Global challenges
Mental Health:
Global Challenges
Journal
MHGCJ-2022
Vol
5,
Issue
2
ISSN 2612-2138
Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ
ISSN 2612-2138
Editorial
Witness as Victim: Clinical Encounters with
Children Who Observed Violence
Galina Itskovich
The Interdisciplinary Council on Development and Learning, New York, USA
Address for correspondence:
Galina Itskovich, LCSW, Inc, 1525 Marine Parkway, Brooklyn, New York, USA, E-mail:
galaitsk@gmail.com
This work is licensed under a Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0).
©Copyright: Itskovich, 2022
Publisher: Sciendo (De Gruyter)
DOI: https://doi.org/10.56508/mhgcj.v5i2.144
Submitted for publication: 23
June 2022
Received: 18 July 2022
Accepted for publication: 02
August 2022
Keywords
war atrocities witness, childhood trauma, body image distortions, trauma informed treatments
In the spring months of 2022, Human Rights
Watch, the international humanitarian group,
released stunning details of the carnage in the
regions around Chernihiv and Kyiv that Russia left
behind. In a report released from May 2022,
Human Rights Watch stated that it was currently
investigating 22 potential summary executions,
nine other unlawful killings, six possible
kidnappings, seven cases of torture and 21
reported incidents of other forms of “unlawful
confinement in inhuman and degrading conditions”
carried out by Russian forces against civilians. But
even this report doesn’t take into account traumatic
impact on witnesses. Having witnessed the crime
once, the witness continues to see the world
through the prism of the observed violence.
The National Child Traumatic Stress Network
defines traumatic stress as the stress response to
a traumatic event of which one is a victim or
witness. Based on this definition, we can establish
that the witness is considered traumatized as well,
and the victim’s trauma is not less impactful on
his/her mental health and psychological well-being.
Watching the untoward, unimaginable acts when a
human life or health are endangered creates
psychological damage of extreme magnitude.
During the Iraq war, the results of the psychiatric
assessment of supporting military who were not
involved in active combat demonstrated that their
PTSD symptoms are roughly equal to / not less
prominent than those of their fighting fellows.
Watching other people’s suffering is toxic. When
the witness is a child, it complicates the
assessment, as child witnesses may be discounted
as “not understanding” or “not impacted”. Adults
tend to think that children “quickly forget” and even
report “better functionality” and “exemplary
behavior” under stress. Yet, empirical and
theoretical findings show that traumatic experience
takes years to process. This is especially pertinent
for young children as their sense of safety depends
on the perceived safety of their attachment figures
(NCTSN). Amplified emotional reactivity and a lack
of control of events leave young children
susceptible to stress symptomatology (Sossin &
Birklein,2006).
Little witnesses which, with the beginning of the
Russian expansion, started pouring into clinical
practices in Ukraine and around the world saw a
lot, most impactfully, deaths of parents, siblings,
neighbors and friends, rape and torture. A different
kind of witnessing is presented by indirect
exposure (via adult conversations or social media
involving violence toward people personally known
to the viewer). In some situations, children had to
make critical decisions about own survival (for
example, hiding under dead bodies) or about
obtaining help for the victims.
Sossin (2006) refers to tension flow between a
parent and a child and non-verbal aspects of stress
transmission. Children expressed internalizing the
emotional pain and experiencing physical aches as
they were witnessing parents in pain, recalled
thinking that “this was the end of me”, or, just the
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opposite, felt numb and separated from/ floating
above their own body.
Once the direct exposure is over, images that
are consolidated into memories and overall
experience of trauma can turn into legacy that
shapes all future experiences. Triggers can appear
at different junctures, reflecting on every aspect of
the memory. Smells, sounds, touch, color, lights,
specific movement pattern or constricted range of
motion – any sensory stimulus can become a
triggering event. Physical reactions such as
increased heartbeat, sweating or bowel
movements can also serve as reminders. Places,
people, objects and situations reminding of the
aggressor (as well as the victim) can initiate the
associative process. For instance, a four-year-old
who survived two episodes of shelling
demonstrated a startled response when presented
with a ball that was colored in rainbow splashes, as
they reminded him of explosions; another
preschooler said that the pen looks like a barrel of
a tank. “According to embodied cognition, our
body, in all its aspects (sensory, motor, and body–
environment interaction), shapes and organizes
our mind, including high-level features (like
memory, concepts, and categories) and abstract
tasks (like reasoning and judgment)” (Morasso et.
al., 2015). Traumatic response can be initiated at
any point, whether by the memory or a bodily
sensation, and then escalate to a full-blown
flashback.
Identifying triggers and resulting behaviors can
become an important instrument for understanding
children’s emotions and functioning in the long
term. When we look at the families who fled the
horrifying scene of atrocity together, they may
present with shared triggers and, consequently,
shared maladaptive behaviors. For instance, a
mother of a child who survived shelling reported
that she had to fight her own urge to hide while
trying to convince her son to look at the July 4th
fireworks.
No matter the modality, such reactions need to
be brought up in clinical encounters. It’s important
not to be afraid to open up the box with terrifying or
shameful event, even as a metaphor in the course
of the play session. It is the reprocessing of trauma
that allows to advance towards the acceptance of
the past trauma and reintegration of the individual
who survived it. Victor Frankl noted about his
Auschwitz experience, “The only thing that we
could control was the attitude towards what was
happening” (). Such “attitude adjustment”,
therefore, is the important aspect of the therapeutic
work. Another crucial aspect is building trusting
relationship with the child witness. The child can
be angry at the significant adult(s) or generalize
this anger to all and any adults for failing to protect
him/her. The child can later depreciate the role of
adults, as part of identifying with the aggressor.
Psychosocial effects of witnessing violence can
be divided into three categories:
Externalizing (aggression/ identification
with the aggressor, tantrums);
Internalizing (withdrawal, anxiousness,
depression); and
Feigning social incompetence
(antisocial, avoidant behavior or
amotivation).
Pervasive sense of gloom and hopelessness,
anxiety, overall depression, grief, anger, fear,
distorted sense of the reality and lowered self-
esteem – this is just a partial list of reactions to
witnessing the atrocity. One more, easily
predictable, effect is the loss of control that can be
manifested in different contexts, right after the
exposure and as a delayed onset. Because of the
activation of the mechanisms of the autonomic
nervous system, displacement takes place quite
frequently. Interaction can start with the minor
disagreement on a playground and escalate to the
full-blown flashback and the symbolic reenactment
of the episode where the child felt helpless in the
face of the mortal danger. Child witnesses can also
behave in the aggressive manner with other kids. If
not addressed, this defense mechanism of
identification with the aggressor can lead to later
distortions and overall normalize violence in their
lives.
Another widespread aftereffect is the survivor’s
guilt of significant intensity. We’re not to forget that
preschoolers look at the world from the egocentric,
and therefore omnipotent, point of view. Not unlike
the feeling of own helplessness, he or she can
irrationally blame themselves, “I was bad, and
mother was tortured,” or, “I didn’t listen to the
grandmother and now she’s dead.” They later
replay the heroic or aggressive scenes, alternately
blaming and redeeming themselves. This play
scenarios, if co-created and interpreted by a
trauma-informed therapist, are pivotal for the
process of psychological recovery and healing.
One more aspect of surviving the atrocity as a
witness is learned helplessness. The child who has
witnessed violence or atrocity can display
regression of ADLs, loss of developmental
milestones and flat affect, overall loss of emotional
functionality, numbness, freezing or outbursts of
aggression at the time of decision making.
Witnessing sexual violence: treatment
approaches
Mass reports of rapes and other types of sexual
assault from the regions around Kyiv rarely
mention children who weren’t physically harmed
but became incidental or, in many described cases,
intentional witness to crime. In one report from the
paramedic, children in Bucha were forced to watch
their parents’ rape, torture and death. In addition to
the obvious psychological damage, watching rape
or sexual assault leads to the distorted body
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schema. Since yearly in human development, we
all have the internal image of what we look like. The
process of developing the inner representation of
one’s own body ends as late as 8 years of age.
Therefore, if we are to discuss preschooler or
younger witnesses, they are subject to cognitive
distortions in the way they perceive their own
bodies. This may have top-down, as well as
bottom-up consequences.
For instance, the distorted body image can
reshape their motor planning skills and control over
their own body in space, feeding and elimination
behaviors, specifically, constipation.
Psychodynamically speaking, defecation is
symbolic of a loss of a body part. Therefore, many
children witnesses may regress, “unlearn” toilet
training or hold the feces. One of the useful
techniques in addressing voluntary withholding
feces is to let the child sit on the potty in front of a
mirror or otherwise involve mirror images, letting
him/her observe their own body and identify feces
as substance that is totally different in color and
consistency from the rest of the body.
Techniques to restore the inner representation
of the body include games that involve identifying
body parts, restoring or developing better body
awareness via labeling motions and naming body
parts, mirror games, spatial awareness, weight
bearing activities. Pillow fight, for example, can be
a productive technique to increase proprioceptive
input and overall body awareness, provided that
the child allows and tolerates touch. Obtaining
permission for touch allows the child to reclaim full
control over his/her own body. If the child is looking
for the proprioceptive input but is adamant about
not being touched, there are other means of forging
physical contact such as building a tent, using a
weighted blanket, setting up a play area near the
wall or in the corner, therefore creating opportunity
for sensing the parameters of his/her own body
without feeling triggered.
To reiterate, safety continues to be the
overarching goal. Physical safety in the therapeutic
setting and at home, creating safe space and
negotiating comfortable distance between the child
and others will accelerate processes of
psychological adaptation and healing. From the
physical safety of good locks and reliable windows
to creating trusting environment where
verbalizations or memories are elicited only with
the child’s consent at a comfortable pace, -
everything needs to be aimed at the creation of a
safe space in every meaning of this word.
It makes sense to discuss the issue of control in
greater detail. One of the pivotal conditions to
regain control would be a symbolic repair of the
child’s world. Dis-membering of dolls and puppets
and re-membering, in a sense of reassembly and
building new connections, fixing what’s broken and
severed in the course of the symbolic play are
aimed at recreating the whole from the parts,
symbolic repair a.k.a. rebirth, restoring subjective
sense of control and omnicentrism. These goals
can be reached by the means of puppet, figurines,
and doll play, and using toys like Mr. Potato Head
that allows to pull apart and then reassemble a
human-like figure. Any theme chosen by the child
will provide ample opportunities to act out this ritual
of reassembly and symbolic rebirth. Keeping in
mind the abovementioned possibility of aggressive
behavior, it is important to remember not to shy
away from aggressive play or disturbing scenarios
generated by the playing child. It’s crucial to stay
with the theme offered and not to disrupt the game
or “make everything alright” if the therapist
him/herself is uncomfortable with the aggression.
However, it is as crucial to repair everything that’s
been pulled apart or broken by the end of each
session. Repair as many toys as possible,
simultaneously involving the child into the symbolic
restoration. Therefore, the therapeutic task of
reassembling the safe world will be achieved.
Another important task is to create new rituals
and routines, specifically, rituals and routines
associated with the victim of violence, whether
alive or deceased. As an example, a child who left
his building at the time of the air raid and never
came back nor ever saw his grandmother who’d
stayed behind, gradually engaged in the memory
game. We tried to identify what his grandmother
looked like, what clothes she wore, what dishes
cooked etc. We started to draw grandmother’s
portraits, restoring from memory different moments
of the prewar life. Forgetting makes one feel guilty;
rebuilding (and even reinventing) memories, on the
other hand, is empowering.
As we work on these tasks, we do not rewrite
the past but rather rebuild disrupted neural
connections, reprocessing memories and
modulating pain and post-traumatic reactions. Any
trauma informed therapy, from EMDR to tapping
techniques, can be useful now as long as the
trusting therapeutic relationship continues to
unfold. Additionally, the fact of mere presence of
the permanent, non-threatening, safe respectful
adult carries the healing properties.
The Ukraine Recovery Conference that took
place in Lugano in July of 2022 introduced the term
"children in early stages of vulnerability." While the
proposed definition is, while understating, also too
broad, it undeniably includes children who
witnessed horrendous violence during the war
unleashed by Russia. This paper merely scratches
the surface when it comes to the tasks of clinical
formulation and treatment of child witnesses, but
it’s important as ever to emphasize the
multidisciplinary, multisystem approach. It will help
the processes of comprehending specific
therapeutic challenges and of successful
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restoration of the sense of agency, trust, and safety
for the young victims.
Conflict of interest
The author declares that she has no conflict of
interest.
References
Assaiante, C., Barlaam, F., Cignetti, F., &
Vaugoyeau, M. (2014). Body schema building
during childhood and adolescence: A
neurosensory approach. Neurophysiologie
Clinique/Clinical Neurophysiology, 44, 3-12.
Frankl, V. E. (1992). Man’s Search For Meaning.
(4th ed.) (I. Lasch, Trans.). Boston: Beacon
Press
Jaffe, P.G, Dermot, I., Hurley, J.& Wolfe, D. (1990).
Children's Observations of Violence: I. Critical
Issues. In Child Development and Intervention
Planning. Canadian Journal of Psychiatry, Vol.
35, No.6.
Morasso, P.G., Casadio, M., Mohan, V., Rea, F., &
Zenzeri, J. (2015). Revisiting the Body-Schema
Concept in the Context of Whole-Body Postural-
Focal Dynamics. Frontiers in Human
Neuroscience
Webb, N. Boyd (Ed) (2015). Play therapy with
children and adolescents in crisis (Lenore C.
Terr. Foreword). (4th ed.). The Guilford Press
Sossin, K.M. & Birklein, S. (2006). Nonverbal
transmission of stress between parent and
young child: Considerations and
psychotherapeutic implications of a study of
affective movement patterns. Journal of Infant,
Child, & Adolescent Psychotherapy, 5, 46-69.
Ukraine Recovery Conference. Social Recovery
(2022). Lugano, Switzerland: Conference
materials (urc2022.com)
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What mental illness means in different cultures:
perceptions of mental health among refugees
from various countries of origin
Sarah Moses, David Holmes
University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Department of Family Medicine, 955 Main Street Buffalo, NY,
USA
Abstract
Introduction: Mental illness remains a significant issue for refugees worldwide. However, there
remains a stigma surrounding mental health, mental illness, and mental health treatment
throughout the world. Cultural stigma is just one of many barriers to mental health care for
refugees that needs to be addressed.
Purpose: The purpose of this review was to distinguish the perceptions of mental health among
refugees according to country of origin, because knowing these cultural differences can break
some of the barriers and lead to better treatment approaches to mental health care for refugees.
Methodology: An extensive literature review of relevant articles published between 2000 and
2021 was performed using the databases APA PsycInfo, Global Health, MEDLINE via Ovid,
CINAHL Plus with Full Text, and Google Scholar. The following groupings of search terms were
used: (i) refugees, asylum seekers, displaced, and migrants; (ii) perceptions of mental illness,
perceptions of mental health, and stigma of mental illness.
Results: There were numerous similarities and differences in the perceptions of mental health
among refugees from different cultures. There were similarities in terms of mental health stigma,
with certain cultures thinking of mental health/illness as taboo, as shameful, or associating it with
evil spirits. A few of the cultures studied had similar ideas about the causes of mental illness,
believing it was due to traumatic events or possession by evil spirits. The refugee groups had
some common treatment options, including informal conversation, religious-based ideas, and
community-level solutions. Some of the differences between refugees from different cultures
involved certain symptoms associated with mental health, including physical symptoms, and
differing degrees of religiosity.
Conclusions: This review of the perceptions of mental health held by refugees from countries
around the world highlights the importance of cultural differences. Mental health care in this
population should focus on cultural competency and community-level solutions and include mobile
health clinics and telehealth.
Keywords
refugee mental health, perceptions of mental health, stigma, mental illness, mental health
treatment
Address for correspondence:
Sarah Moses, MD, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences,
Department of Family Medicine, 955 Main Street Buffalo, NY 14203.
e-mail: smoses2@buffalo.edu
This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0 International
License (CC BY-NC 4.0).
©Copyright: Moses, Holmes, 2022
Publisher: Sciendo (De Gruyter)
DOI: https://doi.org/10.56508/mhgcj.v5i2.126.
Submitted for publication: 19
October 2021
Revised: 09 April 2022
Accepted for publication: 08
May 2022
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Introduction
Mental illness remains a huge problem in the
refugee population despite recent efforts to
combat this unfortunate reality. Blackmore et al.
(2020) conducted a meta-analysis and systematic
review of the prevalence of mental illness in
refugees and asylum seekers. Their review was
conducted across 15 countries, and the
prevalence of posttraumatic stress disorder,
depression, anxiety disorders, and psychosis was
determined. The authors found significantly more
posttraumatic stress disorder and depression in
refugees and asylum seekers than in the general
population (Figure 1). By contrast, they found that
the prevalence of both anxiety disorders and
psychosis in refugees and asylum seekers was
comparable to the prevalence in the general
population (Figure 1). For most of the cases of
posttraumatic stress disorder and depression, the
rates of mental illness among refugees and
asylum seekers were not only high but persisted
for many years after initial resettlement. There
was no difference in prevalence between refugees
displaced fewer than 4 years and those displaced
more than 4 years (Blackmore et al., 2020).
Another systematic review from 2020 found
considerably higher rates of mental health
disorders and biological markers of persistent
stress among refugees than among migrants and
the general population of the host country (Byrow
et al., 2020). As can be gleaned from the study of
15 different countries in the meta-analysis by
Blackmore et al. (2020), mental illness is clearly
prevalent in refugees arriving from many different
countries and is not specific to one country of
origin.
Figure 1. Prevalence of mental illness in
refugees and asylum seekers compared to that in
the general population (Blackmore et al., 2020).
Globally, the stigma surrounding mental illness
remains an important issue due to its high
prevalence and strong impact (Adu et al., 2021).
Often, the stigma from mental illness is defined as
context specific (Major & O'Brien, 2005).
According to a 2021 review article by Adu et al.,
“Mental illness-related stigma is rooted in
culture…it can be societal, familial, perpetuated
by health professionals, or situated within the
individual themselves” (Adu et al., 2021, p. 1).
With stigma playing a large role, there are
numerous barriers to mental health care for
refugees (Koesters et al., 2018). These barriers
are at the patient level, the provider level, and a
systems level. Barriers to mental health care at
the patient level include cultural beliefs about
mental health, linguistic barriers, lack of health
care knowledge, distrust of authority or services,
and financial strain. At the provider level, barriers
involve faulty communication skills and a lack of
cultural competency. At the systems level, there
may be a need for more interpreters and improved
reimbursement systems. Differences between
host countries such as initial restrictions to health
care access can also serve as barriers (Koesters
et al., 2018). Many diverse approaches to
overcoming these barriers have been
implemented and studied in different countries
with different refugee populations (Patel et al.,
2014). Additionally, various types of interventions
have been and continue to be tried and evaluated
in a number of host countries (Giacco & Priebe,
2018). There are certain general principles that
are being emphasized in the efforts to improve
refugees’ mental health care, including
overcoming these barriers to care and promoting
social integration (Giacco & Priebe, 2018).
The systematic review by Byrow et al. (2020)
determined that the most important barriers that
refugees have in seeking mental health care fit
into three categories: cultural, structural, and
refugee-specific factors. Cultural barriers include
mental health stigma, (lack of) knowledge of major
models of mental health, and social concerns. The
review found that research participants in the 24
studies, who were all refugees, talked about
mental illness in a negative way. Unfavorable
cultural perceptions played an important role in
these barriers: “One of the primary barriers to
help-seeking behavior that has been consistently
observed across populations, relates to
perceptions of mental health and mental health
treatment” (Byrow et al., 2020, p. 2). In
consideration of this topic, “perceptions” may be
defined as attitudes, beliefs, or knowledge about
mental health. The review by Byrow et al. (2020)
found that these mental health perceptions impact
refugees’ perceived need for mental health care
and their engagement in mental health care.
Therefore, mental health perceptions can provide
additional knowledge concerning behavioral
differences in the utilization of services in different
populations (Andrade et al., 2014; Byrow et al.,
2020). Overcoming refugees’ barriers to mental
health care is even more challenging because of
the immense heterogeneity across different
populations of refugees, host countries, and
contexts (Koesters et al., 2018). Mental health
perceptions differ between different cultures, with
diverse explanations and beliefs behind them
(Byrow et al., 2020).
0
20
40
60
PTSD Depression Anxiety
Disorders
Psychosis
Prevalence (%)
Refugees and Asylum Seekers
General Population
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Purpose
This article distinguishes the perceptions of
mental health of refugees according to their
country of origin, because knowing these cultural
differences has the potential to improve refugee
mental health care. If the culture-specific
perceptions of refugees from various countries of
origin can be better understood, taken into
consideration, and utilized for treatment purposes,
then the barriers to care will be reduced.
Furthermore, this information could provide insight
into better approaches to refugee mental health
treatment that are more specialized,
individualized, and therefore more effective for
certain populations.
Methodology
Study design
This study was a comprehensive review. The
following electronic databases were searched for
original research and review articles that
assessed perceptions of mental health among
refugees from different countries of origin:
American Psychiatric Association (APA) PsycInfo
database, Global Health database, MEDLINE via
Ovid, and CINAHL Plus with Full Text. This
search included two groupings of terms
(keywords): (i) refugees, asylum seekers,
displaced, and migrants; (ii) perceptions of mental
illness, perceptions of mental health, and stigma
of mental illness.
Inclusion and exclusion criteria
Only relevant peer-reviewed articles published
from the year 2000 to September 2021 were
reviewed. Only articles that included the name of
a specific group of refugees (from one specific
country of origin) in the title were selected. Finally,
only those articles that focused on refugees’
perceptions, ideas, thoughts, or feelings about
mental health were selected. Articles not
published in English were excluded. Duplicate
articles were excluded.
This search produced 4,405 results. Of these,
only articles that included the name of any specific
group of refugees (from one specific country of
origin) in the title were selected. Of these, only
those that focused on refugees’ perceptions,
ideas, thoughts, or feelings about mental health
were selected. Sixty articles met the inclusion
criteria. In addition, to find more information on
specific topics, the references from some of the
articles found were explored and utilized, and an
additional search was completed on Google
Scholar with the search term “refugee perceptions
of mental illness.” Of the 60 articles, only those
that focused on one of four themes (causes of
mental illness, symptoms and behavior associated
with mental illness, mental health treatment, and
mental health stigma) were ultimately included
(Table 1). The search resulted in the review of
eight articles. All eight are primary research
articles. Six of these were from the reference
search and two were found on Google Scholar.
Data collection and analysis
Perceptions within the following four themes
were identified in the reviewed studies: causes of
mental illness, symptoms and behavior associated
with mental illness, mental health treatment, and
mental health stigma (Table 1).
Results
The perceptions of mental illness and mental
health care among refugees from various
countries of origin were categorized into the four
themes described above. Overall, there were both
similarities and distinctions among the five main
refugee populations studied, which are outlined
below.
Somali refugees
The Somali and Somali Bantu are the largest
groups of foreign-born Africans in the United
States and make up 45% of the African refugee
population (Carroll et al., 2007; Johnson et al.,
2009). A substantial proportion of Somali
refugees, between 14% and 31.5% of the
population, suffer from mental illness (Boynton et
al., 2010). A pilot study by Bettmann et al. (2015)
extensively examined the perceptions of mental
health and mental health treatment in Somali and
Somali Bantu refugees in the United States. The
study found that this population mostly described
mental illness in terms of observable behaviors.
Of the 20 participants interviewed, seven of them
believed that just hearing an individual’s verbal
expressions can determine whether someone is
mentally ill. Overall, this population utilized the
terms “worried,” “crazy,” and “stressed” as almost
synonymous with various types of mental illness.
There were several physical symptoms that the
Somali refugees associated with mental illness
(see Table 1). In terms of the stigma of mental
illness, the authors explained that the refugees’
perceptions of stigma were variable from one
individual to the next (Bettmann et al., 2015).
Palmer’s (2006) study in London revealed a
greater emphasis on stigma in certain Somali
refugee communities: “For the overwhelming
majority of Somalis, mental illness carries a
certain taboo and has associations with madness”
(Palmer, 2006, p. 51).
The study by Bettmann et al. (2015) examined
the refugees’ ideas of the causes of mental illness
in detail. The Somali refugees attributed the
causes of mental illness to many factors. Some of
their descriptions seemed very situational and
revolved almost exclusively around important
events in an individual’s life.
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Table 1. Comparison of refugee mental health
perceptions according to country of origin
Theme
Somali Refugees
(Bettmann et al., 2015)
(Palmer, 2006)
Burmese Refugees
(Kim et al., 2021)
(Fellmeth et al., 2015)
Syrian Refugees
(Al Laham et al., 2020)
(Kerbage et al., 2020)
Bhutanese Refugees
(MacDowell et al., 2020)
(Maleku et al., 2021)
Causes of Mental
Illness
Worry, stress,
wanting something
unattainable,
traumatic events,
significant loss
50%: God causes
illness
15%: Possession by
evil spirits
Kim et al. (2021):
Number one cause is
past traumatic
experiences
Post-resettlement
challenges:
expectations unmet,
difficult adjustment,
loss of social support
Possession by evil
spirits
Sinning in past life
Fellmeth et al. (2015):
Current economic,
family, and domestic
challenges
Excessive worry
External stress
including adverse
living conditions
Believed distress was
a normal shared
reaction to adversity
Environmental/struct
ural stressors: lack of
fulfillment of basic
needs
Psychosocial
stressors: loss of
social or occupational
role (including loss
of social networks)
Socio-cultural norms
Possession by evil
spirits
Emphasis on mind-body-
spirit connection
Symptoms and
Behavior Associated
with Mental Illness
Associated many physical
symptoms with mental
illness: “sensations of heat
coming out of the head,
dizziness, poor vision,
feeling that one’s head is
upside down, the inability
to see letters, the inability
to repeat what others say,
feeling nauseous, and lack
of appetite” (Bettmann et
al., 2015, p. 744).
Fellmeth et al. (2015):
Loss of control over
emotions
Inappropriate or
abnormal social
behavior
Excessive worry
Physical symptoms
Mental and physical
symptoms (metaphors of
external tension causing
buildup of pressure and of
being strangled)
Majority described people
with mental health
problems as unpredictable
Mental Health
Treatment
Medical: “the
majority” of
participants believed
in medical treatments
Nonmedical: caring
acts by the family or
community
(including informal
talking)
Religious: “the
majority” of
participants read the
Quran, talking to the
Imam
Kim et al. (2021):
Alternative
treatments such as
praying and
meditation
Advocated for
community-level
solutions: education,
training
Fellmeth et al. (2015):
Most commonly
mentioned and first
line: social and
emotional support
(talking with family
and friends)
Seen as more
extreme: medication,
hospitalization
Neither study indicated
counseling as primary
treatment option
Initial treatment:
seeing religious
healers
Advocated for
community-level
interventions with
increased social
engagement
Only real solution is
resettlement in new
country
Majority believed
there was no cure for
mental illness
Coping mechanism:
support-seeking
behavior (talking
with family, friends,
community members)
Coping mechanism:
physical, mental, and
spiritual practices
including yoga and
walking
Traditional religious
rituals and customs
Mental Health Stigma
U.S. article: context
and treatment
dependent, variable
London article:
mental illness =
taboo = associated
with madness
Kim et al. (2021):
Built into Burmese
cultures
Mental illness is
possession by evil
spirits or due to sins
Mental illness is
taboo, brings shame
to the individual and
family
Mentally ill are
mentally unfit to be
around others
Talking about mental
health openly
jeopardizes role in
community
Mental illness is
associated with
shame and fear
Mental illness is an
internal dysfunction
or “craziness” within
Mental illness is
possession by evil
spirits
57.7%: the term
“mental illness”
causes them to feel
embarrassed
52.2%: it brings
shame to attend
counseling, is seen as
a sign of weakness
>71%: those who
seek counseling are
viewed in an
unfavorable manner
Mental health is
taboo
Mentally ill are seen
as incapable
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Half of the refugees studied believed that God
was the cause of mental illnesses. As one woman
explained, “Everything is because of God. You get
better because of God and you get sick because
of God” (Bettmann et al., 2015, p. 746). In terms
of managing mental illness, “the majority” of the
Somali refugee participants did believe in medical
treatments, including medicine, going to the
hospital, and seeing a doctor (Bettmann et al.,
2015, p. 747). However, they felt that talking to
doctors was a form of assessment but not a form
of treatment. If talking were to be utilized to
manage mental illness, it was informal and with a
family member or friend (Bettmann et al., 2015).
Palmer’s (2006) study indicated that Somali
refugees in London viewed many available
psychiatric treatments with mistrust. The Somali
refugees in the U.S. study discussed many
nonmedical treatments for mental illness. Reading
the Quran, as reported by “the majority of
participants,” was a treatment method for all
illnesses, and mental illness was no exception
(Bettmann et al., 2015, p. 749). The Somali
refugees explained that Imams, who are Islamic
religious leaders, served important roles in the
treatment of mental illness by visiting patients and
reading the Quran for the family. Moreover,
almost half of the participants stated that
individuals with mental illness were kept at home
while they were ill (Bettmann et al., 2015).
Burmese refugees
Burmese refugees are among the largest of
the refugee groups in the United States; between
2002 and 2019, around 178,000 refugees
resettled in the United States from Burma,
otherwise known as Myanmar (Admissions and
arrivals, 2019). A study by Kim et al. (2021) on the
perceptions and barriers to mental health services
in refugees from Burma discussed three themes:
sources of mental illnesses, barriers to service
use, and working toward community solutions.
These Burmese refugees believed that the
number one source of mental illness was past
traumatic experiences and that memories of these
experiences persisted for decades. The other
major source reported was post-resettlement
challenges. In terms of barriers to mental health
service use, there was a glaring lack of
understanding of mental health: “Mental health is
a new concept to most refugees from Burma”
(Kim et al., 2021, p. 967). Most of these
individuals had never lived where mental health
services were available. This lack of knowledge
led to an inability to recognize mental health
problems and to access treatment. Language
difficulty was frequently cited as a barrier,
especially because of the lack of an appropriate
translation of the term “mental health” (and other
mental health terminology) in these refugees’
languages. Another major barrier to care was
cultural stigma: mental health stigma is ingrained
in Burmese cultures. A common faith-based belief
is that mental illness occurs in someone who has
sinned in a past life. When discussing mental
health management, these refugees emphasized
the need for community-level solutions, including
widescale education and training programs for all
individuals in the community (Kim et al., 2021).
In addition, another study exclusively looked at
pregnant refugee and migrant women from
Myanmar who were currently living on the Thai-
Myanmar border (Fellmeth et al., 2015). This
population was studied because of the high
prevalence of mental illness during a woman’s
childbearing years (Stewart et al., 2003).
Specifically, the rates of mental illness are up to
three times higher during the perinatal period than
at other times in a woman’s life (Gavin et al.,
2005). When questioned about the causes of
mental illness, these women emphasized current
challenges in addition to excessive worry
(Fellmeth et al., 2015). In contrast to the study by
Kim et al. (2021) previously discussed, only one of
the 92 pregnant participants believed that trauma
can contribute to mental illness. This article
provided possible explanations for these
contrasting results, including the methods used to
elicit information and this specific population’s
protective factors. A minority of participants
believed that spirits caused mental illness. When
suicide was discussed, these female refugees
described suicide almost exclusively in terms of
shame. As an example of shame leading to
suicide, the study quoted one of the participants,
“One girl I knew killed herself because she lost
some expensive jewelry and felt ashamed when
her family was angry with her” (Fellmeth et al.,
2015, p. 6). Additionally, these refugees believed
suicide was not necessarily caused by mental
illness and described suicide as a separate
condition. In terms of managing mental illness, the
most commonly mentioned first line of treatment
was social and emotional support from talking with
family and friends. These refugees from Myanmar
thought both medication and hospitalization could
be utilized as management strategies, but these
were frequently seen as extreme measures
(Fellmeth et al., 2015).
Syrian refugees
Since the beginning of the Syrian civil war,
over one million Syrians have fled to Lebanon
(Syria regional refugee response, 2019). A study
in Lebanon looked at the mental health
perceptions and experiences of Syrian refugees in
mental health treatment and of Lebanese mental
health professionals (Kerbage et al., 2020).
Similarly to the refugees from Burma, Syrian
refugees associated mental illness with stigma,
shame, and fear (Al Laham et al., 2020). The
Syrian refugee participants, who were in mental
health treatment, believed the greatest causes of
their emotional distress were environmental and
psychosocial stressors (Kerbage et al., 2020).
Sociocultural norms, which were inevitable in
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many cases, also appeared to be intimately
connected to mental health for some individuals
(Al Laham et al., 2020). Additionally, they felt that
their emotional distress was a normal shared
reaction to adversity that everyone in their
community was feeling (Kerbage et al., 2020). In
terms of their specific symptoms of emotional
distress, these Syrian refugees in treatment
believed that all displaced Syrians were
experiencing these same symptoms. Interestingly,
it was common for the Syrian refugees to describe
their mental distress as a buildup of pressure.
They saw mental illness as an internal dysfunction
or “craziness” within an individual and therefore
did not attribute how they were feeling to mental
illness. At the same time, their practitioners and
policymakers (professionals) viewed the distress
of these individuals as symptoms of mental illness
(Kerbage et al., 2020).
Another study on Syrian refugees in Wadi
Khaled, a specific community within Lebanon,
revealed that mental illness was associated with
religious beliefs and the supernatural, including
the idea of possession by evil spirits (Al Laham et
al., 2020). Syrian refugees advocated for
community-level solutions (Kerbage et al., 2020).
Whereas the professionals were recommending
short-term interventions for these refugees, the
refugees believed that the only real solution to
their social and mental health problems was
resettlement in a new country (Kerbage et al.,
2020).
Bhutanese refugees
Bhutanese refugees are another major
population of refugees who have resettled in the
United States (MacDowell et al., 2020). A study by
MacDowell et al. (2020) on these refugees
revealed that this group generally exhibited
negative perceptions of mental illness and mental
health treatment.
Cambodian refugees
Lastly, Wong et al. (2006) studied barriers to
mental health services in Cambodian refugees
from the largest Cambodian refugee community in
the United States. A majority of the barriers
reported were structural, including the high cost of
mental health services, linguistic difficulties, and
transportation issues. Interestingly, Cambodian
refugees reported cultural barriers much less
frequently. Less than 6% of Cambodian refugees
endorsed any mental health concerns related to
stigma, disapproval from family, lack of
confidence in Western medicine, or a higher level
of confidence in indigenous treatments (Wong et
al., 2006). Aside from this information, the data on
Cambodian refugees were limited.
Summary of similarities between different
refugee groups
•Causes of mental illness:
o Traumatic events (Somali, Burmese)
o Possession by evil spirits (Somali,
Burmese, Syrian)
•Physical symptoms associated with
mental illness (Somali, Burmese, Syrian)
•Mental health treatment:
o Informal talking with family and/or friends
(Somali, Burmese, Bhutanese)
o Religious (Somali, Syrian, Bhutanese)
o Community-level solutions (Burmese,
Syrian)
•Mental health stigma:
o Mental health/illness is taboo (Somali,
Burmese, Bhutanese)
o Possession by evil spirits (Burmese,
Syrian)
o Associated with shame (Burmese, Syrian,
Bhutanese)
o Mentally ill are mentally unfit/internally
dysfunctional/incapable (Burmese, Syrian,
Bhutanese)
Discussion
The results indicate that there are many
differences and many similarities in the
perceptions of mental health among refugees
from different countries of origin. The cultures of
refugees greatly influence how they think and feel
about mental health. The commonly reported
causes of mental illness included traumatic events
and possession by evil spirits, and physical rather
than psychological symptoms were often
emphasized. The frequently stated mental health
treatment options included religious methods and
informal conversations. Overall, the mental health
stigma was very prevalent, with multiple refugee
groups regarding mental illness as taboo or
shameful.
This review is novel in its inclusion and
comparison of refugees from numerous countries
of origin. To date, most of the research has
focused on a specific population of refugees from
one cultural background. The study of refugees’
perceptions of mental health has the potential to
aid the refugee mental health crisis. The article by
Kim et al. (2021) on Burmese refugees
emphasizes the importance of addressing the
mental health problems of refugees:
“Unrecognized and untreated mental health
issues may interfere with or even prevent
refugees from successful integration into the host
society” (Kim et al., 2021, p. 966). To give
refugees a fair chance of integrating into their new
society, mental health problems must be tackled.
Furthermore, awareness of cultural perceptions of
mental health can offer valuable information to
service providers and policymakers (Andrade et
al., 2014). When studying Syrian refugees and
professionals, Kerbage et al. (2020) reported that,
“Among professionals, 56 of the 60 repeatedly
highlighted Syrian culture as the main challenge
to working with Syrian refugees. They considered
it an obstacle to the efficient provision of mental
health care” (Kerbage et al., 2020, p. 5). However,
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the culture of one population of refugees can differ
immensely from that of another refugee
population; therefore, studying one culture in
isolation is not sufficient. In their research on
Burmese refugees, the authors determined, “a
one-size-fits-all approach will not work with
refugee communities because of their inherent
ethnocultural and linguistic heterogeneity,” further
reiterating the need for culturally specific mental
health care (Kim et al., 2021, p. 970).
Bettmann, et al. were solely focused on Somali
refugees when they stated, “In order to effectively
approach and treat mental health issues in a
population, it is imperative to first understand
some of the population’s basic beliefs surrounding
mental health” (Bettmann et al., 2015, p. 741).
Nevertheless, some of their findings about the
mental health perceptions of this population were
similar to the perceptions found in other refugee
populations from different cultures. Therefore,
some of their recommendations could prove
useful in these other refugee groups. The studies
on the Somali refugees, Syrian refugees, and the
pregnant Burmese refugees all found that physical
symptoms were frequently reported when
discussing mental health issues (Bettmann et al.,
2015; Fellmeth et al., 2015; Kerbage et al., 2020).
Western-trained physicians often carry a dualistic
body-versus-mind perspective (Kirmayer et al.,
2011). It would be helpful for all medical doctors
treating these populations of refugees to learn
more about the ways in which common mental
illnesses may manifest in physical symptoms in
order to more efficiently and effectively determine
the etiology of these symptoms (Bettmann et al.,
2015). Similarly, in the specified cultures,
symptoms of mental illness were described more
in physical terms, such as the widespread Somali
description of a buildup of pressure, which may
initially seem to be a physical symptom (Bettmann
et al., 2015). Therefore, it would be beneficial for
doctors working with refugees to learn about
some of these common physical descriptions and
to consider that seemingly physical descriptions
may reflect their cultural interpretation of their
mental health symptoms.
In these three groups of refugees, substantial
benefit can come when mental health
professionals work closely with medical doctors to
treat mental illness in a more holistic manner. The
potential of this type of strategy is exemplified in a
community health center in Boston where both
medical doctors and mental health professionals
work, which has led to increased referrals to
mental health care (Bettmann et al., 2015). One
potential solution could be to implement mobile
health clinics that treat both physical and mental
health issues. These clinics could even provide
social needs such as housing and transportation
as an additional component. Im et al. (2021)
applied a multitier mental health and psychosocial
support services (MHPSS) model to provide
mental health care to refugees in a holistic
manner. Their approach was built on existing
MHPSS models, which are used in some refugee
communities, and emphasizes trauma- and
culture-informed care. Refugees have
multilayered mental health needs that can benefit
from the coordinated systems of care and the
holistic framework proposed by Im at al. (2021).
The use of more integrative models for mental
health care in refugee communities could provide
many advantages for refugee mental health.
Because the cultural stigma surrounding
mental health is widespread, the suggestions by
Kim et al. (2021) for Burmese refugees would
likely be helpful for other refugee populations as
well. Mental health stigma is so entrenched in
Burmese culture that even speaking about mental
health openly jeopardizes one’s role in this
community; thus, Burmese refugees need indirect
approaches to mental health. Primary care
doctors for these refugees need to provide
encouragement and referrals. This is because
primary care physicians are “the most effective
way of getting [Burmese] people to use mental
health services… ‘they won’t go on their own
voluntarily’” but “would follow through with their
physician’s recommendations” because they are
viewed as trusted professionals and authority
figures (Kim et al., 2021, p. 969). Because of the
power of primary care physicians in the eyes of
many refugees, there should be routine refugee
mental health screening in primary care settings.
In addition, the importance of cultural competency
must be emphasized to primary care doctors and
mental health professionals working with any
refugee populations in order to effectively interact
with patients and their families (Kim et al., 2021).
Practices that treat even a small number of
refugees should require training in culturally
sensitive care (Byrow et al., 2020). Mental health
practitioners would benefit from learning and
utilizing the DSM-5’s cultural formulation interview
guide as a tool to provide culturally sensitive and
individualized treatment while also enhancing the
therapeutic alliance (Byrow et al., 2020).
Studies of the perceptions of mental illness in
the Somali, Syrian, and Bhutanese refugees
revealed that these groups share a strong focus
on religion (Al Laham et al., 2020; Bettmann et al.,
2015; Maleku et al., 2021). The study on Syrian
refugees in the rural area of Wadi Khaled in
Lebanon described that, in this community,
religious healers are culturally acceptable and
less stigmatizing to go to for mental health
problems than mental health professionals (Al
Laham et al., 2020). This article even described
working with religious healers as the “key to
identifying [mental health] symptoms and creating
referral pathways to [mental health] professionals”
(Al Laham et al., 2020, p. 875). Similarly, the
article by Bettmann et al. (2015) discussed how
refugees’ spiritual explanations and treatments of
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mental illness cannot be disregarded. Instead,
mental health practitioners should directly address
these spiritual aspects and attempt to use these
strongly held beliefs to help them understand a
patient’s symptoms and trajectory (Bettmann et
al., 2015). It is imperative that mental health
professionals working with all three of these
refugee groups collaborate not only with religious
healers and other religious leaders but also with
any additional community leaders. Mental health
and public health professionals could spend time
teaching religious leaders about mental health
problems and the benefits of medical treatment,
counseling, and group therapy. These
professionals could then encourage the leaders to
share this education with their followers, such as
by talking about mental health issues in sermons,
classes, seminars, newsletters, or social media. In
addition, the professionals could ask these
leaders to encourage their followers to seek help
for mental health problems and not suffer in
silence. It would be very beneficial for religious
leaders to inform their followers that suffering from
mental health problems does not mean that the
sufferer has sinned, that he or she does not have
enough spiritual faith, or that this is God’s
punishment. On the contrary, mental illness is a
disease, similar to high blood pressure or any
other physical condition, and should be treated
this way. Understanding this and hearing it from
one’s religious or community leader could
decrease the guilt and shame that so many feel
when they are having mental health problems.
Because the religious, traditional, and familial
practices are deeply valued in the Somali, Syrian,
and Bhutanese cultures, these practices need to
be considered and likely incorporated into any
mental health treatment plan. Working with family
was commonly seen as an initial step in mental
health treatment in the refugee populations
reviewed; thus, the involvement of family and
community members in assessment and
treatment may provide more effective care. The
incorporation of family members would be
especially beneficial for certain refugees from
Myanmar, because the pregnant refugees’ most
commonly used treatment was emotional and
social support from family and close friends
(Fellmeth et al., 2015). The involvement of family
would also benefit Bhutanese refugees, who
discussed seeking social support in order to cope
(Maleku et al., 2021).
Although there were several distinctions
between the mental health perceptions of
refugees from different cultures, there were also
many similarities. Therefore, it is crucial to include
some general recommendations for refugee
mental health care. Providing community-level
solutions is essential. This would include
education and training for community leaders in
addition to education for all individuals within
refugee communities (Kim et al., 2021). In all
refugee groups, there is a need for increased
mental health literacy pertaining to overall mental
health, mental illness, and treatment for
individuals struggling with mental health problems.
The study on pregnant refugees from Myanmar
emphasized the importance of psychoeducation,
particularly because only one participant believed
that trauma could cause mental illness (Fellmeth
et al., 2015). In reality, the trauma that so many
refugees experience contributes to the
development of mental health problems (Johnson
& Thompson, 2008). Because “translation
difficulties, in combination with a lack of
understanding about mental health, aggravate
cultural stigma,” increased mental health literacy
could help to reduce stigma (Kim et al., 2021, p.
970).
In addition to psychoeducation’s potential to
decrease stigma, refugee communities could also
incorporate public stigma interventions that focus
on changing culture-specific negative perceptions
of mental illness (Byrow et al., 2020). Even just
altering the language used when discussing
mental health could have an impact. For example,
Kerbage et al. (2020) noted that Syrian refugees
thought of the MHPSS as a source of support and
felt it was helpful and provided them with a safe
environment to talk about their problems.
However, they did not consider MHPSS to be a
specialized clinic, the idea of which may have
turned many refugees away (Kerbage et al.,
2020). Psychoeducation and improved mental
health literacy would not only impact the initiation
of care but also help with treatment adherence
and maintenance when individuals have a better
understanding of the science of mental illness.
Another potential approach to break the barrier
of mental health stigma is to use telehealth and
mental health apps. Refugees could use their
phones or any other electronic device for
psychiatry visits, counseling sessions, or self-help
interventions. This approach might encourage
refugees who fear the stigma of treatment to seek
mental health care. This is because telehealth
visits and mental health apps can be used in the
privacy of one’s own home, out of view of anyone
who patients might worry would look down on
them for getting mental health treatment.
Telehealth and apps could also help refugees
start mental health treatment and then act as a
bridge to in-person visits with mental health
professionals if needed. In addition to acting as a
bridging aid, these approaches may be used to
augment or complement other types of mental
health treatment. Therefore, both telehealth and
mental health apps could “lower the threshold for
refugees to seek help” (Golchert et al., 2019, p.
2). These mental health interventions would also
allow for greatly increased flexibility in terms of
both treatment time and location. One example of
mobile mental health is Step-by-Step (SbS), a
culturally adaptive e-mental health intervention
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developed by the World Health Organization for
depression (Burchert et al., 2019). In a study on
the usage of SbS among Syrian refugees,
Burchert et al. (2019) found that “The majority of
the respondents reacted positively to the
presented app prototypes, stressing the potential
health impact of the intervention (n = 28; 78%), its
flexibility and customizability (n = 9; 53%) as well
as the easy learnability of the app (n = 12; 33%)”
(p. 1).
In addition, enhancing the sense of community
felt by refugees could have a major effect on
refugee mental health (Kim et al., 2021). This
could be accomplished by facilitating social
engagement to establish better ties to their
community. For most refugees, community and
social connections are lost when they come to a
new country (Kim et al., 2021). In contrast to
these general recommendations that apply to
most of the refugee groups reviewed, it would be
more appropriate to suggest approaches to
improve the structural aspects of mental health
care in Cambodian refugees, because this
population did not report culturally based mental
health barriers and had less concern about stigma
(Wong et al., 2006).
Limitations of the study
There are some limitations to this review.
There was heterogeneity among the studies in
terms of the methods, protocol, and measures
used. These studies were also conducted in
different host countries, which have variable
income levels and barriers to care. Although the
reviewed studies on Syrian refugees and refugees
from Myanmar took place in Lebanon and the
Thai-Myanmar border, respectively, the rest of the
reviewed studies occurred in the United States or
the United Kingdom (London) (Al Laham et al.,
2020; Fellmeth et al., 2015; Kerbage et al., 2020).
As Byrow et al. (2020) emphasized regarding their
review, “Given that most studies included
individuals living in a high-income resettlement
country, these findings may not be generalizable
to individuals in other countries,” especially
considering that the majority of refugees are
located in developing countries (Byrow et al.,
2020, p. 18). Because the study designs were
generally not longitudinal in nature, there is no
way to know how perceptions may have changed
over time. Byrow et al. (2020) felt that the duration
of resettlement and associated variables could
greatly impact a refugee’s knowledge about
mental health and the best treatment strategies.
Future directions
There are many possible future directions. It
would be helpful to examine different refugee
cultures in a more standardized manner. This
could be accomplished with a study that looks at
more than one population of refugees, which
would enable standardization of not only the major
themes assessed but also the methods and
measures utilized. A study that looks at multiple
populations of refugees in a single host country
would achieve even greater uniformity. It would
also be interesting to use longitudinal research
designs to determine if and how the mental health
perceptions in the populations studied change
over time. Longitudinal studies would also enable
researchers to determine if there are key time
points when certain mental health treatment
interventions or programs are most effective
(Byrow et al., 2020). In addition, it would be useful
to determine whether there are associations
between mental health perceptions and specific
mental health treatments that are efficacious.
Research that utilizes culture-specific mental
health perceptions to create interventions for
different refugee groups would enable us to see
how specialized mental health services make a
difference in the mental health outcomes of
refugees.
Conclusions
This review studied the perceptions of mental
health, mental illness, and mental health
treatment among refugees from various countries
of origin, unlike previous studies that focused on
one group of refugees. From this review, it is clear
that refugees’ thoughts and feelings about mental
health are impacted by their specific cultural
group. Refugee groups varied in terms of their
opinions about the causes of mental illness and
the treatment options emphasized by them.
However, mental health was similarly stigmatized
as taboo and perceived as a shameful
dysfunction, and treatment options frequently
revolved around religion and informal family
assistance. Furthermore, physical symptoms of
mental illness were often highlighted, and mental
illness was commonly thought to result from
traumatic events and possession by evil spirits.
Interventions to address the refugee mental health
crisis should take cultural background, including
cultural perceptions of mental illness, into
account. Specifically, refugee mental health care
could be improved with more integrative treatment
methods, greater involvement of primary care
practitioners, psychoeducation of community
leaders, telehealth, and more culturally oriented
approaches.
Funding Sources
This project was partially funded from a grant
from the University at Buffalo Foundation/John E.
Brewer Global Medicine Endowment Account
problems associated with psychoactive substance
abuse (Cabinet of Ministers of Ukraine, 2017).
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Conflict of interest
The authors declare that they have no conflicts
of interest.
Acknowledgements
We thank Nell Aronoff and Karen Dietz, PhD
for assistance in writing, reviewing, and editing
this manuscript. This work was supported by the
University at Buffalo Foundation/John E. Brewer
Global Medicine Endowment Account
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Mental Health: Global Challenges Journal
Mental health policy reactions during the first year
of the COVID-19 pandemic in two worst-hit WHO
European countries: a narrative review and
lessons for the aftermath of mental health care.
Ekin Dagistan
European Student Think Tank, Public Health and Policy Working Group, Amsterdam, Netherlands
French School of Public Health (Ecole des Hautes Etudes en Santé Publique), Paris, France
Abstract
Introduction: The COVID-19 pandemic has been challenging the health care systems and public
wellbeing unprecedentedly. The United Kingdom and Turkiye were the countries worst hit by the
pandemic in the World Health Organization European region.
Purpose: This review investigated the mental health policies in these countries which draw a
contrasting pattern of mental health care, sociodemographic background, and income level.
Following the investigation, we recommended the possible directions to be pursued by European
policymakers
Methodology: The documents were picked from the health policy sections from the websites of
international organizations (European Parliament, OECD, WHO, UN), online data and policy
reports of national ministerial bodies, and general web search. Later, the papers were reviewed
and the author identified the main concepts of the responses to discuss after policy review. The
study was designed as a review; therefore, no statistical framework was conducted.
Results: Identified concepts were as follows: a) continuing service provision for people with
mental health conditions, b) digital mental health care interventions, c) building psychological
resilience for citizens.
Conclusions: A strategy only focusing on treating mental health conditions will not be sustainable
during the post-pandemic era. It is essential to address mental health in all policies to foster a
strong mental health care system.
Keywords
Mental health care; COVID-19; mental health policy; mental health; public health.
Address for correspondence:
Ekin Dagistan, French School of Public Health (Ecole des Hautes Etudes en Santé
Publique), Paris, France. Email: edagistan@gmail.com
This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0 International
License (CC BY-NC 4.0).
©Copyright: Dagistan, 2022
Publisher: Sciendo (De Gruyter)
DOI: https://doi.org/10.56508/mhgcj.v5i2.141
Submitted for publication: 17
May 2022
Revised: 28 July 2022
Accepted for publication: 27
August 2022
Introduction
The COVID-19 pandemic has been
challenging the regional and global health care
systems unprecedentedly since it started more
than two years ago. Mental health care systems
and public well-being have also been taken a toll
due to the pandemic-related regulations and
socio-economic era (Racine et al., 2021).
Psychological well-being is strongly connected
to various personal, interpersonal and economic
elements such as financial situation, employment
status, physical well-being, and sufficient human
interaction (Kaplan et al., 2008; Santini et al.,
2020; Romash, 2020; Romash et al, 2022). These
elements have been affected drastically during the
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Mental Health: Global Challenges Journal
pandemic. Consequently, according to the
Organisation for Economic Co-operation and
Development (OECD), the prevalence of anxiety
and depressive disorders increased in many
countries in 2020 (OECD, 2021b). This increase
can be considered as response to an unexpected
disaster; nonetheless, the long and medium-term
effects of the pandemic are likely to become
detrimental to public mental health.
Due to the aforementioned concerns, the
governments immediately mobilised their mental
health policy strategies against the rapidly
progressing pandemic. As anticipated, many
studies hitherto showed that both the pandemic
and public health measures provoked distress
amongst various populations (Mental Health and
COVID-19, 2022; Racine et al., 2021).
According to the World Health Organization
(WHO) data, The United Kingdom (UK) and
Turkiye were two of the countries worst hit by the
pandemic in the WHO European region during the
first year of the pandemic (WHO Coronavirus
(COVID-19) Dashboard, 2021). The tsunami
effect of this disaster has been felt almost in every
part of the world, yet the populations of these
countries became more susceptible in terms of
having insufficient healthcare and lack of support
for their well-being.
A snapshot of pre-COVID conditions and
COVID-related fiscal and lockdown policies in
Turkiye and the UK
The pandemic hit hard the healthcare systems
all around the world, regardless of the income
levels of the countries. This section provides data
about the pre-pandemic conditions and COVID-
related measures of the two countries.
In 2017, the gross domestic product (GDP)
level per capita was equal to 10,591 US Dollars
($) in Turkiye whereas it was $40,361 in the UK.
The UK spent 9,8% of its GDP ($4,070) on its
health care sector, whereas Turkiye managed to
allocate 4,2% of its GDP ($1,227) (Table 1).
Table 1: Summary of Health and Financial Profiles of Turkiye and the United Kingdom
GDP-Gross domestic product,
US $- the United States Dollar
Source: World Bank data (Data for Turkiye, United Kingdom | Data, 2017; World Bank Country and
Lending Groups – World Bank Data Help Desk, 2021), OECD Health at Glance 2019 (Health at a Glance |
OECD ILibrary, 2019)
The two countries had national mental health
strategies before the pandemic. The UK spent
179,5 the Great British Pound Sterling (GBP) in
terms of the total mental health expenditure per
capita; however, this data was not available for
Turkiye (Table 2).
The density of high-trained mental health
workforce per population in Turkiye was low: 1,64
for psychiatrists and 2,54 for psychologists. On
the other hand, the UK had higher numbers of this
workforce than Turkiye, 11 for psychiatrists and 9
for psychologists. However, not aligned with their
workforce capacity, the burden of mental health
conditions was higher in Turkiye than in the UK;
3,433 and 2,115, respectively (Table 2).
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Mental Health: Global Challenges Journal
Table 2: Mental health profiles in the two countries
EUR- Euro, GBP- the British Pound Sterling,
*Data calculated from the numbers found in the sources
Source: WHO Mental Health Atlas 2017 (Mental Health Atlas 2017, 2018)
Restriction measurements and fiscal support
schemes were similar in the countries. However,
financial allocation differed saliently between two
countries. For example, while the UK spent 32%
of its GDP to support its population financially,
Turkiye allocated only roughly 12% of its GDP for
the same purpose. Moreover, 0,3% of Turkiye's
GDP ($2 billion) was spent on the healthcare
sector as a response to the pandemic. This
amount was $145 billion in the UK, equal to 5,3%
of its GDP.
Both countries reacted the pandemic with
travel restrictions, nation-wide curfews, and
transition to teleworking. However, while the UK
permitted solo physical activities during
confinements; these activities were not excluded
from the regulations in Turkiye (Table 3).
Table 3: COVID-related measures in the two countries
GDP: Gross domestic product
Source: IMF (Fiscal Policies Database, 2021; Policy Responses to COVID19, 2021)
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Mental Health: Global Challenges Journal
In 2016, a return on investment study carried
out with 36 countries estimated that every $1
invested in mental health gives a $4 return (Jorm
et al., 2016). Despite this evidence, the budget
allocated for mental health systems has always
been notoriously low to respond to the needs
(World Health Assembly, 2012).
Purpose
This review investigated the mental health-
related policies in the two European countries
worst hit by the pandemic, two countries that also
draw a contrasting pattern of mental health care
systems, sociodemographic background, and
income level. Following this, the paper
recommended possible directions to be pursued
by the European policymakers to foster mental
health care.
It is undeniable that this study cannot cover all
the struggles we face; nonetheless, it will address
the major issues. These directions are also
controversial topics that belong to the
contemporary history of mental healthcare and
would likely to steer the future of it.
Methodology
The documents were picked from the health
policy sections from the websites of international
organizations (European Parliament, OECD,
WHO, UN), online data and policy reports of
national ministerial bodies, and general web
search. English and Turkish sources were
included in this review; “policy”, “mental health”,
“pandemic”, “COVID-19”, “ruh sağlığı”, “pandemi”,
“politika”, and their variations were used in the
general web search process.
The documents were reviewed and the author
identified the main concepts of the responses to
discuss after policy review. These concepts were
as follows: a) continuing service provision for
people with mental health conditions, b) digital
mental health care interventions, c) building
psychological resilience for citizens. The study
was designed as a review; therefore, no statistical
framework was conducted.
Review and Discussion
Mental health policies in Turkiye and UK
Turkiye
Turkiye’s first case emerged relatively later
than those in other European countries; however,
case numbers accelerated gradually, and the
country still tackles several waves of the
pandemic (Turkiye Confirms First Case of
Coronavirus, 2020).
During the initial year of the pandemic, the
Public Health Directorate issued guidelines to limit
the transmission of the virus while maintaining
health care safely (COVID-19 Rehberi [The
COVID-19 Guideline], 2020). These guidelines
included the reorganisation and adaptation of
psychiatric facilities to the situation. Consequently,
a decrease in inpatient and outpatient psychiatric
capacities was observed (Başar, 2020). The
Ministry also arranged telemedicine settings,
including psychological support lines for those
who could not visit health care facilities due to the
acute COVID-19 infection (Dr. E-Pulse: Video Call
Platform, 2020). The Ministry of Health
additionally published recommendations for video
consultation techniques. However, these were not
implemented effectively in public hospitals
because of insufficient infrastructure and supply
(COVID-19 Health System Response Monitor:
Turkiye, 2021).
The Turkish Psychiatric Association (TPA)
provided hotlines for health care workers who
combat the pandemic in the frontline (Türkiye
Psikiyatri Derneği Sağlık Çalışanlarına Destek
Hattı Açıldı! | TÜRKİYE PSİKİYATRİ DERNEĞİ,
2020). Similarly, the Turkish Ministry of Health
also set up regional psychosocial support call
centres for the general population and health care
workforce (81 İl Psikososyal Destek Hat Bilgileri
[Psychosocial Support Line Informations for 81
Cities], 2020).
TPA continued to establish comprehensive
recommendation papers for health care workers,
the mental health workforce, and several
vulnerable groups during the pandemic (‘COVID-
19 Resources’, 2021). These papers addressed
the critical points on mental health care delivery,
telepsychiatry, treatment of mental conditions with
COVID-19 infection, and psychological self-care
techniques (COVID-19 ve Ruh Sağlığı | TÜRKİYE
PSİKİYATRİ DERNEĞİ, 2020). Some of these
recommendations were translated to Arabic or
Kurdish to protect minorities' well-being (‘COVID-
19 Resource Centre’, 2020).
The UK
The UK had to face multiple lockdowns and
waves, which had deteriorating effects on the
psychological state of its population.
Due to the re-purposing of the National Health
Service (NHS) beds to COVID-19 care and the
worsening mental health state of the population,
psychiatric inpatient clinics suffered from bed
shortages and sometimes overwhelming
occupancy (James, 2021). The increased demand
on mental health care were conveyed to
ambulatory and community care settings (The
Impact of COVID-19 on Mental Health Trusts in
the NHS, 2020). On the other hand, mental health
funding saw an increase that helped maintain the
24/7 helpline services, the closure of the outdated
mental health dormitories, and launching physical
screening programs for vulnerable groups
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Mental Health: Global Challenges Journal
(COVID-19 Health System Response Monitor:
United Kingdom, 2021).
Several organisations such as the Royal
College of Psychiatrists (RCPsych), and the
British Psychological Society prepared mental
health and COVID-19 sections that target
psychological resilience, the well-being of NHS
staff, digital interventions, ethical issues, and the
problems and solutions about the management of
mental health settings (Covid-19 Resources - The
British Psychological Society, 2021; Responding
to COVID-19 | Royal College of Psychiatrists,
2021). Additionally, major voluntary organisations
such as Mind, and the Mental Health UK shared
their tips on protecting mental health (Coronavirus
- Looking after Your Mental Wellbeing, 2020;
Covid-19 and Your Mental Health, 2020). The
NHS itself also provided novel care approaches,
guidances that depict the pandemic's
psychological effects, and possible behavioural
prevention methods for vulnerable groups (such
as young people, ethnic minorities, people with
long COVID) or those with mental health
conditions (Guidance for Parents and Carers on
Supporting Children and Young People’s Mental
Health and Wellbeing during the Coronavirus
(COVID-19) Pandemic, 2021; Guidance for the
Public on the Mental Health and Wellbeing
Aspects of Coronavirus (COVID-19), 2021).
The pre-existing psychological support lines
and groups of voluntary organisations continued
to provide service (‘Mental Health Helplines and
Services during COVID-19’, 2021). The NHS,
Public Health England (PHE), RCPsych, Mental
Health at Work and Frontline19 launched
psychological support lines, counselling and
therapy services for the NHS staff (Frontline19,
2020; NHS England » Health and Wellbeing
Programmes, 2020; ‘Our Frontline’, 2020;
Psychiatrists’ Support Service (PSS) | Royal
College of Psychiatrists, 2020).
Vis-à-vis mental health care was replaced with
video or telephone consultations; however,
physical appointments were also provided for
those who need them. The NHS and the RCPsych
issued guidelines for structuring the fundamentals
of telemedicine (COVID-19 - Working in
Secondary and Specialist Mental Health Settings|
Royal College of Psychiatrists, 2020; Digital -
COVID-19 Guidance for Clinicians | Royal College
of Psychiatrists, 2020; IAPT Guide for Delivering
Treatment Remotely during the Coronavirus
Pandemic, 2020).
In March 2021, the government released an
action plan that involves a multi-disciplinary
recovery approach for mental health care and
public well-being (COVID-19 Mental Health and
Wellbeing Recovery Action Plan, 2021).
Since the early era of the pandemic, the PHE
has been monitoring public mental health
reactions and well-being with surveillance reports,
academic research compilations, and evaluating
the frequency of telesupport service use (COVID-
19 Mental Health and Wellbeing Surveillance,
2020). In addition, several vocational organs and
universities also launched independent surveys or
studies to evaluate public mental health and the
psychological effects of the COVID-19 infection
(COVID-19 Surveys and Research | Royal
College of Psychiatrists, 2021).
The future of mental health care
There is not a one-and-only mental health care
approach which could be applied to every country
because of such differences in the level of
resources, cultural diversities or socioeconomic
structure (Knapp et al., 2007). However, as the
current situation helped draw attention and
funding to mental health, the pandemic could
positively transform this field instead of adding
insult to injury.
The mental health interventions taken by these
countries can be summarised in three concepts:
a) continuing service provision for people with
mental health conditions, b) digital mental health
care interventions, c) building psychological
resilience.
Continuing service provision for people
with mental health conditions
People with mental health conditions suffered
from service disruptions during the pandemic.
According to a WHO survey in 2020, more than
90% of the European countries reported that
essential mental health services had taken a toll.
Globally speaking, this rate was above 90% for
the middle or high-income countries (‘The Impact
of COVID-19 on Mental, Neurological and
Substance Use Services: Results of a Rapid
Assessment’, 2020).
Traditional mental health services are often
criticised because of their inhumane and
ostracising structure (Cohen & Minas, 2017). For
many years, Western European countries have
been designing a stepped-care approach that
improves multi-disciplinary approach including
social care and mental health organisations
instead of institutionalisation. The fruits of these
reforms can be seen in the example of the UK.
Both countries had to reduce their psychiatric
inpatient and outpatient bed capacity during the
pandemic; however, the community and
ambulatory care systems in the UK attempted to
manage this deficit with collateral wellbeing and
social care organisations. These settings aid
various vulnerable groups such as adolescents,
people with suicidal thoughts, severe mental
health conditions or in isolated settings (NHS
England » Crisis and Acute Mental Health
Services, 2021). Despite the leveraging role of
these organitsations, the UK still suffered from
shortages and insufficient care delivery (Campbell
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Mental Health: Global Challenges Journal
& editor, 2019). Looking at the current picture, it
can be argued that more funding will be needed to
face the tertiary psychological effects of the
pandemic.
The pandemic could hold a role as an
accelerating factor for funding deinstitutionalised
care. However, various WHO European countries
still tend to spend most of their mental health
budgets to traditional institutions (World Health
Organization, 2009). These facilities do not
possess evidence-based interventions compared
to other integrated models of mental health care
(Eaton et al., 2011). Community-based
intervention models seem to be both effective and
self-financing on bringing mental health care
(Knapp et al., 2011). The demand for the
treatment for mental health is likely to increase in
the near future, and this single-layered system
alone is no suitable to shoulder the forthcoming
turbulence (COVID-19 Mental Health and
Wellbeing Recovery Action Plan, 2021). An easily
accessible, multi-disciplinary and stigma-free care
environment could break this vicious cycle and
engage more users in prospect. There is a need
for novel national mental health strategy plans
taking post-COVID concerns into account for
WHO European region countries.
Specialised outpatient facilities have also taken
a hit during the pandemic. This hit led to
digitalisation in mental health care as much as
applicable; on the other hand, countries like
Turkiye (lower amount of qualified mental health
workers, means of providing multi-disciplinary
approach, and allocated budget for mental health)
have become vulnerable in terms of providing
sufficient outpatient care. It should also be noted
that primary care integrated referral system and
mental health integrated primary care are absent
in Turkiye, and specialized facilities are the central
pillar for any type of treatment ranging from mild
depression to severe schizophrenia (Table 2).
Therefore, mid- and long-term policies which aim
to prevent congestions in outpatient settings must
be considered before facing the long
consequences of the pandemic.
Particularly for Turkiye and countries with
similar profiles, it is vital to identify risk factors and
plan cost-effective intervention and prevention
methods to minimize specialized care saturation.
It is known that mental health care in primary
settings is more reachable by the population
(Yeung et al., 2004). Cost-effectiveness and
clinical-effectiveness studies also demonstrate
these settings are applicable and sustainable
(Mens et al., 2018; Rost et al., 2004). Turkiye and
alike countries might not have sufficient workforce
resource to fully integrate mental healthcare
provision to primary care; however, prevention
strategies such as increasing awareness between
primary healthcare workers might help overcome
the overwhelming demand on specialised care for
easily treatable psychiatric conditions.
Digital mental health care interventions
The digitalization of medicine had already
begun before the pandemic. Nonetheless, its pace
skyrocketed with regards to a mandatory need
(OECD/European Union, 2020). The elements of
psychiatric care such as psychological therapies,
consultations or evaluations also quickly adapted
to the situation.
The prosperity of digital therapies and
smartphone apps carries a double-edged position
while it also facilitates populations to reach
treatment. Firstly, this expanding marketplace
could become a nest for unapproved methods
(Terry & Gunter, 2018). For instance, a study from
2019 showed that top-mental health apps tend to
use scientific language to evoke population,
without the lack of adequate evidence on their
effectiveness (Larsen et al., 2019). Morover, the
rate of free iPhone anxiety-targeted apps built with
evidence-based approaches was found to be very
low (Kertz et al., 2017). Secondly, the care
provided by these apps was found to be lacking
from emotional support, distracting from real life,
and yielding misinterpretations in care seekers
about themselves (Estrada Martinez De Alva et
al., 2015). Hence, it is crucial to strengthen these
interventions with convenient research studies
and combine them with face-to-face methods
when needed.
Ethical issues regarding data safety,
transparency or patient confidentiality are other
main concerns reported by healthcare workers
(Stoll et al., 2020). These concerns are bilateral in
carer taker and care seeker relationship, and
government and vocational organs should act
collaboratively in order to regulate this area.
Telemedicine helped providing care in the UK;
on the other hand, the lack of telemedicine
settings in public hospitals in Turkiye pushed
citizens to postpone their needs due to fear of
transmission and decreased face-to-face
appointment options. The gap between these two
countries indicate that digital infrastructure of
health care should be promoted and supported
across the WHO European region.
Building psychological resilience
The two countries attempted to mitigate the
immediate psychological shock of the pandemic in
varying degrees by enhancing pre-existing
infrastructures or implementing novel strategies.
Albeit, medium- and long-term effects of the
pandemic will continue to challenge mental health
wellbeing and related areas. Public or individual
well-being are bound to many social determinants,
and stakeholders need to follow a multi-systemic,
multi-disciplinary pathway in order to protect both
individual and public wellbeing (World Health
Organization and Calouste Gulbenkian
Foundation, 2014). Mental health distress could
22
Mental Health: Global Challenges Journal
metamorphise to mental health conditions, if not
acted thoroughly.
Turkiye and the UK implemented several
measures in order to protect economic stability.
However, many studies in contemporary history
showed that economic shocks are likely to trigger
their detrimental psychological effects during
tertiary phase. These shocks impact mental health
in the long term due to economic instability, job
loss, uncertainty and other factors (McDaid, 2017;
Paul & Moser, 2009). It should be therefore kept
in mind that even when the pandemic settles,
time-delayed economic effects will cause
challenging consequences in public mental health.
This becomes extremely important when the
current economic instability and increased cost of
living within the European Union are considered
(EA and EU Economic Snapshot - OECD, 2022).
European policymakers should take into account
that the monitorisation of suicide rates, levels of
depression, anxiety, or substance use is
particularly essential in vulnerable economic
settings.
A study from the Netherlands shows that
people without mental health conditions had a
greater negative impact on their mental well-being
than those with pre-existing mental health
conditions during the first year of the pandemic
(Pan et al., 2021). The most affected groups
consisted of ethnic or racial minorities, women,
people with low-income, students, young or
elderly people (OECD, 2021a, 2021b; Saladino et
al., 2020; Tai et al., 2021). This deteriorating
effect was also present in the English population
demonstrated by the surveillance reports of the
Public Health England (Public Health England,
2020b, 2020a). Such reports and studies indicate
that governments should strengthen their hands to
protect general and vulnerable populations. Key
organisations such as independent bodies, local
governments or initiatives have already been
promoting self-help techniques, peer support
groups, psychological first aid teams or hotlines in
Western countries. In other WHO European
countries, where these organisations are absent
or less active, the deficit can be filled by using key
community members as pillars. Micro- or meso-
level actors could stem from backgrounds such as
religious leaders, union members, managers,
school teachers or local authorities, as the studies
show that these actors are extremely beneficial in
community-based mental healthcare (The
Community Mental Health Framework for Adults
and Older Adults, 2019). According to a study,
religious/spiritual advisors were seen by 35% of
treatment-seeking Asian Americans with a lifetime
mental disorder (John & Williams, 2013). Another
study from the United States also indicated that at
least 57,3% of respondents with mental health
disorders first contacted professionals not working
in mental health area (Wang et al., 2003). Training
the actors from these settings could help monitor,
identify, or control mental distress levels
effectively whereas preventing unnecessary
specialised or primary care consultations.
A Eurofund report from 2017 showed that
remote workers tend to spend more time on work
than those in offices, possibly due to uncertain
working hours (Eurofound and the International
Labour Office, 2017). This impact could become a
risk for working population as the pandemic
catalysed the shift to teleworking rapidly
(European Commission, 2020). According to the
OECD data, the high prevalence of mental health
conditions among the working-age population is
linked to the high economic cost of mental health
conditions (OECD, 2020). Countries with middle-
or high-income, namely most Western countries,
should regularly monitor the mental
consequences of teleworking in terms of
increased loneliness, isolation and burn-out.
The need to address migration-related mental
health issues is increasing as the world has been
seeing the highest numbers of human migration in
the latest years (Jennings, 2011). Unsurprisingly,
the pandemic and migration carry the same
devastating effects: loneliness, feeling of isolation,
discrimination (for instance, racist accusations
about the origin of COVID-19) (Banerjee & Rai,
2020; Fernández et al., 2017). Therefore, the
countries with a higher density of refugee or
immigrated population, notably Western European
countries or countries that have land frontiers with
war territories, should particularly pay attention to
these adverse psychological effects which could
stem from the combination of immigration and the
pandemic (Foad et al., 2015).
Conclusions
The concepts mentioned above and
recommendations reflect the future directions for
mental health policies. Uniquely, they entail a
cross-sectoral structure, namely the "mental
health in all policies” approach, which includes
areas such as technology, healthcare, labour, and
economy (Mental Health In All Policies » Mental
Health and Wellbeing, 2013). A public health
strategy ignoring these areas and only focusing
on treating mental health conditions will not be
sustainable in delivering healthcare during the
post-pandemic era. As the pandemic and its
consequences reshape our society, it is essential
to address these issues to protect and foster a
multi-level mental healthcare system.
Conflict of interest
The author declares that she has no conflicts of
interest.
23
Mental Health: Global Challenges Journal
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Prevalence of depression and anxiety among
university students during COVID-19 in
Bangladesh: A cross sectional study
Minhazur Rahman Rezvi, Md Rakib Hossain, Fariha Haque
University of Dhaka, Bangladesh
Abstract
Introduction: The COVID-19 outbreak has become a challenging crisis for public health. During
the COVID-19 pandemic, the indefinite closure of educational institutions in Bangladesh has a
severe impact on the mental health of students.
Purpose: The purpose of this study is to investigate factors that might have considerable
influence on the mental health of students during quarantine in Bangladesh though they did not
explore in previous studies on mental health status during the pandemic.
Methodology: A standardized questionnaire was generated using PH9 and GAD7 to measure
depression and anxiety levels. A total of 203 responses were collected from university students of
Bangladesh through social media.
Results: Descriptive statistics found that 37% of the students experienced moderate to severe
anxiety while 54% faced moderate to severe depression. Ordinal Logistic Regression analysis
found that anxiety is significantly related to gender, students’ current affiliation status in university
(e.g., sophomore, masters), and time spent on watching TV while depression was related to family
member’s contact with Covid-19, performing multiple activities as hobbies, and spending time in
reading and writing.
Conclusions: This study adds valuable findings in the existing literature, and it will help Students,
university authorities, and government can take productive steps to tackle mental health issues.
Keywords
COVID-19, mental health, university students, quarantine activities, Bangladesh
Address for correspondence:
Minhazur Rahman Rezvi, MSS, Department of Development Studies, University of Dhaka
Email: minhazurrahmanrezvi@gmail.com
This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0 International
License (CC BY-NC 4.0).
©Copyright: Rezvi, Hossain, Haque, 2022
Publisher: Sciendo (De Gruyter)
DOI: https://doi.org/10.56508/mhgcj.v5i2.140
Submitted for publication: 12
April 2022
Revised: 01 August 2022
Accepted for publication: 07
August 2022
28
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Introduction
COVID-19 outbreak has become one of the
most devastating and challenging crisis for public
health in the contemporary world (Islam et al.,
2020). This pandemic has rapidly compounded its
public health burden (Torales et al., 2020) and
has been recognized as a greater risk for
deteriorating mental health conditions of
individuals (WHO 2020a). Along with public
health, the COVID-19 pandemic has a significant
impact on the social and economic aspects
(Bhuiyan et al., 2020; Nicola et al., 2020). In
December 2019, the coronavirus disease
(COVID- 19) pandemic was first identified in a
seafood market in Wuhan City, Hubei in China,
started to spread quickly throughout the world
(Wang et al., 2020). In January 2020, the WHO
declared the outbreak of COVID-19 infection as a
public health emergency of worldwide concern
(WHO, 2020a). Subsequently, on March 11, 2020,
WHO declared COVID-19 as a pandemic (WHO,
2020b). The incidence and mortality due to
COVID-19 have increased dramatically around
the world. Until now, over 56,660,391 people have
infected in the COVID-19 in the world, causing
more than 1,356,705 deaths (As of 19 November
2020; Worldometers, 2020).
Lockdown is considered as effective measure
in slowing the spread of COVID-19 around the
globe (Barkur et al., 2020; Flaxman et al., 2020).
Like other countries, Bangladesh reported the first
COVID-19 case on March 8, 2020 (Daily star,
2020a), and although initially, the virus spread
slowly, a rapid case increment started in April
(Satu et al., 2020). After first COVID-19 detection,
Bangladesh also put the lockdown strategy into
effect on March 26, 2020, to ensure ‘social
distance’ through ‘home quarantine’ to curb the
‘spread’ of the virus among its population (Jahid,
2020; Bhuiyan et al., 2020; Bodrud-Doza et al.,
2020). Although the COVID-19 virus has affected
all districts of the country and around 4 41,159
confirmed cases, 6,305 people died in
Bangladesh (on 19 November 2020;
Worldometers, 2020). However, all education
institutions were shutdown initially from March 18,
2020, to March 31, 2020, across the country and
later extended to November 14, 2020, in phases
(Dhaka tribune, 2020a; Dhaka tribune, 2020b).
Consequently, it has created uncertainty about
academic and professional careers among the
students which intensified mental health problems
among university students (Hossain et al., 2019;
Shamsuddin et al., 2013). Furthermore, COVID-
19, tertiary education institutions have shifted to
an emergency online learning format, which would
be expected to exacerbate more academic
stressors for students (Grubic et al. 2020). Like
other countries, most of the major public
universities in Bangladesh have started to take
online classes, including Dhaka University which
started online classes in July (Daily star, 2020b).
Due to students with fewer facilities (i.e., high
internet service costs, poor internet connection in
the rural area, not having access to a digital
device, etc.), only half or even more students
could not access online class, might be potential
mental distress mediating factors (Islam et al.,
2020; Daily star, 2020b). A study showed that
35.5% of participants (medical students) were in a
state of depression, and 22.1% were in a state of
anxiety (Liu et al., 2020). Cao et al. (2020)
confirmed that 24.9% of Chinese college students
experienced the negative impact of the Covid-19
crisis on mental health due to academic delays
and the economic effects of the pandemic.
Moreover, financial instability, lack of personal
space at home, fear of infecting other family
members, and insecure potential jobs may lead to
a wide range of psychiatric challenges for
university students (Cao et al., 2020; Wang et al.,
2020).
Purpose
This article aims to investigate the impact of
COVID-19 on the mental health status of
university students of Bangladesh. It also attempts
to explore associate factors to mental health (i.e.,
depression and anxiety) and relieving factors
(activities of students) of depression and anxiety
since previous studies done on this area have not
explored these factors. To evaluate the mental
health status of students, this study use Patient
Health Questionnaire-9 (PHQ-9) and Generalized
Anxiety Disorder 7 (GAD-7) screening tools.
Methodology
An online survey was conducted among
students to gather the necessary data. The survey
was conducted from 19th September to 18th
October. During this pandemic, all the educational
institutions were closed, and students were not
able to go out because of quarantine. Depression
was measured by the Patient Health
Questionnaire (PHQ-9). PHQ-9 is useful for
screening depression of the responses that are
used to predict depression of an individual and
what state he/she is in during the survey. The
scores in PHQ-9 range from ‘0 = not at all’ to ‘3 =
nearly every day’ (Kroenke et al., 2001). Levels of
depression were characterized as ‘non-minimal =
0–4’, ‘mild = 5–9’, ‘moderate = 10–14,’
‘moderately severe = 15–19,’ ‘severe = > 20.’
Anxiety was assessed by Generalized Anxiety
Disorder (GAD-7). The questions in the
questionnaire scale range from ‘0 = not at all sure’
to ‘3 = nearly every day’ (Spitzer et al., 2006). The
levels of anxiety for the study were characterized
as ‘mild = 5–9,’ ‘moderate = 10–14, and ‘severe =
> 15’.
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PHQ-9 and GAD7 were proved to be useful
reliable tools in various studies for detecting
depression (Martin et al., 2006; Hossain et al.,
2019). Numerous studies used these methods to
measure anxiety and depression in various
countries (Milić et al., 2019; Liu et al., 2020).
Considering its reliability and widespread usage,
this study will use these two methods to measure
the mental health of university students.
The independent variables taken from the
literature (i.e., gender, age, living area, family
members’ contact with Covis-19, watching TV,
talking with friends and family, spending time in
reading and writing, and lastly, doing religious
activities) consist mostly of factor variables which
range from 0 to 1. If an individual falls into a
specific category s/he was specified as 0 if not
then 1(e.g., if male and 0 if female). Some
continuous variables (i.e., number of activities
performed, family income threshold, and affiliation
with the university) are also included in the
analysis, and they can take any number (e.g., 1 or
7).
Descriptive statistical analysis was conducted
to describe the characteristics of the participants.
Ordered Logistic Regression analysis was done to
predict the association of psychological measures
(PHQ and GAD7) to potential factors. The PHQ
categorizes depression, and as non-minimal, mild,
moderate, moderately severe, and severe, and
GAD7 categorizes anxiety as mild, minimal,
moderate, and severe. This study used OLR since
there is an order in place, and these categories
can be considered as the Likert scale, and a p-
value of ≤0.05 was considered to be significant.
Some of the previous studies done using the
Likert scale mostly use OLR to analyze their data
(Eboli and Mazzulla, 2009), and it stated that OLR
can be used in this case (Hedeker, 2014). After
the regression analysis, assumptions related to
OLR were checked using Omodel and Brant test
which are usually used to test proportional odds
assumption and parallel regressions assumption
(Williams and Quiroz, 2020). The tests conclude
that the overall model does not violate any
assumptions, and the results obtained from the
analysis can be considered reliable.
Results
Table 1 describes the variables, and Table
2 shows the prevalence of anxiety and depression
among students. Out of the Total 203 responses,
mild to severe depression was found among 161
(79%)students. Surprisingly almost everyone face
mild to severe anxiety symptoms. 59 % (119) of
participants were male, and 97% (197) were
within 18 to 25 years. 66% (134) of students live
in urban areas, and the rest are in rural areas.
Mostly (28.7%) students came from a family
having 10000 TK to 30000 TK monthly income.
19.2 %( 39) students were from families having
below 10000 TK monthly income while 24.8 %
(51) students are from affluent families. Family
members of 86.7 % (170) students were not
infected by COVID-19. Almost 5 %( 11) students
were idle during this pandemic. Mostly (39%)
were busy with doing single activities.43.9% (87)
students spent their time watching TV, 46% (93)
students read and wrote, 49% (100) students
spent time with their family and friends,42% (86)
students were busy with religious activities.
Table 1: Frequency table for different selected variables.
Variables
Percentage
Frequency (N= 203)
Gender
Female
41%
84
Male
59%
119
Age
18-25
97%
197
Above 25
3%
6
Current student affiliation with the University
1st and 2nd year
33%
67
3rd year and above
67%
137
Living area
Urban
66%
134
Rural
34%
69
Family income
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Below Tk. 10,000
19%
39
Tk. 10,000-30,000
29%
58
Tk. 30,000-50,000
27%
55
Above Tk. 50,000
25%
51
Family been infected by Covid-19
No
86.7
170
Yes
13.3
33
Number of activities performed
0 to 3
75%
153
4 to 7
25%
50
Activities performed
Did not watch TV
56.1
116
Watched TV
43.9
87
Reading and writing
Done reading and writing
46%
93
Did not read or write
54%
110
Talk with friend and families
Did not talk
51%
103
Talked
49%
100
Doing religious activities
Did not (0)
58%
117
Did (1)
42%
86
Table 3 illustrates the descriptive statistics of
variables and the prevalence of anxiety and
depression among them. The analysis showed
that female suffered more depression (i.e.,
moderate 24% and moderately severe 17%) and
anxiety (17% moderate and 30% severe)
compared to their male counterpart (20%
moderate and 1% moderately severe depression
while 16% moderate and 14% severe anxiety).
Among fresh graduates, only 3% of students were
found to have moderately severe to severe
depression while 23% and 13% of masters’
students were in moderately severe to severe
depression. Anxiety was also found to be severe
among students from senior and master’s years
(23%) compared to their younger counterparts
(13%). Prevalence of moderately severe to severe
depression was found to be high (14% and 12%)
among students from urban areas compared to
students living in the rural area (7% and 1%).
However, students from the urban area suffered
less anxiety (16% moderate anxiety vs. 17%
among rural students) though they also faced
26% severe anxiety compared to 12% among
rural students.
Students with family income less than 10000
TK have faced 5% moderately severe and severe
depression while students with family income
more than 50000 TK suffered 20% and 14%
moderately severe and severe depression. Similar
to students living in rural areas, students from low-
income families suffer from 15% moderate anxiety
compared to 12% among students from high-
income family though they face severe anxiety
more than students from low-income families
(29% vs. 8%). The result also indicated that
students whose family member has been in
contact with Covid-19 have higher depression
(18% severe) and anxiety (30% severe) compared
to students whose family member has not been
intact with Covid-19 who suffered from 6% and
18% severe anxiety and also severe depression.
.
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Table 2: Prevalence of anxiety and depression
Anxiety
Frequency
Percentage
Depression
Frequency
Percentage
Mild anxiety
64
32%
Mild
77
38%
Minimal
anxiety
64
32%
Moderate
43
21%
Moderate
anxiety
33
16%
Moderately severe
24
12%
Severe
anxiety
42
21%
None-minimal
42
21%
Severe
17
8%
Students with family income less than 10000
TK have faced 5% moderately severe and severe
depression while students with family income
more than 50000 TK suffered 20% and 14%
moderately severe and severe depression. Similar
to students living in rural areas, students from low-
income families suffer from 15% moderate anxiety
compared to 12% among students from high-
income family though they face severe anxiety
more than students from low-income families
(29% vs. 8%). The result also indicated that
students whose family member has been in
contact with Covid-19 have higher depression
(18% severe) and anxiety (30% severe) compared
to students whose family member has not been
intact with Covid-19 who suffered from 6% and
18% severe anxiety and also severe depression.
Table 3: Descriptive statistics of depression and anxiety among students
Depression
Variables
none-
mini
mal
Percen
tage
Mild
Percen
tage
Mode
rate
percenta
ge
moder
ately
severe
percen
tage
sever
e
Percen
tage
Gender
Female
18
21%
53
63%
20
24%
14
17%
8
1%
Male
24
20%
24
20%
23
20%
10
1%
9
1%
Age
18-25
40
20%
76
39%
42
21%
24
12%
15
8%
Above
25
2
33%
1
17%
1
17%
0
2
33%
Current student affiliation with
the University
1-st year
9
30%
9
30%
10
33%
1
3%
1
3%
2-nd year
4
19%
22
60%
7
20%
2
5%
2
5%
3-rd year
7
16%
20
44%
10
22%
6
13%
2
4%
4-th year
8
20%
13
33%
6
15%
7
18%
6
15%
fresh
graduate
8
40%
4
20%
3
15%
4
20%
1
5%
Masters
6
19%
9
29%
7
23%
4
13%
5
16%
Living area
Urban
30
22%
42
31%
27
20%
19
14%
16
12%
Rural
12
17%
35
51%
16
23%
5
7%
1
1%
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Family income?
(Monthly)
Below
Tk. 10k
8
21%
17
44%
9
23%
2
5%
2
5%
10-30k
16
28%
20
34%
14
24%
5
9%
3
5%
30-50k
8
15%
21
38%
12
22%
7
13%
7
13%
Above
50k
9
18%
18
35%
8
16%
10
20%
7
14%
Family been
infected by
Covid-19
No
39
23%
67
39%
36
21%
17
10%
11
6%
Yes
3
9%
10
30%
7
21%
7
21%
6
18%
Number of activities performed
0
1
24%
3
27%
2
18%
2
18%
1
14
18%
32
40%
19
40%
3
4%
4
5%
2
8
29%
8
29%
4
14%
11
39%
4
14%
3
8
24%
11
32%
10
29%
4
12%
2
6%
4
1
5%
12
57%
4
19%
3
14%
2
10%
5
6
30%
8
40%
3
15%
2
10%
2
10%
6
4
50%
2
25%
1
13%
1
13%
1
13%
7
1
100%
Activities
performed
No
25
22%
40
34%
27
23%
13
11%
8
7%
Yes
17
20%
37
43%
16
18%
11
13%
9
10%
Done Reading and
writing
Yes
17
18%
35
38%
23
25%
8
9%
11
12%
No
24
22%
42
38%
19
17%
16
15%
8
7%
Talk with friend
and families
No
19
18%
36
35%
23
22%
15
15%
10
10%
Yes
22
22%
41
41%
20
20%
9
9%
8
8%
Done relig.
activities
No
21
18%
42
36%
26
22%
18
15%
10
9%
Yes
21
24%
35
41%
17
20%
6
7%
7
8%
Anxiety
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Variables.
Mini
mal
Percen
tage
mild
percen
tage
mode
rate
percenta
ge
severe
percentage
Gender
Female
20
24%
26
31%
14
17%
25
30%
Male
44
37%
38
32%
19
16%
17
14%
Age
18-25
61
31%
63
32%
33
18%
40
20%
Above
25
3
50%
1
17%
2
33%
Current student affiliation with
the University
1st year
17
57%
6
20%
4
13%
4
13%
2nd
13
35%
10
27%
10
27%
3
8%
3rd
9
20%
19
42%
8
18%
9
20%
4th
10
25%
9
23%
7
18%
14
35%
fresh
graduate
8
40%
6
30%
1
5%
5
25%
Masters
7
23%
14
45%
3
10%
7
23%
Living
area
Urban
42
31%
37
28%
21
16%
35
26%
Rural
22
32%
26
38%
12
17%
8
12%
Family income?
(Monthly)
Below
Tk. 10k
14
36%
16
41%
6
15%
3
8%
10-30k
21
36%
15
26%
10
17%
12
21%
30-50k
18
33%
13
24%
11
20%
12
22%
Above
50k
11
22%
20
39%
6
12%
15
29%
Family been
infect.Covid-19
No
56
33%
55
32%
28
16%
31
18%
Yes
8
24%
9
27%
6
18%
10
30%
Number of activities
performed
0
3
27%
3
27%
2
18%
3
27%
1
23
29%
27
34%
18
23%
14
18%
2
7
25%
9
32%
3
11%
9
32%
3
14
6%
8
24%
5
15%
7
21%
4
7
33%
7
33%
3
14%
3
14%
5
7
35%
7
35%
2
10%
4
20%
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6
3
38%
2
25%
0
2
25%
7
0
1
0
0
Watched
TV
No
39
34%
37
32%
18
16%
19
16%
Yes
25
29%
27
31%
15
17%
23
26%
Done Reading and
writing
Yes
30
32%
32
34%
10
11%
22
24%
No
34
31%
32
29%
23
21%
20
18%
Talk with friend
and families
No
32
31%
38
37%
22
21%
25
24%
Yes
32
32%
26
26%
11
11%
17
17%
Done religious
activities
No
34
29%
38
32%
21
18%
23
20%
Yes
30
35%
26
30%
12
14%
17
20%
Students who performed multiple activities also
tended to have less anxiety and depression.
Students who performed at least 6 activities
reported to have 13% moderate and severe
depression while students with 1 activity reported
18% depression. Anxiety was also high among
students who did less activities. The descriptive
statistics also found that students who done
religious prayers, talked with friends and family
and did not watch TV reported less anxiety and
depression compared to students who done
the contrary.
Table 4: Result of regression analysis
Anxiety
Depression
Variables
B
Odds ratio
P Value
B
Odds ratio
P Value
Gender
-0.7767204
0.459912
0.007**
-0.4598762
0.629848
0.102
Students
Affiliation
0.1939977
1.214093
0.025*
0.1066117
1.10407
0.214
Family
income
-0.1727173
0.841376
0.188
-0.0452464
0.952321
0.728
Family
contact with
Covid
0.1678431
1.182751
0.655
0.974859
2.639802
0.008**
Watching TV
0.8628934
2.370008
0.012*
0.5127267
1.608821
0.126
Talk with
friend and
families
-0.1641943
0.848577
0.616
-0.0594845
0.933966
0.854
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Number of
activities
-0.3022578
0.739148
0.084
-0.3618266
0.71459
0.035*
Reading and
writing
-0.2196312
0.802815
0.54
-0.7212372
0.495631
0.043*
Age
-0.9571335
0.383992
0.276
-0.3150179
0.729776
0.734
Religious
activities
0.3290569
1.389657
0.354
0.0769458
1.079984
0.825
Note: *P-value<0.05, **P-value <0.01, B= coefficient
In Table 4, the regression analysis revealed that
three of the variables ware significant in
determining anxiety. Gender was found to be
significant in determining anxiety which means
that maleinclined to have less anxiety than
females (B= -0.78, p<0.01). Student’s current
affiliation with the university and watching TV
were also significant in determining anxiety which
we also found in descriptive analysis. Students
who were in their graduation year or post-
graduation year inclined to have higher anxiety
than students in the first or second year (B= 0.19,
p<0.5). Among the activities, watching TV was
found to be significant in determining anxiety so,
students who watch TV inclined to have higher
anxiety (B=0.86, p<0.05) than students who did
not watch TV during the quarantine.
Variables that influenced anxiety significantly
did not seem to have a significant relationship with
depression. The result showed that depression
was significantly related to family member’s
contact with Covid-19, reading and writing, and
several activities. Students whose family had
been in contact with Covid-19 seemed to have
higher depression (B= 0.97, p<0.01) compared to
students whose family members did not come into
contact with Covid-19. Among the activities,
students who did reading and writing tended to
have more depression (B= -0.71, p<0.05) than
students who did not. Also, the number of
activities or hobbies were significantly related to
depression (B= -36, p<0.05). Students who have
done more activities (e.g., 5, 6) tend to have less
depression than students who did few activities
Discussion
The findings of this study agree with some
previous studies though they differ with the results
in some respects. The study found that a high rate
of depression and anxiety exist among university
student and some previous studies also found
similar results. For example, Khan et al. (2020)
found that 33.3% of anxiety and 46.92% of mild to
extremely severe depression were affected
among students of Bangladesh. Moreover,
several studies were conducted in other countries
like Wang et al. (2020) also found a high level of
depression among people at the initial level of
quarantine. Various factors are responsible for
deteriorating the quality of mental health among
students during the pandemic. The Covid-19 has
severed personal communication, and increased
student’s academic uncertainty is considered a
substantial factor of depression and anxiety
(Mushtaq et al., 2014; Roy et al., 2020).
This study found that a higher level of anxiety
during quarantine was related to student’s gender
and their affiliations status (i.e., sophomore,
masters) in university. Among quarantine
activities, watching TV was found to be
significantly related to anxiety. Depression had a
significant relationship with the family member’s
infection with Covid-19. Also, several factors
along with reading and writing were related to
depression. Furthermore, some other factors(i.e.,
religious prayers, talking with friends and family,
family income level) influenced the mental health
of students in descriptive statistics, but they were
not found significant in inferential statistics. A
detailed discussion can make sense of these
variables.
As in previous studies, the study found that
gender status was significantly related to anxiety
during the COVID-19. Women tended to have a
higher level of anxiety compared to men for
cognitive and physical reasons (Bahrami and
Yousefi, 2011; Hosseini and Khazali, 2013).
Various studies were conducted to find the causal
relationships behind the women’s higher level of
anxiety. Women incline to ruminate over a
particular issue more than men, therefore,
become victims to higher levels of anxiety
(Johnson and Whisman, 2013). The findings
stated that women were affected by more anxiety
than men during the Covid-19 crisis. However,
some studies reported that they did not found any
significant difference between men and women in
mental health status (Islam et al., 2020). On the
contrary, a study showed that there was a higher
level of anxiety among the male population than
women (Wang et al., 2020).
Some of the previous studies done on mental
health among students during quarantine did not
find or explore the mental health status among
students of different years (Islam et al., 2020;
Khan et al., 2020). This study included students’
current affiliation status at university and found
36
Mental Health: Global Challenges Journal
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that students’ years of studying at the university
have a significant relationship with anxiety.
Students from senior, fresh graduate and post-
graduate levels are more like to face anxiety than
freshmen or sophomore students. On the
contrary, previous studies (i.e., before the
quarantine) found that freshman and sophomores
were more likely to face anxiety (Wyatt and
Oswalt, 2013; Eleftheriades, et al., 2020).
Eleftheriades et al. (2020) stated that it might not
be the case that post-graduate and senior have
minimal anxiety, but a selection bias might be in
work here. Even students with higher anxiety do
not continue their studies; so, only students with
stable mental health can continue their studies at
senior and post-graduate levels. However, a study
found similar findings as this study that a higher
level of anxiety was related to other students than
freshmen during this quarantine (Kecojevic et al.,
2020). So, students studying in university in the
post-graduate or senior year have suffered from
anxiety where selection bias does not occur.
Halting academic progress and uncertainty of
employment opportunities might be a reason
behind this problem.
During quarantine, a high proportion of
students were watching movies and TV shows;
this study found that it was significantly related to
anxiety. Recent studies on mental health during
COVID-19 have not considered this factor (Islam
et al., 2020; Khan et al., 2020; Wang et al., 2020)
though previous studies found that there was a
positive relationship between binge-watching TV
and level of anxiety and depression (Wheeler,
2015; Madhav et al., 2017). Due to lockdown,
people could not go outside, and watching TV was
found as the most common activity among
respondents; they spent more time on TV when
having no home activities to do. Other activities
like gardening or petting animals were found as
regular activities among participants during
quarantine to avoid mental health stress.
Reading and writing thought to improve mental
health (Lewis, 2009; Baikie and Wilhelm, 2005),
but this study found that students with a higher
level of depression performed more reading and
writing than students with a lower level of
depression. The reasons were excessive reading
and writing, and academic workloads during
lockdown had different influences on students’
mental health status. Students were facing a
higher level of depression because of online
classes and academic workload. Similarly,
previous studies stated that students’ mental
health deteriorates when academic workload
increase (Aidan, 2018; Cheung et al., 2020).
Universities of Bangladesh were taking online
classes even though a large number of students
did not have enough resources to access online
classes. Academic workloads with technical
inaccessibility of students increased the level of
anxiety and depression among them.
The study found that Students’ (i.e.,
participants) performed several activities during
lockdown were highly related to their depression
level. The performed activities (e.g., gardening,
petting animals, and talking with friends) of
participants were influenced to improve their
mental health. Takeda et al. (2015) also stated
that performing multiple activities can keep
desirable physical and mental health status
(Pressman et al., 2009). Even though single
activity such as prayers or talking with friends and
family were not significantly related to depression,
therefore, it indicated that doing multiple activities
together improved an individual's mental health
status.\
It also found that Covid-19 infection among
family members was significantly related to
depression. Individuals whose family members
were infected by the Covid-19 had a higher level
of depression. Several studies reported that fear
of infection to Covid-19 might result in
deteriorating mental health (Hossain et al., 2020;
Ahorsu et al., 2020; Wang et al., 2020) though
they did not assess the impact of confirmed cases
on mental health. Previous studies (i.e., pre-
COVID-19) showed similar findings that any family
member's hospitalization increased depression
and anxiety (Belayachi et al., 2013; Fonseca et
al., 2019).
In terms of depression and anxiety, descriptive
statistics found that most of the people who did
not perform religious activities, did not spend
much time talking with friends or family, and had a
family income more than 30,000 TK related to
have a higher level of anxiety and depression; but
those variables were not significant in inferential
statistics. These factors might not significantly
relate to mental health, or the small sample size is
making those variables insignificant. More
research including those factors with a large
sample size might reveal their proper relationship
with mental health.
Strengths and Limitations of the study
The study complements some previous studies
by including some detailed variables that have
significance about mental health. Findings of this
study filled in the gap through contributing a
detailed analysis of mental health during Covid-
19.
However, the small sample size is a limitation
that could not be overcome because of lack of
time and findings. Large sample size is desired
but it is not possible to acquire a large sample
size. Another limitation is that the responses are
not balanced (e.g., female 41% and male 59%).
Despite these setbacks, this study will add
valuable information to the existing.
Conclusions
37
Mental Health: Global Challenges Journal
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The COVID-19’s lockdown, self-isolation, and
social distancing have increased the psychiatric
problems among the Bangladeshi people.
Specifically, the COVID-19 pandemic has also
created mental stress among college and
university students due to academic delays, fear
of the virus, financial instability, and uncertainty of
jobs (Cao et al., 2020; Wang et al., 2020;
Romash, 2020). This study has investigated the
impact of COVID-19 on the mental health status
of university students of Bangladesh. Like
previous studies, the study found that a high rate
of depression and anxiety exist among university
student, and various factors were responsible for
psychiatric stress among students during the
quarantine. The study also observed that a higher
level of anxiety was significantly related to
student’s gender and students’ current affiliation
status (i.e., studying year) in university during the
crisis. Watching TV was also found to be
significantly related to anxiety. Depression had a
significant relationship with the family member’s
infection with Covid-19. Also, the number of
activities during quarantine (e.g., petting animals,
cooking, gardening) along with reading and writing
was found to be significantly related to
depression. Some factors (i.e., religious prayers,
talking with friends and family, family income
level) were found to be influencing mental health
in descriptive statistics, though they were not
statistically significant. Similar to other studies, it
was found that performing multiple activities (e.g.,
gardening, petting animals, talking with friends,
etc.) could work as vital factors to improve the
mental health of students. Also, Bangladesh’s
government, along with the universities should
consider the mental health issue as a challenging
problem; they should work together to minimize
the negative impacts on the mental health of
university students.
Conflict of interest
The authors declare that they have no conflicts
of interest.
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note
Mental health disorders in patients with end-stage
renal failure
Maria Karastathi-Asimakopoulou1, Anna Loudovikou2
1 University of Crete, Faculty of Medicine, Heraklion, Greece
2 Aristotle University of Thessaloniki, School of Philosophy, Thessaloniki, Greece
Abstract
Renal failure is commonly accompanied by psychological distress compounding to mental health
conditions such as anxiety and depression. Common risk factors towards the development of
mental health disorders in people with renal failure include the need to attend regular
hemodialysis session and the burden of related complications. A growing body of evidence has
elucidated the biochemical and immunological underpinnings of mental health disorders in the
context of renal failure. This knowledge calls for strengthening the existing mental health support
frameworks and conducting research with the reported molecular pathways as potential
therapeutic targets.
Keywords
kidney failure, mental health, anxiety, depression
Address for correspondence:
Maria Karastathi-Asimakopoulou, University of Crete, Faculty of Medicine, Andrea
Kalokairinou 13, Giofyrakia, 71500, Heraklion, Greece, mariakarasta8i@gmail.com
This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0 International
License (CC BY-NC 4.0).
©Copyright: Karastathi-Asimakopoulou, Loudovikou 2022
Publisher: Sciendo (De Gruyter)
DOI: https://doi.org/10.56508/mhgcj.v5i2.146
Submitted for publication: 12
July 2022
Revised: 20 August 2022
Accepted for publication: 28
August 2022
Introduction
Approximately 10-15% of the global population
suffers from chronic kidney disease. Its principal
causes include diabetes mellitus and
hypertension, two highly prevalent non –
communicable diseases affecting billions of
people worldwide. End-stage kidney disease, also
known as kidney failure, is the fifth and final stage
in the progression of chronic kidney disease.
Chronic renal failure is a progressive and
irreversible deterioration of renal function. Patients
with this grade of kidney disease cannot survive
without dialysis or a kidney transplant. The
management of this condition entails regular
hemodialysis sessions, dietary restrictions and
recurrent hospitalizations to treat infections,
electrolyte disorders and other kidney disease –
related complications (Goh et.al., 2018). Patients
with renal failure tend to have limited
independence and functionality. This conundrum
affects their quality of life and has a dire impact on
their mental health (Stavropoulou et.al. 2017)
Mental health is a vital component of individual
health and wellbeing. Its presence or absence
reflects on everything people do, think, or say.
This is particularly important for people with renal
failure, the majority of whom are hospitalized with
a primary or recondary diagnosis of a mental
disorder. More than one fifth of these patients had
two or more psychiatric diagnoses. Patients with
end-stage kidney disease experience a higher
rate of mental illness than the general adult
population. Beyond depression, patients might
experience a myriad of psychological distress
symptoms including anxiety and fear of chronic
kidney disease progression (concerns about
hopelessness, death, and dying) (Goh et.al.,
2018). They also might experience recurrent
psychological and physical trauma during the
41
Mental Health: Global Challenges Journal
chronic kidney disease course. The most frequent
mental illness in this population is anxiety
(20.0%), followed by depression (16.8%), stress
reaction/adjustment disorder (2.5%),
somatoform/conversion disorder (0.9%), and
substance abuse disorder (0.6%).Studies have
shown that patients with chronic kidney failure
experience a high level of emotional distress even
in the early stages of disease progression, and in
most of them, they have low feelings of personal
control (Stavropoulou et.al. 2017).
The burden of the disease and its behavioral
implications have always been considered as
principal contributors to psychological distress and
disorders (Stavropoulou et.al. 2017). However,
emerging research shows that a host of
biochemical and immunological mechanisms can
also play an important role in the development
and the progression of mental health conditions
among patients with renal failure. These
mechanisms may mediate the translation of the
social and behavioral burden of the disease in
psychological stress or may contribute
independently to the development of mental
health disorders.
Purpose
This paper provides an overview of biological
mechanisms that may contribute to the
development or the progression of mental health
disorders among patients with end stage kidney
disease.
Methodology
To identify relevant peer-reviewed publications
and gray literature the authors searched PubMed-
Medline and Cochrane Library-Cochrane Central
Register of Controlled Trials (Central) till June 31,
2022.The reference lists of the selected sources
and relevant systematic reviews were also hand -
searched to identify potentially relevant resources.
The search terms: Mentlal health,chronic kidney
disease,renal failure,depression,COVID-19,were
used in combination with Boolean
operators(AND,OR) when appropriate.Studies,
were included if they fulfilled all the following
eligibility criteria: (1) ongoing or published clinical
studies reporting on digital and remote healthcare
applications in the prevention or management of
mental health in endstage chronic failure and (2)
study types: editorials, opinion articles,
perspectives,letters to the editor. No sample size
restriction was applied when screening for eligible
studies.
Results and limitations
For decades it has been known that
immunologic factors have potent influences on
neurotrasmitter metabolism and neuroendocrine
function.A growing number of studies have
investigated the relatioships between cytokines
and depression.Depression is the most common
psychological disorder among patients with end-
stage renal disease (Chen et.al.,2003; Palmer
et.al.,2013). The etiology of dialysis-related
depression is multifactorial and is related to
biological ,psychological ,and social
mechanisms.Some of the biological mechanisms
include increased cytokine levels ,genetic
predisposition ,and neurotrasmitters affected by
uremia.During hemodialysis ,the blood dialyzer
interaction has the potential to activate
mononuclear and denditic cells ,leading to
production of inflammatory cytokines.In particular
,there is evidence that depression is associated
with interleukin (IL-1),(IL-6) (Kamimura et.al.,
2007; Pereira et.al.,1994) tumor necrosis factor
alpha (TNF-a) and C-reactive protein (CRP) (
Hirotsu et.al.,2011). It has been speculated that
proinflammatory cytokines play a role in the
pathogenesis of depression and growing evidence
suggests that the mood disorder is associated
with inflammation (Dantzer et.al., 2004). In several
studies, it was also shown that there is a positive
relation between depression and proinflammatory
cytokines and C-reactive protein (CRP)
(Panagiotakos et.al.,2004), and also the
alterations of cytokines in hemodialysis (HD) may
be related to depression. Furthermore, an
additional study showed that serum
proinflammatory cytokine levels in end-stage renal
disease patients were 10 times higher than in the
normal population (Heimburger et.al., 2000).
However, the repeatability of these results is yet
to be determined, with conflicting evidence being
reported in some occasions. Many factors may
explain these conflicting results, including
variability in age, gender, nationality, and
methodological differences in the measurement of
cytokine concentrations.
Other researches have demonstrated frequent
and close relatioships between serum albumin
levels and depression. Cytokines production,
particulary IL-6, might induce protein catabolism
and lipolysis ,but cytokines have a strong negative
correlation with serum albumin levels
.However,malnutrition ,which is commonly
observed in dialysis patients ,is related to chronic
inflammation .It has also been reported that
malnutrition is associated with emotional
symptoms among hemodialysis
patients.Thus,chronic inflammation and
malnutrition might result in fatique by either
directly activating the central nervous system
throught adrenal axis or by indirectly triggering
multisystem deregylation ( Friedman et.al.,2010).
42
Mental Health: Global Challenges Journal
Figure 1 Τhe biochemical and
immunological underpinnings of mental health
disorders in renal failure are summarized
Accordingly, reduced kidney function has been
independently associated with worse
microstructural integrity of brain white matter, as
evaluated by diffusion tensor imaging magnetic
resonance imaging. Also, albuminuria has been
associated with larger white matter volume and
decreased estimated GFR with higher cerebral
blood flow in nondiabetic hypertensive adults.
Although subclinical cerebrovascular damage in
chronic kidney disease can be easily detected by
MRI, this is not performed routinely in clinical
practice. In addition, studies about this issue are
still scarce. It is important to understand the
mechanisms shared by renal impairment and
brain dysfunction in order to minimize the risk for
future neuropsychiatric conditions due to chronic
kidney disease (Sedaghat et.al., 2015; Tamura
et.al., 2016).
During the last two years, the COVID-19
pandemic has affected the lives of all people,
especially people living with kidney disease. New
challenges and fears surrounding the pandemic
can increase the stress and anxiety (Rayan et.al.,
2021). For patients that go to a dialysis center for
treatment, this can increase their stress and
anxiety of being exposed to COVID-19. If they
have a transplant, they may have a weakened
immune system and fear complications of getting
infected with COVID-19.Social distancing may
also increase feelings of loneliness and isolation.
(Romash et.al., 2020; 2022). We don't have to
forget that suicide is the most serious result of
mental illness among the patients,and the
percentage of suicide attemption have increased
dramatically since the beginning of the COVID-19
pandemic (Reger et.al., 2020)..
Conclusions
To conclude, the prevalence of mental
instability and psychiatric disorder among patients
with chronic kidney disease can be as high as
100%, depending on the diagnosis criteria and the
studied population. The prevalence of depression
and the risk of hospitalization due to psychiatric
disturbances are higher in patients with renal
failure, thus the individual health professionals
and national and international health bodies need
to consider new ways to protect these patient from
the psychological sequelae of chronic kidney
disease. Some examples are the provision of
psychological support by experienced mental
healthcare workers (physicians, psychologists,
community nurses, social workers) throughout the
patients’ treatment. Collaboration between
individual healthcare workers and facilities and
scientific and professional societies is needed in
order to integrate mental health support to the
standard of care and bring quality improvement to
relevant practices that have been already
implemented. In the long term, it is worthwhile to
investigate whether elements of the reported
biochemical and immunological evidence can be
used as biomarkers or therapeutic targets. This
can help devise personalized treatment strategies
for mental health conditions developing along the
progression of kidney disease.
Conflict of interest
The authors declare that they have no conflicts
of interest.
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