case study about depression

Mental Health Case Study: Understanding Depression through a Real-life Example

Through the lens of a gripping real-life case study, we delve into the depths of depression, unraveling its complexities and shedding light on the power of understanding mental health through individual experiences. Mental health case studies serve as invaluable tools in our quest to comprehend the intricate workings of the human mind and the various conditions that can affect it. By examining real-life examples, we gain profound insights into the lived experiences of individuals grappling with mental health challenges, allowing us to develop more effective strategies for diagnosis, treatment, and support.

The Importance of Case Studies in Understanding Mental Health

Case studies play a crucial role in the field of mental health research and practice. They provide a unique window into the personal narratives of individuals facing mental health challenges, offering a level of detail and context that is often missing from broader statistical analyses. By focusing on specific cases, researchers and clinicians can gain a deeper understanding of the complex interplay between biological, psychological, and social factors that contribute to mental health conditions.

One of the primary benefits of using real-life examples in mental health case studies is the ability to humanize the experience of mental illness. These narratives help to break down stigma and misconceptions surrounding mental health conditions, fostering empathy and understanding among both professionals and the general public. By sharing the stories of individuals who have faced and overcome mental health challenges, case studies can also provide hope and inspiration to those currently struggling with similar issues.

Depression, in particular, is a common mental health condition that affects millions of people worldwide. Disability Function Report Example Answers for Depression and Bipolar: A Comprehensive Guide offers valuable insights into how depression can impact daily functioning and the importance of accurate reporting in disability assessments. By examining depression through the lens of a case study, we can gain a more nuanced understanding of its manifestations, challenges, and potential treatment approaches.

Understanding Depression

Before delving into our case study, it’s essential to establish a clear understanding of depression and its impact on individuals and society. Depression is a complex mental health disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities. It can affect a person’s thoughts, emotions, behaviors, and overall well-being.

Some common symptoms of depression include:

– Persistent sad, anxious, or “empty” mood – Feelings of hopelessness or pessimism – Irritability – Loss of interest or pleasure in hobbies and activities – Decreased energy or fatigue – Difficulty concentrating, remembering, or making decisions – Sleep disturbances (insomnia or oversleeping) – Appetite and weight changes – Physical aches or pains without clear physical causes – Thoughts of death or suicide

The prevalence of depression worldwide is staggering. According to the World Health Organization, more than 264 million people of all ages suffer from depression globally. It is a leading cause of disability and contributes significantly to the overall global burden of disease. The impact of depression extends far beyond the individual, affecting families, communities, and economies.

Depression can have profound consequences on an individual’s quality of life, relationships, and ability to function in daily activities. It can lead to decreased productivity at work or school, strained personal relationships, and increased risk of other health problems. The economic burden of depression is also substantial, with costs associated with healthcare, lost productivity, and disability.

The Significance of Case Studies in Mental Health Research

Case studies serve as powerful tools in mental health research, offering unique insights that complement broader statistical analyses and controlled experiments. They allow researchers and clinicians to explore the nuances of individual experiences, providing a rich tapestry of information that can inform our understanding of mental health conditions and guide the development of more effective treatment strategies.

One of the key advantages of case studies is their ability to capture the complexity of mental health conditions. Unlike standardized questionnaires or diagnostic criteria, case studies can reveal the intricate interplay between biological, psychological, and social factors that contribute to an individual’s mental health. This holistic approach is particularly valuable in understanding conditions like depression, which often have multifaceted causes and manifestations.

Case studies also play a crucial role in the development of treatment strategies. By examining the detailed accounts of individuals who have undergone various interventions, researchers and clinicians can identify patterns of effectiveness and potential barriers to treatment. This information can then be used to refine existing approaches or develop new, more targeted interventions.

Moreover, case studies contribute to the advancement of mental health research by generating hypotheses and identifying areas for further investigation. They can highlight unique aspects of a condition or treatment that may not be apparent in larger-scale studies, prompting researchers to explore new avenues of inquiry.

Examining a Real-life Case Study of Depression

To illustrate the power of case studies in understanding depression, let’s examine the story of Sarah, a 32-year-old marketing executive who sought help for persistent feelings of sadness and loss of interest in her once-beloved activities. Sarah’s case provides a compelling example of how depression can manifest in high-functioning individuals and the challenges they face in seeking and receiving appropriate treatment.

Background: Sarah had always been an ambitious and driven individual, excelling in her career and maintaining an active social life. However, over the past year, she began to experience a gradual decline in her mood and energy levels. Initially, she attributed these changes to work stress and the demands of her busy lifestyle. As time went on, Sarah found herself increasingly isolated, withdrawing from friends and family, and struggling to find joy in activities she once loved.

Presentation of Symptoms: When Sarah finally sought help from a mental health professional, she presented with the following symptoms:

– Persistent feelings of sadness and emptiness – Loss of interest in hobbies and social activities – Difficulty concentrating at work – Insomnia and daytime fatigue – Unexplained physical aches and pains – Feelings of worthlessness and guilt – Occasional thoughts of death, though no active suicidal ideation

Initial Diagnosis: Based on Sarah’s symptoms and their duration, her therapist diagnosed her with Major Depressive Disorder (MDD). This diagnosis was supported by the presence of multiple core symptoms of depression that had persisted for more than two weeks and significantly impacted her daily functioning.

The Treatment Journey

Sarah’s case study provides an opportunity to explore the various treatment options available for depression and examine their effectiveness in a real-world context. Supporting a Caseworker’s Client Who Struggles with Depression offers valuable insights into the role of support systems in managing depression, which can complement professional treatment approaches.

Overview of Treatment Options: There are several evidence-based treatments available for depression, including:

1. Psychotherapy: Various forms of talk therapy, such as Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT), can help individuals identify and change negative thought patterns and behaviors associated with depression.

2. Medication: Antidepressants, such as Selective Serotonin Reuptake Inhibitors (SSRIs), can help regulate brain chemistry and alleviate symptoms of depression.

3. Combination Therapy: Many individuals benefit from a combination of psychotherapy and medication.

4. Lifestyle Changes: Exercise, improved sleep habits, and stress reduction techniques can complement other treatments.

5. Alternative Therapies: Some individuals find relief through approaches like mindfulness meditation, acupuncture, or light therapy.

Treatment Plan for Sarah: After careful consideration of Sarah’s symptoms, preferences, and lifestyle, her treatment team developed a comprehensive plan that included:

1. Weekly Cognitive Behavioral Therapy sessions to address negative thought patterns and develop coping strategies.

2. Prescription of an SSRI antidepressant to help alleviate her symptoms.

3. Recommendations for lifestyle changes, including regular exercise and improved sleep hygiene.

4. Gradual reintroduction of social activities and hobbies to combat isolation.

Effectiveness of the Treatment Approach: Sarah’s response to treatment was monitored closely over the following months. Initially, she experienced some side effects from the medication, including mild nausea and headaches, which subsided after a few weeks. As she continued with therapy and medication, Sarah began to notice gradual improvements in her mood and energy levels.

The CBT sessions proved particularly helpful in challenging Sarah’s negative self-perceptions and developing more balanced thinking patterns. She learned to recognize and reframe her automatic negative thoughts, which had been contributing to her feelings of worthlessness and guilt.

The combination of medication and therapy allowed Sarah to regain the motivation to engage in physical exercise and social activities. As she reintegrated these positive habits into her life, she experienced further improvements in her mood and overall well-being.

The Outcome and Lessons Learned

Sarah’s journey through depression and treatment offers valuable insights into the complexities of mental health and the effectiveness of various interventions. Understanding the Link Between Sapolsky and Depression provides additional context on the biological underpinnings of depression, which can complement the insights gained from individual case studies.

Progress and Challenges: Over the course of six months, Sarah made significant progress in managing her depression. Her mood stabilized, and she regained interest in her work and social life. She reported feeling more energetic and optimistic about the future. However, her journey was not without challenges. Sarah experienced setbacks during particularly stressful periods at work and struggled with the stigma associated with taking medication for mental health.

One of the most significant challenges Sarah faced was learning to prioritize her mental health in a high-pressure work environment. She had to develop new boundaries and communication strategies to manage her workload effectively without compromising her well-being.

Key Lessons Learned: Sarah’s case study highlights several important lessons about depression and its treatment:

1. Early intervention is crucial: Sarah’s initial reluctance to seek help led to a prolongation of her symptoms. Recognizing and addressing mental health concerns early can prevent the condition from worsening.

2. Treatment is often multifaceted: The combination of medication, therapy, and lifestyle changes proved most effective for Sarah, underscoring the importance of a comprehensive treatment approach.

3. Recovery is a process: Sarah’s improvement was gradual and non-linear, with setbacks along the way. This emphasizes the need for patience and persistence in mental health treatment.

4. Social support is vital: Reintegrating social activities and maintaining connections with friends and family played a crucial role in Sarah’s recovery.

5. Workplace mental health awareness is essential: Sarah’s experience highlights the need for greater understanding and support for mental health issues in professional settings.

6. Stigma remains a significant barrier: Despite her progress, Sarah struggled with feelings of shame and fear of judgment related to her depression diagnosis and treatment.

Sarah’s case study provides a vivid illustration of the complexities of depression and the power of comprehensive, individualized treatment approaches. By examining her journey, we gain valuable insights into the lived experience of depression, the challenges of seeking and maintaining treatment, and the potential for recovery.

The significance of case studies in understanding and treating mental health conditions cannot be overstated. They offer a level of detail and nuance that complements broader research methodologies, providing clinicians and researchers with invaluable insights into the diverse manifestations of mental health disorders and the effectiveness of various interventions.

As we continue to explore mental health through case studies, it’s important to recognize the diversity of experiences within conditions like depression. Personal Bipolar Psychosis Stories: Understanding Bipolar Disorder Through Real Experiences offers insights into another complex mental health condition, illustrating the range of experiences individuals may face.

Furthermore, it’s crucial to consider how mental health issues are portrayed in popular culture, as these representations can shape public perceptions. Understanding Mental Disorders in Winnie the Pooh: Exploring the Depiction of Depression provides an interesting perspective on how mental health themes can be embedded in seemingly lighthearted stories.

The field of mental health research and treatment continues to evolve, driven by the insights gained from individual experiences and comprehensive studies. By combining the rich, detailed narratives provided by case studies with broader research methodologies, we can develop more effective, personalized approaches to mental health care. As we move forward, it is essential to continue exploring and sharing these stories, fostering greater understanding, empathy, and support for those facing mental health challenges.

References:

1. World Health Organization. (2021). Depression. Retrieved from https://www.who.int/news-room/fact-sheets/detail/depression

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

3. Beck, A. T., & Alford, B. A. (2009). Depression: Causes and treatment. University of Pennsylvania Press.

4. Cuijpers, P., Quero, S., Dowrick, C., & Arroll, B. (2019). Psychological treatment of depression in primary care: Recent developments. Current Psychiatry Reports, 21(12), 129.

5. Malhi, G. S., & Mann, J. J. (2018). Depression. The Lancet, 392(10161), 2299-2312.

6. Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., … & Schatzberg, A. F. (2016). Major depressive disorder. Nature Reviews Disease Primers, 2(1), 1-20.

7. Sapolsky, R. M. (2004). Why zebras don’t get ulcers: The acclaimed guide to stress, stress-related diseases, and coping. Holt paperbacks.

8. Yin, R. K. (2017). Case study research and applications: Design and methods. Sage publications.

Similar Posts

The Link Between Kyleena and Depression: Separating Fact from Fiction

Amidst swirling rumors and heated debates, the potential link between Kyleena, a popular contraceptive, and depression has sparked intense curiosity and concern among women worldwide. This topic has become a focal point of discussion in women’s health circles, prompting a closer examination of the relationship between hormonal contraceptives and mental health. Kyleena, a hormonal intrauterine…

Prozac vs Lexapro for Anxiety: A Comprehensive Comparison

Whispers of relief dance on chemical tightropes as millions seek solace in the delicate balance between Prozac and Lexapro for their anxiety woes. Anxiety disorders have become increasingly prevalent in our fast-paced, high-stress world, affecting millions of people globally. As individuals grapple with the debilitating effects of anxiety, the medical community has turned to antidepressants…

Can Depression Cause Dry Eyes? Understanding the Link between Depression and Dry Eyes

As tears silently evaporate from both eyes and souls, an unexpected connection between depression and dry eyes emerges, challenging our understanding of mental and physical health. This intriguing relationship between two seemingly unrelated conditions has sparked interest among researchers and healthcare professionals alike, prompting a closer examination of how our emotional well-being may influence our…

Outpatient Depression Treatment: A Comprehensive Guide

Navigating the maze of depression treatment options can be overwhelming, but outpatient care offers a beacon of hope for those seeking effective, flexible support without the constraints of hospitalization. Depression is a complex mental health condition that affects millions of people worldwide, and finding the right treatment approach is crucial for recovery and long-term well-being….

The Potential Benefits of Delta-8 for Anxiety and Depression

Amidst the swirling debate surrounding cannabis compounds, a lesser-known cannabinoid called Delta-8 is emerging as a potential beacon of hope for those grappling with anxiety and depression. As researchers delve deeper into the world of cannabinoids, Delta-8 has caught the attention of both scientists and individuals seeking alternative treatments for mental health conditions. This article…

Understanding Talk Therapy for Depression: A Comprehensive Guide

Stepping out of the shadows of depression, talk therapy offers a beacon of hope for those seeking to reclaim their mental well-being and rediscover joy in life. For countless individuals grappling with the weight of depression, the journey towards healing can seem daunting and insurmountable. However, talk therapy has emerged as a powerful tool in…

Ohio State nav bar

The Ohio State University

• BuckeyeLink
• Find People
• Search Ohio State

Patient Case Presentation

Figure 1.  Blue and silver stethoscope (Pixabay, N.D.)

Ms. S.W. is a 48-year-old white female who presented to an outpatient community mental health agency for evaluation of depressive symptoms. Over the past eight weeks she has experienced sad mood every day, which she describes as a feeling of hopelessness and emptiness. She also noticed other changes about herself, including decreased appetite, insomnia, fatigue, and poor ability to concentrate. The things that used to bring Ms. S.W. joy, such as gardening and listening to podcasts, are no longer bringing her the same happiness they used to. She became especially concerned as within the past two weeks she also started experiencing feelings of worthlessness, the perception that she is a burden to others, and fleeting thoughts of death/suicide.

Ms. S.W. acknowledges that she has numerous stressors in her life. She reports that her daughter’s grades have been steadily declining over the past two semesters and she is unsure if her daughter will be attending college anymore. Her relationship with her son is somewhat strained as she and his father are not on good terms and her son feels Ms. S.W. is at fault for this. She feels her career has been unfulfilling and though she’d like to go back to school, this isn’t possible given the family’s tight finances/the patient raising a family on a single income.

Ms. S.W. has experienced symptoms of depression previously, but she does not think the symptoms have ever been as severe as they are currently. She has taken antidepressants in the past and was generally adherent to them, but she believes that therapy was more helpful than the medications. She denies ever having history of manic or hypomanic episodes. She has been unable to connect to a mental health agency in several years due to lack of time and feeling that she could manage the symptoms on her own. She now feels that this is her last option and is looking for ongoing outpatient mental health treatment.

Past Medical History

• Hypertension, diagnosed at age 41

Past Surgical History

• Wisdom teeth extraction, age 22

Pertinent Family History

• Mother with history of Major Depressive Disorder, treated with antidepressants
• Maternal grandmother with history of Major Depressive Disorder, Generalized Anxiety Disorder
• Brother with history of suicide attempt and subsequent inpatient psychiatric hospitalization,
• Brother with history of Alcohol Use Disorder
• Father died from lung cancer (2012)

Pertinent Social History

• Works full-time as an enrollment specialist for Columbus City Schools since 2006
• Has two children, a daughter age 17 and a son age 14
• Divorced in 2015, currently single
• History of some emotional abuse and neglect from mother during childhood, otherwise denies history of trauma, including physical and sexual abuse
• Smoking 1/2 PPD of cigarettes
• Occasional alcohol use (approximately 1-2 glasses of wine 1-2 times weekly; patient had not had any alcohol consumption for the past year until two weeks ago)

• Fundamentals of Bipolar Disorder

Fundamentals of Major Depressive Disorder

• Fundamentals of Schizophrenia
• Fundamentals Certificate Program
• Clinical Article Summaries
• Events Calendar
• Interactive Case Study
• Psychopharmacology
• Test Your Knowledge
• Psychiatric Scale NPsychlopedia
• Psychotherapy NPsychlopedia
• Caregiver Resources
• Educate Your Patient
• Quick Guides
• Clinical Insights
• NP Spotlight
• Peer Exchanges

Top results

Patient case navigator: major depressive disorder.

Introduction

Learning Objectives

• How to perform a structured psychiatric interview
• Standardized psychiatric rating scales appropriate for patients with depressive symptoms
• Common barriers to adequate treatment response
• How to assess and monitor patients for treatment side effects and adequate treatment response

Watch the video:

History and Examination

Medical History

Examination

History of Present Illness

Eric is a 60-year-old man who presents to his primary care nurse practitioner, Tina, with irritability, excessive sleeping, and a lack of interest in his usual hobbies, such as attending baseball games and going to the movies with his wife. He also has been spending much time at home alone, watching television, rather than spending time with his friends or wife, as he usually does. Eric recently retired from his job as a general contractor remodeling people’s kitchens and bathrooms. He enjoyed his job very much and felt a sense of pride in helping people make their homes more functional and attractive. However, his job was very physical, and at times stressful, so Eric felt it was time to retire and find something new with which to occupy his time.

Eric was diagnosed with hypothyroidism 5 years ago and has been on medication ever since. Annual lab tests indicate his thyroid levels have remained within the normal range for the past few years. He also has mild hypertension, which is well-controlled at an adequate dose.

Psychosocial History

Eric reports that he has several close friends and that he got along well with people at work. He denies a history of substance misuse and reports that he occasionally drinks a glass of wine with dinner. He does not smoke. Eric describes his marriage as “very good.” He is also close with his adult daughter and enjoys spending time with his 2 grandchildren.

At age 33, Eric experienced a period of depressed mood after losing his job. During that time, he had problems getting out of bed in the morning because he felt hopeless and sad, stopped socializing with friends, and lost about 4 lbs of body weight in 4 weeks without intentionally dieting. He sought treatment from his primary care physician, who referred him to a psychiatrist for medication and a psychologist for outpatient cognitive-behavioral therapy (CBT). Eric worked with his psychiatrist and tried 4 different selective serotonin reuptake inhibitors (SSRIs) before he ultimately found one that seemed to work for him. He and his psychiatrist decided together that he could stop taking the medication after 1 year because his mood had improved and stabilized. He saw his therapist once weekly for approximately 2.5 years and reports that CBT also helped improve his mood and functioning.

Family History

Eric reports that, throughout his life, his mother had “very low periods” when she seemed extremely sad and had trouble functioning. However, she never sought treatment for these episodes.

Eric’s physical examination indicates he is generally healthy for his age. His vital signs are all within the normal range, and the mental status examination indicates he is fully oriented and alert. Eric’s appearance is that of an older man. His affect is flat, and he has trouble making eye contact, often staring at the floor instead.

Patient Interview

Quiz #1: initial presentation and diagnosis, dsm-5 diagnostic criteria for mdd.

MDE Diagnostic Criteria

Safety Plan

Major Depressive Episode (MDE)

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous function; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

• Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
• Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or retardation nearly every day
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt nearly every day
• Diminished ability to think or concentrate, or indecisiveness, nearly every day
• Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of function

C. The episode is not attributable to the physiological effects of a substance or another medical condition

Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.

• It is important to thoroughly review each of these 9 symptoms with your patients when assessing them for MDD.
• Clinical rating scales can help identify which patients require more in-depth screening for depression.

Quiz #2: DSM-5 Diagnostic Criteria for MDD

Scales for mdd.

PHQ-9 Scale Scoring

QIDS Scale Scoring

Patient Health Questionnaire-9 (PHQ-9)

This scale was developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues with an educational grant from Pfizer inc. No permission required.

Scoring Criteria

Kroenke K, Spitzer RL. Psychiatric Annals. 2002;32:509-521.

The Quick Inventory of Depressive Symptomatology (QIDS)

• The QIDS is a 16-item, multiple-choice questionnaire in which depressive symptoms are rated on a 0-3 scale according to severity
• Items are derived from the 9 diagnostic criteria for major depressive disorder used in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), including sadness, loss of interest or pleasure, poor concentration or decision-making, self-outlook, suicidal ideation, lack of energy, sleep disturbance, appetite change, and psychomotor agitation
• Although the QIDS was initially developed based on DSM-IV criteria, the scale is also compatible with the DSM-5. The core criteria for MDD are consistent across these editions

Rush AJ, et al. Biol Psychiatry. 2003;54(5):573-583.

Bernstein IH, et al. Int J Methods Psychiatr Res. 2009;18(2):138-146.

Quiz #3: Scales for MDD

Treatment initiation and monitoring.

APA Guidelines

Eric's PHQ-9 Score

Treatment Options

American Psychiatric Association (APA) Guidelines for Treatment of MDD

1-2 weeks: Improvement from pharmacologic therapy can be seen as early as 1-2 weeks after starting treatment

2-4 weeks: Some patients may achieve improvement in 2-4 weeks

4-6 weeks: Short-term efficacy trials show antidepressant therapy appears to require 4-6 weeks to achieve maximum therapeutic effects

4-8 weeks: The APA recommends 4-8 weeks of adequate* treatment is needed before concluding that a patient is partially responsive or unresponsive to treatment *Adequate dose and duration Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.

*Adequate dose and duration

Practice Guideline for the Treatment of Patients with Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.

Quiz #4: Treatment Initiation and Monitoring

Assessing for treatment challenges.

Treatment Challenges

Eric's Updated PHQ-9 Score

Possible Challenges to Antidepressant Therapy

• Suboptimal efficacy due to the wrong dose, inadequate length of time on the medication, or the person's individual biology not being responsive to the medication
• Unpleasant side effects of antidepressants can occur, such as weight gain, insomnia, and sexual dysfunction
• Nonadherence to the antidepressant
• As a reminder, the American Psychiatric Association (APA) recommends 4-8 weeks of adequate* treatment is needed before concluding that a patient is partially responsive or unresponsive to treatment

Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.

MDD Diagnosis

Clinical Probes

Treatment Assessment

Monitoring Considerations

Factors to Consider When Making a MDD Diagnosis

• Take a thorough patient history
• Previous or current depressive episodes
• Previous or current manic or hypomanic episodes
• Family history of MDD, bipolar disorder
• Medical comorbidities
• Consider a broad differential diagnosis

Clinical Queries That Aid in Diagnosing Major Depressive Episodes

1. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. American Psychiatric Association; 2013. 2. Kroenke K, et al. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.

APA Practice Guidelines on Treatment Assessment

• Wait 4 to 8 weeks to assess treatment response to antidepressants
• In patients without adequate response, clinicians can consider changing or augmenting with a second medication
• Changes to treatment plans, such as augmenting with a second-generation antipsychotic medication, are reasonable if a patient does not have adequate improvement in 6 weeks
• Consistently follow-up with patients to assess treatment effects, adverse medication effects, and risk of self-harm

APA Practice Guidelines note that the frequency of monitoring should be based on:

• Symptom severity (including suicidal ideation)
• Co-occurring disorders (including general medical conditions)
• Treatment adherence
• Availability of social supports
• Frequency and severity of side effects with medication

Tina Matthews-Hayes is a paid consultant for Abbvie Medical Affairs and was compensated for her time.

American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.​

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders . 5th ed. American Psychiatric Association; 2013. ​
• Kapfhammer HP. Somatic symptoms in depression. Dialogues Clin Neurosci . 2006;8(2):227-239.​
• Bobo WV. The diagnosis and management of bipolar I and II disorders: clinical practice update. Mayo Clin Proc . 2017;92(10):1532-1551.​
• Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med . 2001;16:606-613.​
• Smarr KL, Keefer AL. Measures of depression and depressive symptoms. Arthritis Care Res . 2011;63(S11):S454-S466. doi:10.1002/acr.20556​
• Rush AJ, Trivedi MH, Ibrahim HM, et al. The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), Clinician Rating (QIDS-C), and Self-Report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biol Psychiatry. 2003;54:573-583.​
• Brown ES, Murray M, Carmody TJ, et al. The Quick Inventory of Depressive Symptomatology–Self-report: a psychometric evaluation in patients with asthma and major depressive disorder. Ann Allergy Asthma Immunol. 2008;100(5):433-438. doi:10.1016/S1081-1206(10)60467-X​
• Liu R, Wang F, Liu S, et al. Reliability and validity of the Quick Inventory of Depressive Symptomatology-Self-Report Scale in older adults with depressive symptoms. Front Psychiatry . 2021;12:686711. doi:10.3389/fpsyt.2021.686711 ​
• Bernstein IH, Rush AJ, Suppes T, et al. A psychometric evaluation of the clinician-rated Quick Inventory of Depressive Symptomatology (QIDS-C16) in patients with bipolar disorder. Int J Methods Psychiatr Res . 2009;18(2):138-146. doi:10.1002/mpr.2855​
• Bernstein IH, Rush AJ, Trivedi MH, et al. Psychometric properties of the Quick Inventory of Depressive Symptomatology in adolescents. Int J Methods Psychiatr Res. 2010;19(4):185-194. doi:10.1002/mpr.321 ​
• Kroenke K. Enhancing the clinical utility of depression screening. CMAJ . 2012;184(3):281-282.doi:10.1503/cmaj.112004 ​
• Levinstein MR, Samuels BA. Mechanisms underlying the antidepressant response and treatment resistance. Front Behav Neurosci . 2014;8:208. doi:10.3389/fnbeh.2014.00208​
• Haddad PM, Talbot PS, Anderson IM, McAllister-Williams RH. Managing inadequate antidepressant response in depressive illness. Br Med Bull. 2015;115(1):183-201. doi:10.1093/bmb/ldv03​

This resource is intended for educational purposes only and is intended for US healthcare professionals. Healthcare professionals should use independent medical judgment. All decisions regarding patient care must be handled by a healthcare professional and be made based on the unique needs of each patient.

This is not a diagnostic tool and is not intended to replace a clinical evaluation by a healthcare provider.

Reach out to your family or friends for help if you have thoughts of harming yourself or others, or call the National Suicide Prevention Helpline for information at 800-273-8255.

ABBV-US-00976-MC, V1.0 Approved 12/2023 AbbVie Medical Affairs

Recommended on NP Psych Navigator

Disease Primer

Major depressive disorder (MDD) is one of the most recognized mental disorders in the United States. Learn more about the prevalence, pathophysiology, diagnosis, and management of MDD here.

Clinical Article

State-Dependent Differences in Emotion Regulation Between Unmedicated Bipolar Disorder and Major Depressive Disorder

Rive et al use functional MRI to look at some of the differences between patients with bipolar depression and major depressive disorder.

Unrecognized Bipolar Disorder in Patients With Depression Managed in Primary Care: A Systematic Review and Meta-Analysis

Daveney et al explore the characteristics of patients with mixed symptoms, as compared to those without mixed symptoms, in both bipolar disorder and major depressive disorder.

Welcome To NP Psych Navigator

This website is intended for healthcare professionals inside the United States. Please confirm that you are a healthcare professional inside the US.

You are now leaving NP Psych Navigator

Links to sites outside of NP Psych Navigator are provided as a resource to the viewer. AbbVie Inc accepts no responsibility for the content of non-AbbVie linked sites.

Redirect to:

• Get new issue alerts Get alerts
• Submit a Manuscript

Secondary Logo

Journal logo.

Colleague's E-mail is Invalid

Your message has been successfully sent to your colleague.

Save my selection

A case study of depression: A holistic exploration through the lens of biopsychosocial dynamics

Sarkar, Bubul; Ali, Arif 1 ; Paul, Fayaz Ahmad 2

Tele-MANAS, National Health Mission, Christian Bosti, Guwahati, Assam, Under Ministry of Health and Family Welfare, New Delhi, India

1 Department of Psychiatric Social Work, Institute of Human Behaviour and Allied Sciences, New Delhi, India

2 Department of Psychiatric Social Work, LGB Regional Institute of Mental Health, Tezpur, Assam, India

Address for correspondence: Dr. Arif Ali, Associate Professor, Department of Psychiatric Social Work, Institute of Human Behaviour and Allied Sciences (IHBAS), New Delhi, India. E-mail: [email protected]

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 4.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Depression is a complex mental health condition influenced by biological, psychological, and social factors. Psychiatric social workers play a crucial role in conducting comprehensive assessments and implementing interventions to address the multi-dimensional nature of depression. This case study seeks to evaluate the psychosocial factors associated with a case of depression and to implement an intervention based on the biopsychosocial approach. This single subject case study explores the effectiveness of the bio-psycho-social model in comprehending depression and its treatment through psychiatric social work intervention. The study employs a pre- and post intervention baseline assessment, utilizing tools such as social history Performa, family assessment device, Beck depression inventory, Self-esteem Scale, Social Adaptive Functioning Evaluation, Multi-dimensional Perceived Social Support Scale, and a family questionnaire. The case referred from the Outdoor Department at Lokopriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, Assam, for psychiatric social work assessment and intervention. The results exhibit a significant improvement in pre- and post intervention scores, indicating enhanced daily functioning, reduced depression, increased insight, heightened awareness regarding illness, and improved self-esteem. This study underscores the importance of a biopsychosocial approach in understanding and treating depression comprehensively. The findings emphasize the efficacy of psychiatric social work interventions within this framework, contributing to improved clinical outcomes and facilitating the client’s understanding of their illness. The integration of biological and psychosocial aspects in treatment is essential, necessitating a holistic theoretical paradigm.

Introduction

Depression is a pervasive issue with significant implications for both work and social performance. Understanding the complexity of this disorder requires a comprehensive approach, and the biopsychosocial model stands out as the most effective framework. [ 1 ] Recognizing the uniqueness of each patient in terms of diagnosis, formulation, and treatment is crucial. [ 2 ] As outlined by the biopsychosocial model, the intricate interplay between genetic makeup, mental health, personality, and sociocultural environment shapes individuals’ experiences of health or illness. [ 3 ] This model proposes, and empirical evidence supports, that biological, psychological, and social factors are interdependent and mutually influential. Depression, being a condition with multifaceted origins, necessitates a holistic understanding that considers the entirety of contributing factors. Hence, a comprehensive explanation of depression should encompass all the relevant elements. For effective treatment, a biopsychosocial depression model, integrating biological, social, and psychosocial aspects, is imperative. [ 1 , 3 ] The primary goal of this study is to evaluate a range of psychosocial factors linked to the client’s condition. Our aim is to offer a comprehensive biopsychosocial intervention geared toward improving the client’s overall well-being and psychosocial functioning. By addressing the diverse facets of depression, we aspire to enhance the understanding and effectiveness of interventions, ultimately fostering improved mental health outcomes for the client.

Methodology

A single-subject case study design was employed to investigate the efficacy of psychiatric social work intervention based on a biopsychosocial model in addressing depression. The case was referred from the Outdoor Patient Department at Lokpriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, Assam. A comprehensive examination of pre- and post-test was done to see the effectiveness of the intervention. The Social History Performa was utilized for assessing personal and family history, guiding the formulation of tailored interventions. The psychiatric social work intervention was intricately designed to align with the bio-psycho-social approach, targeting both the individual client and their family members. In the course of the intervention sessions, various scales were administered to comprehensively assess the diverse dimensions of the client’s condition. These scales were strategically chosen to measure and quantify the key aspects related to the biological, psychological, and social components of the client’s mental health. Informed consent was obtained from the patient, and consent was also secured from their family members.

Instruments used for the study

Beck depression inventory.

Beck depression inventory is a comprehensive tool designed to evaluate the various aspects of depression. It includes items for assessing sadness, punishment, pessimism, self-criticality, past failure, loss of pleasure, suicidal thoughts or wishes, guilty feelings, crying, agitation, loss of interest, indecisiveness, worthlessness, and loss of energy. In addition, it explores the changes in sleeping patterns, irritability, appetite, concentration difficulty, tiredness or fatigue, and loss of interest in sex. [ 4 ]

Family assessment device

Family assessment device (FAD) is a tool designed to assess family dynamics across seven domains. It measures problem-solving, communication, role, effective responsiveness, effective involvement, behavioral control, and general functioning within the family context. This tool provides a comprehensive understanding of the family’s interaction patterns and functioning. [ 5 ]

Social adaptive functioning evaluation

This assessment tool focuses on evaluating the social skills by measuring social-interpersonal, instrumental, and life skills functioning. It provides insights into an individual’s ability to navigate various social contexts and adapt to different life situations. [ 6 ]

Self-Esteem scale

The Self-Esteem Scale by Rosenberg is utilized to measure an individual’s global self-worth. It assesses both positive and negative feelings about the self, providing valuable insights into self-perception and emotional well-being. [ 7 ]

Family questionnaire

The family questionnaire is employed to assess expressed emotional status within the family context. Developed by Wiedemann et al. , it specifically measures criticism and emotional over-involvement (EOI) of family members toward patients with mental illness. The questionnaire comprises two subscales: Critical comments and EOI, offering a nuanced understanding of family dynamics and their impact on mental health. [ 8 ]

Background of the case presentation

The client of this case is a 24-year-old male educated up to the primary level residing in Assam, marked by significant socioeconomic challenges. He was married and employed as a daily wage worker. According to the information, the patient could not pursue further education due to financial constraints within the family, compelling him to start working at the age of 19 years. The patient’s work trajectory involved initial employment as a daily wage worker, followed by a stint as a security guard in a private company in Bangalore at the age of 22 years. After a year, he returned to his hometown and continued working as a helper in a local construction company. However, his employment has currently ceased due to ongoing health issues. At the age of 20 years, during his stay in Bangalore, the patient initiated alcohol consumption in social settings with friends. This pattern evolved, leading to solitary alcohol consumption. Postmarriage, he abstained from alcohol for 7 months. The patient also engaged in cannabis use from the age of 19 years, starting with friends and eventually smoking alone. At present, he has refrained from cannabis use for the past 2 months. The client’s marriage to an underage girl of his choice triggered a cascade of challenges. Friends’ comments regarding potential legal consequences, given the underage nature of his wife, led to the patient’s distress. This distress manifested in a low mood, fear of police intervention, and an aversion to work.

Reports indicate that the patient spent significant time in bed, avoiding any productive activities. Despite sharing his concerns with friends, the patient did not receive meaningful assistance. Ongoing unemployment, exacerbated by fear of legal consequences, led to critical comments from family members, especially the wife and parents. The patient’s distress escalated to the point of suicidal attempts, including the consumption of phenyl, necessitating treatment at a civil hospital. The supportive role of the patient’s mother was pivotal, leading to his subsequent referral to a psychiatric hospital. The patient reported feelings of worthlessness, hopelessness, diminished interest in enjoyable activities, decreased social interaction, suicidal thoughts, and disturbances in sleep and appetite. In the mental status examination, the patient appeared well-groomed, maintained eye contact, rapport was established, and cooperated with the examiner. Speech exhibited normal prosody, intensity, and speed. However, thought content revealed ideas of hopelessness, worthlessness, helplessness, and suicidal ideation. The patient demonstrated grade 3 insights. The diagnosis of F32.2 (severe depression without psychotic symptoms) according to International Classification of Disease-10 criteria underscores the complex interplay of socioeconomic challenges, substance use, marital concerns, and mental health issues in this case.

Outcome of the case

Table 1 provides an overview of the family dynamics of the client’s family based on the McMaster FAD. It reveals that the family’s problem-solving (3.0) and general functioning (3.16) were unhealthy, whereas other domains communication (2.1), roles (2.2), affective responsiveness (2.1), affective involvement (1.90), and behavioral control (1.5) were healthy.

The assessment indicated that affective involvement was deemed healthy according to the FAD Scale administered to the mother. However, during the session, over-involvement was observed qualitatively in the patient and family member interviews during the session. This led to the addressing of expressed emotions in the context of the findings.

Table 2 indicates an improvement in the social functioning of the client after the intervention. Various domains, such as bathing and grooming, clothing and dressing, and eating, feeding, and diet, show positive changes postintervention.

Biopsychosocial formulation

The biopsychosocial assessment revealed depressive symptoms in the patient, coupled with a history of harmful substance use (alcohol, cannabis, and tobacco). The patient’s marriage to an underage girl triggered severe distress, leading to exacerbated depressive symptoms and impaired social and occupational functioning. Notably, the patient exhibited low self-esteem, and his illness resulted in a cessation of work, contributing to a financial crisis in the family. The family, belonging to a lower socioeconomic status, experienced heightened stress due to the patient’s illness.

Biopsychosocial intervention

Biopsychosocial intervention sessions involve a holistic approach to addressing mental health concerns by considering the interplay of biological, psychological, and social factors. In the biopsychosocial approach, a thorough assessment is done to understand the biological, psychological, and social aspects of the client’s condition. In biological intervention sessions, emphasis on incorporating medical and pharmacological interventions as needed, such as medication management for psychiatric symptoms. Addressing any physical health issues that may contribute to or be influenced by the mental health condition. In psychological interventions, the session mainly focused on providing psychological therapy focusing on enhancing coping skills, emotional regulation, and cognitive restructuring. In social interventions, the sessions mainly focused on addressing social determinants of mental health, including family dynamics, relationships, and support systems. Strategies were implemented to improve social functioning and interpersonal relationships. Biopsychosocial intervention sessions strive to create a comprehensive and individualized approach that addresses the complexity of mental health issues, aiming for sustained improvement in the client’s overall well-being.

A comprehensive intervention plan was implemented, comprising a total of 14 sessions conducted at both the individual and family levels. The intervention was tailored to address the psychosocial factors identified during the assessment sessions. Each session had a duration of 45–60 min, allowing for in-depth exploration and targeted therapeutic interventions. The patient was prescribed antidepressant (tablet sertraline 50 mg) and sleeping tablet (clonazepam 0.5 mg) to address the biological aspects of depression.

Given the patient’s limited insight at a grade 3 level and a lack of sufficient knowledge about their illness, the therapist employed a combination of insight orientation therapy and psycho education to address these issues. Insight orientation therapy was utilized to help the patient gain a deeper understanding of the symptoms and underlying reasons for their illness, aiming to foster increased insight into their condition. Simultaneously, motivational intervention therapy was implemented to boost the patient’s motivation for change and further develop their insight regarding his illness. The session predominantly concentrated on cultivating and reinforcing the client’s motivation, contributing to a more informed and motivated approach to managing their mental health. Psycho education was delivered to educate the patient about the biopsychosocial factors contributing to their illness, emphasizing the importance of regular medication and follow-up. Supportive counseling was provided to the client, wherein the therapist offered reassurance, encouragement, rationalization, clarification, and behavior goal-setting to provide emotional support, considering the patient’s limited social support network. Activity scheduling was structured for the client, aiming to engage them in daily activities and emphasizing values, pleasure, mastery, and goal achievement. Due to the family’s economic challenges, information about government welfare benefits and vocational training opportunities was provided. The therapist assisted the family in applying for a disability card at the district disability rehabilitation center to access government welfare benefits.

At the family level, psycho-education for family members was provided. The session addressed misunderstandings about mental illness and informed family members about signs, symptoms, and the biopsychosocial nature of the patient’s condition. Early warning signs of relapse were discussed, stressing the importance of regular medication and follow-up. The therapist explained the role of the family in supporting the patient’s treatment journey. Family intervention was conducted to focus on addressing EOI. The therapist worked with the family to manage EOI and critical comments. Supportive counseling for the mother was also provided. The therapist offered emotional support to the patient’s mother, acknowledging her supportive role. This biopsychosocial intervention targeted the patient’s biological, psychological, and social needs, incorporating a tailored approach to address the multifaceted aspects of depression. The combination of medication, insight-oriented therapy, psycho-education, and support at both individual and family levels demonstrates a comprehensive strategy aimed at improving the patient’s overall well-being and functional capacity.

Figure 1 illustrates the changes in the domains of depression, self-esteem, and expressed emotion after the intervention. Postscores indicate significant improvements in depression levels and self-esteem, as well as notable changes in the family’s expressed emotions.

The presented case study adopts a comprehensive biopsychosocial approach to understanding and treating depression. The integration of biological, psychological, and social interventions allowed for a holistic understanding of the client’s condition and provided a foundation for tailored therapeutic strategies. The therapist’s engagement with the patient and family was crucial in establishing rapport and facilitating effective hospital follow-up. Both pharmacotherapy and nonpharmacological interventions were employed, aligning with contemporary research suggesting the efficacy of combined approaches in addressing depression. [ 9 ] The outcomes of the intervention were promising, with notable improvements observed in the patient’s understanding of his illness and increased knowledge within the family regarding depression. Postintervention, significant enhancements were evident in the patient’s daily functioning, leading to reintegration into the workforce. Securing employment as a salesman reflects the positive impact on the client’s overall well-being. Furthermore, the intervention contributed to a noteworthy improvement in self-esteem, emphasizing the importance of addressing psychological aspects in depression management. The efficacy of nonpharmacological therapies in treating mild-to-severe depression aligns with current literature. [ 9 ] This underscores the importance of considering a range of therapeutic options, including psychotherapeutic interventions, alongside pharmacological approaches. The inter-disconnectedness of biological, psychological, and social factors in depression is acknowledged, emphasizing the need for a multifaceted treatment approach.

The biopsychosocial model’s emphasis on integrating biological and psychological interventions resonates with the existing literature. The combinations of psychosocial and pharmacological interventions have demonstrated improved outcomes in severe depression, aiding in recovery and reducing the risk of relapse. [ 10-15 ] The bio-psycho-social approach proved effective in addressing the complex interplay of factors contributing to depression. Integrating biological interventions such as pharmacotherapy with psychological interventions such as insight orientation and motivational therapy, along with social interventions targeting financial difficulties, demonstrated positive outcomes. This aligns with existing literature emphasizing the benefits of combined approaches in treating depression. [ 10 , 12 ]

Following the comprehensive biopsychosocial interventions implemented during the inpatient stay and the subsequent follow-up session, the patient exhibited positive outcomes across multiple domains. Biologically, there was a noticeable improvement in the management of the patient’s symptoms, with any necessary medical and pharmacological interventions contributing to stabilization. Psychologically, the patient demonstrated enhanced insight into their condition, a more robust coping repertoire, and improved emotional regulation. Socially, interventions aimed at addressing the patient’s socioeconomic context resulted in strengthened support systems and improved interpersonal relationships. The holistic approach, incorporating elements of insight orientation therapy, psychoeducation, and motivational intervention therapy, contributed to a more nuanced understanding of the patient’s mental health. The 1-month inpatient treatment, coupled with the postdischarge follow-up, facilitated a smoother transition to the community setting. Overall, the biopsychosocial interventions led to a positive outcome, fostering the patient’s overall well-being and psychosocial functioning.

Strength and limitation

The implementation of a biopsychosocial approach, including various therapeutic modalities such as insight orientation therapy, psychoeducation, and motivational intervention therapy, is a strength. This multifaceted approach addresses the patient’s needs across biological, psychological, and social domains. The positive outcomes observed in the patient across multiple domains (biological, psychological, and social) suggest the effectiveness of the interventions during the inpatient stay and follow-up sessions. The holistic interventions contributed to a more nuanced understanding of the patient’s mental health, fostering overall well-being and psychosocial functioning.

The absence of subsequent follow-up sessions postdischarge is a notable limitation. A single follow-up assessment might not capture the long-term impact of the interventions, and ongoing monitoring could provide a more comprehensive understanding of the patient’s progress. The case study’s findings may be specific to this individual and may not be fully generalizable to a broader population. Factors unique to the patient’s circumstances could limit the applicability of the interventions to other cases.

In conclusion, the biopsychosocial approach is pivotal in enhancing the client’s understanding of depression and improving clinical outcomes. The presented case study exemplifies the effectiveness of psychiatric social work interventions rooted in the bio-psycho-social framework in addressing depression comprehensively. The integration of biological and psychosocial elements proves beneficial in the recovery process, highlighting the importance of a holistic treatment paradigm. This case underscores the notion that a nuanced understanding of depression, considering its multifaceted nature, is crucial for tailoring effective interventions. The combined use of pharmacological and psychosocial strategies, aligned with the principles of the biopsychosocial model, offers a promising avenue for managing depression and reducing the risk of relapse. Supportive literature consistently reinforces the need for an integrated approach, emphasizing that addressing the interconnected factors influencing depression leads to more comprehensive and sustainable therapeutic outcomes. As mental health interventions continue to evolve, the biopsychosocial model stands as a valuable guide in navigating the complexities of depressive disorders.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

• Cited Here |
• Google Scholar

Biopsychosocial model; depression; insight; psychiatric social work; self-esteem

• + Favorites
• View in Gallery

Academia.edu no longer supports Internet Explorer.

To browse Academia.edu and the wider internet faster and more securely, please take a few seconds to  upgrade your browser .

Enter the email address you signed up with and we'll email you a reset link.

• We're Hiring!
• Help Center

Leanne: A Case Study in Major Depressive Disorder, Recurrent

Related Papers

American Journal of Psychiatry

John Markowitz

The Journal of psychotherapy practice and research

Child and Adolescent Psychiatric Clinics of North America

Nick Midgley , Carol Hughes , M. Rustin

Brian Kiluk

The two major forms of treatment for drug abuse, psychosocial treatments and pharmacologic treatments, have a number of differences in terms of their mode of action, time to effect, target symptoms, durability, and applicability across drugs of abuse. While each has specific indications and strengths, no psychotherapy or pharmacotherapy is universally effective, and both forms of treatment have some limitations, particularly when used alone. Several recent examples of the benefits of combined treatments for drug abusers are reviewed. These suggest that for many substance use disorders, outcomes can be broadened, enhanced, and extended by combining our most effective forms of psychotherapy and pharmacotherapy.

Pijar Senjakala Marthesa

MUKIIBI Cabrine

Journal of affective disorders

H. Schauenburg , Falk Leichsenring

There is evidence that psychotherapy is helpful in depressive disorders, with no significant differences between psychotherapies. For psychodynamic therapy (PDT) various models prove to be efficacious. Thus, the evidence for PDT is "scattered" between different forms of PDT, also implying problems in training of psychotherapy and in transferring research to clinical practice. A unified protocol based on empirically-supported methods of PDT in depression may contribute to solve these problems Systematic search for randomized controlled trials fulfilling the following criteria: (a) individual psychodynamic therapy (PDT) of depressive disorders, (b) treatment manuals or manual-like guidelines, (c) PDT proved to be efficacious compared to control conditions, (d) reliable measures for diagnosis and outcome, and (f) adult patients. Fourteen RCTs fulfilled the inclusion criteria. By a systematic review of the applied methods of PDT seven treatment components were identified. A hi...

Lindsay Michele

This study tested the relationships between Young’s (1990, 2003) model of EarlyMaladaptive Schemas (EMSs), negative life events occurring over the past 4 months,depressive symptoms, and anxious symptoms. We also replicated a design testing the ability of EMSs, negative life events, and their interaction to predict depressive and anxious symptoms and extended the design to include specific categories of negative life events (interpersonal and achievement). Results of this study showed that EMSs are predictive of depressive and anxious symptoms, but that negative life events account for a greater prediction. The EMS model was just as highly associated with and predictive of anxious symptoms as it was with depressive symptoms. The study was the first to examine specific types of negative life events and their relationships with EMSs. EMSs may be more highly associated with negative achievement than with negative interpersonal events but the EMSs appear to be vulnerable to global life stress in general

Professional Psychology: Research and Practice

Ellen Poleshuck , Luis Rosario-mccabe

Loading Preview

Sorry, preview is currently unavailable. You can download the paper by clicking the button above.

RELATED PAPERS

Naama Gershy

Laura Mufson

Journal of The American Academy of Child and Adolescent Psychiatry

William Bernet

Journal of the American Academy of Child & Adolescent Psychiatry

Andres Pumariega , Helene Keable

Damian Vargas

RELATED TOPICS

•   We're Hiring!
•   Help Center
• Find new research papers in:
• Health Sciences
• Earth Sciences
• Cognitive Science
• Mathematics
• Computer Science
• Academia ©2024

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• v.15(3); 2023 Mar
• PMC10097604

A Case Study of Depression in High Achieving Students Associated With Moral Incongruence, Spiritual Distress, and Feelings of Guilt

Bahjat najeeb.

1 Institute of Psychiatry, Rawalpindi Medical University, Rawalpindi, PAK

Muhammad Faisal Amir Malik

Asad t nizami, sadia yasir.

Psychosocial and cultural factors play an important, but often neglected, role in depression in young individuals. In this article, we present two cases of young, educated males with major depressive disorder and prominent themes of guilt and spiritual distress. We explore the relationship between moral incongruence, spiritual distress, and feelings of guilt with major depressive episodes by presenting two cases of depression in young individuals who were high-achieving students. Both cases presented with low mood, psychomotor slowing, and selective mutism. Upon detailed history, spiritual distress and feelings of guilt due to internet pornographic use (IPU) and the resulting self-perceived addiction and moral incongruence were linked to the initiation and progression of major depressive episodes. The severity of the depressive episode was measured using the Hamilton Depression Scale (HAM-D). Themes of guilt and shame were measured using the State of Guilt and Shame Scale (SSGS). High expectations from the family were also a source of stress. Hence, it is important to keep these factors in mind while managing mental health problems in young individuals. Late adolescence and early adulthood are periods of high stress and vulnerabe to mental illness. Psychosocial determinants of depression in this age group generally go unexplored and unaddressed leading to suboptimal treatment, particularly in developing countries. Further research is needed to assess the importance of these factors and to determine ways to mitigate them.

Introduction

More attention needs to be paid to the psychological and societal factors which precipitate, prolong, and cause a relapse of depression in high-achieving young individuals. A young, bright individual has to contend with the pressures of -- often quite strenuous -- moral and financial expectations from the family, moral incongruence, spiritual distress, and feelings of guilt.

Moral incongruence is the distress that develops when a person continues to behave in a manner that is at odds with their beliefs. It may be associated with self-perceptions of addictions, including, for example, to pornographic viewing, social networking, and online gaming [ 1 ]. Perceived addiction to pornographic use rather than use is related to the high incidence of feelings of guilt and shame and predicts religious and spiritual struggle [ 2 - 3 ]. Guilt is a negative emotional and cognitive experience that occurs when a person believes that they have negated a standard of conduct or morals. It is a part of the diagnostic criteria for depression and various rating scales for depressive disorders [ 4 ]. Generalized guilt has a direct relationship with major depressive episodes. Guilt can be a possible target for preventive as well as therapeutic interventions in patients who experience major depressive episodes [ 5 ].

We explored the relationship between moral incongruence, spiritual distress, and feelings of guilt with major depressive episodes in high-achieving students. Both patients presented with symptoms of low mood, extreme psychomotor slowing, decreased oral intake, decreased sleep, and mutism. The medical evaluation and lab results were unremarkable. The severity of depressive episodes was measured using the Hamilton Depression Scale (HAM-D). Themes of guilt and shame were measured by using the State of Guilt and Shame Scale (SSGS). This case study was presented as a poster abstract at the ‘RCPsych Faculty of General Adult Psychiatry Annual Conference 2021.’

Case presentation

A 25-year-old Sunni Muslim, Punjabi male educated till Bachelors presented with a one-month history of fearfulness, weeping spells during prolonged prostration, social withdrawal, complaints of progressively decreasing verbal communication to the extent of giving nods and one-word answers, and decreased oral intake. His family believed that the patient's symptoms were the result of ‘Djinn’ possession. This was the patient’s second episode. The first episode was a year ago with similar symptoms of lesser severity that resolved on its own. Before being brought to us, he had been taken to multiple faith healers. No history of substance use was reported. Psychosexual history could not be explored at the time of admission. His pre-morbid personality was significant for anxious and avoidant traits. 

On mental state examination (MSE), the patient had psychomotor retardation. He responded non-verbally, and that too slowly. Once, he wept excessively and said that he feels guilt over some grave sin. He refused to explain further, saying only that ‘I am afraid of myself.’ All baseline investigations returned normal. His score on the Hamilton Depression Rating Scale (HAM-D) was 28 (Very Severe). A diagnosis of major depressive disorder was made. The patient was started on tab sertraline 50 mg per day and tab olanzapine 5 mg per day. After the second electroconvulsive therapy (ECT), his psychomotor retardation improved and he began to open up about his stressors. His HAM-D score at this time was 17 (moderate). He revealed distress due to feelings of excessive guilt and shame due to moral incongruence secondary to internet pornography use (IPU). The frequency and duration of IPU increased during the last six months preceding current illness. That, according to him, led him to withdraw socially and be fearful. He felt the burden of the high financial and moral expectations of the family. He complained that his parents were overbearing and overinvolved in his life. His family lacked insight into the cause of his illness and had difficulty accepting his current state. All these factors, particularly spiritual distress, were important in precipitating his illness. He scored high on both the shame and guilt domains (14/25, and 20/25, respectively) of the State of Shame and Guilt Scale (SSGS).

He was discharged after three weeks following a cycle of four ECTs, psychotherapy, and psychoeducation of the patient and family. At the time of discharge, his HAM-D score was 10 (mild) and he reported no distress due to guilt or feeling of shame. He has been doing well for the past 5 months on outpatient follow-up.

A 21-year-old Sunni Muslim, Punjabi male, high-achieving student of high school presented with low mood, low energy, anhedonia, weeping spells, decreased oral intake, decreased talk, and impaired biological functions. His illness was insidious in onset and progressively worsened over the last 4 months. This was his first episode. He was brought to a psychiatric facility after being taken to multiple faith healers. Positive findings on the MSE included psychomotor slowing, and while he followed commands, he remained mute throughout the interview. Neurological examination and laboratory findings were normal. His score on HAM-D was 24 (very severe). He was diagnosed with major depressive disorder and started on tab lorazepam 1 mg twice daily with tab mirtazapine 15 mg which was built up to 30 mg once daily. He steadily improved, and two weeks later his score on HAM-D was 17 (moderate). His scores on SSGS signified excessive shame and guilt (16/25, and 21/25; respectively). He communicated his stressors which pertained to the psychosexual domain: he started masturbating at the age of 15, and he felt guilt following that but continued to do so putting him in a state of moral incongruence. He perceived his IPU as ‘an addiction’ and considered it a ‘gunahe kabira’ (major sin) and reported increased IPU in the months leading to the current depressive episode leading to him feeling guilt and anguish. Initially, during his illness, he was taken to multiple faith healers as the family struggled to recognize the true nature of the disease. Their understanding of the illness was of him being under the influence of ‘Kala Jadu’ (black magic). His parents had high expectations of him due to him being their only male child. After 3 weeks of treatment and psychotherapy, his condition improved and his HAM-D score came out to be 08 (mild). He was discharged on 30 mg mirtazapine HS and seen on fortnightly visits. His guilt and shame resolved with time after the resolution of depressive symptoms and counseling. We lost the follow-up after 6 months.

Late adolescence and young adulthood can be considered a unique and distinct period in the development of an individual [ 6 ]. It is a period of transition marked by new opportunities for development, growth, and evolution, as well as bringing new freedom and responsibilities. At the same time, this period brings interpersonal conflicts and an increased vulnerability to mental health disorders such as depression and suicidality. Biological, social, and psychological factors should all be explored in the etiology of mental health problems presenting at this age [ 6 ].

Socio-cultural factors played a significant role in the development and course of disease in our patients, and these included the authoritarian parenting style, initial lack of awareness about psychiatric illnesses causing a delay in seeking treatment, high expressed emotions in the family, and the burden of expectations from the family and the peer group. The strict and often quite unreasonable societal and family expectations in terms of what to achieve and how to behave and the resultant onus on a high-scoring, bright young individual make for a highly stressful mental state. 

We used the ICD-10 criteria to diagnose depression clinically in our patients and the HAMD-17 to measure the severity of symptoms [ 7 ]. Both our patients had scores signifying severe depression initially. Psychomotor retardation was a prominent and shared clinical feature. Psychomotor retardation is the slowing of cognitive and motor functioning, as seen in slowed speech, thought processes, and motor movements [ 8 - 9 ]. The prevalence of psychomotor retardation in major depressive disorder ranges from 60% to 70% [ 10 ]. While psychomotor retardation often responds poorly to selective serotonin reuptake inhibitors (SSRI), both tricyclic antidepressants (TCAs) and noradrenergic and specific serotonergic antidepressants (NaSSA) produce a better response [ 9 , 11 ]. In addition, ECT shows a high treatment response in cases with significant psychomotor retardation [ 11 - 12 ].

A growing body of evidence shows that shame and guilt are features of numerous mental health problems. Guilt is the negative emotional and cognitive experience that follows the perception of negating or repudiating a set of deeply held morals [ 4 ]. Guilt can be generalized as well as contextual and is distinct from shame [ 13 ]. The distinction between guilt and shame allows for an independent assessment of the association of both guilt and shame with depressive disorder. As an example, a meta-analysis of 108 studies including 22,411 individuals measuring the association of shame and guilt in patients with depressive disorder found both shame and guilt to have a positive association with depressive symptoms. This association was stronger for shame (r=0.43) than for guilt (r=0.28) [ 14 ]. In our study, we used the State of Shame and Guilt Scale (SSGS), to measure the feelings of guilt and shame [ 15 ]. The SSGS is a self-reported measure and consists of 5 items each for subsets of guilt and shame. SSGS scores showed high levels of guilt and shame in both of our patients.

During the course of treatment, we paid special attention to the psychological, cultural, and social factors that likely contributed to the genesis of the illness, delayed presentation to seek professional help, and could explain the recurrence of the depressive episodes. In particular, we observe the importance, particularly in this age group, of family and societal pressure, spiritual distress, moral incongruence, and feelings of guilt and shame. Moral incongruence is when a person feels that his behavior and his values or judgments about that behavior are not aligned. It can cause a person to more negatively perceive a behavior. As an example, the presence of moral congruence in an individual is a stronger contributor to perceiving internet pornographic use (IPU) as addictive than the actual use itself [ 16 ]. Therefore, moral congruence has a significant association with increased distress about IPU, enhanced psychological distress in general, and a greater incidence of perceived addiction to IPU [ 16 ].

Self-perceived addiction is an individual’s self-judgment that he or she belongs to the group of addicts. The pornography problems due to moral incongruence (PPMI) model is one framework that predicts the factors linking problematic pornographic use with self-perceived addiction. This model associates moral incongruence with self-perceived addiction to problematic pornographic use [ 17 ]. A recent study on the US adult population also showed a high association of guilt and shame with moral incongruence regarding IPU [ 18 ]. Another factor of importance in our patients was spiritual distress, which is the internal strain, tension, and conflict with what people hold sacred [ 19 ]. Spiritual distress can be intrapersonal, interpersonal, or supernatural [ 20 ]. Research indicates that IPU causes people to develop spiritual distress that can ultimately lead to depression [ 16 - 17 ].

Conclusions

In both our cases the initial presentation was that of psychomotor slowing, selective mutism, and affective symptoms of low mood, therefore, a diagnosis of depressive illness was made. One week into treatment, improvement was noted both clinically as well as on the psychometric scales. Upon engaging the patients to give an elaborate psychosexual history, moral incongruence, spiritual distress, and feelings of guilt, linked particularly to self-perceived addiction to IPU were found. Sensitivity to the expectations of the parents, the cognizance of failing them because of illness, and their own and family’s lack of understanding of the situation were additional sources of stress. Hence, it is imperative to note how these factors play an important role in the initiation, progression, and relapse of mental health problems in young individuals. 

Acknowledgments

We are thankful to the participants of this study for their cooperation.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained or waived by all participants in this study

Pardon Our Interruption

As you were browsing something about your browser made us think you were a bot. There are a few reasons this might happen:

• You've disabled JavaScript in your web browser.
• You're a power user moving through this website with super-human speed.
• You've disabled cookies in your web browser.
• A third-party browser plugin, such as Ghostery or NoScript, is preventing JavaScript from running. Additional information is available in this support article .

To regain access, please make sure that cookies and JavaScript are enabled before reloading the page.

• Introduction
• Conclusions
• Article Information

Contributing studies for clinically elevated depression symptoms are presented in order of largest to smallest prevalence rate. Square data markers represent prevalence rates, with lines around the marker indicating 95% CIs. The diamond data marker represents the overall effect size based on included studies.

Contributing studies for clinically elevated anxiety symptoms are presented in order of largest to smallest prevalence rate. Square data markers represent prevalence rates, with lines around the marker indicating 95% CIs. The diamond data marker represents the overall effect size based on included studies.

eTable 1. Example Search Strategy from Medline

eTable 2. Study Quality Evaluation Criteria

eTable 3. Quality Assessment of Studies Included

eTable 4. Sensitivity analysis excluding low quality studies (score=2) for moderators of the prevalence of clinically elevated depressive symptoms in children and adolescence during COVID-19

eTable 5. Sensitivity analysis excluding low quality studies (score=2) for moderators of the prevalence of clinically elevated anxiety symptoms in children and adolescence during COVID-19

eFigure 1. PRISMA diagram of review search strategy

eFigure 2. Funnel plot for studies included in the clinically elevated depressive symptoms

eFigure 3. Funnel plot for studies included in the clinically elevated anxiety symptoms

• Pediatric Depression and Anxiety Doubled During the Pandemic JAMA News From the JAMA Network October 5, 2021 Anita Slomski
• Guidelines Synopsis: Screening for Anxiety in Adolescent and Adult Women JAMA JAMA Clinical Guidelines Synopsis March 8, 2022 This JAMA Clinical Guidelines Synopsis summarizes the 2020 Women’s Preventive Services Initiative recommendation on screening for anxiety in adolescent and adult women. Tiffany I. Leung, MD, MPH; Adam S. Cifu, MD; Wei Wei Lee, MD, MPH
• Addressing the Global Crisis of Child and Adolescent Mental Health JAMA Pediatrics Editorial November 1, 2021 Tami D. Benton, MD; Rhonda C. Boyd, PhD; Wanjikũ F.M. Njoroge, MD
• Effect of the COVID-19 pandemic on Adolescents With Eating Disorders JAMA Pediatrics Comment & Response February 1, 2022 Thonmoy Dey, BSc; Zachariah John Mansell, BSc; Jasmin Ranu, BSc

See More About

Select your interests.

Customize your JAMA Network experience by selecting one or more topics from the list below.

• Academic Medicine
• Acid Base, Electrolytes, Fluids
• Allergy and Clinical Immunology
• American Indian or Alaska Natives
• Anesthesiology
• Anticoagulation
• Art and Images in Psychiatry
• Artificial Intelligence
• Assisted Reproduction
• Bleeding and Transfusion
• Caring for the Critically Ill Patient
• Challenges in Clinical Electrocardiography
• Climate and Health
• Climate Change
• Clinical Challenge
• Clinical Decision Support
• Clinical Implications of Basic Neuroscience
• Clinical Pharmacy and Pharmacology
• Complementary and Alternative Medicine
• Consensus Statements
• Coronavirus (COVID-19)
• Critical Care Medicine
• Cultural Competency
• Dental Medicine
• Dermatology
• Diabetes and Endocrinology
• Diagnostic Test Interpretation
• Drug Development
• Electronic Health Records
• Emergency Medicine
• End of Life, Hospice, Palliative Care
• Environmental Health
• Equity, Diversity, and Inclusion
• Facial Plastic Surgery
• Gastroenterology and Hepatology
• Genetics and Genomics
• Genomics and Precision Health
• Global Health
• Guide to Statistics and Methods
• Hair Disorders
• Health Care Delivery Models
• Health Care Economics, Insurance, Payment
• Health Care Quality
• Health Care Reform
• Health Care Safety
• Health Care Workforce
• Health Disparities
• Health Inequities
• Health Policy
• Health Systems Science
• History of Medicine
• Hypertension
• Images in Neurology
• Implementation Science
• Infectious Diseases
• Innovations in Health Care Delivery
• JAMA Infographic
• Law and Medicine
• Leading Change
• Less is More
• LGBTQIA Medicine
• Lifestyle Behaviors
• Medical Coding
• Medical Devices and Equipment
• Medical Education
• Medical Education and Training
• Medical Journals and Publishing
• Mobile Health and Telemedicine
• Narrative Medicine
• Neuroscience and Psychiatry
• Notable Notes
• Nutrition, Obesity, Exercise
• Obstetrics and Gynecology
• Occupational Health
• Ophthalmology
• Orthopedics
• Otolaryngology
• Pain Medicine
• Palliative Care
• Pathology and Laboratory Medicine
• Patient Care
• Patient Information
• Performance Improvement
• Performance Measures
• Perioperative Care and Consultation
• Pharmacoeconomics
• Pharmacoepidemiology
• Pharmacogenetics
• Pharmacy and Clinical Pharmacology
• Physical Medicine and Rehabilitation
• Physical Therapy
• Physician Leadership
• Population Health
• Primary Care
• Professional Well-being
• Professionalism
• Psychiatry and Behavioral Health
• Public Health
• Pulmonary Medicine
• Regulatory Agencies
• Reproductive Health
• Research, Methods, Statistics
• Resuscitation
• Rheumatology
• Risk Management
• Scientific Discovery and the Future of Medicine
• Shared Decision Making and Communication
• Sleep Medicine
• Sports Medicine
• Stem Cell Transplantation
• Substance Use and Addiction Medicine
• Surgical Innovation
• Surgical Pearls
• Teachable Moment
• Technology and Finance
• The Art of JAMA
• The Arts and Medicine
• The Rational Clinical Examination
• Tobacco and e-Cigarettes
• Translational Medicine
• Trauma and Injury
• Treatment Adherence
• Ultrasonography
• Users' Guide to the Medical Literature
• Vaccination
• Venous Thromboembolism
• Veterans Health
• Women's Health
• Workflow and Process
• Wound Care, Infection, Healing

Others Also Liked

• Download PDF
• X Facebook More LinkedIn

Racine N , McArthur BA , Cooke JE , Eirich R , Zhu J , Madigan S. Global Prevalence of Depressive and Anxiety Symptoms in Children and Adolescents During COVID-19 : A Meta-analysis . JAMA Pediatr. 2021;175(11):1142–1150. doi:10.1001/jamapediatrics.2021.2482

Manage citations:

© 2024

• Permissions

Global Prevalence of Depressive and Anxiety Symptoms in Children and Adolescents During COVID-19 : A Meta-analysis

• 1 Department of Psychology, University of Calgary, Calgary, Alberta, Canada
• 2 Alberta Children’s Hospital Research Institute, Calgary, Alberta, Canada
• Editorial Addressing the Global Crisis of Child and Adolescent Mental Health Tami D. Benton, MD; Rhonda C. Boyd, PhD; Wanjikũ F.M. Njoroge, MD JAMA Pediatrics
• News From the JAMA Network Pediatric Depression and Anxiety Doubled During the Pandemic Anita Slomski JAMA
• JAMA Clinical Guidelines Synopsis Guidelines Synopsis: Screening for Anxiety in Adolescent and Adult Women Tiffany I. Leung, MD, MPH; Adam S. Cifu, MD; Wei Wei Lee, MD, MPH JAMA
• Comment & Response Effect of the COVID-19 pandemic on Adolescents With Eating Disorders Thonmoy Dey, BSc; Zachariah John Mansell, BSc; Jasmin Ranu, BSc JAMA Pediatrics

Question   What is the global prevalence of clinically elevated child and adolescent anxiety and depression symptoms during COVID-19?

Findings   In this meta-analysis of 29 studies including 80 879 youth globally, the pooled prevalence estimates of clinically elevated child and adolescent depression and anxiety were 25.2% and 20.5%, respectively. The prevalence of depression and anxiety symptoms during COVID-19 have doubled, compared with prepandemic estimates, and moderator analyses revealed that prevalence rates were higher when collected later in the pandemic, in older adolescents, and in girls.

Meaning   The global estimates of child and adolescent mental illness observed in the first year of the COVID-19 pandemic in this study indicate that the prevalence has significantly increased, remains high, and therefore warrants attention for mental health recovery planning.

Importance   Emerging research suggests that the global prevalence of child and adolescent mental illness has increased considerably during COVID-19. However, substantial variability in prevalence rates have been reported across the literature.

Objective   To ascertain more precise estimates of the global prevalence of child and adolescent clinically elevated depression and anxiety symptoms during COVID-19; to compare these rates with prepandemic estimates; and to examine whether demographic (eg, age, sex), geographical (ie, global region), or methodological (eg, pandemic data collection time point, informant of mental illness, study quality) factors explained variation in prevalence rates across studies.

Data Sources   Four databases were searched (PsycInfo, Embase, MEDLINE, and Cochrane Central Register of Controlled Trials) from January 1, 2020, to February 16, 2021, and unpublished studies were searched in PsycArXiv on March 8, 2021, for studies reporting on child/adolescent depression and anxiety symptoms. The search strategy combined search terms from 3 themes: (1) mental illness (including depression and anxiety), (2) COVID-19, and (3) children and adolescents (age ≤18 years). For PsycArXiv , the key terms COVID-19 , mental health , and child/adolescent were used.

Study Selection   Studies were included if they were published in English, had quantitative data, and reported prevalence of clinically elevated depression or anxiety in youth (age ≤18 years).

Data Extraction and Synthesis   A total of 3094 nonduplicate titles/abstracts were retrieved, and 136 full-text articles were reviewed. Data were analyzed from March 8 to 22, 2021.

Main Outcomes and Measures   Prevalence rates of clinically elevated depression and anxiety symptoms in youth.

Results   Random-effect meta-analyses were conducted. Twenty-nine studies including 80 879 participants met full inclusion criteria. Pooled prevalence estimates of clinically elevated depression and anxiety symptoms were 25.2% (95% CI, 21.2%-29.7%) and 20.5% (95% CI, 17.2%-24.4%), respectively. Moderator analyses revealed that the prevalence of clinically elevated depression and anxiety symptoms were higher in studies collected later in the pandemic and in girls. Depression symptoms were higher in older children.

Conclusions and Relevance   Pooled estimates obtained in the first year of the COVID-19 pandemic suggest that 1 in 4 youth globally are experiencing clinically elevated depression symptoms, while 1 in 5 youth are experiencing clinically elevated anxiety symptoms. These pooled estimates, which increased over time, are double of prepandemic estimates. An influx of mental health care utilization is expected, and allocation of resources to address child and adolescent mental health concerns are essential.

Prior to the COVID-19 pandemic, rates of clinically significant generalized anxiety and depressive symptoms in large youth cohorts were approximately 11.6% 1 and 12.9%, 2 respectively. Since COVID-19 was declared an international public health emergency, youth around the world have experienced dramatic disruptions to their everyday lives. 3 Youth are enduring pervasive social isolation and missed milestones, along with school closures, quarantine orders, increased family stress, and decreased peer interactions, all potential precipitants of psychological distress and mental health difficulties in youth. 4 - 7 Indeed, in both cross-sectional 8 , 9 and longitudinal studies 10 , 11 amassed to date, the prevalence of youth mental illness appears to have increased during the COVID-19 pandemic. 3 However, data collected vary considerably. Specifically, ranges from 2.2% 12 to 63.8% 13 and 1.8% 12 to 49.5% 13 for clinically elevated depression and anxiety symptoms, respectively. As governments and policy makers deploy and implement recovery plans, ascertaining precise estimates of the burden of mental illness for youth are urgently needed to inform service deployment and resource allocation.

Depression and generalized anxiety are 2 of the most common mental health concerns in youth. 14 Depressive symptoms, which include feelings of sadness, loss of interest and pleasure in activities, as well as disruption to regulatory functions such as sleep and appetite, 15 could be elevated during the pandemic as a result of social isolation due to school closures and physical distancing requirements. 6 Generalized anxiety symptoms in youth manifest as uncontrollable worry, fear, and hyperarousal. 15 Uncertainty, disruptions in daily routines, and concerns for the health and well-being of family and loved ones during the COVID-19 pandemic are likely associated with increases in generalized anxiety in youth. 16

When heterogeneity is observed across studies, as is the case with youth mental illness during COVID-19, it often points to the need to examine demographic, geographical, and methodological moderators. Moderator analyses can determine for whom and under what circumstances prevalence is higher vs lower. With regard to demographic factors, prevalence rates of mental illness both prior to and during the COVID-19 pandemic are differentially reported across child age and sex, with girls 17 , 18 and older children 17 , 19 being at greater risk for internalizing disorders. Studies have also shown that youth living in regions that experienced greater disease burden 2 and urban areas 20 had greater mental illness severity. Methodological characteristics of studies also have the potential to influence the estimated prevalence rates. For example, studies of poorer methodological quality may be more likely to overestimate prevalence rates. 21 The symptom reporter (ie, child vs parent) may also contribute to variability in the prevalence of mental illness across studies. Indeed, previous research prior to the pandemic has demonstrated that child and parent reports of internalizing symptoms vary, 22 with children/adolescents reporting more internalizing symptoms than parents. 23 Lastly, it is important to consider the role of data collection timing on potential prevalence rates. While feelings of stress and overwhelm may have been greater in the early months of the pandemic compared with later, 24 extended social isolation and school closures may have exerted mental health concerns.

Although a narrative systematic review of 6 studies early in the pandemic was conducted, 8 to our knowledge, no meta-analysis of prevalence rates of child and adolescent mental illness during the pandemic has been undertaken. In the current study, we conducted a meta-analysis of the global prevalence of clinically elevated symptoms of depression and anxiety (ie, exceeding a clinical cutoff score on a validated measure or falling in the moderate to severe symptom range of anxiety and depression) in youth during the first year of the COVID-19 pandemic. While research has documented a worsening of symptoms for children and youth with a wide range of anxiety disorders, 25 including social anxiety, 26 clinically elevated symptoms of generalized anxiety are the focus of the current meta-analysis. In addition to deriving pooled prevalence estimates, we examined demographic, geographical, and methodological factors that may explain between-study differences. Given that there have been several precipitants of psychological distress for youth during COVID-19, we hypothesized that pooled prevalence rates would be higher compared with prepandemic estimates. We also hypothesized that child mental illness would be higher among studies with older children, a higher percentage of female individuals, studies conducted later in the pandemic, and that higher-quality studies would have lower prevalence rates.

This systematic review was registered as a protocol with PROSPERO (CRD42020184903) and the Preferred Reporting Items for Systematic Reviews and Meta-analyses ( PRISMA ) reporting guideline was followed. 27 Ethics review was not required for the study. Electronic searches were conducted in collaboration with a health sciences librarian in PsycInfo, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and MEDLINE from inception to February 16, 2021. The search strategy (eTable 1 in the Supplement ) combined search terms from 3 themes: (1) mental illness (including depression and anxiety), (2) COVID-19, and (3) children and adolescents (age ≤18 years). Both database and subject headings were used to search keywords. As a result of the rapidly evolving nature of research during the COVID-19 pandemic, we also searched a repository of unpublished preprints, PsycArXiv . The key terms COVID-19 , mental health , and child/adolescent were used on March 8, 2021, and yielded 38 studies of which 1 met inclusion criteria.

The following inclusion criteria were applied: (1) sample was drawn from a general population; (2) proportion of individuals meeting clinical cutoff scores or falling in the moderate to severe symptom range of anxiety or depression as predetermined by validated self-report measures were provided; (3) data were collected during COVID-19; (4) participants were 18 years or younger; (5) study was empirical; and (6) studies were written in English. Samples of participants who may be affected differently from a mental health perspective during COVID-19 were excluded (eg, children with preexisting psychiatric diagnoses, children with chronic illnesses, children diagnosed or suspected of having COVID-19). We also excluded case studies and qualitative analyses.

Five (N.R., B.A.M., J.E.C., R.E. and J.Z.) authors used Covidence software (Covidence Inc) to review all abstracts and to determine if the study met criteria for inclusion. Twenty percent of abstracts reviewed for inclusion were double-coded, and the mean random agreement probability was 0.89; disagreements were resolved via consensus with the first author (N.R.). Two authors (N.R. and B.A.M.) reviewed full-text articles to determine if they met all inclusion criteria and the percent agreement was 0.80; discrepancies were resolved via consensus.

When studies met inclusion criteria, prevalence rates for anxiety and depression were extracted, as well as potential moderators. When more than 1 wave of data was provided, the wave with the largest sample size was selected. For 1 study in which both parent and youth reports were provided, 26 the youth report was selected, given research that they are the reliable informants of their own behavior. 28 The following moderators were extracted: (1) study quality (see the next subsection); (2) participant age (continuously as a mean); (3) sex (% female in a sample); (4) geographical region (eg, East Asia, Europe, North America), (5) informant (child, parent), (6) month in 2020 when data were collected (range, 1-12). Data from all studies were extracted by 1 coder and the first author (N.R.). Discrepancies were resolved via consensus.

Adapted from the National Institute of Health Quality Assessment Tool for Observation Cohort and Cross-Sectional Studies, a short 5-item questionnaire was used (eTable 2 in the Supplement ). 29 Studies were given a score of 0 (no) or 1 (yes) for each of the 5 criteria (validated measure; peer-reviewed, response rate ≥50%, objective assessment, sufficient exposure time) and summed to give a total score of 5. When information was unclear or not provided by the study authors, it was marked as 0 (no).

All included studies are from independent samples. Comprehensive Meta-Analysis version 3.0 (Biostat) software was used for data analysis. Pooled prevalence estimates with associated 95% confidence intervals around the estimate were computed. We weighted pooled prevalence estimates by the weight of the inverse of their variance, which gives greater weight to large sample sizes.

We used random-effects models to reflect the variations observed across studies and assessed between-study heterogeneity using the Q and I 2 statistics. Pooled prevalence is reported as an event rate (ie, 0.30) but interpreted as prevalence (ie, 30.0%). Significant Q statistics and I 2 values more than 75% suggest moderator analyses should be explored. 30 As recommended by Bornstein et al, 30 we examined categorical moderators when k of 10 or higher and a minimum cell size of k more than 3 were available. A P value of .05 was considered statistically significant. For continuous moderators, random-effect meta-regression analyses were conducted. Publication bias was examined using the Egger test 31 and by inspecting funnel plots for symmetry.

Our electronic search yielded 3094 nonduplicate records (eFigure 1 in the Supplement ). Based on the abstract review, a total of 136 full-text articles were retrieved to examine against inclusion criteria, and 29 nonoverlapping studies 10 , 12 , 13 , 17 , 19 , 20 , 26 , 32 - 53 met full inclusion criteria.

A total of 29 studies were included in the meta-analyses, of which 26 had youth symptom reports and 3 studies 39 , 42 , 48 had parent reports of child symptoms. As outlined in Table 1 , across all 29 studies, 80 879 participants were included, of which the mean (SD) perecentage of female individuals was 52.7% (12.3%), and the mean age was 13.0 years (range, 4.1-17.6 years). All studies provided binary reports of sex or gender. Sixteen studies (55.2%) were from East Asia, 4 were from Europe (13.8%), 6 were from North America (20.7%), 2 were from Central America and South America (6.9%), and 1 study was from the Middle East (3.4%). Eight studies (27.6%) reported having racial or ethnic minority participants with the mean across studies being 36.9%. Examining study quality, the mean score was 3.10 (range, 2-4; eTable 3 in the Supplement ).

The pooled prevalence from a random-effects meta-analysis of 26 studies revealed a pooled prevalence rate of 0.25 (95% CI, 0.21-0.30; Figure 1 ) or 25.2%. The funnel plot was symmetrical (eFigure 2 in the Supplement ); however, the Egger test was statistically significant (intercept, −9.5; 95% CI, −18.4 to −0.48; P  = .02). The between-study heterogeneity statistic was significant ( Q  = 4675.91; P  < .001; I 2  = 99.47). Significant moderators are reported below, and all moderator analyses are presented in Table 2 .

As the number of months in the year increased, so too did the prevalence of depressive symptoms ( b  = 0.26; 95% CI, 0.06-0.46). Prevalence rates were higher as child age increased ( b  = 0.08; 95% CI, 0.01-0.15), and as the percentage of female individuals ( b  = 0.03; 95% CI, 0.01-0.05) in samples increased. Sensitivity analyses removing low-quality studies were conducted (ie, scores of 2) 32 , 43 (eTable 4 in the Supplement ). Moderators remained significant, except for age, which became nonsignificant ( b  = 0.06; 95% CI, −0.02 to 0.13; P  = .14).

The overall pooled prevalence rate across 25 studies for elevated anxiety was 0.21 (95% CI, 0.17-0.24; Figure 2 ) or 20.5%. The funnel plot was symmetrical (eFigure 3 in the Supplement ) and the Egger test was nonsignificant (intercept, −6.24; 95% CI, −14.10 to 1.62; P  = .06). The heterogeneity statistic was significant ( Q  = 3300.17; P  < .001; I 2  = 99.27). Significant moderators are reported below, and all moderator analyses are presented in Table 3 .

As the number of months in the year increased, so too did the prevalence of anxiety symptoms ( b  = 0.27; 95% CI, 0.10-0.44). Prevalence rates of clinically elevated anxiety was higher as the percentage of female individuals in the sample increased ( b  = 0.04; 95% CI, 0.01-0.07) and also higher in European countries ( k  = 4; rate = 0.34; 95% CI, 0.23-0.46; P  = .01) compared with East Asian countries ( k  = 14; rate = 0.17; 95% CI, 0.13-0.21; P  < .001). Lastly, the prevalence of clinically elevated anxiety was higher in studies deemed to have poorer quality ( k  = 21; rate = 0.22; 95% CI, 0.18-0.27; P  < .001) compared with studies with better study quality scores ( k  = 4; rate = 0.12; 95% CI, 0.07-0.20; P  < .001). Sensitivity analyses removing low quality studies (ie, scores of 2) 32 , 43 yielded the same pattern of results (eTable 5 in the Supplement ).

The current meta-analysis provides a timely estimate of clinically elevated depression and generalized anxiety symptoms globally among youth during the COVID-19 pandemic. Across 29 samples and 80 879 youth, the pooled prevalence of clinically elevated depression and anxiety symptoms was 25.2% and 20.5%, respectively. Thus, 1 in 4 youth globally are experiencing clinically elevated depression symptoms, while 1 in 5 youth are experiencing clinically elevated anxiety symptoms. A comparison of these findings to prepandemic estimates (12.9% for depression 2 and 11.6% for anxiety 1 ) suggests that youth mental health difficulties during the COVID-19 pandemic has likely doubled.

The COVID-19 pandemic, and its associated restrictions and consequences, appear to have taken a considerable toll on youth and their psychological well-being. Loss of peer interactions, social isolation, and reduced contact with buffering supports (eg, teachers, coaches) may have precipitated these increases. 3 In addition, schools are often a primary location for receiving psychological services, with 80% of children relying on school-based services to address their mental health needs. 54 For many children, these services were rendered unavailable owing to school closures.

As the month of data collection increased, rates of depression and anxiety increased correspondingly. One possibility is that ongoing social isolation, 6 family financial difficulties, 55 missed milestones, and school disruptions 3 are compounding over time for youth and having a cumulative association. However, longitudinal research supporting this possibility is currently scarce and urgently needed. A second possibility is that studies conducted in the earlier months of the pandemic (February to March 2020) 12 , 51 were more likely to be conducted in East Asia where self-reported prevalence of mental health symptoms tends to be lower. 56 Longitudinal trajectory research on youth well-being as the pandemic progresses and in pandemic recovery phases will be needed to confirm the long-term mental health implications of the COVID-19 pandemic on youth mental illness.

Prevalence rates for anxiety varied according to study quality, with lower-quality studies yielding higher prevalence rates. It is important to note that in sensitivity analyses removing lower-quality studies, other significant moderators (ie, child sex and data collection time point) remained significant. There has been a rapid proliferation of youth mental health research during the COVID-19 pandemic; however, the rapid execution of these studies has been criticized owing to the potential for some studies to sacrifice methodological quality for methodological rigor. 21 , 57 Additionally, several studies estimating prevalence rates of mental illness during the pandemic have used nonprobability or convenience samples, which increases the likelihood of bias in reporting. 21 Studies with representative samples and/or longitudinal follow-up studies that have the potential to demonstrate changes in mental health symptoms from before to after the pandemic should be prioritized in future research.

In line with previous research on mental illness in childhood and adolescence, 58 female sex was associated with both increased depressive and anxiety symptoms. Biological susceptibility, lower baseline self-esteem, a higher likelihood of having experienced interpersonal violence, and exposure to stress associated with gender inequity may all be contributing factors. 59 Higher rates of depression in older children were observed and may be due to puberty and hormonal changes 60 in addition to the added effects of social isolation and physical distancing on older children who particularly rely on socialization with peers. 6 , 61 However, age was not a significant moderator for prevalence rates of anxiety. Although older children may be more acutely aware of the stress of their parents and the implications of the current global pandemic, younger children may be able to recognize changes to their routine, both of which may contribute to similar rates of anxiety with different underlying mechanisms.

In terms of practice implications, a routine touch point for many youth is the family physician or pediatrician’s office. Within this context, it is critical to inquire about or screen for youth mental health difficulties. Emerging research 42 suggests that in families using more routines during COVID-19, lower child depression and conduct problems are observed. Thus, a tangible solution to help mitigate the adverse effects of COVID-19 on youth is working with children and families to implement consistent and predictable routines around schoolwork, sleep, screen use, and physical activity. Additional resources should be made available, and clinical referrals should be placed when children experience clinically elevated mental distress. At a policy level, research suggests that social isolation may contribute to and confer risk for mental health concerns. 4 , 5 As such, the closure of schools and recreational activities should be considered a last resort. 62 In addition, methods of delivering mental health resources widely to youth, such as group and individual telemental health services, need to be adapted to increase scalability, while also prioritizing equitable access across diverse populations. 63

There are some limitations to the current study. First, although the current meta-analysis includes global estimates of child and adolescent mental illness, it will be important to reexamine cross-regional differences once additional data from underrepresented countries are available. Second, most study designs were cross-sectional in nature, which precluded an examination of the long-term association of COVID-19 with child mental health over time. To determine whether clinically elevated symptoms are sustained, exacerbated, or mitigated, longitudinal studies with baseline estimates of anxiety and depression are needed. Third, few studies included racial or ethnic minority participants (27.6%), and no studies included gender-minority youth. Given that racial and ethnic minority 64 and gender-diverse youth 65 , 66 may be at increased risk for mental health difficulties during the pandemic, future work should include and focus on these groups. Finally, all studies used self- or parent-reported questionnaires to examine the prevalence of clinically elevated (ie, moderate to high) symptoms. Thus, studies using criterion standard assessments of child depression and anxiety disorders via diagnostic interviews or multimethod approaches may supplement current findings and provide further details on changes beyond generalized anxiety symptoms, such symptoms of social anxiety, separation anxiety, and panic.

Overall, this meta-analysis shows increased rates of clinically elevated anxiety and depression symptoms for youth during the COVID-19 pandemic. While this meta-analysis supports an urgent need for intervention and recovery efforts aimed at improving child and adolescent well-being, it also highlights that individual differences need to be considered when determining targets for intervention (eg, age, sex, exposure to COVID-19 stressors). Research on the long-term effect of the COVID-19 pandemic on mental health, including studies with pre– to post–COVID-19 measurement, is needed to augment understanding of the implications of this crisis on the mental health trajectories of today’s children and youth.

Corresponding Author: Sheri Madigan, PhD, RPsych, Department of Psychology University of Calgary, Calgary, AB T2N 1N4, Canada ( [email protected] ).

Accepted for Publication: May 19, 2021.

Published Online: August 9, 2021. doi:10.1001/jamapediatrics.2021.2482

Author Contributions: Drs Racine and Madigan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Racine, Madigan.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Racine, McArthur, Eirich, Zhu, Madigan.

Critical revision of the manuscript for important intellectual content: Racine, Cooke, Eirich, Madigan.

Statistical analysis: Racine, McArthur.

Administrative, technical, or material support: Madigan.

Supervision: Racine, Madigan.

Conflict of Interest Disclosures: Dr Racine reported fellowship support from Alberta Innovates. Dr McArthur reported a postdoctoral fellowship award from the Alberta Children’s Hospital Research Institute. Ms Cooke reported graduate scholarship support from Vanier Canada and Alberta Innovates Health Solutions outside the submitted work. Ms Eirich reported graduate scholarship support from the Social Science and Humanities Research Council. No other disclosures were reported.

Additional Contributions: We acknowledge Nicole Dunnewold, MLIS (Research and Learning Librarian, Health Sciences Library, University of Calgary), for her assistance with the search strategy, for which they were not compensated outside of their salary. We also acknowledge the contribution of members of the Determinants of Child Development Laboratory at the University of Calgary, in particular, Julianna Watt, BA, and Katarina Padilla, BSc, for their contribution to data extraction, for which they were paid as research assistants.

• Register for email alerts with links to free full-text articles
• Access PDFs of free articles
• Manage your interests
• Save searches and receive search alerts