research paper mental illness

August 29, 2024

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socio-economics & political approaches

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public mental health and policy

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Mental health psychology

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• Published: 24 October 2019

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

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

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

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

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

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

Conclusions

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

Peer Review reports

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

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

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

Stage 1: identify the research question

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

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

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

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

Stage 2: identify the relevant studies

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

Stage 3: literature selection

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

PRISMA Flow Diagram

Stage 4: charting the data

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

Stage 5: collating, summarizing, and reporting the results

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

Characteristics of included literature

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

Number of sources by characteristics of included literature

Frequency of themes in literature ( n  = 91)

Mental health concerns and their prevalence in the literature

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

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

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

Causes of mental health concerns

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

Effects of mental health concerns on physicians and patients

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

Solutions and interventions

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

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

Barriers to seeking and providing care

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

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

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

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

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

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

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

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

Availability of data and materials

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

Abbreviations

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

United States of America

World Health Organization

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

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Defining mental health literacy: a systematic literature review and educational inspiration

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Society-related Fears and Personal Mental Health

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This paper explores the relationship between society-related fears and personal mental health. Respondents of an online survey representing the German population (18 + years) answered how much they are worried about eight societal developments (armed conflicts, social inequality, rise of right-wing extremism, crime and terror, immigration, climate change, artificial intelligence, pandemics). The analysis demonstrate that the sum score of society-related fears is significantly associated with higher levels of anxiety and depression. Particularly concerns about poverty, digitalization and pandemics are associated with higher anxiety and depression scores. Further explorations show that specific fears are intermingled with political ideologies, i.e. people fear different societal developments according to their ideological standpoints. Politically left-leaning individuals regard climate change and rising right-wing extremism as more threatening, while politically right-leaning individuals’ fears relate more strongly to migrants, terror and crime. The fears with the largest negative effect on mental health are poverty and armed conflicts for individuals who identify as left and digitalization for individuals who identify as right. Overall, findings lend support to the general notion that the world’s current ‘polycrisis’ is highly relevant and generally detrimental for mental health and human wellbeing.

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Introduction

A myriad of crisis scenarios related to economic, financial, humanitarian, social, political or environmental problems are occupying public discourse. Whether war or global warming, each crisis has the potential to induce fear. Crises are per definition events of great difficulty and danger that potentially can disrupt society and harm the wellbeing of many people (Walby, 2015 ). As such, crises systematically produce a moment of ambiguity and uncertainty, pointing to a future that is open at best, and endangered at worst (Steg, 2019 ). Some authors have even argued that contemporary society is characterized by “multiple crises” (Brand, 2009 ) or “polycrisis” (Lawrence et al., 2024 ). These terms refer to a condition where crisis of amplifying severity follow each other at an accelerating pace, thus becoming a kind of permanent condition.

In fact, many of society’s crisis pose a real threat to people and their quality of life: For instance, the climate crisis destroys livelihoods and biodiversity in many regions of the planet, leading to global warming and extreme weather events (Abbasi et al., 2023 ). Rising levels of economic inequality and further social frictions between rich and poor are associated with anxiety, stress and poor health (Pickett & Wilkinson, 2015 ). Digitalization and artificial intelligence (AI) have the potential to disrupt employment: Forecasts suggest that 47% of current jobs are “at high risk” of being replaced by technology within the next 20 years (Frey & Osborne, 2017 ). It is reasonable to assume that these developments could trigger fears and thus produce a public mood of “an extraordinarily uncertain and threatening future” (Borisch, 2023 : 332).

In several theoretical accounts it has been argued that fear has become the basic, underlying tone of contemporary society (Bauman, 2006 ; Bude, 2014 ; Furedi, 1997 ). In Bauman’s terms ( 2006 ), it is a vague and undefined “liquid fear” that is rather a kind of background feeling of permanent uncertainty in a society in which reliable certainties erode. According to him, the persistence of fear relates to the speed of change in late modernity and the associated loss of fixed points of reference. Furedi ( 1997 ) states that a “culture of fear” is grounded in a ubiquitous perception of the world as a dangerous place. He understands this as a collective disposition, i.e. as a very basic and underlying sentiment that attaches itself to and shapes concrete human experiences.

Bude ( 2014 ) claims that current society is no longer held together by the promise of social advancement (as in previous decades), but rather by the threat of social exclusion. He also argues that a fundamental insecurity exists, namely that younger generations cannot take it for granted that the future will be better than the present and the past. This perception creates a fear of social decline that reaches deep into the middle class and helps to create constantly self-optimizing personalities who are driven by the subliminal fear of falling out of the middle of society.

Some authors emphasize the social constructionist nature of fear (Furedi, 1997 ; Tudor, 2003 ) and stress that contemporary culture has a tendency to foreground risk. The divergence between objective risk and subjective feelings of threat can be best illustrated in the field of crime and terrorism, where studies show that people’s fear is substantially shaped by media consumption (Romer et al., 2003 ; Williamson et al., 2019 ). Hence, fear is often not based on experience, but rather on risk communication (Guzelian, 2004 ). Particularly the news media are a key factor in the promotion and amplification of a “discourse of fear” (Altheide, 2002 ). However, the public discourse must not necessarily amplify fear, but could potentially also calm fear, highlighting the plasticity of society-related fears (Heins, 2021 ).

As all societal crises have serious and negative implications for a large number of people, it is not surprising that public opinion polls from Germany show that a majority of Germans reports that crises, such as the climate or migration crisis, cause them worry (Infratest dimap, 2024 ; Ipsos, 2024 ). In recent decades, war, crime, and migration have been the issues Germans have been most concerned about, however, with significant fluctuations over time (Lübke, 2019 ). Less clear is the question whether society-related fear is associated with increased risks of personal mental health issues.

One previous German survey study examined the relationship between personal anxiety and fears related to the social and societal environment (Adolph et al., 2016 ). They show, for instance, that higher levels of fear related to political and economic issues, including terrorism or environmental disasters, are associated with severe anxiety symptoms. They argue that an “intensity continuum” exists that stretches from political and economic anxieties over anxieties related to the person’s social life to various forms of clinical anxiety at the personal level (Adolph et al., 2016 ).

That society can be a source of fear is certainly not an entirely new idea. Yet, society-related fears have hardly been systematically included in the discourse on mental health and wellbeing to date. This paper aims to address three key questions that have not yet been adequately answered: (1) What is the proportion of people who are worried or afraid of specific societal crises ? (2) To what extent does fear of societal crises reflect people’s political positions ? (3) Does fear of societal crises as a whole , or any individual societal fear , have an impact on personal mental health ? The present paper explores these questions based on survey data that represent the German population.

Literature Review

Although the topic of society-related fear has received too little attention in the wellbeing and mental health literature, exceptions are studies that more narrowly address one specific crisis or one specific fear. Hence, studies addressing economic recessions, crime fear, the COVID-19 pandemic, or climate anxiety could help summarizing the state of knowledge. In addition, I also summarize few studies that addressed society-related fears more generally with its links to individual mental health or wellbeing outcomes. Finally, I recap literature that examined or reflected on the ideological nature of society-related fears and concerns.

Society-related Fears and Their Consequences for Wellbeing and Mental Health

A scoping review based on 127 quantitative studies conducted in OECD countries summarizes that depression and anxiety levels rise during economic recessions , particularly in those groups with insecure jobs (Guerra & Eboreime, 2021 ). This finding also holds for life satisfaction, which declines in times of economic crisis (Burger et al., 2023 ). In a series of experimental studies participants reported higher levels of fear when they found themselves in an experimental group that had to expect a status decline or downward mobility (Jetten et al., 2021 ). Data from the European Quality of Life Survey also demonstrate that status anxiety is associated with unhappiness (Delhey & Dragolov, 2014 ). Empirical trend analyses from Germany further show that the fear of job loss and social decline increased in the German middle class in periods where the labor market was difficult and the economic outlook rather pessimistic (Lengfeld & Hirschle, 2009 ; Schöneck et al., 2011 ). Closely related to status anxiety are fears about increasing levels of social inequality , which rank among the most frequently mentioned worries reported by Germans (Ipsos, 2024 ).

Regarding fear of crime , studies show that the regional crime rate is positively associated with fear (Bug et al., 2015 ) and negatively associated with wellbeing (Powdthavee, 2005 ). However, the perception of crime is also important and predicts lower life satisfaction even when controlling for victimization experiences (Brenig & Proeger, 2018 ) or real crime rates (Manning et al., 2022 ). An Austrian study further shows that fear of crime relates to underlying social and existential threats, i.e. constituting a generalized syndrome of insecurity (Hirtenlehner, 2006 ). Sometimes, public discourse relates fear of crime to immigration , as there is a widespread perception that immigrants contribute to increased levels of crime (Gurinskaya et al., 2024 ; Hirtenlehner, 2019 ). Academics have also discussed fears related to immigration (Blanc, 2023 ; Bloom, 2015 ). Data from several European countries show that fear of immigration has increased over three decades, in Germany particularly during the so-called “immigration crisis” of 2015/16 (Fraser & Üngör, 2019 ). A “migration panic” is nurtured by economic anxieties, concerns about status decline and perceptions of disorder (Hirtenlehner, 2019 ). However, inasmuch such perceptions translate into personal anxiety has not been thoroughly researched yet.

Germany, as well as many other European countries, has experienced a rise in right-wing extremism (Pisoiu & Ahmed, 2016 ). Many regard the rise of populist and extremist movements and right-wing parties as worrying. Anecdotal evidence from Germany suggests that the 2024 mass demonstrations against right-wing parties were driven in part by anxiety and concern (WDR, 2024 ). A commercial poll from February 2024 suggests that 59% of Germans fear a rise of (right-wing) political extremism (R + V Infocenter, 2024 ). However, there is a lack of scientific research on the relationship between fear of extremism and personal anxiety or wellbeing levels.

In the context of the COVID-19 pandemic fear also played a role. A cross-national analysis of European countries reveals that in stages of the pandemic with higher death rates, life satisfaction dropped (Easterlin & O’Connor, 2023 ). A review shows that COVID-19 related fear was associated with mental health problems, such as anxiety, distress, depression, and insomnia (Şimşir et al., 2022 ). Woman usually reported higher levels of COVID-19 related fear (Metin et al., 2022 ). A survey experiment from Sweden further shows that fear (in the sense of scare) and anxiety (in the sense of worry) were higher in participants who were reminded of the deadliness of the virus and the strained situation in the health care system (Renström & Bäck, 2021 ).

Climate anxiety or eco-anxiety, i.e. the fear concerning the devastating consequences of climate change for life on earth, is another emerging field of research. To date, some studies found associations between climate anxiety and personal mental health issues, such as elevated levels of stress, anxiety and depression (Hajek & König, 2023 ; Heinzel et al., 2023 ; Pihkala, 2020 ; Thomson & Roach, 2023 ; Wullenkord et al., 2021 ). Moreover, climate anxiety negatively correlates with age, indicating that this type of fear – in contrast to most other society-related fears – is particularly threatening for younger age groups (Hajek & König, 2023 ; Heinzel et al., 2023 ).

Research also addressed fears associated with the development and diffusion of digital and AI technologies. These fears may include the possible replacement of humans in a significant proportion of occupations (Frey & Osborne, 2017 ), the lack of human control over emerging “super AI” systems, for instance, in the military domain (Sehrawat, 2017 ) or concerns about privacy violations (Li & Huang, 2020 ). Fear of AI technologies, such as autonomous robots or driving systems, may extend to 18–26%, according to representative U.S. and German surveys (Liang & Lee, 2017 ; Meinlschmidt et al., 2023 ). Studies further show that a negative view and concerns regarding AI technologies correlate with lower life satisfaction at micro and macro social levels (Hinks, 2024 ; Zhao et al., 2024 ).

Finally, a source of fear are wars and armed conflicts . Research shows that the experience of armed conflicts is a trigger for various mental health problems (Charlson et al., 2019 ). Witnessing armed conflicts in closer proximity may also cause concerns, i.e. about a possible escalation of that war. War anxiety is associated with stress and insomnia (Vargová et al., 2024 ). About 50% of Germans reported severe fear of war in a survey carried out in March 2022 (Hajek et al., 2023a ). Moreover, another German study measured a higher anxiety level in the population in the first weeks of the Russian war against Ukraine as during the COVID-19 pandemic (Gottschick et al., 2023 ). Fears either of Germany becoming involved in a war or the outbreak of a nuclear war were both associated with heightened levels of anxiety and depression (Hajek et al., 2023b ).

Apart from studies that have looked at single fears, there are few studies that examined society-related fears in general, i.e., independent of one specific problem or crisis. Using “big data”, a US study on fear in society concludes that fear is on the rise (Kovács, 2023 ). Analyzing approximately 7 million online reviews by applying a semantic coding approach with computational linguistics, it is illustrated that anxiety-related content increased by 20% from 2006 to 2021. Another descriptive account (Ipsos, 2024 ) indicates that issues such as “inflation”, “crime and violence”, “poverty and social inequality” and “climate change” represent the primary fears of the German population, with 24–29% expressing concern about each of these developments.

Regarding the literature on society-related fears, it seem reasonable to assume that (a) a larger proportion of the German population is concerned about societal developments and trends and (b) a link could exist between fears related to the societal level and mental health issues at the personal level.

The Ideological Nature of Society-related Fears

Not everyone shares the same societal fears and concerns. Individual differences, however, do not reflect purely personal characteristics, but can be situated within a larger political or ideological framework. For instance, Nussbaum ( 2018 ) describes that working class Americans are threatened by globalization and digitalization and that particularly right-wing populists can easily capitalize from these fears. For example, fear helps create a desire for a strong leader, mobilize for extreme positions, and scapegoat minorities. Recent accounts elaborate on the mechanisms that link insecurity and migration-related anxiety on the one hand to right-wing ideologies and support on the other, highlighting the role of affective reactions to political issues and the search for stable sources of meaning and identity (Salmela & von Scheve, 2017 ; Yendell & Pickel, 2019 ). Fear of migrant crime and the perception that a cultural or national identity is threatened are textbook examples for topics that right-wing parties usually exploit. For instance, recent opinion polls indicate that 90% of supporters of the far-right party, Alternative für Deutschland , express concern about a perceived decline of German culture and language (Infratest dimap, 2024 ). Some scholars even argue that a heightened sensitivity to perceive uncertainty and change as threatening is at the core of conservative ideologies (Jost et al., 2007 ).

Notwithstanding the link between a culture of fear, conservatism and right-wing populism, the relationship might still be more complex. Nussbaum ( 2018 ) further explains that people, who self-identify as “left”, also fear societal developments. In the US context, they fear the removal of “hard-won rights for women and minorities” or the “collapse of democratic freedoms – of speech, travel, association, press” (Nussbaum, 2018 : p. 2). In Germany, supporters of the Social Democratic Party report higher levels of fear related to wars compared to supporters of center-right and far-right parties (Hajek & König, 2022 ), whereas supporters of the Green Party are most worried about the consequences of climate change (Infratest dimap, 2024 ). It can be conjectured from these findings that there are fears on both sides of the ideological spectrum, but it is other societal developments that are interpreted as most threatening.

Which societal developments trigger fear is likely to depend on an individual’s ideological standpoint. It can be assumed, for example, that the population group that is most concerned about the climate crisis and the population group that is most concerned about incoming refugees are anything, but identical. Rather, each crisis “emotionalizes” and threatens a different population group. If this assumption is correct, then fear should depend on the political and ideological lens through which people look at society. Furthermore, a person’s ideological standpoint could also influence which societal developments or crises translate into personal fears and thus might impair mental health. A more exploratory analysis thus tests whether or not (a) society-related fears are associated with ideological standpoints and (b) whether or not differences exist between people who identify as politically “left”, “right”, and “center” in terms of the effects of particular societal fears on personal mental health.

Study Design and Data Collection

This study used a cross-sectional design, drawing on data from a large-scale representative survey. The survey was integrated into an existing German panel to which access was provided by Forsa, a company specializing in public opinion research. In order to ensure a probability sample that accurately represents the German population, Forsa employs an offline recruitment process for all panelists that utilizes Random Digit Dialing (RDD; Wolter et al., 2009 ). The RDD procedure guarantees that all individuals with a telephone connection, whether mobile or landline, have an equal opportunity to be invited into the panel, thereby ensuring that the panel’s composition mirrors that of the German population. All panelists gave their written consent to be contacted for this study and participated voluntarily. They received information about the present study via Email together with a link to the anonymous online questionnaire. Respondents were able to answer the questionnaire directly on their computers, tablets, or mobile phones and were permitted to terminate the survey at any point and resume at a later time. Data collection was carried out between January 5 and January 13, 2024.

The resulting sample ( N  = 1,001) broadly represents the population living in Germany (≥ 18 years) with access to the Internet. The mean age is 48.4 years (SD = 17.2). The sample includes similar proportions of males (50.4%) and females (49.6%). With regard to education, 22.1% have a lower secondary grade (“Hauptschulabschluss”), 34.3% have a medium secondary grade (“Mittlere Reife”), and 43.6% have a higher secondary grade (“Abitur”). Despite the fact that the raw data reflect the composition of the German population fairly well, still a weighting factor is applied in all analyses that corrects for minor bias in the sample, most notably for a slight underrepresentation of younger age groups and individuals living in East German federal states.

Mental Health Issues

Mental health complaints are measured with the Patient Health Questionnaire for Depression and Anxiety (PHQ-4; Kroenke et al., 2009 ). The PHQ-4, introduced as a brief screening tool for anxiety and depression, has proved its validity and reliability and its briefness makes it particularly useful for large-scale surveys (Adzrago et al., 2024 ; Kroenke et al., 2009 ; Löwe et al., 2010 ). Respondents are asked how often they have been bothered by four symptoms in the past two weeks. Two items refer to anxiety (e.g. “not being able to stop or control worrying”) and two items measure depressive symptoms (e.g. “little interest or pleasure in doing things”). The rating scale provided allows responses from 1=“not at all”, 2=“several days”, 3=“more than half the days” to 4=“nearly every day”. The final scale has a good reliability (Cronbach’s α = 0.88); its mean is M  = 1.68 ( SD  = 0.73; min = 1.00; max = 4.00).

Society-related Fears

A new measure was created to capture society-related fears. Respondents were presented with a list of eight societal developments and crises and then were asked how often they had fears or worries related to the crisis described. The list of potentially worrying societal developments included: a) climate change and its consequences, b) immigration of refugees and asylum seekers, c) poverty and rising levels of social inequality, d) digitalization and artificial intelligence, e) wars and armed conflicts, f) crime and terrorism, g) the rise of right-wing extremist parties and movements, h) pandemics and novel pathogens. Respondents could use a 5-point Likert scale to rate the fear related to each of these developments ranging from 1=“no fear at all” to 5=“very strong fear”. Figure  1 shows descriptive statistics of these eight items. Besides the single items, the analyses also use a mean score of the eight variables ( M  = 3.58; SD  = 0.62; min = 1.00; max = 5.00).

Means scores for eight society-related fears. Error bars show 95% confidence interval of the mean. Percentages in brackets indicate the proportion of respondents with “strong” or “very strong” fear. Data represent the German population 18 + years with Internet access ( N  = 1,001)

Political ideology

The Left-Right Self-Placement scale (LRS) measures a basic political stand on a left-right dimension. In Germany, a “right” orientation refers to conservative, market-liberal, and nationalistic attitudes, whereas a “left” orientation favors progressive and egalitarian policies. Scholars consider the left-right pole as the most important and as a rather stable ideological dimension, which relates to voting behavior and is part of most studies that examine political or ideological issues (Klingemann, 1972 ; Knutsen, 1998 ). Participants indicated their ideological orientation on a LRS scale that ranged from 1=“left” to 10=“right”. In the present sample, the mean score of the scale is M  = 5.49 ( SD  = 2.21; min = 1.00; max = 10.00).

Demographic Variables

The regression models include a variety of covariates, given that anxiety and mental health levels vary with socioeconomic and sociodemographic variables. Previous studies refer to increased mental health problems among older and socioeconomically disadvantages groups, females, and immigrants (Adolph et al., 2016 ; Guerra & Eboreime, 2021 ; Metin et al., 2022 ; Walther et al., 2021 ), whereas being in a relationship (Pieh et al., 2020 ) or being religiously affiliated (Hodapp & Zwingmann, 2019 ) could somewhat protect from mental health issues. Therefore, I control for age (in years), gender (1=“female”, 0=“male”), the highest educational degree obtained by the respondent (1=“lower secondary education” to 4=“tertiary education”), the respondent’s personal net income (in 10 income groups from 1= “no income” to 10 “>5.000 €”), relationship status (1=“living with partner”, 0=“single/widowed”), immigrant status (1=“1st/2nd generation immigrants”, 0=“natives”), religious affiliation (1=“any denominational affiliation”, 0=“no denominational affiliation) and residence (1 = East Germany, 0 = West Germany). Controlling for these variables allows for a more accurate estimation of the effect of society-related fears. It needs to be pointed out that the variable for income – despite being measured in 10 categories – is meant to estimate a linear effect, i.e., that a higher income level is associated with fewer mental health problems.

Analytical Approach

The paper first presents mean values with standard errors of the mean for the eight society-related fears, indicating the level of worry the surveyed crises and developments cause among Germans. In addition, I indicate the proportion of respondents who reported “strong” or “very strong” fear, i.e. those with response options 4 and 5. In a second step, associations of society-related fears and political ideology are examined. Based on the respondents’ position on the LRS scale, the paper analyses inasmuch society-related fears vary between individuals who position on the left, on the right or in the center of the ideological spectrum. A one-way ANOVA is applied for each fear to test for significant differences between the three ideological groups (“left”, “center”, “right”). Thirdly, I calculate multiple linear (ML) regression models with personal mental health (PHQ-4) as the dependent variable. The ML regressions assess whether individuals with higher levels of society-related fears report worse mental health. A first model shows whether all societal fears in sum are associated with mental health complaints. For this purpose, regression models were calculated in which a mean score was included that reflects the extent to which a person feels threatened by the eight societal developments examined here. A second regression model then tests for associations between mental health and the single society-related fears. I calculate this regression also separately for individuals who identify as politically left, right and center, as it is likely that ideology affects the relationship between societal developments and personal mental health issues. Both regression models include the above-mentioned sociodemographic control variables. Because these models consider the eight society-related fears simultaneously and thus account for possible correlations between them, I also report zero order correlations for each fear. This allows estimating the effect of each fear on mental health with and without controlling for the influence of the other society-related fears. The regression models document unstandardized and standardized regression estimates (b, β). All data analyses were performed using IBM SPSS 29.

The Proportion of Germans who are Afraid of Specific Societal Crises

The eight society-related problems selected here do indeed arouse fears and concerns in a large proportion of people (Fig.  1 ). The highest fear level is shown for wars and armed conflicts ( M  = 4.12; SD  = 0.94; SE  = 0.030), causing “strong” or “very strong” concerns in 76% of all respondents. Growing social inequality and concerns about poverty also cause fear, with 72% being worried about this issue ( M  = 3.95; SD  = 0.99; SE  = 0.032). Two-thirds (67%) say they are concerned about the rise of right-wing extremism ( M  = 3.95; SD  = 1.25; SE  = 0.040). Crime and terror ( M  = 3.81; SD  = 1.06; SE  = 0.034), as well as immigration and flight to Germany ( M  = 3.73; SD  = 1.17; SE  = 0.038), are also issues of worry to six in ten Germans (64% and 61% respectively). Climate change has a lower average score ( M  = 3.35; SD  = 1.21; SE  = 0.039) and is a concern for half of respondents (49%). The least fearful issues are digitalization and AI ( M  = 3.02; SD  = 1.15; SE  = 0.037) and pandemics and novel pathogens ( M  = 2.82; SD  = 1.13; SE  = 0.036), with a third (33%) and a fourth (26%) of respondents reporting “strong” or “very strong” fear.

Society-related Fears’ Relation to People’s Political Positions

All society-related fears are significantly associated with respondents’ ideological position on the LRS scale, but to varying degrees (Fig.  2 ). People on the left of the ideological spectrum are significantly more worried about the rise of right-wing extremist movements (η²=0.22; p  < .001) and also significantly more worried about the consequences of climate change (η²=0.12; p  < .001). Conversely, people on the political right are far more concerned about migration (η²=0.20; p  < .001) as well as crime and terror (η²=0.07; p  < .001). By comparison, the differences in the other society-related fears are less pronounced: wars and conflicts cause slightly more concern among people on the left (η²=0.03; p  < .001), as do increasing poverty and social inequality (η²=0.02; p  < .001). People on the right are slightly more afraid of the consequences of digitalization and AI (η²=0.01; p  < .04) and slightly less afraid of pandemics (η²=0.01; p  = .04). Overall, it is clear that most people experience certain societal developments as threatening, but as assumed, ideological standpoints play a crucial role in determining which developments and which crises trigger the most fear.

Means scores for eight society-related fears depending on individuals’ ideological left-right self-placement. Error bars show 95% confidence interval of the mean. Self-reported scores of 1–4 were considered “left”, scores of 5 and 6 were considered “center”, scores of 7–10 were considered “right”. Data represent the German population 18 + years with Internet access ( N  = 1,001)

Associations of Society-related Fears with Personal Mental Health

A first set of multiple linear regression models examine whether the sum of all society-related worries reported by a respondent is associated with mental health complaints (Table  1 ). Models 1a and 1b both show that personal anxiety and depression scores are significantly associated with society-related worries, also when controls are included ( b  = 0.28; β = 0.24; p  < .001). A 1-unit increase of society-related fears is associated with a 0.28-point increase on the 4-point PHQ scale. The model 1b also suggests that age ( b =-0.01; β=-0.20; p  < .001), income ( b =-0.04; β=-0.14; p  < .001) and being in a relationship ( b =-0.16; β=-0.10; p  < .01) are associated with a lower risk of personal anxiety and depressive tendencies. Migrants report slightly more mental health problems compared to respondents without an immigration background ( b  = 0.21; β = 0.09; p  < .01).

In addition, Model 1c also includes a quadratic term for society-related fear, which is significant and points to a non-linear relationship ( b  = 0.10; β = 0.61; p  = .01). In fact, the level of anxiety and depression increases exponentially the more societal developments a person perceives as threatening, which is illustrated in Fig.  3 .

Estimated effects of society-related fears on mental health (PHQ-4) scores. The figures shows the combination of the main effect for society-related fears plus the squared effect, indicating a non-linear relationship. Data represent the German population 18 + years with Internet access ( N  = 1,001)

Further regression analyses explore whether specific societal concerns are associated with mental health problems (Table  2 ). These analyses show significant relations for some variables (Model 2a). Zero order correlations (i.e., without controls) indicate that concerns about poverty and inequality ( r  = .18), digitalization and AI ( r  = .16), pandemics ( r  = .16), war and armed conflicts ( r  = .12), right-wing extremism ( r  = .07) and climate change ( r  = .07) significantly correlate with increased mental health problems. A multiple regression model (i.e., which controls for correlations between society-related fears) points to three significant effects: Worries related to pandemics ( b  = 0.09; β = 0.14; p  < .001), poverty and growing social inequality ( b  = 0.07; β = 0.10; p  < .01), as well as digitalization and AI ( b  = 0.05; β = 0.08; p  = .03) are related to higher anxiety and depression scores.

A model only with individuals who self-place on the left side of the LRS scale (Model 2b) shows that concerns about wars and military conflicts ( b  = 0.14; β = 0.14; p  = .03), poverty and inequality ( b  = 0.14; β = 0.15; p  = .01), pandemics ( b  = 0.11; β = 0.16; p  = .02) and digitalization ( b  = 0.10; β = 0.14; p  = .03) negatively affect mental health. In contrast, a similar model for individuals who position politically in the center indicates that only the fear of pandemics is associated with poor mental health ( b  = 0.07; β = 0.12; p =  .04). Among right-leaning individuals (Model 2d) only worries about digitalization and AI are significantly associated with higher anxiety and depression scores ( b  = 0.15; β = 0.26; p  < .01).

Scientific accounts (Adolph et al., 2016 ; Kovács, 2023 ) and common sense both suggest that mental health problems, such as personal anxiety or depression, can increase in times of multiple crises. Building on theorizing on fear in (post-)modern society (Bauman, 2006 ; Bude, 2014 ; Furedi, 1997 ) this article is meant as a pilot study to explore some empirical relationships between society-related concerns and personal mental health. Results show that Germans were most concerned about societal developments and crises such as wars, social inequalities, right-wing extremism, crime and terror, or immigration. At the time of the survey, a majority of the respondents – between 76% and 61% – regarded these developments as highly worrying. However, societal developments are perceived as worrisome to varying degrees, depending on the individual’s ideological position. Left-leaning individuals are concerned about poverty, a rightward shift in society, or climate change, while right-leaning individuals rather perceive immigration and crime as threats. Most importantly, however, findings reveal that society-related fears are associated with mental health issues. Precisely, the regression models show a non-linear relationship: Mental health issues increase exponentially, the more frightened an individual is by the current societal crises. Hence, particularly in times of “polycrisis” (Lawrence et al., 2024 ), societal fears become a relevant and detrimental factor for human wellbeing.

The results are straightforward when it comes to the finding that people who are more worried about societal trends and conditions report poorer mental health. The results are less clear when it comes to single societal developments. These do not seem to have all the same negative effect on mental well-being. Instead, some fears do not at all correlate with personal mental health, while others are only weakly correlated. Generally, this aligns with the notion of an “intensity continuum” of anxiety (Adolph et al., 2016 ). Building on this idea, it can be postulated that some fears that relate to society and the wider living environment may be perceived as less stressful or less intense compared to fears that relate to something in the immediate personal environment. In addition, some scholars argue that society-related worries, such as immigration-related fears, could translate in personal anger instead of personal fear (Rico, 2024 ). In any case, there is some plasticity in individual reactions towards crises and not every threatening societal development must necessarily translate into a heightened personal experience of anxiety or a reduced level of happiness. Although, however, society-related concerns may not be experienced as intensely as personal fears, they often persist for longer periods. Concerns about the consequences of climate change, for instance, are likely to persist not just a few months, but years and decades. These worries probably lie in the background and not in the foreground of individual experience. It would be valuable thus to gain a more nuanced understanding of the experiential characteristics that differentiate a rather distal and abstract society-related anxiety from a more proximal and concrete anxiety related to the personal level.

Concerning particular fears, it seems that the societal developments that trigger anxieties and potentially impair mental health highly depend on ideologies (Nussbaum, 2018 ). Findings presented here do not support previous studies that showed that ecological concerns generally translate into lower levels of mental health (Hajek & König, 2023 ; Heinzel et al., 2023 ). The findings also do not support the assumption that all societal developments are perceived more threatening by people on the conservative side of the political landscape (Jost et al., 2007 ). By analyzing ideological orientations, this article rather supports the notion that political worldviews shape society-related concerns. For instance, fears about war and poverty are more likely to have a negative effect on mental health among left-leaning individuals, but not among individuals who self-position in the center or at the right of the ideological spectrum. Fear related with the diffusion of AI technologies is also associated with reduced mental wellbeing among left- and right-leaning individuals, but not among those in the political center. Although the present study could not reveal the mechanisms that lead to this effect, it is plausible to assume that concerns about privacy violations and surveillance may play a role (for a discussion see Zuboff, 2022 ) that could trouble particularly individuals with more radical political views on the ideological poles.

In terms of sociodemographic variables, the present study lends support to the previous findings that individuals from lower socioeconomic strata exhibit heightened concern about societal developments (Adolph et al., 2016 ) and that individuals in a relationship display a reduced tendency to worry (Pieh et al., 2020 ). However, the analyses revealed no gender effects. While females have been found to express more fears during the pandemic (Metin et al., 2022 ), the present study suggests that they do not generally worry more about societal developments than males.

This study has strengths and limitations: I consider a strength to be the simultaneous analysis of a number of societal fears (rather than focusing on a single fear) in a coherent approach based on representative data. This allows for comparisons and generalizations. Only few studies have yet provided similar data and analyses (as an exception: Adolph et al., 2016 ). In addition, the inclusion of ideology proved to be worthwhile. However, it is a limitation that the LRS scale captures only one dimension of political ideology and that the eight societal fears analyzed here may not be comprehensive. In particular, it is likely that different crises will manifest in the future, which could lead to different worries and concerns. In particular, the cross-sectional design is a limiting factor, as it allows only robust correlations to be shown. My argument favors the interpretation that societal crises and related fears reduce mental health and well-being. However, the design used here cannot rule out the opposite assumption, that people with mental health problems view societal conditions more negatively and may react more anxiously in times of crisis. Future studies could address some of these limitations, for example by using longitudinal research designs or by including multidimensional measures of political orientations and ideologies.

Building on Bauman’s ( 2006 ) concept of “liquid fear”, one could argue that fear in contemporary Western societies is ephemeral, virtually free-floating and not tied to a specific threat. Hence, fear could move from one current problem to the next. If one takes this argument seriously, questions about fear-inducing social developments could represent only a snapshot in time, which could look different just a few weeks later. Nevertheless, the social crises examined here are by no means only short-term issues: the consequences of climate change, the conflicts between rich and poor, or the disruptions caused by AI will continue to preoccupy humanity for years to come. However, it is unclear whether people will get used to these matters and, at some point, start taking these uncertainties for granted. Future studies that empirically examine the stability or volatility of society-related fears over time are therefore most relevant.

In conclusion, the analysis presented here makes clear that the relationship between societal crises and related fears, on the one hand, and mental health and well-being, on the other, deserves to be studied more closely than it has been. Society-related fears may be important predictors of health, especially in times of great uncertainty and crises of planetary scale. A social science perspective, which no longer sees mental health and well-being solely as an individual characteristic, but rather as embedded in a societal, social and communicative context (e.g., Heins, 2021 ; Hirtenlehner, 2019 ; Romer et al., 2003 ; Williamson et al., 2019 ), could be particularly valuable in this regard.

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Mutz, M. Society-related Fears and Personal Mental Health. Applied Research Quality Life (2024). https://doi.org/10.1007/s11482-024-10367-0

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Participant Behavior and Community Response in Online Mental Health Communities: Insights from Reddit

39 Pages Posted: 30 Aug 2024

Virginia Morini

University of Pisa

Maria Sansoni

affiliation not provided to SSRN

Giulio Rossetti

Dino pedreschi, carlos castillo.

Universitat Pompeu Fabra

The growing presence of online mutual-help communities has significantly changed how people access and provide mental health support. While extensive research has explored self-disclosure and social support dynamics within these communities, less is known about users' distinctive behavioral patterns, posting intents, and community response. This study analyzes a large-scale, five-year Reddit dataset of 67 mental health-related subreddits, comprising over 3.4 million posts and 24 million comments from approximately 2.4 million users. We categorize subreddits based on the Diagnostic and Statistical Manual of Mental Disorders and compare behavioral patterns found in these communities with Reddit non-mental health ones. Leveraging Reddit's post flair feature, we define a ground truth for post intents and apply an automated classification method to infer intents across the dataset. We then use causal inference analysis to assess the effect of community responses on subsequent user behavior.Our analysis reveals that mental health-related subreddits feature unique characteristics in content length, throwaway account usage, user actions, persistence, and community response. These online behaviors mirror those in other mutual-help Reddit communities and resonate with offline patterns, while diverging from non-support-oriented subreddits. We also find that seeking support and venting are the predominant posting intents, with users tending to maintain consistent intents over time. Furthermore, we observe that receiving comments and reactions significantly influences user follow-up engagement, fostering increased participation.These findings highlight the supportive role of online mental health communities and emphasize the need for tailored design to optimize user experience and support for individuals facing mental health challenges.

Keywords: Online Mental health communities, Reddit, mental health, Self-disclosure, Posting Intents, Community Response

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Mental Health, Substance Use, and Child Maltreatment

Child maltreatment is a pressing concern in the United States, with more than four million children referred to child protective services in 2022. Reducing child maltreatment is a national health objective given the substantial, negative consequences for children who experience maltreatment, both in the short- and long-term. Parental mental health and substance use disorders are strongly associated with child maltreatment. In this study, we use administrative data over the period 2004 to 2021 to study the relationship between the number of mental health and substance use treatment centers per county and child maltreatment reports. Our findings provide evidence that better access to mental health and substance use treatment reduces child maltreatment reports. In particular, an 8% increase in the supply of treatment would reduce maltreatment reports by 1%. These findings suggest that recent and ongoing efforts by the federal government to expand mental health and substance use treatment availability may lead to reduced child maltreatment.

All authors contributed equally to this study. Authors are listed in alphabetical order. Research reported in this publication was supported by the National Institute on Mental Health of the National Institutes of Health under Award Number 1R01MH132552 (PI: Johanna Catherine Maclean). Dr. Meinhofer acknowledges support from the Foundation for Opioid Response Efforts GR00015582 and the National Institute on Drug Abuse K01DA051777. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Institutes of Health or the Foundation for Opioid Response Efforts. We thank Douglas Webber and Jiaxin Wei for excellent comments. All errors are our own. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

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Impact of COVID-19 pandemic on mental health in the general population: A systematic review

Jiaqi xiong.

a Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON

Orly Lipsitz

c Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario

Flora Nasri

Leanna m.w. lui, hartej gill, david chen-li, michelle iacobucci.

e Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

f Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore

Amna Majeed

Roger s. mcintyre.

b Department of Psychiatry, University of Toronto, Toronto, Ontario

d Brain and Cognition Discovery Foundation, Toronto, ON

Associated Data

As a major virus outbreak in the 21st century, the Coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented hazards to mental health globally. While psychological support is being provided to patients and healthcare workers, the general public's mental health requires significant attention as well. This systematic review aims to synthesize extant literature that reports on the effects of COVID-19 on psychological outcomes of the general population and its associated risk factors.

A systematic search was conducted on PubMed, Embase, Medline, Web of Science, and Scopus from inception to 17 May 2020 following the PRISMA guidelines. A manual search on Google Scholar was performed to identify additional relevant studies. Articles were selected based on the predetermined eligibility criteria.

Results: Relatively high rates of symptoms of anxiety (6.33% to 50.9%), depression (14.6% to 48.3%), post-traumatic stress disorder (7% to 53.8%), psychological distress (34.43% to 38%), and stress (8.1% to 81.9%) are reported in the general population during the COVID-19 pandemic in China, Spain, Italy, Iran, the US, Turkey, Nepal, and Denmark. Risk factors associated with distress measures include female gender, younger age group (≤40 years), presence of chronic/psychiatric illnesses, unemployment, student status, and frequent exposure to social media/news concerning COVID-19.

Limitations

A significant degree of heterogeneity was noted across studies.

Conclusions

The COVID-19 pandemic is associated with highly significant levels of psychological distress that, in many cases, would meet the threshold for clinical relevance. Mitigating the hazardous effects of COVID-19 on mental health is an international public health priority.

1. Introduction

In December 2019, a cluster of atypical cases of pneumonia was reported in Wuhan, China, which was later designated as Coronavirus disease 2019 (COVID-19) by the World Health Organization (WHO) on 11 Feb 2020 ( Anand et al., 2020 ). The causative virus, SARS-CoV-2, was identified as a novel strain of coronaviruses that shares 79% genetic similarity with SARS-CoV from the 2003 SARS outbreak ( Anand et al., 2020 ). On 11 Mar 2020, the WHO declared the outbreak a global pandemic ( Anand et al., 2020 ).

The rapidly evolving situation has drastically altered people's lives, as well as multiple aspects of the global, public, and private economy. Declines in tourism, aviation, agriculture, and the finance industry owing to the COVID-19 outbreak are reported as massive reductions in both supply and demand aspects of the economy were mandated by governments internationally ( Nicola et al., 2020 ). The uncertainties and fears associated with the virus outbreak, along with mass lockdowns and economic recession are predicted to lead to increases in suicide as well as mental disorders associated with suicide. For example, McIntyre and Lee (2020b) have reported a projected increase in suicide from 418 to 2114 in Canadian suicide cases associated with joblessness. The foregoing result (i.e., rising trajectory of suicide) was also reported in the USA, Pakistan, India, France, Germany, and Italy ( Mamun and Ullah, 2020 ; Thakur and Jain, 2020 ). Separate lines of research have also reported an increase in psychological distress in the general population, persons with pre-existing mental disorders, as well as in healthcare workers ( Hao et al., 2020 ; Tan et al., 2020 ; Wang et al., 2020b ). Taken together, there is an urgent call for more attention given to public mental health and policies to assist people through this challenging time.

The objective of this systematic review is to summarize extant literature that reported on the prevalence of symptoms of depression, anxiety, PTSD, and other forms of psychological distress in the general population during the COVID-19 pandemic. An additional objective was to identify factors that are associated with psychological distress.

Methods and results were formated based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( Moher et al., 2010 ).

2.1. Search strategy

A systematic search following the PRISMA 2009 flow diagram ( Fig. 1 ) was conducted on PubMed, Medline, Embase, Scopus, and Web of Science from inception to 17 May 2020. A manual search on Google Scholar was performed to identify additional relevant studies. The search terms that were used were: (COVID-19 OR SARS-CoV-2 OR Severe acute respiratory syndrome coronavirus 2 OR 2019nCoV OR HCoV-19) AND (Mental health OR Psychological health OR Depression OR Anxiety OR PTSD OR PTSS OR Post-traumatic stress disorder OR Post-traumatic stress symptoms) AND (General population OR general public OR Public OR community). An example of search procedure was included as a supplementary file.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) study selection flow diagram. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

2.2. Study selection and eligibility criteria

Titles and abstracts of each publication were screened for relevance. Full-text articles were accessed for eligibility after the initial screening. Studies were eligible for inclusion if they: 1) followed cross-sectional study design; 2) assessed the mental health status of the general population/public during the COVID-19 pandemic and its associated risk factors; 3) utilized standardized and validated scales for measurement. Studies were excluded if they: 1) were not written in English or Chinese; 2) focused on particular subgroups of the population (e.g., healthcare workers, college students, or pregnant women); 3) were not peer-reviewed; 4) did not have full-text availability.

2.3. Data extraction

A data extraction form was used to include relevant data: (1) Lead author and year of publication, (2) Country/region of the population studied, (3) Study design, (4) Sample size, (5) Sample characteristics, (6) Assessment tools, (7) Prevalence of symptoms of depression/anxiety/ PTSD/psychological distress/stress, (8) Associated risk factors.

2.4 Quality appraisal

The Newcastle-Ottawa Scale (NOS) adapted for cross-sectional studies was used for study quality appraisal, which was modified accordingly from the scale used in Epstein et al. (2018) . The scale consists of three dimensions: Selection, Comparability, and Outcome. There are seven categories in total, which assess the representativeness of the sample, sample size justification, comparability between respondents and non-respondents, ascertainments of exposure, comparability based on study design or analysis, assessment of the outcome, and appropriateness of statistical analysis. A list of specific questions was attached as a supplementary file. A total of nine stars can be awarded if the study meets certain criteria, with a maximum of four stars assigned for the selection dimension, a maximum of two stars assigned for the comparability dimension, and a maximum of three stars assigned for the outcome dimension.

3.1. Search results

In total, 648 publications were identified. Of those, 264 were removed after initial screening due to duplication. 343 articles were excluded based on the screening of titles and abstracts. 41 full-text articles were assessed for eligibility. There were 12 articles excluded for studying specific subgroups of the population, five articles excluded for not having a standardized/ appropriate measure, three articles excluded for being review papers, and two articles excluded for being duplicates. Following the full-text screening, 19 studies met the inclusion criteria.

3.2. Study characteristics

Study characteristics and primary study findings are summarized in Table 1 . The sample size of the 19 studies ranged from 263 to 52,730 participants, with a total of 93,569 participants. A majority of study participants were over 18 years old. Female participants ( n  = 60,006) made up 64.1% of the total sample. All studies followed a cross-sectional study design. The 19 studies were conducted in eight different countries, including China ( n  = 10), Spain ( n  = 2), Italy ( n  = 2), Iran ( n  = 1), the US ( n  = 1), Turkey ( n  = 1), Nepal ( n  = 1), and Denmark ( n  = 1). The primary outcomes chosen in the included studies varied across studies. Twelve studies included measures of depressive symptoms while eleven studies included measures of anxiety. Symptoms of PTSD/psychological impact of events were evaluated in four studies while three studies assessed psychological distress. It was additionally observed that four studies contained general measures of stress. Three studies did not explicitly report the overall prevalence rates of symptoms; notwithstanding the associated risk factors were identified and discussed.

Summary of study sample characteristics, study design, assessment tools used, prevalence rates and associated risk factors.

3.3. Quality appraisal

The result of the study quality appraisal is presented in Table 2 . The overall quality of the included studies is moderate, with total stars awarded varying from four to eight. There were two studies with four stars, two studies with five stars, seven studies with six stars, seven studies with seven stars, and one study with eight stars.

Results of study quality appraisal of the included studies.

3.4. Measurement tools

A variety of scales were used in the studies ( n  = 19) for assessing different adverse psychological outcomes. The Beck Depression Inventory-II (BDI-II), Patient Health Questionnaire-9/2 (PHQ-9/2), Self-rating Depression Scales (SDS), The World Health Organization-Five Well-Being Index (WHO-5), and Center for Epidemiologic Studies Depression Scale (CES-D) were used for measuring depressive symptoms. The Beck Anxiety Inventory (BAI), Generalized Anxiety Disorder 7/2-item (GAD-7/2), and Self-rating Anxiety Scale (SAS) were used to evaluate symptoms of anxiety. The Depression, Anxiety, and Stress Scale- 21 items (DASS-21) was used for the evaluation of depression, anxiety, and stress symptoms. The Hospital Anxiety and Depression Scale (HADS) was used for assessing anxiety and depressive symptoms. Psychological distress was measured by The Peritraumatic Distress Inventory (CPDI) and the Kessler Psychological Distress Scale (K6/10). Symptoms of PTSD were assessed by The Impact of Event Scale-(Revised) (IES(-R)), PTSD Checklist (PCL-(C)-2/5). Chinese Perceived Stress Scale (CPSS-10) was used in one study to evaluate symptoms of stress.

3.5. Symptoms of depression and associated risk factors

Symptoms of depression were assessed in 12 out of the 19 studies ( Ahmed et al., 2020 ; Gao et al., 2020 ; González-Sanguino et al., 2020 ; Huang and Zhao, 2020 ; Lei et al., 2020 ; Mazza et al., 2020 ; Olagoke et al., 2020 ; Ozamiz-Etxebarria et al., 2020 ; Özdin and S.B. Özdin, 2020 ; Sønderskov et al., 2020 ; Wang et al., 2020a ; Wang et al., 2020b ). The prevalence of depressive symptoms ranged from 14.6% to 48.3%. Although the reported rates are higher than previously estimated one-year prevalence (3.6% and 7.2%) of depression among the population prior to the pandemic ( Huang et al., 2019 ; Lim et al., 2018 ), it is important to note that presence of depressive symptoms does not reflect a clinical diagnosis of depression.

Many risk factors were identified to be associated with symptoms of depression amongst the COVID-19 pandemic. Females were reported as are generally more likely to develop depressive symptoms when compared to their male counterparts ( Lei et al., 2020 ; Mazza et al., 2020 ; Sønderskov et al., 2020 ; Wang et al., 2020a ). Participants from the younger age group (≤40 years) presented with more depressive symptoms ( Ahmed et al., 2020 ; Gao et al., 2020 ; Huang and Zhao, 2020 ; Lei et al., 2020 ; Olagoke et al., 2020 ; Ozamiz-Etxebarria et al., 2020 ;). Student status was also found to be a significant risk factor for developing more depressive symptoms as compared to other occupational statuses (i.e. employment or retirement) ( González et al., 2020 ; Lei et al., 2020 ; Olagoke et al., 2020 ). Four studies also identified lower education levels as an associated factor with greater depressive symptoms ( Gao et al., 2020 ; Mazza et al., 2020 ; Olagoke et al., 2020 ; Wang et al., 2020a ). A single study by Wang et al., 2020b reported that people with higher education and professional jobs exhibited more depressive symptoms in comparison to less educated individuals and those in service or enterprise industries.

Other predictive factors for symptoms of depression included living in urban areas, poor self-rated health, high loneliness, being divorced/widowed, being single, lower household income, quarantine status, worry about being infected, property damage, unemployment, not having a child, a past history of mental stress or medical problems, having an acquaintance infected with COVID-19, perceived risks of unemployment, exposure to COVID-19 related news, higher perceived vulnerability, lower self-efficacy to protect themselves, the presence of chronic diseases, and the presence of specific physical symptoms ( Gao et al., 2020 ; González-Sanguino et al., 2020 ; Lei et al., 2020 ; Mazza et al., 2020 ; Olagoke et al., 2020 ; Ozamiz-Etxebarria et al., 2020 ; Özdin and Özdin, 2020 ; Wang et al., 2020a ).

3.6. Symptoms of anxiety and associated risk factors

Anxiety symptoms were assessed in 11 out of the 19 studies, with a noticeable variation in the prevalence of anxiety symptoms ranging from 6.33% to 50.9% ( Ahmed et al., 2020 ; Gao et al., 2020 ; González-Sanguino et al., 2020 ; Huang and Zhao, 2020 ; Lei et al., 2020 ; Mazza et al., 2020 ; Moghanibashi-Mansourieh, 2020 ; Ozamiz-Etxebarria et al., 2020 ; Özdin and Özdin, 2020 ; Wang et al., 2020a ; Wang et al., 2020b ).

Anxiety is often comorbid with depression ( Choi et al., 2020 ). Some predictive factors for depressive symptoms also apply to symptoms of anxiety, including a younger age group (≤40 years), lower education levels, poor self-rated health, high loneliness, female gender, divorced/widowed status, quarantine status, worry about being infected, property damage, history of mental health issue/medical problems, presence of chronic illness, living in urban areas, and the presence of specific physical symptoms ( Ahmed et al., 2020 ; Gao et al., 2020 ; González-Sanguino et al., 2020 ; Huang and Zhao, 2020 ; Lei et al., 2020 ; Mazza et al., 2020 ;  Moghanibashi-Mansourieh, 2020 ; Ozamiz-Etxebarria et al., 2020 ; Ozamiz-Etxebarria et al., 2020 ; Wang et al., 2020a ; Wang et al., 2020b ).

Additionally, social media exposure or frequent exposure to news/information concerning COVID-19 was positively associated with symptoms of anxiety ( Gao et al., 2020 ; Moghanibashi-Mansourieh, 2020 ). With respect to marital status, one study reported that married participants had higher levels of anxiety when compared to unmarried participants ( Gao et al., 2020 ). On the other hand, Lei et al. (2020) found that divorced/widowed participants developed more anxiety symptoms than single or married individuals. A prolonged period of quarantine was also correlated with higher risks of anxiety symptoms. Intuitively, contact history with COVID-positive patients or objects may lead to more anxiety symptoms, which is noted in one study ( Moghanibashi-Mansourieh, 2020 ).

3.7. Symptoms of PTSD/ psychological distress/stress and associated risk factors

With respect to PTSD symptoms, similar prevalence rates were reported by Zhang and Ma (2020) and N. Liu et al. (2020) at 7.6% and 7%, respectively. Despite using the same measurement scale as Zhang and Ma (2020) (i.e., IES), Wang et al. (2020a) noted a remarkably different result, with 53.8% of the participants reporting moderate-to-severe psychological impact. González et al. ( González-Sanguino et al., 2020 ) noted 15.8% of participants with PTSD symptoms. Three out of the four studies that measured the traumatic effects of COVID-19 reported that the female gender was more susceptible to develop symptoms of PTSD. In contrast, the research conducted by Zhang and Ma (2020) found no significant difference in IES scores between females and males. Other risk factors included loneliness, individuals currently residing in Wuhan or those who have been to Wuhan in the past several weeks (the hardest-hit city in China), individuals with higher susceptibility to the virus, poor sleep quality, student status, poor self-rated health, and the presence of specific physical symptoms. Besides sex, Zhang and Ma (2020) found that age, BMI, and education levels are also not correlated with IES-scores.

Non-specific psychological distress was also assessed in three studies. One study reported a prevalence rate of symptoms of psychological distress at 38% ( Moccia et al., 2020 ), while another study from Qiu et al. (2020) reported a prevalence of 34.43%. The study from Wang et al. (2020) did not explicitly state the prevalence rates, but the associated risk factors for higher psychological distress symptoms were reported (i.e., younger age groups and female gender are more likely to develop psychological distress) ( Qiu et al., 2020 ; Wang et al., 2020 ). Other predictive factors included being migrant workers, profound regional severity of the outbreak, unmarried status, the history of visiting Wuhan in the past month, higher self-perceived impacts of the epidemic ( Qiu et al., 2020 ; Wang et al., 2020 ). Interestingly, researchers have identified personality traits to be predictive of psychological distresses. For example, persons with negative coping styles, cyclothymic, depressive, and anxious temperaments exhibit greater susceptibility to psychological outcomes ( Wang et al., 2020 ; Moccia et al., 2020 ).

The intensity of overall stress was evaluated and reported in four studies. The prevalence of overall stress was variably reported between 8.1% to over 81.9% ( Wang et al., 2020a ; Samadarshi et al., 2020 ; Mazza et al., 2020 ). Females and the younger age group are often associated with higher stress levels as compared to males and the elderly. Other predictive factors of higher stress levels include student status, a higher number of lockdown days, unemployment, having to go out to work, having an acquaintance infected with the virus, presence of chronic illnesses, poor self-rated health, and presence of specific physical symptoms ( Wang et al., 2020a ; Samadarshi et al., 2020 ; Mazza et al., 2020 ).

3.8. A separate analysis of negative psychological outcomes

Out of the nineteen included studies, five studies appeared to be more representative of the general population based on the results of study quality appraisal ( Table 1 ). A separate analysis was conducted for a more generalizable conclusion. According to the results of these studies, the rates of negative psychological outcomes were moderate but higher than usual, with anxiety symptoms ranging from 6.33% to 18.7%, depressive symptoms ranging from 14.6% to 32.8%, stress symptoms being 27.2%, and symptoms of PTSD being approximately 7% ( Lei et al., 2020 ; Liu et al., 2020 ; Mazza et al., 2020 ; Wang et al., 2020b ; Zhang et al., 2020 ). In these studies, female gender, younger age group (≤40 years), and student population were repetitively reported to exhibit more adverse psychiatric symptoms.

3.9. Protective factors against symptoms of mental disorders

In addition to associated risk factors, a few studies also identified factors that protect individuals against symptoms of psychological illnesses during the pandemic. Timely dissemination of updated and accurate COVID-19 related health information from authorities was found to be associated with lower levels of anxiety, stress, and depressive symptoms in the general public ( Wang et al., 2020a ). Additionally, actively carrying out precautionary measures that lower the risk of infection, such as frequent handwashing, mask-wearing, and less contact with people also predicted lower psychological distress levels during the pandemic ( Wang et al., 2020a ). Some personality traits were shown to correlate with positive psychological outcomes. Individuals with positive coping styles, secure and avoidant attachment styles usually presented fewer symptoms of anxiety and stress ( Wang et al., 2020 ; Moccia et al., 2020 ). ( Zhang et al. 2020 ) also found that participants with more social support and time to rest during the pandemic exhibited lower stress levels.

4. Discussion

Our review explored the mental health status of the general population and its predictive factors amid the COVID-19 pandemic. Generally, there is a higher prevalence of symptoms of adverse psychiatric outcomes among the public when compared to the prevalence before the pandemic ( Huang et al., 2019 ; Lim et al., 2018 ). Variations in prevalence rates across studies were noticed, which could have resulted from various measurement scales, differential reporting patterns, and possibly international/cultural differences. For example, some studies reported any participants with scores above the cut-off point (mild-to-severe symptoms), while others only included participants with moderate-to-severe symptoms ( Moghanibashi-Mansourieh, 2020 ; Wang et al., 2020a ). Regional differences existed with respect to the general public's psychological health during a massive disease outbreak due to varying degrees of outbreak severity, national economy, government preparedness, availability of medical supplies/ facilities, and proper dissemination of COVID-related information. Additionally, the stage of the outbreak in each region also affected the psychological responses of the public. Symptoms of adverse psychological outcomes were more commonly seen at the beginning of the outbreak when individuals were challenged by mandatory quarantine, unexpected unemployment, and uncertainty associated with the outbreak ( Ho et al., 2020 ). When evaluating the psychological impacts incurred by the coronavirus outbreak, the duration of psychiatric symptoms should also be taken into consideration since acute psychological responses to stressful or traumatic events are sometimes protective and of evolutionary importance ( Yaribeygi et al., 2017 ; Brosschot et al., 2016 ; Gilbert, 2006 ). Being anxious and stressed about the outbreak mobilizes people and forces them to implement preventative measures to protect themselves. Follow-up studies after the pandemic may be needed to assess the long-term psychological impacts of the COVID-19 pandemic.

4.1. Populations with greater susceptibility

Several predictive factors were identified from the studies. For example, females tended to be more vulnerable to develop the symptoms of various forms of mental disorders during the pandemic, including depression, anxiety, PTSD, and stress, as reported in our included studies ( Ahmed et al., 2020 ; Gao et al., 2020 ; Lei et al., 2020 ). Greater psychological distress arose in women partially because they represent a higher percentage of the workforce that may be negatively affected by COVID-19, such as retail, service industry, and healthcare. In addition to the disproportionate effects that disruption in the employment sector has had on women, several lines of research also indicate that women exhibit differential neurobiological responses when exposed to stressors, perhaps providing the basis for the overall higher rate of select mental disorders in women ( Goel et al., 2014 ; Eid et al., 2019 ).

Individuals under 40 years old also exhibited more adverse psychological symptoms during the pandemic ( Ahmed et al., 2020 ; Gao et al., 2020 ; Huang and Zhao, 2020 ). This finding may in part be due to their caregiving role in families (i.e., especially women), who provide financial and emotional support to children or the elderly. Job loss and unpredictability caused by the COVID-19 pandemic among this age group could be particularly stressful. Also, a large proportion of individuals under 40 years old consists of students who may also experience more emotional distress due to school closures, cancelation of social events, lower study efficiency with remote online courses, and postponements of exams ( Cao et al., 2020 ). This is consistent with our findings that student status was associated with higher levels of depressive symptoms and PTSD symptoms during the COVID-19 outbreak ( Lei et al., 2020 ; Olagoke et al., 2020 , Wang et al., 2020a ; Samadarshi et al., 2020 ).

People with chronic diseases and a history of medical/ psychiatric illnesses showed more symptoms of anxiety and stress ( Mazza et al., 2020 ; Ozamiz-Etxebarria et al., 2020 ; Özdin and Özdin, 2020 ). The anxiety and distress of chronic disease sufferers towards the coronavirus infection partly stem from their compromised immunity caused by pre-existing conditions, which renders them susceptible to the infection and a higher risk of mortality, such as those with systemic lupus erythematosus ( Sawalha et al., 2020 ). Several reports also suggested that a substantially higher death rate was noted in patients with diabetes, hypertension and other coronary heart diseases, yet the exact causes remain unknown ( Guo et al., 2020 ; Emami et al., 2020 ), leaving those with these common chronic conditions in fear and uncertainty. Additionally, another practical aspect of concern for patients with pre-existing conditions would be postponement and inaccessibility to medical services and treatment as a result of the COVID-19 pandemic. For example, as a rapidly growing number of COVID-19 patients were utilizing hospital and medical resources, primary, secondary, and tertiary prevention of other diseases may have unintentionally been affected. Individuals with a history of mental disorders or current diagnoses of psychiatric illnesses are also generally more sensitive to external stressors, such as social isolation associated with the pandemic ( Ho et al., 2020 ).

4.2. COVID-19 related psychological stressors

Several studies identified frequent exposure to social media/news relating to COVID-19 as a cause of anxiety and stress symptoms ( Gao et al., 2020 ; Moghanibashi-Mansourieh, 2020 ). Frequent social media use exposes oneself to potential fake news/reports/disinformation and the possibility for amplified anxiety. With the unpredictable situation and a lot of unknowns about the novel coronavirus, misinformation and fake news are being easily spread via social media platforms ( Erku et al., 2020 ), creating unnecessary fears and anxiety. Sadness and anxious feelings could also arise when constantly seeing members of the community suffering from the pandemic via social media platforms or news reports ( Li et al., 2020 ).

Reports also suggested that poor economic status, lower education level, and unemployment are significant risk factors for developing symptoms of mental disorders, especially depressive symptoms during the pandemic period ( Gao et al., 2020 ; Lei et al., 2020 ; Mazza et al., 2020 ; Olagoke et al., 2020 ;). The coronavirus outbreak has led to strictly imposed stay-home-order and a decrease in demands for services and goods ( Nicola et al., 2020 ), which has adversely influenced local businesses and industries worldwide. Surges in unemployment rates were noted in many countries ( Statistics Canada, 2020 ; Statista, 2020 ). A decrease in quality of life and uncertainty as a result of financial hardship can put individuals into greater risks for developing adverse psychological symptoms ( Ng et al., 2013 ).

4.3. Efforts to reduce symptoms of mental disorders

4.3.1. policymaking.

The associated risk and protective factors shed light on policy enactment in an attempt to relieve the psychological impacts of the COVID-19 pandemic on the general public. Firstly, more attention and assistance should be prioritized to the aforementioned vulnerable groups of the population, such as the female gender, people from age group ≤40, college students, and those suffering from chronic/psychiatric illnesses. Secondly, governments must ensure the proper and timely dissemination of COVID-19 related information. For example, validation of news/reports concerning the pandemic is essential to prevent panic from rumours and false information. Information about preventative measures should also be continuously updated by health authorities to reassure those who are afraid of being infected ( Tran, et al., 2020a ). Thirdly, easily accessible mental health services are critical during the period of prolonged quarantine, especially for those who are in urgent need of psychological support and individuals who reside in rural areas ( Tran et al., 2020b ). Since in-person health services are limited and delayed as a result of COVID-19 pandemic, remote mental health services can be delivered in the form of online consultation and hotlines ( Liu et al., 2020 ; Pisciotta et al., 2019 ). Last but not least, monetary support (e.g. beneficial funds, wage subsidy) and new employment opportunities could be provided to people who are experiencing financial hardship or loss of jobs owing to the pandemic. Government intervention in the form of financial provisions, housing support, access to psychiatric first aid, and encouragement at the individual level of healthy lifestyle behavior has been shown effective in alleviating suicide cases associated with economic recession ( McIntyre and Lee, 2020a ). For instance, declines in suicide incidence were observed to be associated with government expenses in Japan during the 2008 economic depression ( McIntyre and Lee, 2020a ).

4.3.2. Individual efforts

Individuals can also take initiatives to relieve their symptoms of psychological distress. For instance, exercising regularly and maintaining a healthy diet pattern have been demonstrated to effectively ease and prevent symptoms of depression or stress ( Carek et al., 2011 ; Molendijk et al., 2018 ; Lassale et al., 2019 ). With respect to pandemic-induced symptoms of anxiety, it is also recommended to distract oneself from checking COVID-19 related news to avoid potential false reports and contagious negativity. It is also essential to obtain COVID-19 related information from authorized news agencies and organizations and to seek medical advice only from properly trained healthcare professionals. Keeping in touch with friends and family by phone calls or video calls during quarantine can ease the distress from social isolation ( Hwang et al., 2020 ).

4.4. Strengths

Our paper is the first systematic review that examines and summarizes existing literature with relevance to the psychological health of the general population during the COVID-19 outbreak and highlights important associated risk factors to provide suggestions for addressing the mental health crisis amid the global pandemic.

4.5. Limitations

Certain limitations apply to this review. Firstly, the description of the study findings was qualitative and narrative. A more objective systematic review could not be conducted to examine the prevalence of each psychological outcome due to a high heterogeneity across studies in the assessment tools used and primary outcomes measured. Secondly, all included studies followed a cross-sectional study design and, as such, causal inferences could not be made. Additionally, all studies were conducted via online questionnaires independently by the study participants, which raises two concerns: 1] Individual responses in self-assessment vary in objectivity when supervision from a professional psychiatrist/ interviewer is absent, 2] People with poor internet accessibility were likely not included in the study, creating a selection bias in the population studied. Another concern is the over-representation of females in most studies. Selection bias and over-representation of particular groups indicate that most studies may not be representative of the true population. Importantly, studies in inclusion were conducted in a limited number of countries. Thus generalizations of mental health among the general population at a global level should be made cautiously.

5. Conclusion

This systematic review examined the psychological status of the general public during the COVID-19 pandemic and stressed the associated risk factors. A high prevalence of adverse psychiatric symptoms was reported in most studies. The COVID-19 pandemic represents an unprecedented threat to mental health in high, middle, and low-income countries. In addition to flattening the curve of viral transmission, priority needs to be given to the prevention of mental disorders (e.g. major depressive disorder, PTSD, as well as suicide). A combination of government policy that integrates viral risk mitigation with provisions to alleviate hazards to mental health is urgently needed.

Authorship contribution statement

JX contributed to the overall design, article selection , review, and manuscript preparation. LL and JX contributed to study quality appraisal. All other authors contributed to review, editing, and submission.

Declaration of Competing Interest

Acknowledgements.

RSM has received research grant support from the Stanley Medical Research Institute and the Canadian Institutes of Health Research/Global Alliance for Chronic Diseases/National Natural Science Foundation of China and speaker/consultation fees from Lundbeck, Janssen, Shire, Purdue, Pfizer, Otsuka, Allergan, Takeda, Neurocrine, Sunovion, and Minerva.

Supplementary material associated with this article can be found, in the online version, at doi: 10.1016/j.jad.2020.08.001 .

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• 07 October 2021

Young people’s mental health is finally getting the attention it needs

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A kite-flying festival in a refugee camp near Syria’s border with Turkey. The event was organized in July 2020 to support the health and well-being of children fleeing violence in Syria. Credit: Muhammed Said/Anadolu Agency/Getty

Worldwide, at least 13% of people between the ages of 10 and 19 live with a diagnosed mental-health disorder, according to the latest State of the World’s Children report , published this week by the United Nations children’s charity UNICEF. It’s the first time in the organization’s history that this flagship report has tackled the challenges in and opportunities for preventing and treating mental-health problems among young people. It reveals that adolescent mental health is highly complex, understudied — and underfunded. These findings are echoed in a parallel collection of review articles published this week in a number of Springer Nature journals.

Anxiety and depression constitute more than 40% of mental-health disorders among young people (those aged 10–19). UNICEF also reports that, worldwide, suicide is the fourth most-common cause of death (after road injuries, tuberculosis and interpersonal violence) among adolescents (aged 15–19). In eastern Europe and central Asia, suicide is the leading cause of death for young people in that age group — and it’s the second-highest cause in western Europe and North America.

Collection: Promoting youth mental health

Sadly, psychological distress among young people seems to be rising. One study found that rates of depression among a nationally representative sample of US adolescents (aged 12 to 17) increased from 8.5% of young adults to 13.2% between 2005 and 2017 1 . There’s also initial evidence that the coronavirus pandemic is exacerbating this trend in some countries. For example, in a nationwide study 2 from Iceland, adolescents (aged 13–18) reported significantly more symptoms of mental ill health during the pandemic than did their peers before it. And girls were more likely to experience these symptoms than were boys.

Although most mental-health disorders arise during adolescence, UNICEF says that only one-third of investment in mental-health research is targeted towards young people. Moreover, the research itself suffers from fragmentation — scientists involved tend to work inside some key disciplines, such as psychiatry, paediatrics, psychology and epidemiology, and the links between research and health-care services are often poor. This means that effective forms of prevention and treatment are limited, and lack a solid understanding of what works, in which context and why.

This week’s collection of review articles dives deep into the state of knowledge of interventions — those that work and those that don’t — for preventing and treating anxiety and depression in young people aged 14–24. In some of the projects, young people with lived experience of anxiety and depression were co-investigators, involved in both the design and implementation of the reviews, as well as in interpretation of the findings.

Quest for new therapies

Worldwide, the most common treatment for anxiety and depression is a class of drug called selective serotonin reuptake inhibitors, which increase serotonin levels in the brain and are intended to enhance emotion and mood. But their modest efficacy and substantial side effects 3 have spurred the study of alternative physiological mechanisms that could be involved in youth depression and anxiety, so that new therapeutics can be developed.

Mental health: build predictive models to steer policy

For example, researchers have been investigating potential links between depression and inflammatory disorders — such as asthma, cardiovascular disease and inflammatory bowel disease. This is because, in many cases, adults with depression also experience such disorders. Moreover, there’s evidence that, in mice, changes to the gut microbiota during development reduce behaviours similar to those linked to anxiety and depression in people 4 . That suggests that targeting the gut microbiome during adolescence could be a promising avenue for reducing anxiety in young people. Kathrin Cohen Kadosh at the University of Surrey in Guildford, UK, and colleagues reviewed existing reports of interventions in which diets were changed to target the gut microbiome. These were found to have had minimal effect on youth anxiety 5 . However, the authors urge caution before such a conclusion can be confirmed, citing methodological limitations (including small sample sizes) among the studies they reviewed. They say the next crop of studies will need to involve larger-scale clinical trials.

By contrast, researchers have found that improving young people’s cognitive and interpersonal skills can be more effective in preventing and treating anxiety and depression under certain circumstances — although the reason for this is not known. For instance, a concept known as ‘decentring’ or ‘psychological distancing’ (that is, encouraging a person to adopt an objective perspective on negative thoughts and feelings) can help both to prevent and to alleviate depression and anxiety, report Marc Bennett at the University of Cambridge, UK, and colleagues 6 , although the underlying neurobiological mechanisms are unclear.

In addition, Alexander Daros at the Campbell Family Mental Health Institute in Toronto, Canada, and colleagues report a meta-analysis of 90 randomized controlled trials. They found that helping young people to improve their emotion-regulation skills, which are needed to control emotional responses to difficult situations, enables them to cope better with anxiety and depression 7 . However, it is still unclear whether better regulation of emotions is the cause or the effect of these improvements.

Co-production is essential

It’s uncommon — but increasingly seen as essential — that researchers working on treatments and interventions are directly involving young people who’ve experienced mental ill health. These young people need to be involved in all aspects of the research process, from conceptualizing to and designing a study, to conducting it and interpreting the results. Such an approach will lead to more-useful science, and will lessen the risk of developing irrelevant or inappropriate interventions.

Science careers and mental health

Two such young people are co-authors in a review from Karolin Krause at the Centre for Addiction and Mental Health in Toronto, Canada, and colleagues. The review explored whether training in problem solving helps to alleviate depressive symptoms 8 . The two youth partners, in turn, convened a panel of 12 other youth advisers, and together they provided input on shaping how the review of the evidence was carried out and on interpreting and contextualizing the findings. The study concluded that, although problem-solving training could help with personal challenges when combined with other treatments, it doesn’t on its own measurably reduce depressive symptoms.

The overarching message that emerges from these reviews is that there is no ‘silver bullet’ for preventing and treating anxiety and depression in young people — rather, prevention and treatment will need to rely on a combination of interventions that take into account individual needs and circumstances. Higher-quality evidence is also needed, such as large-scale trials using established protocols.

Along with the UNICEF report, the studies underscore the transformational part that funders must urgently play, and why researchers, clinicians and communities must work together on more studies that genuinely involve young people as co-investigators. Together, we can all do better to create a brighter, healthier future for a generation of young people facing more challenges than ever before.

Nature 598 , 235-236 (2021)

doi: https://doi.org/10.1038/d41586-021-02690-5

Twenge, J. M., Cooper, A. B., Joiner, T. E., Duffy, M. E. & Binau, S. G. J. Abnorm. Psychol. 128 , 185–199 (2019).

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Thorisdottir, I. E. et al. Lancet Psychiatr. 8 , 663–672 (2021).

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Murray, E. et al. Brain Behav. Immun. 81 , 198–212 (2019).

Cohen Kadosh, K. et al. Transl. Psychiatr. 11 , 352 (2021).

Bennett, M. P. et al. Transl Psychiatr. 11 , 288 (2021).

Daros, A. R. et al. Nature Hum. Behav . https://doi.org/10.1038/s41562-021-01191-9 (2021).

Krause, K. R. et al. BMC Psychiatr. 21 , 397 (2021).

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September National Health Observances: Healthy Aging, Sickle Cell Disease, and More

Each month, we feature select National Health Observances (NHOs) that align with our priorities for improving health across the nation. In September, we’re raising awareness about healthy aging, sickle cell disease, substance use recovery, and HIV/AIDS. 

Below, you’ll find resources to help you spread the word about these NHOs with your audiences. 

• Healthy Aging Month Each September, we celebrate Healthy Aging Month to promote ways people can stay healthy as they age. Explore our healthy aging resources , bookmark the Healthy People 2030 and Older Adults page , share our Move Your Way® materials for older adults , and check out the Physical Activity Guidelines for Americans Midcourse Report . You can also share resources related to healthy aging from the National Institute on Aging — and register for the 2024 National Healthy Aging Symposium to hear from experts on innovations to improve the health and well-being of older adults.
• National Recovery Month The Substance Abuse and Mental Health Services Administration (SAMHSA) sponsors National Recovery Month to raise awareness about mental health and addiction recovery. Share our MyHealthfinder resources on substance use and misuse — and be sure to check out Healthy People 2030’s evidence-based resources related to drug and alcohol use . 
• National Sickle Cell Awareness Month National Sickle Cell Awareness Month is a time to raise awareness and support people living with sickle cell disease. Help your community learn about sickle cell disease by sharing these resources from the National Heart, Lung, and Blood Institute (NHLBI) . You can also encourage new and expecting parents to learn about screening their newborn baby for sickle cell . And be sure to view our Healthy People 2030 objectives on improving health for people who have blood disorders .
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• National Gay Men’s HIV/AIDS Awareness Day (September 27) National Gay Men’s HIV/AIDS Awareness Day on September 27 highlights the impact of HIV on gay and bisexual men and promotes strategies to encourage testing. Get involved by sharing CDC’s social media toolkit and HIV information to encourage men to get tested — and share our MyHealthfinder resources to help people get tested for HIV and talk with their doctor about testing .

We hope you’ll join us in promoting these important NHOs with your networks to help improve health across the nation!

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