case study about psychological disorder

Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

• Theresa Cerulli, MD
• Tina Matthews-Hayes, DNP, FNP, PMHNP

Custom Around the Practice Video Series

Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.

EP: 1 . Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Ep: 2 . clinical significance of bipolar disorder, ep: 3 . clinical impressions from patient case #1, ep: 4 . diagnosis of bipolar disorder, ep: 5 . treatment options for bipolar disorder, ep: 6 . patient case #2: 47-year-old man with treatment resistant depression (trd), ep: 7 . patient case #2 continued: novel second-generation antipsychotics, ep: 8 . role of telemedicine in bipolar disorder.

Michael E. Thase, MD : Hello and welcome to this Psychiatric Times™ Around the Practice , “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.

Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.

Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.

We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.

Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.

On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.

At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.

Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.

So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.

Transcript Edited for Clarity

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

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• April 01, 2024 | VOL. 181, NO. 4 CURRENT ISSUE pp.255-346
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DSM-5 Clinical Cases

• Rachel A. Davis , M.D.

Search for more papers by this author

DSM-5 Clinical Cases makes the rather overwhelming DSM-5 much more accessible to mental health clinicians by using clinical examples—the way many clinicians learn best—to illustrate the changes in diagnostic criteria from DSM-IV-TR to DSM-5. More than 100 authors contributed to the 103 case vignettes and discussions in this book. Each case is concise but not oversimplified. The cases range from straightforward and typical to complicated and unusual, providing a nice repertoire of clinical material. The cases are realistic in that many portray scenarios that are complicated by confounding factors or in which not all information needed to make a diagnosis is available. The authors are candid in their discussions of difficulties arriving at the correct diagnoses, and they acknowledge the limitations of DSM-5 when appropriate.

The book is conveniently organized in a manner similar to DSM-5. The 19 chapters in DSM-5 Clinical Cases correspond to the first 19 chapters in section 2 of DSM-5. As in DSM-5, DSM-5 Clinical Cases begins with diagnoses that tend to manifest earlier in life and advances to diagnoses that usually occur later in life. Each chapter begins with a discussion of changes from DSM-IV. These changes are further explored in the cases that follow.

Each case vignette is titled with the presenting problem. The cases are formatted similarly throughout and include history of present illness, collateral information, past psychiatric history, social history, examination, any laboratory findings, any neurocognitive testing, and family history. This is followed by the diagnosis or diagnoses and the case discussion. In the discussions, the authors highlight the key symptoms relevant to DSM-5 criteria. They explore the differential diagnosis and explain their rational for arriving at their selected diagnoses versus others they considered as well. In addition, they discuss complicating factors that make the diagnoses less clear and often mention what additional information they would like to have. Each case is followed by a list of suggested readings.

As an example, case 6.1 is titled Depression. This case describes a 52-year-old man, “Mr. King,” presenting with the chief complaint of depressive symptoms for years, with minimal response to medication trials. The case goes on to describe that Mr. King had many anxieties with related compulsions. For example, he worried about contracting diseases such as HIV and would wash his hands repeatedly with bleach. He was able to function at work as a janitor by using gloves but otherwise lived a mostly isolative life. Examination was positive for a strong odor of bleach, an anxious, constricted affect, and insight that his fears and behaviors were “kinda crazy.” No laboratory findings or neurocognitive testing is mentioned.

The diagnoses given for this case are “OCD, with good or fair insight,” and “major depressive disorder.” The discussants acknowledge that evaluation for OCD can be difficult because most patients are not so forthcoming with their symptoms. DSM-5 definitions of obsessions and compulsions are reviewed, and the changes to the description of obsessions are highlighted: the term urge is used instead of impulse so as to minimize confusion with impulse-control disorders; the term unwanted instead of inappropriate is used; and obsessions are noted to generally (rather than always) cause marked anxiety or distress to reflect the research that not all obsessions result in marked anxiety or distress. The authors review the remaining DSM-5 criteria, that OCD symptoms must cause distress or impairment and must not be attributable to a substance use disorder, a medical condition, or another mental disorder. They discuss the two specifiers: degree of insight and current or past history of a tic disorder. They briefly explore the differential diagnosis, noting the importance of considering anxiety disorders and distinguishing the obsessions of OCD from the ruminations of major depressive disorder. They also point out the importance of looking for comorbid diagnoses, for example, body dysmorphic disorder and hoarding disorder.

This brief case, presented and discussed in less than three pages, leaves the reader with an overall understanding of the diagnostic criteria for OCD, as well as a good sense of the changes in DSM-5.

DSM-5 Clinical Cases is easy to read, interesting, and clinically relevant. It will improve the reader’s ability to apply the DSM-5 diagnostic classification system to real-life practice and highlights many nuances to DSM-5 that one might otherwise miss. This book will serve as a valuable supplementary manual for clinicians across many different stages and settings of practice. It may well be a more practical and efficient way to learn the DSM changes than the DSM-5 itself.

The author reports no financial relationships with commercial interests.

• Cited by None

146 Case Studies: Real Stories Of People Overcoming Struggles of Mental Health

At Tracking Happiness, we’re dedicated to helping others around the world overcome struggles of mental health.

In 2022, we published a survey of 5,521 respondents and found:

• 88% of our respondents experienced mental health issues in the past year.
• 25% of people don’t feel comfortable sharing their struggles with anyone, not even their closest friends.

In order to break the stigma that surrounds mental health struggles, we’re looking to share your stories.

Overcoming struggles

They say that everyone you meet is engaged in a great struggle. No matter how well someone manages to hide it, there’s always something to overcome, a struggle to deal with, an obstacle to climb.

And when someone is engaged in a struggle, that person is looking for others to join him. Because we, as human beings, don’t thrive when we feel alone in facing a struggle.

Let’s throw rocks together

Overcoming your struggles is like defeating an angry giant. You try to throw rocks at it, but how much damage is one little rock gonna do?

Tracking Happiness can become your partner in facing this giant. We are on a mission to share all your stories of overcoming mental health struggles. By doing so, we want to help inspire you to overcome the things that you’re struggling with, while also breaking the stigma of mental health.

Which explains the phrase: “Let’s throw rocks together”.

Let’s throw rocks together, and become better at overcoming our struggles collectively. If you’re interested in becoming a part of this and sharing your story, click this link!

Case studies

April 24, 2024

How Boxing and Therapy Help Me Recover My Identity After Extreme Weight Loss

“When my body changed so drastically and rapidly, it broke my sense of self-identity. About a year into my weight loss, I began to experience early dissociation, depersonalization, and dissociative amnesia. I broke into two people. Me of now and her of before.”

Struggled with: Depression Dissociative amnesia

Helped by: Exercise Self-improvement Therapy

April 18, 2024

How Therapy, Medication and Baking Help Me Navigate Depression and OCD

“I was hospitalized for my eating disorder and my depression several times throughout my college career struggling with the will to live… I was desperate to be “normal” but my brain really got in the way of that.”

Struggled with: Anxiety Depression Eating disorder OCD Suicidal

Helped by: Medication Self-improvement Therapy Treatment

April 16, 2024

How I Found My Self-Worth After Battling Chronic Pain, Anxiety and Panic Attacks

“I remember being floored with a horrible throat infection, and I was just crying. I was done suffering, I couldn’t do it anymore, I was really broken down. That was about 2 years ago now, and it shifted something in my brain. Instead of going down the drain – and keeping that negativity going – it suddenly hit me that I’m the only one responsible for how I feel.”

Struggled with: Anxiety Chronic pain Panic attacks Stress

Helped by: Medication Self-Care Self-improvement Therapy

April 11, 2024

How a Mindset Change Helped Me Break Free From Childhood Trauma and Toxicity

“My mother said she wanted to end it in bloodshed and she waited for him to come home from his late-night meeting. She thought better of it when he was late arriving home. She was overwhelmed with thoughts of her in prison and me in foster care. To say that she made the right decision in achieving the goal of a good life is an answer I struggled to answer for many years.”

Struggled with: Abuse Anxiety Childhood CPTSD Depression

Helped by: Mindfulness Reinventing yourself Self-improvement Therapy

April 9, 2024

Healing From Postpartum Depression With Therapy, Friends & Exercise

“I wasn’t sure how to feel better for a while. People talk about ‘getting help’ but that’s a blanket term and unfortunately it’s not a band-aid you can just put on and suddenly be yourself again. It takes time to find the right therapist, medication if that’s what you decide to do, to find a new rhythm with family, and in my case, I really needed friends locally.”

Struggled with: Postpartum depression

Helped by: Exercise Social support Therapy

April 4, 2024

My Journey from Loneliness and Isolation to Creating an Online Haven for Seniors

“When one is home alone, all day, with nothing to do, nobody to speak with, stuck with their thoughts both good and bad, it’s easy to slip back into a depressive state. Feeling unneeded, unwanted, no happiness, no joy, no reason to get out of bed – just suffering with “the blahs”.”

Struggled with: Depression Loneliness

Helped by: Self-improvement Social support

April 2, 2024

Surviving a Workplace Shooting and Navigating PTSD, Insomnia With Marathons and Prayers

“My symptoms began immediately following a workplace shooting on Saturday, November 28, 2015, and were exasperated due to the activity of the company, the criminals, and the cops. The company treated me as if I were a criminal, the criminals attempted to kill me three additional times, and the cops (Houston Police Department Organized Crime Unit) treated me as if I was a thorn in their flesh.”

Struggled with: Depression Insomnia PTSD Stress

Helped by: Exercise Religion Treatment Volunteering

March 28, 2024

How The Support of Others Helped Me Heal After a Mental Breakdown

“I do not recommend having a breakdown when trying to raise boys. I would cry, eat all the time, and feel like my brain was full of fuzz. I could barely function. There was that day when I got home from taking the kids to school, and thought to myself that if there was a gun in the house, someone else would have had to pick them up from school that day.”

Struggled with: Depression Divorce Stress

Helped by: Journaling Social support Therapy

March 26, 2024

Journaling and Therapy Helped Me After Surviving a Car Accident and a Late Pregnancy Loss

“I vividly remember one day a few months after getting hit by the car when I wondered if my life would ever feel peaceful, pain-free, or joyful again. I was simply getting in and out of the passenger seat of a vehicle, my whole body gripped with pain and stiffness when I experienced a flash of fear that my health would never improve.”

Struggled with: Chronic pain Depression Grief PTSD

Helped by: Journaling Therapy

March 21, 2024

From the C-Suites to the Streets and Back – Overcoming Addiction, Anxiety, Depression and PTSD

“Over the past decade, I have struggled with substance abuse immensely leading to anxiety, depression, and PTSD. After losing thirteen corporate jobs and ending up homeless, beaten up, and absolutely broken on the streets I have finally come to terms with my situation and am finding a path towards long-term sobriety and happiness.”

Struggled with: Addiction Anxiety Depression PTSD

Helped by: Mindfulness Rehab Religion Self-improvement Social support

Evidence-based Approaches to Support Student Mental Health

• Andrea Feldman
• 24 April 2024

The college years throw a lot of new challenges at us. Maybe you’re the first in your family to go to college. You’re developing a new sense of independence. Figuring out how to live with roommates. Dealing with new financial responsibilities and academic pressures.

That’s a lot all by itself — but as Associate Professor Sam Rosenthal noted during her recent Health Equity lecture outlining the behavioral health of college-age students, a staggering 75% of mental health disorders are established by the mid-twenties. That means that the 18-25 cohort exhibits the highest rates of anxiety and depressive symptoms, and they’re also extremely vulnerable to developing parallel addictive behaviors.

“Those with social support reduce their risk of insomnia by 33%, their risk of anxiety by 47% and their risk of depression by 50%. That’s dramatic.”

But the data is only one side of the story, and Rosenthal prefaced her talk by noting, “I do want you to know we’re going to get to a positive note of the solutions by the end.” And it may not surprise you to learn that community-building — strengthening our real-world bonds to others — plays a crucial role in improving our individual mental health. (Put down that phone, while you’re at it.)

A Career Built on Studying Behavioral Health

Rosenthal has built an impressive career on her research into the multi-factor forces driving mental-health trends in young adults.

In addition to teaching and serving as the director of JWU’s Center for Student Research and Interdisciplinary Collaboration, she serves as an evaluator for the Rhode Island Department of Health and as the lead epidemiologist for the State Epidemiological Outcomes Workgroup (SEOW). Under the aegis of SEOW, she administers the RI Young Adult Survey (RIYAS), which focuses on the behavioral health of 18-25-year-olds.

Assessing the Pandemic Spike

Depression rates among young adults have doubled in the past 10 years. But the pandemic sent these rates soaring — Rosenthal calls the spike “extreme” — due to a polycrisis of factors, including social isolation, disrupted academic studies, and unprecedented loss. During the 2020-21 academic year, noted Rosenthal, 60% of college-age students reported at least one mental health disorder, and 75% experienced psychological distress. 1 in 5 young adults in Rhode Island reported losing a loved one to Covid-19.

Once you start taking into account the social upheaval of recent years — from gun violence to racial discrimination, climate change anxiety and political turmoil — and you have a massive amount of collective trauma having a ripple effect on already fragile mental health states.

Rosenthal provided a top-level overview of two recent studies. The Healthy Mind study surveyed more than 76,000 students from 400 institutions during the 2022-23 academic year. In October 2022, Rosenthal and her co-researchers used an NIH grant to survey 586 JWU students assessing their levels of depression, anxiety, insomnia and social support.

While the Healthy Mind study clocked depression rates at 41%, the JWU case study reported 53% — that’s “higher than what we saw in the national study, but actually comparable to what we saw in the Rhode Island state study,” explained Rosenthal. “And also we have a huge representation of sexual gender minority students, which is likely to be driving some of these higher rates for us as well.” (The JWU study demographics broke down as 15.1% cisgender male, 47.4% cisgender female and 37.5% sexual or gender minority.)

So, what are the solutions for combatting these numbers? For Rosenthal, who has done multiple studies correlating social media use and depression, building up social support networks is “critically important”: “Those with social support reduce their risk of insomnia by 33%, their risk of anxiety by 47% and their risk of depression by 50%. That’s dramatic.”

“Gratitude is really powerful. I often tell my students to break up anxiety with gratitude.”

Mindfulness, Quiet Hours & Other Mental Health Boosts

Rosenthal opened the conversation to students and faculty in the audience to share their ideas for boosting our community connections and strengthening overall well-being.

Sarah and Jasmine, two undergraduate students in the Public Health program , shared how much JWU’s 3-credit Mindfulness for Health & Wellbeing class helped them. (This course is currently an elective, but there is talk of making it requirement.)

The course provides students with the opportunity to learn the principles of mindfulness, develop their own mindfulness mediation practice, and apply principles of mindfulness to daily life.

Prior to taking the class, Jasmine had been struggling with time management. Having never meditated before, it took her some time to acclimate to the practice. But now, she says, “I feel like this class has definitely not only forced me to try new things, but I’ve made it a part of my daily routine. It’s definitely helped me!”

Initially, Sarah noted that she “had a really hard time sitting down with myself and going through [the process].” Gradually, with the guidance of Professor Jennifer Swanberg, “I've been able to develop my own practice that I find beneficial. There are those times where I still feel frustration, but now I feel more prepared to deal with it.”

In the Occupational Therapy department, faculty celebrate Grati-Tuesdays, where they keep a running list of what they are thankful for. “Gratitude is really powerful,” noted Assistant Professor Kathryn Burke. “I often tell my students to break up anxiety with gratitude. Thinking about something that you’re grateful for can sometimes help get your brain out of that downward spiral that everything is terrible.”

Other suggestions included:

• A peer mentorship program to help increase social support
• Moving 11:59pm assignment deadlines to 8pm
• Minimizing the number of early morning classes
• Enforcing quiet hours in residence halls
• Expanding the number of safe community spaces (like the Bridge for Diversity, Equity and Social Justice ) where students can share with their peers

“Creating a sense of belonging is crucially important,” concluded Rosenthal. “We need to have safe spaces to hold people when the rest of the world feels unsafe.”

JWU has a wealth of confidential mental health resources, including counseling services in Providence and Charlotte . Individual counseling sessions and consultations are available by appointment, as well as resources for mental health screenings, education and crisis intervention.

Related Reading:

• 6 Ways College Students Can Improve Their Mental Health
• Self-Care Tips to Use During Exams
• JWU Alumni Share Insight on DEI and Belonging

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• v.23(Suppl 1); 2014 Jan

The psychological perspective on mental health and mental disorder research: introduction to the ROAMER work package 5 consensus document

Hans‐ulrich wittchen.

1 Institute of Clinical Psychology and Psychotherapy & Center for Epidemiology and Longitudinal Studies (CELOS), Technische Universität Dresden, Dresden Germany

Susanne Knappe

Gunter schumann.

2 MRC‐SGDP Centre, Institute of Psychiatry, King's College, London UK

This paper provides an overview of the theoretical framework of the Psychological Sciences' reviews and describes how improved psychological research can foster our understanding of mental health and mental disorders in a complementary way to biomedical research. Core definitions of the field and of psychological interventions and treatment in particular are provided. The work group's consensus regarding strength and weaknesses of European Union (EU) research in critical areas is summarized, highlighting the potential of a broader comprehensive “Behaviour Science programme” in forthcoming programmatic EU funding programmes. Copyright © 2013 John Wiley & Sons, Ltd.

Introduction

Undoubtedly, there is increasing convergence between biomedical and psychological research on mental health and mental disorders. Both fields study the same or similar phenomena with similar approaches and methods. Thus, it is not surprising that appraisals of strength and weaknesses in both fields will often come to the same conclusions (Schumann et al ., 2013 ). Despite this continued trend of growing convergence and synergy, there are important, though sometimes subtle differences due to different traditions, theories, principles, and methods that justify a separate presentation and discussion of biomedical and psychological perspectives, highlighting specific needs and priorities that would have been neglected in a joint presentation. Consistent with this appraisal the work group (ROAMER work package 5, WP5) felt it would be helpful to define the field and arrive at consensus about its scope and definitions.

The contribution of the Psychological Sciences

Psychology can broadly be defined as an academic and applied discipline that involves the scientific study of basic psychological functions like perception, cognition, attention, emotion, motivation, as well as complex psychological processes such as decision‐making, volition and behaviour control, including its neural and biological underpinnings, personality, behaviour and interpersonal relationships. Psychology covers normal mental functions and behaviours and addresses the question when, why and how they can become dysfunctional. Thus, psychology covers mental health and abnormal functions and behaviours, like in mental disorders with the goal of understanding individuals, groups and social systems. Psychology has been described as a “hub science” (Cacioppo, 2007 ) with psychological findings linking to research and perspectives from the social sciences, natural sciences, medicine, and the humanities, such as philosophy. During the last centuries, the field of psychology has undergone several theoretical paradigm shifts (i.e. structuralism, functionalism, psychoanalysis, behaviourism, cognitivism) and is currently typically structured in subfields of which Biological, Experimental, Developmental and Clinical Psychology have become closest to the biomedical field (Haslam and Lusher, 2011 ). But, depending on the theoretical orientation, methods and psychological fields of interest, psychological institutions and psychological research can be grouped under social sciences, the natural sciences or the biomedical sciences, etc. In fact, terms like behavioural neuroscience or cognitive‐affective neuroscience are used almost synonymously and have given rise to denote the field as Psychological Sciences. Corollaries pertaining to the Psychological Sciences include:

• As compared to the biomedical field, the Psychological Sciences emphasize more explicitly a comprehensive interactional bio‐psycho‐social approach to understand and predict a broad construct of “ behaviour” that refers to neurobiological, cognitive, affective and social‐behavioural units of analyses – and should not be misunderstood as denoting simply open motor behaviour.
• To this end, the relative role of biological, psychological and particularly social‐environmental variables and their dynamic interplay in promoting normal and abnormal behaviour is examined within a “dimensional” rather a “categorical” approach (diagnostic approach).
• Consistent with a broad construct of behaviour, Psychological Science research uses a range of specific experimental and empirical methods (qualitative and quantitative, subjective and objective) and paradigms in human and animal research to observe causal and correlational relationships between psychosocial, environmental, psychological and biological variables.
• Psychological Sciences emphasize environmental variables and a developmental perspective by appreciating the highly dynamic interplay over time, for example in psychological constructs of vulnerability – stress models as well as interactional constructs like resilience and coping to understand behaviour change and its determinants.
• Based on such models, constructs and methods of the science of psychology has also provided a set of unique methods and techniques for psychological interventions (i.e. psychotherapy) with the goal of preventing, treating and rehabilitating dysfunctional behaviour and mental disorders.

Within the context of this appraisal, we define psychological treatments and interventions as clinically relevant, empirically supported interventions of any type that are based on knowledge and expertise of the Psychological Sciences by using psychological methods and means (as opposed to drugs as in psychiatry), typically by communication and/or behavioural exercises (Wittchen and Hoyer, 2011 ).

This definition includes a large group of methods and approaches, developed to address the needs of patients and groups of patients with mental disorders or mental health problems, as well as their networks of support (e.g. partner and family) and covering prevention, treatment and rehabilitation in all ages. Psychological treatments and interventions might range from highly sophisticated psychotherapy, delivered by specialized psychotherapists, to the application of specific behavioural techniques as part of a broader treatment plan (e.g. psychoeducation or motivational interviewing) by any health provider, including web‐based and e‐health applications, whenever the criteria of the earlier definition are met and efficacy and/or effectiveness is established by randomized clinical trials or equivalent designs (van der Feltz‐Cornelis and Adèr, 2000 ).

Because dysfunctional behaviour (also denoted in the literature as abnormal or clinically relevant behaviour) has large and pervasive effects on health outcomes, there is a broad consensus in the scientific community that there is a continued strong need to improve research with the goal to provide a better understanding of (a) the mechanisms underlying adaptive and dysfunctional behaviour, (b) the mechanisms of behaviour change with regard to (c) normal‐adaptive healthy as well as (d) dysfunctional and clinically significant behaviours as in mental disorders. Towards this goal the work group sees the strong need to adopt a comprehensive “Science of Behaviour” programme, in order to make substantial progress in research of mental health, mental disorders also reflected in substantial improvements in public health as well as savings in healthcare costs (NIH, 2009 ).

It should be noted that we did not work specifically on substance use disorders because of the existence of another European research programme dealing exlusively with this topic ( http://www.alicerap.eu ).

Core issues and topics from a Psychological Science perspective

The subsequent papers are position papers by members of the “roadmap for mental health research in Europe” –initiative (ROAMER) work package 5 (Haro et al ., 2014 ). They address selected and interrelated core areas that are considered to be of particular relevance for an improved future research agenda on mental health. Based on their expertise they were invited as part of the ROAMER discussion process to jointly contribute to a birds‐eye view on important issues in mental health and mental disorder research from a Psychological Science perspective. The choice of topics was selective, though based on prior discussions and consensus of the ROAMER expert work group on “Psychological Research and Treatments”. 1 Their accounts should not be regarded as state‐of‐the‐art reviews. Rather, the aim is to highlight the unique contributions of psychology by these position papers, complementing the contributions of the biomedical field, avoiding replication.

In the first contribution (Wittchen et al ., 2014 ) several fundamental barriers to progress in the area of basic and applied research on behaviour and behaviour change are addressed. A general lack of understanding the basic mechanisms of behaviour, behaviour change as well as moderators and mediators of behaviour in the context of interventions is concluded, highlighting the strong need of respective intensified research. Common “health risk behaviours” are taken as examples to specify what type of research is needed to identify mechanisms and determinants of behaviour initiation, maintenance and behaviour change as well as the critical trajectories between them to provide ultimately also a better understanding of the causes and the treatment of mental disorders. The paper also addresses the question to what degree mechanisms relevant for specific disorders or health risk behaviours are the same, or different across disorders and conditions, and to what degree individual variation (genetic, or individual capacities such as “self‐regulation”), stress and emotion play a role. This discussion is linked to the specific context of psychotherapy research, providing examples how this perspective helps to identify core ingredients and mechanisms of behaviour change.

The position paper by Goschke ( 2014 ) emphasizes the work group's consensus that only improved research of basic and more complex normal and dysfunctional psychological functions and processes, including their neural underpinnings and social contexts, will ultimately allow us to improve our understanding of normative and non‐normative behaviours (i.e. mental disorders), their developmental pathways and processes. This paper describes in greater detail how we might advance in this direction by focusing on “Functions and dysfunctions of cognitive control and decision‐making as transdiagnostic core mechanisms in mental disorders”.

Emmelkamp et al . ( 2014 ) specifically address various domains of clinical research and “state of the art” psychotherapy research in particular. They focus largely on the currently best established, though imperfect, first‐line treatment for many disorders and how to advance research on components, mechanism and effectiveness research. Four topical domains are highlighted in particular that are characterized by partly different research needs. Namely: (a) psychological models and paradigms of mental disorders from a cognitive perspective, (b) methodological issues of improved psychotherapy research, (c) the special needs in psychotherapy of children and adolescents, and (d) the incorporation of e‐health innovations.

The final paper (Fava et al ., 2014 ) provides a methodological framework for improved research on comorbidity and discusses perspectives on the future clinical research agenda within this context.

Conclusions on strengths and weaknesses

Overall, the position papers on psychological perspectives converge on several strengths of the European research field: i.e. a substantial body of expertise and knowledge in both basic and clinical research, strong and increasingly more intimate collaborative ties to the biomedical field, and a broader coverage of mental health issues as opposed to mental disorder research in the biomedical field (Wittchen et al ., 2014 ; Goschke et al ., 2014 ; Emmelkamp et al ., 2014 ; Fava et al ., 2014 ).

At the same time, they also converge on several major general weaknesses, characteristic not only for Europe but worldwide, namely: (a) the fragmentation of research activities in many areas, (b) the lack of coordination and synergy in European research in this field, and (c) the lack of coordinated long‐term programmes with regard to a broader “Science of Behaviour” perspective as the fundamental framework.

On the structural level the work group highlights that there are remarkable gaps in our knowledge regarding the situation of research on psychological treatments and interventions in Europe. In fact – and despite some coordinated EU‐efforts in this domain – it is impossible to determine the degree to which psychological treatments are applied in the EU countries, where and what kind of research and service delivery programmes are in place and how they are integrated into the wider network of mental health care infrastructure. As a result, Europe lacks even the most basic prerequisites for an evidence‐based mental health research policy in this field.

In terms of specific gaps and needs for future research the authors point out marked deficits and provide suggestions on advances needed to meet these research needs. A short summary of these suggestions is given in Table  1 . In sum, the position papers emphasize to varying degrees that a combined approach, appreciating traditional diagnostic classificatory models as well as a facet‐oriented, dimensional multi‐level domain approach by functions and elements of behaviour might be the best way forward. Overall, there seems to be consensus that the field would profit significantly from a concerted programme of the “Science of Behaviour Change”.

Goals and needs for future research in Psychological Science

Declaration of interest statement

The authors have no competing interests.

Acknowledgements

This work was supported by the European Commission's Seventh Framework Programme Project ROAMER (FP7‐HEALTH‐2011/No 282586).

This paper has been prepared by the authors in the context of the ROAMER project (work package 5, led by Hans‐Ulrich Wittchen). The statements and the position of the paper are made by the authors, based on the work group discussions and thus they reflect an intermediate outcome of the work group. They should not be considered as an official statement of the ROAMER project or as a final outcome or conclusion of the overall programme.

The position papers were generated as part of the activities of a group of leading European experts on psychological research and intervention, in order to provide an assessment of the state‐of‐the‐art of research in different domains, identifying major advances and promising methods and pointing out gaps and problems which ought to be addressed in future research (see Appendix). A similar critical appraisal with partly similar conclusions is concurrently provided elsewhere (Schumann et al ., 2013 ) by the ROAMER work group “Biomedical research”. Experts in both work groups have been selected for their academic excellence and for their competence in the different units of analysis needed to comprehensively characterize particular symptom domains. Their contributions do not aim to be systematic reviews of the field but rather provide a well‐informed opinion of the authors involved. They also do not represent official statements of the ROAMER consortium, but are meant to inform the discussion on psychological research and intervention in mental disorders among interested stakeholders, including researchers, clinicians and funding bodies. Recommendations made in this issue will undergo a discussion and selection process within the ROAMER consortium, and contribute to a final roadmap, which integrates all aspects of mental health research. We thus hope to provide an informed and comprehensive overview of the current state of psychological research in mental health, as well as the challenges and advances ahead of us.

Table A1 ROAMER work package 5 authors and experts (in alphabetical order by last name)

1 Core experts of the ROAMER work package on Psychological Research and Treatments are Drs Arnoud Arntz, Francesc Colom, Pim Cuijpers, Tim Dalgleish, Daniel David, Giovanni A. Fava, Arne Holte, Uwe Koch‐Gromus, Ilse Kryspin‐Exner, Wolfgang Lutz, and Hans‐Ulrich Wittchen. They were supported by dozens of advisors and consultants.

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Mental health and the pandemic: What U.S. surveys have found

The coronavirus pandemic has been associated with worsening mental health among people in the United States and around the world . In the U.S, the COVID-19 outbreak in early 2020 caused widespread lockdowns and disruptions in daily life while triggering a short but severe economic recession that resulted in widespread unemployment. Three years later, Americans have largely returned to normal activities, but challenges with mental health remain.

Here’s a look at what surveys by Pew Research Center and other organizations have found about Americans’ mental health during the pandemic. These findings reflect a snapshot in time, and it’s possible that attitudes and experiences may have changed since these surveys were fielded. It’s also important to note that concerns about mental health were common in the U.S. long before the arrival of COVID-19 .

Three years into the COVID-19 outbreak in the United States , Pew Research Center published this collection of survey findings about Americans’ challenges with mental health during the pandemic. All findings are previously published. Methodological information about each survey cited here, including the sample sizes and field dates, can be found by following the links in the text.

The research behind the first item in this analysis, examining Americans’ experiences with psychological distress, benefited from the advice and counsel of the COVID-19 and mental health measurement group at Johns Hopkins Bloomberg School of Public Health.

At least four-in-ten U.S. adults (41%) have experienced high levels of psychological distress at some point during the pandemic, according to four Pew Research Center surveys conducted between March 2020 and September 2022.

Young adults are especially likely to have faced high levels of psychological distress since the COVID-19 outbreak began: 58% of Americans ages 18 to 29 fall into this category, based on their answers in at least one of these four surveys.

Women are much more likely than men to have experienced high psychological distress (48% vs. 32%), as are people in lower-income households (53%) when compared with those in middle-income (38%) or upper-income (30%) households.

In addition, roughly two-thirds (66%) of adults who have a disability or health condition that prevents them from participating fully in work, school, housework or other activities have experienced a high level of distress during the pandemic.

The Center measured Americans’ psychological distress by asking them a series of five questions on subjects including loneliness, anxiety and trouble sleeping in the past week. The questions are not a clinical measure, nor a diagnostic tool. Instead, they describe people’s emotional experiences during the week before being surveyed.

While these questions did not ask specifically about the pandemic, a sixth question did, inquiring whether respondents had “had physical reactions, such as sweating, trouble breathing, nausea, or a pounding heart” when thinking about their experience with the coronavirus outbreak. In September 2022, the most recent time this question was asked, 14% of Americans said they’d experienced this at least some or a little of the time in the past seven days.

More than a third of high school students have reported mental health challenges during the pandemic. In a survey conducted by the Centers for Disease Control and Prevention from January to June 2021, 37% of students at public and private high schools said their mental health was not good most or all of the time during the pandemic. That included roughly half of girls (49%) and about a quarter of boys (24%).

In the same survey, an even larger share of high school students (44%) said that at some point during the previous 12 months, they had felt sad or hopeless almost every day for two or more weeks in a row – to the point where they had stopped doing some usual activities. Roughly six-in-ten high school girls (57%) said this, as did 31% of boys.

On both questions, high school students who identify as lesbian, gay, bisexual, other or questioning were far more likely than heterosexual students to report negative experiences related to their mental health.

Mental health tops the list of worries that U.S. parents express about their kids’ well-being, according to a fall 2022 Pew Research Center survey of parents with children younger than 18. In that survey, four-in-ten U.S. parents said they’re extremely or very worried about their children struggling with anxiety or depression. That was greater than the share of parents who expressed high levels of concern over seven other dangers asked about.

While the fall 2022 survey was fielded amid the coronavirus outbreak, it did not ask about parental worries in the specific context of the pandemic. It’s also important to note that parental concerns about their kids struggling with anxiety and depression were common long before the pandemic, too . (Due to changes in question wording, the results from the fall 2022 survey of parents are not directly comparable with those from an earlier Center survey of parents, conducted in 2015.)

Among parents of teenagers, roughly three-in-ten (28%) are extremely or very worried that their teen’s use of social media could lead to problems with anxiety or depression, according to a spring 2022 survey of parents with children ages 13 to 17 . Parents of teen girls were more likely than parents of teen boys to be extremely or very worried on this front (32% vs. 24%). And Hispanic parents (37%) were more likely than those who are Black or White (26% each) to express a great deal of concern about this. (There were not enough Asian American parents in the sample to analyze separately. This survey also did not ask about parental concerns specifically in the context of the pandemic.)

Looking back, many K-12 parents say the first year of the coronavirus pandemic had a negative effect on their children’s emotional health. In a fall 2022 survey of parents with K-12 children , 48% said the first year of the pandemic had a very or somewhat negative impact on their children’s emotional well-being, while 39% said it had neither a positive nor negative effect. A small share of parents (7%) said the first year of the pandemic had a very or somewhat positive effect in this regard.

White parents and those from upper-income households were especially likely to say the first year of the pandemic had a negative emotional impact on their K-12 children.

While around half of K-12 parents said the first year of the pandemic had a negative emotional impact on their kids, a larger share (61%) said it had a negative effect on their children’s education.

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John Gramlich is an associate director at Pew Research Center

How Americans View the Coronavirus, COVID-19 Vaccines Amid Declining Levels of Concern

Online religious services appeal to many americans, but going in person remains more popular, about a third of u.s. workers who can work from home now do so all the time, how the pandemic has affected attendance at u.s. religious services, economy remains the public’s top policy priority; covid-19 concerns decline again, most popular.

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Diagnostic error in mental health: a review.

Bradford A, Meyer AND, Khan S, et al. Diagnostic error in mental health: a review. BMJ Qual Saf. 2024;Epub Apr 4. doi:10.1136/bmjqs-2023-016996.

Diagnostic errors in mental health disorders have not yet received the same attention as diagnostic errors in other care settings. This article describes diagnostic pitfalls for common mental health disorders including schizophrenia, anxiety, attention deficit hyperactivity (ADHD), autism spectrum, mood , and bipolar disorders. The authors urge parallel development of interventions to reduce misdiagnosis and estimating error rates.

Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions. November 10, 2021

Patient perspectives on the usefulness of an artificial intelligence-assisted symptom checker: cross-sectional survey study. March 11, 2020

Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians. June 6, 2012

Patient perspectives on how physicians communicate diagnostic uncertainty: an experimental vignette study. January 24, 2018

Types and origins of diagnostic errors in primary care settings. March 6, 2013

Pediatric clinician perspectives on communicating diagnostic uncertainty. August 7, 2019

Should patients get direct access to their laboratory test results?: An answer with many questions. January 30, 2005

Advancing diagnostic equity through clinician engagement, community partnerships, and connected care. February 22, 2023

The path to diagnostic excellence includes feedback to calibrate how clinicians think. February 20, 2019

Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. May 12, 2021

Measure Dx: implementing pathways to discover and learn from diagnostic errors. September 28, 2022

Operational measurement of diagnostic safety: state of the science. October 7, 2020

Technology-based closed-loop tracking for improving communication and follow-up of pathology results. February 2, 2022

Communicating findings of delayed diagnostic evaluation to primary care providers. July 27, 2016

Crowdsourcing diagnosis for patients with undiagnosed illnesses: an evaluation of CrowdMed. February 3, 2016

The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. April 30, 2014

Electronic health record-based surveillance of diagnostic errors in primary care. November 2, 2011

Evaluation of outcomes from a national patient-initiated second-opinion program. June 24, 2015

Recommendations for using the Revised Safer Dx instrument to help measure and improve diagnostic safety. August 21, 2019

Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system. May 4, 2022

Rethinking resident supervision to improve safety: from hierarchical to interprofessional models. October 26, 2011

Patient generated research priorities to improve diagnostic safety: a systematic prioritization exercise. April 5, 2023

Lack of timely follow-up of abnormal imaging results and radiologists' recommendations. February 11, 2015

Resilient actions in the diagnostic process and system performance. July 17, 2013

Patient perceptions of receiving test results via online portals: a mixed-methods study. January 17, 2018

Development and validation of electronic health record–based triggers to detect delays in follow-up of abnormal lung imaging findings. May 27, 2015

Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care organizations. June 22, 2022

Defining diagnostic error: a scoping review to assess the impact of the National Academies' report Improving Diagnosis in Health Care. May 25, 2022

Impact of a national QI programme on reducing electronic health record notifications to clinicians. March 21, 2018

Electronic health record–related safety concerns: a cross-sectional survey. August 20, 2014

Managing interruptions to improve diagnostic decision-making: strategies and recommended research agenda. March 29, 2023

Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation. March 3, 2021

Workarounds and test results follow-up in electronic health record–based primary care. August 3, 2016

Physicians' diagnostic accuracy, confidence, and resource requests: a vignette study. September 11, 2013

Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data. October 8, 2014

Advancing diagnostic safety research: results of a systematic research priority setting exercise. February 24, 2021

Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments. August 25, 2021

Diagnostic errors related to acute abdominal pain in the emergency department. November 25, 2015

Characteristics and predictors of missed opportunities in lung cancer diagnosis: an electronic health record-based study. June 23, 2010

Health care provider factors associated with patient-reported adverse events and harm. May 20, 2020

Emergency physicians' views of direct notification of laboratory and radiology results to patients using the internet: a multisite survey. March 25, 2015

Learning from patients' experiences related to diagnostic errors is essential for progress in patient safety. November 7, 2018

Safety huddles to proactively identify and address electronic health record safety. January 25, 2017

Electronic trigger-based intervention to reduce delays in diagnostic evaluation for cancer: a cluster randomized controlled trial. September 9, 2015

Exploring situational awareness in diagnostic errors in primary care. September 21, 2011

Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes. April 13, 2022

Patient-initiated second opinions: systematic review of characteristics and impact on diagnosis, treatment, and satisfaction. July 15, 2015

Application of electronic trigger tools to identify targets for improving diagnostic safety. October 17, 2018

Errors in diagnosis of spinal epidural abscesses in the era of electronic health records. September 27, 2017

Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events. May 25, 2022

Electronic detection of delayed test result follow-up in patients with hypothyroidism. February 15, 2017

Computerized triggers of big data to detect delays in follow-up of chest imaging results. September 28, 2016

Electronic triggers to identify delays in follow-up of mammography: harnessing the power of big data in health care. November 29, 2017

Evaluating a mobile application for improving clinical laboratory test ordering and diagnosis. May 23, 2018

Finding diagnostic errors in children admitted to the PICU. February 8, 2017

A program to provide clinicians with feedback on their diagnostic performance in a learning health system. October 28, 2020

Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. August 21, 2013

Identifying diagnostic errors in primary care using an electronic screening algorithm. February 21, 2007

Accuracy of the Safer Dx Instrument to identify diagnostic errors in primary care. March 9, 2016

Cognitive interventions to reduce diagnostic error: a narrative review. May 16, 2012

Identifying psychiatric diagnostic errors with the Safer Dx Instrument. September 30, 2020

Challenges in communication from referring clinicians to pathologists in the electronic health record era. June 20, 2018

Communication outcomes of critical imaging results in a computerized notification system. May 16, 2007

An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study. November 26, 2014

Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? March 17, 2010

Characteristics of disease-specific and generic diagnostic pitfalls: a qualitative study. February 9, 2022

Inpatient notes: reducing diagnostic error—a new horizon of opportunities for hospital medicine. October 26, 2016

The challenges in defining and measuring diagnostic error. June 24, 2015

Payment innovations to improve diagnostic accuracy and reduce diagnostic error. November 7, 2018

A roadmap to advance patient safety in ambulatory care. January 20, 2021

Artificial intelligence in clinical diagnosis: opportunities, challenges, and hype. July 19, 2023

Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential? October 7, 2009

Reducing diagnostic error through medical home-based primary care reform. August 11, 2010

Eight recommendations for policies for communicating abnormal test results. May 5, 2010

Defining health information technology–related errors: new developments since To Err Is Human. August 3, 2011

Eight rights of safe electronic health record use. September 23, 2009

Assigning responsibility to close the loop on radiology test results. July 12, 2017

Improving diagnosis in health care—the next imperative for patient safety. November 18, 2015

Measuring and improving patient safety through health information technology: the Health IT Safety Framework. October 14, 2015

Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety. November 7, 2018

Electronic health records and National Patient-Safety Goals. November 21, 2012

General internists in pursuit of diagnostic excellence in primary care: a #ProudtobeGIM thread that unites us all. April 18, 2018

Toward more proactive approaches to safety in the electronic health record era. September 13, 2017

Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. January 28, 2015

A sociotechnical framework for safety-related electronic health record research reporting: the SAFER reporting framework. June 24, 2020

Policies to promote shared responsibility for safer electronic health records. September 29, 2021

Reducing the risk of diagnostic error in the COVID-19 era. May 27, 2020

Advancing the research agenda for diagnostic error reduction. August 28, 2013

Using fault trees to advance understanding of diagnostic errors. November 1, 2017

Five strategies for a safer EHR modernization journey. December 6, 2023

Diagnostic errors in the neonatal intensive care unit: state of the science and new directions. October 23, 2019

Identifying trigger concepts to screen emergency department visits for diagnostic errors. December 16, 2020

Electronic health record-based triggers to detect potential delays in cancer diagnosis. August 28, 2013

A decade of health information technology usability challenges and the path forward. February 13, 2019

Creating an oversight infrastructure for electronic health record–related patient safety hazards. November 30, 2011

Tracking progress in improving diagnosis: a framework for defining undesirable diagnostic events. February 14, 2018

Electronic health record alert–related workload as a predictor of burnout in primary care providers. August 30, 2017

Improving the safety of health information technology requires shared responsibility: it is time we all step up. August 2, 2017

Patient safety goals for the proposed Federal Health Information Technology Safety Center. November 19, 2014

Contingency planning for electronic health record–based care continuity: a survey of recommended practices. October 15, 2014

Inattentional blindness in medicine. April 17, 2024

Assessing diagnostic performance. February 14, 2024

The intersection of traumatic childbirth and obstetric racism: a qualitative study. February 7, 2024

Development of prescribing indicators related to opioid-related harm in patients with chronic pain in primary care- a modified e-Delphi study. January 17, 2024

Abusive supervision and its relationship with nursing workforce and patient safety outcomes: a systematic review. January 17, 2024

Diagnostic Quality Improvement Repository. January 10, 2024

Influence of comorbid depression and diagnostic workup on diagnosis of physical illness: a randomized experiment. December 20, 2023

Understanding And Addressing Pre-Hospital Diagnostic Delays. September 20, 2023

Pediatric Diagnostic Safety: State of the Science and Future Directions. September 13, 2023

Assessing the utility of ChatGPT throughout the entire clinical workflow: development and usability study. September 13, 2023

Diagnostic errors in uncommon conditions: a systematic review of case reports of diagnostic errors. September 13, 2023

Experimental evidence for structured information-sharing networks reducing medical errors. August 9, 2023

Racism in health services for adolescents: a scoping review. August 2, 2023

Racial and ethnic bias in the diagnosis of alcohol use disorder in veterans. July 19, 2023

Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis. July 12, 2023

‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care. July 5, 2023

Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review. June 28, 2023

Context matters: toward a multilevel perspective on context in clinical reasoning and error. June 21, 2023

Identifying electronic health record contributions to diagnostic error in ambulatory settings through legal claims analysis. May 3, 2023

Annual Perspective

Person-first treatment strategies: weight bias and impact on mental health of people living with obesity. April 19, 2023

Difficult diagnosis in the ICU: making the right call but beware uncertainty and bias. March 22, 2023

Prosocial voice in the hierarchy of healthcare professionals: the role of emotions after harmful patient safety incidents. March 22, 2023

Towards conceptualizing patients as partners in health systems: a systematic review and descriptive synthesis. March 8, 2023

The role of bias in clinical decision-making of people with serious mental illness and medical co-morbidities: a scoping review. February 22, 2023

The woman who cried pain: do sex-based disparities still exist in the experience and treatment of pain? February 8, 2023

The value of learning from near misses to improve patient safety: a scoping review. January 25, 2023

Structural racism and adverse maternal health outcomes: a systematic review. December 21, 2022

WebM&M Cases

Conceptual and practical challenges associated with understanding patient safety within community-based mental health services. December 7, 2022

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Anxiety Disorders

We all experience anxiety. For example, speaking in front of a group can make us anxious, but that anxiety also motivates us to prepare and practice. Driving in heavy traffic is another common source of anxiety, but it helps keep us alert and cautious to avoid accidents. However, when feelings of intense fear and distress become overwhelming and prevent us from doing everyday activities, an anxiety disorder may be the cause.

Anxiety disorders are the most common mental health concern in the United States. Over 40 million adults in the U.S. ( 19.1% ) have an anxiety disorder. Meanwhile, approximately  7%  of children aged 3-17 experience issues with anxiety each year. Most people develop symptoms before age 21.

Anxiety disorders are a group of related conditions, each having unique symptoms. However, all anxiety disorders have one thing in common: persistent, excessive fear or worry in situations that are not threatening. People typically experience one or more of the following symptoms:

Emotional symptoms:

• Feelings of apprehension or dread
• Feeling tense or jumpy
• Restlessness or irritability
• Anticipating the worst and being watchful for signs of danger

Physical symptoms:

• Pounding or racing heart and shortness of breath
• Sweating, tremors and twitches
• Headaches, fatigue and insomnia
• Upset stomach, frequent urination or diarrhea

Types Of Anxiety Disorders

There are many types of anxiety disorders, each with different symptoms. The most common types of anxiety disorders include:

Generalized Anxiety Disorder (GAD)

GAD produces chronic, exaggerated worrying about everyday life. This worrying can consume hours each day, making it hard to concentrate or finish daily tasks. A person with GAD may become exhausted by worry and experience headaches, tension or nausea.

Social Anxiety Disorder

More than shyness, this disorder causes intense fear about social interaction, often driven by irrational worries about humiliation (e.g. saying something stupid or not knowing what to say). Someone with social anxiety disorder may not take part in conversations, contribute to class discussions or offer their ideas, and may become isolated. Panic attacks are a common reaction to anticipated or forced social interaction.

Panic Disorder

This disorder is characterized by panic attacks and sudden feelings of terror sometimes striking repeatedly and without warning. Often mistaken for a heart attack, a panic attack causes powerful physical symptoms including chest pain, heart palpitations, dizziness, shortness of breath and stomach upset. Many people will go to desperate measures to avoid an attack, including social isolation.

We all tend to avoid certain things or situations that make us uncomfortable or even fearful. But for someone with a phobia, certain places, events or objects create powerful reactions of strong, irrational fear. Most people with specific phobias have several things that can trigger those reactions; to avoid panic, they will work hard to avoid their triggers. Depending on the type and number of triggers, attempts to control fear can take over a person’s life.

Other anxiety disorders include:

• Agoraphobia
• Selective mutism
• Separation anxiety disorder
• Substance/medication-induced anxiety disorder, involving intoxication or withdrawal or medication treatment

Scientists believe that many factors combine to cause anxiety disorders:

• Genetics.   Studies support the evidence that anxiety disorders “run in families,” as some families have a higher-than-average amount of anxiety disorders among relatives.
• Environment.  A stressful or traumatic event such as abuse, death of a loved one, violence or prolonged illness is often linked to the development of an anxiety disorder.

Physical symptoms of an anxiety disorder can be easily confused with other medical conditions, like heart disease or hyperthyroidism. Therefore, a doctor will likely perform an evaluation involving a physical examination, an interview and lab tests. After ruling out an underlying physical illness, a doctor may refer a person to a mental health professional for evaluation.

Using the Diagnostic and Statistical Manual of Mental Disorders (DSM) a mental health professional is able to identify the specific type of anxiety disorder causing symptoms as well as any other possible disorders that may be involved. Tackling all disorders through comprehensive treatment is the best recovery strategy.

Different anxiety disorders have their own distinct sets of symptoms. This means that each type of anxiety disorder also has its own treatment plan. But there are common types of treatment that are used.

• Psychotherapy , including cognitive behavioral therapy
• Medications , including antianxiety medications and antidepressants
• Complementary health approaches , including stress and relaxation techniques

Related Conditions

Anxiety disorders can occur along with other mental health conditions, and they can often make related conditions worse. So, talk with a mental health care professional if you are experiencing anxiety and any of the following:

• Substance Use
• Attention Deficit Hyperactivity Disorder ( ADHD )
• Eating Disorders
• Trouble Sleeping

Reviewed December 2017

Once it is clear there is no underlying physical condition present or medication side effect causing your anxiety, then exploring options for mental health treatment is essential.

The types of treatment proven to be most effective for many people experiencing an anxiety disorder involve a combination of psychotherapy and medication. Your preferences in a treatment plan are essential, however, so discuss the best approaches and options with your treatment team.

Co-occurring conditions, like depression, are common when a person has anxiety. Be sure to work with your treatment team to make sure these other conditions are not overlooked.

Psychotherapy

Cognitive Behavioral Therapy (CBT)  is the most researched  psychotherapy  for anxiety disorders. In general, CBT focuses on finding the counterproductive thinking patterns that contribute to anxiety. CBT offers many constructive strategies to reduce the beliefs and behaviors that lead to anxiety.

CBT is also effective when delivered outside of the traditional in-person setting. Working with a therapist using  telehealth technology  — like video or phone calls or online learning modules that teach CBT concepts —  can be just as effective  as traditional face-to-face therapy.

CBT has the largest research base to support its effectiveness, though it can be difficult to figure out which therapists are trained in CBT. There is no single national certification program for this skill. Ask your therapist how they approach treating anxiety and their trainings in these approaches.

Exposure Response Prevention  is a psychotherapy for specific anxiety disorders like phobias and social anxiety. Its aim is to help a person develop a more constructive response to a fear. The goal is for a person to “expose” themselves to that which they fear, in an attempt to experience less anxiety over time and develop effective coping tools.

Some people find that medication is helpful in managing an anxiety disorder. Talk with your health care provider about the potential benefits, risks and side effects.

• Anti-anxiety medications . Certain medications work solely to reduce the emotional and physical symptoms of anxiety. Benzodiazepines can be effective for short-term reduction of symptoms, but can create the risk of dependence when used for a long time. Be sure to review these potential risks if you select these medicines.  Click here  for more information on these medications.
• Antidepressants . Many antidepressants may also be useful for treating anxiety. These can also be useful if your anxiety has a co-occurring depression. Be sure to check our  Medication page  for more information.

Complementary Health Approaches

More and more people have started using  complementary and alternative treatments  along with conventional treatment to help with their recovery. Some of the most common approaches for treating anxiety include:

• Self-management strategies , such as allowing for specific periods of time for worrying. Someone who becomes an expert on their condition and its triggers gains more control over their day.
• Stress and Relaxation Techniques  often combine breathing exercises and focused attention to calm the mind and body. These techniques can be an important component in treating phobias or panic disorder.
• Yoga . The combination of physical postures, breathing exercises and meditation found in yoga have helped many people improve the management of their anxiety disorder.
• Exercise . Aerobic exercise can have a positive effect on your stress and anxiety. Check with your primary care doctor before beginning an exercise plan.
• Surviving the Bed Shortage in Mental Health Treatment Facilities: A Teenager’s Experience

If you, a family member or friend is experiencing symptoms of an anxiety disorder, there is help. NAMI is here to provide you with support and information about community resources for you and your family.

Find education programs and support groups  at your local NAMI . Contact the NAMI HelpLine at 1-800-950-NAMI (6264) or  [email protected]  if you have any questions about anxiety or want help finding support and resources.

Helping Yourself

Anxiety disorders can impact even the smallest details of life. It’s important to get help and learn how to remain resilient during difficult times. Here are some ways you can help yourself move forward:

• Become an expert.  Learn about medication and  treatment options . Keep up with current research. Build a personal library of useful websites and helpful books.
• Know your triggers and stressors.  If large groups make you nervous, go to a park and sit on an out-of-the-way bench. If taking a walk outdoors reduces your anxiety before a big meeting, schedule a 10-minute walk before the meeting starts. Being mindful of triggers and stressors will help you live your life with fewer limitations.
• Partner with your health care providers.  Actively participate in your treatment by working with mental health care professionals to develop a plan that works for you. Talk with them about your goals, decide on a recovery pace you’re comfortable with and stick to your plan. Don’t quit when something doesn’t go well. Instead, talk to your doctor or therapist about possible changes.
• Get healthy.  Studies have reported that 30 minutes of vigorous, aerobic exercise can eliminate symptoms, while low-key activities like meditation, yoga or Tai Chi relieve stress. Regular exercise can reduce many symptoms. Diet is also an important factor, so try to eat healthy, balanced meals and pay attention to food sensitivities. In some people, certain foods or additives can cause unpleasant physical reactions, which may lead to irritability or anxiety.
• Avoid drugs and alcohol.  These substances may  seem  to help with anxiety at first, but can disrupt emotional balance, sleep cycles and interact with medications. Coffee, energy drinks and cigarettes worsen anxiety.
• Find support.  Share your thoughts, fears and questions with others. NAMI offers  support groups and education programs , as well as online discussion communities.

Learn more about  managing your mental health and finding support  while living with mental illness.

Helping A Family Member Or Friend

Learn about your loved one’s triggers, stressors and symptoms. By being informed and aware, you may help prevent an increase in symptoms. Look for things like rapid breathing, fidgeting or avoidance behaviors. Discuss your friend or family member’s past experiences with them so they can recognize the signs early as well.

• Play a role in treatment.  Increasingly, mental health professionals are recommending couple or family-based treatment programs. And on occasion, a therapist might enlist a loved one to help reinforce behavior modification techniques with homework. Ultimately, the work involved in recovery is the responsibility of the person with the disorder, but you can play an active, supportive role.
• Communicate.  Speak honestly and kindly. Make specific offers of help and follow through. Tell the person you care about her. Ask how she feels and don’t judge her for her anxious thoughts.
• Allow time for recovery.  Understanding and patience  need to be balanced  with pushing for progress and your expectations.
• React calmly and rationally.  Even if your loved one is in a crisis, it’s important to remain calm. Listen to him and make him feel understood, then take the next step in getting help.

Find out more about  taking care of your family member or friend  (without forgetting about yourself!).

• Tips For Easing Back-to-School Anxiety
• Being Queer is Joyful

Know the warning signs of mental illness

Learn more about common mental health conditions

NAMI HelpLine is available M-F, 10 a.m. – 10 p.m. ET. Call 800-950-6264 , text “helpline” to 62640 , or chat online. In a crisis, call or text 988 (24/7).

• Open access
• Published: 23 April 2024

Prevalence of anxiety, depression, and post-traumatic stress disorder among Omani children and adolescents diagnosed with cancer: a prospective cross-sectional study

• Laila S. Al-Saadi 1 ,
• Moon Fai Chan 1 ,
• Amal Al Sabahi 2 ,
• Jalila Alkendi 2 ,
• Nawal Al-Mashaikhi 3 ,
• Hana Al Sumri 1 ,
• Amal Al-Fahdi 4 &
• Mohammed Al-Azri 1  

BMC Cancer volume  24 , Article number:  518 ( 2024 ) Cite this article

Metrics details

Children and adolescents diagnosed with cancer often experience psychological distress, encompassing anxiety, depression, and post-traumatic stress disorder (PTSD). This study aimed to evaluate the prevalence of these conditions among Omani children and adolescents diagnosed with cancer, alongside identifying contributing factors.

A prospective cross-sectional study was conducted from October 2021 to June 2023 among a cohort of Omani children and adolescents (6–18 years old) diagnosed with cancer at three primary cancer referral centres in Oman. Validated Arabic-language versions of the Screen for Child Anxiety Related Disorders, the Center for Epidemiologic Studies Depression Scale for Children, and the Impact of Event Scale-Revised instruments were used to assess symptoms of anxiety, depression, and PTSD, respectively. An initial assessment (T1) was undertaken within the first 3 months of diagnosis, followed by a second assessment (T2) 3–6 months later.

Of 113 eligible participants, 101 agreed to participate in the study (response rate: 95.6%), with 92 (91.0%) completing both assessments and included in the final analysis. Prevalence rates of anxiety, depression, and PTSD decreased from 43.5%, 56.5%, and 32.6%, respectively, at T1, to 38.0%, 35.9%, and 23.9% at T2. All average scores were below diagnostic cut-off points, except for the depression score at T1. Anxiety and depression scores decreased significantly ( p  = 0.043 and 0.001, respectively) between T1 and T2, as did the overall prevalence of depression ( p  = 0.004). At T1, linear regression analysis showed significant correlations between anxiety scores and the child’s age and PTSD score ( p  < 0.05); these variables were also correlated with depression scores ( p  ≤ 0.001). At T2, significant correlations were observed between anxiety scores and the child’s age and PTSD scores ( p  < 0.001). At both T1 and T2, anxiety, depression, and PTSD scores remained significantly correlated ( p  < 0.001).

Conclusions

Omani children and adolescents recently diagnosed with cancer exhibit a high prevalence of anxiety, depression, and PTSD over time. Age-appropriate communication, ongoing support, and mental health services are recommended to help this patient group cope with their diagnosis and manage their emotional wellbeing. There is a need for future research to determine the effectiveness of specific psychological interventions in reducing the frequency of these disorders.

Peer Review reports

Cancer in childhood and adolescence ranked as the sixth leading contributor to the total global cancer burden in 2019 [ 1 ]. An estimated 429,000 individuals under 19 years of age are diagnosed with cancer every year, with 141–185 cases per million reported worldwide [ 2 , 3 ]. Approximately 100,000 children and adolescents die annually from cancer, with the vast majority of deaths (90%) occurring in low- and middle-income countries (LMICs) [ 1 ]. Furthermore, those diagnosed with cancer in LMICs have a low five-year survival rate of 30%, in stark contrast to high-income countries where survival rates exceed 80% due to significant advances in cancer treatment [ 2 , 3 ].

In Arab countries, over 18,000 children below the age of 15 years are diagnosed with cancer every year, with annual incidence rates ranging from 7.5 to 12.8 cases per 100,000 children, although variations may be due to differences in registration accuracy [ 4 ]. In Oman, approximately 31% of the total population is under 19 years of age [ 5 ]. In 2019, a total of 2,307 patients were diagnosed with cancer, of which 2,089 patients (91.5%) were of Omani nationality and 124 (5.9%) comprised children aged 0 to 14 years [ 6 ]. However, the anticipated total number of annual cancer diagnoses is projected to rise to 8,549 by the year 2040 [ 7 ].

Anxiety, depression, and post-traumatic stress disorder (PTSD) are frequent in children and adolescents with cancer, with pooled prevalence rates of 13.92%, 20.43%, and 20.90%, respectively [ 8 ]. Recent research underscores a higher incidence of anxiety and depression in paediatric cancer patients and the heightened vulnerability of this demographic to post-traumatic stress symptoms, emphasising the need for a nuanced understanding of emotional challenges throughout the cancer diagnosis, treatment, recovery, and survivorship journey [ 9 , 10 , 11 , 12 ]. In itself, a diagnosis of cancer, along with accompanying physical symptoms and treatment side-effects, can lead to excessive tension, discomfort, and fear of death [ 8 , 13 ]. Symptoms of depression, including low mood, despair, guilt, and loss of interest in usual activities, may also challenge patients’ ability to function and adhere to treatment [ 14 ].

As Oman continues to make significant improvements in healthcare delivery and medical treatment, cancer survival rates among children and adolescents have improved. However, the emotional toll of a cancer diagnosis cannot be underestimated, and an understanding of these psychological repercussions is crucial as an essential indicator of patients’ well-being to ensure the provision of comprehensive oncologic care [ 8 ]. Indeed, it has been found that that the activity of making jewelry from beads was effective in reducing the state and trait anxiety levels of children with cancer [ 15 ]. Our study therefore aimed to identify the prevalence of anxiety, depression, and PTSD among Omani children and adolescents diagnosed with cancer and their associated factors, and to describe changes occurring over time.

Study design and setting

A cross-sectional study was conducted targeting all Omani children and adolescents aged six to 19 years diagnosed with any type of cancer between 1st October 2021 and 30th June 2023. The study was conducted at the National Oncology Centre (NOC) of the Royal Hospital, the Paediatric Haematology Unit of the Sultan Qaboos University Hospital (SQUH), and the Sultan Qaboos Comprehensive Cancer Care and Research Centre (SQCCCRC). These centres, located in Muscat, the capital city of Oman, serve as the primary referral cancer centres providing integrated care for cancer patients throughout Oman.

Recruitment of participants

Participants were recruited during their visits to either the outpatient clinics of the three referral centres or upon admission to the oncology/haematology wards. Children and adolescents who were non-Omani or had cognitive and behavioural disorders (as documented in their medical records) were excluded from the study.

Data collection

An Arabic version of the Screen for Child Anxiety Related Disorders (SCARED) tool was used to screen for anxiety symptoms over the past three months [ 16 , 17 ]. It consists of various questions or items related to anxiety symptoms, and individuals are typically asked to respond based on their experiences which is valuable for understanding the child’s mental health status over a recent period [ 16 ]. This child self-report instrument includes 41 items scored on a 3-point scale (from 0 to 2), yielding five factors matching classifications outlined in the Diagnostic and Statistical Manual of Mental Disorder, fifth edition (DSM-IV) [ 16 ]. Overall, a total SCARED score of ≥ 25 may indicate the presence of an anxiety disorder, while scores of > 30 are more specific to anxiety. According to a validation study, internal consistency (Cronbach’s α) for the translated tool is 0.91, ranging between 0.65 and 0.89 for individual subscales [ 16 ].

Depressive symptoms were assessed using an Arabic version of the Center for Epidemiologic Studies Depression Scale for Children (CES-DC) [ 18 , 19 ]. It consists of a series of questions that ask about various feelings and behaviours associated with depression, such as sadness, irritability, changes in appetite or sleep patterns, and feelings of worthlessness [ 19 ]. Respondents rate how often they have experienced each symptom over a specific period, typically within the past week [ 19 ]. This self-report scale consists of 20 items scored on a 4-point scale (from 0 to 3), for a total score ranging from 0 to 60, with higher scores more indicative of depression [ 18 ]. The cut-off CES-DC score is 15, with scores of 15–60 considered indicative of significant symptoms of depression. The Arabic version of the CES-DC has previously demonstrated high internal consistency (Cronbach’s α = 0.90) [ 18 ].

An Arabic version of the Impact of Event Scale-Revised (IES-R) was used to measure symptoms of post-traumatic stress [ 20 , 21 ]. The IES-R is a self-report scale designed to assess current subjective distress for any major life event in children, adolescents, and adults, assessing the core symptom cluster of avoidance, intrusion, and hyperarousal [ 20 , 21 ]. The tool has been also used to evaluate the extent of distress experienced by individuals who have been exposed to a traumatic event such as accidents, natural disasters, combat, or other life-threatening situations [ 21 ]. The scale helps clinicians and researchers understand the psychological impact of these events on individuals [ 20 ]. The tool consists of 22 items scored on a 5-point scale (from 0 to 4), of which 14 items correspond directly to symptom criteria outlined in the DSM-IV. Total scores range from 0 to 88, with a cut-off IES-R score of 33 and above indicative of a probable diagnosis of PTSD [ 20 , 21 ]. According to previous research, the Arabic version of the self-report IES-R scale has demonstrated acceptable internal consistency (Cronbach’s α = 0.94) [ 20 ].

Arabic versions of the SCARED, CES-DC, and IES-R instruments were administered twice to assess for symptoms of anxiety, depression, and PTSD, respectively. The first assessment (T1) was conducted at any time within the first 3 months of diagnosis, while the second assessment (T2) was conducted 3 to 6 months after T1. Research assistants administered the questionnaire to participants aged 6 to 12 years, while the instruments were self-administered by participants aged 12 years or older. In both cases, a research assistant remained available to clarify any questions that the participants might have had during completion. Additional sociodemographic and clinical information was recorded by the researchers based on data gathered from the participants’ medical records or elicited from the children’s parents or primary caregivers at T1. Cancer risk was estimated based on the participant’s age at diagnosis, disease stage, tumour histology, MYCN status (amplified versus nonamplified), and tumour cell ploidy status [ 22 ].

Statistical analysis

Statistical analysis was performed using SPSS Statistics Software for Windows, version 23 (IBM Corp., Armonk, NY). Descriptive statistics, including percentages, frequencies, means, and standard deviations, were used to delineate the participants’ sociodemographic and clinical characteristics, as well as their average anxiety, depression, and PTSD scores. Paired t-tests and McNemar’s tests were utilised to assess differences in average anxiety, depression, and PTSD scores between the two time points. Analysis of variance and independent sample t-tests were employed to assess variations between the dependent variable (average anxiety, depression, or PTSD scores) and independent variables (sociodemographic and clinical characteristics). Pearson’s Chi-squared test was applied to explore associations between psychological outcomes and sociodemographic and clinical characteristics. Linear regression models were used to investigate correlations between sociodemographic and clinical characteristics and average anxiety, depression, and PTSD scores. The researchers adhered to a significance level of 5% throughout the analysis.

Characteristics of the participants

Out of the 113 Omani children and adolescents diagnosed with cancer during the study period, 101 agreed to participate, yielding a response rate of 95.6%. However, only 92 participants (91.0%) completed both T1 and T2 assessments and were included in the final analysis. Of these, 83 (90.2%) received a new diagnosis of cancer, while nine (9.8%) had suffered relapses. The mean age was 11.4 ± 3.6 years, with a median of 11.0 years. Most participants ( n  = 62; 67.4%) were children (aged 6–12 years). Males ( n  = 52; 56.5%) outnumbered females ( n  = 40; 43.5%). Leukaemia was the most frequent diagnosis ( n  = 38; 41.3%), with most participants receiving chemotherapy as the sole form of treatment ( n  = 56; 60.9%). Most participants were assessed within the first month of diagnosis ( n  = 66; 71.7%), with their cancer diagnosis not being disclosed to them ( n  = 65; 70.7%) [see Table  1 ].

Prevalence of anxiety, depression, and PTSD

Overall, 40 (43.5%) and 35 (38.0%) participants exhibited anxiety symptoms at T1 and T2, respectively, while 52 (56.5%) and 33 (35.9%) reported depressive symptoms and 30 (32.6%) and 22 (23.9%) had probable diagnoses of PTSD. There was a significant reduction in the prevalence of depression between T1 and T2 ( p  = 0.004). Similarly, average scores decreased significantly for both anxiety (23.7 ± 10.6 vs. 21.7 ± 11.0; p  = 0.043) and depression (17.67 ± 10.7 vs. 13.6 ± 8.9; p  = 0.001) during this interval [see Table  2 ].

Factors associated with anxiety, depression, and PTSD

At T1, the univariate analysis revealed a statistically significant increase in average scores for anxiety ( p  = 0.005), depression ( p  < 0.001), and PTSD ( p  < 0.001) as the child’s age advanced. Adolescents (aged 13–18 years) demonstrated significantly increased anxiety ( p  = 0.041), depression ( p  = 0.012), and PTSD ( p  = 0.001) scores compared to children (aged 6–12 years). Participants identified as having a high risk of cancer exhibited significantly increased PTSD scores ( p  = 0.001), while those aware of their cancer diagnosis showed significant increases in both anxiety ( p  = 0.003) and PTSD ( p  = 0.004) scores. Increased anxiety scores correlated with significant increases in both depression ( p  < 0.001) and PTSD ( p  < 0.001) scores; similarly, increased depression scores were associated with higher anxiety ( p  < 0.001) and PTSD ( p  < 0.001) scores, while elevated PTSD scores were associated with significant increases in both anxiety ( p  < 0.001) and depression ( p  < 0.001) scores [see Table  3 ].

At T2, the univariate analysis similarly showed significant increases in anxiety ( p  = 0.001), depression ( p  < 0.001), and PTSD ( p  < 0.001) scores as age increased, with adolescents exhibiting greater ( p  = 0.006), depression ( p  = 0.001), and PTSD ( p  = 0.002) scores compared to children. Participants with a high risk of cancer had significantly higher anxiety ( p  = 0.007) and depression ( p  = 0.007) scores, while those aware of their diagnosis demonstrated significantly higher scores for anxiety ( p  = 0.007), depression ( p  = 0.003), and PTSD ( p  = 0.005). Increased anxiety scores correlated with increased depression ( p  < 0.001) and PTSD ( p  < 0.001) scores, while increased depression scores correlated with increased anxiety ( p  < 0.001) and PTSD ( p  < 0.001) scores. Finally, increased PTSD scores were associated with significant increases in both anxiety ( p  < 0.001) and depression ( p  < 0.001) scores [see Table  4 ].

A linear regression analysis was conducted to establish links between anxiety, depression, and PTSD scores and various sociodemographic, clinical, and psychological factors. At T1, significant correlations were observed between anxiety scores and age (β = 0.762; p  < 0.001), age group (adolescents vs. children; β = -0.217; p  = 0.001), and PTSD scores (β = 0.209; p  = 0.025), with an adjusted R 2 value of 0.861. Depression scores demonstrated significant correlations with age (β = 0.460; p  = 0.001) and PTSD scores (β = 0.488; p  < 0.001), with an adjusted R 2 value of 0.849. Finally, PTSD scores were significantly correlated with cancer risk (β = 0.147; p  = 0.025), anxiety scores (β = 0.287; p  = 0.016), and depression scores (β = 0.604; p  < 0.001), with an adjusted R 2 value of 0.827 [see Table  5 ].

At T2, anxiety scores were found to be significantly correlated with age (β = 0.553; p  < 0.001), age group (adolescents vs. children; β = -0.134; p  = 0.014), and PTSD scores (β = 0.400; p  < 0.001), with an adjusted R 2 value of 0.896. Depression scores were significantly correlated with age (β = 0.297; p  = 0.018) and PTSD scores (β = 0.431; p  < 0.001), with an adjusted R 2 value of 0.837. Finally, PTSD scores showed significant correlations with both anxiety (β = 0.622; p  < 0.001) and depression (β = 0.426; p  < 0.001) scores, with an adjusted R 2 value of 0.839 [see Table  5 ].

To our knowledge, this is the first study conducted in Oman to identify the prevalence of anxiety, depression, and PTSD among Omani children and adolescents diagnosed with cancer, associated factors, and to describe changes occurring over time. Our findings revealed that a high number of children and adolescents with cancer in Oman exhibit symptoms of anxiety (43.5%), depression (56.5%), and PTSD (32.6%) within the first three months of diagnosis. Prevalence rates of these psychological disorders, especially anxiety and depression, were notably higher compared to the pooled rates reported in a recent systematic review and meta-analysis of previous literature (13.92%, 20.43%, and 20.90%, respectively) [ 8 ]. However, these differences might be attributed to variations in the measurement and screening tools used across different studies.

Alternatively, another explanation for the high prevalence rates of anxiety, depression, and PTSD symptoms observed in our study could be linked to the lack of specialized or psychosocial supportive care for cancer patients in Oman, particularly at the time of diagnosis [ 23 ]. This is likely exacerbated by the fact that, in certain Arab cultures, including in Oman, there remains considerable stigma surrounding mental health issues, posing a challenge for individuals to actively seek or obtain psychological support [ 24 , 25 ]. Moreover, limitations in healthcare resources, such as a shortage of mental health professionals, may further hinder access to psychological support services for cancer patients [ 24 ]. Finally, a lack of widespread awareness regarding the significance of psychological support for cancer patients, particularly children and adolescents, could contribute to a shortage of available programs and services [ 26 ].

We also found that symptoms of anxiety, depression, and PTSD among children and adolescents diagnosed with cancer decreased over time; these findings are supported by other longitudinal studies [ 27 , 28 , 29 ]. Other research has shown that a healthy family environment is a strong protective factor against the development of these disorders, as well as improving the quality of life of children and adolescents diagnosed with cancer [ 30 , 31 ]. In Oman, support extended by family members and friends to cancer patients has been observed to significantly reduce mental distress and alleviate the adverse side-effects associated with cancer treatment [ 23 ]. Moreover, cancer patients in Oman have been shown to develop various coping mechanisms and adaptive strategies to deal with the emotional impacts of a cancer diagnosis, including denial, optimism, withdrawal, and a strong reliance on Islamic beliefs and practices [ 32 ]. These factors likely play a role in decreasing psychological distress over time.

The results of our study indicated that the child’s age had a significant impact on their anxiety, depression, and PTSD scores, with adolescents exhibiting a higher likelihood of experiencing these conditions compared to children. Other studies have also highlighted a notable increase in major depressive episodes during the transition to adolescence [ 33 , 34 ]. This finding aligns with the understanding that adolescence is marked by hormonal changes and an enhanced ability to comprehend emotions [ 35 ]. Moreover, adolescents with cancer may face substantial disruptions to their education, potentially missing school due to the demands of treatment and recovery [ 36 ]. Repercussions may extend beyond academic skills, encompassing a range of missed opportunities, such as participation in sports, group activities, excursions, and award ceremonies, as well as the absence of daily structure and routine provided in the scholastic environment [ 37 ]. Prolonged absences from school and limited peer interaction can contribute to the development of emotional, behavioural, and psychological challenges [ 37 , 38 ].

We also found that children and adolescents who were informed of their diagnosis exhibited significantly higher anxiety, depression, and PTSD scores compared to those who remained unaware of their condition. The relationship between disclosure of a cancer diagnosis and mental health outcomes is complex, and individual reactions can vary widely. Some children and adolescents may benefit from being informed, as this allows them to be more actively involved in their own care and treatment decision-making, while others may find comfort in not knowing the full extent of their illness [ 39 ]. Fundamentally, awareness of a cancer diagnosis results in a deeper cognitive understanding of illness severity, the side-effects of treatment, social stigma, and health uncertainties, all of which can increase anxiety and stress [ 40 ]. However, in Omani culture, it is routine for some parents and family members to try to protect their loved ones or keep their hopes up by choosing to withhold knowledge of their diagnosis [ 23 ].

Our findings showed that high-risk patients had significantly higher PTSD scores during the first three months of diagnosis. Patients with more aggressive types of cancer often require more intensive and invasive treatment regimens, such as surgery and radiation, resulting in long periods of hospitalization, all of which may contribute to increased stress, anxiety, and trauma [ 41 ]. Furthermore, the aggressive nature of the cancer and its associated treatment can create a sense of uncertainty about the future, including treatment outcomes and the potential for relapse [ 42 ]. Indeed, the physical and emotional toll of aggressive cancer can be overwhelming as a result of the side-effects of treatment, including changes in physical appearance and disruptions to daily life, factors which can contribute to symptoms of depression [ 43 ].

The results of our study should be considered in the light of certain limitations. Firstly, the study involved a prospective, cross-sectional design in which Omani children and adolescents were screened for symptoms of anxiety, depression and PTSD at two separate time intervals following diagnosis. The length of time between these intervals might not have been adequate to track dynamic changes in anxiety and PTSD over time, thereby limiting our understanding of the long-term psychological effects of cancer diagnoses. An extended study period with more frequent assessments could have potentially enabled a more in-depth exploration of the psychological challenges faced by children and adolescents at different points in their cancer experiences.

Secondly, the information regarding anxiety, depression, and PTSD symptoms was self-assessed by the participants; such self-reporting is susceptible to various biases, including memory recall influenced by the passage of time, emotional states, and individual differences in cognitive processing. Thus, the participants may have unintentionally provided inaccurate or incomplete information regarding their psychological experiences, leading to potential discrepancies between reported and actual symptoms. Finally, we cannot rule out the effect of the confounding variables such as socioeconomic status that are associated with both the independent variable (the factor of interest) and the dependent variable (mental health outcome).

To our knowledge, this is the first study conducted in Oman to identify the prevalence of anxiety, depression, and PTSD symptoms, along with their associated factors, among Omani children and adolescents diagnosed with cancer. The findings indicated that children and adolescents in Oman exhibited high levels of anxiety, depression, and PTSD within the first three months of a cancer diagnosis. Implementing routine screening protocols for psychological symptoms among children and adolescents diagnosed with cancer, particularly within the first three months of diagnosis, is imperative. The early identification of mental health challenges can facilitate timely intervention and support, particularly for adolescents, as they are more likely to suffer from psychological and emotional distress.

Furthermore, integrating mental health services into standard care protocols for paediatric and adolescent cancer patients in Oman could significantly enhance outcomes and support the delivery of holistic care. An urgent need exists for the provision of additional resources and specialised training for healthcare professionals in Oman, enabling them to recognize and address the psychological needs of children and adolescents with cancer. To advance the field, future research should consider employing longitudinal interventional designs, extending assessment durations, and incorporating a more comprehensive set of psychological variables. This approach will bolster the robustness and applicability of findings concerning mental health in the context of cancer. Additionally, longitudinal designs will enable the observation of changes in self-reported symptoms over time, offering a more nuanced understanding of the evolving psychological state of individuals navigating cancer.

Data availability

The datasets supporting the conclusions of this article are available from the corresponding author upon reasonable request.

Abbreviations

Center for Epidemiologic Studies Depression Scale for Children

Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition

Impact of Event Scale-Revised

Low and Middle-Income Countries

V-Myc Avian Myelocytomatosis Viral Oncogene Neuroblastoma-Derived Homolog

National Oncology Centre

Post-Traumatic Stress Disorder

Screen for Child Anxiety Related Disorders

Statistical Package for the Social Sciences

Sultan Qaboos Comprehensive Cancer Care and Research Centre

Sultan Qaboos University Hospital

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Acknowledgements

The authors would like to thank the parents and guardians of the participants for allowing their children to take part in the study. The authors also extend their gratitude to the respective authorities of the NOC, SQUH, and SQCCCRC for permitting this study to be conducted.

The authors received no financial support for the research, authorship, and/or publication of this article.

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LA, MFC, AA, JA, NA, AF, and MA contributed to the study conception and design. Data collection was performed by LAS. Data analysis was performed by LA, MFC, and HA. The first draft of the manuscript was written by LAS and MA. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Al-Saadi, L.S., Chan, M.F., Al Sabahi, A. et al. Prevalence of anxiety, depression, and post-traumatic stress disorder among Omani children and adolescents diagnosed with cancer: a prospective cross-sectional study. BMC Cancer 24 , 518 (2024). https://doi.org/10.1186/s12885-024-12272-z

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Module 13: Disorders of Childhood and Adolescence

Case studies: disorders of childhood and adolescence, learning objectives.

• Identify disorders of childhood and adolescence in case studies

Case Study: Jake

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts. [1]

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.

Case Study: Kelli

Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.

• Kolaitis, G., Bouwkamp, C.G., Papakonstantinou, A. et al. A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability, and 47,XXY syndrome in combination with a 7q11.23 duplication, 11p15.5 deletion, and 20q13.33 deletion. Child Adolesc Psychiatry Ment Health 10, 33 (2016). https://doi.org/10.1186/s13034-016-0121-8 ↵
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• A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability.... Authored by : Gerasimos Kolaitis, Christian G. Bouwkamp, Alexia Papakonstantinou, Ioanna Otheiti, Maria Belivanaki, Styliani Haritaki, Terpsihori Korpa, Zinovia Albani, Elena Terzioglou, Polyxeni Apostola, Aggeliki Skamnaki, Athena Xaidara, Konstantina Kosma, Sophia Kitsiou-Tzeli, Maria Tzetis . Provided by : Child and Adolescent Psychiatry and Mental Health. Located at : https://capmh.biomedcentral.com/articles/10.1186/s13034-016-0121-8 . License : CC BY: Attribution
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Obstructive sleep apnea and mental disorders: a bidirectional mendelian randomization study

• Heming Liu 1 ,
• Xuemei Wang 1 ,
• Hu Feng 1 ,
• Shengze Zhou 1 ,
• Jinhua Pan 1 ,
• Changping Ouyang 1 &
• Xiaobin Hu 1  

BMC Psychiatry volume  24 , Article number:  304 ( 2024 ) Cite this article

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Previous studies have reported associations between obstructive sleep apnea (OSA) and several mental disorders. However, further research is required to determine whether these associations are causal. Therefore, we evaluated the bidirectional causality between the genetic liability for OSA and nine mental disorders by using Mendelian randomization (MR).

We performed two-sample bidirectional MR of genetic variants for OSA and nine mental disorders. Summary statistics on OSA and the nine mental disorders were extracted from the FinnGen study and the Psychiatric Genomics Consortium. The primary analytical approach for estimating causal effects was the inverse-variance weighted (IVW), with the weighted median and MR Egger as complementary methods. The MR Egger intercept test, Cochran’s Q test, Rucker’s Q test, and the MR pleiotropy residual sum and outlier (MR-PRESSO) test were used for sensitivity analyses.

MR analyses showed that genetic liability for major depressive disorder (MDD) was associated with an increased risk of OSA (odds ratio [OR] per unit increase in the risk of MDD, 1.29; 95% CI, 1.11–1.49; P  < 0.001). In addition, genetic liability for OSA may be associated with an increased risk of attention-deficit/hyperactivity disorder (ADHD) (OR = 1.26; 95% CI, 1.02–1.56; p  = 0.032). There was no evidence that OSA is associated with other mental disorders.

Our study indicated that genetic liability for MDD is associated with an increased risk of OSA without a bidirectional relationship. Additionally, there was suggestive evidence that genetic liability for OSA may have a causal effect on ADHD. These findings have implications for prevention and intervention strategies targeting OSA and ADHD. Further research is needed to investigate the biological mechanisms underlying our findings and the relationship between OSA and other mental disorders.

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Mental disorders are a significant global health concern and rank among the top 10 causes of burden worldwide. According to estimates, the number of mental disorder cases increased by 48.1% in 2019 compared to 1990, and the proportion of global disability-adjusted life years (DALYs) attributable to mental disorders increased from 2.3–9.4% [ 1 ]. However, the etiology of mental disorders remains unclear, and there is evidence to suggest that Obstructive sleep apnea (OSA) may be associated with a variety of mental disorders [ 2 ]. OSA is a condition caused by repeated episodes of upper airway collapse and obstruction during sleep associated with arousal from sleep with or without oxygen desaturation [ 3 ]. In the general population, the prevalence of OSA is approximately 3–7% in males and 2–5% in females [ 4 ]. Both mental disorders and OSA can significantly impact patients’ quality of life. It is crucial to establish a clear causal relationship between these conditions to inform effective prevention and treatment strategies.

In recent years, an increasing number of researches have been devoted to exploring the relationship between OSA and various mental disorders. Two cohort studies suggested that bipolar disorder (BD) and schizophrenia (SCZ) were associated with increased risks of OSA [ 5 , 6 ]. A Japanese study has also found that preschoolers with autism spectrum disorder (ASD) are more likely to have obstructive sleep apnea than the general population [ 7 ]. Moreover, there is evidence of a potential bidirectional relationship between OSA and attention deficit hyperactivity disorder (ADHD), anxiety disorder (ANX), major depressive disorder (MDD), and Post-Traumatic Stress Disorder (PTSD) [ 8 , 9 , 10 , 11 ]. However, the ability of these studies to establish causality is insufficient, and even prospective observational studies may be subject to inherent confounding or selection bias. Currently, there are limited studies on this topic, and it remains unclear whether OSA is the cause or a downstream effect of mental disorders. Therefore, any potential causal relationship still requires further research.

In this case, the genetic epidemiological method of Mendelian randomization (MR) is a powerful tool to evaluate the causal relationship between OSA and mental disorders. MR uses single nucleotide polymorphisms (SNPs) as instrumental variables to estimate their effect on the outcome of interest, minimizing bias affecting observational epidemiological studies [ 12 , 13 , 14 ] and thus enhancing causal inference of exposure and outcome. Due to the random allocation of genetic variation during meiosis and the natural causal effect of genetic variation on phenotype, SNPs are independent of potential confounders, and therefore confounders and reverse causality bias can be minimized [ 15 ]. Two-sample MR refers to MR analysis using two independent samples from different studies or databases, which are typically collected from publicly available large-scale genome-wide association studies (GWAS), and has the advantage of increased statistical power [ 16 ]. Therefore, we conducted a two-sample bidirectional MR analysis using the latest GWAS to investigate the potential association between OSA and mental disorders.

Study design

A two-sample bidirectional MR was used to evaluate the potential causal association between obstructive sleep apnoea and nine mental disorders (Fig.  1 ). The MR design is based on three fundamental assumptions three basic assumptions: (1) genetic variants must be highly correlated with exposure; (2) genetic variants cannot be associated with any potential confounders; (3) genetic variants influence outcome solely through the exposure [ 15 ]. This study used summary-level data from publicly available GWAS. Ethical approval was obtained for all original studies.

Workflow of a two-sample bidirectional MR study on obstructive sleep apnea and mental disorders.

Data source

Obstructive sleep apnea

Summary statistics for OSA were obtained from the FinnGen database with 375,657 individuals of European ancestry. FinnGen is a large public-private partnership aimed at collecting and analyzing genomic and health data from 500,000 Finnish biobank participants [ 17 ]. The GWAS included 38,998 OSA cases and 336,659 controls. Diagnostic criteria for OSA cases were based on ICD codes (ICD-10: G47.3; ICD-9: 3472), derived from the Finnish National Hospital Discharge Registry and the Causes of Death Registry. More details on the OSA GWAS can be found at https://r9.risteys.finngen.fi/endpoints/G6_SLEEPAPNO/ and https://finngen.gitbook.io/documentation/methods/phewas/ .

• Mental disorders

We used summary statistics for 9 mental disorders from different studies [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 ], which were obtained from the Psychiatric Genomics Consortium (PGC). The mental disorders included in this study are ADHD, AN, ANX, autism spectrum disorder (ASD), BD, MDD, obsessive-compulsive disorder (OCD), PTSD, and SCZ. For consistency with the OSA data, genetic data of European ancestry were used for all nine mental disorders to avoid heterogeneity. Sample sizes for each GWAS study are listed below: ADHD(38,691 cases and 186,843 controls), AN(16,992 cases and 55,525 controls), ANX(7,016 cases and 14,745 controls), ASD(18,381 cases and 27,969 controls), BD(41,917 cases and 371,549 controls), MDD(246,363 cases and 561,190 controls), OCD(2,688 cases and 7,037 controls), PTSD(23,212 cases and 151,447 controls), SCZ(53,386 cases and 77,258 controls). A detailed description of the data sources can be found in Additional file 1 .

Selection of instrument variables

The number of instrumental variables (IVs) determines statistical power and the presence of confounding factors, so the appropriate number of IVs is needed. We used four different p -value thresholds, p  < 5 × 10 − 6 (ANX, ASD, OCD, PTSD), p  < 5 × 10 − 7 (AN), p  < 5 × 10 − 8 (ADHD, BD, MDD, OSA), and p  < 5 × 10 − 12 (SCZ), and without linkage disequilibrium (10,000 kilobase pairs apart and r 2  < 0.001) to select SNPs as instrumental variables. The linkage disequilibrium (LD) reference was obtained from http://fileserve.mrcieu.ac.uk/ld/1kg.v3.tgz . After clumped SNPs for independence, PhenoScanner [ 27 , 28 ] was used to assess previous associations with potential confounding traits. PhenoScanner is a curated database holding publicly available results from large-scale genome-wide association studies. To meet the assumptions of the MR design, we excluded SNPs that were strongly associated with other traits or diseases ( p  < 5 × 10 − 8 ) to rule out possible pleiotropic effects. To evaluate the weak instrument bias, we calculated the instrument strength (F-statistic) for each IV according to the following formula: \( F= \frac{{beta}^{2}}{{se}^{2}}\) (beta: the effect size of SNP on exposure; se: its corresponding standard error) [ 29 ]. We removed SNPs associated with exposure if they could not be matched to SNPs in the outcome. Details of the SNPs that were selected as IVs are shown in Additional files 2 and 3 .

Statistical analysis

In MR analysis, the inverse-variance weighted (IVW) model is the main method for assessing the bidirectional relationship between exposure and outcome. However, if there is horizontal pleiotropy and invalid instrument bias, IVW cannot provide unbiased estimates of causal effects [ 30 , 31 ]. Therefore, we use two different MR methods that are relatively robust to horizontal pleiotropy, although at the cost of reduced statistical power [ 32 ]. First, causal effects are estimated using the weighted median method, in which only 50% of the SNPs need to be valid instruments [ 33 ]. Second, MR Egger estimates causal effects by setting an intercept that allows horizontal pleiotropy to be unbalanced or directed [ 31 , 34 ]. In addition, we used several sensitivity analyses including the MR Egger intercept test, Cochran’s Q test, Rucker’s Q test and the MR pleiotropy residual sum and outlier (MR-PRESSO) test to determine the validity and robustness of the results. The MR Egger regression provides a test for directional pleiotropy through its intercept [ 35 ]. The Cochran’s Q test and Rucker’s Q test were performed to assess the heterogeneity, and if heterogeneity was present, outlier SNPs were excluded by observing the funnel plot or sorting RSSobs in MR-PRESSO and the MR analysis was repeated [ 36 ]. MR-PRESSO was used to detect pleiotropic bias, identify outliers, and obtain the corrected results by removing outliers [ 37 ].

Associations between genetic liability for OSA and risk of mental disorders were expressed as odds ratios (ORs) and their 95% confidence intervals (CIs). We indexed the strength of evidence against the no association by the exact p -value. A p -value less than 0.0056 (0.05/9) was considered to be statistically significant evidence for a causal association. A p -value below 0.05, but above the Bonferroni-corrected threshold, was considered suggestive evidence for a potential causal association. We used an online tool called mRnd ( https://shiny.cnsgenomics.com/mRnd/ ) to calculate the statistical power of the MR analysis [ 38 ]. All statistical analyses were performed using R (version 4.3.1) with the packages “TwoSampleMr”, “MR-PRESSO” and “ieugwasr”.

Genetically predicted obstructive sleep apnea on mental disorders

The associations of OSA with 9 mental disorders are demonstrated in Fig.  2 . We observed only a weak association between genetic liability for OSA and increased risk of ADHD (IVW, OR = 1.26; 95% CI, 1.02–1.56; p  = 0.032), and there was no evidence that other mental disorders were associated with OSA. The results of the estimation using the weighted median and MR Egger methods, as well as information on statistical power, Q P -value and P intercept -value, are presented in Additional file 4 . The F-statistic of each IV we selected for OSA was greater than 10, indicating a low probability of weak instrument bias [ 39 ]. The MR-Egger intercept analysis did not indicate horizontal pleiotropy. The Rucker’s Q test revealed possible heterogeneity of individual SNPs between the effect estimates of OSA and SCZ (Rucker’s Q = 13.964, Q p -value = 0.030). Therefore, we excluded one outlier SNP (rs59333125) and performed a second MR analysis, which showed no heterogeneity (Rucker’s Q = 6.670, Q p -value = 0.246). For the SNPs we used, MR-PRESSO did not detect any potential outliers.

Associations between genetic liability for obstructive sleep apnea and risk of psychiatric disorders. For outcome phenotype SCZ, the result is shown after removing outliers due to heterogeneity.

Genetically predicted mental disorders on obstructive sleep apnea

The associations of 9 mental disorders with OSA are demonstrated in Fig.  3 . The genetic liability for MDD had an effect estimate consistent with an increased risk of OSA. However, Cochran’s Q test indicated the presence of heterogeneity (Cochran’s Q = 43.195, Q p -value = 0.009), we excluded two outlier SNPs (rs4141983, rs9529218) and performed a second MR analysis (IVW, OR = 1.37; 95%CI, 1.20–1.57; p  < 0.001), which did not show heterogeneity (Cochran’s Q = 29.474, Q p -value = 0.132). The results of the estimation using the weighted median and MR Egger methods, as well as information on statistical power, Q P -value and P intercept -value, are presented in Additional file 5 . The scatterplot, leave-one-out-sensitivity forest plot, and funnel plot of MR estimation results for MDD associated with OSA are provided in Additional file 6 . F-statistic greater than 10 for each IV for the 9 mental disorders, indicating a small magnitude of weak instrument bias. MR-Egger intercept analysis did not identify any pleiotropic SNPs. And Cochran’s Q test suggested potential heterogeneity in ADHD (Cochran’s Q = 28.816, Q p -value = 0.001, BD (Cochran’s Q = 38.784, Q p -value = 0.039), PTSD (Cochran’s Q = 22.605, Q p -value = 0.047) and SCZ (Cochran’s Q = 38.169, Q p -value = 0.012), so we excluded outlier SNPs for ADHD (rs7844069, rs2025286), BD (rs10994415), PTSD (rs1268149), and SCZ (rs145071536, rs16851048) and performed a second MR analysis, which showed no heterogeneity (Additional file 5 ). One outlier SNP in ASD (rs28729902) was excluded using the MR-PRESSO test. After correction for possible outliers, the causal effect estimates for ADHD, ASD, BD, PTSD and SCZ were still not statistically significant.

Associations between genetic liability for mental disorders and risk of obstructive sleep apnea. For exposure phenotype ASD, the result is shown after removing outliers with the MR-PRESSO test. For exposure phenotype ADHD, BD, MDD, PTSD and SCZ, the figure shows the results of the second MR analysis with outlier SNPs removed due to heterogeneity.

In our study, we performed a bidirectional MR analysis based on several large genetic populations to assess the association between genetic liability for OSA and the risk of mental disorders. Our results found possible genetic evidence that OSA was associated with an increased risk of ADHD. In the opposite direction, genetic liability for MDD was associated with an increased risk of OSA.

Our study provides suggestive evidence of a possible association between OSA and ADHD based on larger populations. Although few observational studies have conclusively confirmed the potential causal relationship between OSA and ADHD, there are still evidences that support our findings. A meta-analysis showed that children with Sleep-disordered breathing (SDB) are at increased risk of presenting with ADHD symptoms such as inattention and hyperactivity [ 40 ]. OSA is usually accompanied by decreased oxygen saturation and sleep disruption. These symptoms may affect brain development, which in turn affects cognitive function and leads to poor concentration [ 41 , 42 ]. From a pathophysiological perspective, inflammatory cytokines (C-reactive protein and interleukin-6) are elevated in children with SDB, which may lead to cognitive dysfunction [ 43 , 44 , 45 ]. In addition, several studies have shown that adenotonsillectomy (a treatment for OSA) can improve ADHD symptoms and cognitive problems [ 8 , 40 , 46 , 47 , 48 ]. However, the relationship between OSA and ADHD may be reciprocal rather than in the traditional one-way relationship, although a reverse relationship was not observed in our study. Symptoms of ADHD overlap with a diagnosis of OSA, and attentional deficits have been reported in up to 95% of OSA patients [ 49 ]. A case-control study found that 28 out of 30 ADHD patients had comorbid sleep disorders, 15 of whom had OSA [ 50 ]. In summary, the relationship between OSA and ADHD is complex and needs to be further explored in future studies.

Our study found that MDD was associated with an increased risk of OSA incidence, which is consistent with a recent MR study [ 51 ]. However, observational studies similar to ours are limited. Only one population-based longitudinal study suggested that a bidirectional link between MDD and OSA exists. This study, which included 27,073 depressed patients and 135,365 controls, demonstrated that having depression was associated with an increased risk of future OSA (HR = 2.30; 95%CI, 2.11–2.50) [ 10 ]. More observational studies consider OSA as a risk factor for MDD [ 52 , 53 , 54 , 55 ], so the relationship between MDD and OSA seems to be reciprocal as well. Two systematic reviews showed that both the prevalence of MDD among patients with OSA and the prevalence of OSA among patients with MDD were higher than in the general population [ 56 , 57 ]. This may be due to a partial overlap of symptoms and diagnostic criteria or common underlying mechanisms between MDD and OSA [ 58 , 59 , 60 ]. However, the following pathophysiological mechanisms support our derived unidirectional association between MDD and OSA. First, increased inflammatory cytokines in depressed patients may lead to neurological damage and altered circadian rhythms, which may increase the risk of OSA and exacerbate the symptoms of OSA [ 61 , 62 ]. Second, patients with depressive disorders are usually associated with central nervous system 5-HT dysfunction, with decreased plasma tryptophan (a 5-HT precursor), decreased 5-HT metabolites in cerebrospinal fluid, and decreased 5-HT 1 receptor binding [ 63 ]. The 5-HT reduction affects dilator muscles of the upper airway, narrowing the size of the upper airway, which may contribute to the incidence of OSA [ 64 ]. Third, some sleep medications and benzodiazepines are used to treat depression, and their tranquillizing effects may decrease the muscle tone of upper airway dilator muscles, thereby increasing the risk of OSA [ 65 , 66 , 67 ]. In conclusion, the relationship between MDD and OSA has not been clarified, and further research into pathogenesis is needed to provide effective and feasible treatments.

The main strength of this study is the use of two-sample bidirectional MR to assess the relationship between OSA and mental disorders, minimizing confounders and reverse causality present in observational studies. Moreover, we limited the population of the GWAS study to Europeans to minimize heterogeneity arising from ethnic differences. In addition, the IVs we used were extracted from the most recent GWAS with a large sample size, and the likelihood of weak instrument bias was minimal and only related to the exposures we were focused on.

However, there are several limitations to this study. First, both OSA and the nine mental disorders are binary exposures, and we could not know whether there would be selective bias due to underdiagnosis [ 29 ], as well as exclusive restriction bias due to the possibility that genetic variants would influence outcomes via continuous risk factors [ 68 ]. In addition, due to the lack of individual-level data from the GWAS study, we were unable to know whether the severity of the disease and medication would cause potential bias. Second, we used different thresholds for screening IVs, but this may have led to inconsistencies in the reliability of the results. Fewer IVs, while greatly reducing the potential for pleiotropy, reduced statistical power. Third, the biological roles and mechanisms of SNPs are not currently fully understood [ 69 ], and the presence of horizontal pleiotropy cannot be completely ruled out, although we performed sensitivity analyses using various methods to rule out horizontal pleiotropy. Fourth, MR estimates reflect the cumulative effects of exposure over individuals’ lifetimes, which are likely to be stronger than in observational studies and clinical trials. However, it is difficult to determine the relationship between OSA and mental disorders using randomized clinical trials due to the limitations of ethical rules and the uncertainty of etiology, and more observational studies are needed in the future to validate our findings. Finally, limiting the ancestry of the population to Europeans reduced the bias due to population stratification, but also limited the extrapolation of the results to other races.

Our study provided genetic evidence that MDD is associated with an increased risk of OSA without a bidirectional relationship. In addition, we also found genetic evidence that OSA is a potential causal risk factor for ADHD. We did not find a causal relationship between OSA and AN, ANX, ASD, BD, OCD, PTSD, and SCZ. Clinically, these findings contribute to the identification, treatment, and prevention of OSA and ADHD in patients. Further investigation is required to better understand the biological mechanisms underlying the relationship between OSA and other mental disorders. This will aid clinicians in providing more effective treatment for these conditions.

Data availability

All data used in this study are obtained from open access databases or published manuscripts. FinnGen: https://r9.risteys.finngen.fi/endpoints/G6_SLEEPAPNO . https://storage.googleapis.com/finngen-public-data-r9/summary_stats/finngen_R9_G6_SLEEPAPNO.gz . PGC: https://pgc.unc.edu/for-researchers/download-results .

Abbreviations

Attention-deficit/hyperactivity disorder

Anorexia nervosa

Anxiety disorder

Autism spectrum disorder

Bipolar disorder

Confidence interval

Genome-wide association studies

Instrumental variables

Inverse variance weighted

Linkage disequilibrium

Major depressive disorder

Mendelian randomization

Mendelian randomization pleiotropy residual sum and outlier test

Obsessive-compulsive disorder

Psychiatric Genomics Consortium

Post-traumatic stress disorder

Schizophrenia

Sleep-disordered breathing

Single nucleotide polymorphism

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We sincerely appreciate FinnGen and the PGC for providing publicly available GWAS data. We would also like to thank other faculty members in the Department of Epidemiology and Health Statistics for their help.

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Heming Liu, Xuemei Wang, Hu Feng, Shengze Zhou, Jinhua Pan, Changping Ouyang & Xiaobin Hu

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HM L wrote the main manuscript as well as analysed the data. XM W and H F used PhenoScanner to exclude instrumental variables associated with other traits or diseases. CP OY and JH P made data curation. SZ Z and XB H reviewed the manuscript.

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Correspondence to Xiaobin Hu .

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Liu, H., Wang, X., Feng, H. et al. Obstructive sleep apnea and mental disorders: a bidirectional mendelian randomization study. BMC Psychiatry 24 , 304 (2024). https://doi.org/10.1186/s12888-024-05754-8

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Post-Traumatic Stress Disorder

Two-fers in mental health services, intergenerational bargains..

Posted April 22, 2024 | Reviewed by Michelle Quirk

• What Is PTSD?
• Find counselling to heal from trauma
• Therapeutic and wellness interventions often positively impact more than one problem.
• Interventions with positive impacts spanning more than one generation are special bargains.
• Therapeutic interventions focused on children can have positive impacts on their parents.

The concept of a “two-fer” dates to the late 19th century when two (usually cheap) cigars would be sold for the price of one. This sales gimmick generalized and is now a staple of cable TV marketing , often introduced by an excited, “But wait! There’s more. Get a second whizamadoodle. Just pay extra shipping and handling. That’s two whizamadoodles for the price of one. A real bargain!”

For clinicians and policy wonks, however, a real public health bargain is what one might call a therapeutic two-fer, an intervention that simultaneously targets two co-occurring problematic symptoms, such as depression and anxiety . One of the greatest public health bargains of all is a clinical intervention for one generation that positively affects another generation as well. Most commonly this intergenerational two-fer is observed between parents and their children.

The Great Smoky Mountains Study

One of the first research studies to systematically examine the intergenerational two-fer effect of an increase in a family’s base income and better outcomes for their children was the Great Smoky Mountains Study (GSMS). 1 Begun in 1992, by E. Jane Costello, William Copeland, and Adrian Angold of Duke University, the GSMS investigated children’s mental health needs in rural America. Serendipitously in 1996, a casino opened on a Cherokee reservation located in the study area. A proportion of the casino profits (~$4000) was distributed equally to every enrolled member of the tribe (children’s shares were held by the Tribal Council until graduation from high school or age 21). Anglo-American families in surrounding counties did not receive any additional income. The GSMS compared the average number of DSM-IV emotional and behavioral symptoms in Anglo and Native American children for the 4 years before and 4 years after the casino opened. Native American families receiving this income supplement showed marked improvements in their children’s mental and behavioral health with no changes in the Anglo children.

More recently, a similar study examining the long-term, intergenerational effects of a large cash transfer to Native American families found that beneficial effects were measurable in their children and even their grandchildren many years later. 2 Specifically, their children had healthier pregnancies as adults and their children’s children (i.e., the grandchildren of the original cash recipients) were healthier at birth compared with equivalent Anglo families that did not receive the cash transfer. This suggests that such interventions may even have “three-fer” intergenerational effects.

Another Three-Fer

A study published this year followed up on a parent, child, and school-based intervention carried out at low-income schools in four states for children who showed signs of aggression in first grade. When these children became parents, those who had received the intervention were less likely to use corporal punishment , and their children were significantly less likely to use general medical inpatient services or either inpatient or outpatient mental health services. The authors conclude that “Investing in interventions for the mental health of children could reduce service use burdens across generations.” 3

Child PTSD Prevention Program Reduces Parental PTSD Symptoms

Studies and meta-analyses have consistently found that posttraumatic stress disorder ( PTSD ) symptoms in parents adversely affect their offspring. Likewise, PTSD symptoms in children affect their parents. (This is likely also true for major depression and generalized anxiety disorder). Correspondingly, there are examples where therapeutic interventions that address PTSD symptoms in one generation reduce PTSD symptoms in another.

For example, a multi-site (10), meta-analysis of PTSD symptoms in parents whose children received the Child and Family Traumatic Stress Intervention, a brief, manualized mental health intervention that significantly decreases the likelihood of acutely traumatized children developing full-fledged PTSD, also significantly reduced PTSD symptoms in their parents. 4 In fact, virtually all of the most efficacious child trauma treatment programs involve the parents—although to different degrees.

It should be noted, however, that small percentages (3 percent in the above study) of parents are more symptomatic following participation in child-focused trauma interventions. There doesn’t seem to be a single explanation for this negative effect. But it speaks to the complicated, reciprocal interactions existing between parents and their children.

The Expanded Child Tax Credit

Perhaps the most powerful psychosocial two-fer on the horizon is the potential reinstatement of the Expanded Child Tax Credit (ECTC), which has not been determined as of this draft. Following the tragically short-lived, original ECTC, an analysis compared 2021 rates of child abuse (i.e., emergency room visits coded as child abuse-related) with the same periods in 2018 and 2019. There were significant reductions in child maltreatment for males and non-Hispanic white children following distribution of the original ECTC payments. 5 These reductions in child maltreatment reports were limited, however, to relatively short time periods following a family’s receipt of an ECTC payment. Other research hints at longer-lived positive outcomes, but as with the birth and third-generation outcomes for family income transfers, we need much longer-term follow-up studies to document such benefits.

From a public health perspective, the sad fact is that there is no greater bargain than early interventions to support caregivers and children, but it often takes years to see the payoff, while the politicians who make the ultimate decisions about funding such services primarily think in terms of the next election cycle.

1. Costello, E.J., Copeland, W., Angold, A., (2016). The Great Smoky Mountains Study: Developmental epidemiology in the southeastern United States. Soc. Psychiatry Psychiatr. Epidemiol. 51(5):639–646.

2. Bustos, B., Lopez, M., Dodge, K.A., Lansford, J.E., Copeland, W.E., Odgers, C.L., Bruckner, T.A., (2024). Family cash transfers in childhood and birthing persons and birth outcomes later in life. SSM – Population Health 24: https//doi.org/101016/j.ssmph.2024.101623.

3. Rothenberg, W., Lansford, J., Godwin, J., Dodge, K. et. al (2024) Intergenerational effects of the Fast Track intervention on next-generation child outomes. A preregistered randomized controlled trial. American Journal of Psychiatry 181:213–222.

4. Hahn, H., Putnam, K., Epstein, C., Marans, S., Putnam, F. (2019). Child and Family traumatic stress intervention (CFTSI) reduces parental posttraumatic stress symptoms: A multi-site meta-analysis (MSMA). Child Abuse and Neglect. 92:106–115.

5. Bullinger, L.R., Boy, A. (2023). Association of Expanded Child Tax Credit Payments with Child Abuse and Neglect Emergency Department Visits. JAMA Network Open . 6(2):e2255639 doil10.1001/jamanetworkopen.2022.66639

Judith Lewis Herman, M.D., is a semi-retired professor of psychiatry at Harvard Medical School. Frank W. Putnam, M.D. , is a professor of clinical psychiatry at the University of North Carolina School of Medicine.

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