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1 Thomas Jefferson University Hospital
PMID: 28613597
Bookshelf ID: NBK430847

Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. The American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies the depressive disorders into:

Disruptive mood dysregulation disorder

Major depressive disorder

Persistent depressive disorder (dysthymia)

Premenstrual dysphoric disorder

Depressive disorder due to another medical condition

The common features of all the depressive disorders are sadness, emptiness, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function.

Because of false perceptions, nearly 60% of people with depression do not seek medical help. Many feel that the stigma of a mental health disorder is not acceptable in society and may hinder both personal and professional life. There is good evidence indicating that most antidepressants do work but the individual response to treatment may vary.

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Conflict of interest statement

Disclosure: Suma Chand declares no relevant financial relationships with ineligible companies.

Disclosure: Hasan Arif declares no relevant financial relationships with ineligible companies.

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The Critical Relationship Between Anxiety and Depression

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Six distinct types of depression identified in Stanford Medicine-led study

Brain imaging, known as functional MRI, combined with machine learning can predict a treatment response based on one’s depression “biotype.”

June 17, 2024 - By Rachel Tompa

Researchers have identified six subtypes of depression, paving the way toward personalized treatment. Damerfie - stock.adobe.com

Editor's note: This article was updated July 5 to include new research.

In the not-too-distant future, a screening assessment for depression could include a quick brain scan to identify the best treatment.

Brain imaging combined with machine learning can reveal subtypes of depression and anxiety, according to a new study led by researchers at Stanford Medicine. The study , published June 17 in the journal Nature Medicine , sorts depression into six biological subtypes, or “biotypes,” and identifies treatments that are more likely or less likely to work for three of these subtypes.

Better methods for matching patients with treatments are desperately needed, said the study’s senior author, Leanne Williams , PhD, the Vincent V.C. Woo Professor, a professor of psychiatry and behavioral sciences, and the director of Stanford Medicine’s Center for Precision Mental Health and Wellness . Williams, who lost her partner to depression in 2015, has focused her work on pioneering the field of precision psychiatry .

Around 30% of people with depression have what’s known as treatment-resistant depression , meaning multiple kinds of medication or therapy have failed to improve their symptoms. And for up to two-thirds of people with depression, treatment fails to fully reverse their symptoms to healthy levels.

That’s in part because there’s no good way to know which antidepressant or type of therapy could help a given patient. Medications are prescribed through a trial-and-error method, so it can take months or years to land on a drug that works — if it ever happens. And spending so long trying treatment after treatment, only to experience no relief, can worsen depression symptoms.

“The goal of our work is figuring out how we can get it right the first time,” Williams said. “It’s very frustrating to be in the field of depression and not have a better alternative to this one-size-fits-all approach.”

Biotypes predict treatment response

To better understand the biology underlying depression and anxiety, Williams and her colleagues assessed 801 study participants who were previously diagnosed with depression or anxiety using the imaging technology known as functional MRI, or fMRI, to measure brain activity. They scanned the volunteers’ brains at rest and when they were engaged in different tasks designed to test their cognitive and emotional functioning. The scientists narrowed in on regions of the brain, and the connections between them, that were already known to play a role in depression.

Using a machine learning approach known as cluster analysis to group the patients’ brain images, they identified six distinct patterns of activity in the brain regions they studied.

Leanne Williams

The scientists also randomly assigned 250 of the study participants to receive one of three commonly used antidepressants or behavioral talk therapy. Patients with one subtype, which is characterized by overactivity in cognitive regions of the brain, experienced the best response to the antidepressant venlafaxine (commonly known as Effexor) compared with those who have other biotypes. Those with another subtype, whose brains at rest had higher levels of activity among three regions associated with depression and problem-solving, had better alleviation of symptoms with behavioral talk therapy. And those with a third subtype, who had lower levels of activity at rest in the brain circuit that controls attention, were less likely to see improvement of their symptoms with talk therapy than those with other biotypes.

The biotypes and their response to behavioral therapy make sense based on what they know about these regions of the brain, said Jun Ma, MD, PhD, the Beth and George Vitoux Professor of Medicine at the University of Illinois Chicago and one of the authors of the study. The type of therapy used in their trial teaches patients skills to better address daily problems, so the high levels of activity in these brain regions may allow patients with that biotype to more readily adopt new skills. As for those with lower activity in the region associated with attention and engagement, Ma said it’s possible that pharmaceutical treatment to first address that lower activity could help those patients gain more from talk therapy.

“To our knowledge, this is the first time we’ve been able to demonstrate that depression can be explained by different disruptions to the functioning of the brain,” Williams said. “In essence, it’s a demonstration of a personalized medicine approach for mental health based on objective measures of brain function.”

In another recently published study , Williams and her team showed that using fMRI brain imaging improves their ability to identify individuals likely to respond to antidepressant treatment. In that study, the scientists focused on a subtype they call the cognitive biotype of depression, which affects more than a quarter of those with depression and is less likely to respond to standard antidepressants. By identifying those with the cognitive biotype using fMRI, the researchers accurately predicted the likelihood of remission in 63% of patients, compared with 36% accuracy without using brain imaging. That improved accuracy means that providers may be more likely to get the treatment right the first time. The scientists are now studying novel treatments for this biotype with the hope of finding more options for those who don’t respond to standard antidepressants.

For example, in research published July 5 in Nature Mental Health , Williams’ team showed that transcranial magnetic stimulation was particularly effective for the cognitive biotype. The study enrolled 43 veterans, with 26 identified by fMRI as having the cognitive biotype. After 30 daily sessions of transcranial magnetic stimulation that targeted the cognitive control circuit, veterans with the cognitive biotype recovered the deficits in their brain connectivity and improved on tests of cognitive control. Most of the improvement occurred within the first five days of treatment. The findings further demonstrate the promise of using biotypes to take the guesswork out of depression treatment.

Further explorations of depression

The different biotypes also correlate with differences in symptoms and task performance among the trial participants. Those with overactive cognitive regions of the brain, for example, had higher levels of anhedonia (inability to feel pleasure) than those with other biotypes; they also performed worse on executive function tasks. Those with the subtype that responded best to talk therapy also made errors on executive function tasks but performed well on cognitive tasks.

One of the six biotypes uncovered in the study showed no noticeable brain activity differences in the imaged regions from the activity of people without depression. Williams believes they likely haven’t explored the full range of brain biology underlying this disorder — their study focused on regions known to be involved in depression and anxiety, but there could be other types of dysfunction in this biotype that their imaging didn’t capture.

Williams and her team are expanding the imaging study to include more participants. She also wants to test more kinds of treatments in all six biotypes, including medicines that haven’t traditionally been used for depression.

Her colleague Laura Hack , MD, PhD, an assistant professor of psychiatry and behavioral sciences, has begun using the imaging technique in her clinical practice at Stanford Medicine through an experimental protocol . The team also wants to establish easy-to-follow standards for the method so that other practicing psychiatrists can begin implementing it.

“To really move the field toward precision psychiatry, we need to identify treatments most likely to be effective for patients and get them on that treatment as soon as possible,” Ma said. “Having information on their brain function, in particular the validated signatures we evaluated in this study, would help inform more precise treatment and prescriptions for individuals.”

Researchers from Columbia University; Yale University School of Medicine; the University of California, Los Angeles; UC San Francisco; the University of Sydney; the University of Texas MD Anderson; and the University of Illinois Chicago also contributed to the study.

Datasets in the study were funded by the National Institutes of Health (grant numbers R01MH101496, UH2HL132368, U01MH109985 and U01MH136062) and by Brain Resource Ltd.

Rachel Tompa Rachel Tompa is a freelance science writer.

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu .

Hope amid crisis

Psychiatry’s new frontiers

Stanford Medicine magazine: Mental health

Open access
Published: 15 July 2024

Enhancing psychological well-being in college students: the mediating role of perceived social support and resilience in coping styles

Shihong Dong 1 ,
Huaiju Ge 1 ,
Wenyu Su 1 ,
Weimin Guan 1 ,
Xinquan Li 1 ,
Yan Liu 2 ,
Qing Yu 1 ,
Yuantao Qi 2 ,
Huiqing Zhang 3 &
Guifeng Ma 1

BMC Psychology volume 12 , Article number: 393 ( 2024 ) Cite this article

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The prevalence of depression among college students is higher than that of the general population. Although a growing body of research suggests that depression in college students and their potential risk factors, few studies have focused on the correlation between depression and risk factors. This study aims to explore the mediating role of perceived social support and resilience in the relationship between trait coping styles and depression among college students.

A total of 1262 college students completed questionnaires including the Trait Coping Styles Questionnaire (TCSQ), the Patient Health Questionnaire-9 (PHQ-9), the Perceived Social Support Scale (PSSS), and the Resilience Scale-14 (RS-14). Common method bias tests and spearman were conducted, then regressions and bootstrap tests were used to examine the mediating effects.

In college students, there was a negative correlation between perceived control PC and depression, with a significant direct predictive effect on depression ( β = -0.067, P < 0.01); in contrast, negative control NC showed the opposite relationship ( β = 0.057, P < 0.01). PC significantly positively predicted perceived social support ( β = 0.575, P < 0.01) and psychological resilience ( β = 1.363, P < 0.01); conversely, NC exerted a significant negative impact. Perceived social support could positively predict psychological resilience ( β = 0.303, P < 0.01), and both factors had a significant negative predictive effect on depression. Additionally, Perceived social support and resilience played a significant mediating role in the relationship between trait coping styles and depression among college students, with three mediating paths: PC/NC → perceived social support → depression among college students (-0.049/0.033), PC/NC→ resilience → depression among college students (-0.122/-0.021), and PC/NC → perceived social support → resilience → depression among college students (-0.016/0.026).

The results indicate that trait coping styles among college students not only directly predict lower depression but also indirectly influence them through perceived social support and resilience. This suggests that guiding students to confront and solve problems can alleviate their depression.

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Introduction

Depression is a complex mental disorder, characterized by cognitive, affective and psychosocial symptoms [ 1 , 2 ]. It is projected that by 2030, depression will rank first globally in terms of years lived with disability [ 3 , 4 ]. Depression is also one of the most common mental health issues among contemporary college students [ 5 , 6 ]. Studies have shown that the detection rate of depression among Chinese college students ranges from 23–34% [ 7 , 8 ]. Compared to non-student populations, college students have a higher prevalence of depression, and this rate seems to be increasing [ 9 ]. This vulnerable group of college students is in a unique developmental stage, facing pressures not only from life but also from the demands of academic coursework and complex interpersonal relationships, making the factors influencing depression among college students, particularly complex [ 9 , 10 ].

Exploring the mechanisms by which influencing factors affect the occurrence of depression in college students is of significant importance for early prevention [ 11 ]. Research has demonstrated that trait coping style is one of the risk factors for depression among college students. Trait coping refers to the strategies individuals employ in challenging situations, categorized into positive coping and negative coping [ 12 , 13 ]. Positive coping focuses on taking effective action and changing stressful situations, typically associated with problem-solving behaviors and regulation of positive emotions, which can help reduce the incidence of depression [ 14 ]. Conversely, negative coping is a passive approach centered around negative evaluations and emotional expression, often involving avoiding problems and social isolation, which is more likely to lead to the development of depression [ 14 ]. Research indicates that positive coping strategies are inversely correlated with depression, serving as protective factors against depression. Conversely, negative coping strategies are positively associated with depression, acting as risk factors for its onset [ 15 ].

Perceived social support refers to an individual’s subjective emotional state of feeling supported and understood by family, friends, and other sources [ 16 , 17 ]. Prior studies have shown that perceived social support can directly impact an individual’s level of depression and also have indirect effects [ 18 ]. The data indicate that social support can significantly influence coping mechanisms, with groups having higher levels of social support tended to respond more actively and positively to stress from various sources [ 19 ]. Social support is considered an important mediating factor in determining the relationship between psychological stress and health, representing an emotional experience where individuals feel supported, respected, and understood [ 16 ]. The relationship between individuals’ coping strategies and depression may be influenced by the mediating role of perceived social support [ 20 , 21 ]. In addition to this, resilience plays a role in all three.Resilience refers to the ability to adapt to stress and adversity, enhancing an individual’s psychological well-being [ 22 ]. Both coping styles and perceived social support significantly predict resilience positively [ 23 ]. For individuals with strong resilience, possessing a high level of adaptive capacity can mitigate the negative effects of stress on individuals, thereby enhancing their mental health.

In recent years, there has been a growing body of research on the prevalence of depression among college students. However, the rates of depression vary in different environments, and there is limited research on the mechanisms through which trait coping styles, perceived social support, and resilience impact depression. Therefore, this study aims to investigate the mechanisms through which positive coping styles(PC), negative coping styles(NC), perceived social support, and resilience influence depression among college students. Additionally, it seeks to analyze the mediating roles of perceived social support and resilience in this context. The goal is to provide insights into the reasons behind depression among college students under different coping strategies, aiding in timely psychological adjustment to promote the comprehensive development of the mental and physical well-being of college students.

The following assumptions were made:

Hypothesis 1

PC has a significant negative predictive effect on depression among college students. NC has a significant positive predictive effect on depression among college students.

Hypothesis 2

Perceived social support serves as a mediator between PC/NC and depression among college students.

Hypothesis 3

Resilience mediates the relationship between PC/NC and depression among college students.

Hypothesis 4

Perceived social support and psychological resilience mediate the relationship between PC/NC and depression among college students in a serial manner.

Data and methods

This is a cross-sectional study that was conducted from January through February 2024. Using the Questionnaire Star network platform, we presented the questionnaire online, which was openly accessible to college students at a university in Shandong. The average time to complete the survey was 15 min. Participation was voluntary and students were informed about the purpose of the study. Confidentiality was assured and questionnaires were submitted anonymously. A total of 1267 enrolled college students participated in the questionnaire survey. After excluding invalid questionnaires, 1262 valid questionnaires were included, resulting in an effective rate of 99.57%.

Trait coping style questionnaire

The Trait Coping Style Questionnaire (TCSQ) [ 24 ], developed by Qianjin Jiang, was utilized to assess the trait coping styles of college students. This questionnaire reflects the participants’ approaches to coping with situations, comprising a total of 20 items. It consists of two dimensions: negative coping style and positive coping style, each with 10 items. Using a 5-point Likert scale ranging from “definitely not” to “definitely yes,” scores were assigned from 1.00 to 5.00. The Cronbach’s α coefficient for negative coping style was 0.906 and for positive coping style was 0.786 in this study.

Depression scale

The Patient Health Questionnaire-9 (PHQ-9) [ 25 ] was used to assess depressive symptoms in the past two weeks. This scale consists of 9 items rated on a 4-point Likert scale ranging from “not at all” to “nearly every day,” with scores from 0 to 3. The total score ranges from 0 to 27, with higher scores indicating more severe depressive symptoms. The Cronbach’s α coefficient for this scale in the current study was 0.884.

Perceived Social Support Scale

The Perception Social Support Scale (PSSS) was compiled by James A.Blumenthal in 1987 and later translated and modified by Qianjin Jiang to form the Chinese version of the Zimetm Perception Social Support Scale (PSSS) [ 26 , 27 ]. PSSS comprises 12 self-assessment items rated on a 7-point Likert scale. The scale includes three dimensions: family support (items 3, 4, 8, 11), friend support (items 6, 7, 9, 12), and other support (items 1, 2, 5, 10), with a total score ranging from 12 to 84. Scores of 12–36 indicate low support, 37–60 indicate moderate support, and 61–84 indicate high support. The Cronbach’s α for this scale in the current survey was 0.968.

Resilience scale

The Resilience Scale (RS-14) [ 28 ] Chinese version consists of 14 items, each rated on a 7-point Likert scale from “not at all” to “completely,” with scores ranging from 1 to 7. The total score ranges from 14 to 98, with higher scores indicating better resilience. The Cronbach’s α for this scale in the current study was 0.925.

Statistical analysis

Data were organized and analyzed using SPSS 26.0 software. Confirmatory factor analysis was first conducted on the questionnaires. Descriptive analysis was then performed on the scores of each scale. Spearman was used to examine the relationships between trait coping styles, perceived social support, resilience, and depression. Mediation analysis was carried out using the SPSS PROCESS macro 3.4.1 software model 6 developed by Hayes, specifically designed for testing complex models. Model 6 was applied for two mediating variables, followed by the bias-corrected percentile Bootstrap method with 5000 resamples to estimate the 95% confidence interval of the mediation effect. A significant mediation effect was indicated if the 95% confidence interval (CI) did not include zero. A significance level of P < 0.05 was considered statistically significant.

Examination of common method bias

Systematic errors in indicator data results caused by the same data collection method or measurement environment can typically be assessed through the Harman single-factor test on 55 items in the dataset to examine common method bias. The results indicated that there were 7 factors with eigenvalues greater than 1, and the variance explained by the first factor was 34.84%, which was below the critical threshold of 40%. Therefore, this study may not have a significant common method bias.

Descriptive statistics and correlation analysis

The mean scores, standard deviations, and correlations of each variable are presented in Table 1 . PC ( r = -0.326, P < 0.01), resilience ( r =-0.445, P < 0.01), and perceived social support ( r =-0.405, P < 0.01) were negatively correlated with depression. PC ( r = 0.336, P < 0.01) and resilience ( r = 0.469, P < 0.01) were significantly positively correlated with perceived social support. PC was significantly positively correlated with resilience( r = 0.635, P < 0.01). NC was significantly positively correlated with depression( r = 0.322, P < 0.01) and PC( r = 0.146, P < 0.01). NC was significantly negatively correlated with perceived social support ( r =-0.325, P < 0.01).

Analysis of chain mediation effects

The chain mediation model was validated using SPSS PROCESS Model 6. Trait coping styles were considered as the independent variable, while depression among college students was treated as the dependent variable. Perceived social support and resilience were included as the mediating variables, culminating in the path model depicted in Figs. 1 and 2 .

The results of the regression analysis, as shown in Table 2 , indicated that PC could significantly predict perceived social support in a positive direction ( β = 0.575, P < 0.01). Both PC ( β = 1.363, P < 0.01) and perceived social support ( β = 0.303, P < 0.01) had significant positive predictive effects on psychological resilience. When simultaneously predicting depression using PC, perceived social support, and psychological resilience, all three exhibited significant negative predictive effects ( β = -0.067, β = -0.085, β = -0.090, P < 0.01). NC could significantly predict perceived social support in a negative direction ( β = -0.457, P < 0.01). When NC ( β = 0.191, P < 0.01) and perceived social support ( β = 0.508, P < 0.01) jointly predict psychological resilience, they both had significant positive predictive effects. When simultaneously predicting depression using NC, perceived social support, and psychological resilience, NC ( β = 0.057, P < 0.01) showed a significant positive predictive effect, while perceived social support ( β = -0.072, P < 0.01) and psychological resilience ( β = -0.112, P < 0.01) demonstrated significant negative predictive effects.

Further employing the Bootstrap sampling method, with 5000 repetitions, the significance of the mediating effects and chain mediation effects between trait coping styles and depression among college students was examined. The results indicated that the direct effects of PC/NC on depression were significant, with direct impact values of -0.067/0.057 (26.38%/60.00%). Perceived social support and psychological resilience mediated the relationship between PC/NC and depression, with this mediation encompassing three pathways: the separate mediating effect of perceived social support, with effect values of -0.049 and 0.033 respectively; the separate mediating effect of resilience, with effect values of -0.122 and − 0.021 respectively; and the serial mediating effect from perceived social support to resilience, with effect values of -0.016, -0.021, and 0.026. The 95% confidence intervals for all pathways did not include 0, indicating significant indirect effects. Therefore, the total indirect effects were − 0.187 (73.62%) and 0.038 (40.00%), showing that PC had a weaker direct effect on depression compared to NC, but a stronger indirect effect. This was illustrated in Table 3 .

Chain mediation model of perceived social support and resilience between PC and depression. ** p < 0.01

Chain mediation model of perceived social support and resilience between NC and depression. ** p < 0.01

Previous research on the associations and specific pathways among depressive symptoms, trait coping styles, perceived social support, and resilience in college students has been limited. Therefore, this study utilized a chain mediation model to examine how trait coping styles, perceived social support, and resilience influence depressive symptoms in college students. The results indicate that perceived social support and resilience not only act as separate mediators between PC/NC and depression but also exhibit a chain mediation effect.

Mechanisms of the impact of PC/NC on depression in college students

This study found that trait coping styles can significantly and negatively predict depressive symptoms in college students directly, consistent with previous research [ 29 ]. In recent years, amidst the backdrop of the pandemic, numerous studies have emerged domestically and internationally focusing on college students’ mental health from the perspective of crisis event coping [ 30 ]. These studies have predominantly concentrated on trait coping styles as a mediating variable in predicting the occurrence of depressive symptoms, with fewer studies examining the direct impact of trait coping styles on depressive symptoms. College students, being in a unique developmental stage, face challenges from various aspects and bear the pressures of academic coursework, interpersonal relationships, and future employment. Research indicates that trait coping styles are a key factor influencing mental health [ 31 ]. Implementing healthy coping techniques and interventions can help individuals overcome negative emotions caused by stress, which is an adaptive coping mechanism that assists college students in facing stress and enhancing problem-solving abilities, thus preventing or reducing the occurrence of depression. Conversely, adopting passive or avoidant coping strategies, leading to inadequate resolution of stress events, can increase psychological stress [ 14 ], thereby exerting a negative impact on the mental health of college students [ 32 ]. Therefore, trait coping styles play a negative predictive role in depressive symptoms among college students. PC was a positive predictor of depression and NC was a negative predictor of depression. This is consistent with previous studies [ 24 , 29 ].

Separate mediating effects of perceived social support and resilience

After introducing perceived social support and resilience as two mediating variables, the predictive effect of PC/NC on depressive symptoms in college students remained significant. The results show that PC can positively predict perceived social support, and NC is the opposite, consistent with previous research [ 33 ]. Trait coping styles are an important predictive factor in altering college students’ perceptions of social support and the occurrence of depression. Individuals who adopt negative coping styles tend to perceive relatively less external support. Some argue that social support plays a reverse predictive role in trait coping styles; the more social support college students receive and feel, the more likely they are to actively adopt positive coping strategies to alleviate stress, potentially due to variations in study subjects and time [ 34 ]. In this pathway, perceived social support can significantly and negatively predict depressive symptoms, aligning with previous research findings [ 35 ]. Perceived social support is considered a crucial mediating factor influencing mental health, referring to an individual’s ability to perceive support and understanding from family, friends, and others. College students with lower levels of perceived social support often feel neglected and undervalued, leading to negative evaluations and self-doubt, making them more susceptible to depression. PC/NC and perceived social support can interact and influence the occurrence of depressive symptoms in college students [ 16 ].

Research indicates that PC can significantly and positively predict resilience, with an indirect effect value of 48.03%.In this pathway, the mediating effect of resilience is more pronounced, consistent with previous studies [ 36 ]. There is a close connection between resilience and coping styles; college students who adopt positive coping strategies often exhibit stronger psychological resilience, being more willing to confront issues and seek help from others to solve problems. When facing pressures such as academic challenges, they approach them with a positive mindset, overcoming adversity [ 37 ]. It is believed that adopting positive coping strategies to address problems can enhance college students’ levels of psychological resilience [ 10 , 38 ]. Resilience can significantly and negatively predict depressive symptoms. depressive symptoms, College students with higher levels of resilience tend to define the severity of events less severely when stress events occur, resulting in lower psychological burdens and reduced likelihood of experiencing depressive symptoms [ 10 ]. Additionally, when facing setbacks or stress, individuals who adopt positive coping strategies actively utilize internal and external protective factors to combat current difficulties and pressures, and employ effective emotional control to mitigate the impact, thereby enhancing their levels of psychological resilience and reducing the occurrence of depression.

Chain mediation effect of perceived social support and psychological resilience

This study elucidates that PC/NC perceived social support, and psychological resilience are independent factors influencing depressive symptoms in college students, with perceived social support and psychological resilience playing a mediating role between coping styles and depressive symptoms. The share of total indirect effect values is 73.62% and 40.00%, respectively, with the third chain path accounting for 6.30% and 27.37% of the total effect ratio, respectively. This confirms the existence of this chain mediation effect, although the chain mediation effect is not as pronounced as the individual mediation effects. Positive coping styles not only directly negatively predict depressive symptoms in college students but also exert an indirect influence on depressive symptoms through perceived social support and psychological resilience. Likewise, negative coping styles not only directly positively predict depressive symptoms in college students but also have an indirect impact on depressive symptoms through perceived social support and psychological resilience, thus demonstrating the value and significance of these two mediating variables in reducing the occurrence of depressive symptoms in college students.

Initially, adopting positive coping styles and being able to perceive social support are crucial factors influencing psychological resilience in college students. There exists a relatively stable systemic relationship between students’ social support and psychological resilience, confirming that social support can enhance individuals’ levels of psychological resilience [ 16 ]. Furthermore, coping styles can affect the occurrence of depressive symptoms from both internal and external perspectives. This is because the social support perceived by college students includes not only tangible social support resources but also their subjective perception of social support, with these two factors constituting external and internal protective factors of psychological resilience [ 39 ]. Positive coping and effective adaptation can enhance college students’ perception of social support, enabling them to mobilize personal, familial, and societal protective factors better when facing various life challenges, thereby mitigating or eliminating difficulties and suppressing the onset of depressive symptoms, whereas negative coping styles yield the opposite effect. The chain mediation proposed in this study integrates the research on perceived social support, psychological resilience, and depressive symptoms in college students, facilitating a more comprehensive understanding of the internal mechanisms through which coping styles influence depressive symptoms in college students. This holds significance in advocating for a proactive attitude in college students to confront and resolve difficulties and in increasing attention to the mental health of college students.

Limitations, strengths and future research

The findings of this study hold theoretical value and practical implications, offering a reference basis for improving the mental health of college students. However, there are certain limitations to consider. Firstly, the survey in this study was conducted through self-reporting, which may introduce certain biases. Future research could explore data collection through various methods. Secondly, this study employed a cross-sectional design to investigate the impact of trait coping styles, on depression among college students and its potential mechanisms. However, this research approach does not allow for causal inferences between variables, and further validation of the study’s conclusions could be achieved through longitudinal or experimental research.

In summary, this study aims to improve the mental health of college students by examining how their coping styles, along with their perceived social support and psychological resilience, affect depressive symptoms. The research analyzes the connections between these factors and suggests that positive coping styles may help prevent depression. However, the study has its limitations and future research should use long-term experiments to better understand these relationships. Since depression in college students can be influenced by many factors, future studies should also consider additional variables and use a mix of experimental and longitudinal approaches to more clearly understand how to reduce depression in this group.

Data availability

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

Abbreviations

Patient Health Questionnaire-9

Trait Coping Style Questionnaire

Positive coping styles

Negative coping styles

Resilience Scale

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Acknowledgements

We would like to provide our extreme thanks and appreciation to all students who participated in our study.

This work was financially supported by the National Food Safety Risk Center Joint Research Program [grant number (LH2022GG06)] and the Weifang Medical College Teaching Reform Program (2023YBC008).

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SD and GM conceived and designed the study. HG, WS, WG, and YL undertook the data collection and analysis. SD, QY, YQ, XLand HZ drafted the manuscript. SD and GM reviewed the manuscript. The authors read and approved the final manuscript.

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Dong, S., Ge, H., Su, W. et al. Enhancing psychological well-being in college students: the mediating role of perceived social support and resilience in coping styles. BMC Psychol 12 , 393 (2024). https://doi.org/10.1186/s40359-024-01902-7

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DOI : https://doi.org/10.1186/s40359-024-01902-7

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Introduction
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Article Information

Outcomes are estimated from bivariate and multivariable generalized estimating equation models. aOR, indicates adjusted odds ratio; GAD-7, Generalized Anxiety Disorder 7-item scale; PHQ-9, Patient Health Questionnaire 9-item scale; whiskers, 95% CIs.

eTable 1. Survey Instruments

eTable 2. Prevalence of Exposure Over Time

eTable 3. Prevalence of Outcomes Over Time by Exposure Group

eTable 4. E-Value Calculation for Association Between Puberty Blockers or Gender-Affirming Hormones and Mental Health Outcomes

eTable 5. Examining Association Between Puberty Blockers or Gender-Affirming Hormones and Mental Health Outcomes Separately

eTable 6. Bivariate Model Restricted to Youths Ages 13 to 17 Years

eTable 7. Multivariable Model Restricted to 90 Youths Ages 13 to 17 Years

eTable 8. Sensitivity Analyses using Patient Health Questionnaire 8-item Scale Score of 10 or Greater for Moderate to Severe Depression

eFigure 1. Schematic of Generalized Estimating Equation Model

eFigure 2. Association Between Receipt of Gender-Affirming Hormones or Puberty Blockers and Mental Health Outcomes

eReferences

Medical Groups Defend Patient-Physician Relationship and Access to Adolescent Gender-Affirming Care JAMA Medical News & Perspectives April 19, 2022 This Medical News article discusses physicians’ advocacy to protect patients and the patient-physician relationship amid efforts by politicians to limit access or criminalize gender-affirming care. Bridget M. Kuehn, MSJ
As Laws Restricting Health Care Surge, Some US Physicians Choose Between Fight or Flight JAMA Medical News & Perspectives June 13, 2023 In this Medical News article, 13 physicians and health care experts spoke with JAMA about the increasing efforts to criminalize evidence-based medical care in the US. Melissa Suran, PhD, MSJ
Data Errors in eTables 2 and 3 JAMA Network Open Correction July 26, 2022
Improving Mental Health Among Transgender and Gender-Diverse Youth JAMA Network Open Invited Commentary February 25, 2022 Brett Dolotina, BS; Jack L. Turban, MD, MHS

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Tordoff DM , Wanta JW , Collin A , Stepney C , Inwards-Breland DJ , Ahrens K. Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care. JAMA Netw Open. 2022;5(2):e220978. doi:10.1001/jamanetworkopen.2022.0978

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Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care

1 Department of Epidemiology, University of Washington, Seattle
2 Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
3 School of Medicine, University of Washington, Seattle
4 Department of Psychiatry and Behavioral Medicine, Department of Adolescent and Young Adult Medicine, Seattle Children’s Hospital, Seattle, Washington
5 University of California, San Diego School of Medicine, Rady Children's Hospital
6 Division of Adolescent Medicine, Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington
Invited Commentary Improving Mental Health Among Transgender and Gender-Diverse Youth Brett Dolotina, BS; Jack L. Turban, MD, MHS JAMA Network Open
Medical News & Perspectives Medical Groups Defend Patient-Physician Relationship and Access to Adolescent Gender-Affirming Care Bridget M. Kuehn, MSJ JAMA
Medical News & Perspectives As Laws Restricting Health Care Surge, Some US Physicians Choose Between Fight or Flight Melissa Suran, PhD, MSJ JAMA
Correction Data Errors in eTables 2 and 3 JAMA Network Open

Question Is gender-affirming care for transgender and nonbinary (TNB) youths associated with changes in depression, anxiety, and suicidality?

Findings In this prospective cohort of 104 TNB youths aged 13 to 20 years, receipt of gender-affirming care, including puberty blockers and gender-affirming hormones, was associated with 60% lower odds of moderate or severe depression and 73% lower odds of suicidality over a 12-month follow-up.

Meaning This study found that access to gender-affirming care was associated with mitigation of mental health disparities among TNB youths over 1 year; given this population's high rates of adverse mental health outcomes, these data suggest that access to pharmacological interventions may be associated with improved mental health among TNB youths over a short period.

Importance Transgender and nonbinary (TNB) youths are disproportionately burdened by poor mental health outcomes owing to decreased social support and increased stigma and discrimination. Although gender-affirming care is associated with decreased long-term adverse mental health outcomes among these youths, less is known about its association with mental health immediately after initiation of care.

Objective To investigate changes in mental health over the first year of receiving gender-affirming care and whether initiation of puberty blockers (PBs) and gender-affirming hormones (GAHs) was associated with changes in depression, anxiety, and suicidality.

Design, Setting, and Participants This prospective observational cohort study was conducted at an urban multidisciplinary gender clinic among TNB adolescents and young adults seeking gender-affirming care from August 2017 to June 2018. Data were analyzed from August 2020 through November 2021.

Exposures Time since enrollment and receipt of PBs or GAHs.

Main Outcomes and Measures Mental health outcomes of interest were assessed via the Patient Health Questionnaire 9-item (PHQ-9) and Generalized Anxiety Disorder 7-item (GAD-7) scales, which were dichotomized into measures of moderate or severe depression and anxiety (ie, scores ≥10), respectively. Any self-report of self-harm or suicidal thoughts over the previous 2 weeks was assessed using PHQ-9 question 9. Generalized estimating equations were used to assess change from baseline in each outcome at 3, 6, and 12 months of follow-up. Bivariate and multivariable logistic models were estimated to examine temporal trends and investigate associations between receipt of PBs or GAHs and each outcome.

Results Among 104 youths aged 13 to 20 years (mean [SD] age, 15.8 [1.6] years) who participated in the study, there were 63 transmasculine individuals (60.6%), 27 transfeminine individuals (26.0%), 10 nonbinary or gender fluid individuals (9.6%), and 4 youths who responded “I don’t know” or did not respond to the gender identity question (3.8%). At baseline, 59 individuals (56.7%) had moderate to severe depression, 52 individuals (50.0%) had moderate to severe anxiety, and 45 individuals (43.3%) reported self-harm or suicidal thoughts. By the end of the study, 69 youths (66.3%) had received PBs, GAHs, or both interventions, while 35 youths had not received either intervention (33.7%). After adjustment for temporal trends and potential confounders, we observed 60% lower odds of depression (adjusted odds ratio [aOR], 0.40; 95% CI, 0.17-0.95) and 73% lower odds of suicidality (aOR, 0.27; 95% CI, 0.11-0.65) among youths who had initiated PBs or GAHs compared with youths who had not. There was no association between PBs or GAHs and anxiety (aOR, 1.01; 95% CI, 0.41, 2.51).

Conclusions and Relevance This study found that gender-affirming medical interventions were associated with lower odds of depression and suicidality over 12 months. These data add to existing evidence suggesting that gender-affirming care may be associated with improved well-being among TNB youths over a short period, which is important given mental health disparities experienced by this population, particularly the high levels of self-harm and suicide.

Transgender and nonbinary (TNB) youths are disproportionately burdened by poor mental health outcomes, including depression, anxiety, and suicidal ideation and attempts. 1 - 5 These disparities are likely owing to high levels of social rejection, such as a lack of support from parents 6 , 7 and bullying, 6 , 8 , 9 and increased stigma and discrimination experienced by TNB youths. Multidisciplinary care centers have emerged across the country to address the health care needs of TNB youths, which include access to medical gender-affirming interventions, such as puberty blockers (PBs) and gender-affirming hormones (GAHs). 10 These centers coordinate care and help youths and their families address barriers to care, such as lack of insurance coverage 11 and travel times. 12 Gender-affirming care is associated with decreased rates of long-term adverse outcomes among TNB youths. Specifically, PBs, GAHs, and gender-affirming surgeries have all been found to be independently associated with decreased rates of depression, anxiety, and other adverse mental health outcomes. 13 - 16 Access to these interventions is also associated with a decreased lifetime incidence of suicidal ideation among adults who had access to PBs during adolescence. 17 Conversely, TNB youths who present to care later in adolescence or young adulthood experience more adverse mental health outcomes. 18 Despite this robust evidence base, legislation criminalizing and thus limiting access to gender-affirming medical care for minors is increasing. 19 , 20

Less is known about the association of gender-affirming care with mental health outcomes immediately after initiation of care. Several studies published from 2015 to 2020 found that receipt of PBs or GAHs was associated with improved psychological functioning 21 and body satisfaction, 22 as well as decreased depression 23 and suicidality 24 within a 1-year period. Initiation of gender-affirming care may be associated with improved short-term mental health owing to validation of gender identity and clinical staff support. Conversely, prerequisite mental health evaluations, often perceived as pathologizing by TNB youths, and initiation of GAHs may present new stressors that may be associated with exacerbation of mental health symptoms early in care, such as experiences of discrimination associated with more frequent points of engagement in a largely cisnormative health care system (eg, interactions with nonaffirming pharmacists to obtain laboratory tests, syringes, and medications). 25 Given the high risk of suicidality among TNB adolescents, there is a pressing need to better characterize mental health trends for TNB youths early in gender-affirming care. This study aimed to investigate changes in mental health among TNB youths enrolled in an urban multidisciplinary gender clinic over the first 12 months of receiving care. We also sought to investigate whether initiation of PBs or GAHs was associated with depression, anxiety, and suicidality.

This cohort study received approval from the Seattle Children’s Hospital Institutional Review Board. For youths younger than age 18 years, caregiver consent and youth assent was obtained. For youths ages 18 years and older, youth consent alone was obtained. The 12-month assessment was funded via a different mechanism than other survey time points; thus, participants were reconsented for the 12-month survey. The study follows the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We conducted a prospective observational cohort study of TNB youths seeking care at Seattle Children’s Gender Clinic, an urban multidisciplinary gender clinic. After a referral is placed or a patient self-refers, new patients, their caregivers, or patients with their caregivers are scheduled for a 1-hour phone intake with a care navigator who is a licensed clinical social worker. Patients are then scheduled for an appointment at the clinic with a medical provider.

All patients who completed the phone intake and in-person appointment between August 2017 and June 2018 were recruited for this study. Participants completed baseline surveys within 24 hours of their first appointment and were invited to complete follow-up surveys at 3, 6, and 12 months. Youth surveys were used to assess most variables in this study; caregiver surveys were used to assess caregiver income. Participation and completion of study surveys had no bearing on prescribing of PBs or GAHs.

We assessed 3 internalizing mental health outcomes: depression, generalized anxiety, and suicidality. Depression was assessed using the Patient Health Questionnaire 9-item scale (PHQ-9), and anxiety was assessed using the Generalized Anxiety Disorder 7-item scale (GAD-7). We dichotomized PHQ-9 and GAD-7 scores into measures of moderate or severe depression and anxiety (ie, scores ≥10). 26 , 27 Self-harm and suicidal thoughts were assessed using PHQ-9 question 9 (eTable 1 in the Supplement ).

Participants self-reported if they had ever received GAHs, including estrogen or testosterone, or PBs (eg, gonadotropin-releasing hormone analogues) on each survey. We conducted a medical record review to capture prescription of androgen blockers (eg, spironolactone) and medications for menstrual suppression or contraception (ie, medroxyprogesterone acetate or levonorgestrel-releasing intrauterine device) during the study period.

We a priori considered potential confounders hypothesized to be associated with our exposures and outcomes of interest based on theory and prior research. Self-reported gender was ascertained on each survey using a 2-step question that asked participants about their current gender and their sex assigned at birth. If a participant’s self-reported gender changed across surveys, we used the gender reported most frequently by a participant (3 individuals identified as transmasculine at baseline and as nonbinary on all follow-up surveys). We collected data on self-reported race and ethnicity (available response options were Arab or Middle Eastern; Asian; Black or African American; Latinx; Native American, American Indian, or Alaskan Native or Native Hawaiian; Pacific Islander; and White), age, caregiver income, and insurance type. Race and ethnicity were assessed as potential covariates owing to known barriers to accessing gender-affirming care among transgender youth who are members of minority racial and ethnic groups. For descriptive statistics, Asian and Pacific Islander groups were combined owing to small population numbers. We included a baseline variable reflecting receipt of ongoing mental health therapy other than for the purpose of a mental health assessment to receive a gender dysphoria diagnosis. We included a self-report variable reflecting whether youths felt their gender identity or expression was a source of tension with their parents or guardians. Substance use included any alcohol, marijuana, or other drug use in the past year. Resilience was measured by the Connor-Davidson Resilience Scale (CD-RISC) 10-item score developed to measure change in an individual’s state resilience over time. 28 Resilience scores were dichotomized into high (ie, ≥median) and low (ie, <median). Prior studies of young adults in the US reported mean CD-RISC scores ranging from 27.2 to 30.1. 29 , 30

We used generalized estimating equations to assess change in outcomes from baseline at each follow-up point (eFigure 1 in the Supplement ). We used a logit link function to estimate adjusted odds ratio (aOR) for the association between variables and each mental health outcome. We initially estimated bivariate associations between potential confounders and mental health outcomes. Multivariable models included variables that were statistically significant in bivariate models. For all outcomes and models, statistical significance was defined as 95% CIs that did not contain 1.00. Reported P values are based on 2-sided Wald test statistics.

Model 1 examined temporal trends in mental health outcomes, with time (ie, baseline, 3, 6, and 12 months) modeled as a categorical variable. Model 2 estimated the association between receipt of PBs or GAHs and mental health outcomes adjusted for temporal trends and potential confounders. Receipt of PBs or GAHs was modeled as a composite binary time-varying exposure that compared mean outcomes between participants who had initiated PBs or GAHs and those who had not across all time points (eTable 2 in the Supplement ). All models used an independent working correlation structure and robust standard errors to account for the time-varying exposure variable.

We performed several sensitivity analyses. Because our data were from an observational cohort, we first considered the degree to which they were sensitive to unmeasured confounding. To do this, we calculated the E-value for the association between PBs or GAHs and mental health outcomes in model 2. The E-value is defined as the minimum strength of association that a confounder would need to have with both exposure and outcome to completely explain away their association (eTable 4 in the Supplement ). 31 Second, we performed sensitivity analyses on several subsets of youths. We separately examined the association of PBs and GAHs with outcomes of interest, although we a priori did not anticipate being powered to detect statistically significant outcomes owing to our small sample size and the relatively low proportion of youths who accessed PBs. We also conducted sensitivity analyses using the Patient Health Questionnaire 8-item scale (PHQ-8), in which the PHQ-9 question 9 regarding self-harm or suicidal thoughts was removed, given that we analyzed this item as a separate outcome. Lastly, we restricted our analysis to minor youths ages 13 to 17 years because they were subject to different laws and policies related to consent and prerequisite mental health assessments. We used R statistical software version 3.6.2 (R Project for Statistical Computing) to conduct all analyses. Data were analyzed from August 2020 through November 2021.

A total of 169 youths were screened for eligibility during the study period, among whom 161 eligible youths were approached. Nine youths or caregivers declined participation, and 39 youths did not complete consent or assent or did not complete the baseline survey, leaving a sample of 113 youths (70.2% of approached youths). We excluded 9 youths aged younger than 13 years from the analysis because they received different depression and anxiety screeners. Our final sample included 104 youths ages 13 to 20 years (mean [SD] age, 15.8 [1.6] years). Of these individuals, 84 youths (80.8%), 84 youths, and 65 youths (62.5%) completed surveys at 3, 6, and 12 months, respectively.

Our cohort included 63 transmasculine youths (60.6%), 27 transfeminine youths (26.0%), 10 nonbinary or gender fluid youths (9.6%), and 4 youths who responded “I don’t know” or did not respond to the gender identity question on all completed questionnaires (3.8%) ( Table 1 ). There were 4 Asian or Pacific Islander youths (3.8%), 3 Black or African American youths (2.9%); 9 Latinx youths (8.7%); 6 Native American, American Indian, or Alaskan Native or Native Hawaiian youths (5.8%); 67 White youths (64.4%); and 9 youths who reported more than 1 race or ethnicity (8.7%). Race and ethnicity data were missing for 6 youth (5.8%).

At baseline, 7 youths had ever received PBs or GAHs (including 1 youth who received PBs, 4 youths who received GAHs, and 2 youths who received both PBs and GAHs). By the end of the study, 69 youths (66.3%) had received PBs or GAHs (including 50 youths who received GAHs only [48.1%], 5 youths who received PBs only [4.8%], and 14 youths who received PBs and GAHs [13.5%]), while 35 youths had not received either PBs or GAHs (33.7%) (eTable 3 in the Supplement ). Among 33 participants assigned male sex at birth, 17 individuals (51.5%) had received androgen blockers, and among 71 participants assigned female sex at birth, 25 individuals (35.2%) had received menstrual suppression or contraceptives by the end of the study.

A large proportion of youths reported depressive and anxious symptoms at baseline. Specifically, 59 individuals (56.7%) had baseline PHQ-9 scores of 10 or more, suggesting moderate to severe depression; there were 22 participants (21.2%) scoring in the moderate range, 11 participants (10.6%) in the moderately severe range, and 26 participants (25.0%) in the severe range. Similarly, half of participants had a GAD-7 score suggestive of moderate to severe anxiety at baseline (52 individuals [50.0%]), including 20 participants (19.2%) scored in the moderate range, and 32 participants (30.8%) scored in the severe range. There were 45 youths (43.3%) who reported self-harm or suicidal thoughts in the prior 2 weeks. At baseline, 65 youths (62.5%) were receiving ongoing mental health therapy, 36 youths (34.6%) reported tension with their caregivers about their gender identity or expression, and 34 youths (32.7%) reported any substance use in the prior year. Lastly, we observed a wide range of resilience scores (median [range], 22.5 [1-38], with higher scores equaling more resiliency). There were no statistically significant differences in baseline characteristics by gender.

In bivariate models, substance use was associated with all mental health outcomes ( Table 2 ). Youths who reported any substance use were 4-fold as likely to have PHQ-9 scores of moderate to severe depression (aOR, 4.38; 95% CI, 2.10-9.16) and 2-fold as likely to have GAD-7 scores of moderate to severe anxiety (aOR, 2.07; 95% CI, 1.04-4.11) or report thoughts of self-harm or suicide in the prior 2 weeks (aOR, 2.06; 95% CI, 1.08-3.93). High resilience scores (ie, ≥median), compared with low resilience scores (ie, <median), were associated with lower odds of moderate or severe anxiety (aOR, 0.51; 95% CI, 0.26-0.999).

There were no statistically significant temporal trends in the bivariate model or model 1 ( Table 2 and Table 3 ). However, among all participants, odds of moderate to severe depression increased at 3 months of follow-up relative to baseline (aOR, 2.12; 95% CI, 0.98-4.60), which was not a significant increase, and returned to baseline levels at months 6 and 12 ( Figure ) prior to adjusting for receipt of PBs or GAHs.

We also examined the association between receipt of PBs or GAHs and mental health outcomes in bivariate and multivariable models (eFigure 2 in the Supplement ). After adjusting for temporal trends and potential confounders ( Table 4 ), we observed that youths who had initiated PBs or GAHs had 60% lower odds of moderate to severe depression (aOR, 0.40; 95% CI, 0.17-0.95) and 73% lower odds of self-harm or suicidal thoughts (aOR, 0.27; 95% CI, 0.11-0.65) compared with youths who had not yet initiated PBs or GAHs. There was no association between receipt of PBs or GAHs and moderate to severe anxiety (aOR, 1.01; 95% CI, 0.41-2.51). After adjusting for time-varying exposure of PBs or GAHs in model 2 ( Table 4 ), we observed statistically significant increases in moderate to severe depression among youths who had not received PBs or GAHs by 3 months of follow-up (aOR, 3.22; 95% CI, 1.37-7.56). A similar trend was observed for self-harm or suicidal thoughts among youths who had not received PBs or GAHs by 6 months of follow-up (aOR, 2.76; 95% CI, 1.22-6.26). Lastly, we estimated E-values of 2.56 and 3.25 for the association between receiving PGs or GAHs and moderate to severe depression and suicidality, respectively (eTable 4 in the Supplement ). Sensitivity analyses obtained comparable results and are presented in eTables 5 through 8 in the Supplement .

In this prospective clinical cohort study of TNB youths, we observed high rates of moderate to severe depression and anxiety, as well as suicidal thoughts. Receipt of gender-affirming interventions, specifically PBs or GAHs, was associated with 60% lower odds of moderate to severe depressive symptoms and 73% lower odds of self-harm or suicidal thoughts during the first year of multidisciplinary gender care. Among youths who did not initiate PBs or GAHs, we observed that depressive symptoms and suicidality were 2-fold to 3-fold higher than baseline levels at 3 and 6 months of follow-up, respectively. Our study results suggest that risks of depression and suicidality may be mitigated with receipt of gender-affirming medications in the context of a multidisciplinary care clinic over the relatively short time frame of 1 year.

Our findings are consistent with those of prior studies finding that TNB adolescents are at increased risk of depression, anxiety, and suicidality 1 , 11 , 32 and studies finding long-term and short-term improvements in mental health outcomes among TNB individuals who receive gender-affirming medical interventions. 14 , 21 - 24 , 33 , 34 Surprisingly, we observed no association with anxiety scores. A recent cohort study of TNB youths in Dallas, Texas, found that total anxiety symptoms improved over a longer follow-up of 11 to 18 months; however, similar to our study, the authors did not observe statistically significant improvements in generalized anxiety. 22 This suggests that anxiety symptoms may take longer to improve after the initiation of gender-affirming care. In addition, Olson et al 35 found that prepubertal TNB children who socially transitioned did not have increased rates of depression symptoms but did have increased rates of anxiety symptoms compared with children who were cisgender. Although social transition and access to gender-affirming medical care do not always go hand in hand, it is noteworthy that access to gender-affirming medical care and supported social transition appear to be associated with decreased depression and suicidality more than anxiety symptoms.

Time trends were not significant in our study; however, it is important to note that we observed a transient and nonsignificant worsening in mental health outcomes in the first several months of care among all participants and that these outcomes subsequently returned to baseline by 12 months. This is consistent with findings from a 2020 study 36 in an academic medical center in the northwestern US that observed no change in TNB adolescents’ GAD-7 or PHQ-9 scores from intake to first follow-up appointment, which occurred a mean of 4.7 months apart. Given that receipt of PBs or GAHs was associated with protection against depression and suicidality in our study, it could be that delays in receipt of medications is associated with initially exacerbated mental health symptoms that subsequently improve. It is also possible that mental health improvements associated with receiving these interventions may have a delayed onset, given the delay in physical changes after starting GAHs.

Few of our hypothesized confounders were associated with mental health outcomes in this sample, most notably receipt of ongoing mental health therapy and caregiver support; however, this is not surprising given that these variables were colinear with baseline mental health, which we adjusted for in all models. Substance use was the only variable associated with all mental health outcomes. In addition, youths with high baseline resilience scores were half as likely to experience moderate to severe anxiety as those with low scores. This finding suggests that substance use and resilience may be additional modifiable factors that could be addressed through multidisciplinary gender-affirming care. We recommend more granular assessment of substance use and resilience to better understand support needs (for substance use) and effective support strategies (for resilience) for TNB youths in future research.

This study has a number of strengths. This is one of the first studies to quantify a short-term transient increase in depressive symptoms experienced by TNB youths after initiating gender-affirming care, a phenomenon observed clinically by some of the authors and described in qualitative research. 37 Although we are unable to make causal statements owing to the observational design of the study, the strength of associations between gender-affirming medications and depression and suicidality, with large aOR values, and sensitivity analyses that suggest that these findings are robust to moderate levels of unmeasured confounding. Specifically, E-values calculated for this study suggest that the observed associations could be explained away only by an unmeasured confounder that was associated with both PBs and GAHs and the outcomes of interest by a risk ratio of 2-fold to 3-fold each, above and beyond the measured confounders, but that weaker confounding could not do so. 31

Our findings should be interpreted in light of the following limitations. This was a clinical sample of TNB youths, and there was likely selection bias toward youths with supportive caregivers who had resources to access a gender-affirming care clinic. Family support and access to care are associated with protection against poor mental health outcomes, and thus actual rates of depression, anxiety, and suicidality in nonclinical samples of TNB youths may differ. Youths who are unable to access gender-affirming care owing to a lack of family support or resources require particular emphasis in future research and advocacy. Our sample also primarily included White and transmasculine youths, limiting the generalizability of our findings. In addition, the need to reapproach participants for consent and assent for the 12-month survey likely contributed to attrition at this time point. There may also be residual confounding because we were unable to include a variable reflecting receipt of psychotropic medications that could be associated with depression, anxiety, and self-harm and suicidal thought outcomes. Additionally, we used symptom-based measures of depression, anxiety, and suicidality; further studies should include diagnostic evaluations by mental health practitioners to track depression, anxiety, gender dysphoria, suicidal ideation, and suicide attempts during gender care. 2

Our study provides quantitative evidence that access to PBs or GAHs in a multidisciplinary gender-affirming setting was associated with mental health improvements among TNB youths over a relatively short time frame of 1 year. The associations with the highest aORs were with decreased suicidality, which is important given the mental health disparities experienced by this population, particularly the high levels of self-harm and suicide. Our findings have important policy implications, suggesting that the recent wave of legislation restricting access to gender-affirming care 19 may have significant negative outcomes in the well-being of TNB youths. 20 Beyond the need to address antitransgender legislation, there is an additional need for medical systems and insurance providers to decrease barriers and expand access to gender-affirming care.

Accepted for Publication: January 10, 2022.

Published: February 25, 2022. doi:10.1001/jamanetworkopen.2022.0978

Correction: This article was corrected on July 26, 2022, to fix minor errors in the numbers of patients in eTables 2 and 3 in the Supplement.

Corresponding Author: Diana M. Tordoff, MPH, Department of Epidemiology, University of Washington, UW Box 351619, Seattle, WA 98195 ( [email protected] ).

Author Contributions : Diana Tordoff had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Diana Tordoff and Dr Wanta are joint first authors. Drs Inwards-Breland and Ahrens are joint senior authors.

Concept and design: Collin, Stepney, Inwards-Breland, Ahrens.

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

Drafting of the manuscript: Tordoff, Wanta, Collin, Stepney, Inwards-Breland.

Critical revision of the manuscript for important intellectual content: Wanta, Collin, Stepney, Inwards-Breland, Ahrens.

Statistical analysis: Tordoff.

Obtained funding: Inwards-Breland, Ahrens.

Administrative, technical, or material support: Ahrens.

Supervision: Wanta, Inwards-Breland, Ahrens.

Conflict of Interest Disclosures: Diana Tordoff reported receiving grants from the National Institutes of Health National Institute of Allergy and Infectious Diseases unrelated to the present work and outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported Seattle Children’s Center for Diversity and Health Equity and the Pacific Hospital Preservation Development Authority.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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Open access
Published: 19 July 2024

Living a private lie: intersectional stigma, depression and suicidal thoughts for selected young key populations living with HIV in Zambia

Joseph Mumba Zulu 1 , 2 ,
Henna Budhwani 3 ,
Bo Wang 4 ,
Anitha Menon 5 , 6 , 7 ,
Deogwoon Kim 4 ,
Mirriam Zulu 1 ,
Patrick Nyamaruze 8 ,
Kaymarlin Govender 8 &
Russell Armstrong 8

BMC Public Health volume 24 , Article number: 1937 ( 2024 ) Cite this article

Metrics details

Limited research has been conducted on the forms, manifestations and effects of intersectional stigma among young HIV-positive men who have sex with men (MSM) and transgender women (TGW) in Zambia. In this study, we aimed to address this gap by elucidating the experiences of these in a small group of young, HIV + MSM and TGW in Zambia.

We applied a mixed-methods design. Data were collected from January 2022 to May 2022. Qualitative data were collected using in-depth interviews while quantitative data were collected using a questionnaire. Qualitative transcripts were coded using thematic analysis while paper-based questionnaire data were entered into Kobo Connect. Descriptive statistics, using chi-squared tests were calculated using Excel. In this paper, we provide a descriptive profile of the sample and then focus on the qualitative findings on intersectional stigma, depression, and contemplation of suicide.

We recruited 56 participants from three sites: Lusaka, Chipata, and Solwezi districts. Participants’ mean age was 23 years. The study found that 36% of all participants had moderate to significant symptoms of depression, 7% had major depression, 30% had moderate signs of anxiety, 11% had high signs of anxiety, 4% had very high signs of anxiety and 36% had contemplated suicide at least once. A greater proportion of TGW had moderate to significant symptoms of depression (40%) or major depression (10%) compared to MSM, at 33% and 6%, respectively ( X 2 = 0.65; p = 0.42). Similarly, more TGW (55%) had contemplated suicide than MSM peers (36%, X 2 =1.87; p = 0.17). In the qualitative data, four emergent themes about the forms, manifestations, and effects of intersectional stigma were (1) HIV, sexual orientation, and gender identity disclosure; (2) Dual identity; (3) Challenges of finding and maintaining sexual partners; (4) Coping and resilience. Overall, having to hide both one’s sexuality and HIV status had a compounding effect and was described as living “a private lie.”

Effectively addressing stigmas and poor mental health outcomes among young HIV-positive MSM and TGW will require adopting a socio-ecological approach that focuses on structural interventions, more trauma-informed and identity-supportive care for young people with HIV, as well as strengthening of authentic community-informed public health efforts.

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Introduction

Sub-Saharan Africa (SSA) is severely affected by the HIV epidemic, with Zambia being one of the most affected countries [ 1 , 2 ]. The most current (2018) Zambia Demographic Health Survey indicates that the adult (15–49 years) HIV prevalence was 11.1% in Zambia [ 3 ]. The higher rates were among key populations reaching 21% among men who have sex with men (MSM) and 22% among transgender women (TGW) in 2020 [ 4 ]. While coverage of life-saving antiretroviral therapy (ART) was estimated to be 90% of all people living with HIV (PLHIV) in SSA, significant inequities remain in enrolling and sustaining people on ART [ 1 , 2 ]. There are significant variations in the estimates across countries [ 1 , 2 ]. Even though key populations accounted for 46% of new HIV infections across southern Africa in 2022 [ 5 ], MSM and TGW tend to be the least targeted by programs [ 6 ]. There are disparities in programs targeting and supporting alleviation of HIV-related health burden among MSM and TGW who simultaneously face various challenges, including mental health issues and stigmas, compounding their overall health vulnerabilities [ 1 , 2 , 7 ].

Young MSM and TGW, compared to the young heterosexual group, experience more mental health challenges [ 8 , 9 , 10 ], arising from victimization, bullying, internalized homophobia and discrimination [ 11 ], violence, socio-cultural and religious attitudes regarding sexual or gender diversity [ 12 ], and criminalization of sexual or gender diversity in Zambia and other African settings [ 10 , 13 ]. Sections 155–157 of the Zambian Penal Code criminalize any form of consensual same- sex conduct [ 10 , 13 ]. Legal challenges and socio-cultural contextual barriers such as high risks of stigma, discrimination, and violence linked to the criminalization of practices regarding sexual or gender diversity tend to compound mental health challenges within this population [ 14 ]. These mental health stressors negatively interact with important HIV-related health outcomes, including uptake and retention in HIV programmes, medication adherence, and achieving and sustaining viral suppression [ 15 , 16 ]. It is important to understand in detail the mental health issues in this group given that the developmental stage is associated with increased independence, risk-taking, and changing social support [ 17 ].

Young key populations living with HIV (YPLWH) aged between 18 and 24 years face disproportionate HIV stigma [ 18 , 19 ] that negatively affects HIV health management [ 19 ]. In addition to HIV stigma, some of these key populations have to also deal with sexual orientation and gender identity (SOGI) related stigma [ 19 ]. The convergence of multiple stigmatized identities within a person or group, or intersectional stigma tends to further worsen health outcomes in key populations [ 20 ]. An intersectional perspective provides an opportunity to think holistically about how living with multiple stigmatized identities affects behaviours, and different health outcomes [ 21 ], and to critically examine how systems of oppression interact at the societal, community, and individual levels [ 22 ].

Country -specific knowledge about the forms, manifestations and effects of intersectional stigma as experienced by young MSM and TGW with HIV in Zambia is beginning to emerge, largely relying on survey-based, cross-sectional research [ 3 ]. How contextual factors work as drivers of stigma, and how these drivers then manifest themselves as intersectional stigma in the lives of young MSM and TGW with HIV and the consequences of this manifestation including negative influences on different aspects of mental health has not been fully explored especially for HIV-positive MSM [ 23 ], and TGW in African settings [ 24 , 25 ]. It is critical to consider multiple stigmatized identities in order to develop effective intervention strategies and improve the psychosocial well-being of marginalized populations [ 26 ].

While there is a substantive presence of sexual and gender minorities in Zambia, very little research in any form has emerged [ 10 ]. As the country increases its efforts to address HIV and to improve its capacity to reach or exceed its 2030 targets and commitments, it becomes important to address these knowledge gaps. The target is to test 95% of all PLHIV, have 95% of those diagnosed on ART and achieve viral suppression for 95% by 2025 in order to end AIDS by 2030 [ 10 ]. This study used a mixed-methods design to arrive at an intersectional view of the experiences of young, HIV-positive MSM and TGW in Zambia to understand how intersectional stigma is constructed and how it affects mental health outcomes in Zambia. This study is part of the regional study on exploring the influence of intersectional stigma on uptake and retention in ART programmes for selected key population groups in three Southern African Development Community (SADC) countries – Malawi, Zambia and Zimbabwe.

The conceptual framework for the research draws on emerging trends in stigma theory and research, including the concepts of minority stress, intersectionality and intersectional stigma [ 27 , 28 ]. In the framework, stigma is defined as the “the co-occurrence of labelling, stereotyping, separation, status loss, and discrimination in a context in which power is exercised” [ 29 ]. In this view, stigma is a product of social and structural relations where status and value are contested and resolved through gains and losses in social position and worth. This is similar to Parker and Aggleton who describe HIV-related stigma and discrimination as “social processes linked to the reproduction of inequality and exclusion” [ 28 ]. While the mechanics of stigma may emanate from structural forces, what matters most is how these interact with and affect the health and well-being of individuals in communities [ 28 ].

Intersectional stigma, sexual and gender diversity and HIV: a conceptual framework

Given this range and depth of issues needing further exploration, a flexible conceptual framework was proposed for this research project. While, on the one hand, it took account of evolving theory and practice related to stigma in the southern African region and beyond, it did not pre-define or preclude the emergence of a more nuanced and context-specific understanding given the dearth of previous research to date that asks similar questions( Fig. 1 , below):

Conceptual framework

At the outset, the social environment (1) in Zambia included social and structural processes that may drive and perpetuate stigma or prevent or limit stigma. Within this context, stigma manifests itself (2) and is experienced by individuals (3) in a variety of forms, largely as either enacted stigma, anticipated or feared stigma, or internalised stigma. The effects of stigma is felt by individuals (4) with a range of physical, mental or social consequences. The individuals respond with different strategies and behaviours to cope with these effects (5), to become resilient, or to resist and transform stigma [ 13 , 30 ]. One measure of the success of these efforts is behavioural intentions to enrol in and/or remain in HIV care and intentions towards positive prevention [ 22 ]. How these links and pathways operate for individuals are influenced by mediators and moderators. Mediators (6) intensity stigma effects [ 13 ]. Moderators (7) operate more broadly across the framework and include an individual’s background conditions or starting point as experiences of stigma accumulate [ 13 ]. An intersectional approach (8) posits that all of the relationships and linkages described previously are “interdependent and mutually constitutive” and that these generate some degree of “causal complexity” [ 31 ]. Intersectionality opens up the possibility that such interactions are, “synergistic, producing different and distinct experiences of oppression and opportunity“ [ 32 ].

Methodology

Study design.

The study followed a mixed-methods, parallel design with simultaneous collection of qualitative and quantitative data from the same study sample. Mixed methods designs are preferable for intersectionality research since intersectionality is conceptualised as a multilevel and multidimensional framework [ 33 , 34 ]. The different methodologies may be advantageous as they might effectively apply to the different levels and particular features of intersectionality [ 33 , 34 ]. Using the two approaches allowed for triangulation and a richer analysis of the complex phenomena underlying intersectional stigma for the study participants [ 30 , 35 ]. This study largely reports qualitative data on experiences of intersectional stigma as well as depression and suicide thoughts. The qualitative study component adopted a phenomenological study design as the aim was to document experiences of mental health and causes of mental health among young, HIV positive MSM and TGW [ 36 ].

Study population

The study population involved young MSM and TGW in Zambia, all self-disclosed as HIV-positive and currently on ART. The inclusion criteria consisted of age (18 to 24 years); self-identifying as gay, bisexual or MSM, or TGW or female with a gender at birth being male; self-identifying as HIV-positive; and self-identifying as currently on ART. All potential participants who were screened for eligibility enrolled or agreed to participate in the study. Participants who did not meet all of these criteria, as administered through an eligibility test at the start of the data collection encounter, were excluded. At total of 56 young people agreed to participate and completed both the questionnaire and the in-depth interview. There were 29 from Lusaka, 14 from Chipata and 13 from Solwezi. Lusaka was selected because it is the capital city of Zambia. Chipata was included as it is a border town while Solwezi is an emerging mining town. Further, these districts are among those with the highest HIV cases.

Given the Zambian context where sexual/ gender diversity has been criminalized, and the lack of previous research experience within the study population, snow-ball sampling was used to recruit potential participants in three locations (Chipata, Lusaka and Solwezi) [ 10 ]. This is a sampling method in which one interviewee provides a name of at least one more potential interviewee; and in turn this interviewee also recommends another or more potential interviewees, and so on [ 37 ]. Before recruiting participants, a mobiliser (a member of the MSM community) and members of the peer interview team confidentially promoted the study within their different social networks. In addition, organisations providing HIV services were also contacted to promote the study and encourage participation. To reduce bias, we started with a sample with seeds that were as diverse as possible. This was done by recruiting participants through seven peer interview team members [ 37 ].

Data collection

Data collection occurred in secure, confidential settings. Data were collected from January 2022 to May 2022. Locations were chosen based on the recommendations of the study team and by representatives of sexual minority organisations consulted during the study design. The qualitative component involved semi-structured interviews while the quantitative component involved a self-administered, confidential questionnaire. The data collection tools were translated into the local languages (Nyanja and Bemba). The interviews were conducted once. Each participant was screened in terms of eligibility criteria and then was asked to complete informed consent form. A survey was administered followed by short break and then a semi-structured interview. Each survey took about 30 min while the semi-structured interviews ranged between 35 min and 1 h. We provided for a 30 min break between the survey and semi-structured interviews to ensure that the timing of the survey and semi-structured interviews did not compromise participant response. During the break, the respondent was provided with refreshments.

The self-administered survey was constructed of multiple-choice, closed-ended items that gathered data on SOGI, socio-economic characteristics, living arrangements and relationships status, length of time living with HIV, preferred providers for HIV services, self-reported ART adherence and knowledge of viral suppression. Participants were asked ‘Do you consider yourself as: male, female, which we said was ‘self-defined’. In terms of sexual orientation, participants had five choices: gay, bisexual, transgender, heterosexual, and other. No TGW identified as heterosexual. It also included sections on alcohol and drug use (using the Alcohol Use Disorders Identification Test [AUDIT] and the Drug Use Disorders Identification Test [DUDIT]), and experiences with physical or sexual violence (having experienced violence or having done such things to others) [ 38 , 39 ]. Three specific items addressed mental health: the Center for Epidemiological Studies-Depression (CES-D)-10 scale, the General Anxiety Disorder (GAD)-7 scale, and the Suicide Behaviors Questionnaire-Revised (SBQ-R), all of which had been previously validated in Zambia or a similar African setting although not with the specific population for this study [ 40 , 41 , 42 ]. Additional sections addressed experiences of stigma and discrimination related to SOGI and HIV status using questions adapted from the PLHIV Stigma Index 2.0 tool [ 23 ].

To provide insight into the potential effects of intersectional stigma on an individual’s mental well-being, as part of the questionnaire, participants completed the CESD-10 (symptoms of depression) and the SBQ-R screening tools (thoughts and experiences of suicide) [ 40 , 41 , 42 ]. According to the CESD-10 methodology, a score of 0–10 means low to no symptoms of depression, 11–15 moderate symptoms of depression, and 16–25 moderate to severe symptoms of depression [ 40 , 41 , 42 ].

The semi structured guide explored the following topics: experiences growing up in family and community; future expectations; self-concept, including sexuality, gender identity and HIV status; strategies for day-to-day living, including managing disclosure, protection of social status and resilience; negative experiences (stigma, discrimination or violence, actual or feared) related to SOGI and HIV status; effects of stigma and discrimination on mental health, and coping and recovering strategies, including experiences seeking mental health support; experiences with ART, including adherence enablers and challenges; and, finally, ideas for change and improvement. The interviews were conducted by experienced members of the key populations network who had been engaged as research assistants in two other studies on young key populations. The research assistants also participated in transcribing the data and data validation process.

Data analysis

For qualitative data, audio recordings were transcribed verbatim by the trained research team. Thematic analysis based on structural coding aligned to the conceptual framework was used to analyse the data [ 43 ]. Data saturation, which is the stage when no additional new information can be attained was reached during data collection [ 44 ]. This was discussed with the data collection team and also validated during coding process in the coding team. The two lead investigators developed a coding manual and initially coded four transcripts (JMZ and RA). The manual and coded transcripts were reviewed by a third researcher for clarity and consistency (PN). Subsequently, the code book and all transcripts were loaded to Nvivo (12 pro). Transcripts were independently coded with periodic quality assurance checks using Nvivo.

For quantitative data, survey results were entered into Excel and analysed using descriptive statistical techniques to generate descriptors and other insights regarding the study participants on key dimensions linked to the conceptual framework. The paper survey results were entered into Kobo Connect by a data manager. Periodic quality assurance checks were performed by the research coordinator to minimize data entry errors. Chi-square tests (including fisher’ exact tests) to examine the differences in proportions between the two groups were done. Excel data were converted into SAS data for analysis. Statistical significance was set at p < 0.05. A validation workshop was held in Lusaka in order to validate the findings of the study.

This study was approved by the Research Ethics Committee of the University of Zambia, the National Health Research Authority as well as Biomedical Health Research Ethics Committee of the University of KwaZulu-Natal. At no time was personal identifying information collected. Following administration of an eligibility assessment and verbal informed consent procedures, participants completed an anonymous questionnaire in English and placed it in a sealed envelope. Subsequently, participants were asked again to consent to audio recording and, if agreeable, proceeded through a semi-structured, in-depth interview lasting between 30 and 40 min. Participants in the study volunteered to take part, and interviewees had the freedom to withdraw from the study at any time. Additionally, participants were given details about counselling and care referral options if needed.

The results section has been divided into quantitative and qualitative research sections. The quantitative results are presented first.

Quantitative results

The characteristics of the study’s participants are summarised in Table 1 below.

Of the total number of participants, 64% (36) initially identified as MSM and 36% (20) as transgender women. In terms of self-assigned gender, two thirds (66%) defined themselves as male, 12% as female, and 22% as transgender. With regard to sexual orientation, over half of the participants (55%) described themselves as gay; eight participants (14%) described themselves as bisexual. The remaining 31% identified themselves as transgender women with primarily male sexual partners (Table 1 ).

More than two-thirds of participants (69%) indicated that they had been diagnosed with HIV within the past two years. One TGW participant indicated that she had acquired HIV at birth. Almost three-quarters (72%) indicated they had been on ART for two years or less. Almost half of participants (47%) were diagnosed at government facilities and a similar proportion (50%) indicated that they were also receiving their ongoing care at these facilities. Place of service was mainly government facilities or NGO facilities-with higher proportion of MSM visiting these services (Table 2 ).

Effects on mental health

The range of stigma-related effects on the participants - included a negative influence on mental health as well as other emotional, social, or physical harms, and an increase in anxiety about recurrent experiences in the future.

Symptoms of depression

From the responses, over half of the participants (55%) had a score < 10, indicating that they had low to no symptoms of depression while 36% had moderate to significant symptoms of depression and 7% had major depression. This proportion was higher for the MSM participants (61%) compared to the TGW participants (45%). It was also observed that a greater proportion of TGW participants had moderate to significant symptoms of depression (40%) or major depression (10%) compared to the MSM participants, at 33% and 6% respectively ( X 2 =0.65; p = 0.42). These results were statistically non-significant, possibly due to small sample sizes in the study.

Thoughts and experiences of suicide

The questionnaire further inquired about thoughts and experiences of suicide using the SBQ-R tool. The results are shown below (Fig. 2 ):

The study found that 57% of all participants had never contemplated suicide. Of the remainder, 36% had contemplated suicide at least once, and 13% had done so in the previous year. TGW participants (55%) had contemplated suicide more than their MSM peers (36%) ( X 2 = 1.87; p = 0.17). Few had disclosed such thoughts to others (18% for all participants, 25% for TGW). Finally, four (7%) of the young participants (three MSM and one TGW) indicated that it was likely they may still attempt suicide at some point in the future. These states of mental health and what influenced them were also explored in detail in the qualitative results. In addition, the study found that 30% of the all participants had moderate signs of anxiety, 11% had high signs of anxiety while 4% had very high signs of anxiety. Of these participants, 11% of MSM and 25% of TGW reported high or very high GAD-7 scores ( p = 0.110). It should the noted that the above trends were statistically non-significant , possibly due to small sample sizes in the study.

SBQ-R results

Qualitative results

This section presents qualitative findings of countries about the forms, manifestations and effects of intersectional stigma among young, HIV + MSM and TGW in Zambia. The first part presents results on intersectional stigmas - origins, experiences, and fears. The emergent themes of the nature and extent of these experiences include (1) HIV, sexual orientation and gender identity disclosure; (2) Dual identity; (3) Challenges of finding and maintaining sexual partners; (4) Coping and resilience.

The nature and extent of these experiences

Anxieties about, or experiences of stigma influenced disclosures and sometimes lead to complex arrangements for managing who could know what about them, whether about their sexual orientation, gender identity or health status. There were a number of differences between participants in terms of what they chose to disclose, why and to whom. There was as similar range of differences in terms of the reactions and consequences of such disclosures. For many participants, disclosing information about SOGI had much higher risks than disclosure about health status; perhaps an expected result given the Zambian context where HIV has a greater degree of public visibility and acceptance. This was not the case for all participants, however.

HIV, sexual orientation and gender identity disclosure

While a small number of participants had disclosed their sexual orientation or gender identity to almost no one beyond sexual or romantic partners, others had shared this information and had expressed a degree of need to do so. As one participant stated when responding to the question why he had shared his sexual orientation with (highly) selective friends and family members:

Because I was being suffocated with my secret! [ZMA-LSK-MB-MSM5] .

For this participant, since he felt that his identity would eventually reveal itself, it was important for him to take the first step and to share it with others he trusted, including members of his family. For both the above participants, actively disclosing their sexuality to family and friends was an important, affirming step, despite the risks.

Because I love myself the way I am, that’s why I told them…. It wasn’t easy. They were suspecting, so I thought through it and just ended up telling them. But it took some time, but in the end they accepted. [ ZAM-LSK-MB-MSM1] .

With regard to disclosure of HIV status, while the reasons and circumstances for sharing or not sharing information were different, they were only slightly less difficult for many participants and still carried real or feared risks of different types of harm linked to stigma. The reasons given by participants to disclose their HIV status were often pragmatic. Some had shared information about their HIV status with others so that they could be better supported, including being reminded to take medication, or being helped with collecting it from health facilities. Others had shared their HIV status to be assured of emotional, financial, and physical support from family members, friends, or partners. For some, sharing information about their health status was a practical move, something to be done for good reason:

Because they [family members] need to know. You may find that they discover and get surprised that I am on treatment. They need to know my status. They need to know everything about me. [ZAM-LSK-MB-MSM1] .

Similar to information about their SOGI, some participants were more selective and careful with whom they told and why. The reasons for these considerations were, for the most part, the avoidance of stigma, as well as availability of a supportive and accommodative family environment as this TWG participant explained:

It’s my family because they are aware of this. And they give me courage to push and be strong. Maybe it was not difficult for them to accept because one of my siblings was born with HIV. So they accept me and force me to drink. [ZAM-LSK-NN-TGW-02] .

Meanwhile, once information began to circulate in this wider social context, whether initiated by the participants themselves, or happenings despite their efforts to conceal or keep these things hidden, the influence of stigma and the fear surrounding it intensified;

Ah challenges. The most painful thing is you know you are in a group people are just talking about HIV and so on. You know you feel that guilt to say maybe these people know about me or maybe someone told them -----, so you just feel that and it will be paining inside you, you feel it just in you. [ZAM-CHP-NN-TGW-03] .

This situation sometimes lead to complex arrangements for managing who could know what about them, whether about their SOGI or health status. As a result of these concerns, in some cases, people who received information about their health status were different from who received information about sexual orientation or gender identity. As shown below, the respondent thought that friends would not accept his HIV status, family would not accept his sexual orientation, so the two identities and groups must remain distinct at all times. This type selective disclosure was classified as “ two persons in one.”

It’s very easy, actually. Okay, I can’t say it’s easy. Those that know about my sexual orientation are friends from Lusaka and basically I am in Lusaka for school and when I am in school they know about my sexual orientation but not my HIV status. When I go back home, they know about my HIV status, but not my sexual orientation. So I, like, I am two persons in one. --MSM, 22 years, Lusaka, Zambia. [ZAM-LSK-CW-MSM6] .

Participants explained that they struggled on a daily basis to carefully assess individuals before disclosing either their HIV status or SOGI or both. There was a skill that was acquired to read “the way someone looks” and their level of “maturity” that makes it safe or not to share information. “Manners and behaviour” determined who could keep the “secret” of an individual’s identity and their HIV status:

I only see someone who is close to me and someone who is matured enough, or someone who can really understand, that is when I can disclose to say no… Not someone who is immature, they start telling everybody, no this guy is on medication, this guy is on this, this guy, eh. [ZAM-CHP-MB-MSM9] .

The burden or cost of hiding both HIV stigma and SOGI could become unbearable. The need to compromise, to hide, had a weight that accumulated to the extent that it pierced and deflated self-confidence and self-acceptance. Constant denial in social setting can lead to a more profound internal denial. The trajectory from external to internalised stigma is clear in the example below.

So, it affects me because you cannot, like, live the whole lot of your life hiding, yes? So, it does affect me a lot, yes….It affects me psychologically, sometimes I feel like denying myself, It affects me physically, mentally. -- [ZAM-CHP-MB-MSM1] .

Intersectional stigma was also evident in norms around sexuality and HIV status and ART uptake. HIV disclosure especially to family members and close friends was a challenge as these people had never seen them with girlfriends. A participant shared his account of people would potentially attribute SOGI in this case being gay as the reason for being HIV positive. For them, it was important to hide including not telling the truth when asked about sexual orientation in order to maintain social support and reduce stress.

It comes to my sexual orientation, it’s kind of difficult for me to tell them that I am attracted to men because what if they send me away from home? That will be difficult. I might get stressed and even stop maybe taking my drugs and then my family members will conclude that it’s because of this (gay) maybe which led me to have HIV. [ZAM-LSK-CW-MSM9] .

Participants reported that they preferred to keep their HIV status to themselves as disclosing it would indirectly lead to disclosing one’s sexual orientation, and possibly lose social support. The difficult to openly disclose SOGI made some respondents fail to also disclose their HIV status as in this example.

I wouldn’t even dare to tell my uncle. He is too tough. He might just ask me, ‘I have never seen you with a girl, so where did you get this from? [ZAM-LSK-NN- TGW 3] .

For the young participants, intersectional stigma was indeed a potent force in their contexts, one that was experienced with intricate variations in its forms, manifestations, intensities and effects across many respondents. Handling the double burden of SOGI and HIV stigmatization from society was in general mentally challenging as they always feared to be laughed at and blamed by society. Due to fear of experiencing this double stigma, some participants reported that they preferred not to disclose that the they were gay and also living with HIV- a situation on one respondent classified as a “a private lie” .

It’s not easy am telling you. I don’t just come out in open and tell people that am HIV positive. I don’t. I do hide myself. Reason being scared of the society they will start laughing at me, pointing fingers at me…. So its like am living like a private lie where I have to be hiding for who I am (MSM). It’s like I just can’t come out and tell people that am HIV positive, am gay. — [ZAM-SOL-WC-MSM-06] .

Dual identity

For those who reported experiencing stigma, traces of intersectional stigma emerged in how participants described themselves, as sexual minorities and individuals living with HIV. Some described how the awareness of being HIV positive at the time when they still struggling to accept their SOGI complicated the self-acceptance process as explained by this young man.

So at first before I was even diagnosed having HIV I, you know, I had negative thoughts about my sexual orientation …I thought I wasn’t normal …… and then I looked away when I discovered I had HIV, I had two burdens I had my sexual orientation and I had the HIV status so I thought why have two problems …. I had anxiety I because I was thinking a lot I didn’t know what will what will become of my life . [ZAM- LSK- MB- MSM- 03] .

Another MSM described the burden or struggle of living and accepting both the HIV and SOGI as living a ‘cursed’ life.

It’s really hard. At times you just feel maybe it’s a curse and you having in this world and here is you trying to accept your sexual orientation and you are HIV positive so it’s hard . [ ZAM-LSK-WC-MSM-02 ] .

Some young people narrated that the HIV status had brought an additional challenge on top of the law that criminalizes SOGI. The burden of managing or navigating issues related to both the criminalization of SOGI and their HIV status was explained by one MSM who hoped that things can change for better in the future.

It even becomes worse now, because in Zambia they have not legalized gay rights, and on top of that, you have HIV. So, it’s a burden on me unless maybe in the future, if God allows, that they legalize gay rights, then at least I will have one less burden! --MSM, 23 years, Lusaka. [ZAM-LSK-WC-MSM1] .

A few explained that having to hide both identities was emotionally stressful as the they could not trust anyone with information about any of their identities

Especially my emotions, I never wanted to trust anyone. I was stressed, my emotions were bad -…Even my physical experience, I started getting fat. I get fat whenever I’m stressed . [ZAM-LSK-NN-TGW-02] .

The degree to which they accepted these things about themselves, the influence of stigma became more prominent as they expressed themselves in their social environments, beginning with who they told about themselves, what they disclosed and why. Anxieties about, or experiences of double stigma influenced these disclosures with some of them stating that both HIV and SOGI were the same, and preferred to hide both.

There is nothing simple, they are both the same. Since you need to hide for both. You just can’t randomly tell someone that you are on medication and you also just go and tell someone who is not gay that you are gay. So, these things are the same . [ZAM-SOl-CW-MSM-07] .

Although participants gave a range of descriptions with regard to these identities, most were anchored in a strong sense of understanding and acceptance that SOGI were a fundamental and enduring part of who they were as persons. This is how one young participant described himself:

I was born like this and there is a purpose as to why I am like this. So, whatever people might say about me is not what or who I am. I am who I am today. [ZAM-LSK-CW-MSM5] .

For another respondent, his sexual orientation had a “purpose” that is given at “birth” and this anchors his confidence and assurance: “I am who I am today” and not anything else. Another participant had a similar level of self-assurance:

I am gay and I love who I am, because it’s something I didn’t just come up with, but it’s something that I feel is in me and I was born with it…So, I feel okay with it myself.-- [ZAM-CHP-MB-MSM8] .

A TGW had a similar level of confidence, as in this example:

Being a TGW, it is not something that you just wake up today and just say, ‘I am a TGW.’ No, it is about the way you feel yourself. The way I feel myself it is important. I feel like a woman; I see the woman in me. So, it is very important to me.-- [ZAM-LSK-NN- TGW 3] .

Similarly, some respondents did not struggle living with HIV. The fact that there are family, friends and others also living with HIV brings a sense of solidarity and hope and greatly facilitates accepting and integrating one’s health status into one’s self identity. Those that had initially struggled to accept their HIV status also described how social support from health workers, friends and family members greatly facilitated acceptance. Health workers provided support when young people visited the health facilities. Health workers also played a key role to encourage them to start taking HIV medication as in this example:

Because the person I found [at the health facility] counselled me about how people who are living with HIV might also survive, explaining how many (medication) to take…So I said, let me try, just try. [ZAM-SOL-WC-MSM8] .

Challenges of finding and maintaining sexual partners

Romantic and sexual relationships for all young people are important, regardless of SOGI or health status. They propel personal development and help young people to know themselves. For the study participants, finding and keeping partners was critical to coping and resilience. Being rejected was challenging and contributed to mental health risks. What was surprising in the data was how much of the stigma and rejection was driven by peers who should otherwise be less prejudiced or fearful. Participants reported that it was hard to balance the tension regarding finding romantic and sexual partners given the complex legal context, and HIV risk of stigma from peers.

The challenge… is that it is difficult to balance the two because while you are thinking about HIV you also have to think of having sex with your fellow men. [ZAM-CHP-MB-MSM-02] .

They reported that if not well managed disclosing ones HIV while trying to get into a sexual relationship could damage social reputations, limit sexual or romantic attractiveness in an environment with limited sexual options, and lower self-worth amongst the participants as explained by one TWG who was into sex work.

It is an embarrassment for every person to know that you are on drugs (ART) ….because my business will be affected as people will run away or avoid being with me. So my business can be affected in so many ways like men who want to sleep with me they can avoid me once they know that I am HIV positive. [ZAM-LSK-TC-TGW-04] .

This risk of intra-community stigma and its consequences appeared both more potent from sexual minority peers. Some participants struggled accepting themselves and integrating their HIV status with the tension regarding finding romantic and sexual partners given the complex legal context, which made some participants to pretend that they were HIV negative whenever they were with their partners, as this young man explained.

Being a [gay] young man living with HIV is very, very hard. There come people that would really want to start a stable and nice relationship with you. And then there is just something there in your heart that will tell, ‘Okay, should I tell this person I am HIV or I shouldn’t? Should I just play along?’ And then it’s very hard. That person is also a human being….I hide my status because I never want to lose the people that are dear to me. -- [ZAM-LSK-MB-MSM5] .

Some young HIV-positive MSM and TGW narrated that they always worried that people might know that they were on ART. One person experienced involuntary disclosure (outing) by her boyfriend:

I felt bad, he spilled the secret because he drinks and if he was negative, I would have ended our relationship from there but I understand him, that’s how he is. [ZAM-LSK-NN-TGW-02] .

Respondents reported that they feared that people within the community might make fun of or stigmatize them once they knew that they were HIV positive which could result into rejection within the relationships.

I disclosed it to someone I had met, who I thought we would be together forever. I decided to let them know that I insist on using condoms because I am on medication. The person didn’t take it well, he said “Ah okay, but we just have to part ways. [ZAM-LSK-CW-MSM-10].

Rejection from the current partner or potential partner was painful and could trigger suicidal thoughts as explained below.

My partner wasn’t comfortable with me living with HIV, he was like I can’t date you this and that but I was like no, it wasn’t my fault but never the less it happened. So, it’s up to you to accept me or leave me because I don’t mind, this is the way I am and later on he started having like this mind of thought to say oh I feel like killing myself . [ZAM-LSK-CW-MSM-05] .

Coping strategies and resilience

Many respondents reported that they had developed different positive ways of coping with the effects of stigma. These positive coping strategies helped them to cope with many mental health challenges that they experienced. These positive experiences included exercise (sports, walking, and swimming), meditation and prayer, reading, or just keeping busy, as in these examples:

I work out, I go to the gym, I do a bit of meditation, I read certain books that usually sharpen my mental faculties. [ZAM-CHP-MB-MSM8] . I worship my Lord, and I know that everything is possible with Him by my side. [ZAM-CHP-NN- TGW 2] .

A TGW explained that she managed the mental health challenges through undertaking many duties at home. By keeping busy, she was able to keep her mind focused and refreshed as explained below.

I keep my mind off things that are making me feel bad and I do different kinds of chores around the house, to remove the pressure I have. [ZAM-LSK-NN- TGW 4] .

Focussing on positive or purposeful activities relieved stress or lifted the burden of poor mental health for these young people. Staying sexually activity was also important as explained below:

So, when I have sex, it helps me to think better. [ZAM-CHP-MB-MSM2] .

Finally, some participants had very positive and empowering ways of recovering from stress or poor mental health. These attitudes and practices put them in a position of becoming resilient and being able to resist the negative aspects of their experiences as sexual minorities and as PLHIV. This young participant found such resilience after recovering from a violent attack:

It [the attack] affected in a way that they attacked me and I didn’t like it. But it also strengthened me such that when someone passes a comment, I can stand and say, ‘So!?’ I can just tell them what they want to hear. I would say, okay this is me, if you won’t accept me, bypass me. [ZAM-LSK-WC-MSM10] .

Another young person found a way to become more self-reliant and handle his own issues. He explained that he did not like to involve other people in his problems as they might think that he is not resilient enough to address the problems.

I handle my issues on my own. I do not like to involve too many people because they can look down on me that, every day, I have issue, like I’m always having the same issues, every day. So, you will find that I handle my issues on my own in whatever situation I am in. Unless when the issue is too big that is when I can go to a counsellor. [ZAM-LSK-WC-MSM4] .

A few narrated that they were able to cope by taking to friends who work with NGOs that provide services to young key populations. Such discussions helped the young key populations to manage the challenges associated with being HIV and MSM as explained below.

First of all, it makes me feel terrible about myself and it also made me feel I amount to nothing because am now a person living with HIV and I have this sexual orientation going on so it’s really hard but then with the help of these Non-governmental organizations I have friends that I can talk to that really understand yah. [ZAM-LSK-WC-MSM-02] .

This individual found a way to be immune to disturbances. A TGW participant explained that she preferred not to think too much about what people say about her as doing so might stress her much more.

I just sit back and relax, and not think too much about people, because one day they might get sick as well. Because we are all sick in the world, nobody is perfect. So, I just sit back and relax, and cool myself down, and say to myself that everything will just be okay, yah.[ZAM-LSK-TC- TGW 2] .

This study aimed at exploring how intersectional stigma is constructed among young, HIV-positive MSM and TGW in Zambia and how it affects mental health outcomes. This is one of the rare studies done in Zambia on MSM and TGW on intersectional stigma, depression and suicidal thoughts. The study showed that a convergence of multiple stigmatized identities or experiences among MSM and TGW affected their mental health. Most of the participants experienced dual stigma, that is SOGI stigma and HIV stigma. More TGW participants had moderate to significant symptoms of depression (40%) or major depression (10%) compared to the MSM participants, at 33% and 6% respectively. Similarly, more TGW participants (55%) had contemplated suicide than MSM (36%). These findings align with a literature review on intersectional stigma which demonstrated that intersecting forms of stigma can impact mental and physical health, as well as related health behaviors [ 45 ]. In this context, Logie et al. [ 46 ] have mapped the relationships between intersectional stigmas, depression, and adverse HIV outcomes among HIV-positive women in Canada which they assert can be synergistic and compounding.

Stigma coupled with the existence of the law that criminalize same sex relationships, made some MSMs and TGW not only to hide their HIV status and ART but also their SOGI. Thus, in the context of this study, intersectional stigma was shaped by prevalent views and perceptions that a given identity (SOGI) and respective HIV status was deviation from accepted social norms. Each identity worsened levels of stress, and vulnerability levels among MSM and TGW. These findings align with a recent scoping review of HIV-related intersectional stigma among sexual and gender minorities in sub-Saharan Africa [ 47 ]. We thus agree on the need for increased recognition of how an individual’s membership in multiple stigmatized groups including HIV-related stigma may not only be a manifestation of fears related to the health condition itself, but also negative attitudes regarding behaviors and identities originally associated with HIV transmission including sexual orientation [ 48 ].

The double burden of hiding SOGI and HIV status from relatives, friends, partners and community members triggered loneliness, more stress, loss of self-esteem, anxiety, depression and suicidal thoughts among MSM and TWG. We note that if not well managed, these mental health challenges could undermine HIV self-management behaviour among MSM and TGW which could affect both the physical and mental wellbeing. This finding corresponds with previous research that has documented an association between HIV-related stigma experienced by young MSM in Chicago and other psychosocial factors related to HIV (i.e., psychological distress, lower self-esteem, loneliness) [ 49 ].

The findings suggest the existence of a social structure which constrains young, HIV-positive MSM and TGW’s ability to freely live out their HIV status, take and adhere to ART, as well as disclose their HIV status and SOGI. Such a limiting social structure could affect their health status not only by reducing their ability to adhere to treatment but also constrain safe sexual practices. Examples of unsafe practices included some participants in this study reporting engaging in unprotected sex and not disclosing their HIV status to their partners for fear of losing them. We thus conclude that this discriminatory social structure is problematic as it limits MSM and TGW’s agency which is ‘the capacity to transpose and extend personal schemas to new contexts [ 50 ], including disclosing their HIV status and identity to new sexual partners, friends, health workers and in some cases family members.

Further, an excluding structure could have negative implications on MSM and TGWs’ ability to confidently define, understand and accept their HIV positive identity, and live positively given that significant others, such as partners, friends, health workers are the key drivers of stigmatization. It has been argued that ‘feedback about one’s position can provide a sense of security or sense of threat to self’ [ 51 ]. Thus, feedback in the form of stigma and mistrust, can over time make the MSM and TGW living with HIV to view themselves as lesser members of the family, school and society. Hence, it is crucial for interventions targeting intersectional stigma to emphasize the significance of thoroughly examining the impact that stigmatizing language, behaviors, and attitudes can have on individuals, potentially leading to the categorization of individuals into “us” and “others” [ 52 ]. In this study, we note that this classification could have strongly led to a limited sense of belonging to their families by some MSM and TGW and possible suicidal thoughts or a wish of dying from AIDS by stopping ART.

These excluding social structures could also make the young participants not chose to access social support, including from other MSM or TGW peers. As a way of responding to these negative mental health outcomes, MSM and TGW adopted different forms of positive or wellbeing enabling coping strategies. The positive coping strategies included exercising, listening to music, singing, chatting and praying. We also note that others reported adopting negative (dysfunctional) coping behaviours, a finding which is similar to another study on mental coping behaviours among young MSM in Zambia [ 10 ].

Strengths and limitations of the study

The adoption of the mixed study design enhanced the strength of the study. Triangulating data collection methods helped in developing a comprehensive account of experiences of intersectional stigma and mental health challenges among young MSM and TGW living with HIV. Credibility of the findings was enhanced through thoroughly documenting the research process including recruitment, as well as data collection, entry, transcribing and analysis processes. In addition, sharing the results with stakeholders including young TGW and MSM living with HIV helped in clarifying and validating the findings. Our findings cannot be generalized to whole country as the participants in our study were only drawn from three provinces. Further the sample size was small as it consisted of 56 participants. Despite these limitations, the study provides useful information to enhance programming for young TGW and MSM living with HIV as there is dearth of such studies in Zambia and arguably across much of Africa that address the many challenges that key populations face on a day-to-day.

Most young HIV-positive MSM and TGW experienced intersecting forms of stigma at household, community and health system levels. The intersectional stigma was rooted within different salient historical, cultural, and socioeconomic contexts. Fear of disclosure of both SOGI and HIV status from relatives, friends, partners and community members triggered poor mental health outcomes which included anxiety, depression and suicidal thoughts. Socio-cultural and religious attitudes regarding SOGI and criminalization of sexual or gender diversity in Zambia also contributed this intersectional stigma. In trying to respond to these mental health challenges, young, HIV-positive MSM and TGW adopted several positive coping strategies. To address intersectional stigma and related mental health challenges, we recommend strengthening implementation of laws and policies that provide a favourable environment for MSM and TGW living with HIV, including stigma reduction policies that ameliorate the negative impacts of multiple intersecting stigmas. There is also a need to meaningfully engage MSM and TGW who are at the centre of experiencing these intersectional stigmas, as well as political and community leaders in the development of interventions aimed at addressing social, cultural and legal practices that lead to stigmatisation. We further recommend mixed methods implementation research on community based interventions for reducing mental health challenges among young, HIV positive MSM and TGW in an African setting. These interventions should focus more on trauma-informed and identity-supportive care for young people with HIV.

Data availability

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

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Acknowledgements

This research project was funded under the HIV/AIDS Special Fund Round III Initiative of the Southern African Development Community. We would like to extend our sincere gratitude to the study participants for their time and valuable insight/input during the interviews.

We acknowledge the financial support from the HIV/AIDS Special Fund Round III Initiative of the Southern African Development Community.

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Zulu, J.M., Budhwani, H., Wang, B. et al. Living a private lie: intersectional stigma, depression and suicidal thoughts for selected young key populations living with HIV in Zambia. BMC Public Health 24 , 1937 (2024). https://doi.org/10.1186/s12889-024-19278-z

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Published: 13 July 2021

Systematic review and meta-analysis of depression, anxiety, and suicidal ideation among Ph.D. students

Emily N. Satinsky 1 ,
Tomoki Kimura 2 ,
Mathew V. Kiang 3 , 4 ,
Rediet Abebe 5 , 6 ,
Scott Cunningham 7 ,
Hedwig Lee 8 ,
Xiaofei Lin 9 ,
Cindy H. Liu 10 , 11 ,
Igor Rudan 12 ,
Srijan Sen 13 ,
Mark Tomlinson 14 , 15 ,
Miranda Yaver 16 &
Alexander C. Tsai 1 , 11 , 17

Scientific Reports volume 11 , Article number: 14370 ( 2021 ) Cite this article

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Epidemiology
Health policy
Quality of life

University administrators and mental health clinicians have raised concerns about depression and anxiety among Ph.D. students, yet no study has systematically synthesized the available evidence in this area. After searching the literature for studies reporting on depression, anxiety, and/or suicidal ideation among Ph.D. students, we included 32 articles. Among 16 studies reporting the prevalence of clinically significant symptoms of depression across 23,469 Ph.D. students, the pooled estimate of the proportion of students with depression was 0.24 (95% confidence interval [CI], 0.18–0.31; I 2 = 98.75%). In a meta-analysis of the nine studies reporting the prevalence of clinically significant symptoms of anxiety across 15,626 students, the estimated proportion of students with anxiety was 0.17 (95% CI, 0.12–0.23; I 2 = 98.05%). We conclude that depression and anxiety are highly prevalent among Ph.D. students. Data limitations precluded our ability to obtain a pooled estimate of suicidal ideation prevalence. Programs that systematically monitor and promote the mental health of Ph.D. students are urgently needed.

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A repeated cross-sectional analysis assessing mental health conditions of adults as per student status during key periods of the COVID-19 epidemic in France

Relationship between depression and quality of life among students: a systematic review and meta-analysis

Introduction.

Mental health problems among graduate students in doctoral degree programs have received increasing attention 1 , 2 , 3 , 4 . Ph.D. students (and students completing equivalent degrees, such as the Sc.D.) face training periods of unpredictable duration, financial insecurity and food insecurity, competitive markets for tenure-track positions, and unsparing publishing and funding models 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 —all of which may have greater adverse impacts on students from marginalized and underrepresented populations 13 , 14 , 15 . Ph.D. students’ mental health problems may negatively affect their physical health 16 , interpersonal relationships 17 , academic output, and work performance 18 , 19 , and may also contribute to program attrition 20 , 21 , 22 . As many as 30 to 50% of Ph.D. students drop out of their programs, depending on the country and discipline 23 , 24 , 25 , 26 , 27 . Further, while mental health problems among Ph.D. students raise concerns for the wellbeing of the individuals themselves and their personal networks, they also have broader repercussions for their institutions and academia as a whole 22 .

Despite the potential public health significance of this problem, most evidence syntheses on student mental health have focused on undergraduate students 28 , 29 or graduate students in professional degree programs (e.g., medical students) 30 . In non-systematic summaries, estimates of the prevalence of clinically significant depressive symptoms among Ph.D. students vary considerably 31 , 32 , 33 . Reliable estimates of depression and other mental health problems among Ph.D. students are needed to inform preventive, screening, or treatment efforts. To address this gap in the literature, we conducted a systematic review and meta-analysis to explore patterns of depression, anxiety, and suicidal ideation among Ph.D. students.

Flowchart of included articles.

The evidence search yielded 886 articles, of which 286 were excluded as duplicates (Fig. 1 ). An additional nine articles were identified through reference lists or grey literature reports published on university websites. Following a title/abstract review and subsequent full-text review, 520 additional articles were excluded.

Of the 89 remaining articles, 74 were unclear about their definition of graduate students or grouped Ph.D. and non-Ph.D. students without disaggregating the estimates by degree level. We obtained contact information for the authors of most of these articles (69 [93%]), requesting additional data. Three authors clarified that their study samples only included Ph.D. students 34 , 35 , 36 . Fourteen authors confirmed that their study samples included both Ph.D. and non-Ph.D. students but provided us with data on the subsample of Ph.D. students 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 . Where authors clarified that the sample was limited to graduate students in non-doctoral degree programs, did not provide additional data on the subsample of Ph.D. students, or did not reply to our information requests, we excluded the studies due to insufficient information (Supplementary Table S1 ).

Ultimately, 32 articles describing the findings of 29 unique studies were identified and included in the review 16 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 (Table 1 ). Overall, 26 studies measured depression, 19 studies measured anxiety, and six studies measured suicidal ideation. Three pairs of articles reported data on the same sample of Ph.D. students 33 , 38 , 45 , 51 , 53 , 56 and were therefore grouped in Table 1 and reported as three studies. Publication dates ranged from 1979 to 2019, but most articles (22/32 [69%]) were published after 2015. Most studies were conducted in the United States (20/29 [69%]), with additional studies conducted in Australia, Belgium, China, Iran, Mexico, and South Korea. Two studies were conducted in cross-national settings representing 48 additional countries. None were conducted in sub-Saharan Africa or South America. Most studies included students completing their degrees in a mix of disciplines (17/29 [59%]), while 12 studies were limited to students in a specific field (e.g., biomedicine, education). The median sample size was 172 students (interquartile range [IQR], 68–654; range, 6–6405). Seven studies focused on mental health outcomes in demographic subgroups, including ethnic or racialized minority students 37 , 41 , 43 , international students 47 , 50 , and sexual and gender minority students 42 , 54 .

In all, 16 studies reported the prevalence of depression among a total of 23,469 Ph.D. students (Fig. 2 ; range, 10–47%). Of these, the most widely used depression scales were the PHQ-9 (9 studies) and variants of the Center for Epidemiologic Studies-Depression scale (CES-D, 4 studies) 63 , and all studies assessed clinically significant symptoms of depression over the past one to two weeks. Three of these studies reported findings based on data from different survey years of the same parent study (the Healthy Minds Study) 40 , 42 , 43 , but due to overlap in the survey years reported across articles, these data were pooled. Most of these studies were based on data collected through online surveys (13/16 [81%]). Ten studies (63%) used random or systematic sampling, four studies (25%) used convenience sampling, and two studies (13%) used multiple sampling techniques.

Pooled estimate of the proportion of Ph.D. students with clinically significant symptoms of depression.

The estimated proportion of Ph.D. students assessed as having clinically significant symptoms of depression was 0.24 (95% confidence interval [CI], 0.18–0.31; 95% predictive interval [PI], 0.04–0.54), with significant evidence of between-study heterogeneity (I 2 = 98.75%). A subgroup analysis restricted to the twelve studies conducted in the United States yielded similar findings (pooled estimate [ES] = 0.23; 95% CI, 0.15–0.32; 95% PI, 0.01–0.60), with no appreciable difference in heterogeneity (I 2 = 98.91%). A subgroup analysis restricted to the studies that used the PHQ-9 to assess depression yielded a slightly lower prevalence estimate and a slight reduction in heterogeneity (ES = 0.18; 95% CI, 0.14–0.22; 95% PI, 0.07–0.34; I 2 = 90.59%).

Nine studies reported the prevalence of clinically significant symptoms of anxiety among a total of 15,626 Ph.D. students (Fig. 3 ; range 4–49%). Of these, the most widely used anxiety scale was the 7-item Generalized Anxiety Disorder scale (GAD-7, 5 studies) 64 . Data from three of the Healthy Minds Study articles were pooled into two estimates, because the scale used to measure anxiety changed midway through the parent study (i.e., the Patient Health Questionnaire-Generalized Anxiety Disorder [PHQ-GAD] scale was used from 2007 to 2012 and then switched to the GAD-7 in 2013 40 ). Most studies (8/9 [89%]) assessed clinically significant symptoms of anxiety over the past two to four weeks, with the one remaining study measuring anxiety over the past year. Again, most of these studies were based on data collected through online surveys (7/9 [78%]). Five studies (56%) used random or systematic sampling, two studies (22%) used convenience sampling, and two studies (22%) used multiple sampling techniques.

Pooled estimate of the proportion of Ph.D. students with clinically significant symptoms of anxiety.

The estimated proportion of Ph.D. students assessed as having anxiety was 0.17 (95% CI, 0.12–0.23; 95% PI, 0.02–0.41), with significant evidence of between-study heterogeneity (I 2 = 98.05%). The subgroup analysis restricted to the five studies conducted in the United States yielded a slightly lower proportion of students assessed as having anxiety (ES = 0.14; 95% CI, 0.08–0.20; 95% PI, 0.00–0.43), with no appreciable difference in heterogeneity (I 2 = 98.54%).

Six studies reported the prevalence of suicidal ideation (range, 2–12%), but the recall windows varied greatly (e.g., ideation within the past 2 weeks vs. past year), precluding pooled estimation.

Additional stratified pooled estimates could not be obtained. One study of Ph.D. students across 54 countries found that phase of study was a significant moderator of mental health, with students in the comprehensive examination and dissertation phases more likely to experience distress compared with students primarily engaged in coursework 59 . Other studies identified a higher prevalence of mental ill-health among women 54 ; lesbian, gay, bisexual, transgender, and queer (LGBTQ) students 42 , 54 , 60 ; and students with multiple intersecting identities 54 .

Several studies identified correlates of mental health problems including: project- and supervisor-related issues, stress about productivity, and self-doubt 53 , 62 ; uncertain career prospects, poor living conditions, financial stressors, lack of sleep, feeling devalued, social isolation, and advisor relationships 61 ; financial challenges 38 ; difficulties with work-life balance 58 ; and feelings of isolation and loneliness 52 . Despite these challenges, help-seeking appeared to be limited, with only about one-quarter of Ph.D. students reporting mental health problems also reporting that they were receiving treatment 40 , 52 .

Risk of bias

Twenty-one of 32 articles were assessed as having low risk of bias (Supplementary Table S2 ). Five articles received one point for all five categories on the risk of bias assessment (lowest risk of bias), and one article received no points (highest risk). The mean risk of bias score was 3.22 (standard deviation, 1.34; median, 4; IQR, 2–4). Restricting the estimation sample to 12 studies assessed as having low risk of bias, the estimated proportion of Ph.D. students with depression was 0.25 (95% CI, 0.18–0.33; 95% PI, 0.04–0.57; I 2 = 99.11%), nearly identical to the primary estimate, with no reduction in heterogeneity. The estimated proportion of Ph.D. students with anxiety, among the 7 studies assessed as having low risk of bias, was 0.12 (95% CI, 0.07–0.17; 95% PI, 0.01–0.34; I 2 = 98.17%), again with no appreciable reduction in heterogeneity.

In our meta-analysis of 16 studies representing 23,469 Ph.D. students, we estimated that the pooled prevalence of clinically significant symptoms of depression was 24%. This estimate is consistent with estimated prevalence rates in other high-stress biomedical trainee populations, including medical students (27%) 30 , resident physicians (29%) 65 , and postdoctoral research fellows (29%) 66 . In the sample of nine studies representing 15,626 Ph.D. students, we estimated that the pooled prevalence of clinically significant symptoms of anxiety was 17%. While validated screening instruments tend to over-identify cases of depression (relative to structured clinical interviews) by approximately a factor of two 67 , 68 , our findings nonetheless point to a major public health problem among Ph.D. students. Available data suggest that the prevalence of depressive and anxiety disorders in the general population ranges from 5 to 7% worldwide 69 , 70 . In contrast, prevalence estimates of major depressive disorder among young adults have ranged from 13% (for young adults between the ages of 18 and 29 years in the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions III 71 ) to 15% (for young adults between the ages of 18 and 25 in the 2019 U.S. National Survey on Drug Use and Health 72 ). Likewise, the prevalence of generalized anxiety disorder was estimated at 4% among young adults between the ages of 18 and 29 in the 2001–03 U.S. National Comorbidity Survey Replication 73 . Thus, even accounting for potential upward bias inherent in these studies’ use of screening instruments, our estimates suggest that the rates of recent clinically significant symptoms of depression and anxiety are greater among Ph.D. students compared with young adults in the general population.

Further underscoring the importance of this public health issue, Ph.D. students face unique stressors and uncertainties that may put them at increased risk for mental health and substance use problems. Students grapple with competing responsibilities, including coursework, teaching, and research, while also managing interpersonal relationships, social isolation, caregiving, and financial insecurity 3 , 10 . Increasing enrollment in doctoral degree programs has not been matched with a commensurate increase in tenure-track academic job opportunities, intensifying competition and pressure to find employment post-graduation 5 . Advisor-student power relations rarely offer options for recourse if and when such relationships become strained, particularly in the setting of sexual harassment, unwanted sexual attention, sexual coercion, and rape 74 , 75 , 76 , 77 , 78 . All of these stressors may be magnified—and compounded by stressors unrelated to graduate school—for subgroups of students who are underrepresented in doctoral degree programs and among whom mental health problems are either more prevalent and/or undertreated compared with the general population, including Black, indigenous, and other people of color 13 , 79 , 80 ; women 81 , 82 ; first-generation students 14 , 15 ; people who identify as LGBTQ 83 , 84 , 85 ; people with disabilities; and people with multiple intersecting identities.

Structural- and individual-level interventions will be needed to reduce the burden of mental ill-health among Ph.D. students worldwide 31 , 86 . Despite the high prevalence of mental health and substance use problems 87 , Ph.D. students demonstrate low rates of help-seeking 40 , 52 , 88 . Common barriers to help-seeking include fears of harming one’s academic career, financial insecurity, lack of time, and lack of awareness 89 , 90 , 91 , as well as health care systems-related barriers, including insufficient numbers of culturally competent counseling staff, limited access to psychological services beyond time-limited psychotherapies, and lack of programs that address the specific needs either of Ph.D. students in general 92 or of Ph.D. students belonging to marginalized groups 93 , 94 . Structural interventions focused solely on enhancing student resilience might include programs aimed at reducing stigma, fostering social cohesion, and reducing social isolation, while changing norms around help-seeking behavior 95 , 96 . However, structural interventions focused on changing stressogenic aspects of the graduate student environment itself are also needed 97 , beyond any enhancements to Ph.D. student resilience, including: undercutting power differentials between graduate students and individual faculty advisors, e.g., by diffusing power among multiple faculty advisors; eliminating racist, sexist, and other discriminatory behaviors by faculty advisors 74 , 75 , 98 ; valuing mentorship and other aspects of “invisible work” that are often disproportionately borne by women faculty and faculty of color 99 , 100 ; and training faculty members to emphasize the dignity of, and adequately prepare Ph.D. students for, non-academic careers 101 , 102 .

Our findings should be interpreted with several limitations in mind. First, the pooled estimates are characterized by a high degree of heterogeneity, similar to meta-analyses of depression prevalence in other populations 30 , 65 , 103 , 104 , 105 . Second, we were only able to aggregate depression prevalence across 16 studies and anxiety prevalence across nine studies (the majority of which were conducted in the U.S.) – far fewer than the 183 studies included in a meta-analysis of depression prevalence among medical students 30 and the 54 studies included in a meta-analysis of resident physicians 65 . These differences underscore the need for more rigorous study in this critical area. Many articles were either excluded from the review or from the meta-analyses for not meeting inclusion criteria or not reporting relevant statistics. Future research in this area should ensure the systematic collection of high-quality, clinically relevant data from a comprehensive set of institutions, across disciplines and countries, and disaggregated by graduate student type. As part of conducting research and addressing student mental health and wellbeing, university deans, provosts, and chancellors should partner with national survey and program institutions (e.g., Graduate Student Experience in the Research University [gradSERU] 106 , the American College Health Association National College Health Assessment [ACHA-NCHA], and HealthyMinds). Furthermore, federal agencies that oversee health and higher education should provide resources for these efforts, and accreditation agencies should require monitoring of mental health and programmatic responses to stressors among Ph.D. students.

Third, heterogeneity in reporting precluded a meta-analysis of the suicidality outcomes among the few studies that reported such data. While reducing the burden of mental health problems among graduate students is an important public health aim in itself, more research into understanding non-suicidal self-injurious behavior, suicide attempts, and completed suicide among Ph.D. students is warranted. Fourth, it is possible that the grey literature reports included in our meta-analysis are more likely to be undertaken at research-intensive institutions 52 , 60 , 61 . However, the direction of bias is unpredictable: mental health problems among Ph.D. students in research-intensive environments may be more prevalent due to detection bias, but such institutions may also have more resources devoted to preventive, screening, or treatment efforts 92 . Fifth, inclusion in this meta-analysis and systematic review was limited to those based on community samples. Inclusion of clinic-based samples, or of studies conducted before or after specific milestones (e.g., the qualifying examination or dissertation prospectus defense), likely would have yielded even higher pooled prevalence estimates of mental health problems. And finally, few studies provided disaggregated data according to sociodemographic factors, stage of training (e.g., first year, pre-prospectus defense, all-but-dissertation), or discipline of study. These factors might be investigated further for differences in mental health outcomes.

Clinically significant symptoms of depression and anxiety are pervasive among graduate students in doctoral degree programs, but these are understudied relative to other trainee populations. Structural and clinical interventions to systematically monitor and promote the mental health and wellbeing of Ph.D. students are urgently needed.

This systematic review and meta-analysis follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach (Supplementary Table S3 ) 107 . This study was based on data collected from publicly available bibliometric databases and did not require ethical approval from our institutional review boards.

Eligibility criteria

Studies were included if they provided data on either: (a) the number or proportion of Ph.D. students with clinically significant symptoms of depression or anxiety, ascertained using a validated scale; or (b) the mean depression or anxiety symptom severity score and its standard deviation among Ph.D. students. Suicidal ideation was examined as a secondary outcome.

We excluded studies that focused on graduate students in non-doctoral degree programs (e.g., Master of Public Health) or professional degree programs (e.g., Doctor of Medicine, Juris Doctor) because more is known about mental health problems in these populations 30 , 108 , 109 , 110 and because Ph.D. students face unique uncertainties. To minimize the potential for upward bias in our pooled prevalence estimates, we excluded studies that recruited students from campus counseling centers or other clinic-based settings. Studies that measured affective states, or state anxiety, before or after specific events (e.g., terrorist attacks, qualifying examinations) were also excluded.

If articles described the study sample in general terms (i.e., without clarifying the degree level of the participants), we contacted the authors by email for clarification. Similarly, if articles pooled results across graduate students in doctoral and non-doctoral degree programs (e.g., reporting a single estimate for a mixed sample of graduate students), we contacted the authors by email to request disaggregated data on the subsample of Ph.D. students. If authors did not reply after two contact attempts spaced over 2 months, or were unable to provide these data, we excluded these studies from further consideration.

Search strategy and data extraction

PubMed, Embase, PsycINFO, ERIC, and Business Source Complete were searched from inception of each database to November 5, 2019. The search strategy included terms related to mental health symptoms (e.g., depression, anxiety, suicide), the study population (e.g., graduate, doctoral), and measurement category (e.g., depression, Columbia-Suicide Severity Rating Scale) (Supplementary Table S4 ). In addition, we searched the reference lists and the grey literature.

After duplicates were removed, we screened the remaining titles and abstracts, followed by a full-text review. We excluded articles following the eligibility criteria listed above (i.e., those that were not focused on Ph.D. students; those that did not assess depression and/or anxiety using a validated screening tool; those that did not report relevant statistics of depression and/or anxiety; and those that recruited students from clinic-based settings). Reasons for exclusion were tracked at each stage. Following selection of included articles, two members of the research team extracted data and conducted risk of bias assessments. Discrepancies were discussed with a third member of the research team. Key extraction variables included: study design, geographic region, sample size, response rate, demographic characteristics of the sample, screening instrument(s) used for assessment, mean depression or anxiety symptom severity score (and its standard deviation), and the number (or proportion) of students experiencing clinically significant symptoms of depression or anxiety.

Risk of bias assessment

Following prior work 30 , 65 , the Newcastle–Ottawa Scale 111 was adapted and used to assess risk of bias in the included studies. Each study was assessed across 5 categories: sample representativeness, sample size, non-respondents, ascertainment of outcomes, and quality of descriptive statistics reporting (Supplementary Information S5 ). Studies were judged as having either low risk of bias (≥ 3 points) or high risk of bias (< 3 points).

Analysis and synthesis

Before pooling the estimated prevalence rates across studies, we first transformed the proportions using a variance-stabilizing double arcsine transformation 112 . We then computed pooled estimates of prevalence using a random effects model 113 . Study specific confidence intervals were estimated using the score method 114 , 115 . We estimated between-study heterogeneity using the I 2 statistic 116 . In an attempt to reduce the extent of heterogeneity, we re-estimated pooled prevalence restricting the analysis to studies conducted in the United States and to studies in which depression assessment was based on the 9-item Patient Health Questionnaire (PHQ-9) 117 . All analyses were conducted using Stata (version 16; StataCorp LP, College Station, Tex.). Where heterogeneity limited our ability to summarize the findings using meta-analysis, we synthesized the data using narrative review.

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Acknowledgements

We thank the following investigators for generously sharing their time and/or data: Gordon J. G. Asmundson, Ph.D., Amy J. L. Baker, Ph.D., Hillel W. Cohen, Dr.P.H., Alcir L. Dafre, Ph.D., Deborah Danoff, M.D., Daniel Eisenberg, Ph.D., Lou Farrer, Ph.D., Christy B. Fraenza, Ph.D., Patricia A. Frazier, Ph.D., Nadia Corral-Frías, Ph.D., Hanga Galfalvy, Ph.D., Edward E. Goldenberg, Ph.D., Robert K. Hindman, Ph.D., Jürgen Hoyer, Ph.D., Ayako Isato, Ph.D., Azharul Islam, Ph.D., Shanna E. Smith Jaggars, Ph.D., Bumseok Jeong, M.D., Ph.D., Ju R. Joeng, Nadine J. Kaslow, Ph.D., Rukhsana Kausar, Ph.D., Flavius R. W. Lilly, Ph.D., Sarah K. Lipson, Ph.D., Frances Meeten, D.Phil., D.Clin.Psy., Dhara T. Meghani, Ph.D., Sterett H. Mercer, Ph.D., Masaki Mori, Ph.D., Arif Musa, M.D., Shizar Nahidi, M.D., Ph.D., Arthur M. Nezu, Ph.D., D.H.L., Angelo Picardi, M.D., Nicole E. Rossi, Ph.D., Denise M. Saint Arnault, Ph.D., Sagar Sharma, Ph.D., Bryony Sheaves, D.Clin.Psy., Kennon M. Sheldon, Ph.D., Daniel Shepherd, Ph.D., Keisuke Takano, Ph.D., Sara Tement, Ph.D., Sherri Turner, Ph.D., Shawn O. Utsey, Ph.D., Ron Valle, Ph.D., Caleb Wang, B.S., Pengju Wang, Katsuyuki Yamasaki, Ph.D.

A.C.T. acknowledges funding from the Sullivan Family Foundation. This paper does not reflect an official statement or opinion from the County of San Mateo.

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A.C.T. conceptualized the study and provided supervision. T.K. conducted the search. E.N.S. contacted authors for additional information not reported in published articles. E.N.S. and T.K. extracted data and performed the quality assessment appraisal. E.N.S. and A.C.T. conducted the statistical analysis and drafted the manuscript. T.K., M.V.K., R.A., S.C., H.L., X.L., C.H.L., I.R., S.S., M.T. and M.Y. contributed to the interpretation of the results. All authors provided critical feedback on drafts and approved the final manuscript.

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Satinsky, E.N., Kimura, T., Kiang, M.V. et al. Systematic review and meta-analysis of depression, anxiety, and suicidal ideation among Ph.D. students. Sci Rep 11 , 14370 (2021). https://doi.org/10.1038/s41598-021-93687-7

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v.31(1); Spring 2008

The Nature of Clinical Depression: Symptoms, Syndromes, and Behavior Analysis

In this article we discuss the traditional behavioral models of depression and some of the challenges analyzing a phenomenon with such complex and varied features. We present the traditional model and suggest that it does not capture the complexity of the phenomenon, nor do syndromal models of depression that dominate the mainstream conceptualization of depression. Instead, we emphasize ideographic analysis and present depression as a maladaptive dysregulation of an ultimately adaptive elicited emotional response. We emphasize environmental factors, specifically aversive control and private verbal events, in terms of relational frame theory, that may transform an adaptive response into a maladaptive disorder. We consider the role of negative thought processes and rumination, common and debilitating aspects of depression that have traditionally been neglected by behavior analysts.

As the field of clinical behavior analysis grows, it will benefit from analyses of increasingly complex and common clinical phenomena, especially those with significant public health implications. One such phenomenon is clinical depression, considered to be the “common cold” of outpatient populations. Up to 25 million people in the United States alone meet criteria for some type of depressive disorder in a given year (M. B. Keller, 1994 ). Depressive disorders also result in considerable financial expenditure including time spent away from the workplace and an increase in health care costs. Based on broad measures that include work absenteeism, treatment costs, and other factors, the annual economic cost of depressive disorders in the United States may be over $40 billion ( Antonouccio, Thomas, & Danton, 1997 ). Suicide is the ultimate cost.

Perhaps nowhere in clinical psychology is the medicalization of behavioral problems more complete than with depression. Depression is largely seen by the general public and mainstream media as a neuropsychiatric illness (e.g., Wingert & Kantrowitz, 2002 ) with a fluctuating course that is best described in disease-state terms such as disorder, episodes, remission, recovery, relapse , and recurrence ( Frank et al., 1991 ). An additional assumption is that this disorder may be diagnosed and labeled using the symptom checklists of the standard diagnostic system, the Diagnostic and Statistical Manual of Mental Disorders ( DSM-IV-TR ; American Psychiatric Association, 2000 ). The basic ontological assumption is that depression is an illness that occurs episodically and can be described adequately in medical terms. Thus, more depression is treated in primary care than in any other mental health or health care setting ( Kessler, McGonagle, Swartz, Blazer, & Nelson, 2003 ; Shapiro, 1984 ), and guidelines for treatment in these settings recommend antidepressant treatment without specialty referral unless the patient has complicating factors such as comorbid substance use or suicide risk ( Schulberg, Katon, Simon, & Rush, 1998 ). Even in these cases, specialty referral is first to psychiatry for medication management, and only a small number of individuals diagnosed with depression will be seen by a clinical psychologist, much less a behaviorally oriented practitioner.

A hallmark of behavior analysis has been its condemnation of the misappropriation of lay terms as scientific, technical terms (e.g., Skinner, 1945 ). The first task is precise specification of the behavioral phenomena invoked by the term. There are several obstacles to achieving this precision with the term depression, which have been excellently presented for the term anxiety by Friman, Hayes, and Wilson (1998) . The case for depression is quite similar. First, the term depression was never meant as a technical term and actually has a metaphorical, idiomatic basis. Second, our psychiatric nomenclature and mainstream usage of the term suggest that depression is an empirical phenomenon with an essential composition. To a behavior analyst, the term depression is not a technical term, does not precisely map onto any empirical or behavioral phenomena, and has no essential composition. Thus, given the exhaustive medicalization of the phenomenon of depression, there exists an immense gap between a behavioral analysis of depression and mainstream usage of it as a medical term with its various associations and meanings.

Behavior-analytic writings on clinical depression (e.g., Dougher & Hackbert, 1994 , 2000 ; Ferster, 1973 ; Lewinsohn, 1974 ; see Eifert, Beach, & Wilson, 1998 , for an alternative, paradigmatic behavioral model) have been illuminative but sparse. Although research on depression has outpaced research on virtually every other disorder by psychiatric and cognitive-behavioral researchers, behavior analysts have been alarmingly silent. There are undoubtedly many reasons for this silence (e.g., a lack of training programs that focus on behavior analysis and traditional psychopathology and more reinforcement for studying familiar topics). More relevant to the current paper is the possibility that the exhaustive medicalization of the term; the wealth of non-behavior-analytic research data on biology and genetics, personality, and cognitive factors; and the emphasis on private events in depression—on how depression feels and on changing that feeling—may function to evoke avoidance in behavior analysts.

This is unfortunate, because behavior analysis can not only provide an integrative view of depression, taking into consideration genetics, biology, enduring patterns of responding labeled personality , verbal (“cognitive”) behavior, and private events, but it can do so with a theoretical consistency and pragmatic utility unmatched by other theoretical systems. In this paper we attempt to start at the beginning, with a discussion of what depression is to a behavior analyst and how this contrasts with mainstream usage of the term as a medical syndrome. We review the traditional operant model of depression that emphasized reductions in behavior as a response to environmental events. We then tackle several areas of inquiry important to an understanding of depression that have traditionally been neglected by behavior analysts, including private events and the role of verbal behavior in depression. We see this not as completing a behavioral analysis but as a reminder of the importance of idiographic, functional analyses of specific individuals for this complex phenomenon.

What Is Depression? Tacting Depression and Its Symptoms

We describe depression in radical behavioral terms, emphasizing the occasions on which the term is used and deemphasizing any underlying unitary disease, physiological, or emotional state to which the term refers. Depression comes from the late Latin word depressare and the classical Latin word deprimere . Deprimere literally means “press down”; de translates into “down” and premere translates into “to press.” In essence, the term appears to denote a feeling of heaviness, of being “pressed down,” that is also referred to as “sad,” “blue,” or simply “down.” Depression also refers to a depressed topography or the fact of being pressed down. Depression as a referent to mood or emotional state appeared as early as 1665 and merely meant a lowering of mood or spirits ( Simpson & Weiner, 1989 ). Thus, the core experience of depression appears to be a private event tacted as depressed or in psychiatric terms as dysphoric . However, a minority of individuals will meet criteria for depression and deny depressed mood or present with irritable mood instead. These individuals may have deficits in accurate tacting of private experience, or they may represent diagnostic Type II errors and should not be classified as depressed.

It is important not to associate what is tacted as depression with a specific pattern of physiological responding or reify it as a particular emotional state. The antecedent conditions and underlying physiologies associated with the experience of depression may vary widely, and no core composition can be assumed. Emotional states such as sadness are simply co-occurring behavioral responses (elicited unconditioned reflexes, conditioned reflexes, operant predispositions) that appear to be integrated because the behaviors are occasioned by common discriminanda and are controlled by common consequences ( Skinner, 1953 ). For example, a child with overbearing parents experiences an emotional state of sadness and a co-occurring behavioral response of crying when her parents criticize her. The crying is negatively reinforced when her parents comfort her and stop criticizing her, which may also result in a change of her emotional state.

The particular quality of an emotional state labeled depression should vary with the characteristics of the environmental triggers. For example, private events labeled as depressed may be associated with overworking and receiving little reinforcement for long stretches of time or with grieving the death of a loved partner. In each case the underlying physiology is presumably different, but the experienced phenomena may be sufficiently similar to prompt the tact. More specific discrimination training may be useful (e.g., the first situation may be better labeled as burned out and the second as grieving ) but given the problems associated with training the tacting of private events ( Moore, 1980 ) it is not clear that an individual will be able to make these discriminations reliably.

The psychiatric nomenclature emphasizes this core experience and several additional symptoms. Depressed mood or dysphoria is the primary feature of major depressive disorder (MDD), the most common depressive diagnosis. In addition to this core experience, there are several other symptoms of MDD, including loss of interest in activities, sleep and appetite changes, guilt and hopelessness, fatigue, restlessness, concentration problems, and suicidal ideation. As discussed in detail below, the medical model holds that this constellation of symptoms represents a syndrome, but complexity is immediately introduced because the presence and nature of these symptoms vary considerably across clients ( Líndal & Stefánsson, 1991 ). For example, some clients experience vegetative symptoms of depression (decreased appetite and insomnia) whereas, less commonly, others experience reversed vegetative symptoms of increased appetite and hypersomnia. Similarly, psychomotor retardation is more common and agitation is less common, and both may be demonstrated by the same individual at different times.

To account for this complexity, DSM-IV-TR has parsed depression into various additional categories, each with similar and overlapping characteristics, and there are an increasing number of diagnostic categories of depressive disorders or problems involving sad or irritable affect. In fact, Appendix B of DSM-IV-TR lists 17 proposed disorders for further study, six of which deal with disorders of mood. Although detailed review of these subcategories is outside the purview of this paper, it should be noted that although there may indeed be different syndromes with different etiologies and treatment implications, a behavior-analytic view holds that the current proliferation of depressive disorders is largely unnecessary. We see not several distinct disorders but a phenomenon of depression with great variability in time course, symptom severity, and correlated conditions. All the disorders share a depressed mood symptom that parallels the core experience of the problem, and all share several additional criteria with MDD, often differing only in duration or number of symptoms. From an idiographic behavior-analytic perspective, there exists not one or three or several depressive disorders—there are as many depressive disorders as there are depressed individuals.

The constellation of depressive disorders with shared characteristics suggests that the tact depression involves a variety of public and private antecedent stimulating events that vary from occasion to occasion but have sufficient overlapping properties to occasion consistent usage of the term. We view the diversity of additional symptoms represented by these disorders as consistent with the diversity of environmental causes of depression, physiological states labeled depression , and psychological responses to the environmental causes and physiological states. Thus, no overarching depressive syndromes are posited or assumed at this point. Nonetheless, commonalities in history, environmental antecedents, and symptom presentation exist and may guide treatment decisions.

Thus, our understanding of depression must allow for the great variety of stimulus conditions that occasion use of the term. We can discard several classes of use that we can simply label as incorrect. For example, an individual learning a foreign language may simply state the wrong word. Likewise, a person may be diagnosed with depression but later it is determined that the person has a large cancerous tumor that is causing the symptoms. Although a complete behavioral analysis must account for these usages, they are not interesting from a clinical standpoint. More important are instances in which the term is not used but could be. For example, a person visits a psychologist and complains of several symptoms of depression but not depressed mood. Another person would label the private experience as “depressed,” but the current client did not develop adequate private stimulus control over the experience. The psychologist performs a diagnostic interview, and the client falls one symptom short of the diagnosis of MDD. In this case it is advantageous to consider the person depressed even though it is possible that neither the psychologist nor the client will use the term.

Traditional Behavioral Models of Depression

Skinner wrote very little on depression; when he did, he emphasized overt behavior rather than the core affective experience, in line with an operant rather than respondent model. For example, in 1953 he wrote,

If we remove a man from his characteristic surroundings, a large part of his social behavior cannot be emitted and may therefore become more and more probable: he will return to his old surroundings whenever possible and will be particularly “sociable” when he does so. Other parts of his behavior become strong because they are automatically reinforced under the prevailing deprivation; he will talk to anyone who will listen about his old surroundings, his old friends, and what he used to do. This is all a result of deprivation. But nostalgia is also an emotional condition in which there is a general weakening of other forms of behavior—a “depression,” which may be quite profound. We cannot classify this as the result of deprivation because the behavior which is thus affected has not been specifically restrained. (p. 165)

Three aspects of this passage are noteworthy. First, as Skinner typically did, by placing the term depression in quotes he was careful to avoid giving it any special status other than that of a verbal description. As discussed above, this practice of placing such terms in quotes may be awkward and tiresome but serves as a reminder that certain assumptions are not to be made when using them. The quotes also serve as a reminder of an important verbal quality to the term, discussed below. Second, Skinner described the core experience as an “emotional condition,” suggesting an elicited component. Consistent with an operant model, he did not elaborate on this point and instead focused on overt behavioral reductions. Third, Skinner highlighted the centrality of reduced positive reinforcement in depression. Simply put, social behavior depends on a reinforcing environment; change the environment so that responses do not yield reinforcement and one reduces the behavior.

This notion became the foundation of Lewinsohn's (1974) theory and dominated the behavioral literature for several decades. Lewinsohn described depression as characterized primarily by a low rate of response-contingent positive reinforcement (RCPR). In a nutshell, Lewinsohn emphasized environmental events that produce losses of major sources of RCPR, such as a divorce or the loss of a job, and social skills deficits that limit an individual's ability to reobtain RCPR once it has been lost. Thus, his model focused on the behavioral reductions often seen in depression. Lewinsohn assumed the core experience to be an elicited by-product of these situations, but he did not detail this process. Other symptoms of depression (e.g., fatigue, somatic symptoms, and cognitive symptoms) were assumed to be evoked or to be secondary elaborations of other symptoms.

We hold that Lewinsohn's (1974) characterization of the core affective experience of depression as an elicited by-product of losses of or reductions in positive reinforcement is fundamental to understanding depression. Some cases of depression clearly are described best by Lewinsohn's model, such as single, discrete episodes of depression with clear environmental precipitants and with symptom profiles that emphasize behavioral reductions that resolve when the environments are reinstated. For example, a person may become depressed after a divorce or loss of job, and the depression resolves when the person finds a new relationship partner or a new job. With cases of chronic depression, Lewinsohn's model emphasizes persistently insufficient levels of reinforcement and social skills deficits that prevent the individual from changing the situation, and this model also seems to be adequate for some cases. For example, a person who becomes depressed after a divorce, resulting in a net reduction in positive reinforcement, and does not have adequate social skills for initiating new romantic relationships will likely become chronically depressed until the necessary social skills are learned.

All of this is nothing new. However, Lewinsohn's (1974) model vastly underestimated the variety and complexity of factors that can reduce behavior. Indeed, the field of behavior analysis, if nothing else, has demonstrated functional processes that can increase or decrease behavior. All functional processes that decrease behavior are potentially relevant, if the behavioral reductions produced are large and generalized and a dysphoric reaction occurs concomitant with the behavioral reductions. For example, extreme persistent and uncontrollable punishment may lead to substantial behavioral reductions, elicited negative affect, and depression as per Seligman's early learned helplessness model ( Overmier & Seligman, 1967 ).

Further consideration of this complexity is provided by Hopko, Lejuez, Ruggiero, and Eifert (2003) and Lejuez, Hopko, and Hopko (2001) , who analyzed depression in terms of the matching law ( Herrnstein, 1970 ). Briefly, this suggests that the behavioral reductions seen in depression are not accurately seen as the simple product of reductions in positive reinforcement but rather as the product of ratios of reinforcement for depressed relative to nondepressed (or healthy) behavior. In other words, the sum total of reinforcement available in a person's environment must be taken into consideration, not just reinforcement for target behaviors. As a simple example, a depressed person may not get out of bed due to loss of a job (loss of positive reinforcer for getting out of bed), but positive reinforcers for staying in bed (e.g., spouse who now takes care of the person or makes the person breakfast) must also be considered. The bottom line is that the situation is complicated, and nothing less than a complete functional analysis of the individual's environment is required if one is to attempt a full functional analysis of depression.

Aversive Control in Depression

Skinner also suggested that depression may be an emotional response to aversive controlling practices, especially aversive social control (1953, pp. 360–363). Similarly, Ferster (1973) suggested that depression is characterized as much by increased escape and avoidance repertoires as by reduced positive repertoires. In fact, research indicates that more cases of depression are characterized by the accrual of multiple chronic mild stressors, such as work-related stress, homemaking demands, and financial trouble than by major losses such as divorce or the loss of a job ( Billings & Moos, 1984 ; Kessler, 1997 ; Mazure, 1998 ; Monroe & Depue, 1991 ; Paykel, 1982 ). In these cases we suggest that the core elicited affective experience of depression is as much a product of increased aversive control as it is reduced appetitive control.

It is important to recognize, however, that the two sources of control are often intimately related. Ferster (1973) suggested that the depressed escape and avoidance repertoire is largely passive, which also leads to a decrease in positive reinforcement relative to what an active repertoire would provide. For example, consider a client who stayed in bed all day and did not go to work, thereby avoiding a stressful meeting with his boss where he believed he was going to be reprimanded. Staying in bed successfully avoids this outcome, but it also prevents contact with other contingencies that might function to ameliorate depression—for example, if the client was wrong and no reprimand was forthcoming. Similarly, an individual with social phobia, which is highly comorbid with depression ( Mineka, Watson, & Clark, 1998 ), may be negatively reinforced by successfully avoiding situations that may result in social humiliation or embarrassment, but avoidance of such situations also reduces opportunities for contact with positive social reinforcement. In other words, an increase in aversive social control here almost guarantees a decrease in appetitive social control. These aversive environments evoke and maintain behavior that is immediately effective as a response to these contingencies but maladaptive over the long term in that access to positive reinforcers is diminished.

Such aversive situations may elicit anxiety rather than depression per se, but the point is that a repertoire characterized by excessive escape and avoidance behavior (and elicited affect labeled anxiety ) will undoubtedly result in decreased contact with positive reinforcement (and elicited affect labeled depression ) over time. Thus, anxiety should precede and then become comorbid with depression, and this pattern appears to characterize many comorbid cases ( Mineka et al., 1998 ). In fact, the well-established comorbidity of anxiety and depressive disorders should be a function of the degree to which anxious avoidance also results in a loss of positive reinforcement. Hayes, Wilson, Gifford, Follette, and Strosahl (1996) have provided a convincing review showing that avoidance may underlie a host of psychological problems, including depression, and the specific relation between avoidance and depression has received empirical support as well (reviewed by Ottenbreit & Dobson, 2004 ). Finally, research indicates that over the course of treatment for social phobia, change in anxiety predicts change in depression, but change in depression does not predict change in anxiety ( Moscovitch, Hofmann, Suvak, & In-Albon, 2005 ), suggesting that symptoms of depression are at least partially maintained by a social environment that has aversive functions.

To summarize our analysis to this point, there are many pathways to depression. Depression is not a precise, technical term and has no essential composition. It is not a syndrome. The term refers to a chronic experience of feeling sad or down and to associated symptoms that vary widely. This symptomatic heterogeneity is due to the heterogeneity of historical and environmental controlling variables. That said, some processes may be more common in depression, and awareness of these processes would help to limit what could be a vast assessment of many potentially irrelevant variables ( Hayes & Follette, 1992 ). Two broad processes have been highlighted here: (a) losses of, reductions in, or persistently insufficient levels of positive reinforcement as per Lewinsohn (1974) , and (b) increases in environmental aversive control (negatively reinforcing and punishment contingencies). When chronic, both processes may be seen as functioning as enduring motivating operations for depression ( Dougher & Hackbert, 2000 ). Of course, multiple sources of control are probable.

An Adaptive Syndrome or Maladaptive Response? Genetics and Evolutionary Theories

In contrast to an idiographic functional analysis of depression, the medical disease model posits that depression is a syndrome or multiple syndromes and one inherits risk for this syndromal response. The model relies to a considerable degree on research indicating at least some genetic involvement in depression ( Wallace, Schneider, & McGuffin, 2002 ). However, the family, twin, and adoption studies on which this conclusion is based point to a larger environmental contribution than genetic contribution in all but the most severe cases of depression ( Wallace et al., 2002 ). Furthermore, researchers and theorists from a variety of perspectives have highlighted methodological flaws and unsubstantiated assumptions of this research ( Ceci & Williams, 1999 ; Hayes, 1998 ; Turkheimer, 1998 ) that have the collective effect of lowering heritability estimates even further as well as questioning their very basis. Nonetheless, it seems likely that some inherited vulnerability to depression exists in some cases, and a full behavior-analytic account can include this possibility.

A typical behavioral argument against the medical disease model of depression is to accept that depression is a syndrome but posit that it is adaptive, the product of contingencies of survival ( Skinner, 1953 ). In fact, many evolutionary explanations for depression have been offered (e.g., Bowlby, 1980 ; Gilbert, 1992 ; Leahy, 1997 ; Price, Sloman, Gardner, Gilbert, & Rohde, 1994 ; P. J. Watson & Andrews, 2002 ; see McGuire & Troisi, 1998 , for a review), and such evolutionary accounts are important to consider and are consistent with behavioral theory ( Corwin & O'Donohue, 1995 ). There are three broad themes under which these theories fall: resource conservation, social competition, and attachment ( Allen & Badcock, 2003 ).

Theories of resource conservation posit that depression permits the conservation of resources and disengagement from unsuccessful goal-directed activity by decreasing appetite, energy levels, and motivation ( Leahy, 1997 ; Nesse, 2000 ). For instance, when in a new environment with unknown contingencies, such as traveling to a foreign country, one is more likely to be functioning in a way to avoid negative reinforcement or punishment while trying to learn the rules of the new environment. If one were to engage in a goal-directed activity, such as trying to obtain a job, one would likely not be successful. Social-competition theories view depression as a deescalation or yielding reaction to a defeat. This is said to be adaptive because it signals submission to the victor and allows acceptance of social subordination and the avoidance of unnecessary conflict ( Price, 1967 , 1998 ; Price et al., 1994 ). An example of this can be seen in a boxing match, when one fighter is knocked down for a full 10 counts. The loser typically displays behaviors including sloped posture, decreased eye contact, and avoidance (all depressed behaviors) as opposed to getting back up and continuing to fight. Finally, attachment theories of the adaptive nature of depression claim that a depressive reaction is an adaptive response to the loss of interpersonal relationships that helps to maintain the proximity of caregivers or reestablish an attachment by signaling a need for assistance from others and eliciting that assistance ( Averill, 1968 ; Bowlby, 1980 ; Frijda, 1994 ). This can easily be seen by a lost boy in a busy mall. When the child begins to cry, passersby typically attend to him, try to find the boy's parents, and comfort him during the search.

We suggest that depression is neither a syndrome nor adaptive. Any theory of depression as an adaptive syndrome has to overcome two primary hurdles inherent in the phenomenon. First, given the variability in symptom profiles in depression, one has to pick which set of symptoms of depression comprises the syndrome, or alternately posit multiple syndromes with different symptom sets (M. C. Keller & Nesse, 2006 ). For example, are both melancholic and atypical depression adaptive syndromes? Given that some of symptoms associated with melancholic depression (insomnia and loss of appetite) are the opposite of those associated with atypical depression (hypersomnia and increased appetite), it is impossible for the same theory to account for both presentations.

Second, the nature and chronicity of depressive symptoms seem to be maladaptive. For example, a transient sad mood in response to a loss certainly seems adaptive in that it elicits empathy and evokes helping behaviors in others. If this is true, then such an affective respondent reaction may have evolved due to contingencies of survival. It would be expected to have certain losses as antecedents and to resolve when support is acquired. However, in clinical depression the sad mood is often chronic and unresponsive to helping behaviors. In fact, although the evolutionary account suggests that the response should garner social support, research is clear that depressive behaviors result in decreased social support ( Coyne, 1976 ; Gotlib & Lee, 1989 ; Joiner & Metalsky, 2001 ) and worse psychosocial functioning in general ( Barnett & Gotlib, 1988 ). Suicide is another example. Although suicidal gestures may be seen as operant attempts to garner support ( Linehan, 1993 ), completed suicide is difficult to conceive of as an operant (i.e., learned) behavior ( Hayes, Strosahl, & Wilson, 1999 ) and is clearly not adaptive in terms of survival.

A more likely scenario is that depression itself is not adaptive, but the core experience represents a variation of an adaptive affective response ( Nettle, 2004 ; also see Nesse, 2000 ). In other words, the capability to experience moderate low mood or sadness in appropriate situations (but not become clinically depressed) may have many of the same short-term benefits that have been used to support the claim that depression is adaptive. Support for this view comes from personality researchers, who have posited the temperamental trait of negative affectivity as a trait that is selected for and normally distributed ( Nettle, 2004 ; D. Watson & Clark, 1984 ), and considerable research suggests that this trait may be a vulnerability factor for both depression and anxiety (L. A. Clark & Watson, 1991 ; L. A. Clark, Watson, & Mineka, 1994 ).

Although the notions of temperament or traits are unnecessary, it is reasonable to suggest that there may be a range in the duration and magnitude of affective reactions that are adaptive. A depressed individual could represent a deviation from that range in that he or she experiences negative affect longer and to a greater extent in response to an environmental event. In other words, the propensity to experience mild and appropriate levels of negative affect may be adaptive and thus appear on a continuum; those at one of the extreme ends of this continuum may be quite sensitive to fluctuations in reinforcement contingencies, suffer from chronic negative affect, and be at risk for clinical depression.

It is important to remember that we are proposing a scenario in which there is a genetic contribution to the likelihood of the core affective experience in depression but the remaining symptoms are potentially free to vary and should be described in terms of antecedents and consequences. Of course, there may be an adaptive, normally distributed range in the sensitivity of these additional behaviors (e.g., sleep) to environmental stimuli that represent separate inherited vulnerabilities. This view of depression is consistent with recent biological findings that suggest that depression is likely a product of multiple genes and a complex gene–environment interaction ( Wallace et al., 2002 ), as well as neuroscientific findings of mixed and variable structural and functional abnormalities in several brain regions, with few depressed individuals displaying the complete package of deficits, leading researchers to conclude that depression refers to a heterogeneous group of disorders as well ( Davidson, Pizzagalli, Nitschke, & Putnam, 2002 ). Thus, other scientific fields are taking tentative steps away from a syndromal view of depression and toward an idiographic analysis.

The Shift From Adaptive to Maladaptive Behavior

As discussed above, elicited affective experiences are normal, adaptive, and not disordered. Depression appears to be a maladaptive dysregulation or extension of this adaptive experience. Genetic vulnerabilities aside, it is important to identify the historical and environmental processes responsible for this shift from a normal, adaptive experience of elicited affect to a disordered experience of depression.

Obviously, chronically maladaptive environments may produce chronically maladaptive behavior. Perhaps the simplest and ultimate example of this is a concentration camp ( Frankel, 1984 ). Such an environment, almost completely lacking in positive reinforcers and abundant in stable and salient aversive stimuli, may result in rather consistent depressed behavior and negative affect. However, it is safe to say that most depressed people do not live in such environments. Processes through which environments characterized by variable positive and negative reinforcers and punishers result in relatively stable experiences of depression need to be identified. For example, consider a person who has a handful of close friends with whom she interacts with on a regular basis, men who are showing interest in her romantically, good career prospects including an upcoming promotion (all opportunities for positive reinforcement), but still cannot sleep at night and considers herself to be depressed. The question remains, why do so many people engage in repertoires that are more consistent with impoverished environments than with those environments in which they live? Below we consider two processes: avoidance of aversive private events and the role of verbal behavior.

Avoidance of Private Events

Two similar processes by which an adaptive elicited response can lead to chronic and maladaptive depression in the absence of chronically maladaptive environments recently have been proposed and linked to treatment techniques: Martell, Addis, and Jacobson's (2001) theory behind behavioral activation (BA) and Hayes et al.'s (1999) model of experiential avoidance for acceptance and commitment therapy (ACT). The two models differ in several respects (see Kanter, Baruch, & Gaynor, 2006 , for a full comparison).

Both models argue that problematic avoidance in depression is not always a response to the environment per se, but is a response to the core aversive experience of depression (which is in turn a response to the environment). Both models suggest that the core affective experience, once elicited, may play a functional role in maintaining, exacerbating, and creating the additional symptoms of depression. Specifically, if we allow that the initial elicited private response is functionally aversive, it may evoke behavior designed to avoid and escape the private response. For example, after a difficult breakup, a man may experience an increase in feelings of anxiety and negative self-referential thoughts. Although this individual now may avoid public stimuli based on formal stimulus properties (e.g., romantic relationships), he also may avoid the newly elicited thoughts and feelings in a variety of ways (e.g., heavy drinking). The key to understanding how this applies to depression is the notion that avoidance of private events, even when it works in the short term, produces additional long-term problems. In the example above, the man feels better in the short run after drinking, but the long-term consequences would likely include an even more impoverished environment. Through this process, flexible repertoires of problem solving and repertoires based on stable positive reinforcement are either extinguished, depotentiated, or never developed.

BA interventions have focused on disrupting how aversive private events can function as discriminative stimuli or motivating operations for avoidance behavior. For example, consider a client who stayed in bed all day because she felt depressed and thereby was able to avoid the additional stress and fatigue associated with her unpleasant work situation. Although she may experience her work situation as aversive to some extent at all times, the heaviness and fatigue experienced upon awakening in the morning and tacted as “feeling depressed” may signal that working would be experienced as especially aversive on that particular day. According to BA, staying in bed in this situation is negatively reinforced through avoidance of an especially aversive work day. However, it creates more long-term problems and solves none in that it does nothing to address the aversive work situation proactively ( Kanter et al., 2006 ).

ACT offers additional theoretical elaborations that suggest a more prominent role for verbal behavior in avoidance processes. First, ACT suggests that experiential avoidance repertoires are maintained over long periods of time because they are rule governed or verbally controlled ( Hayes & Ju, 1998 ). In other words, individuals develop rules that dictate experiential avoidance, and these rule-governed avoidance repertoires may persist in the face of histories of reinforcement to the contrary. For example, a depressed man may tell himself, “If bad things happen in my life, I will take it like a man.” Such self-talk may lead to denial of certain private events such as sadness or grief (e.g., after his father died) despite an environment that would shape more effective behavior (e.g., a loving wife who wants to discuss his feelings), were it not for verbal control.

There may in fact be no way to distinguish a rule-governed avoidance repertoire (i.e., ACT) from a directly conditioned avoidance repertoire (i.e., BA) in a clinical setting, in that the topographies may look similar, the relevant reinforcement histories are distal, and reporting on them accurately will be unreliable. At issue is the degree to which a depressed individual's avoidance is rule governed. In fact, Rehm (1979 , 1989) has argued that depressed individuals demonstrate deficits in the ability to generate and follow rules, and his self-management therapy program attempts to improve self-monitoring, self-evaluation, and self-reinforcement skills. In accord with these views are findings that depressed individuals demonstrate increased self-reported preferences for immediate over delayed reinforcement compared to nondepressed individuals, suggesting less rule following in depressed individuals ( Rehm & Plakosh, 1975 ). Two additional studies have shown that dysphoric individuals demonstrate greater schedule sensitivity and less rule-governed behavior compared to nondepressed individuals ( Baruch, Kanter, Busch, Richardson, & Barnes-Holmes, 2007 ; Rosenfarb, Burker, Morris, & Cush, 1993 ). However, these studies demonstrate significant variability in schedule sensitivity, and McAuliffe (2003) found the opposite (increased rule-governed behavior in depressed adolescents), again highlighting the need for idiographic analysis and acknowledging both increased rule-governed behavior and decreased rule-governed behavior to be problematic in depression.

To reiterate the important themes at this point, it bears repeating that an idiographic analysis is required. Some cases of depression may be adequately conceptualized in terms of Lewinsohn's (1974) traditional model of reductions in response-contingent positive reinforcement, whereas others may be more accurately conceptualized in terms of ACT's or BA's models of avoidance. In both the traditional model and the new conceptualizations, the core experience is seen as an elicited response to environmental events that produce reductions in positive reinforcement. However, the new conceptualizations speculate how one's reaction to that experience may in fact perpetuate and exacerbate it, and in some cases this may be the case.

The Functions of Private Events in Behavior Analysis

Allowing that a private response is functionally aversive creates some problems for behavior analysis. Simply put, the classic exhortation to focus functional analyses on manipulable environmental variables may lead some to conclude that private events are simple respondent by-products and have no functional value. This stance on the nonfunctional value of private events is one of the great perplexities of behavior analysis. It is a perplexity because, to most humans, thoughts and emotions—as we have come to label them—are not only felt quite strongly at times but it feels as if they control our behavior ( Schnaitter, 1978 ). This is especially true regarding avoidance behavior, which is often described as negatively reinforced by a reduction in aversive emotional experience (e.g., Barlow, 2002 ). In other words, it seems as if we avoid not only the conditions that occasion depression but also feeling depression itself. It may have been behavior analysts' rigid adherence to this simple view of private events, which runs counter to common sense for many researchers, therapists, and clients, that bolstered the cognitive revolution and the subsequent obsolescence of behavioral approaches to treatment of depression, as well as adult outpatient psychotherapy in general, which is dominated by “feeling” talk.

Skinner presented a much more nuanced and complex view. On the one hand, he consistently defined reinforcers and discriminative stimuli as environmental stimuli on pragmatic rather than ontological grounds ( Skinner, 1945 , 1953 ). Simply put, reinforcers are labeled as such only if functional analysis has determined, or at least in principle could determine, that a manipulable event evidences such a function. Private events in general are not manipulable in this sense and thus have been typically defined as dependent rather than independent variables. Put differently, Skinner consistently argued that emotions are not causes.

However, in other places Skinner allowed private events to participate, partially, in the control of behavior. For example, he wrote,

Emotional responses may be interpreted as in part an escape from the emotional components of anxiety. Thus we avoid the dentist's office, not only because it precedes painful stimulation and is therefore a negative reinforcer, but because, having preceded such stimulation, it arouses a complex emotional condition which is also aversive. The total effect may be extremely powerful. (1953, p. 179)

In this example, the emotional components of anxiety clearly have taken on functional stimulus properties. Likewise, Skinner's analysis of self-knowledge (1957, 1974) depended heavily on the supposition that private events exert discriminative control over tacting. In this case, the use of the term private event rather than private behavior may have been Skinner's acknowledgment of the complexity, but the complexity is not resolved simply by changing the term. In these cases, although the private events in question are assumed to have acquired at least partial control over other behavior, environmental variables are important for the historical development of the control (see also Hayes & Brownstein, 1986). For example, in the case of the tact of “sad,” the private stimulation involved is seen as the discriminative stimulus for the resulting tact, and that stimulation has obtained functional significance through social mediation ( Moore, 1980 ). Thus, it is consistent with behavior analysis (or at least, with behavior analysis's inconsistency) to allow functionally salient private events to evoke avoidance behavior.

The Role of Verbal Behavior in Depression

Perhaps the biggest obstacle for traditional behavioral theorists to overcome when discussing depression is the role of language. In general, an extremely large and unquestionable body of research establishes the presence of negative cognitive content during depressive episodes, leading cognitive researchers to assume a causal role for cognition in depression (D. A. Clark, Beck, & Alford, 1999 ). Although longitudinal research has failed to establish negative cognitive biases as independent predictors of depression ( Ingram, Miranda, & Segal, 1998 ), it is clear that thinking influences feeling on a moment-to-moment basis. Cognitive researchers see this influence as sufficiently causal, but behavior analysts instead search for environmental conditions responsible for such behavior–behavior relations ( Hayes & Brownstein, 1986 ). Regardless, it is clear that negative thinking predominates in many depressions, and such thinking may elicit aversive affect.

Research on stimulus equivalence (e.g., Sidman, 1994 ) readily accounts for the relation between cognition and mood. Simply put, through participation in equivalence relations with nonverbal stimuli, verbal stimuli may obtain eliciting functions. Although there are many examples of this effect, perhaps the clearest example is work by Dougher and colleagues on the transfer of aversive elicitation and avoidance functions through equivalence classes. Using match-to-sample procedures, Dougher, Augustson, Markham, Greenway, and Wulfert (1994) taught 8 subjects two four-member equivalence classes, paired one member of one class with electric shock, and then demonstrated transfer of elicited arousal to other members of the class that had not been directly paired with the shock. Augustson and Dougher (1997) subsequently demonstrated that avoidance responding similarly transfers through equivalence classes. After pairing one member of one class with shock, subjects were taught that they could avoid this member by repeatedly pressing a key on the keyboard. Subjects then demonstrated transfer of avoidance response functions to other class members.

Growing research on relational frame theory (RFT; Hayes, Barnes-Holmes, & Roche, 2001 ) extends these findings. According to RFT, verbal behavior (including thinking) is technically seen as the behavior of framing events relationally: responding to one stimulus in terms of its given or inferred relation to other stimuli. For example, a woman caught speeding receives a ticket. If that person thinks that people who get speeding tickets are bad drivers, she may then consider herself a bad driver. RFT views equivalence as just one type of relation (i.e., sameness ) and views deriving relations among stimuli in the absence of direct conditioning as a generalized operant ( Barnes-Holmes & Barnes-Holmes, 2000 ).

Responding in accordance with other derived relations has also been demonstrated, including relations of sameness, opposition , and difference ( Roche & Barnes, 1996 , 1997 ; Steele & Hayes, 1991 ; Whelan & Barnes-Holmes, 2004 ), more than and less than ( Dymond & Barnes, 1995 ; O'Hora, Roche, Barnes-Holmes, & Smeets, 2002 ; Whelan, Barnes-Holmes, & Dymond, 2006 ), and before and after ( O'Hora, Barnes-Holmes, Roche, & Smeets, 2004 ; see also Barnes & Roche, 1996 ; Hayes & Barnes, 1997 ). Evidence is mounting that these relations may result in the transformation of functions in accordance with the relations trained, akin to the transfer of function seen with equivalence relations (for a review, see Dymond & Rehfeldt, 2001 ). Thus if that same woman who received a speeding ticket has a history of avoiding authority figures who reprimanded her in the past (e.g., teachers and supervisors), she may then begin to avoid police officers as well. These stimulus functions may be quite arbitrary and unrelated to current environmental features. Thus, the behavior of relational framing has a potentially transformative effect on the environment; environmental stimuli that would otherwise control behavior may not do so and new stimuli, idiosyncratic to the individual's verbal learning history, may exert control.

The importance of these findings to depression, and other psychological disorders, cannot be overstated. To the extent that stimulus equivalence and RFT present a behavior-analytic model of language and cognition, these theories provide behavior analysts with a vocabulary and theory with which cognitive variables can be conceptualized and understood. Negative self-statements so often seen in depression acquire their meanings and functions through transformations of function that occur in relational framing. For verbal stimuli to obtain these specific functions, previous specific-exemplar training involving the specific stimuli participating in relational frames is not necessary. All that is necessary is a history that establishes relational framing as a generalized operant and a history in which the specific stimuli at issue are related in a relational network.

There appear to be two uses of the term relational network , and a brief diversion on this issue is necessary because one of the usages may be potentially confusing to behavior analysts. First, a relational network may refer to a sentence or another unit of speech that sets the context for relational activity ( Barnes-Holmes, Hayes, Dymond, & O'Hora, 2001 )—there is no issue with this usage. Second, a relational network may be used to graphically depict the full set of relations between specific stimuli and the transformations of function that are relevant to a particular stimulus. Such networks are often displayed in RFT or stimulus equivalence experiments to depict the specific relations trained, but a network may also be employed more loosely when the history can only be assumed. For example, Blackledge (2003) displayed a network to account for a person taking a walk in the woods that elicits fear due to a verbal history in which it was learned that snakes are to be found in woods. This usage bears considerable resemblance to nonbehavioral entities such as schemas and requires clarification. One has to be careful to maintain that the network, unlike a schema, is the not the cause of behavior. The network is a description of a history, and it is this history, along with the current environmental and verbal events, that functions as the cause. The history is described in terms of a network to emphasize how the functions of any term in the network may be transformed in accordance with the network, but such transformations are a product of a history of verbal behavior described as a network, not the network per se. It is easy to lose sight of behavior analysis at this point; thus, it is important to remember that these functions of relational framing were obtained through a history of interaction with the social and verbal community. Historical environmental factors result in the transformation and reduction of control by the current environment. These effects are easily described in terms of relational networks and stimulus functions that are transformed across members of the network.

The important point is that verbal behavior can dysregulate and extend normal adaptive experiences of aversive elicitation into disordered experiences. Consider an individual who has received a poor work evaluation. This naturally elicits aversive affect that, if transient, can be considered normal and adaptive. However, this individual may begin to think about the event, and the content of thinking will be a complex product of multiple historical and current antecedents. Given a history that has established high-strength relational networks of “loss,” “failure,” “helplessness,” or similar networks, a transient setback such as a poor job evaluation can become functionally overwhelming. The key point is that the core experience of depression, the elicited affect, was normal and adaptive without verbal elaboration. With verbal elaboration, however, the experience is magnified and extended, and may become disordered.

Examples of verbal elaborations of potentially normal experiences abound in the clinical literature on depression. In fact, cognitive therapy for depression ( Beck, Rush, Shaw, & Emery, 1979 ) assumes challenging these unrealistic verbal elaborations to be the primary task of therapy. Discussion of whether such cognitive interventions are successful, for the reasons cognitive therapists say they are, is beyond the scope of this paper. Rather, we simply highlight the finding that many depressed individuals appear to have become depressed in the absence of environmental histories that would indicate such a response to be adaptive, and point to verbal behavior to account for the elaboration of such histories into a disorder. Language vastly expands the range of situations that can function as depression-eliciting and depression-maintaining stimuli, because the functions of the stimuli largely may be determined by one's idiosyncratic verbal learning history.

As an example, a depressed individual may respond to all social events as participating in a verbal relation with a host of other aversive stimuli (e.g., the words fake, small-talk, embarrassment, boring, stressful, idiot, foolish, exposed and the words for a range of aversive private sensations germane to escape, panic, etc.). Although another individual may respond to the relation between the stimuli party and stressful on occasion, there is flexibility in responding based on other historical and contextual features. For the depressed individual, however, this verbal class may be so well formed through a fairly idiosyncratic history of verbal and nonverbal pairings of these stimuli, and so negatively reinforced through past derived escape and avoidance experiences, that there may be few or no contexts in which the term party does not elicit the functions of other aversive stimuli or function as a derived discriminative stimulus for escape or avoidance. This rigid avoidance repertoire vastly narrows the range of behavioral options available and most likely will lead to rather stable reductions in response-contingent social reinforcement.

The Function of Rumination

In addition to negative cognitive content in depression, research clearly identifies a particular ruminative cognitive style in depression. In fact, a ruminative cognitive style predicts the onset ( Just & Alloy, 1997 ; Nolen-Hoeksema, 2000 ), length ( Umberson, Wortman, & Kessler, 1992 ), and severity ( Nolen-Hoeksema, Parker, & Larson, 1994 ) of depressive episodes. Depressed individuals may spend long periods of time “lost in thought,” rehashing events of the day and stewing over problems; this leads to increased negatively biased thoughts, poor problem solving, inhibition of operant behavior, impaired concentration, increased stress, and increased problems ( Lyubomirsky & Tkach, 2004 ). A complete behavioral analysis of depression needs to account for the relation between negative cognitive content and depressed mood as well as the function of rumination.

An appreciation of the somewhat unique features of verbal behavior in terms of antecedent and consequential control provides some insight into the function of rumination in depression. First, it bears repeating that thinking, like any behavior, is under the control of multiple and complex historical and situational stimuli. Consider a depressed student attending a lecture in a class in which she is doing poorly. She is having a hard time keeping up with the professor, and thoughts about her poor performance on the last test occur. The initial stimuli for such thoughts are obvious. As this continues, it is common that this student may end up thinking about a completely different topic, with unexpected twists and turns in thought, arriving at thoughts that she will never get her degree, that there must be something wrong with her brain, and that she is a complete failure. She now begins to think about a negative interaction with a friend the previous day, and thinks that her friendship was never genuine, that she is a failure as a friend as well as in school, and so forth. These twists and turns may increasingly be under the stimulus control of previous thoughts and decreasingly under the control of the current external environment. As described by RFT, the contextual cues that occasion relational framing and its content may themselves be relational and arbitrary in nature; thus, other than previous verbal behavior (which may be private), little environmental support is necessary to occasion verbal behavior and control its content. This in fact is consistent with Skinner's (1953) account. As Skinner put it, “The speaker's own verbal behavior automatically supplies stimuli for echoic, textual, or intraverbal behavior, and these in turn generate stimuli for further responses” (p. 439). He referred to such a thinking process as a “simple soliloquy” and noted, “Regardless of the respectability of the connections, such a ‘train of thought’ … is scarcely to be distinguished from a ‘flight of ideas’” (p. 439). We may refer to such thinking instead as rumination.

The question of reinforcing variables for such behavior remains. RFT suggests that verbal behavior occurs so frequently and relentlessly because of a history of reinforcement provided by the wider community for coherence or sense making in one's verbal behavior (see Hayes et al., 1999 ). It is argued that during early language-training experiences, the verbal behavior of the speaker is evaluated for coherence by the verbal community and is differentially reinforced. Over time, these processes (the verbal behavior, its evaluation in terms of coherence, and its reinforcement) become covert and automatic so that the derivation and rehearsal of coherent verbal relations becomes self-reinforcing (see Barnes-Holmes et al., 2001 ). Skinner (1953) highlighted that thinking is productive, in that it has an effect on the thinker and is reinforcing because it does so. Both processes are undoubtedly applicable. We would like the depressed student to think about her class performance and the poor friend interaction in such a way that it leads to improved performances and interactions in the future, but in many cases it does not. More likely is an avoidance function—the rumination may function to reduce the anxiety about the class performance and the interaction without increasing the anxiety of dealing with the problems in the moments they occur. As long as the cognitive solutions make sense and reduce anxiety, the rumination may continue, even if it is ultimately unproductive.

Accepting that sense making is reinforcing, one may still argue that the content of rumination often does not make sense and should not be reinforcing. In the current example, one poor performance in a class does not make one a failure as a student, and one poor friend interaction does not make one a failure as a friend. Indeed, pointing out that such content is not logical and is not evidence based is the hallmark of cognitive therapy ( Beck et al., 1979 ). However, to a behavior analyst sense making is idiographic and occurs in the context of the individual's unique history and experiences. For this individual, we would expect a history in which other negative experiences were interpreted as evidence of complete failure by caregivers and important others, or something similar ( Bolling, Kohlenberg, & Parker, 2000 ). The current context also plays a role: The negative affect of depression provides a context in which interpretations of failure make sense, and the interpretation of friendship failure makes sense given the previous interpretation of school failure.

An important point is that as this individual continues to ruminate, the class lecture is continuing and the student is now largely divorced from contact with any potentially external controlling variables. Thus, verbal behavior, when it occurs, may be quite relentless in overpowering, transforming, and reducing environmental control. As seen in the example of rumination, if the aforementioned student continues ruminative thought throughout her class period she would not be engaged in class discussions and would therefore miss any opportunities of praise or encouragement from the professor. She may also miss necessary information for her next assignment, thereby not only reducing her rate of receiving response-contingent reinforcement but also increasing the likelihood of punishment through a lowered grade. After leaving class and realizing this mistake, she may continue to ruminate now about her difficulty in lecture as well as her previous interaction, which results in further attentional distancing from her immediate environment and additional negative affect.

Summary and Conclusions

There are many pathways to depression. Depression is not a precise, technical term, has no essential composition, and is not a syndrome. The term refers to a core experience of feeling sad or down and to associated symptoms that vary widely. This symptomatic heterogeneity is due to the heterogeneity of historical antecedents and consequences. The core experience may be seen as an elicited by-product of losses of, reductions in, or persistently insufficient levels of positive reinforcement. However, Lewinsohn (1974) , with his focus on environments characterized directly by losses of response-contingent positive reinforcement, presented a fairly unitary operant model that obscured the heterogeneity of depressive symptom profiles. Given the ubiquity of depression and the diversity of its symptom presentations, both reductions in positive reinforcement and increases in aversive control may function as enduring motivating operations ( Dougher & Hackbert, 2000 ). Of course, multiple sources of control are probable. Thus, idiographic assessment is required to determine both the relative importance of positive and aversive control and to determine specific target variables for any given individual. Clinical behavior analysts treating depression would be well served to engage in detailed, idiographic, and historical functional assessments that inform treatment course and technique.

We argue that a modern behavioral account of depression must incorporate controlling variables at both environmental and interoceptive levels, with a recognition of the role of avoidance and verbal behavioral processes. We have emphasized that the core experience of depression is a private event—elicited negative affect that is felt and tacted in a variety of ways. This affect itself is not problematic and is in fact adaptive, but it becomes chronic, maladaptive, or dysregulated through environmental and learned behavioral processes. A key process may be avoidance: Responses to the original private events that function to avoid or escape the event may be negatively reinforced and establish a cycle of increasing negative affect and avoidance, a vicious spiral into depression.

Verbal processes may be particularly important as well, in that research on stimulus equivalence and RFT clearly demonstrates how private stimulus events can be transformed and elaborated when related verbally to other events. Thus, stimulus events that would not otherwise function to elicit depressive affect may come to do so through verbal processes, already aversive stimuli may become more so through verbal processes, and verbal processes may establish avoidance and other dysfunctional responses to such stimuli that otherwise would not be established. Rumination—a hallmark feature of depression—is an example of how verbal behavioral processes may result in negative reinforcement through reducing contact with the current physical environment but exacerbate depressive functioning. Behavior-analytic research on the role of verbal processes in depression is in its infancy, but as research in these areas continues to accumulate, analyses of complex phenomena such as depression may benefit greatly.

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Major depressive disorder: Validated treatments and future challenges
INTRODUCTION. Depression is a common psychiatric disorder and a major contributor to the global burden of diseases. According to the World Health Organization, depression is the second-leading cause of disability in the world and is projected to rank first by 2030[].Depression is also associated with high rates of suicidal behavior and mortality[].
Biological, Psychological, and Social Determinants of Depression: A
In this paper, we describe and present the vast, fragmented, and complex literature related to this topic. This review may be used to guide practice, public health efforts, policy, and research related to mental health and, specifically, depression. ... This paper discusses key areas in depression research; however, an exhaustive discussion of ...
The neuroscience of depressive disorders: A brief review of the past
Notably, biases in emotional information processing seem to be not only observable in currently depressed individuals, but also in individuals at risk for depression, such as those with a history of depressive disorder (LeMoult et al., 2009), a first-degree relative with depression (Le Masurier et al., 2007), certain genetic variants (Pérez ...
Treatment outcomes for depression: challenges and opportunities
Our lack of knowledge cannot be put down to a scarcity of research in existing treatments. In the past decades, more than 500 randomised trials have examined the effects of antidepressant medications, and more than 600 trials have examined the effects of psychotherapies for depression (although comparatively few are conducted for early-onset depression).
The serotonin theory of depression: a systematic umbrella ...
Authors of papers were contacted for clarification when data was missing or unclear. ... with most research on depression focusing on the 5-HT 1A receptor [11, 34].
Psychological treatment of depression: A systematic overview of a 'Meta
The paper gives a complete overview of what is known about therapies for depression. ... we have developed a 'Meta-analytic Research Domain' (MARD) of all randomized trials of psychological treatments of depression. ... Depression in most studies was moderate to severe. Response (50 % improvement between baseline and endpoint) was the main ...
Major Depressive Disorder: Advances in Neuroscience Research and
Analysis of Published Papers. In the past decade, the total number of papers on depression published worldwide has increased year by year as shown in Fig. Fig.1A. 1 A. Searching the Web of Science database, we found a total of 43,863 papers published in the field of depression from 2009 to 2019 (search strategy: TI = (depression$) or ts = ("major depressive disorder$")) and py = (2009-2019 ...
Major depressive disorder: hypothesis, mechanism, prevention and
In addition, it has been observed that stimulating NLRP3 inflammasome assembly can induce depression-like behaviors in rodents exposed to LPS or CUMS. 156,157 Research on the effect of astrocyte ...
Advances in depression research: second special issue, 2020, with
The current speed of progress in depression research is simply remarkable. We have therefore been able to create a second special issue of Molecular Psychiatry, 2020, focused on depression, with ...
Depression Research and Treatment
Depression Research and Treatment, First Published: 16 May 2024; Full text; PDF; References; Research Article. Open access. The Prevalence of Depression and Anxiety and Its Association with Sleep Quality in the First‐Year Medical Science Students.
Depression and Anxiety
Depression and Anxiety welcomes original research and review articles covering neurobiology (genetics and neuroimaging), epidemiology, experimental psychopathology, and treatment (psychotherapeutic and pharmacologic) aspects of mood and anxiety disorders and related phenomena in humans.
(PDF) Depression
PDF | Major depression is a mood disorder characterized by a sense of inadequacy, despondency, decreased activity, pessimism, anhedonia and sadness... | Find, read and cite all the research you ...
Depression
Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. The American Psychiatric Association's Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies the depressive disorders into: … Depression is a mood disorder that causes a persistent feeling of sadness and loss of ...
The Experience of Depression: A Qualitative Study of Adolescents With
Dundon (2006) reviewed the current state of research in her meta-synthesis and was able to include six qualitative studies of depressed and non-depressed adolescents. All studies were carried out in North America with two more recent additions from Australia ( McCann, Lubman, & Clark, 2012 ) and the United Kingdom ( Midgley et al., 2015 ).
The Critical Relationship Between Anxiety and Depression
Across all psychiatric disorders, comorbidity is the rule (), which is definitely the case for anxiety and depressive disorders, as well as their symptoms.With respect to major depression, a worldwide survey reported that 45.7% of individuals with lifetime major depressive disorder had a lifetime history of one or more anxiety disorder ().These disorders also commonly coexist during the same ...
Six distinct types of depression identified in Stanford Medicine-led
Stanford Medicine-led research identifies a subtype of depression. Using surveys, cognitive tests and brain imaging, researchers have identified a type of depression that affects about a quarter of patients. The goal is to diagnose and treat the condition more precisely.
An Exploratory Study of Students with Depression in Undergraduate
Depression is a top mental health concern among undergraduates and has been shown to disproportionately affect individuals who are underserved and underrepresented in science. As we aim to create a more inclusive scientific community, we argue that we need to examine the relationship between depression and scientific research. While studies have identified aspects of research that affect ...
Anxiety, Depression and Quality of Life—A Systematic Review of Evidence
The forward reference search was conducted until January 2021 using Web of Science to identify cited papers. 2.2. Study Selection Process. The study selection process is ... A systematic review from the European depression in diabetes (EDID) research consortium. Curr. Diabetes Rev. 2009; 5:112-119. doi: 10.2174/157339909788166828. [PMC free ...
Enhancing psychological well-being in college students: the mediating
The prevalence of depression among college students is higher than that of the general population. Although a growing body of research suggests that depression in college students and their potential risk factors, few studies have focused on the correlation between depression and risk factors. This study aims to explore the mediating role of perceived social support and resilience in the ...
Effects of Psilocybin-Assisted Therapy on Major Depressive Disorder
Secondary outcome measures for depressive symptoms were the Beck Depression Inventory II (score range: 0-63, with higher scores indicating severe depression) 40 and the 9-item Patient Health Questionnaire (score range: 0-27, with higher scores indicating severe depression). 41 The Columbia-Suicide Severity Rating Scale (severity of ideation ...
Depression
Depression refers to a state of low mood that can be accompanied with loss of interest in activities that the individual normally perceived as pleasurable, altered appetite and sleep/wake balance ...
Associations of Depression, Anxiety, Worry, Perceived Stress, and
Number of distress types is a count of probable depression, probable anxiety, somewhat or very worried about COVID, highest-quartile perceived stress, and lonely some of the time or often. ... In contrast to the Matta et al. paper which asked participants whether they thought they had had COVID-19 ("Since March, do you think you have been ...
Phonetic cues to depression: A sociolinguistic perspective
The current paper reviews research from both fields and considers the implications they have for each other, ... (Ladd, p.c.), argues that 'social presentation' is a variable that should be 'taken into account' in speech depression research (Ellgring & Scherer, 1996, p. 87).
Evolution and Emerging Trends in Depression Research From 2004 to 2019
Econometric analysis of the relationship between vitamin D deficiency and depression was performed by Yunzhi et al. and Shauni et al. performed a bibliometric analysis of domestic and international research papers on depression-related genes from 2003 to 2007. A previous review of depression-related bibliometric studies revealed that there is ...
Mental Health Outcomes in Transgender and Nonbinary Youths Receiving
This cohort study investigates whether gender-affirming care is associated with decreased depression, anxiety, and suicidality among transgender and ... VanderWeele TJ, Ding P. Sensitivity analysis in observational research: introducing the E-value. Ann Intern Med. 2017;167(4) :268-274. doi:10.7326 ... citing six papers to support ...
Living a private lie: intersectional stigma, depression and suicidal
Background Limited research has been conducted on the forms, manifestations and effects of intersectional stigma among young HIV-positive men who have sex with men (MSM) and transgender women (TGW) in Zambia. In this study, we aimed to address this gap by elucidating the experiences of these in a small group of young, HIV + MSM and TGW in Zambia. Methods We applied a mixed-methods design. Data ...
Systematic review and meta-analysis of depression, anxiety, and
Among 16 studies reporting the prevalence of clinically significant symptoms of depression across 23,469 Ph.D. students, the pooled estimate of the proportion of students with depression was 0.24 ...
Mindfulness-based interventions in mental health populations.
The continued interest in mindfulness-based interventions (MBIs) has been paralleled by scientific research investigating the effects of these types of programs on a wide variety of client populations as well as in healthy individuals. Research in this area has expanded exponentially in the past decades. Due to the exponential growth in research, this chapter focuses primarily on systematic ...
The Nature of Clinical Depression: Symptoms, Syndromes, and Behavior
More relevant to the current paper is the possibility that the exhaustive medicalization of the term; the wealth of non-behavior-analytic research data on biology and genetics, personality, and cognitive factors; and the emphasis on private events in depression—on how depression feels and on changing that feeling—may function to evoke ...
Trigeminal ganglion neurons are directly activated by influx of CSF
Current evidence suggests that migraine headache is driven by activation of sensory nerve endings in the dura mater (10-14).However, efflux of cortical solutes to dura mater is limited by the arachnoid barrier layer, and these solutes only pass into dura mater along bridging veins draining into the the meningeal lymphatics and parasagittal spaces close to the major venous sinuses (15-19 ...

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Six distinct types of depression identified in Stanford Medicine-led study

Biotypes predict treatment response

Further explorations of depression

Hope amid crisis

Enhancing psychological well-being in college students: the mediating role of perceived social support and resilience in coping styles

Introduction

Hypothesis 1

Hypothesis 2

Hypothesis 3

Hypothesis 4

Data and methods

Trait coping style questionnaire

Depression scale

Resilience scale

Statistical analysis

Examination of common method bias

Descriptive statistics and correlation analysis

Analysis of chain mediation effects

Mechanisms of the impact of PC/NC on depression in college students

Separate mediating effects of perceived social support and resilience

Chain mediation effect of perceived social support and psychological resilience

Limitations, strengths and future research

Data availability

Abbreviations

Acknowledgements

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Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care

Living a private lie: intersectional stigma, depression and suicidal thoughts for selected young key populations living with HIV in Zambia

Introduction

Intersectional stigma, sexual and gender diversity and HIV: a conceptual framework

Methodology

Study population

Data collection

Data analysis

Quantitative results

Effects on mental health

Symptoms of depression

Thoughts and experiences of suicide

Qualitative results

The nature and extent of these experiences

HIV, sexual orientation and gender identity disclosure

Dual identity

Challenges of finding and maintaining sexual partners

Coping strategies and resilience

Strengths and limitations of the study

Data availability

Acknowledgements

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