less percentage of people with secondary education or higher as opposed to the adults. Socio-economic condition of the participants reflected that majority (about 52.9%) of them had financial stability (43% accounting for balance and 9.9% accounting for sufficient funds most of the time), while 32.2% reported occasional instability and 15.1% had precarious financial situations. Two major occupations in the overall participants were homemakers (40%) and retired persons (22.1%). Overall 5.6% were engaged in government or non-government employment, comprised of 7.6% in the adults age group and 3.5% older adults age group. Majority of the participants were married, and the second largest matrimonial class was widow with differential proportions in adults (3%) and older adults (32%). The socio-demographic characteristics of the participants by two age groups (adults and older adults) are shown in (Table  1 ).

Overall, perceived awareness of MHCs was low ranging from 3.3% (bipolar disorder) to 42% (drug addiction). Adults were more aware of most of the MHCs than the older adults (for example, drug addiction: 52.0% of adults vs. 30.8% of older adults, dementia disorder: 33.1% of adults vs. 20.8% of older adults), which is also evident from the significant associations of age groups and MHCs. Of participants who were aware of MHCs, more than about 90% were able to identify at least one symptom with slightly lower than 80% being cognizant of bipolar disorder symptom.

Almost all the participants were in favour of treating the MHCs. Although awareness of MHCs appeared to be associated with age groups, knowledge and attitude did not exhibit any impact of age. For instance, the proportion of positive attitude towards treating depression was 99% and did not vary significantly across the two age groups (adults and older adults Table  2 ).

Of the total participants 42.5% (38.0% of women vs. 47.2% of men, p  < 0.001) were aware of any common MHCs, while 3.4% were aware of all three common MHCs. However, only 28.1% were aware of any severe MHCs while 1.3% were aware of all three severe MHCs. Among those who were aware of at least one MHCs, only 9 (0.9%) and 6 (0.9%) participants, reported that they had suffered common and severe MHCs respectively (Table  3 ). Awareness of any common MHCs was significantly higher in males compared to females and a similar pattern was observed in both underlying age groups for both common and severe MHCs (Fig.  1 ). Higher level of education (e.g.,73% of people with at least bachelor’s degree were aware of depression compared to 1% of people with no or primary level of education) and better SES appeared to be associated with higher prevalence of awareness of all the MHCs except anxiety (Table  4 ).

figure 1

Percentage of awareness of common and severe mental health conditions in women (left) and men (right) by age group

The awareness scores obtained from Rasch analysis were categorised into two groups: persons having awareness scores greater than or equal to zero were considered to possess ‘average or above level of awareness’, and scores lower than zero were deemed to possess ‘below average level of awareness’. The mean (95% CI) awareness score of common MHCs was −4.29 (−4.38, − 4.19), and for severe MHCs was −2.18 (−2.25, − 2.12), indicating that, participants had a below average level of awareness. Only 82 (3.4%) and 113 (4.7%) participants had an awareness score above zero for common and severe awareness of MHCs respectively. Overall, this indicates they had an above average level of awareness. People who had bachelor’s or higher level of education were the sole group to have an above average awareness score for severe MHCs (multivariate adjusted mean (95% CI) score, 0.32 (0.04, 0.61)) (Additional file 1 ).

Multiple regression analysis was performed where person measure was considered as the dependent variable and gender, age, SES, education as independent variables. After controlling the effects of age, SES and level of education, awareness of common MHCs was 42% greater in males than in females (β (95% CI): 0.42 (0.25, 0.59)). Age was negatively associated with awareness implying that every increase of 10 years of age was associated with 17% lower prevalence of awareness (β (95% CI): − 0.17 (− 0.22, − 0.12)), given the other variables in the model. Having at least secondary level of education was associated with 177% higher prevalence of awareness compared to people with no education or primary level of education (β (95% CI): 1.77 (1.58–1.97)). Availability of sufficient funds most or all of the time contributed 43% higher prevalence of awareness compared to unstable financial situation (insufficient funds at least some of the time) (β (95% CI), 0.43 (0.26, 0.61)). On the other hand, gender had no significant association with the awareness of severe MHCs. Age was negatively associated with 6% lower prevalence of the awareness of severe MHCs (β (95% CI): − 0.17 (− 0.22, − 0.12)). Having at least secondary level of education was associated with 81% higher prevalence of awareness of severe MHCs compared to people with no education or primary level of education (β (95% CI): 0.81 (0.67–0.95)). Availability of sufficient funds most or all the time contributed to a 43% higher prevalence of awareness compared to unstable financial situations (insufficient funds at least some of the time) (β (95% CI), 0.25 (0.13, 0.38)) (Table  5 ).

This study was the very first kind that focused on the MHL amongst the general population in a rural district of Bangladesh. The study reported a very limited awareness about all six MHCs in general population; the lowest being 3.3% of those interviewed were aware of bipolar disorder and the highest being 42% were aware about drug addiction. More than 50% of people were not aware of any of the MHCs, whereas less than 1% people were aware of all the MHCs. Factors associated with lower awareness of MHCs were older age, female gender, lower level of education, lower level of SES, occupations of labourers or housewives. However, irrespective of age, gender, level of education or SES, most of the participants were able to identify at least one symptom of each of the MHCs items given they were aware of the MHCs, and almost all of them had positive attitudes toward medical or psychological treatments for such conditions.

The association of low level of education and female gender with low awareness of MHCs in this study appeared to align with the findings reported from in India [ 47 ]. One of the findings of this study about men being more aware of MHCs than women in both adult and older adult subgroups is quite consistent with that of the study conducted in Qatar [ 21 ]. However, another study conducted in Germany reported that the perception of awareness of MHCs among women was higher than men [ 17 ]. The disparity of awareness between Bangladeshi women and German women might be due to the fact that women in rural areas in Bangladesh are not sufficiently knowledgeable about the causes of MHCs, not well educated compared to men, do not have sufficient computer literacy, and have limited access to internet or daily newspapers. This study also revealed that education was positively associated with greater awareness of MHCs, which is quite coherent with the findings from other studies [ 47 , 48 ]. Low SES [ 49 ], labourers [ 50 ] or housewives [ 51 ] were found to be associated with lower level of education, especially in the Asian countries, indicating lower level of education is one of the main barriers of attaining greater awareness of MHCs.

Another barrier in attaining awareness of MHCs can be attributed to the fact of inadequate access to medical facilities in Bangladesh. Bangladesh is the sixth most populous country in the world with approximately 50,000 medical doctors for 160 million people. Among the medical doctors, less than 1% (500) are psychiatrists, indicating less than 1 psychiatrist per 300,000 people to provide specialised treatment [ 52 ]. This ratio is much lower compared to 126 psychiatrists in Switzerland, and 44 psychiatrists in the United States [ 53 ]. For inpatient care, Bangladesh only has one dedicated mental health hospital, and 50 psychiatric units in general hospitals [ 52 ]. Such resources are insufficient to provide service for the large population in Bangladesh. The lack of visibility of such services in rural areas may contribute to the poor levels of awareness of MHCs amongst the population living in these areas.

This study provides the first reliable data on the MHL and its associated socio-demographic factors amongst general population in a typical rural district in Bangladesh. The analysis was based on a large data set collected directly through a face-to-face interview from adults and older adults. The sophisticated Rasch analysis technique was applied to quantify the MHCs item responses from a binary scale to a logarithmic scale where the binary scale suffers from identifying the real difference between two binary outcomes.

One of the criticisms of this study could be the measurement of the construct ‘socio-economic status’. The subjectivity in reporting availability of funds may affect the appropriateness and validity of socio-economic status. Secondly, the appropriateness of the KAP measure may be questioned because of the single factor/question criterion (where the answer is ‘yes’ and ‘no’) in defining the term ‘knowledge’ and ‘Attitude’. Participants were deemed knowledgeable when the participants could identify at least one symptoms of the MHCs given that they were aware of the disorders. Moreover, participants were regarded showing positive attitudes if they who were aware of the MHCs were in favour of taking medical treatment or psychological counselling. It could be argued that questions pertaining to attitudes based on ‘yes’ and ‘no’ answers may fail to capture the attitudes towards mental health adequately. Thirdly, this study did not address the potential limitation of this study is its external validity. The findings based on a single-occasion collection of data from a rural district in Bangladesh may not be truly reflective of a national perspective due to differential demographics and level of awareness of MHCs in different parts of the country.

The level of awareness of MHCs was very low. All participants exhibited positive attitude towards treatments of MHCs given they were aware of the conditions. Females, lower education, older adults, and low SES groups were more likely to have a low level of awareness in most of the MHCs. The study provides evidence-based information for planning and implementation of appropriate intervention, especially in high-risk groups such as women and older adults, to increase MHL in rural Bangladesh. Public health programmes should also target those of low socioeconomic status and aim at increasing knowledge of MHCs in rural Bangladesh.

Availability of data and materials

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

Abbreviations

Knowledge, attitudes and practice

Mental Health Conditions

  • Mental health literacy

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Acknowledgements

We particularly acknowledge the contribution of Md Rafiqul Islam, Md Sajibul Islam, Saburan Nesa and Arzan Hosen for their hard work in door-to-door data collection. Finally, we would like to express our gratitude to the study participants for their voluntary participation.

The Faculty of Health, Arts and Design (FHAD) of the Swinburne University of Technology under the Research and Development Grant Scheme (RDGS) funded data collection for this research project. The funders had no role in the design of the study, data collection or analysis, interpretation of data or writing the manuscript.

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All authors contributed to the conception, design and plan the study. FMAI and MNU jointly contributed to data acquisition. MNU analysed the data, drafted the manuscript and interpreted the study findings. FMAI supervised the overall analyses and contributed in preparation of the manuscript. FMAI and SB substantially reviewed and revised the manuscript. All authors have read and approved its final version.

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Uddin, M.N., Bhar, S. & Islam, F.A. An assessment of awareness of mental health conditions and its association with socio-demographic characteristics: a cross-sectional study in a rural district in Bangladesh. BMC Health Serv Res 19 , 562 (2019). https://doi.org/10.1186/s12913-019-4385-6

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

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

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

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

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

Conclusions

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

Peer Review reports

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

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

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

Stage 1: identify the research question

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

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

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

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

Stage 2: identify the relevant studies

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

Stage 3: literature selection

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

figure 1

PRISMA Flow Diagram

Stage 4: charting the data

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

Stage 5: collating, summarizing, and reporting the results

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

Characteristics of included literature

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

figure 2

Number of sources by characteristics of included literature

figure 3

Frequency of themes in literature ( n  = 91)

Mental health concerns and their prevalence in the literature

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

figure 4

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

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

Causes of mental health concerns

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

Effects of mental health concerns on physicians and patients

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

Solutions and interventions

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

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

Barriers to seeking and providing care

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

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

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

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

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

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

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

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

Availability of data and materials

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

Abbreviations

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

United States of America

World Health Organization

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

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

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Mental Health Problems among Young People—A Scoping Review of Help-Seeking

Katrin häggström westberg.

1 School of Health and Welfare, Halmstad University, SE-301 18 Halmstad, Sweden; [email protected] (M.N.); [email protected] (J.M.N.); [email protected] (P.S.)

2 Affecta Psychiatric Clinic, Sperlingsgatan 5, SE-302 48 Halmstad, Sweden

Maria Nyholm

Jens m. nygren, petra svedberg, associated data.

Documentation on the database searches, the stepped screening process and the thematic analysis are available from the corresponding author upon reasonable request.

Young people’s mental health is a public health priority, particularly as mental health problems in this group seem to be increasing. Even in countries with supposedly good access to healthcare, few young people seek support for mental health problems. The aim of this study was twofold, firstly to map the published literature on young people’s experiences of seeking help for mental health problems and secondly to validate whether the Lost in Space model was adaptable as a theoretical model of the help-seeking process described in the included articles in this scoping review. A scoping review was conducted in which we searched for literature on mental health help-seeking with a user perspective published between 2010 and 2020 in different databases. From the 2905 studies identified, we selected 12 articles for inclusion. The review showed how young people experience unfamiliarity and insecurity with regard to issues related to mental health and help-seeking. A strong wish for self-reliance and to safe-guard one’s own health were consistent among young people. Support structures were often regarded as inaccessible and unresponsive. There was a high level of conformity between the model on help-seeking and the analysed articles, reinforcing that help-seeking is a dynamic and psychosocial process.

1. Introduction

Young people’s mental health is a major public health issue. Mental health problems among young people contribute to impaired physical and mental health extending into adulthood [ 1 , 2 , 3 ]. Promoting young people’s mental health is an integral component in ensuring their development and improving health and social wellbeing across their lifespan [ 3 ]. In light of the high rate of mental health problems among this group, a corresponding high rate of help-seeking and use of support resources might be assumed; however, few young people actually seek and eventually access professional help. Delays in looking for help can be lengthy and are prevalent even in countries with good access to healthcare [ 4 , 5 , 6 , 7 , 8 , 9 ]. The process of searching for support involves barriers that relate to both individual and social context factors [ 8 , 10 ]. This contributes to the complexity involved in offering interventions to support them and highlights the need to understand the help-seeking process, whether online or in person, for young people with mental health problems.

Help-seeking is usually described as a rational, agency-based process where the individual plans, decides and acts on symptoms [ 11 ]. However, research also describes that help-seeking is not solely an individual act; rather, it is influenced by social factors throughout the process. Societal, organizational support structures set the limits and stipulate the opportunities to seek help [ 12 ]. Help-seeking thus depends both on factors at the individual level and structural resources for young people. Many studies that examine help-seeking for mental health among young people using cross-sectional designs on either the general community, or school populations [ 8 , 13 ] are based on descriptive data that is often generated through surveys, and focus on attitudes, rather than on experiences [ 14 ]. The main focus of previous literature has been on individual factors, such as mental health literacy, and less information can be found on the structural factors involved [ 8 , 13 ]. This calls for a deeper and more nuanced understanding of young people’s mental health help-seeking regarding contextual factors, with particular focus on their experiences and perspectives. An improved understanding of help-seeking for mental health problems can be used to improve practice and service delivery, and ultimately benefit young people’s mental health.

In this study, qualitative research exploring the help-seeking process in Sweden from the perspectives of young people with mental health problems was used as the theoretical point of departure [ 15 ]. Within this previous research, we produced a theoretical model of help-seeking, the Lost in Space model [ 15 ]. It showed how help-seeking was a long, non-sequential and dynamic process. In this research, young people described a process of moving in and out of the three help-seeking phases, Drifting, Navigating and Docking. Drifting was characterized by insecurity and unfamiliarity, with a lack of knowledge of mental health and the support system; Navigating was characterized by structural obstacles, a fragmented support system and wishes for help; while Docking was characterized by experiences of finding help. For the purpose of confirmability and usefulness, it is essential to validate and understand if the model can be applied to other settings and contexts—for example, whether the model is consistent with the experiences of help-seeking by young people in other countries. Therefore, the aim of this study was twofold, firstly to map the published literature on young people’s experiences of seeking help for mental health problems and secondly to validate whether the previously published Lost in Space model was adaptable as a theoretical model of the help-seeking process described in the included articles in this scoping review.

A scoping review was deemed the most preferable approach to responding to this broad area of interest [ 16 ]. Scoping reviews maintain a broad window for inclusion of studies of a range of types and levels of quality [ 17 ]. Our scoping review protocol was developed using the scoping review methodological framework proposed by Arksey and and O’Malley, entailing five framework stages. The framework was further developed by Levac, with a qualitative elaboration of the material [ 17 , 18 ]. These stages provide a clear sequential order in which to identify and collect studies, chart the data and report results, and the scoping review protocol was used for guiding the research.

2.1. Stage 1: Identifying the Research Question

A multidisciplinary research team with experience of health science research, including public health, nursing, and youth research was assembled to discuss and clarify the scope of inquiry and identify research questions. The target population of interest was defined as young people (ages 11–25) with experience of mental health problems, and experience of help-seeking in that regard. Mental health problems were defined as commonly experienced problems of depression or anxiety, as well as behavioural and emotional problems. Considering the concept of help-seeking, the term is used to understand the delay of care and to explore possible pathways for mental health promotion. For this study, help-seeking was defined as seeking and/or accessing professional help for mental health problems. Conceptually, help-seeking was regarded as a process influenced by social, psychological and contextual factors [ 12 ]. The research questions for this study were (1) to map general characteristics of published literature focusing on the young people’s experiences of seeking help for mental health problems, and (2) to explore how the previously published theoretical model Lost in Space could be further refined and complemented via an abductive approach, drawing the final set of categories and themes informed by the papers reviewed in this study.

2.2. Stage 2: Identifying Relevant Studies

A search strategy was developed in collaboration with a librarian to develop search terms using subject heading terms adapted to each of the three included databases: Medline/PubMed, PsycINFO and CINAHL. The search terms for the target population were adolescents, young and emerging adults; for the health outcome, they were mental health, depression, anxiety, and for the concept of interest, the term was help-seeking. Other criteria were limiting searches to studies written in English, and studies being published between 2010 and 2020 due to rapidly evolving research and policy changes in this area as well as the increased rates of mental health problems among young people. The searches were conducted during summer 2020. See Table S1 (Supplementary Materials) for the full search strategy.

Inclusion and Exclusion Criteria

Studies were eligible for inclusion if they investigated help-seeking among young people with mental health problems aged between 11 and 25. Only studies that specifically investigated young people’s own perspectives of experiencing or having experienced mental health problems and help-seeking were included. Since the intention was to understand help-seeking among young people with common mental health problems, studies on particular target groups or populations were excluded, such as studies on specific treatment interventions. Likewise, studies focusing on help-seeking attitudes or potential help-seeking intentions of general populations without personal experience of mental health help-seeking were excluded. Studies had to specifically focus on adolescents or young people; thus, studies with a more population-based perspective, or encompassing wider age groups, were excluded. Theses were not included as it was assumed that any material within a thesis on help-seeking, that otherwise fitted the inclusion criteria, would appear as published articles. Comments, editorials, consensus statements and other opinion-based papers were excluded, along with studies solely exploring the perspectives of others, other than the help-seekers themselves (e.g., families, helpers, professionals, etc.).

2.3. Stage 3: Study Selection

All identified studies from the searches were imported to the management reference tool EndNote, version 20.1, and duplicates were removed. Screening was carried out with a sequential, stepped approach and an iterative process between the authors of the study [ 18 ]. In the first step of study selection, titles and periodically abstracts were screened by KHW, who discarded obviously irrelevant studies based on the exclusion criteria. In the second step of study selection, abstracts of the remaining studies were screened independently by three of the authors (KHW, PS and MN) to determine eligibility based on the defined inclusion and exclusion criteria. Disagreements between the authors were discussed with a fourth author (JN) until consensus was reached. The third step required KHW to examine the full-text of the remaining articles to determine eligibility, subsequently discussing the articles with all authors. A PRISMA diagram ( Figure 1 ) details the screening process with number of papers retrieved and selection of the included studies.

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Article search and selection process—PRISMA diagram.

2.4. Stage 4: Charting the Data

Data charting was conducted in accordance with scoping review standards using a template that was developed for the extraction of information from each study regarding the following: authorship, year of publication, journal, source of origin, design, population and age group, aims of the study, methodology and important results [ 17 ]. A descriptive, numerical summarization was made, presenting the extent, nature and scope of included studies [ 18 ], see Table S2 (Supplementary Materials) for the full bibliographic information of the included studies.

2.5. Stage 5: Collating, Summarizing and Reporting Results

A qualitative thematic analysis was conducted to examine and aggregate the findings from the help-seeking process, as depicted in the included studies [ 18 ]. For the thematic analysis, an abductive approach was taken [ 19 ], based on the previous Lost in Space model [ 15 ]. According to such an approach, hypotheses can be explicated through deduction and verified through induction. Abduction thus means that new explanations are based on background theories and, whilst taking empirical material and restrictions into account, may lead to elaborated knowledge [ 19 ].

The analysis began with reading the findings in the included articles several times, then identifying and inductively coding text and quotes [ 20 ] in relation to young people’s experiences of seeking help for mental health problems. In this phase, data were inductively scrutinized to discover experiences, expressions and perspectives, keeping codes close to the data; for example, the text ‘Some young people reported that discussing uncomfortable emotions was unfamiliar’ was coded as the theme Unfamiliarity. The deductive process followed, in which the theoretical model Lost in Space was employed. It describes help-seeking among young people with mental health problems in a Swedish context [ 15 ]. A categorization matrix was developed based on the model, emanating from the original subcategories and categories, the themes within the subcategories and the properties of themes. The deductive process in the analysis involved going back to the data and placing the inductively derived codes into themes and subcategories of the theoretical model. All themes from the original model were found through coding the analysed articles. Codes from the new material that did not match the original theoretical model subcategories contributed with new aspects to existing themes of the model and, in some cases, generated new themes, thereby broadening the understanding of help-seeking. In one instance, the name of one subcategory was altered to reflect new material. KWH performed the data analysis and, to enhance the quality and validity of the analysis, the data analysis was discussed continuously with all authors.

3.1. Mapping the Characteristics of Published Literature

In total, 1540 articles were identified as potentially relevant records, after duplicates were removed through the database searches. After the first screening of title and abstract, 1207 articles were excluded on the basis of age, format type, content (i.e., not dealing with help-seeking), focusing on specific populations or not being based on a user perspective. In the second round of screening, another 243 articles were excluded due to the eligibility criteria. In the third round of screening, the remaining 90 articles were reviewed in full-text and of these 12 articles met the full set of eligibility criteria.

The characteristics of the included studies are described in Table S2 (Supplementary Materials) . Seven articles were published between 2010 and 2015, and five after 2016. The designs were mostly qualitative, with individual interviews ( n = 9) and focus groups ( n = 7). Seven articles employed a combination of methods (for example, mixed methods), and two articles included information from surveys. The focus of articles covered: social and organizational factors impacting help-seeking, functional concerns, attitudes towards computerized mental health support, attitudes to consulting primary care, perceptions and help-seeking behaviours in schools, exploration and identification of barriers and facilitators in general populations with and without previous experience of mental health support, barriers and facilitators in male groups, links between masculinity and help-seeking, comparisons of groups’ help-seeking strategies and descriptions of experiences, self-management and help-seeking. The recruitment of participants varied, utilising educational settings ( n = 4), youth mental health services ( n = 2), community websites ( n = 1), primary care ( n = 1), youth services ( n = 2), previous participation in longitudinal studies ( n = 2) and community samples ( n = 3). Four articles focused specifically on young males, and four on barriers to help-seeking. Three articles were set in the USA, one in Canada, three in Australia and five in Europe. The age range, 11–25, was seen in a variation of age clusters, with the smallest age range being two years (ages 20–22) and the largest 13 years (ages 12–25); the mean age range covered was six years.

3.2. Examination of the Help-Seeking Process from the Perspectives of Young People

The findings from this examination showed a high level of agreement with the theoretical model Lost in Space. Overall, the results showed that help-seeking was a dynamic and psychosocial process without sequentially fixed stages, where young people expressed an unfamiliarity with, insecurity about and lack of knowledge of mental health issues, a longing for self-reliance and, in some contexts, a presence of stigma. Young people did not consider the support structures to be responsive or accessible. Below, Figure 2 outlines the examination of the help-seeking process from the perspectives of young people. It includes confirmed content of the old model, new content derived from the analysed articles, and elaborations according to the abductive method. The ‘number of meaning units’ refers to coded material in the analysed articles. ‘Original’ refers to subcategories and themes from the Lost in Space model, where findings were corroborated by codes from the analysed articles (‘confirmed content’), other elements that emerged showed further dimensions of experiences that contributed to new perspectives of established subcategories in the model (‘new content’), and some themes that emerged in the analysis were not readily encompassed within the subcategories in the original model (‘new’) (see Figure 2 ).

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Examination of the help-seeking process from young people’s perspectives.

3.2.1. Drifting

Drifting, the initial category of the Lost in Space model, encompassed a general feeling of unfamiliarity, lack of knowledge, trivialising oneself and problems due to insecurity often by normalizing and minimizing one’s experiences. Young people’s voices in the analysed articles corroborated Drifting well, through similar expressions and experiences.

Fumbling in Life

In the original model, Fumbling in life encompassed themes of unfamiliarity, insecurity and trivialisation. Likewise, young people in the analysed articles expressed unfamiliarity with both mental health problems and not recognizing oneself. Lack of knowledge was frequently described both with regard to communicating, distinguishing and assessing emotions but also regarding where and when to seek help, leading to a sense of insecurity. Because of this insecurity, young people practised trivialisation, trying to make their problems smaller or unimportant. They also had the impression and fear that their problems would not be sufficient to receive support. In some of the analysed articles, trivialisation was presented as a rational strategy, enabling young people to downplay their problems and rationalizing not actively dealing with them or approaching others for help, whereas, in the original model, trivialisation was carried out due to a sense of insecurity. In this section, no conceptual changes to the original model are suggested.

In the original model, Struggling was characterized by simultaneous descriptions of mental health problems and incessant attempts and strategies to feel better, ambivalence and a longing for self-reliance. These themes re-appeared in the included articles. Mental health problems were described by the participants as emotional problems, panic attacks, sadness, self-harm, anxiety and lack of motivation. Within Struggling in the original model, young people usually referred to mental health problems as being something “within” (internal) rather than originating “outside” (global). However, in several of the analysed articles, the mental health problems were attributed to something “outside”. Hence, young people also related mental health problems to relationships, stress and risk-taking behaviour.

Themes on endeavouring strategies trying to deal with mental health problems were common in the included studies, as was also the case in the Lost in Space model, pointing to the more-or-less continual and relentless attempts and strategies young people performed in order to deal with their problems. Although it was proposed by young people in individual studies that seeking help requires effort, lack of effort was not a dominant issue for young people in either the original model or in most analysed articles. In some articles, an in-depth exploration of the strategies employed was undertaken, according to having an ‘approach’ or ‘avoidant’ character, or gendered differences, adding to the variation in strategies, whereas in the model, an abundance of strategies was ascertained; however, the type of strategy was not explored. Denial was a common strategy in both the original model and in the included articles. In the Lost in Space model, this was described as “shutting off”, with the intent of ignoring feelings and problems. This strategy was directed towards oneself: wanting to manage things, being strong and coping. In some of the analysed articles, denial was presented as relating to a sense of embarrassment, or as being done in order to protect others. Several reasons were attributed to this phenomenon: that young people did not want to trouble others, did not want to burden or alarm others, and did not trust others. In the model, reasons for denial were differentiated by a sense of responsibility, enacted by, for example, not sharing information with family and friends. Withholding information thus seemed to relate to aspects additional to a sense of responsibility and self-reliance.

A frequent theme in both the original model and in the findings from the included articles was self-reliance. Statements of wanting to be strong, trying to cope on one’s own, not sharing information and an elevated sense of responsibility to manage one’s life and mental health problems were evident. Ambivalence as a theme recurred throughout the material, in both the included studies and the original model. Young people expressed simultaneous and contradictory feelings and thoughts towards both themselves and their problems, others and help-seeking per se. They were often hesitant to seek help, whilst at the same time expressing a need and a longing for help.

The analysis of the included articles suggested no major conceptual changes to the original model, although the themes Endavouring strategies and Mental health problems are both elaborated.

Reaching a Point of No Return

Within Reaching a point of no return in the original model, young people expressed deterioration and a reaching out for support, often with the help of others. In Lost in Space, others were called ’catalysts’, showcasing their importance in actually initiating a help-seeking process. Within the analysed articles, important others were consistently brought up by the young people, with examples of others coaching, supporting, guiding and, in some instances, taking control of the help-seeking process. A new perspective in the included articles was a negative perception of control, and how others exerted control over them, compelling them to seek help. While this aspect of negative control did not emerge in the original model, an elaboration of the model may expand on the various functions of the important others, e.g., by dividing them into controllers vs. supporters. The other theme in this subcategory, deterioration, was brought up in several articles, as in the Lost in Space model. This indicated a worsening of symptoms and a decreased ability to function. Young people described not leaving the house, escalated behavioural problems, self-harm and suicide attempts, or ‘having a melt-down’ as triggers for seeking help. Young people also described how their problems were ‘revealed’ and others became aware of their problems, which in turn led to seeking help.

The included articles emphasise that seeking help is often a long process that takes place during a prolonged time-span. Therefore, in this section, a change of title of the subcategory Reaching a point of no return, to Transitioning towards decision, is suggested.

3.2.2. Navigating

The category Navigating depicted attempts of trying to find support, personal reflections, hopes and longings and wrestling with structural barriers. Expressions from young people in the analysed articles conformed well with the subcategories Trying to dock and Wrestling with structure.

Trying to Dock

This subcategory in the Lost in Space model entailed descriptions of personal reflections, hopes, longings and disappointment when trying to seek support. All themes from the original model were exemplified in the included articles. Hopes for help, as well as being safe, noticed and understood, were common in the included articles, as were accounts of the opposite, feeling unsupported. Miscommunication while not being understood or listened to also appeared in both materials as did accounts of being treated like a child and not taken seriously, thus containing references to issues of power. Several analysed articles contained descriptions by young people on how support was perceived as impersonal and instrumental rather than person-centred. This added aspects of negative references to professionalism and reliance on medication. Young people expressed the importance of reframing negative and medical terminology in positive and informal terms. Both materials contained descriptions of young people feeling unsupported, which led to continued and continual efforts of seeking support. A new theme, trust, was identified in the thematic analysis from descriptions of lack of confidence in treatment, and how familiarity facilitated help-seeking. A lack of trust was depicted as arising from limited prior contact, from anxiety about seeking help, from concerns about professional competence and from negative perceptions of professionals. Within the theme of trust in the articles, concerns about confidentiality and parental involvement surfaced, whereas, in the original model, these concerns were interpreted as structural obstacles.

Common themes in the articles were stigma and shame, whereas in the original model, this was not pervasive. The included articles relayed young people’s strong sense of shame about seeking help. They perceived it as a display of weakness. Fear of social consequences, ridicule and a longing to fit in led young people to describe a feeling of shame or embarrassment, and to having thoughts of what others would think and say. They also made efforts to conceal both mental health problems and help-seeking. Articles focusing exclusively on males stressed the gendered aspect of this, claiming that this group was affected by masculine ideals of strength and autonomy, which hindered displays of weakness and prevented help-seeking. In the original model, some findings relating to this theme were described; however, the term stigma was never used. Instead, this was described in the subcategory Wrestling with structure, in relation to seeking support in school, with references of embarrassment and an undesirable show of weakness in front of peers.

In this section, the analysed articles provide more aspects on the Feeling unsupported and Miscommunication themes. The large presence of codes in the new material relating to Stigma and Trust suggests the incorporation of Stigma and Trust as unique themes into the model.

Wrestling with Structure

In both the original model and the analysed articles, there were multiple references to structural obstacles, such as access, waiting times, resources, continuity, inadequate chains of support, and lack of coordination between supporters. Young people voiced feelings of not being met by professionals in an appropriate and timely manner, and concerns about how they were passed on, being referred to other support structures, and how there was a perceived lack of resources, making access difficult. Help-seeking was described as inconsistent, with repeated attempts at initiating and discontinuing help. Young people in several articles, and the original model, expressed that primary care was not an option when seeking support. Primary care was regarded as handling physical health complaints and that its practitioners were not being skilled in mental health issues. Particularly for the ‘younger’ of the young people, expressions that primary care was not directed at their age group were voiced. The inadequate support services theme was thus corroborated by young people in other contexts.

Confidentiality and age issues were concerns for the young people, both within the original model and the thematic analysis, primarily relating to parental control and insight. Both materials contained descriptions of how young people assumed and were concerned that confidential information shared with professional supporters would be communicated to parents. In some articles, this was said to relate to the theme of trust; however, confidentiality was mainly related to being a minor lacking power. Young people also voiced that being a minor was as an obstacle for independently accessing help. Likewise, age was an issue for the ‘older’ young people, who reported feeling out-of-place at youth-specific services. In the original model, a sense of resignation, often related to difficulties accessing support and feeling unsupported, was evident. The included articles provided additional material relating to this, as a sense of powerlessness appeared in several subcategories, and in the process as a whole.

The analysis supported a clearer conceptual division between subcategories Wrestling with structure and Trying to dock in the model. The latter entailed primarily personal accounts and experiences, expressions of hopes, disappointments and recounts of feelings, and the former referred primarily to structural conditions. Recurring references in relation to powerlessness suggest this is elevated to a permeating theme, capturing young people’s experience of seeking help.

3.2.3. Docking

Docking in the original model contained references from young people to the subcategories Finding support and Changing as a person.

Finding Support

All original themes of the subcategory Finding support were found in the thematic analysis. In both the original model and the analysed articles, young people described experiences of being validated, accepted, recognized and listened to. The importance of the comfort of support and initial positive contact was stressed. Descriptions of good and bad supporters and preferences regarding, for example, gender and profession, were evident. Both materials contained descriptions of negative outcomes and unwanted consequences from having sought help; for example, in the original model, this was described as problems being exaggerated and social services becoming involved. In the analysed articles were descriptions of referrals to support services appearing as punitive rather than helpful. This subcategory also contained accounts in both the analysed articles and the original model of young people being disregarded and not being taken seriously.

In this section, no changes to the model are suggested.

Changing as a Person

In the original model, this subcategory described the consequences of successful help-seeking in the form of gaining knowledge and positive personal change. Young people in the original model stressed the positive aspects and changes after having experienced mental health problems. Some references were found in the articles with regard to this subcategory, with personal change depicted as finding a more positive outlook on life through one’s own determination and decisiveness.

In this section, the analysed articles provide more aspects on the theme Changing as a person, but no changes to the model are suggested.

Overall, the findings from the analysis aided in developing an elaborated model of help-seeking, Figure 3 . The overall notion of help-seeking as a fluid and dynamic process with the three categories Drifting, Navigating and Docking was reinforced.

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Elaborated and further developed theoretical model of help-seeking among young people for mental health problems.

4. Discussion

This scoping review aimed to map published literature on young people’s experiences of seeking help for mental health problems, and to validate whether the previously published model Lost in Space was adaptable as a theoretical model of the help-seeking process. A high level of conformity was found between help-seeking as depicted by the original Lost in Space model and the analysed articles of this study. The analysis reinforced that help-seeking is to be regarded as a fluid and psychosocial process, often experienced by users as unfamiliar and obstacle-laden, tainted by feelings of powerlessness [ 21 , 22 , 23 , 24 ].

4.1. Discussion and Implications in Relation to the Original Model Lost in Space

After reviewing up-to-date literature on user perspectives of help-seeking for mental health problems among young people, it is clear that the depiction of the initial stage of help-seeking, as being characterized by a sense of drifting, was, to a large extent, corroborated from young people’s experiences described in the reviewed articles. Regardless of context, young people expressed a general feeling of unfamiliarity and a lack of knowledge, often coupled with a sense of insecurity, and trivialisation of experiences [ 21 , 22 , 23 , 25 , 26 , 27 , 28 , 29 , 30 ]. This was also supported by a large number of codes and expressions relating to the endeavouring strategies theme in an effort to be self-reliant [ 22 , 23 , 25 , 26 , 27 , 28 , 29 , 30 , 31 ]. This points to the more-or-less continual and relentless nature of the efforts of young people to deal with their problems. A strong wish for self-reliance was consistently stressed in the reviewed articles, with a large variation and number of strategies used to implement self-reliance and deal with mental health problems. Incorporating an elaboration regarding the characteristics of strategies—whether positive/negative, destructive/constructive or approach/avoidant strategies—would provide an additional perspective on how mental health is dealt with by young people. The reviewed articles confirmed that reaching a decision to seek help often takes place with the aid of others [ 21 , 22 , 23 , 24 , 25 , 29 , 31 , 32 ] and distinction between ‘controllers’ and ‘supporters’ in this regard may further elaborate the model. Re-naming of the subcategory Reaching a point of no return into Transitioning towards decision would reflect the transitional nature of the mental health help-seeking process.

The category Navigating, capturing both personal experiences and structural barriers, was well confirmed by the review. Reflections of not being met by professionals in an appropriate and timely manner, and observations of a perceived lack of resources making access difficult, surfaced in both the original model and the included articles [ 23 , 26 , 29 ]. Accounts of not being taken seriously, being treated like a child, not listened to and disregarded, indicating power-issues relating to the experiences of young people, as well as descriptions of inconsistent use of support, repeatedly initiating and discontinuing help, appeared in the original model as well as the included articles [ 22 , 26 , 28 , 29 ]. Stigma and Trust surfaced as new themes, and Stigma in particular appeared with a large number of codes in the analysed articles. Young people described a feeling of shame, embarrassment, thoughts of what others would think and say and various efforts to conceal both mental health problems and their help-seeking [ 21 , 22 , 23 , 25 , 26 , 27 , 28 , 31 ]. Several articles dealt exclusively with young men and boys, proposing that the reasons for not seeking help were strongly conditioned by gender, with masculine ideals of strength and autonomy acting as obstacles for help-seeking [ 21 , 23 , 28 , 31 ]. Similar findings emerged in the Lost in Space model, where issues of self-reliance, wanting to be strong, and shunning displays of weakness, were shared between participants, and were not gender specific. Cultural variations may account for this difference between studies and findings. This said, most participants in studies on help-seeking are female and the findings may translate poorly to other populations and contexts. Help-seeking is exceptionally low among boys and young men, which in itself calls for a focus on specific populations with particularly low help-seeking [ 33 , 34 ].

The latter part of the original model, Docking, was not as well corroborated through the analysis. There were few descriptions of actually finding support and even fewer of personal reflections on the effects of finding help [ 21 , 22 , 31 ]. It may be that research on the help-seeking process does not focus on support and is discontinued as soon as support is established, and aspects of this may be found in other literature on service utilization or treatment satisfaction. However, by dividing the help-seeking journey into smaller isolated fractions, focus on the process as a whole could be missed, resulting in a stunted model and less understanding of the help-seeking process. Overall, the included articles reinforced the model of help-seeking as a dynamic and psychosocial process, consisting of different stages but without being sequentially fixed.

4.2. Discussion and Implications in Practice

This review on help-seeking for common mental health problems included young people from the age of 11 to 25, thus also including young adults. The studies described in the included articles were based on varied recruitment strategies from different contexts. No specific patterns according to age or context could be discerned. The concerns voiced in the studies included themes on structural barriers of the support system, an unfamiliarity and lack of knowledge of mental health and the support system, and simultaneously, a wish for self-reliance, suggesting possible strategies for meeting the help-seeking needs of young people. Although this study aimed to include articles focusing on groups that were wide enough to be defined as population-based, the focus of the included articles tended to be on particular populations, stressing the vulnerability and poor help-seeking of one particular group. Thus, the research had ethno-centric tendencies, whereas there were large overlaps and resemblances of experiences by young people in the help-seeking process regardless of contexts. The attribution of non-help-seeking to stigma and cultural norms amongst Black, Latino and Chinese American youth was observed by others, pointing to this being a more general, rather than group-specific phenomenon [ 32 ].

Structural factors, and how young people experience the support system, play an important role in the help-seeking process. Despite different contexts, young people expressed similar concerns relating to issues of availability and accessibility. There were views that waiting times were too long, resources were too few, and in some contexts, that costs and distances posed problems [ 21 , 23 , 25 , 26 , 28 , 29 ]. Other research has shown that there is a perceived inaccessibility of the support system across different groups of young people regarding resources, entry requirements and coordination between services [ 13 ]. Structural obstacles stretch over different geographical and socio-economic backgrounds at the macro level, with high-income countries still showing substantial delays and poor help-seeking rates for young people [ 14 , 35 ]. Thus, even in favourable circumstances, young people perceive structural barriers, pointing to how the support system does not accommodate the fluid and changeable nature of help-seeking. Young people regard mental health as a complex social and relational matter [ 36 ]. They often present with diagnostically confusing symptoms, and support systems that are traditionally organized according to medical specialities may not meet the needs of young people with common mental health problems [ 37 ]. Integrated youth centres, focusing on meeting young people’s needs in one place through multidisciplinary support with consideration of the context, show promising results [ 38 , 39 ]. In comparison to traditional support, which is by definition siloed and often entails entry requirements according to diagnostic thresholds, integrated youth-friendly services seem to increase help-seeking and access to support, even among groups that are usually hard to reach [ 33 , 39 ]. Studies in a Swedish context have pointed out that youth health clinics providing services to build upon with multi-professional teams and expertise on mental health are available throughout Sweden [ 40 ].

Young people reported a lack of knowledge on mental health and the support system, leading to a sense of insecurity and possibly a delay of help-seeking. Improved health literacy among young people may facilitate help-seeking through mechanisms of awareness of service availability and symptom recognition [ 13 ]. However, improved help-seeking and mental health among young people may require more than only improved knowledge. Previous reviews have, for example, shown past positive experiences and outcomes of help-seeking and positive contacts with support professionals to be facilitators for seeking help [ 4 , 8 ]. At the same time, a preference for self-reliance when facing mental health problems is consistently reported, with this being particularly prominent in studies with participants having previous experience of mental health problems and mental health support, contradicting the findings of past experiences facilitating help-seeking [ 8 , 23 ]. Young women in particular seem to have poor expectations regarding therapeutic outcomes, signalling a lack of trust in professional supporters, with treatment being perceived as impersonal and protocol-driven [ 23 ]. The results of this study identified the importance of supporters’ ability to meet young people responsively, using a person-centred approach. Young people felt more comfortable when the supporters did not use medical language and emphasized the importance of using positive and informal terms for improving communication between the young person and the supporter. Other studies have confirmed this finding, underlining the importance of having young staff who are skilled, respectful, welcoming, and allow for participation and shared decision-making [ 39 ].

With this review showing how young people experience mental health help-seeking as a psychosocial and fluid process, often with lack of knowledge and a sense of insecurity, prompt consideration of the organization of present support systems is needed. Young people need to be met in a person-centred and flexible manner. Perhaps, this is where the greatest effort is needed, addressing issues of power from the perspectives of young people, improving opportunities for personal self-reliance and personalized support.

5. Methodological Considerations

This review has some limitations. The choice of databases and keywords was developed in accordance with an experienced health literature librarian; however, making a choice always entails the risk that some information may have been missed. Other databases and different keywords may have produced different results. The criteria for including articles were that they should deal with the direct perspectives of young people who had experienced mental health problems and/or help-seeking. Whilst excluding those who had no experience of help-seeking (thus all articles dealing with intentions to seeking help only) might have been a clear-cut and easy choice, that would also have meant that we excluded those with experience of mental health problems who had not sought help for various reasons; thus, avoidance is also a perspective that is worth taking into consideration.

We aimed to include studies focusing on groups wide enough to be defined as population-based; nevertheless, these still often utilized an ethnocentric perspective, such as having a particular ethnic descent. This automatically raises the issue of generalizability and transferability. It was evident that studies consistently focused on particular populations, stressing the vulnerability and poor help-seeking of this particular group. However, similar claims kept reappearing, regardless of which particular group was being studied. A noteworthy phenomenon is that all included articles were published in Western countries. This also limits the transferability of the findings, as young people around the world may be situated in significantly different contexts.

In order to limit bias, the work was conducted by alternating methods of individual and joint reviews. However, subjectivity is a relevant issue that the authors of this review could not completely avoid.

6. Conclusions and Implication

The field of help-seeking among young people for mental health problems is receiving growing attention in research and academic literature. However, this review shows that there is substantial heterogeneity among studies with regard to methods, populations and how help-seeking is investigated. In qualitative literature exploring user perspectives, help-seeking is depicted as a fluid, dynamic and psychosocial process, validating the theoretical model of Lost in Space. Important findings include the presence of stigma, a lack of knowledge of mental health issues, a longing for self-reliance and a sense of powerlessness expressed by young people in various contexts and countries. Paying attention to these findings would imply acknowledging young people’s sense of feeling lost, making support services more flexible and person-centred.

Acknowledgments

Caroline Karlsson greatly contributed with the graphical model.

Supplementary Materials

The following are available online at https://www.mdpi.com/article/10.3390/ijerph19031430/s1 , Table S1, full search strategy, Table S2, characteristics of included studies.

Author Contributions

All authors (K.H.W., M.N., J.M.N. and P.S.) made significant contributions to the original paper. K.H.W., M.N., J.M.N. and P.S. together identified the research question and designed the study. The data search was conducted by K.H.W., and stepped screening was performed by K.H.W., M.N., J.M.N. and P.S. In addition, K.H.W. drafted the manuscript and M.N., J.M.N. and P.S. provided critical revision of the paper in terms of important intellectual content. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

This study did not require ethical clearance.

Informed Consent Statement

Not applicable.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

  • Current Opinion
  • Open access
  • Published: 28 November 2019

Mental Health In Elite Athletes: Increased Awareness Requires An Early Intervention Framework to Respond to Athlete Needs

  • Rosemary Purcell 1 , 2 ,
  • Kate Gwyther 1 , 2 &
  • Simon M. Rice   ORCID: orcid.org/0000-0003-4045-8553 1 , 2  

Sports Medicine - Open volume  5 , Article number:  46 ( 2019 ) Cite this article

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The current ‘state of play’ in supporting elite athlete mental health and wellbeing has centred mostly on building mental health literacy or awareness of the signs of mental ill-health amongst athletes. Such awareness is necessary, but not sufficient to address the varied mental health needs of elite athletes. We call for a new model of intervention and outline the backbone of a comprehensive mental health framework to promote athlete mental health and wellbeing, and respond to the needs of athletes who are at-risk of developing, or already experiencing mental health symptoms or disorders. Early detection of, and intervention for, mental health symptoms is essential in the elite sporting context. Such approaches help build cultures that acknowledge that an athlete’s mental health needs are as important as their physical health needs, and that both are likely to contribute to optimising the athlete’s overall wellbeing in conjunction with performance excellence. The proposed framework aims at (i) helping athletes develop a range of self-management skills that they can utilise to manage psychological distress, (ii) equipping key stakeholders in the elite sporting environment (such as coaches, sports medicine and high-performance support staff) to better recognise and respond to concerns regarding an athlete’s mental health and (iii) highlighting the need for specialist multi-disciplinary teams or skilled mental health professionals to manage athletes with severe or complex mental disorders. Combined, these components ensure that elite athletes receive the intervention and support that they need at the right time, in the right place, with the right person.

Currently, there is no comprehensive framework or model of care to support and respond to the mental health needs of elite athletes.

We propose a framework that recognises the impact of general and athlete-specific risk factors, and engages key individuals that may identify and promote athlete mental health.

The framework is adaptable and responsive to varied career stages and mental health states.

There has been a rapid increase in research examining the mental health of elite athletes culminating with the International Olympic Committee’s (IOC’s) recent Expert Consensus Statement on mental health in elite athletes [ 1 ]. This statement provides a comprehensive analysis of, and recommendations for, the treatment of both high prevalence (e.g. anxiety and mood symptoms) and more complex mental health disorders (e.g. eating and bipolar disorders) in the elite sporting context. This is a timely resource which will help guide and ultimately improve the clinical management of athletes by sports medicine, mental health, and allied health professionals. The primary focus of the consensus statement, along with much of the extant literature, is on managing the individual athlete affected by mental ill-health. There has been little scholarly and service-level attention to more comprehensive frameworks that (a) recognise the role of the broader elite sports ecology as both a contributor to athlete mental health difficulties and a facilitator of their remediation, and (b) approaches that emphasise the prevention of mental health symptoms, along with early detection and intervention to restore athlete wellbeing (and ideally optimise performance).

Risk Factors for Mental Ill-health in Elite Athletes

Meta-analytic reviews indicate that elite athletes experience broadly comparable rates of mental ill-health relative to the general population in relation to anxiety, depression, post-traumatic stress and sleep disorders [ 2 , 3 ]. This should not be unexpected given the considerable overlap in the years of active elite competition and the primary ages of onset for most mental disorders [ 4 , 5 , 6 ].

Increasing evidence points to a range of both athlete-specific and general risk factors associated with mental ill-health in elite athletes. Athlete-specific risk indicators include sports-related injury and concussion [ 3 , 7 , 8 , 9 ], performance failure [ 10 ], overtraining (and overtraining syndrome) [ 11 ] and sport type (e.g. individual sports conferring a higher risk that team sports) [ 12 ]. General risk indicators include major negative life events [ 13 , 14 ], low social support [ 15 , 16 ] and impaired sleep [ 17 , 18 ]. These risk factors may impact the severity and onset of particular mental health symptoms, but can also guide appropriate response strategies.

The salience of particular risk factors may vary across career phases. For example, in junior development years, supportive relationships with parents and coaches are imperative to athlete wellbeing [ 19 , 20 ]. During the high performance and elite phase, in addition to the coaching relationship, environmental and training demands become more relevant to mental health and wellbeing [ 21 ], including extended travel away from home and exposure to unfamiliar (training) environments [ 22 ]. Environmental conditions and travel may be especially salient for the mental health of para-athletes, who often encounter disruptive logistical issues associated with travel, such as a lack of adaptive sport facilities and sleeping conditions [ 23 ]. Prominent risk factors during the transition out of sport include involuntary or unplanned retirement and lack of a non-athletic identity, both of which are associated with a range of psychological challenges [ 24 ]. For para-athletes, involuntary retirement due to declassification (i.e. no longer meeting the required criteria to be classified as a para-athlete) is a unique burden [ 25 ].

Optimising the Mental Health and Wellbeing of Elite Athletes: Barriers and Facilitators

A comprehensive framework for mental health in elite athletes needs to consider the range of relevant risk factors across key career phases, as well as factors that inhibit or facilitate the ability to effectively respond to athletes’ needs. Key barriers include more negative attitudes towards help-seeking amongst athletes than the general population [ 26 ], as well as greater stigma and poorer mental health literacy. Fear of the consequences of seeking help (e.g. loss of selection) and lack of time are also influential [ 26 , 27 , 28 ]. Facilitative factors include support and acknowledgment from coaches [ 27 ] who can help to create a non-stigmatised environment where help-seeking can be normalised [ 28 ]. Approaches that seek to optimise athletic performance while simultaneously providing intervention for mental health symptoms may also facilitate engagement [ 29 , 30 ]. Brief anti-stigma interventions and mental health literacy programs that seek to increase knowledge of mental health symptoms have been shown to improve help-seeking intentions in elite athletes [ 31 , 32 , 33 ], although the impact of such programs on help-seeking behaviours is not known.

Are there Existing Frameworks or Models of Care for Mental Health in Elite Sport?

To date there are no published frameworks regarding how best to support the mental health needs of elite athletes. In addition to the IOC Consensus Statement, recent position statements have emphasised the need to build awareness of mental health problems and increase help-seeking behaviours [ 34 , 35 , 36 ]. These initiatives are unquestionably warranted; however, improving awareness and help-seeking behaviours are at best pointless, and at worst unsafe, if systems of care to respond to athlete’s need are not available. A whole of system approach needs to be developed simultaneously.

Beyond the peer-reviewed literature, useful guidelines exist within selected sporting associations regarding supporting athlete wellbeing [ 37 , 38 , 39 ]. These resources highlight a number of critical factors in managing athlete mental health in the sporting context including (i) the sports’ responsibility for managing the athlete’s care and support (e.g. duty of care issues); (ii) the need for regular screening or monitoring of athletes to detect changes in mental state or behaviour; (iii) privacy and confidentiality regarding mental health as key ethical issues and challenges; (iv) athlete preferences for help-seeking (how and from whom); (v) the need to refer out to or engage external mental health professionals where expertise does not exist within the sporting environment; and (vi) the value of trained peer workers (former athletes/players) to provide support and guidance to athletes and to coordinate activities related to professional development needs (such as public speaking or financial planning) and individual goal-setting (e.g. around educational or post-sport vocational interests). However, no single framework incorporates all of these factors nor is there a framework that focuses on the spectrum of athlete/player mental health needs, from symptom prevention to specialist mental health care. There has been some progress in developing mental health guidelines in collegiate-level athletes [ 40 , 41 , 42 ], which highlight the need to provide specific and targeted support, while noting that few comprehensive or targeted models of care for mental health have been developed for this population.

Developing a Comprehensive Mental Health Framework to Support Elite Athletes

Many of the general and athlete-specific risk factors for mental ill-health are potentially modifiable (e.g. coping strategies, coaching style, training demands) and require intervention at the individual athlete, the sporting or environmental and/or organisational levels. A comprehensive framework for athlete mental health that is conceptualised within the broader ‘ecology’ of elite sporting environments will be best able to respond to the range of risk indicators in this context (see Fig. 1 ). Ecological systems help to explain the relationship between the aspects or experiences of an individual (termed ‘ontogenetic’ factors, such as coping or substance use) and the broader social and cultural contexts in which they exist [ 43 ]. In the case of elite athletes, this includes the ‘microsystem’ of coach(es), teammates (where appropriate) and family/loved ones. The wider sporting environment (e.g. the athlete’s sport, its rules and governing body) forms the exosystem, while the role of national and international sporting bodies and the media and broader society form the macrosystem.

figure 1

An ecological systems model for elite athlete mental health

Any mental health framework that ignores wider ecological factors runs the risk of focusing exclusively on, and potentially pathologising the individual athlete, when other factors may be more influential in contributing to, or perpetuating poor mental health. Such factors may include maladaptive relationships with coaches or parents, social media abuse and/or financial pressures.

In addition to ecological factors, a comprehensive framework for mental health should encompass both prevention and early intervention, consistent with established models that are influential in public health and social policy (e.g. Haggerty and Mrazek’s mental health promotion spectrum [ 44 ]; see Fig. 2 ). An early intervention framework can optimise athlete mental wellbeing and respond rapidly to mental health symptoms and disorders as they emerge to best maintain the athlete’s overall function.

figure 2

The mental health promotion spectrum

Within this framework, the prevention stages aim to reduce the risk of mental health symptoms developing or to minimise their potential impact and severity; the treatment and early intervention stages seek to identify and halt the progression of emerging mental health difficulties; and the continuing care stages help an individual to recover and prevent relapse, typically through ongoing clinical care with a mental health professional [ 44 ].

Based on the extant literature regarding risk factors for mental ill-health in elite athletes, along with existing sporting guidelines or statements regarding athlete wellbeing, and our experience developing and implementing early intervention services and system reform for young people’s mental health [ 45 , 46 , 47 ], we propose the following framework to respond to the mental health of elite athletes (see Fig. 3 ).

figure 3

Elite athlete mental health and wellbeing framework

Preventative or ‘Foundational’ Components

Core foundational components should include (i) mental health literacy to improve understanding, reduce stigma and promote early help-seeking; (ii) a focus on athlete development (both career and personal development goals) and skill acquisition to help attain these goals; and (iii) mental health screening of, and feedback to, athletes. The purpose of these foundational components is to enhance awareness of the importance of athlete wellbeing across the elite sport ‘ecology’. This in turn addresses workplace duty of care and occupational health and safety responsibilities towards athletes’ overall wellbeing in the context of sport-related stressors.

Mental Health Literacy

Mental health literacy programs should be provided to athletes, coaches and high-performance support staff to help to create a culture that values enhancing the mental health and wellbeing of all stakeholders. Programs should also be offered to the athlete’s family or friends to build their capacity to identify symptoms and encourage help-seeking, particularly as these are the individuals from whom athletes will initially seek help and support [ 48 , 49 ]. Engaging an array of individuals, including organisational staff, in these programs broadens the reach of mental health literacy within an athlete’s (or sport’s) ecology (see Fig. 1 ). Gulliver and colleagues effectively trialled the delivery of a mental health literacy program to elite athletes via team-based workshops facilitated by mental health professionals [ 26 ]. This delivery method is preferred given the opportunity for qualified facilitators to discuss and explore athlete questions or concerns (especially regarding confidentiality and the implications of help-seeking for selection) and to potentially problem-solve together. The content of such training should be customised to address the specific aspects of the sport (e.g. team-based versus individual sport) and developmental stages (e.g. junior versus retiring athletes). Basic program content should cover (i) athlete-specific and general risk factors that can increase susceptibility to mental ill-health; (ii) key signs or symptoms of impaired wellbeing; (iii) how and from whom to seek help, both within and outside the sport; and (iv) basic techniques for athletes to self-manage transient mood states or psychological distress, such as relaxation techniques, adaptive coping strategies, self-compassion and mindfulness.

Individually Focused Development Programs

Individually focused development programs can assist athletes to identify personal/vocational goals and acquire the skills necessary to achieve them. This is necessary to help develop a parallel non-athletic identity, the skills to manage life-sport balance and to prepare for the eventual end of competitive sport. The latter may be challenging in younger athletes who often lack the longer-term perspective or life experience to perceive the need for such planning. However, a focus on developing a non-athletic identity must occur at all phases of the sporting career and not be confined to the transition out of sport phase, since building such skills takes time (and athletes are prone to unplanned retirement due to injury). These activities are ideally facilitated by a skilled, well-trained ‘peer workforce’. These are individuals who have a lived experience of mental ill-health and sufficient training to share their knowledge to help support others in similar situations [ 50 ]. In the sporting context, a peer workforce could include former athletes or coaches who work with current athletes to discuss and normalise experiences of mental health symptoms or their risk factors. Former athletes can assist with athlete development programs and mobilise athletes to the importance of actively participating with such programs, based on their own experiences [ 39 ].

Mental Health Screening

Mental health screening should be included alongside routine physical health checks by medical staff as part of a comprehensive framework. Screening items should be sensitive to the elite context [ 50 , 51 ] and should be designed to provide feedback to athletes to help promote improved self-awareness, such as their mental state and triggers for symptoms. Critical times to screen are following severe injury (including concussion) and during the transition into, and out of sport [ 1 ], and the lead-up to and post major competitions may also be periods of higher risk. It is important to note that there is currently a lack of widely validated athlete-specific screening tools, though one elite athlete sensitised screening measure—the Athlete Psychological Strain Questionnaire—has been validated in a large sample of male elite athletes reporting strong psychometric properties [ 52 ], and is under further validation with female and junior athletes. Research potential exists to not only develop further athlete-specific measures, but to determine who is best suited to conduct screening, and what credentials or training may be required to ensure safety and integrity in this process (e.g. that appropriate help or referral is provided to athletes who screen positive).

Indicated (‘at-risk’) Prevention Programs

The second phase is indicated prevention programs for those considered or assessed as being ‘at-risk’ of impaired mental health and wellbeing. This phase aims to mitigate the likelihood of deterioration in mental health by detecting symptoms as early as possible and facilitating referral to appropriate health professionals. Key staff within the sports system can be assisted to develop skills in early symptom identification and to promote professional help-seeking. This includes coaches, athletic trainers and teammates (where appropriate) who are in a position to notice ‘micro’ changes in an athlete over days or weeks, and sports medicine staff, such as physiotherapists who may detect other non-observable signs, such as changes in energy or body tension. We term these individuals ‘navigators’ in the mental health framework, as they have a crucial role in observing the athlete’s behaviour or mental state and being able to link them to professional care. These navigators can be provided with additional training (adjunctive to mental health literacy) to better recognise and interpret the athlete’s behaviour in relation to their overall wellbeing, understand athlete privacy concerns that inhibit the disclosure of mental health symptoms and build self-efficacy to be able to raise their concerns safely with the affected athlete or medical/mental health staff.

Sport administrators should also consider developing guides on ‘what to do if concerned about an athlete’s mental wellbeing’ and make these available to all relevant staff. These should include information regarding appropriate referral sources, responses (e.g. prevention program vs. early intervention) and facilitators to engage athletes, such as support and encouragement [ 27 , 28 ] and/or linking mental wellbeing with athletic performance [ 29 , 30 ]. Protocols or guides for responding to mental health concerns become less stigmatised when wellbeing needs are already routinely promoted via foundational programs.

Early Intervention

Early intervention is necessary in instances where the performance and life demands placed on an athlete exceed their ability to cope (i.e. major career-threatening injury or significant life stress). Structured clinical interventions for mild to moderate mental ill-health are typically indicated at this phase and should ideally be provided ‘in-house’ by mental health clinicians, such as sports or clinical psychologists or psychiatrists, or medical staff where appropriate (e.g. pharmacotherapy). The use of in-house professionals helps to counter the low levels of service use associated with referring athletes out to external service providers and the stigma that is associated with the athlete needing expert ‘outside help’ [ 53 ]. Where requisite in-house expertise does not exist, this can be managed by the use of qualified consultants, but ideally these professionals should be ‘embedded’ to some extent within the sporting environment to ensure that athletes and other staff understand ‘who they are and what their role is’, even if their presence is infrequent [ 54 ]. When referral out is necessary, or preferred by the athlete, ideally this should be to a mental health professional with appropriate sport sensitised training, knowledge and experience assisting elite athletes.

Early interventions need not always be face-to-face, but can be augmented by telephone or web-enabled consultations, the latter particularly relevant given the frequency with which elite athletes travel unaccompanied by the sporting entourage. All interventions, regardless of the mode of delivery, should use an individualised care approach that is based on assessment and conceptualisation of the individual athlete’s presenting problem(s). The intervention should target the psychological processes of the athlete that are impeding mental health [ 55 ] and take account of the specific familial, sporting and organisational issues that may be impacting on the athlete’s wellbeing.

An example of an early intervention model of care is the Australian Institute of Sport (AIS) mental health referral network [ 56 ]. Athletes are assessed by an AIS mental health advisor, who can make a referral, if necessary, to a qualified mental health practitioner who has been credentialed to work within the network. This practitioner then works individually with the athlete to address their needs and ideally restore their mental health and functioning [ 57 ].

Specialist Mental Health Care

Despite best efforts to prevent or intervene early, some athletes will nonetheless experience severe or complex psychopathology requiring specialist mental health care, particularly where there is a risk of harm to self or others. In some cases, this may include hospitalisation or specialist inpatient or day programs. The IOC Expert Consensus Statement provides a summary of recommended clinical interventions for a range of mental disorders, including bipolar, psychotic, eating and depressive disorders, and suicidality [ 1 ]. Developing and implementing a mental health emergency plan may also be required, particularly in cases where an athlete presents with an acute disturbance in their mental state, for instance agitation/paranoia, or suicidal ideation [ 58 ]. The IOC Expert Consensus Statement recommends that structured plans should acknowledge and define what constitutes a mental health emergency, identify which personnel (or local emergency services) are contacted and when, and consider relevant mental health legislation [ 1 ].

There is also arguably a need for ‘return to sport or training’ guidance for athletes who have been unable to compete or train for their sport due to mental illness, akin to guidelines for managing concussion [ 59 ]. Such guidance could potentially provide a graduated, step-by-step protocol that prepares not only the athlete for a successful return to sport, but also the microsystem that supports them.

Conclusions

We have proposed a comprehensive framework for elite athlete mental health. More research is needed to bolster the efficacy of the approaches discussed here in the elite sports context, as well as other factors that are under-researched in the literature, such as gender-specific considerations in mental health [ 60 ] and considerations for para-athletes [ 23 ]. We are mindful that coaches and other high-performance staff are vulnerable to mental health problems [ 61 ] and the needs of these individuals need to be incorporated into a more inclusive model of care. Further, we recognise the scope of this framework does not cover the needs of non-elite athletes. Elements of this framework may be tailored in the future to be applicable and contextualised for non-elite environments where there may be limited resources, less professional staffing and greater limitations in athlete schedules.

Despite the exponential increase in research interest related to athlete mental wellbeing, major service delivery and treatment gaps remain. Evaluating the efficacy of mental health prevention and intervention programs via controlled trials or other high-quality designs is urgently needed. Program evaluation should ideally adopt an ecological systems approach to account for competition-related, individual-vulnerability and organisational factors on mental health outcomes, for example by seeking to measure system-level variables (e.g. the degree of perceived psychological safety within the sporting organisation [ 62 , 63 ]) and individual athlete-level variables (e.g. coping skills, relationship with coach, injury history). As initiatives are evaluated and enhanced or adapted, developers should consult with elite sport organisations and individuals to ensure the relevance and sport sensitivity of their programs. Increased resources and research funding to support the evaluation and implementation of athlete mental health programs is needed, such as currently exists for managing athletes’ physical health (e.g. musculoskeletal injuries, concussion).

Finally, we are acutely aware that a framework such as that articulated here requires substantial investment and that such funding is scant even in high income settings. The foundational and at-risk components lend themselves, we believe, to be adaptable to low resource settings, given the emphasis on athlete self-management and a trained peer workforce. Adaptations to providing early intervention in low resource settings will be needed, and innovations in general mental health can act as a blueprint [ 64 ]. Regardless of settings or resources, investment in a comprehensive response to athlete mental health needs attention if it is to ever gain parity with physical health.

Availability of Data and Materials

Not applicable.

Abbreviations

International Olympic Committee

Australian Institute of Sport

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A research agenda for mental health in sub-Saharan Africa

  • Tholene Sodi   ORCID: orcid.org/0000-0001-7592-5145 1 ,
  • Melanie Abas 2 ,
  • Mohammed Abdulaziz 3 ,
  • Action Amos 4 , 5 ,
  • Rochelle A. Burgess 6 , 7 ,
  • Charlotte Hanlon   ORCID: orcid.org/0000-0002-7937-3226 8 , 9 ,
  • Adelard Kakunze 3 ,
  • Lily Kpobi   ORCID: orcid.org/0000-0002-7074-5804 10 ,
  • Crick Lund 8 , 11 ,
  • Kibachio J. Mwangi 12 ,
  • Victoria Mutiso 13 ,
  • Charlene Sunkel 14 ,
  • Peter Yaro   ORCID: orcid.org/0000-0001-6977-6550 15 &
  • Louise Arseneault 16  

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As with other parts of the world, African countries are dealing with the repercussions of rising rates of mental health conditions , especially among young people 1 . Countries in sub-Saharan Africa have limited financial resources to address these challenges while facing other pressing priorities such as food insecurity and malnutrition, rapid urbanization, infectious disease outbreaks and prolonged conflicts 2 . Mental health research continues to be underfunded and mental health services are a neglected aspect of healthcare throughout the continent.

A 2-day workshop was initiated jointly by the Academy of Science of South Africa (ASSAf) and the UK Academy of Medical Sciences (AMS) to explore the development of a strategic research agenda in this area, with a focus on life course and multisectoral approaches to mental health research and interventions. This event brought together mental health researchers, policymakers, implementers and people with lived experience of mental health conditions from many parts of Africa and beyond. This initiative was rooted in two previous international meetings addressing sustainable development and social determinants of mental health in low- and middle-income countries.

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COVID-10 Mental Disorders Collaborators. Lancet 398 , 1700–1712 (2021).

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United Nations. The Sustainable Development Goals Report 2022 https://bit.ly/494Zs3o (2022).

Chibanda, D. et al. Lancet Psychiatry 8 , 553–555 (2021).

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MacDougall, A. G. et al. Int. J. Ment. Health 51 , 32–60 (2022).

Africa CDC. Non-Communicable Diseases, Injuries Prevention and Control, and Mental Health Promotion Strategy (2022–2026) https://bit.ly/3wecfla (2022).

The Academy of Medical Sciences. Advancing Multisectoral and Life-Course Approaches in Mental Health Research: Workshop Report https://bit.ly/42p9nOB (2022).

Lund, C. et al. Lancet Psychiatry 5 , 357–369 (2018).

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Acknowledgements

The authors are grateful to the Academy of Science of South Africa and the UK Academy of Medical Sciences for organizing the workshop.

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SAMRC-DSI/NRF-UL Research Chair in Mental Health and Society, University of Limpopo, Sovenga, South Africa

Tholene Sodi

Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

Melanie Abas

Africa Centres for Disease Control and Prevention, Addis Ababa, Ethiopia

Mohammed Abdulaziz & Adelard Kakunze

Pan African Network of Persons with Psychosocial Disabilities Uganda, Kampala, Uganda

Action Amos

Centre for Clinical Brain Science, University of Edinburgh, Edinburgh, UK

UCL Institute for Global Health, University College London, London, UK

Rochelle A. Burgess

Department of Social Work, Community Development, University of Johannesburg, Johannesburg, South Africa

Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

Charlotte Hanlon & Crick Lund

Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

Charlotte Hanlon

Regional Institute for Population Studies, University of Ghana, Accra, Ghana

Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa

World Health Organization South Africa, Pretoria, South Africa

Kibachio J. Mwangi

Africa Mental Health Research and Training Foundation, Nairobi, Kenya

Victoria Mutiso

Global Mental Health Peer Network, Paarl, South Africa

Charlene Sunkel

BasicNeeds-Ghana, Tamale, Ghana

Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

Louise Arseneault

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Correspondence to Tholene Sodi .

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College of Nursing

Leadership for an innovative practice role: the dually certified nurse practitioner.

View as pdf A later version of this article appeared in  Nurse Leader ,  Volume 21, Issue 6 , December 2023 . 

Nurse leaders have repeatedly called for an expansion of nursing education, research, and clinical practice to identify and meet the social and healthcare needs of diverse and vulnerable populations. The National Institute of Nursing Research’s mission calls for optimizing health and advancing health equity through five lenses, as reflected in their new strategic plan: Health Equity, Social Determinants of Health, Population and Community Health, Prevention and Health Promotion, and Systems and Models of Care. 1 Further, the National Academy of Medicine’s (formerly the Institute of Medicine) reports on the Future of Nursing specifically call for nurses to provide care and to lead or contribute to solutions for vulnerable populations. These national nursing priorities build upon a foundation established by Berwick and colleagues 4 which advanced our understanding that access to culturally- based care should be provided where people live and be available when they need it.

Programs preparing nurse practitioners are ideally suited to respond to these calls to action. Important innovations are emerging in Doctor of Nursing Practice (DNP) programs. These changes are due to three main factors: First, growing market demands, especially the dearth of psychiatric providers; second, an increasing number of registered nurses entering DNP programs who wish to pursue dual certification; and finally, more current nurse practitioners (NPs) are returning to earn post-master’s degree certification in a second specialty. 5,6 Dual certification DNP curricula are comprehensive and challenging. Successful graduates have the knowledge, expertise, and skills to positively impact patient outcomes within the increasingly complex healthcare infrastructure. Although there are many plans of study for dual certification, of particular interest for this article are NPs with dual certification in primary care and psychiatry (PC/PMHNP). These NPs are exceptionally well qualified to provide and lead care for patients across the lifespan and with varying levels of acuity as well as high needs/high-cost patients 7 in institutional and community-based settings. Primary care settings and rural communities with compromised accessibility to specialty care such as psychiatry stand to benefit from incorporating a dually certified PC/PMHNP.  The purpose of this paper is to inform nurse leaders about this emerging role and provide tangible ways on how nurse leaders can support implementation. 

Introducing the Dually Certified Practitioner Role  

Nationally, approximately 20% of Americans experience a mental illness yearly, but only half are treated 8 Lack of care is a consequence of many factors including costs/coverage, too few care providers, and the stigma of receiving psychiatric care. The consequences of having a mental illness are high and include increased comorbidity risks for cardiovascular and metabolic diseases, substance use disorders, and other illnesses adversely affecting quality of life. Moreover, the COVID-19 pandemic amplified preexisting psychiatric disorders and increased anxiety and depression in the general public.

Access to mental health care is particularly challenging due to limited available mental health facilities. Dual PC/PMHNP providers in primary care settings increase access to mental health services by reducing the stigma attached to seeking services in a psychiatric setting, reducing wait times associated with referrals, and decreasing the need for persons seeking mental health care to negotiate additional schedules and relationships. National data indicate a decrease in primary care physicians’ growth by approximately 7% while nurse practitioner growth is expected to increase by 40% over the next decade, particularly amongst the care of rural and underserved populations. 9  Consequently, NPs have unique opportunities to address common challenges for practicing in rural settings in the care of patients with complex chronic physical and mental health conditions.

NPs are a source of affordable, quality, and trustworthy healthcare and are recognized for their expertise in preventive care. They are also highly effective at optimizing the patient experience, improving patient outcomes, and minimizing costs for the care of complex patients.  Dual-track NP programs that combine primary care and psychiatric mental health care by advanced practice nurses were first developed in 1997. 10 The combination of primary care and psychiatric mental health NP preparation enables the integration of medical and behavioral health care promotion, prevention, and management. The integration of primary and mental health care also facilitates holistic care, allowing providers to evaluate the effectiveness of medical and psychiatric therapies on the whole patient. 11

NP academic program curricula follow closely the National Organization of Nurse Practitioner Faculty (NONPF) Core Competencies that provide a foundation for NP role expectations and are aligned with the American Association of College of Nursing (AACN) Essentials for graduate nursing education. 12,13 Population-specific competencies (e.g., FNP, PMHNP) are also provided by NONPF to ensure clinical expertise preparation required for certification and entry into practice. 14 Curriculum design for dual NP programs has not been standardized, allowing academic institution flexibility in program design. Moreover, there is a lack of consensus amongst nursing academicians about the structure and makeup of a dual NP program.  Many regulatory bodies (state boards of nursing and certification bodies) do not track whether individuals have more than one NP certification, or if they do, make it publicly available. 

The University of Iowa College of Nursing has offered dual-track NP programming amongst the 8 specialty tracks since 2015 with 18 BSN-DNP dual graduates and specifically 13 PC/PMHNP graduates at the time of this publication.  Evaluations from graduates reveal high satisfaction with dual-track preparation with few disadvantages that included additional rigor and tuition requirements. 6 A pilot program, supported by funding from a Telligen Community grant in 2022, developed and implemented additional coursework and practicum experiences with a focus on integrative care for PC/PMHNP dual program students.  

The remainder of the paper focuses on benefits, barriers, and implementation of the dually certified PC/PMHNP role. Content is based on the literature and authors’ clinical experiences in the role. We include illustrative examples that reflect our practice observations and leadership in developing and implementing the role. 

Benefits Associated with the Dual Practitioner Role

Systems that employ dually certified nurse practitioners receive many benefits. These include a holistic approach, decreased stigma, patient empowerment through education and relationships, cross-system care across the care trajectory, and consultant expertise, as described next.  

Holistic approach

Many patients with physical conditions have co-occurring psychiatric conditions which impact both hospitalization and cost. 15, 16  The PC/PMHNP can address both the psychiatric and physical conditions yielding less fragmentation. 

The visit becomes holistic when the patient is empowered to think, “What do I need today?” For example, the visit might be for psychiatric medication management follow-up, but the patient says, “My meds are doing well, but my throat is sore and my knee is bothering me.”  The NP can shift and let the patient drive the visit. This is particularly important for people with serious mental illness (SMI) and substance use disorder whose most frequent contact is with psychiatry. If I were working only in a psychiatry office, I could only address psychiatric concerns, whereas in an integrated practice, I can address the whole person. We know physical health concerns are often underreported and under-addressed in people with SMI, so having the capacity for patients to bring up other health concerns is helpful. It reduces visits, builds trust and I can pick up on what might be a small issue before it becomes something bigger.

Streamlined care fosters efficiency, safety, and cost-effectiveness

Patients with co-occurring physical and psychiatric symptoms have higher healthcare utilization and thus are more costly to treat. 17 Further, they may be unaware of the connection between mental health symptoms and somatic expressions, or of how mental health symptoms can worsen medical conditions and vice versa. As a result, they are at risk for duplication of services and polypharmacy.  

Consider the case of a woman with post-traumatic stress disorder (PTSD) and major depressive disorder who was seen after a negative workup in the ER for chest discomfort. The NP and the woman worked together to process the episode, evaluating a recent trigger attributed to her PTSD. Moving forward the NP and the patient have a new way of talking about physical symptoms and PTSD-related anxiety. The NP can investigate any future somatic concerns and conduct a physical exam and, as appropriate, link somatic symptoms, (e.g., headache, chest pain) to increased anxiety. This reduces duplication of services, multiple visits and decreases the risk of inappropriate polypharmacy. 

Streamlined care can also benefit the larger system. Mergers are happening between hospital systems and community mental health. NPs can seamlessly move between community systems (e.g., residential care facilities, group homes, family settings) and institutionally based settings such as hospitals and nursing homes. Further, they can advocate and communicate with many disciplines as patients move across care settings. Additionally, dually certified NPs can serve as consultants, provide case reviews and collaborate with other health professionals within the health care system.

A more streamlined approach to care means patients do not work as hard to get what they need. 17 Having only one healthcare provider can minimize confusion, increase trust, and promote appropriate engagement in healthcare which may diminish ER visits and hospitalizations. This has the potential to lower costs, but rigorous cost evaluation studies are needed. 

Stigma reduction

Persons with mental illness are particularly vulnerable to the adverse effects of stigma such as shame, isolation, hopelessness, and discrimination. 18  

People are embarrassed to bring up their psychiatric concerns but when they know that I am also a psychiatric provider, they are relieved. I see the mental health concerns and can normalize symptoms and come up with a plan. Further, they are seeing me in a primary care office and don’t have to go to the psychiatry office, which is destigmatizing.

Dually certified PC/PMHNP are “empowerment enablers”

Patient empowerment 19 can be enhanced through working with a dually certified PC/PMHNP. As described below, the NP’s holistic lens contributed to efficiency, patient empowerment, and enhanced job satisfaction.  

I have seen growth in patient self-awareness and understanding of their own health. Nursing excels at taking time to provide patient education and promote self-management, but when we approach this through dual role/holistic services, patients gain an understanding of how their symptoms or day-to-day health is not an isolated representation of one problem, but rather a whole-body expression of what is going on. For example, if a patient living with diabetes and depression presents with an increase in average blood sugar readings they have a better understanding of how the two are interconnected --it sets us up to have a very different conversation as provider and patient than if I was only treating one condition and not the other. It is very rewarding to see patients empowered by understanding their own body/health. 

Barriers to Implementing the Role

Several issues arise as barriers in the implementation of the dual cert role. These include constraints in the practice environment, practice logistics, and issues with full practice authority.

Practice environment

Because many healthcare administrators are unaware of this emerging role, it takes creativity and vision to inform them of the benefits of hiring a dually certified NP. One effective means to eliminate/minimize this barrier is to engage a physician or medical director champion.  

The medical director quickly realized my vision for the dual role. If he hadn’t embraced the full capacity of the dual-prepared NP provider, I could have been reduced to primarily serving as either an FNP or PMHNP rather than the opportunity to use both at the same time.

Practice logistics

Issues with scheduling, appointment times, electronic health records, billing, and reimbursement may impede dually certified NP in maximizing their role. The NP often sees complex patients who require longer than a 15-minute appointment, especially when there is a need for collaboration with other disciplines. Further, some electronic health records may have automatic access restrictions on psychiatric notes which poses a barrier to communication for enacting full team-based care. 

Another barrier that dual-certified NPs face is changing the paradigm from volume-based to quality and value-based reimbursement. Billing and coding professionals based in primary care may not be prepared to support the added coding capacities that the dual cert NP possesses such as the counseling codes available to the psychiatric provider.

Full practice authority

Lack of full practice authority is a barrier to implementation of the dual cert role. In states where NPs require collaborative practice agreements, the NP with dual certification would require two physicians of varied specialties to practice. 

Facilitating Role Awareness and Adoption

Although there are many benefits to this role, it is still not well recognized nor understood.  Before this role can be widely adopted, an evidence base of improved clinical outcomes and cost-effectiveness must be provided to healthcare system leaders.  None of the currently published manuscripts on the dually certified role address cost nor systematically evaluate outcomes of the role. 

The dually certified NP must be able to confidently articulate their emerging role to health system administrators, medical leadership, members of the healthcare team, and patients.

It’s about owning the role and educating. When I am meeting with a patient for the first time, I introduce myself stating, “I am fully certified for family practice and psychiatric mental health. I have some patients I see for one or the other and some patients I see for both.” Often the patient is coming to me for one or the other because they don’t even know that such a thing exists. So, taking 20-30 seconds to explain my role to patients in this way has grown my dual/holistic practice. They often respond, “Oh, I didn’t know you could do that.” And typically, by the end of the visit they have decided to establish care with me for both services. 

Dually prepared nurse practitioners have an obligation to enhance awareness through the dissemination of information about the role. Dissemination can be by presentations, discussions, and publications in arenas where nurse executives and hospital administrators are likely to read and convene. 

NPs must also collect data on their own practice. Data on patient outcomes and satisfaction and cost savings will help validate the effectiveness of their role. NPs can also collect data on their insurance reimbursements using psychiatric counseling codes (e.g., 90833) to demonstrate the value of allowing extended appointment times and the financial benefits of quality over quantity. Partnering with health system administration leadership, schools of nursing and health services researchers is essential to foster role adoption and needed policy changes.

Future Directions

This is a new role that requires a vision of non-fragmented care for high-cost, complex patients with co-occurring mental health and physical health care needs. Nurse leaders can impact implementation of the role through a variety of means. These include advocating to Medicaid for dual-certified NP-led demonstration projects for high-cost patients, such as people with schizophrenia; expansion of dual cert programs at colleges of nursing nationwide; and promoting presentations/ posters related to dual cert roles and outcome studies at professional conferences. Nursing regulatory leaders in state and national boards of nursing, certification centers, and credentialing bodies play a particularly important role in assisting with gathering data on those NPs who maintain dual certification. Nurse leaders must also spearhead efforts to establish full practice authority through working in collaboration with their state and national boards of nursing, professional nursing organizations, and legislators. In states where there is already full scope of practice, they must remain vigilant for encroachments into full scope of practice.

As noted, national reports such as the Future of Nursing, encouraged the provision of care by nurses especially to vulnerable populations. Dually certified NPs are ideally prepared to provide care to high-needs/high-cost patients. 

This article is a beginning step to elucidating the dual certification role. Much more is needed to expand educational programs and the full practice of dually certified NPs. Most particularly we lack an evidence base on cost-effectiveness and patient outcomes. This is where nursing leaders in academic, regulation, and healthcare systems can collaborate to pave the way and expand program offerings, enhance awareness, and promote employment of dual certified NPs.

Acknowledgment

The authors wish to acknowledge Christopher Sang for his support in editing the manuscript.  

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