mental health issues in phd students

‘You have to suffer for your PhD’: poor mental health among doctoral researchers – new research

Lecturer in Social Sciences, University of Westminster

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Cassie Hazell has received funding from the Office for Students.

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PhD students are the future of research, innovation and teaching at universities and beyond – but this future is at risk. There are already indications from previous research that there is a mental health crisis brewing among PhD researchers.

My colleagues and I studied the mental health of PhD researchers in the UK and discovered that, compared with working professionals, PhD students were more likely to meet the criteria for clinical levels of depression and anxiety. They were also more likely to have significantly more severe symptoms than the working-professional control group.

We surveyed 3,352 PhD students, as well as 1,256 working professionals who served as a matched comparison group . We used the questionnaires used by NHS mental health services to assess several mental health symptoms.

More than 40% of PhD students met the criteria for moderate to severe depression or anxiety. In contrast, 32% of working professionals met these criteria for depression, and 26% for anxiety.

The groups reported an equally high risk of suicide. Between 33% and 35% of both PhD students and working professionals met the criteria for “suicide risk”. The figures for suicide risk might be so high because of the high rates of depression found in our sample.

We also asked PhD students what they thought about their own and their peers’ mental health. More than 40% of PhD students believed that experiencing a mental health problem during your PhD is the norm. A similar number (41%) told us that most of their PhD colleagues had mental health problems.

Just over a third of PhD students had considered ending their studies altogether for mental health reasons.

There is clearly a high prevalence of mental health problems among PhD students, beyond those rates seen in the general public. Our results indicate a problem with the current system of PhD study – or perhaps with academic more widely. Academia notoriously encourages a culture of overwork and under-appreciation.

This mindset is present among PhD students. In our focus groups and surveys for other research , PhD students reported wearing their suffering as a badge of honour and a marker that they are working hard enough rather than too much. One student told us :

“There is a common belief … you have to suffer for the sake of your PhD, if you aren’t anxious or suffering from impostor syndrome, then you aren’t doing it "properly”.

We explored the potential risk factors that could lead to poor mental health among PhD students and the things that could protect their mental health.

Financial insecurity was one risk factor. Not all researchers receive funding to cover their course and personal expenses, and once their PhD is complete, there is no guarantee of a job. The number of people studying for a PhD is increasing without an equivalent increase in postdoctoral positions .

Another risk factor was conflict in their relationship with their academic supervisor . An analogy offered by one of our PhD student collaborators likened the academic supervisor to a “sword” that you can use to defeat the “PhD monster”. If your weapon is ineffective, then it makes tackling the monster a difficult – if not impossible – task. Supervisor difficulties can take many forms. These can include a supervisor being inaccessible, overly critical or lacking expertise.

A lack of interests or relationships outside PhD study, or the presence of stressors in students’ personal lives were also risk factors.

We have also found an association between poor mental health and high levels of perfectionism, impostor syndrome (feeling like you don’t belong or deserve to be studying for your PhD) and the sense of being isolated .

Better conversations

Doctoral research is not all doom and gloom. There are many students who find studying for a PhD to be both enjoyable and fulfilling , and there are many examples of cooperative and nurturing research environments across academia.

Studying for a PhD is an opportunity for researchers to spend several years learning and exploring a topic they are passionate about. It is a training programme intended to equip students with the skills and expertise to further the world’s knowledge. These examples of good practice provide opportunities for us to learn about what works well and disseminate them more widely.

The wellbeing and mental health of PhD students is a subject that we must continue to talk about and reflect on. However, these conversations need to happen in a way that considers the evidence, offers balance, and avoids perpetuating unhelpful myths.

Indeed, in our own study, we found that the percentage of PhD students who believed their peers had mental health problems and that poor mental health was the norm, exceeded the rates of students who actually met diagnostic criteria for a common mental health problem . That is, PhD students may be overestimating the already high number of their peers who experienced mental health problems.

We therefore need to be careful about the messages we put out on this topic, as we may inadvertently make the situation worse. If messages are too negative, we may add to the myth that all PhD students experience mental health problems and help maintain the toxicity of academic culture.

• Mental health
• Academic life
• PhD research

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• Published: 26 August 2020

Understanding the mental health of doctoral researchers: a mixed methods systematic review with meta-analysis and meta-synthesis

• Cassie M. Hazell   ORCID: orcid.org/0000-0001-5868-9902 1 ,
• Laura Chapman 2 ,
• Sophie F. Valeix 3 ,
• Paul Roberts 4 ,
• Jeremy E. Niven 5 &
• Clio Berry 6  

Systematic Reviews volume  9 , Article number:  197 ( 2020 ) Cite this article

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Data from studies with undergraduate and postgraduate taught students suggest that they are at an increased risk of having mental health problems, compared to the general population. By contrast, the literature on doctoral researchers (DRs) is far more disparate and unclear. There is a need to bring together current findings and identify what questions still need to be answered.

We conducted a mixed methods systematic review to summarise the research on doctoral researchers’ (DRs) mental health. Our search revealed 52 articles that were included in this review.

The results of our meta-analysis found that DRs reported significantly higher stress levels compared with population norm data. Using meta-analyses and meta-synthesis techniques, we found the risk factors with the strongest evidence base were isolation and identifying as female. Social support, viewing the PhD as a process, a positive student-supervisor relationship and engaging in self-care were the most well-established protective factors.

Conclusions

We have identified a critical need for researchers to better coordinate data collection to aid future reviews and allow for clinically meaningful conclusions to be drawn.

Systematic review registration

PROSPERO registration CRD42018092867

Peer Review reports

Student mental health has become a regular feature across media outlets in the United Kingdom (UK), with frequent warnings in the media that the sector is facing a ‘mental health crisis’ [ 1 ]. These claims are largely based on the work of regulatory authorities and ‘grey’ literature. Such sources corroborate an increase in the prevalence of mental health difficulties amongst students. In 2013, 1 in 5 students reported having a mental health problem [ 2 ]. Only 3 years later, however, this figure increased to 1 in 4 [ 3 ]. In real terms, this equates to 21,435 students disclosing mental health problems in 2013 rising to 49,265 in 2017 [ 4 ]. Data from the Higher Education Statistics Agency (HESA) demonstrates a 210% increase in the number of students terminating their studies reportedly due to poor mental health [ 5 ], while the number of students dying by suicide has consistently increased in the past decade [ 6 ].

This issue is not isolated to the UK. In the United States (US), the prevalence of student mental health problems and use of counselling services has steadily risen over the past 6 years [ 7 ]. A large international survey of more than 14,000 students across 8 countries (Australia, Belgium, Germany, Mexico, Northern Ireland, South Africa, Spain and the United States) found that 35% of students met the diagnostic criteria for at least one common mental health condition, with highest rates found in Australia and Germany [ 8 ].

The above figures all pertain to undergraduate students. Finding equivalent information for postgraduate students is more difficult, and where available tends to combine data for postgraduate taught students and doctoral researchers (DRs; also known as PhD students or postgraduate researchers) (e.g. [ 4 ]). The latest trend analysis based on data from 36 countries suggests that approximately 2.3% of people will enrol in a PhD programme during their lifetime [ 9 ]. The countries with the highest number of DRs are the US, Germany and the UK [ 10 ]. At present, there are more than 281,360 DRs currently registered across these three countries alone [ 11 , 12 ], making them a significant part of the university population. The aim of this systematic review is to bring attention specifically to the mental health of DRs by summarising the available evidence on this issue.

Using a mixed methods approach, including meta-analysis and meta-synthesis, this review seeks to answer three research questions: (1) What is the prevalence of mental health difficulties amongst DRs? (2) What are the risk factors associated with poor mental health in DRs? And (3) what are the protective factors associated with good mental health in DRs?

Literature search

We conducted a search of the titles and abstracts of all article types within the following databases: AMED, BNI, CINAHL, Embase, HBE, HMIC, Medline, PsycInfo, PubMed, Scopus and Web of Science. The same search terms were used within all of the databases, and the search was completed on the 13th April 2018. Our search terms were selected to capture the variable terms used to describe DRs, as well as the terms used to describe mental health, mental health problems and related constructs. We also reviewed the reference lists of all the papers included in this review. Full details of the search strategy are provided in the supplementary material .

Inclusion criteria

Articles meeting the following criteria were considered eligible for inclusion: (1) the full text was available in English; (2) the article presented empirical data; (3) all study participants, or a clearly delineated sub-set, were studying at the doctoral level for a research degree (DRs or equivalent); and (4) the data collected related to mental health constructs. The last of these criteria was operationalised (a) for quantitative studies as having at least one mental health-related outcome measure, and (b) for qualitative studies as having a discussion guide that included questions related to mental health. We included university-published theses and dissertations as these are subjected to a minimum level of peer-review by examiners.

Exclusion criteria

In order to reduce heterogeneity and focus the review on doctoral research as opposed to practice-based training, we excluded articles where participants were studying at the doctoral level, but their training did not focus on research (e.g. PsyD doctorate in Clinical Psychology).

Screening articles

Papers were screened by one of the present authors at the level of title, then abstract, and finally at full text (Fig. 1 ). Duplicates were removed after screening at abstract. At each level of screening, a random 20% sub-set of articles were double screened by another author, and levels of agreement were calculated (Cohen’s kappa [ 13 ]). Where disagreements occurred between authors, a third author was consulted to decide whether the paper should or should not be included. All kappa values evidence at least moderate agreement between authors [ 14 ]—see Fig. 1 for exact kappa values.

PRISMA diagram of literature review process

Data extraction

This review reports on both quantitative and qualitative findings, and separate extraction methods were used for each. Data extraction was performed by authors CH, CB, SV and LC.

Quantitative data extraction

The articles in this review used varying methods and measures. To accommodate this heterogeneity, multiple approaches were used to extract quantitative data. Where available, we extracted (a) descriptive statistics, (b) correlations and (c) a list of key findings. For all mental health outcome measures, we extracted the means and standard deviations for the DR participants, and where available for the control group (descriptive statistics). For studies utilising a within-subjects study design, we extracted data where a mental health outcome measure was correlated with another construct (correlations). Finally, to ensure that we did not lose important findings that did not use descriptive statistics or correlations, we extracted the key findings from the results sections of each paper (list of key findings). Key findings were identified as any type of statistical analysis that included at least one mental health outcome.

Qualitative data extraction

In line with the meta-ethnographic method [ 15 ] and our interest in the empirical data as well as the authors’ interpretations thereof, i.e. the findings of each article [ 16 ], the data extracted from the articles comprised both results/findings and discussion/conclusion sections. For articles reporting qualitative findings, we extracted the results and discussion sections from articles verbatim. Where articles used mixed methods, only the qualitative section of the results was extracted. Methodological and setting details from each article were also extracted and provided (see Appendix A) in order to contextualise the studies.

Data analysis

Quantitative data analysis, descriptive statistics.

We present frequencies and percentages of the constructs measured, the tools used and whether basic descriptive statistics ( M and SD ) were reported. The full data file is available from the first author upon request.

Effect sizes

Where studies had a control group, we calculated a between-group effect size (Cohen’s d ) using the formula reported by Wilson [ 17 ], and interpreted using the standard criteria [ 13 ]. For all other studies, we sought to compare results with normative data where the following criteria were satisfied: (a) at least three studies reported data using the same mental health assessment tool; (b) empirical normative data were available; and (c) the scale mean/total had been calculated following original authors’ instructions. Only the Perceived Stress Scale (PSS) 10- [ 18 ] and 14-item versions [ 19 ] met these criteria. Normative data were available from a sample of adults living in the United States: collected in 2009 for the 10-item version ( n = 2000; M = 15.21; SD = 7.28) [ 20 ] and in 1983 for the 14-item version ( n = 2355; M = 19.62; SD = 7.49) [ 18 ].

The meta-analysis of PSS data was conducted using MedCalc [ 21 ], and based on a random effects model, as recommended by [ 22 ]. The between-group effect sizes (DRs versus US norms) were calculated comparing PSS means and standard deviations in the respective groups. The effect sizes were weighted using the variable variances [ 23 ].

Correlations

Where at least three studies reported data reflecting a bivariate association between a mental health and another variable, we summarised this data into a meta-analysis using the reported r coefficients and sample sizes. Again, we used MedCalc [ 21 ] to conduct the analysis using a random effects model, based on the procedure outlined by Borenstein, Hedges, Higgins and Rothstein [ 24 ]. This analysis approach involves converting correlation coefficients into Fisher’s z values [ 25 ], calculating the summary of Fisher’s z , and then converting this to a summary correlation coefficient ( r ). The effect sizes were weighted in line with the Hedges and Ollkin [ 23 ] method. Heterogeneity was assessed using the Q statistic, and I 2 value—both were interpreted according to the GRADE criteria [ 26 ]. Where correlations could not be summarised within a meta-analysis, we have reported these descriptively.

Due to the heterogenous nature of the studies, the above methods could not capture all of the quantitative data. Therefore, additional data (e.g. frequencies, statistical tests) reported in the identified articles was collated into a single document, coded as relating to prevalence, risk or protective factors and reported as a narrative review.

Qualitative data analysis

We used thematic analytic methods to analyse the qualitative data. We followed the thematic synthesis method [ 16 , 27 ] and were informed by a thematic analysis approach [ 28 , 29 ]. We took a critical realist epistemological stance [ 30 , 31 ] and aimed to bring together an analysis reflecting meaningful patterns amongst the data [ 29 ] or demi-regularities, and identifying potential social mechanisms that might influence the experience of such phenomena [ 31 ]. The focus of the meta-synthesis is interpretative rather than aggregative [ 32 ].

Coding was line by line, open and complete. Following line-by-line coding of all articles, a thematic map was created. Codes were entered on an article-by-article basis and then grouped and re-grouped into meaningful patterns. Comparisons were made across studies to attempt to identify demi-regularities or patterns and contradictions or points of departure. The thematic map was reviewed in consultation with other authors to inductively create and refine themes. Thematic summaries were created and brought together into a first draft of the thematic structure. At this point, each theme was compared against the line-by-line codes and the original articles in order to check its fit and to populate the written account with illustrative quotations.

Research rigour

The qualitative analysis was informed by independent coding by authors CB and SV, and analytic discussions with CH, SV and LC. Our objective was not to capture or achieve inter-rater reliability, rather the analysis was strengthened through involvement of authors from diverse backgrounds including past and recent PhD completion, experiences of mental health problems during PhD completion, PhD supervision experience, experience as employees in a UK university doctoral school and different nationalities. In order to enhance reflexivity, CB used a journal throughout the analytic process to help notice and bracket personal reflections on the data and the ways in which these personal reflections might impact on the interpretation [ 29 , 33 ]. The ENTREQ checklist [ 34 ] was consulted in the preparation of this report to improve the quality of reporting.

Quality assessment

Quantitative data.

The quality of the quantitative papers was assessed using the STROBE combined checklist [ 35 ]. A random 20% sub-sample of these studies were double-coded and inter-rater agreement was 0.70, indicating ‘substantial’ agreement [ 14 ]. The maximum possible quality score was 23, with a higher score indicating greater quality, with the mean average of 15.97, and a range from 0 to 22. The most frequently low-scoring criteria were incomplete reporting regarding the management of missing data, and lack of reported efforts to address potential causes of bias.

Qualitative data

There appeared to be no discernible pattern in the perceived quality of studies; the highest [ 36 , 37 , 38 , 39 , 40 ] and lowest scoring [ 41 , 42 , 43 , 44 , 45 , 46 ] studies reflected both theses and journal publications, a variety of locations and settings and different methodologies. The most frequent low-scoring criteria were relating to the authors’ positions and reflections thereof (i.e. ‘Qualitative approach and research paradigm’, ‘Researcher characteristics and reflexivity’, ‘Techniques to enhance trustworthiness’, ‘Limitations’, ‘Conflict of interest and Funding’). Discussions of ethical issues and approval processes was also frequently absent. We identified that we foregrounded higher quality studies in our synthesis in that these studies appeared to have greater contributions reflected in the shape and content of the themes developed and were more likely to be the sources of the selected illustrative quotes.

Mixed methods approach

The goal of this review is to answer the review questions by synthesising the findings from both quantitative and/or qualitative studies. To achieve our goal, we adopted an integrated approach [ 47 ], whereby we used both quantitative and qualitative methods to answer the same review question, and draw a synthesised conclusion. Different analysis approaches were used for the quantitative and qualitative data and are therefore initially reported separately within the methods. A separate synthesised summary of the findings is then provided.

Overview of literature

Of the 52 papers included in this review (Table 1 ), 7 were qualitative, 29 were quantitative and 16 mixed methods. Most articles (35) were peer-reviewed papers, and the minority were theses (17). Only four of the articles included a control group; in three instances comprising students (but not DRs) and in the other drawn from the general population.

Quantitative results

Thirty-five papers reported quantitative data, providing 52 reported sets of mental health related data (an average of 1.49 measures per study): 24 (68.57%) measured stress, 10 (28.57%) anxiety, 9 (25.71%) general wellbeing, 5 (14.29%) social support, 3 (8.57%) depression and 1 (2.86%) self-esteem. Five studies (9.62%) used an unvalidated scale created for the purposes of the study. Fifteen studies (28.85%) did not report descriptive statistics.

Of the four studies that included a control group, only two of these reported descriptive statistics for both groups on a mental health outcome [ 66 , 69 ]. There is a small (Cohen’s d = 0.27) and large between-group effect (Cohen’s d = 1.15) when DRs were compared to undergraduate and postgraduate clinical psychology students respectively in terms of self-reported stress.

The meta-analysis of DR scores on the PSS (both 10- and 14-item versions) compared to population normative data produced a large and significant between-group effect size ( d = 1.12, 95% CI [0.52, 1.73]) in favour of DRs scoring higher on the PSS than the general population (Fig. 2 ), suggesting DRs experience significantly elevated stress. However, these findings should be interpreted in light of the significant between-study heterogeneity that can be classified as ‘considerable’ [ 26 ].

A meta-analysis of between-group effect sizes (Cohen’s d ) comparing PSS scores (both 10- and 14-item versions) from DRs and normative population data. *Studies using the 14 item version of the PSS; a positive effect size indicates DRs had a higher score on the PSS; a negative effect size indicates that the normative data produced a higher score on the PSS; black diamond = total effect size (based on random effects model); d = Cohen’s d ; Q = heterogeneity; Z = z score; I 2 = proportion of variance due to between-study heterogeneity; p = exact p value

To explore this heterogeneity, we re-ran the meta-analysis separately for the 10- and 14-item versions. The effect size remained large and significant when looking only at the studies using the 14-item version ( k = 6; d = 1.41, 95% CI [0.63, 2.19]), but was reduced and no longer significant when looking at the 10-item version only ( k = 3; d = 0.57, 95% CI [− 0.51, 1.64]). However, both effect sizes were still marred by significant heterogeneity between studies (10-item: Q = 232.02, p < .001; 14-item: Q = 356.76, p < .001).

Studies reported sufficient correlations for two separate meta-analyses; the first assessing the relationship between stress (PSS [ 18 , 19 ]) and perceived support, and the second between stress (PSS) and academic performance.

Stress x support

We included all measures related to support irrespective of whom that support came from (e.g. partner support, peer support, mentor support). The overall effect size suggests a small and significant negative correlation between stress and support ( r = − .24, 95% CI [− 0.34, − 0.13]) (see Fig. 3 ), meaning that low support is associated with greater perceived stress. However, the results should be interpreted in light of the significant heterogeneity between studies. The I 2 value quantifies this heterogeneity as almost 90% of the variance being explained by between-study heterogeneity, which is classified as ‘substantial’ (26).

Forest plot and meta-analysis of correlation coefficients testing the relationship between stress and perceived support. Black diamond = total effect size (based on random effects model); r = Pearson’s r ; Q = heterogeneity; Z = z score; I 2 = proportion of variance due to between-study heterogeneity; p = exact p value

Stress x performance

The overall effect size suggests that there is no relationship between stress and performance in their studies ( r = − .07, 95% CI [− 0.19, 0.05]) (see Fig. 4 ), meaning that DRs perception of their progress was not associated with their perceived stress This finding suggests that the amount of progress that DRs were making during their studies was not associated with stress levels.

Forest plot and meta-analysis of correlation coefficients testing the relationship between stress and performance. Black diamond = total effect size (based on random effects model); r = Pearson’s r ; Q = heterogeneity; Z = z score; I 2 = proportion of variance due to between-study heterogeneity; p = exact p value

Other correlations

Correlations reported in less than three studies are summarised in Fig. 5 . Again, stress was the most commonly tested mental health variable. Self-care and positive feelings towards the thesis were consistently found to negatively correlate with mental health constructs. Negative writing habits (e.g. perfectionism, blocks and procrastination) were consistently found to positively correlate with mental health constructs. The strongest correlations were found between stress, and health related quality of life ( r = − .62) or neuroticism ( r = .59), meaning that lower stress was associated with greater quality of life and reduced neuroticism. The weakest relationships ( r < .10) were found between mental health outcomes and: faculty concern, writing as knowledge transformation, innate writing ability (stress and anxiety), years married, locus of control, number of children and openness (stress only).

Correlation coefficients testing the relationship between a mental health outcome and other construct. Correlation coefficients are given in brackets ( r ); * p < .05; each correlation coefficient reflects the results from a single study

Several studies reported DR mental health problem prevalence and this ranged from 36.30% [ 54 ] to 55.9% [ 67 ]. Using clinical cut-offs, 32% were experiencing a common psychiatric disorder [ 64 ]; with another study finding that 53.7% met the questionnaire cut-off criteria for depression, and 41.9% for anxiety [ 67 ]. One study compared prevalence amongst DRs and the general population, employees and other higher education students; in all instances, DRs had higher levels of psychological distress (non-clinical), and met criteria for a clinical psychiatric disorder more frequently [ 64 ].

Risk factors

Demographics Two studies reported no significant difference between males and females in terms of reported stress [ 57 , 73 ], but the majority suggested female DRs report greater clinical [ 80 ], and non-clinical problems with their mental health [ 37 , 64 , 79 , 83 , 89 ].

Several studies explored how mental health difficulties differed in relation to demographic variables other than gender, suggesting that being single or not having children was associated with poorer mental health [ 64 ] as was a lower socioeconomic status [ 71 ]. One study found that mental health difficulties did not differ depending on DRs’ ethnicity [ 51 ], but another found that Black students attending ‘historically Black universities’ were significantly more anxious [ 87 ]. The majority of the studies were conducted in the US, but only one study tested for cross-cultural differences: reporting that DRs in France were more psychologically distressed than those studying in the UK [ 67 ].

Work-life balance Year of study did not appear to be associated with greater subjective stress in a study involving clinical psychology DRs (Platt and Schaefer [ 75 ]), although other studies suggested greater stress reported by those in the latter part of their studies [ 89 ], who viewed their studies as a burden [ 81 ], or had external contracts, i.e. not employed by their university [ 85 ]. Regression analyses revealed that a common predictor of poor mental health was uncertainty in DR studies; whether in relation to uncertain funding [ 64 ] or uncertain progress [ 80 ]. More than two-thirds of DRs reported general academic pressure as a cause of stress, and a lack of time as preventing them from looking after themselves [ 58 ]. Being isolated was also a strong predictor of stress [ 84 ].

Protective factors

DRs who more strongly endorsed all of the five-factor personality traits (openness, conscientiousness, extraversion, agreeableness and neuroticism) [ 66 ], self-reported higher academic achievement [ 40 ] and viewed their studies as a learning process (rather than a means to an end) [ 82 ] reported fewer mental health problems. DRs were able to mitigate poor mental health by engaging in self-care [ 72 ], having a supervisor with an inspirational leadership style [ 64 ] and building coping strategies [ 56 ]. The most frequently reported coping strategy was seeking support from other people [ 37 , 58 ].

Qualitative results

Meta-synthesis.

Four higher-order themes were identified: (1) Always alone in the struggle, (2) Death of personhood, (3) The system is sick and (4) Seeing, being and becoming. The first two themes reflect individual risk/vulnerability factors and the processes implicated in the experience of mental distress, the third represents systemic risk and vulnerability factors and the final theme reflects individual and systemic protective mechanisms and transformative influences. See Table 2 for details of the full thematic structure with illustrative quotes.

Always alone in the struggle

‘Always alone in the struggle’ reflects the isolated nature of the PhD experience. Two subthemes reflect different aspects of being alone; ‘Invisible, isolated and abandoned’ represents DRs’ sense of physical and psychological separation from others and ‘It’s not you, it’s me’ represents DRs’ sense of being solely responsible for their PhD process and experience.

Invisible, isolated and abandoned

Feeling invisible and isolated both within and outside of the academic environment appears a core DR experience [ 39 , 43 , 81 ]. Isolation from academic peers seemed especially salient for DRs with less of a physical presence on campus, e.g. part-time and distance students, those engaging in extensive fieldwork, outside employment and those with no peer research or lab group [ 36 , 52 , 68 ]. Where DRs reported relationships with DR peers, these were characterised as low quality or ‘not proper friendships’ and this appeared linked to a sense of essential and obvious competition amongst DRs with respect to current and future resources, support and opportunities [ 39 ], in which a minority of individuals were seen to receive the majority share [ 36 , 74 ]. Intimate sharing with peers thus appeared to feel unsafe. This reflected the competitive environment but also a sense of peer relationships being predicated on too shared an experience [ 39 ].

In addition to poor peer relations, a mismatch between the expected and observed depth of supervisor interest, engagement and was evident [ 40 , 81 ]. This mismatch was clearly associated with disappointment and anger, and a sense of abandonment, which appeared to impact negatively on DR mental health and wellbeing [ 42 ] (p. 182). Moreover, DRs perceived academic departments as complicit in their isolation; failing to offer adequate opportunities for academic and social belonging and connections [ 42 , 81 ] and including PGRs only in a fleeting or ‘hollow’ sense [ 37 ]. DRs identified this isolation as sending a broader message about academia as a solitary and unsupported pursuit; a message that could lead some DRs to self-select out of planning for future in academia [ 37 , 42 ]. DRs appeared to make sense of their lack of belonging in their department as related to their sense of being different, and that this difference might suggest they did not ‘fit in’ with academia more broadly [ 74 ]. In the short-term, DRs might expend more effort to try and achieve a social and/or professional connection and equitable access to support, opportunities and resources [ 74 ]. However, over the longer-term, the continuing perception of being professionally ‘other’ also seemed to undermine DRs’ sense of meaning and purpose [ 81 ] and could lead to opting out of an academic career [ 62 , 74 ].

Isolation within the PhD was compounded by isolation from one’s personal relationships. This personal isolation was first physical, in which the laborious nature of the PhD acted as a catalyst for the breakdown of pre-existing relationships [ 76 ]. Moreover, DRs also experienced a sense of psychological detachment [ 45 , 74 ]. Thus, the experience of isolation appeared to be extremely pervasive, with DRs feeling excluded and isolated physically and psychologically and across both their professional and personal lives.

It’s not you, it’s me

‘It’s not you, it’s me’ reflects DRs’ perfectionism as a central challenge of their PhD experience and a contributor to their sense of psychological isolation from other people. DRs’ perfectionism manifested in four key ways; firstly, in the overwhelming sense of responsibility experienced by DRs; secondly, in the tendency to position themselves as inadequate and inferior; thirdly, in cycles of perfectionist paralysis; and finally, in the tendency to find evidence which confirms their assumed inferiority.

DRs positioned themselves as solely responsible for their PhD and for the creation of a positive relationship with their supervisor [ 36 , 52 , 81 ]. DRs expressed a perceived need to capture their supervisors’ interest and attention [ 36 , 52 , 74 ], feeling that they needed to identify and sell to their supervisors some shared characteristic or interest in order to scaffold a meaningful relationship. DRs appeared to feel it necessary to assume sole responsibility for their personal lives and to prohibit any intrusion of the personal in to the professional, even in incredibly distressing circumstances [ 42 ].

DRs appeared to compare themselves against an ideal or archetypal DR and this comparison was typically unfavourable [ 37 ], with DRs contrasting the expected ideal self with their actual imperfect and fallible self [ 37 , 42 , 52 ]. DRs’ sense of inadequacy appeared acutely and frequently reflected back to them by supervisors in the form of negative or seemingly disdainful feedback and interactions [ 41 , 76 ]. DRs framed negative supervisor responses as a cue to work harder, meaning they were continually striving, but never reaching, the DR ideal [ 76 ]. This ideal-actual self-discrepancy was associated with a tendency towards punitive self-talk with clear negative valence [ 38 ].

DRs appear to commonly use self-castigation as a necessary (albeit insufficient) means to motivate themselves to improve their performance in line with perfectionistic standards [ 38 , 41 ]. The oscillation between expectation and actuality ultimately resulted in increased stress and anxiety and reduced enjoyment and motivation. Low motivation and enjoyment appeared to cause procrastination and avoidance, which lead to a greater discrepancy between the ideal and actual self; in turn, this caused more stress and anxiety and further reduced enjoyment and motivation leading to a sense of stuckness [ 76 ].

The internalisation of perceived failure was such that DRs appeared to make sense of their place, progress and possible futures through a lens of inferiority, for example, positioning themselves as less talented and successful compared to their peers [ 37 ]. Thus, instances such as not being offered a job, not receiving funding, not feeling connected to supervisors, feeling excluded by academics and peers were all made sense of in relation to DRs’ perceived relative inadequacy [ 36 ].

Death of personhood

The higher-order theme ‘Death of personhood’ reflects DRs’ identity conflict during the PhD process; a sense that DRs’ engage in a ‘Sacrifice of personal identity’ in which they feel they must give up their pre-existing self-identity, begin to conceive of themselves as purely ‘takers’ personally and professionally, thus experiencing the ‘Self as parasitic’, and ultimately experience a ‘Death of self-agency’ in relation to the thesis, the supervisor and other life roles and activities.

A sacrifice of personal identity

The sacrifice of personal identity first manifests as an enmeshment with the PhD and consequent diminishment of other roles, relationships and activities that once were integral to the DRs’ sense of self [ 59 , 76 ]. DRs tended to prioritise PhD activities to the extent that they engaged in behaviours that were potentially damaging to their personal relationships [ 76 ]. DRs reported a sense of never being truly free; almost physically burdened by the weight of their PhD and carrying with them a constant ambient guilt [ 37 , 38 , 44 , 76 ]. Time spent on non-PhD activities was positioned as selfish or indulgent, even very basic activities of living [ 76 ].

The seeming incompatibility of aspects of prior personal identity and the PhD appears to result in a sense of internal conflict or identity ‘collision’ [ 59 ]. Friends and relatives often provided an uncomfortable reflection of the DR’s changing identity, leaving DRs feeling hyper-visible and carrying the burden of intellect or trailblazer status [ 74 ]; providing further evidence for the incompatibility of their personal and current and future professional identities. Some DRs more purposefully pruned their relationships and social activities; to avoid identity dissonance, to conserve precious time and energy for their PhD work, or as an acceptance of total enmeshment with academic work as necessary (although not necessarily sufficient) for successful continuation in academia [ 40 , 52 , 77 ]. Nevertheless, the diminishment of the personal identity did not appear balanced by the development of a positive professional identity. The professional DR identity was perceived as unclear and confusing, and the adoption of an academic identity appeared to require DRs to have a greater degree of self-assurance or self-belief than was often the case [ 37 , 81 ].

Self as parasitic

Another change in identity manifested as DRs beginning to conceive of themselves as parasitic. DRs spoke of becoming ‘takers’, feeling that they were unable to provide or give anything to anyone. For some DRs, being ‘parasitic’ reflected them being on the bottom rung of the professional ladder or the ‘bottom of the pile’; thus, professionally only able to receive support and assistance rather than to provide for others. Other DRs reported more purposefully withdrawing from activities in which they were a ‘giver’, for example voluntary work, as providing or caring for others required time or energy that they no longer had [ 38 , 44 ]. Furthermore, DRs appeared to conceive of themselves as also causing difficulty or harm to others [ 81 ], as problems in relation to their PhD could lead them to unwillingly punishing close others, for example, through reducing the duration or quality of time spent together [ 38 ].

Feeling that close others were offering support appeared to heighten the awareness of the toll of the PhD on the individual and their close relationships, emphasising the huge undertaking and the often seemingly slow progress, and actually contributing to the sense of ambient guilt, shame, anger and failure [ 38 ]. Moreover, DRs spoke of feeling extreme guilt in perceiving that they had possibly sacrificed their own, and possibly family members’, current wellbeing and future financial security [ 49 ].

Death of self-agency

In addition to their sense of having to sacrifice their personal identity, DRs also expressed a loss of their sense of themselves as agentic beings. DRs expressed feeling powerless in various domains of their lives. First, DRs positioned the thesis as a powerful force able to overwhelm or swallow them [ 46 , 52 , 59 ]. Secondly, DRs expressed a sense of futility in trying to retain any sense of personal power in the climate of academia. An acute feeling of powerlessness especially in relation to supervisors was evident, with many examples provided of being treated as means to an end, as opposed to ends in themselves [ 39 , 42 , 62 ]. Supervisors did not interact with DRs in a holistic way that recognised their personhood and instead were perceived as prioritising their own will, or the will of other academics, above that of the DR [ 39 , 62 ].

Furthermore, DRs reported feeling as if they were used as a means for research production or furthering their supervisors’ reputations or careers [ 62 ]. DRs perceived that holding on to a sense of personal agency sometimes felt incompatible with having a positive supervisor relationship [ 42 ]. Thus whilst emotional distress, anger, disappointment, sadness, jealousy and resentment were clearly evident in relation to feeling excluded, used or over-powered by supervisors [ 37 , 42 , 52 , 62 ], DRs usually felt unable to change supervisor irrespective of how seriously this relationship had degraded [ 37 , 62 ]. Instead, DRs appeared to take on a position of resignation or defensive pessimism, in which they perceived their supervisors as thwarting their personhood, personal goals and preferences, but typically felt compelled to accept this as the status quo and focus on finishing their PhDs [ 42 ]. DRs resignation was such that they internalised this culture of silence and silenced themselves; tending to share litanies of problems with supervisors whilst prefacing or ending the statements with some contradictory or undermining phrase such as ‘but that’s okay’ [ 42 , 52 ].

The apparent lack of self-agency extended outward from the PhD into DRs not feeling able to curate positive life circumstances more generally [ 76 ]. A lack of time was perhaps the key struggle across both personal and professional domains, yet DRs paradoxically reported spending a lot of time procrastinating and rarely (if ever) mentioned time management as a necessary or desired coping strategy for the problem of having too little time [ 46 ]. The lack of self-agency was not only current but also felt in reference to a bleak and uncertain future; DRs lack of surety in a future in academia and the resultant sense of futility further undermined their motivation to engage currently with PhD tasks [ 38 , 40 ].

The system is sick

The higher-order theme ‘The system is sick’ represents systemic influences on DR mental health. First, ‘Most everyone’s mad here’ reflects the perceived ubiquity mental health problems amongst DRs. ‘Emperor’s new clothes’ reflects the DR experience of engaging in a performative piece in which they attempt to live in accordance with systemic rather than personal values. Finally, ‘Beware the invisible and visible walls’ reflects concerns with being caught between ephemeral but very real institutional divides.

Most everyone’s mad here

No studies focused explicitly on experiences of DRs who had been given diagnoses of mental health problems. Some study participants self-disclosed mental health problems and emphasised their pervasive impact [ 50 ]. Further lived experiences of mental distress in the absence of explicit disclosure were also clearly identifiable. The ‘typical’ presentation of DRs with respect to mental health appeared characterised as almost unanimous [ 39 ] accounts of chronic stress, anxiety and depression, emotional distress including frustration, anger and irritability, lack of mental and physical energy, somatic problems including appetite problems, headaches, physical pain, nausea and problems with drug and alcohol abuse [ 39 , 46 , 59 , 76 ]. Health anxiety, concerns regarding perceived new and unusual bodily sensations and perceived risks of developing stress-related illnesses were also common [ 46 , 59 , 76 ]. A PhD-specific numbness and hypervigilance was also reported, in which DRs might be less responsive to personal life stressors but develop an extreme sensitivity and reactivity to PhD-relevant stimuli [ 39 ].

An interplay of trait and state factors were suggested to underlie the perceived ubiquity of mental health problems amongst DRs. Etiological factors associated with undertaking a PhD specifically included the high workload, high academic standards, competing personal and professional demands, social isolation, poor resources in the university, poor living conditions and poverty, future and career uncertainty [ 36 , 41 , 43 , 46 , 49 , 76 ]. The ‘nexus’ of these factors was such that the PhD itself acted as a crucible; a process of such intensity that developing mental health problems was perhaps inevitable [ 39 ].

The perceived inevitability of mental health problems was such that DRs described people who did not experience mental health problems during a PhD as ‘lucky’ [ 39 ]. Supervisors and the wider academic system were seen to promote an expectation of suffering, for example, with academics reportedly normalising drug and alcohol problems and encouraging unhealthy working practices [ 39 ]. Furthermore, DRs felt that academics were uncaring with respect to the mental challenge of doing a PhD [ 39 ]. Nevertheless, academics were suggested to deny any culpability or accountability for mental health problems amongst DRs [ 39 , 59 , 74 ]. The cycle of indigenousness was further maintained by a lack of mental health literacy and issues with awareness, availability and access to help-seeking and treatment options amongst DRs and academics more widely [ 39 ]. Thus, DRs appeared to feel they were being let down by a system that was almost set up to cause mental distress, but within which there was a widespread denial of the size and scope of the problem and little effort put into identifying and providing solutions [ 39 , 59 ]. DRs ultimately felt that the systemic encouragement of unhealthy lifestyles in pursuit of academic success was tantamount to abuse [ 62 ].

A performance of optimum suffering

Against a backdrop of expected mental distress, DRs expressed their PhD as a performative piece. DRs first had to show just the right amount of struggle and difficulty; feeling that if they did not exhibit enough stress, distress and ill-health, their supervisors or the wider department might not believe they were taking their PhD seriously enough [ 40 ]. At the same time, DRs felt that their ‘researcher mettle’ was constantly being tested and they must rise to this challenge. This included first guarding against presenting oneself as intellectually inferior [ 36 ]. Yet it also seemed imperative not to show vulnerability more broadly [ 74 ]. Disclosing mental or physical health problems might lead not only to changed perceptions of the DR but to material disadvantage [ 74 ]. The poor response to mental health disclosures suggested to some DRs that universities might be purposefully trying to dissuade or discourage DRs with mental health problems or learning disabilities from continuing [ 74 ]. The performative piece is thus multi-layered, in that DRs must experience extreme internal psychological struggles, exhibit some lower-level signs of stress and fatigue for peer and faculty observance, yet avoid expressing any real academic or interpersonal weakness or the disclosure of any diagnosable disability or disease.

Emperor’s new clothes

DRs described feeling beholden to the prevailing culture in which it was expected to prioritise above all else developing into a competitive, self-promoting researcher in a high-performing research-active institution [ 39 , 42 ]. Supervisors often appeared the conduit for transmission of this academic ideal [ 74 ]. DRs felt reticent to act in any way which suggested that they did not personally value the pursuit of a leading research career above all else. For example, DRs felt that valuing teaching was non-conformist and could endanger their continuing success within their current institution [ 55 ]. Many DRs thus exhibited a sense of dissonance as their personal values often did not align with the institutional values they identified [ 74 ]. Yet DRs expressed a sense of powerlessness and a feeling of being ‘caught up’ in the values of the institution even when such values were personally incongruent [ 74 ]. The psychological toll of this sense of inauthenticity seemed high [ 55 ]. Where DRs acted in ways which ostensibly suggested values other than prioritising a research career, for example becoming pregnant, they sensed disapproval [ 76 ]. DRs also felt unable to challenge other ‘institutional myths’ for example, the perceived institutional denial of the duration of and financial struggle involved in completing a PhD [ 49 ]. There was a perceived tendency of academics to locate problems within DRs as opposed to acknowledging institutional or systemic inequalities [ 49 ]. DRs expressed strongly a sense in which there is inequity in support, resources and opportunities, yet universities were perceived as ignoring such inequity or labelling such divisions as based on meritocracy [ 36 , 74 ].

Beware the invisible and visible walls

DRs described the reality of working in academia as needing to negotiate a maze of invisible and visible walls. In the former case, ‘invisible walls’ reflect ephemeral norms and rules that govern academia. DRs felt that a big part of their continuing success rested upon being able to negotiate such rules [ 39 ]. Where rules were violated and explicit or implicit conflicts occurred, DRs were seen to be vulnerable to being caught in the ‘crossfire’ [ 36 ]. DRs identified academic groups and departments as being poor in explicitly identifying, discussing and resolving conflicts [ 37 ]. The intangibility of the ‘invisible walls’ gave rise to a sense of ambient anxiety about inadvertently transgressing norms and divides, such that some DRs reported behaving in ways that surprised even themselves [ 37 ].

Gendered and racial micropolitics of academic institutions were seen to manifest as more visible walls between people, with institutions privileging those with ‘insider’ status [ 36 ]. Women and people of colour typically felt excluded or disadvantaged in a myriad of observable and unobservable ways, with individuals able to experience both insider and outsider statuses simultaneously [ 36 , 37 ], for example when a male person of colour [ 36 ]. Female DRs suggested that not only must women prove themselves to a greater extent than men to receive equal access to resources, opportunities and acclaim but also are typically under additional pressure in both their professional and personal lives [ 37 , 52 , 76 ]. Women also felt that they had to take on more additional roles and responsibilities and encountered more conflicts in their personal lives compared to men [ 52 ]. Examples of professionally successful women in DRs’ departments were described as those who had crossed the divide and adopted a more traditionally male role [ 40 ]. Thus, being female or non-White were considered visible characteristics that would disadvantage people in the competitive academic environment and could give rise to a feeling of increased stress, pressure, role conflicts, and a feeling of being unsafe.

Seeing, being and becoming

The higher-order theme of ‘Seeing, being and becoming’ reflects protective and transformative influences on DR mental health. ‘De-programming’ refers to the DRs disentangling their personal beliefs and values from systemic values and also from their own tendency towards perfectionism. ‘The power of being seen’ reflects the positive impact on DR mental health afforded by feeling visible to personal and professional others. ‘Finding hope, meaning and authenticity’ refers to processes by which DRs can find or re-locate their own self-agency, purpose and re/establish a sense of living in accordance with their values. ‘The importance of multiple goals, roles and groups’ represents the beneficial aspects of accruing and sustaining multiple aspects to one’s identity and connections with others and activities outside the PhD. Finally, ‘The PhD as a process of transcendence’ reflects how the struggles involved in completing a PhD can be transformative and self-actualising.

De-programming

DRs reported being able to protect their mental health by ‘de-programming’ and disentangling their attitudes and practices from social and systemic values and norms. This disentangling helped negate DRs’ adopting unhealthy working practices and offered some protection against experiencing inauthenticity and dissonance between personal and systemic values.

First, DRs spoke of rejecting the belief that they should sacrifice or neglect personal relationships, outside interests and their self-identity in pursuit of academic achievement. DRs could opt-out entirely by choosing a ‘user-friendly’ programme [ 44 ] which encouraged balance between personal and professional goals, or else could psychologically reject the prevailing institutional discourse [ 40 ]. Rather than halting success, de-programming from the prioritisation of academia above all else was seen to be associated not only with reduced stress but greater confidence, career commitment and motivation [ 40 , 50 ]. It was also suggested possible to ‘de-programme’ in the sense of choosing not to be preoccupied by the ‘invisible walls’ of academia and psychologically ‘opt out’ of being concerned by potential conflicts, norms and rules governing academic workplace conduct [ 36 ]. Interaction with people outside of academia was seen to scaffold de-programming, by helping DRs to stay ‘grounded’ and offering a model what ‘normal’ life looks like. People outside of academia could also help DRs to see the truth by providing unbiased opinions regarding systemic practices [ 39 ].

A further way in which de-programming manifested was in DRs challenging their perfectionist beliefs. This include re-framing the goal as not trying to be the archetype of a perfect DR, and accepting that multiple demands placed on one individual invariably requires compromise [ 40 , 76 ]. DRs spoke of the need to conceptualise the PhD as a process, rather than just a product [ 46 , 82 ]. The process orientation facilitated framing of the PhD as just one-step in the broader process of becoming an academic as opposed to providing discrete evidence of worth [ 82 ]. Within this perspective, uncertainty itself could be conceived as a privilege [ 81 ]. The PhD was then seen as an opportunity rather than a test [ 37 , 46 ]. Moreover, the process orientation facilitated viewing the PhD as a means of growing into a contributing member of the research community, as opposed to needing to prove oneself to be accepted [ 82 ]. Remembering the temporary nature of the PhD was advised [ 45 ] as was holding on to a sense that not completing the PhD was also a viable life choice [ 76 ]. DRs also expressed, implicitly or explicitly, a decision to change their conceptualisation of themselves and their progress; choosing not to perceive themselves as stuck, but planning, learning and progressing [ 38 , 39 , 81 , 82 ]. This new perspective appeared to be helpful in reducing mental distress.

The power of being seen

DRs described powerful benefits to feeling seen by other people, including a sense of belonging and mattering, increased self-confidence and a sense of positive progress [ 37 ]. Being seen by others seems to provoke the genesis of an academic identity; it brings DRs into existence as academics. Being seen within the academic institution also supports mental health and can buffer emotional exhaustion [ 37 , 52 , 55 , 81 ]. DRs expressed a need to feel that supervisors, academics and peers were interested in them as people, their values, goals, struggles and successes; yet they also needed to feel that they and their research mattered and made a difference within and outside of the institution [ 42 , 52 , 81 ]. It was clear that DRs could find in their disciplinary communities the sense of belonging that often eluded them within their immediate departments [ 42 ]. Feeling a sense of belonging to the academic community seemed to buffer disengagement and amotivation during the PhD [ 81 ]. Positive engagement with the broader community was scaffolded by a sense of trust in the supervisor [ 81 ]. DRs often felt seen and supported by postdocs, especially where supervisors appeared absent or unsupportive [ 50 ].

Spending time with peers could be beneficial when there was a sense of shared experience and walking alongside each other [ 39 ]. Friendship was seen to buffer stress and protect against mental health problems through the provision of social and emotional support and help in identifying struggles [ 39 , 43 ]. In addition to relational aspects, the provision of designated physical spaces on campus or in university buildings also seemed important to being seen [ 37 ]. Peers in the university could provide DRs with further physical embodiments of being seen, for example, gift-giving in response to their birthdays or returning from leave [ 37 , 50 ]. Outside of the academic institution, DRs described how being seen by close others could support DRs to be their authentic selves, providing an antidote to the invisible walls of academia [ 50 ]. Good quality friendships within or outside academia could be life-changing, providing a visceral sense of connection, belonging and authenticity that can scaffold positive mental health outcomes during the PhD [ 39 ]. Pets could also serve to help DRs feel seen but without needing to extend too much energy into maintaining social relationships [ 50 ].

Finally, DRs also needed to see themselves, i.e. to begin to see themselves as burgeoning academics as opposed to ‘just students’ [ 81 ]. Feeling that the supervisor and broader academic community were supportive, developing one’s own network of process collaborators and successfully obtaining grant funding seemed tangible markers that helped DRs to see themselves as academics [ 37 , 81 ]. Seeing their own work published was also helpful in providing a boost in confidence and being a joyful experience [ 42 ]. Moreover, with sufficient self-agency, DRs can not only see themselves but render themselves visible to other people [ 37 ].

Multiple goals, roles and groups

In antidote to the diminished personal identity and enmeshment with the PhD, DRs benefitted from accruing and sustaining multiple goals, roles, occupations, activities and social group memberships. Although ‘costly’ in terms of increased stress and role conflicts, sustaining multiple roles and activities appeared essential for protecting against mental health problems [ 50 , 68 ].

Leisure activities appeared to support mental health through promoting physical health, buffering stress, providing an uplift to DRs’ mood and through the provision of another identity other than as an academic [ 44 , 50 , 76 ]. Furthermore, engagement in activities helped DRs to find a sense of freedom, allowing them to carve up leisure and work time and psychologically detach from their PhD [ 68 , 76 ]. Competing roles, especially family, forced DRs to distance themselves from the PhD physically which reinforced psychological separation [ 50 , 59 ]. Engaging in self-care and enjoyable activities provided a sense of balance and normalcy [ 39 , 44 , 68 ]. This normalcy was a needed antidote to abnormal pressure [ 59 ]. Even in the absence of fiercely competing roles and priorities, DRs still appeared to benefit from treating their PhD as if it is only one aspect of life [ 59 ]. Additional roles and activities reduced enmeshment with the PhD to the extent that considering not completing the PhD was less averse [ 40 ]. This position appeared to help DRs to be less overwhelmed and less sensitive to perceived and anticipated failures.

Finding hope, meaning and authenticity

Finding hopefulness and meaning within the PhD can scaffold a sense of living a purposeful, enjoyable, important and authentic life. Hopefulness is predicated on the ability to identify a goal, i.e. to visualise and focus on the desired outcome and to experience both self-agency and potential pathways towards the goal. Hopefulness was enhanced by the ability to break down tasks into smaller goals and progress in to ‘baby steps’ [ 38 , 59 ]. In addition, DRs benefitted from finding explicit milestones against which they can compare their progress [ 59 ], as this appeared to feed back into the cycle of hopeful thinking and spur further self-agency and goal pursuit.

The experience of meaning manifested in two main ways; first as the more immediate lived experience of passion in action [ 76 ]. Secondly, DRs found meaning in feeling that in their PhD and lives more broadly they were living in accordance with their values, for example, experiencing their own commitment in action through continuing to work on their PhD even when it was difficult to do so [ 76 ]. DRs who were able to locate their PhD within a broader sense of purpose appeared to derive wellbeing benefits. There was a need to ensure that values were in alignment, for example, finding homeostasis between emotional, intellectual, social and spiritual parts of the self [ 46 , 59 , 90 ].

The processes of finding hopefulness and meaning appear to be largely relational. Frequent contact with supervisors in person and social and academic contact with other DRs were basic scaffolds for hope and meaning [ 52 ]. DRs spoke of how a sense that their supervisors believed in them inspired their self-agency and motivation [ 42 , 62 , 76 ]. Partners, friends and family could also inspire motivation for continuing in PhD tasks [ 44 , 76 ]. Other people also could help instil a sense of motivation to progress and complete the PhD; a sense of being seen is to be beholden to finish [ 39 ]. Meaning appeared to be scaffolded by a sense of contribution, belonging and mattering [ 81 ] and could arise from the perception of putting something into the collective pot, inspiring hopefulness and helping others [ 39 , 42 ]. Moreover, hopefulness, meaning and authenticity also appeared mutually reinforcing [ 81 ]. Finding meaning and working on a project which is in accordance with personal values, preferences and interests is also helpful in completing the PhD and provides a feedback loop into hope, motivation and agentic thinking [ 39 , 81 ]. Furthermore, DRs could use agentic action to source a community of people who share their values, enabling them to engage in collective authenticity [ 39 ].

The PhD as a process of transcendence

The immense challenge of the PhD could be a catalyst for growth, change and self-actualisation, involving empowerment through knowledge, self-discovery, and developing increased confidence, maturity, capacity for self-direction and use of one’s own autonomy [ 44 , 82 ]. The PhD acted as a forge in which DRs were tested and became remoulded into something greater than they had been before [ 44 , 82 , 90 ]. The struggles endured during the PhD caused DRs to reconsider their sense of their own capacities, believing themselves to be more able than they previously would have thought [ 50 ]. The struggles endured added to the sense of accomplishment. A trusted and trusting supervisor appears to aid in the PhD being a process of transcendence [ 62 ].

More broadly, the PhD also helped DRs to transcend personal tragedy, allowing immersion in a meaningful activity which begins as a means of coping and becomes something completely [ 39 ]. The PhD could also serve as a transformative selection process for DRs’ social relationships, with some relationships cast aside and yet others formed anew [ 39 ]. Overall, therefore, the very aspects of the PhD which were challenging, and distressing could allow DRs to transcend their former selves and, through the struggle, become something more.

Summation of results

The findings regarding the risk and protective factors associated with DR mental health have been summarised in Table 3 in relation to (1) the type of research evidencing the factor (i.e. whether the evidence is quantitative only, part of the meta-synthesis only, or evident in both results sections); and (2) the volume of evidence (i.e. whether the factor was found in a single study or across multiple studies). The factors in the far-right column (i.e. the factors found across multiple research studies utilising both qualitative and quantitative methods) are the ones with the strongest evidence at present.

This systematic review summarises a heterogeneous research area, with the aim of understanding the mental health of DRs, including possible risk and protective factors. The qualitative and quantitative findings presented here suggest that poor mental health is a pertinent problem facing DRs; stress appears to be a key issue and significantly in excess of that experienced in the general population. Several risk and protective factors at the individual, interpersonal and systemic levels emerged as being important in determining the mental health of DRs. The factors with the strongest evidence-base (i.e. those supported by multiple studies using qualitative and quantitative findings) denote that being female and isolated increases the risk of the mental health problems, whereas seeing the PhD as a process, feeling socially supported, having a positive supervisor relationship and engaging in self-care is protective.

Results in context

Stress can be defined as (1) the extent to which a stimulus exerts pressure on an individual, and their propensity to bear the load; (2) the duration of the response to an aversive stimuli, from initial alert to exhaustion; or (3) a dynamic (im)balance between the demands and personal resource to manage those demands [ 91 ]. The Perceived Stress Scale (PSS) [ 18 , 19 ] used in our meta-analysis is aligned with the third of these definitions. As elaborated upon within the Transactional Model of Stress [ 92 ], stress is conceptualised as a persons’ appraisal of the internal and external demands put upon them, and whether these exceed their available resources. Thus, our results suggest that, when compared to the general population, PhD students experience a greater maladaptive imbalance between their available resources and the demands placed upon them. Stress in itself is not a diagnosable mental health problem, yet chronic stress is a common precipitant to mental health difficulties such as depression and posttraumatic stress disorder [ 93 , 94 ]. Therefore, interventions should seek to bolster DRs’ resources and limit demands placed on them to minimise the risks associated with acute stress and limit its chronicity.

Individual factors

Female DRs were identified as being at particular risk of developing mental health difficulties. This may result from additional hurdles when studying in a male-dominated profession [ 95 , 96 , 97 ], and the expectation that in addition to their doctoral studies, females should retain sole or majority responsibility for the domestic and/or caring duties within their family [ 52 , 76 ]. It may also be that females are more willing to disclose and seek help for mental health difficulties [ 98 ]. Nevertheless, the World Health Organisation (WHO) mental health survey results indicate that whilst anxiety and mood disorders are more prevalent amongst females, externalising disorders are more common in males [ 99 ]. As the vast majority of studies in this review focussed on internalising problems (e.g. stress, anxiety and depression) [ 37 , 64 , 79 , 80 , 83 , 89 ], this may explain the gender differences found in this review. Further research is needed to explore which perspective, if any, may explain gender gap in our results.

Perhaps unsurprisingly, self-care was associated with reduced mental health problems. The quantitative findings suggest that all types of self-care are likely to be protective of mental health (i.e. physical, emotional, professional and spiritual self-care). Self-care affords DRs the opportunity to take time away from their studies and nurture their non-PhD identities. However, the results from our meta-synthesis suggest that DRs are not attending to their most basic needs much less engaging in self-care behaviours that correspond to psychological and/or self-fulfilment needs [ 100 ]. Consequently, an important area for future enquiry will be identifying the barriers preventing DRs from engaging in self-care.

Interpersonal factors

Across both quantitative and qualitative studies, interpersonal factors emerged as the most salient correlate of DR mental health. That is, isolation was a risk factor, whereas connectedness to others was a protective factor. There was some variability in how these constructs were conceptualised across studies, i.e. (1) isolation: a lack of social support, having fewer social connections, feeling isolated or being physically separate from others; and (2) social connectedness: multiple group membership, academic relationships or non-academic relationships; but there was no indication that effects varied between concepts. The relationship between isolation and negative health consequences is well-established, for example both physical and mental health problems [ 101 ], and even increased mortality [ 102 ]. Conversely, social support is associated with reduced stress in the workplace [ 103 , 104 ]. Reducing isolation is therefore a promising interventional target for improving DRs’ mental health.

The findings regarding isolation are even more alarming when considered alongside the findings from several studies that PhD studies are consistently reported to dominate the lives of DRs, resulting in poor ‘work-life balance’ and losing non-PhD aspects of their identities. The negative impact of having fewer identities [ 105 ] can be mitigated by having a strong support network [ 106 ], and increasing multiple group memberships [ 107 ]. But for DRs, it is perhaps the absence of this social support, combined with identity impoverishment, which can explain the higher than average prevalence of stress found in our meta-analysis.

Systemic factors

DRs’ attitudes towards their studies may be a product of top-down systemic issues in academia more broadly. Experiencing mental health problems was reported as being the ‘norm’, but also appeared to be understood as a sign of weakness. The meta-synthesis results suggest that DRs believed their respective universities prioritise academic success over workplace wellbeing and encourage unhealthy working habits. Working in an unsupportive and pressured environment is strongly associated with negative psychological outcomes, including increased depression, anxiety and burnout [ 108 ]. The supervisory relationship appeared a particularly important aspect of the workplace environment. The quantitative analysis found a negative correlation between inspirational supervision and mental health problems. Meta-synthetic finding suggested toxic DR-supervisor relationships characterised by powerlessness and neglect, as well as relationships where DRs felt valued and respected—the former of these being associated with poor mental health, and the latter being protective. The association between DR-supervisor relationship characteristics needs to be verified using quantitative methods. Furthermore, DRs’ sense that they needed to exhibit ‘optimum suffering’, which appears to reflect a PhD-specific aspect of a broader academic performativity [ 109 ], is an important area for consideration. An accepted narrative around DRs needing to experience a certain level of dis/stress would likely contribute to poor mental health and as an impediment to the uptake and effectiveness of proffered interventions. Although further research is needed, it is apparent that individual interventions alone are not sufficient to improve DR mental health, and that a widespread culture shift is needed in order to prevent the transmission of unhealthy work attitudes and practices.

Limitations of the literature

Although we found a respectable number of articles in this area, the focus and measures used varied to the extent that typical review analysis procedures could not be used. That is, there was much heterogeneity in terms of how mental health was conceptualised and measured, as well as the range of risk and protective factors explored. Similarly, the quality of the studies was hugely variable. Common flaws amongst the literature include small sample sizes, the use of unvalidated tools and the incomplete reporting of results. Furthermore, for qualitative studies specifically, there appeared to be a focus on breadth instead of depth, particularly in relation to studies using mixed methods.

The generalisability of our findings is limited largely due to the lack of research conducted outside of the US, but also because we limited our review to papers written in English only. The nature of doctoral studies varies in important ways between studies. For example, in Europe, PhD studies usually apply for funding to complete their thesis within 3–4 years and must know their topic of interest at the application stage. Whereas in the US, PhD studies usually take between 5 and 6 years, involve taking classes and completing assignments, and the thesis topic evolves over the course of the PhD. These factors, as well as any differences in the academic culture, are likely to affect the prevalence of mental health problems amongst DRs and the associated risk and protective factors. More research is needed outside of the US.

‘Mental health’ in this review was largely conceptualised as a type of general wellbeing rather than a clinically meaningful construct. None of the studies were ostensibly focused on sampling DRs who were currently experiencing or had previously experienced mental health problems per se, meaning the relevance of the risk, vulnerability and protective factors identified in the meta-synthesis may be more limited in this group. Few studies used clinically meaningful measures. Where clinical measures were used, they captured data on common mental health problems only (i.e. anxiety and depression). Due to these limitations, we are unable to make any assertions about the prevalence of clinical-level mental health problems amongst DRs.

Limitations of this review

As a result of the heterogeneity in this research area, some of the results presented within this review are based on single studies (e.g. correlation data; see Fig. 5 ) rather than the amalgamation of several studies (e.g. meta-analysis/synthesis). To aid clarity when interpreting the results of this review, we have (Table 3 ) summarised the volume of evidence supporting risk and protective factors. Moreover, due to the small number of studies eligible for inclusion in this review, we were unable to test whether any of our findings are related to the study characteristics (e.g. year of publication, country of origin, methodology).

We were able to conduct three meta-analyses, one of which aimed to calculate the between-group effect size on the PSS [ 18 , 19 ] between DRs and normative population data. Comparing these data allowed us to draw some initial conclusions about the prevalence of stress amongst DRs, yet we were unable to control for other group differences which might moderate stress levels. For example, the population data was from people in the United States (US) in 1 year, whereas the DR data was multi-national at a variety of time points; and self-reported stress levels may vary with nationality [ 110 ] or by generation [ 111 , 112 ]. Moreover, two of the three meta-analyses showed significant heterogeneity. This heterogeneity could be explained by differences in the sample characteristics (e.g. demographics, country of origin), doctoral programme characteristics (e.g. area of study, funding status, duration of course) or research characteristics (e.g. study design, questionnaires used). However, due to the small number of studies included in these meta-analyses, we were unable to test any of these hypotheses and are therefore unable to determine the cause of this heterogeneity. As more research is conducted on the mental health of DRs, we will be able to conduct larger and more robust meta-analyses that have sufficient power and variance to statistically explore the causes of this heterogeneity. At present, our findings should be interpreted in light of this limitation.

Practice recommendations

Although further research is clearly needed, we assert that this review has identified sufficient evidence in support of several risk and protective factors to the extent that they could inform prevention and intervention strategies. Several studies have evidenced that isolation is toxic for DRs, and that social support can protect against poor mental health. Initiatives that provide DRs with the opportunity to network and socialise both in and outside of their studies are likely to be beneficial. Moreover, there is support for psychoeducation programmes that introduce DRs to a variety of self-care strategies, allow them to find the strategies that work for them and encourage DRs to make time to regularly enact their chosen strategies. Finally, the supervisory relationship was identified as an important correlate of DR mental health. Positive supervision was characterised as inspirational and inclusive, whereas negative supervision productised DRs or neglected them altogether. Supervisor training programmes should be reviewed in light of these findings to inform how institutions shape supervisory practices. Moreover, the initial findings reported here evidence a culture of normalising and even celebrating suffering in academia. It is imperative therefore that efforts to improve and protect the mental health of DRs are endorsed by the whole institution.

Research recommendations

First, we encourage further large-scale mental health prevalence studies that include a non-PhD comparison group and use validated clinical tools. None of the existing studies focused on the presence of serious mental health problems—this should be a priority for future studies in this area. Mixed-methods explorations of the experiences of DRs who have mental health problems, including serious problems, and in accessing mental health support services would be a welcome addition to the literature. More qualitative studies involving in-depth data collection, for example interview and focus group techniques, would be useful in further supplementing findings from qualitative surveys. Our review highlights a need for better communication and collaboration amongst researchers in this field with the goal of creating a level of consistency across studies to strengthen any future reviews on this subject.

The results from this systematic review, meta-analysis and meta-synthesis suggest that DRs reported greater levels of stress than the general population. Research regarding the risk and protective factors associated with the mental health of DRs is heterogenous and disparate. Based on available evidence, robust risk factors appear to include being isolated and being female, and robust protective factors include social support, viewing the PhD as a process, a positive DR-supervisor relationship and engaging in self-care. Further high-quality, controlled research is needed before any firm statements can be made regarding the prevalence of clinically relevant mental health problems in this population.

Availability of data and materials

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

Abbreviations

Confidence intervals

Doctoral researchers

Higher Education Statistics Agency

Perceived Stress Scale

Standard deviation

United Kingdom

United States

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Acknowledgements

Thank you to the Office for Students for their funding to support this work; and thank you to the University of Sussex Doctoral school and our steering group for championing and guiding the ‘Understanding the mental health of Doctoral Researchers (U-DOC)’ project.

The present project was supported by the Office for Students Catalyst Award. The funder had no involvement in the design of the study, the collection, analysis or interpretation of the data, nor the writing of this manuscript.

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CH contributed to the conceptualisation, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, supervision, validation, visualisation, writing—original draft preparation and writing—review and editing of this paper. LC contributed to the data curation, investigation, project administration, validation and writing—review and editing of this paper. SV contributed to the data curation, formal analysis, investigation, project administration, validation and writing—review and editing of this paper. PR contributed to the funding acquisition, project administration, supervision and writing—review and editing of this paper. JN contributed to the conceptualisation, funding acquisition, methodology, project administration, supervision, validation, writing—original draft preparation and writing—review and editing of this paper. CB contributed to the conceptualisation, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, supervision, validation, visualisation, writing—original draft preparation and writing—review and editing of this paper. The author(s) read and approved the final manuscript.

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Hazell, C.M., Chapman, L., Valeix, S.F. et al. Understanding the mental health of doctoral researchers: a mixed methods systematic review with meta-analysis and meta-synthesis. Syst Rev 9 , 197 (2020). https://doi.org/10.1186/s13643-020-01443-1

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Graduate Student Mental Health and Well-being

Project summary.

A growing body of evidence indicates that mental health challenges are common among graduate students. Unfortunately, many barriers exist to effective support and care. Beginning in 2019, CGS and The JED Foundation undertook a project to create an evidence base to inform future policies, programs and resources. Below are the results of that project, including the report, “Supporting Graduate Student Mental Health and Well-being: Evidence-Informed Recommendations for the Graduate Community.”

Report and Recommendations

On April 29, 2021, CGS and the JED Foundation released a report, “Supporting Graduate Student Mental Health and Well-being: Evidence-Informed Recommendations for the Graduate Community,” which contextualizes the urgency of this issue and includes results from a CGS member survey, priority areas for future research, and examples of programs aligned with key recommendations. The findings and recommendations summarized in the report are intended to provide a starting point for discussion and action for all campus groups with a vested interest in the quality of graduate education, including presidents and provosts, graduate deans, department chairs, faculty members, graduate students, and funders. Also embedded in the report is a “Statement of Principles and Commitments of Graduate Deans,” which provides institutions a blueprint for action to support the academic success and well-being of all students.

The report and supplemental documents related to it can be viewed and downloaded below.

• Supporting Graduate Student Mental Health and Well-being: Evidence-Informed Recommendations for the Graduate Community (Full Report)
• Executive Summary and Recommendations
• Communications Toolkit
• Call to Action and List of Signatories (last updated January 30th, 2024)

Webinar: Supporting Graduate Student Mental Health and Well-being: Evidence and Recommendations to Catalyze Action

Consultant papers.

CGS and JED commissioned three essays on aspects of graduate student mental health and well-being. Authored by experts in their fields, these explore cultural and organizational issues surrounding graduate student mental health; issues specific to international students, and legal issues.

• “ Unique Challenges and Opportunities for Supporting Mental Health and Promoting the Well-being of International Graduate Students ” by Jenny J. Lee (University of Arizona)
• “ Promoting Graduate Student Wellbeing: Cultural, Organizational, and Environmental Factors in the Academy ” by Julie R. Posselt (University of Southern California)
• “ Balancing Access and Safety for Graduate Students with Mental Health Issues ” by Hannah S. Ross (Middlebury College)

Other Resources

• “ CGS & JED Release Evidence-Informed Recommendations and Resources to Support Graduate Student Mental Health & Well-being ” (Press Release)
• Webinar: “ A Framework on Graduate Student Mental Health: CGS Members Share Ideas and Guidance ” (3.16.2021)
• Hironao Okahana, “Pressing Issue: Mental Wellness of Graduate Students” (4.9.2018)

In Partnership with

Project Funders

New research reveals what underlies the mental health crisis among science graduate students and calls for action to address key stressors

Tempe, AZ, Nov. 12, 2024  – A comprehensive  study from Arizona State University's  Research for Inclusive STEM Education (RISE) Center highlights significant mental health challenges affecting graduate science students. Conducted by lead researcher  Katelyn Cooper and team, this research identifies specific factors within research and teaching responsibilities that contribute to the high rates of anxiety and depression among graduate students. These findings underscore a pressing need for targeted support and intervention strategies in higher education institutions.

Surveying 2,161 Master’s and PhD students with depression and/or anxiety from 142 U.S. institutions, the study reveals that research responsibilities have a considerably greater negative impact on mental health than teaching duties. Common stressors in research, such as harsh criticism, unattainable expectations and academic failures are shown to exacerbate symptoms of anxiety and depression. The mental health impact is especially pronounced for women and financially unstable students, who are more likely to report severe repercussions from these stressors. Severe anxiety and depression not only diminish motivation and productivity but also increase the likelihood of students contemplating program withdrawal. Importantly, data show that graduate students with high levels of anxiety are nearly three times more likely to consider leaving their programs than those with mild anxiety, while students experiencing severe depression are five times more likely to consider withdrawal compared to those with milder symptoms.

This study also highlighted positive aspects of research and teaching, such as receiving emotional support from mentors, that bolster grad student mental health. Based on these data, the RISE Center recommends specific interventions to mitigate the mental health crisis among graduate science students. These include enhanced teacher training, which is currently sparse in many programs, and peer mentorship opportunities that could offer both academic and social support.

This study is the first to outline how the dual pressures of research and teaching contribute to the mental health crisis among science graduate students, offering an evidence-based roadmap for institutions to build more supportive and inclusive academic environments. The RISE Center calls on academic leaders and policymakers to draw on these findings to promote mental well-being and support retention among graduate students in STEM fields.

Access the Full Study The study is available through ASU's RISE Center and  Nature Biotechnology with additional data and analysis accessible on GitHub, inviting further exploration and transparency for interested stakeholders.

Contact Information Supplementary Information is available for this paper. Correspondence and requests for materials should be addressed to Katelyn Cooper at  [email protected] . Reprints and permissions information is available at www.nature.com/reprints .

About the Research for Inclusive STEM Education Center Arizona State University's Research for Inclusive STEM Education Center is dedicated to advancing inclusion and mental health within STEM fields. The center’s initiatives focus on fostering diversity, mental health support, and resilience to prepare and support the next generation of scientific leaders.

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Cassie M Hazell

January 12th, 2022, is doing a phd bad for your mental health.

9 comments | 79 shares

Estimated reading time: 6 minutes

Poor mental health amongst PhD researchers is increasingly being recognised as an issue within higher education institutions. However, there continues to be unanswered questions relating to the propensity and causality of poor mental health amongst PhD researchers. Reporting on a new comparative survey of PhD researchers and their peers from different professions, Dr Cassie M Hazell and Dr Clio Berry find that PhD researchers are particularly vulnerable to poor mental health compared to their peers. Arguing against an inherent and individualised link between PhD research and mental health, they suggest institutions have a significant role to play in reviewing cultures and working environments that contribute to the risk of poor mental health.

Evidence has been growing in recent years that mental health difficulties are common amongst PhD students . These studies understandably have caused concern in academic circles about the welfare of our future researchers and the potential toxicity of academia as a whole. Each of these studies has made an important contribution to the field, but there are some key questions that have thus far been left unanswered:

• Is this an issue limited to certain academic communities or countries?
• Do these findings reflect a PhD-specific issue or reflect the mental health consequences of being in a graduate-level occupation?
• Are the mental health difficulties reported amongst PhD students clinically meaningful?

We attempted to answer these questions as part of our Understanding the mental health of DOCtoral researchers (U-DOC) survey. To do this we surveyed more than 3,300 PhD students studying in the UK and a control group of more than 1,200 matched working professionals about their mental health. In our most recent paper , we compared the presence and severity of mental health symptoms between these two groups. Using the same measures as are used in the NHS to assess symptoms of depression and anxiety, we found that PhD students were more likely to meet criteria for a depression and/or anxiety diagnosis and have more severe symptoms overall. We found no difference between these groups in terms of their overall suicidality. However, survey responses corresponding to past suicidal thinking and behaviour, and future suicide intent were generally highly rated in both groups.

42% of PhD students reported that they believed having a mental health problem during your PhD is the norm

We also asked PhD students about their perceptions and lived experience of mental health. Sadly, 42% of PhD students reported that they believed having a mental health problem during your PhD is the norm. We also found similar numbers saying they have considered taking a break from their studies for mental health reasons, with 14% actually taking a mental health-related break. Finally, 35% of PhD students have considered ending their studies altogether because of their mental health.

We were able to challenge the working theory that the reason for our findings is that those with mental health difficulties are more likely to continue their studies at university to the doctoral level. In other words, the idea that doing a PhD doesn’t in any way cause mental health problems and these results are instead the product of pre-existing conditions. Contrary to this notion, we found that PhD students were not more likely than working professionals to report previously diagnosed mental health problems, and if anything, when they had mental health problems, these started later in life than for the working professionals. Additionally, we found that our results regarding current depression and anxiety symptoms remained even after controlling for a history of mental health difficulties.

The findings from this paper and our other work on the U-DOC project  has highlighted that PhD students seem to be particularly vulnerable to experiencing mental health problems. We found several factors to be key predictors of this poor mental health ; specifically not having interests and relationships outside of PhD studies, students’ perfectionism, impostor thoughts, their supervisory relationship, isolation, financial insecurity and the impact of stressors outside of the PhD .

the current infrastructure, systems and practices in most academic institutions, and in the wider sector, are increasing PhD students’ risk of mental health problems and undermining the potential joy of pursuing meaningful and exciting research

So, does this mean that doing a PhD is bad for your mental health? Not necessarily. There are several aspects of the PhD process that are conducive to mental health difficulties, but it is absolutely not inevitable. Our research (and our own experiences!) suggests that doing a PhD can be an incredibly positive experience that is intellectually stimulating, personally satisfying, and gives a sense of meaning and purpose. We instead believe a more appropriate conclusion to draw from our work is that the current infrastructure, systems and practices in most academic institutions, and in the wider sector, are increasing PhD students’ risk of mental health problems and undermining the potential joy of pursuing meaningful and exciting research.

Reducing this issue to the common rhetoric that “PhD studies cause mental health problems” is problematic for several reasons: Firstly, it ignores the many interacting moving parts at work here that variably increase and reduce risk of poor mental health across people, time, and place. Secondly, it does not acknowledge the pockets of incredibly good practice in the sector we can learn from and implement more widely. Finally, it reinforces the notion that poor mental health is the norm for PhD students which then becomes a self-fulfilling prophecy- and itself ignores the joy of pursuing a thesis in something potentially so personally meaningful. Nonetheless, a significant paradigm shift is needed in academia to reduce the current environmental toxins so that studying for a PhD can be a truly enjoyable and fulfilling process for all.

Note: This article gives the views of the author, and not the position of the Impact of Social Science blog, nor of the London School of Economics. Please review our  Comments Policy  if you have any concerns on posting a comment below.

Image Credit: Geralt via Pixabay. 

About the author

Dr Cassie M Hazell (she/her) is a lecturer in Social Sciences at the University of Westminster. Her research is on around mental health, with a special interest in implementation science. She is the co-founder of the international Early Career Hallucinations Research (ECHR) group and Early-Mid Career representative on the Research Council at her institution.

Dr Clio Berry is a Senior Lecturer in Healthcare Evaluation and Improvement in the Brighton and Sussex Medical School. She is interested in the application of positive and social psychology approaches to mental health problems and social outcomes for young people and students. Her work spans identification of risk and resilience factors in predicting mental health and social problems and their outcomes, and in the development and evaluation of clinical and non-clinical interventions.

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My own experience of doing a PhD (loneliness, the lack of routine, imposter syndrome) has led to my discouraging my daughter, who has a history of mental health issues, from considering it at the moment, despite her having the academic aptitude and even a topic. I would hazard a guess that the problems are worse in the humanities than in the applied sciences, where most PhD students tend to work as part of research teams and be well supported in more structured environments.

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Fascinating research… I had a terrible PhD, but most of the mental health issues arose after the fact. If you ever conducted another survey it would be interesting to include those who had recently finished a PhD.

Looking at your follow up BJPsyche paper, I noticed you haven’t gone into the correlation between subject and mental health. I’d be interested to know how sciences vs humanities compared.

I see that your work is very restrained in discussing the causes of mental health issues, and I’m sure you have plenty of hypothesis. In my experience, a key factor is that there is no mechanism to hold supervisors to account for the quality of their supervision. (Linking to the point above, I believe in the sciences supervisors with poor outcomes do suffer repetitional damage – not so in the humanities.)

I’d also add that the UK’s Viva system, which I believe is unique globally, is a recipe for disaster – years of work evaluated over the course of just a couple of hours by examiners who, again, are not held accountable in any way.

I wrote my experience up here: https://medium.com/the-faculty/i-had-a-brutal-phd-viva-followed-by-two-years-of-corrections-here-is-what-i-learned-about-vivas-5e81175aa5d

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What can universities do to support the well-being and mental health of postgraduate researchers? February 1st, 2022

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Open Access

Peer-reviewed

Research Article

“How is your thesis going?”–Ph.D. students’ perspectives on mental health and stress in academia

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Eberhard Karls Universität Tübingen, Tübingen, Germany, sustainAbility Ph.D. Initiative at the Eberhard Karls Universität, Tübingen, Germany

Roles Conceptualization, Data curation, Writing – original draft, Writing – review & editing

Roles Conceptualization, Data curation, Writing – review & editing

Roles Conceptualization, Writing – review & editing

Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

Roles Writing – review & editing

Roles Conceptualization, Data curation, Formal analysis, Methodology, Software, Supervision, Writing – original draft, Writing – review & editing

• Julian Friedrich, 
• Anna Bareis, 
• Moritz Bross, 
• Zoé Bürger, 
• Álvaro Cortés Rodríguez, 
• Nina Effenberger, 
• Markus Kleinhansl, 
• Fabienne Kremer, 
• Cornelius Schröder

• Published: July 3, 2023
• https://doi.org/10.1371/journal.pone.0288103
• Peer Review
• Reader Comments

Mental health issues among Ph.D. students are prevalent and on the rise, with multiple studies showing that Ph.D. students are more likely to experience symptoms of mental health-related issues than the general population. However, the data is still sparse. This study aims to investigate the mental health of 589 Ph.D. students at a public university in Germany using a mixed quantitative and qualitative approach. We administered a web-based self-report questionnaire to gather data on the mental health status, investigated mental illnesses such as depression and anxiety, and potential areas for improvement of the mental health and well-being of Ph.D. students. Our results revealed that one-third of the participants were above the cut-off for depression and that factors such as perceived stress and self-doubt were prominent predictors of the mental health status of Ph.D. students. Additionally, we found job insecurity and low job satisfaction to be predictors of stress and anxiety. Many participants in our study reported working more than full-time while being employed part-time. Importantly, deficient supervision was found to have a negative effect on Ph.D. students’ mental health. The study’s results are in line with those of earlier investigations of mental health in academia, which likewise reveal significant levels of depression and anxiety among Ph.D. students. Overall, the findings provide a greater knowledge of the underlying reasons and potential interventions required for advancing the mental health problems experienced by Ph.D. students. The results of this research can guide the development of effective strategies to support the mental health of Ph.D. students.

Citation: Friedrich J, Bareis A, Bross M, Bürger Z, Cortés Rodríguez Á, Effenberger N, et al. (2023) “How is your thesis going?”–Ph.D. students’ perspectives on mental health and stress in academia. PLoS ONE 18(7): e0288103. https://doi.org/10.1371/journal.pone.0288103

Editor: Khader Ahmad Almhdawi, Jordan University of Science and Technology Faculty of Applied Medical Science, JORDAN

Received: March 23, 2023; Accepted: June 20, 2023; Published: July 3, 2023

Copyright: © 2023 Friedrich et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The anonymized data set is available at https://doi.org/10.23668/psycharchives.12914 . All code for the analysis can be found at https://github.com/coschroeder/mental_health_analysis .

Funding: We acknowledge support by the Open Access Publishing Fund of University of Tübingen. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Work situations can be demanding and have a profound influence on employees’ mental health and well-being across different sectors and disciplines [ 1 ]. Multiple studies show that the mental health status of people working in academia and especially that of Ph.D. students seems to be particularly detrimental when compared to the public [e.g., 2 , 3 ]. Disorders such as anxiety and depression are on the rise in the general population [ 4 , 5 ]. Multiple studies show that this is even more severe in academia [ 6 – 10 ] and in particular Ph.D. students are affected by mental health problems [ 11 , 12 ]. Worldwide surveys grant support for Ph.D. students’ suboptimal and alarming mental health situations [ 13 , 14 ].

A comprehensive study with more than 2000 participants (90% Ph.D. students, 10% Master students) from over 200 institutions across different countries showed that graduate students were more than six times more likely to experience symptoms of depression and anxiety than the general public [ 2 ]. Furthermore, a global-scale meta-analysis [ 3 ] and several other studies concerned with the mental health of Ph.D. students in different countries, e.g., the United States [ 7 , 9 ], the United Kingdom [ 6 ], France [ 15 ], Poland [ 8 ], Belgium [ 16 ] or Germany [ 11 , 12 ] voice concerns about the mental health situation of Ph.D. students. Recent research conducted in Belgium has consistently found a higher prevalence of mental health problems among Ph.D. students compared to different groups of other highly educated individuals [ 16 ]. In the same study, 50% of the Ph.D. students reported that they suffer from some form of mental health problem, and every third is at risk of a common psychiatric disorder [ 16 ]. A similar picture is forming in Germany. For example, the prevalence of at least moderate depression among doctoral researchers at the Max Planck Society, one of the biggest academic societies in Germany, was between 9.6% and 11.6% higher than in the age-related general population [ 11 ].

Increasing numbers of anxiety and depression among Ph.D. students

Recent studies describe not only a high prevalence but also a rising tendency of mental health issues among Ph.D. students. In a study from 2017, 12% of the respondents reported seeking help for depression or anxiety related to their Ph.D. [ 13 ], while in 2019, the result was even more drastic, as 36% of the respondents reported that having searched for help for those same reasons [ 14 ]. Several studies among doctoral researchers within the Max Planck Society show similar results. For instance, a survey in 2019 showed that the average of the Ph.D. students were at risk for an anxiety disorder and another sample from 2020 provided even more robust support for this claim [ 11 , 12 ]. Furthermore, the mean depression score increased from 2019 to 2020 in both samples [ 11 ].

Risk factors and resources

Given these alarming statistics, several studies addressed risks and resources for increased mental health issues. Other studies have revealed that gender, perceived work-life balance, and mentorship quality are correlated with mental health issues [ 2 , 17 ]. Specifically, female gender [ 17 ] and transgender/gender-nonconforming Ph.D. students are, on average, more likely to suffer from mental health issues [ 2 ]. In contrast, a positive and supportive mentoring relationship or a supervisor’s leadership style, and a good work-life balance are positively associated with better mental health [ 2 , 16 ]. While some authors [ 18 ] reported a negative correlation between the Ph.D. stage and mental health, with students at later stages disclosing greater levels of distress, others [ 16 ] did not find significant differences in this regard. Moreover, another report identified that Ph.D. students’ satisfaction levels strongly correlate with their relationship with their supervisors, number of publications, hours worked, and received guidance from advisors [ 19 ]. Furthermore, several studies showed a positive correlation between job satisfaction [ 20 , 21 ] as well as a negative correlation between job insecurity [ 22 ] and mental health or perceived stress, also in Ph.D. students.

Aim and research questions

Taken together, the alarming findings on the psychological status of Ph.D. students around the globe cannot be denied. However, data on the situation of Ph.D. students in Germany are scarce [ 11 , 12 , 23 ]; thus, comparisons of different universities within a country can hardly be made. However, addressing those differences is particularly relevant since the working conditions, concerning contract types, financial situations or supervision vary strongly among different countries, geographical regions and universities or institutions [ 24 ]. Furthermore, little is known about the reasons for this precarious situation and where exactly the need for action lies [ 25 ]. Therefore, the aim of this study was to conduct a survey among Ph.D. students at a university in the southwest of Germany to assess Ph.D. students’ mental health status. Additionally, the present study also reveals information on the extent of the need for additional support services and pinpoints the specific areas where these services ought to be emphasized. In order to help identify relevant indicators, this investigation provides empirically sound findings on the mental health situation of Ph.D. students in Germany.

Materials and methods

Sample and procedure.

Overall, 589 participants (60.3% female, 0.8% of diverse gender, M Age = 28.8, SD Age = 3.48, range 17–48 years) out of a total of enrolled 2552 Ph.D. students (response rate: 23.1%; actual numbers of Ph.D. students at the University of Tübingen higher as some Ph.D. students are not enrolled) took part in an online survey from October to December 2021. Instructions, items, and scales were all presented in English. Participants could answer the open questions in German or English and were comprised of Ph.D. students across various stages of their Ph.D. at the University of Tübingen without further exclusion criteria. The online questionnaire was sent to Ph.D. students’ email addresses via mailing distribution lists in cooperation with the central institution for strategic researcher development (Graduate Academy) of the University of Tübingen and with Ph.D. representatives of different faculties. Ethics approval was obtained by the “Ethics Committee of the Faculty of Economics and Social Science of the University of Tübingen” and written informed consent was given by the participants.

The distribution of faculty affiliation of the participants was heterogeneous with shares of 61.8% Science, 12.4% Humanities, 11.7% Economics and Social Sciences. These numbers reflect the different sizes of faculties and are roughly aligned with the relative numbers of students (41.7% Science, 24.8% Medicine, 16.2% Humanities, 7.5% Economics and Social Sciences), with a clear underrepresentation of the Medical Faculty. Faculties with less than 20 participants or participants with multiple answers were grouped into one category for further analysis (Others 14.1%, see S1 Table ). 67.9% of the participants were German and in total, 82.9% came from European countries. During data collection, the participants were at different stages of their Ph.D. ranging from 0 to over 130 months with a mean time of two and a half years (30.0 months) of Ph.D. progress.

First, demographic data and background information on the current Ph.D. situation were collected. In a second part, to get a differentiated view, we included different measures to operationalize the mental health status of Ph.D. students. The quantitative questionnaire assessed 1) general health, generalized anxiety disorder, as well as internally reviewed self-generated questions, 2) life and job satisfaction, and quantitative job insecurity, and 3) stressors (institutional and systemic), causes of stress and potential solutions. This study also collected information regarding the degree of participants’ familiarity with the mental health resources available at the university, e.g., points of contacts for counseling, in order to evaluate whether Ph.D. students make use of these services. Moreover, participants were asked to name additional services that they may consider necessary.

General health and stressors.

General health was assessed by two items of the Perceived Health Questionnaire (PHQ-2) [ 26 ]. Participants were asked to indicate how frequently they had experienced depressed moods and anhedonia over the past four weeks on a scale from 1 (not at all) to 4 (nearly every day). Additionally, they were presented with seven items of the Generalized Anxiety Disorder scale (GAD-7) [ 27 ] capturing the severity of various anxiety signs like nervousness, restlessness, and easy irritation on a scale from 1 (not at all) to 4 (nearly every day). Both scales were used in this combination in a previous study in German higher education [ 28 ]. Furthermore, we included two binary questions on whether the participants are currently in psychotherapy and if they have ever been diagnosed with a mental disorder.

The condensed version of the Perceived Stress Scale (PSS) [ 29 ] was used to get the degree of stressful situations in life in the last twelve months or since the start of the Ph.D. [ 30 ]. The response scale ranged from 0 (never) to 4 (very often), the following being a sample item: “… how often have you felt that you were unable to control the important things in your life?” To check the internal consistency of the four items, we calculated Cronbach’s alpha which was .79.

Job satisfaction and life satisfaction.

Three items on a scale from 1 (strongly disagree) to 5 (strongly agree) were used to measure job satisfaction [ 31 ], where a higher mean score indicated higher job satisfaction. A sample item is: “I am satisfied with my job.” Cronbach’s alpha was .86. Additionally, we added one item concerning general life satisfaction [adapted from 32 ] with the same response categories to get a more holistic insight.

Job insecurity.

To assess the fear of losing the job itself, quantitative job insecurity was measured with three items (e.g., “I am worried about having to leave my job before I would like to.”) [ 33 ] on a scale from 1 (strongly disagree) to 5 (strongly agree). We calculated a mean score with higher scores indicating higher job insecurity. Cronbach’s alpha was .80.

Institutional and systemic stressors.

For institutional stressors, we focused mainly on the role of supervision and included eight questions, four were framed using positive wording and four with negative wording, each with a scale from 1 (not at all) to 5 (all of the time). We summarized these questions in two constructs (positive support/negative support) which had Cronbach’s alphas of .85 and .76, respectively. As for systemic stressors, we included two questions on long-term contracts and on future perspectives, again using a scale from 1 (strongly disagree) to 5 (strongly agree).

To cover the potential impacts of the COVID-19 pandemic and the implemented regulations, we included two questions to evaluate whether the pandemic affected the students’ general situation. On the one hand, participants were asked to pick the statement that best describes the effects of the pandemic in general (“yes, it improved my general situation”, “yes, it worsened my general situation”, “yes, but it neither worsened nor improved my general situation”, “no”), and on the other hand, they were asked to evaluate whether the particular answers provided in this survey had been affected by the pandemic from 1 (very likely) to 5 (very unlikely).

Rating procedure and open answers

Causes of stress and potential solutions..

We included three open-ended questions in the questionnaire to get a deeper understanding of the perceived causes of stress, potential ways to improve mental health, and ways to improve the overall situation of Ph.D. students. The questions were: (1) “What is/are the cause(s) of your stress?” (2) “What would need to change to improve your mental health status?” (3) “What could be done to improve your situation?” Participants could mention as many points as they wanted (without any word limit). To analyze these questions, we built categories by following the model of inductive category development [ 34 ]. Two raters screened the first and last 20 responses in the data set and created categories for reoccurring topics (for a list containing all categories see S5 – S7 Tables). In the next steps, two new raters rated all open answers with the developed categories and added additional categories if needed. Applicable categories were rated with 1 (“category was mentioned”) or 0 (“category was not mentioned”). For example, the following response to question (1) “[My] supervisor is on maternity leave with open end, i.e. I have no one to talk to about my topic and have almost nothing so far […] I feel like I’m not good enough at this, not sure I will be able to succeed–everyone else has other projects and publications except me–no topic-related network” was rated with 1 in the following four categories: supervision (quality & quantity), social integration & interactions (private & professional), self-perception (internal factors), and perceived lack of relevant competences & experience–(sense) of progress and success. The full list of categories and inter-rater reliability as measured by Krippendorf’s Alpha is reported in Table 3 [ 35 ].

Descriptive statistics of work environment and workload

The largest part of the participants (65.5%) was temporarily employed, 12.1% got a scholarship, 7.6% were permanently employed, and 6.5% were not employed at all. The mean for total contract length was 34.3 months, with a range between two and 72 months. About 10.5% of the participants had a contract for only 12 months or shorter. A similar large variation was found in the percentage of employment with a mean of 63%, ranging from 10% to 100% of employment. For workload, we found a mean of 36.0 hours of Ph.D.-related work per week with a standard deviation of 15.6 hours. After taking a closer look at high workloads, we found that 31.3% of the participants work 45 hours or more (21.5% work 50 hours and more) per week. On top of their Ph.D. work, many Ph.D. students work in other jobs, which combined with the hours spent for Ph.D.-related work, summed up to the mean of 44.1 overall working hours per week. A detailed description can be found in S1 Table .

Faculty-wise comparison

In an explorative manner, we compared the mean differences of the most important variables between different faculties. Most of the analyzed variables did not show significant differences. Still, we want to stress that the highly imbalanced sample sizes (see S3 Table ) could lead to false negative outcomes due to the small numbers of participants in some groups. However, we found that the mean job insecurity was significantly different between faculties ( p < .001, Kruskal-Wallis rank sum test) with comparable low job insecurity in the faculties of law ( M = 2.10, SD = 1.22) and theology ( M = 2.38, SD = 1.19) and high insecurity in the faculty of humanities ( M = 3.32, SD = 0.91).

In total, 41.9% of the participants stated that their general situation worsened due to the pandemic, while 28.5% stated that the pandemic affected but it neither worsened nor improved their general situation. 33.5% of the participants stated that their responses in this study were “very likely” or “likely” to be affected by the pandemic, with a mean of 2.97 ( SD = 1.26).

General health and stressors

The mean of the sum score for PHQ-2 in our study was 2.32 which is below the cut-off of three for major depression [ 26 ]. Yet, 33.1% of the participants were above the cut-off. For the GAD-7, the sum score for the study’s sample was 8.49. Cut points of 5 might be interpreted as mild, cut points of 10 as moderate and 15 as severe levels of anxiety [ 27 ], which implies a mild risk level for generalized anxiety with the suggestion of a follow-up examination in this sample. When asking for mental disorders, we found that 19.9% of the participants ( n = 99) have already been diagnosed with a mental disorder and 15.5% ( n = 77) are currently in psychotherapy. The sum score for the Perceived Stress Scale (PSS) of 7.79 (with Min = 0, Max = 15) was above the total sum score compared to a representative British sample (6.11) [ 36 ] and a representative German community sample (4.79 for PSS-4) [ 37 ]. Job satisfaction of our participants with a total sum score of 10.06 was lower compared to a sum score of 12.79 in a German sample of workers in small- and medium sized enterprises [ 38 ]. The mean score for job satisfaction was 3.35, also lower than in a sample of Ph.D. students in Belgium (3.9) [ 39 ]. Job insecurity was with a total sum score of 8.76 higher compared to the German small- and medium sized enterprises sample (5.67) [ 38 ]. Consistently, more than 80% of the Ph.D. students in our study were worried about the lack of permanent or long-term contracts in academia ( M = 4.25, SD = 1.09; 5 indicating a strong agreement). Nevertheless, around half of the participants (54.5%) believed that having a Ph.D. would help them find a good job ( M = 3.49, SD = 0.97). We found a mean score of 3.48 ( SD = 0.98) for the positive support questions which is above average over response levels. Around 57.1% of the Ph.D. students felt supported by their supervisor “most” or “all of the time”. Around 55.7% felt comfortable when contacting the supervisor for support. The negative support construct was with a mean score of 2.18 below average: 46.7% of the participants had never felt looked down, and 62.6% had never felt mistreated by their supervisor. Nevertheless, 28.6% of the Ph.D. students answered feelings of degradation and 19.1% felt mistreated more than “some of the time”. When it comes to the frequency of the meetings with the supervisor, the mean reported a value of 2.4 laying somewhere between having meetings once a month (2) and at least every three months (3). However, 18.2% reported meeting their supervisor only once every six months or less. For sample items and detailed values see S2 Table .

When we analyzed the relationship between the studied outcomes, we found that all major constructs correlated significantly (see Table 1 ). High correlations occurred between the items of the related PHQ-2 and GAD-7 as well as their connections to the PSS. Understandably, the two institutional support dimensions were highly correlated ( r = -.69).

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https://doi.org/10.1371/journal.pone.0288103.t001

Regression for perceived stress, depression, and anxiety

To predict potential driving factors for the two more direct mental health measurements, namely depression and anxiety, and for perceived stress, we employed linear regression models with these three constructs as response variables controlling for age and gender. We included relevant risk factors and stressors such as job insecurity, perceived stress, negative support and resources such as job and life satisfaction, and positive support to get a comprehensible overview over predictors. All analyses were carried out in R statistics version 4.1.3.

For depression, significant predictors were job satisfaction (β = -0.1, SE = 0.04, p < .05), life satisfaction (β = -0.3, SE = 0.04, p < .001), perceived stress (β = 0.4, SE = 0.05, p < .001) and negative institutional support (β = 0.11, SE = 0.05, p < .05, see Table 2 ). The model explained 46.7% of the variance, F (8, 482) = 54.5, p < .01.

https://doi.org/10.1371/journal.pone.0288103.t002

For anxiety, all studied variables except job satisfaction and positive support were significant predictors with a variance explanation of 36.0%, F (8, 392) = 29.5, p < .01 (see Table 2 ). Noticeable was the strong influence of perceived stress on anxiety. Specifically, we observed that with an increase of one unit in perceived stress, the level of GAD-7 increased by 2.02 units and was in line with the high correlation ( r = .52, p < .01, Table 2 ).

For perceived stress, we found that job insecurity (β = 0.15, SE = 0.02, p < .01), life satisfaction (β = -0.32, SE = 0.03, p < .01) as well as negative institutional support (β = 0.13, SE = 0.04, p < .01) were significant predictors with a model variance explanation of 42.7%, F (4, 486) = 53.5, p < .01. The detailed results for this regression analysis can be found in S4 Table .

Qualitative answers

In the following, we report the main categories with short sample quotes as well as the mean frequency of the two raters (see Table 3 ; details in S5 – S7 Tables). The inter-rater reliability as indicated by Krippendorff’s alpha for the top five categories of all questions was above α ≥ .67, except for the category Manageable Workload for question MH06_1 (see Table 3 ) with α = .62; CI [0.50; 0.74]. A threshold of .67 is commonly considered as the lower conceivable limit that still allows tentative conclusions [ 40 ].

https://doi.org/10.1371/journal.pone.0288103.t003

Causes of stress.

The question “What is/are the cause(s) of your stress?” was answered by n = 446 participants. To cover the breadth of the responses, we built 18 categories. The most frequently mentioned categories were Workload & Time Pressure (mean rating frequency = 211), Self-Perception ( M = 132.5), Job-Insecurity ( M = 93), Social Integration & Interactions ( M = 91), and Supervision Quality & Quantity ( M = 88.5). The category Workload & Time Pressure includes all responses referring to the amount of work and/or deadlines. The category Self-Perception includes responses that indicate a perceived lack of competences or other personal doubts, concerns, and worries (e.g., “Since I started my Ph.D. I have almost constantly felt stupid”, “feeling like not belonging in academia, lack of self-confidence, feeling of making too little progress”). The category Job Insecurity reflects responses regarding contract length and general uncertainty about future employment (e.g., “scholarship is to be ended”, “Not knowing how things will work out after the PhD”, “Hopelessness of scientific career because there are too few full-time positions”). The category Social Integration & Interactions covers responses regarding the integration and sense of belonging in the work environment (e.g., “not valued by colleagues”, “being socially isolated at work”) as well as social issues in the private life (e.g., “Mostly my personal life, or often the lack thereof”, “problems with parents”). The category Supervision Quality & Quantity was used to capture all supervision-related responses including comments about the lack of support, feedback, frequency of meetings, or supervisors’ interest in the topics (e.g., “no clear communication with supervisor”, “lack of support from supervisor, even gossiping about me behind my back”).

Potential ways to improve the mental health status.

When asked “What would need to change to improve your mental health status?”, the Ph.D. students’ responses ( n = 307) included various topics, some addressing compensation and income-related aspects, others highlighting supportive supervision. Overall, the responses lead to twelve different categories. Most answers referred to Supportive Supervision ( M = 98.5), followed by Job Security/Contract ( M = 59). Sample quotes with respect to supervision are e.g., “more feedback from supervisor or even more interest in my topic” or “more regular support by supervisor”. The category Job Security/Contract contains comments with respect to contract length and aspects for future employment (e.g., “no more worries about not being able to get my contract renewed”). The category Manageable Workload ( M = 56.5) includes all responses around work-life balance (e.g., “having also activities beside work”, “clear work hours”). The fourth category was Compensation & Financial Security ( M = 35) and included all income- and compensation-related aspects of the job (e.g., “Be paid 100% would be a start”, “Get paid for all the time at work”). The category Less Additional Tasks ( M = 27.5) was used to specifically cover responses mentioning the number of additional tasks within the job (“Less work in teaching/work unrelated to PhD”).

Ways to improve the personal situation.

In addition to the previous question, which focused on general ways to improve the mental health status, we asked the Ph.D. students the following question: “What could be done to improve your situation?” Based on the themes and topics mentioned in the responses ( n = 281) we built eleven categories. The categories mentioned the most were Job-Security & Compensation ( M = 85.5), followed by Supportive Supervision ( M = 68), Services and Support System ( M = 39.5), Decrease Pressure to Perform ( M = 39.5), and Manageable Workload ( M = 36). The category Job-Security & Compensation includes responses like “chances of getting a long-term job in academia, not just the three-year programs” or “Fair payment (half of students get 50% others 65% even at the same institute)”. For the category Supportive Supervision “Regular meetings with people who are supportive & have an expertise in my research topic” can serve as a sample quote. The category Services and Support System was built to cover the responses named a solution outside the working group and team, such as “it would be helpful to see a university-based psychologist outside of the regular working hours” or “more courses (or better communications about them) about stress management”. The next category was labeled Decrease Pressure to Perform and included all responses that highlighted a high level of perceived pressure, such as “the performance pressure (every talk at a seminar is a job talk) is a big problem” or “Instead of pressuring academics to publish as much as possible, there should be more focus on the quality instead of the quantity of their articles/publication”. The last category, Manageable Workload , contained answers with respect to the amount of work (e.g., “Normal working hours, having really free-time without having the feeling that I should be working, it should be normal to take all vacation days”).

Summary of the qualitative answers.

With respect to the open answers, it can be summarized that the factors named as causes for stress and the possible solutions cover a wide range of topics. However, there are reoccurring topics across all three questions, such as supervision, workload, and job security. The role of supervision is a reemerging motif in the qualitative content analysis. While the quality and quantity of supervision were seen as a cause of stress, supportive supervision has a positive impact on the mental health status as well as the whole situation of the Ph.D. students. Furthermore, job insecurity was mentioned as an important stressor, while stable contracts and appropriate compensation for the work and fewer extra tasks were also added for improvement. Workload and time pressure were the most often stated causes of stress, followed by self-doubts and worries about not having enough competencies for the job. A manageable workload, fewer additional tasks, and a lower pressure to perform were indicated by the participants as valuable improvements.

Summary of the main findings

The conducted survey investigates the mental health of Ph.D. students at a university in the southwest of Germany and gives insights into what causes stress and mental health disorders and where there is a need for further support services. Our qualitative and quantitative analyses revealed interesting and consistent results on the alarming situation of the mental health of Ph.D. students.

First, our quantitative results revealed that one-third of the participants were above the cut-off for depression which is an indicator of a high risk of depression that should be checked by a health professional. On average, the surveyed Ph.D. students were at a mild risk level for an anxiety disorder. While our study design does not allow us to diagnose mental illnesses, it identifies problems that need to be pursued further. It reveals some unhealthy working conditions and increased risks for mental illnesses. Our qualitative and quantitative results showed consistently that many of the most prominent issues for our study’s participants are personal factors such as perceived stress, life satisfaction and self-doubt, but modulated by structural deficits such as financial and job security as well as workload and time pressure. The quantitative analyses revealed that life satisfaction, perceived stress and negative support are the main predictors for anxiety disorders as well as depression. Additionally, low job satisfaction was a significant predictor of depression and job insecurity for anxiety. Furthermore, we identified job insecurity, life satisfaction as well as negative institutional support as predictors for perceived stress.

Second and besides mental health problems, our quantitative analyses showed how supervision and the work environment played a role in the mental health and general well-being of Ph.D. students. Deficient supervision could affect Ph.D. students’ perceived job insecurity and job dissatisfaction. Although good supervision was not a predictor for satisfaction, being comfortable with contacting the supervisor could lower the perceived stress. This shows the importance of the supervisor-student relationship and highlights the importance of the social work environment, which was also mentioned by study participants in the open-end questions. While the categories in the qualitative analyses mainly served to find recurring themes, they can also be used to distinguish between different levels. Some participants reflected causes of stress on a personal level (e.g., self-perception). In contrast, others set the focus on the supervisor level or working group level, or even on the more structural abstract level of the academic system.

Third, our study does not only investigate the mental health situation of Ph.D. students, but we also analyze how the situation and mental health status could be improved. Many suggestions were straightforward given the results of the causes of stress, i.e., bad supervision should be improved, and a secure income should be guaranteed. However, we were also able to show that Ph.D. students wish to make use of services and support systems that could be provided by the university. Furthermore, less pressure to perform and a manageable workload with fewer additional tasks besides the Ph.D. project might decrease the stress level and improve mental health status.

Overall, detrimental mental health is a known problem in academia, and we show another example of its extent as well as opportunities for improvement at a German university.

Comparison to other studies

Data on Ph.D. students’ situation in Germany are scarce, and we, therefore, perform a broader comparison with Ph.D. students around the world. However, the results of this comparison should be taken with caution as our questionnaire and time of survey conduction are unique. We focus mainly on PHQ-2 [ 26 ] and GAD-7 [ 27 ], for which other studies in Germany during the pandemic showed that–compared to pre-COVID-19 reference values–these measurements were significantly increased [ 41 ]. Two studies conducted during the COVID-19 pandemic include the same scales [ 41 , 42 ] and reveal similar results for the general population in Germany, while in our later study from October to December 2021, the risk for anxiety and depression is slightly higher. In our study, one-third of the participants (33.1%) was above the cut-off for major depression, compared to the studies in a 1.5-year earlier timeframe, where 14.1% (March to May 2020; n = 15704, 70.7% female gender; 42.6% university education) [ 42 ] and 21.4% (March to July 2020; n = 16918; 69.7% female gender; 42.4% university education [ 41 ] of the participants with diverse occupations were above the cut-off. Furthermore, in our study, 39.2% of the participants were at the mild risk level for anxiety compared to 27.4% of the participants in an earlier study [ 41 ]. This shows the increase in depression and anxiety during the pandemic and even higher numbers in our study compared with the German general population. Nevertheless, compared to a survey at public research universities in the United States from May to July 2020, the number of doctoral students screened for major depressive disorder symptoms with the same measurements PHQ-2 was higher with 36% [ 43 ], indicating high numbers of mental issues in academia in several countries.

While using the same scales and items for job satisfaction and job insecurity, our study showed worse sum scores compared to a sample of employers and employees in small- and medium sized enterprises in Germany (December 2020 to May 2021; n = 828; 53.7% female gender, M = 41.5 years; 38.8% higher education entrance qualification) [ 38 ]. It seems that Ph.D. students have higher job insecurity and job dissatisfaction compared to workers in diverse branches and occupations. This may result from different contract types, as workers, especially in industrial sectors, have long-term contracts. The recurrent factor of time pressure and workload, also mentioned in the open-end questions, is backed up by the raw numbers of the contract types and working hours, which may also lead to job dissatisfaction. Although the mean contract type in our study is 63%, the mean number of hours dedicated to Ph.D. work ( M = 36.0, SD = 15.6 hours) is almost in the range of a full-time position. What is more, the participants reported a total weekly workload ( M = 44.1, SD = 11.4 hours) that exceeds a typical full-time position in Germany [ 44 ]. The discrepancy between Ph.D. work and corresponding contract types results in a mean of 12.1 hours of overwork per week (based on a 38.5-hour full-time contract, which is the standard contract for Ph.D. students in Germany). This is in line with previous studies where the authors found a mean of 12.6 hours of overwork per week for Ph.D. students in Science, Technology, Engineering, and Mathematics disciplines in Germany [ 45 ]. However, the authors did not include any further work obligations and corrected for contract types with low percentages, and thus the results are difficult to compare directly. Furthermore, we used gender as a control variable, which turned out to be statistically significant for anxiety and stress. This is in line with related work where the female gender was reported to be higher correlated with mental disorders [ 2 , 17 , 46 , 47 ].

Strengths and limitations

Generalization..

While we aimed for our study to reflect the current situation for Ph.D. students as best as possible, there are points that are limiting the generalization of the results or are beyond the scope of this survey. First, we collected the data between October and December 2021, a time at which the ordinance on protection against risks of infection with the SARS-CoV-2 virus (“Coronavirus-Schutzverordnung”) [ 48 ] was still in place in Germany and influenced private and working life. About one-third (33.5%) of our study population stated that it is very likely or likely that the pandemic affected their answers. Nonetheless, a pandemic is a situation that can reoccur and is only one more reason to proactively set up a resilient Ph.D. graduation system. Another research group [ 49 ] investigated how mental health care should change as a consequence of the COVID-19 pandemic and concluded that the pandemic could even be seen as a chance to improve mental health services [ 49 ]. Nevertheless, we would like to point out that generalizing from a mental health study conducted during a pandemic may be difficult.

Overall, around 23% of all Ph.D. students at the University of Tübingen [ 50 ] participated in our study, which is slightly below the response rate in other similar studies [e.g., 16 ]. Considering that university students are very frequently invited to various questionnaires and studies, and given that our survey lasted approximately 20 minutes, it can be argued that the participants were motivated to invest time into their responses. However, our study population remains small compared to the total number of Ph.D. students in Germany. Moreover, we want to emphasize the likely sample bias in our data. We recruited participants mainly via mailing lists and our project therefore probably has especially appealed to people who are already interested in health or aware of mental health issues. However, given our relatively large coverage of almost a quarter of all Ph.D. students at the University of Tübingen, even a selective sample can give us insights into overall tendencies. The transferability of our results to other German universities or even universities in other countries is also not guaranteed as the academic systems can largely differ. Additionally, the results of this study are influenced by the overall living conditions the Ph.D. students experience. As Tübingen is a small town in the southwest of Germany, a comparison to larger cities or other countries might not be viable as the conditions probably differ largely.

Finally, even within one university, the generalization of our results is further limited by the uneven distribution of the participants across faculties. Most participants (61.8%) were from the Science Faculty, which is also the largest department (in terms of the highest total number of students) at the University of Tübingen. This skewness limits the faculty-wise comparisons, and we would expect to find interesting insights into the different graduate programs by conducting detailed comparisons. These differences could not only arise from different academic traditions but also from the highly varying expectations on the scope of a Ph.D. thesis. It follows that more detailed and systematic monitoring and data collection in national and international surveys are needed.

Methodology.

In a cross-sectional study, we investigate the current situation of Ph.D. students. While this is a valid and important instrument to access the current state, it cannot give us information about the dynamic changes in the transition phase between undergraduate studies and the Ph.D. as well as across the Ph.D. [ 51 ]. To track these changes or make comparisons over time, a longitudinal study design or propensity score matching procedures [ 52 ] could give further insights. It is therefore desirable to establish regular surveys and monitoring systems either on a university level or in a national survey to provide information on the impact of undertaken actions and implemented changes. We used a mixed quantitative and qualitative research approach. While this provides information on distinct levels, there are some pitfalls. For example, the open answer categories were defined post-hoc. While this gives the possibility for the participants to express their thoughts freely, it makes a systematic analysis more difficult, and the analysis might be biased by the evaluators. Overall, it is important to summarize and statistically analyze our study results on an overall level, but it must not be forgotten that every person and Ph.D. project is individual.

Implications for research and practice

The overall scarce data, paired with worrisome flashlights on the mental health situation of Ph.D. students in different countries, highlights the need for more systematic monitoring of mental health in academia. For this purpose, standardized as well as domain-specific scales for Ph.D. students need to be established and longitudinal data needs to be collected. This would enable researchers to measure the effect of larger environmental changes (such as the COVID-19 pandemic or economic developments) and to measure the impact of interventions targeted to improve the situation. At the same time, we propose including qualitative measurements to assess unknown variables and the unique situation each Ph.D. student faces. These could also inform the development of additional quantitative measurable constructs to reflect the dynamic situation in academia. Such monitoring systems can either be implemented at the university level to give detailed insights into the situation at a specific university or on a national level to get an overall impression of Ph.D. students’ health issues. Optimally, a survey should be promoted from an independent self-governing institution dedicated to advancing science and research. While the demands for a better mental health situation for Ph.D. students are obvious, systematical and political changes need to be addressed in the research community and in academia.

Our mixed methods research approach allows us not only to find out more about the issues of Ph.D. students but also to draw conclusions about what is needed to improve their situation. However, finding solutions to a recognized problem is not a straightforward task, and complex problems often require a step-by-step solution. Therefore, we assume that more practical implications, which could be indicated by an established monitoring system, will be necessary once the first steps have been taken.

In general, we can group interventions into at least four levels that can influence each other: the Ph.D. students themselves, the supervisors, the universities or research institutions, and the greater political context and academic culture. Building on the responses about potential improvements and additional services, we identified the following practical implications:

On an individual level, the main interventions could happen in capacity building (e.g., in time/project management, self-reflection or mental health awareness) but also by being more proactive about changing working modes (e.g., establishing collaborations or a peer counseling system) or by improving the social environment. This could additionally lead to a change in self-perception, for which direct interventions might be more difficult. At this point, we want to highlight that changes on the individual level aim to prevent the development of mental health problems and strengthen the resilience of Ph.D. students. They can at no point replace professional support once such problems have been manifested.

The level of supervision seems to be the most urgent and promising target for an improvement of Ph.D. students’ situation. As supervisors are usually defining a project and its goals, but also additional teaching or other tasks, they are responsible for setting the workload and time constraints. Not only the hard constraints of the working conditions but also the quality of supervision was often mentioned to be highly deficient. Possible interventions could target improving the skills in personnel management of supervisors. But also, clear supervision requirements and guidelines could be imposed by the university. Such agreements (including expectations on the thesis, supervision times and conciliation mechanisms) might be an option to enhance the agreements in a supervisor-student relationship. While these suggestions are not new, and some of them are theoretically established in some university departments, our study results suggest that they are often ignored or not properly implemented, and more binding agreements and control mechanisms need to be made. Establishing additional external supervision, where for example the personnel management is reflected, might also give new perspectives and enhance demanding situations. At this point, it has to be considered that there are strong dependencies between Ph.D. students and their supervisors since, in many cases, it is the supervisors who have a major impact on the outcome of a Ph.D. thesis, such as the final grade. It remains challenging how Ph.D. students can criticize the supervising situation without negatively impacting the personal relationship with their supervisors.

Further interventions on the level of universities and research institutions might include support in bureaucratic processes and providing more information on different contact points (e.g., for mental health services). It is obvious that the aforementioned interventions (such as capacity building courses for Ph.D. students and supervisors) are dependent on the support of the central facilities of the research institution. Furthermore, highlighting the high prevalence of mental health problems, for example, at mandatory introductory sessions for Ph.D. students, might help to raise awareness about this topic. This could help unexperienced young researchers to notice signs of anxiety and depression early on before these mental disorders manifest. Finally, public events on this topic could reduce the stigma associated with it, making it easier for affected Ph.D. students to seek help. Such events might also be used to remind the students that it is important to take care not only of their physical but also mental health, for instance, by strengthening social relationships and pursuing hobbies which are not work-related.

Lastly, there are also changes in the political setting and academic culture needed. This includes a fair payment system, reasonable control of contract lengths and extensions, and more perspectives for long-term positions in academia. Considering that the vast majority of Ph.D. students will end up in positions outside of academia, it could be beneficial to better prepare students for careers in alternative job markets, such as industry. Such interventions might directly influence the job insecurity and job dissatisfaction of Ph.D. students. In Germany, the current regulations for temporary academic employment are being evaluated [ 53 ], but even propositions from the conference of university rectors [ 54 ] seem not to be sufficient for fundamental changes. These changes would also need a shift in the academic culture [ 55 ], in which “publish or perish” is still a guiding theme leading to high pressure to perform. Working on a cultural shift is a task for all scientists. This will lead to a more sustainable work culture from which all stakeholders might benefit.

All in all, there is an interplay and dependence of all mentioned levels. Importantly, most problems mentioned in the survey can result from shortcomings on multiple levels, and therefore interventions on more than one level are needed for a satisfying solution. For example, changes to improve the mental health situation on an individual level can be dependent on the consent of the supervisor and can also be negatively impacted by already existing mental health issues. In addition to individual responsibility for health, it is important to systematically target prevention and change the system on the aforementioned levels so that Ph.D. students are better and more quickly supported when mental health problems arise.

This study shows once again the detrimental mental health situation of Ph.D. students in academia. By analyzing the mental health of Ph.D. students at a German university, we found alarming hints of depressive and anxious tendencies that are in line with other comparable studies. Furthermore, we have identified main stressors, such as perceived stress or self-doubts, and resources, such as a positive student-supervisor relationship. Understanding conditional factors and being able to improve the situation depend on such identifications. With our study, we provide first insights of the status quo for the University chair, the Graduate Academy, and other stakeholders in the academic system. We invite them to inspect the results and suggestions responsibly so that actions to assess and improve the conditions for Ph.D. students’ mental health and well-being can be taken in the future. Based on our data, additional offers for Ph.D. students, as well as their supervisors, should be created and existing ones sustainably modified. Positive conditions and resources for mental health and well-being will not restrict to academia but will affect all areas of life. While an increased mental health state is an indispensable value on its own, additional benefits can be created for research, teaching, practice, and society. As such, mental health is a big part of sustainable living and should have a high priority for all people. While this is already acknowledged in the sustainable development goals, further steps need to be taken to raise awareness and provide support throughout society.

Supporting information

S1 table. sample items and descriptives of ph.d. students ( n = 589): percentage (%), mean ( m ), standard deviation ( sd ), minimum and maximum ( min - max )..

https://doi.org/10.1371/journal.pone.0288103.s001

S2 Table. Used scales and items with percentage (%), mean ( M ), standard deviation ( SD ), minimum and maximum ( Min - Max ), median , Cronbach’s alpha .

https://doi.org/10.1371/journal.pone.0288103.s002

S3 Table. Faculty wise mean comparison on the job insecurity scale.

https://doi.org/10.1371/journal.pone.0288103.s003

S4 Table. Linear regression model for perceived stress and the predictors.

https://doi.org/10.1371/journal.pone.0288103.s004

S5 Table. Categories and ratings for the causes of stress.

https://doi.org/10.1371/journal.pone.0288103.s005

S6 Table. Categories and ratings for an improvement of mental health.

https://doi.org/10.1371/journal.pone.0288103.s006

S7 Table. Categories and ratings for an improvement of the situation.

https://doi.org/10.1371/journal.pone.0288103.s007

Acknowledgments

We would like to express our gratitude to all participants of the survey as well to the sustainAbility Ph.D. initiative at the University of Tübingen. We thank Dr. Stephanie Rosenstiel for support with the ethics approval and Prof. Dr. Birgit Derntl and Prof. Dr. Andreas Fallgatter for their helpful feedback on the conception of the questionnaire. We thank Mumina Javed and Monja Neuser for their support in the early phase of the project.

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• Open access
• Published: 09 November 2024

Mental health and lifestyle-related behaviors in medical students in a Jordanian University, and variations by clerkship status

• Yasmeen Dodin 1   na1 ,
• Nour Obeidat 1   na1 ,
• Razan Dodein 2 , 3 ,
• Khaled Seetan 3 ,
• Samah Alajjawe 4 ,
• Manar Awwad 4 ,
• Majd Adwan 4 ,
• Amal Alhawari 4 ,
• Arwa ALkatari 4 ,
• Amat Al-lateef Alqadasi 4 &
• Ghaith Alsheyab 4  

BMC Medical Education volume  24 , Article number:  1283 ( 2024 ) Cite this article

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The rigors of medical education often take a toll on students' mental well-being, resulting in heightened stress, anxiety, depression, somatization, and thoughts of self-harm. This study aimed to determine the prevalence of mental health problems among Jordanian medical students (Yarmouk University), explore the links between mental state and demographic and lifestyle factors, and compare mental health profiles between pre-clinical/pre-clerkship (years 1–3) and clinical/clerkship (years 4–6) students.

An online survey was distributed to undergraduate medical students at Yarmouk University. Mental health was measured using validated tools (depression: Patient Health Questionnaire, PHQ-9; eating disorders: SCOFF; Generalized Anxiety Disorder Scale, GAD-7; Somatic Symptoms: Patient Health Questionnaire, PHQ-15; overall stress (single-item measure); ability to handle stress; stressors and coping mechanisms. Data on sociodemographic factors, academic performance, and lifestyle choices, also were collected. Bivariate and multivariable analyses evaluated the associations between academic level and mental health, accounting for sociodemographic and lifestyle factors.

Of the 618 medical students who responded, 48.4% screened positive for depression, 36.7% for anxiety, and 63.6% for high level of stress. Slightly over half experienced somatic symptoms, and 28.6% exhibited signs of eating disorders. Roughly, 26% had suicidal thoughts, as measured by item 9 of the PHQ-9 scale. Low reported rates of healthy behaviors were observed (e.g. balanced diets, 5.7%; vigorous physical activity, 17.0%). Smoking prevalence was 24.6%, notably higher among clinical students. At the multivariable level, stress, insomnia, eating disorders and cigarette smoking were significantly associated with depression, anxiety and somatization. Higher physical activity scores were associated with lower depression risk. Females were significantly more likely than males to fall in more severe somatization categories.

This study highlights the need to address the alarming rates of mental health problems among Jordanian medical students. While few significant differences were observed between pre-clinical and clinical students, the high rates of depression, anxiety, stress, and negative health practices in both groups suggest the need for interventions that begin at enrollment as well as during transitions to clinical settings. Prioritizing mental health support and promoting healthier lifestyles among medical students are vital steps toward nurturing resilient, well-rounded future medical professionals.

Peer Review reports

Mental health problems (MHPs) refer to the existence of symptoms related to mental disorders, such as depression, anxiety, stress, or compulsive behavior [ 1 , 2 ]. In young people, MHPs tend to be overlooked, and thus need to be identified and addressed in a timely manner [ 3 ]. Preventing or managing MHPs is further challenged by the observation of high rates of MHPs in those who can contribute to screening and addressing MHPs (e.g. physicians and medical students) [ 4 , 5 ].

Specifically with regards to medical students, researchers have documented that medical students are more likely to experience heightened levels of stress, anxiety, depression, burnout, and suicidal thoughts [ 4 , 6 , 7 , 8 ]. Mental health may be detrimentally influenced by fear of failure, academic overload, patient contact, heightened parental expectations, extensive curriculum, examinations, limited leisure time, inadequate recreational facilities, and residing in hostels [ 9 , 10 ]. Conversely, healthy lifestyles have been recognized to play an important role in positively modifying physical as well as mental health [ 10 , 11 , 12 , 13 ].

In low-to-middle income countries in the Arab World, while there are some published studies investigating MHP in medical students [ 14 , 15 , 16 , 17 ], most do not examine the potential determinants of psychological morbidity of medical students in a comprehensive approach (i.e. including the various factors such as sociodemographic, academic, lifestyle-related factors as well as the multiple MHPs that may exist). In Jordan in particular, a country that has witnessed a surge in the number of students enrolled in Medical schools (as of the year 2022 19,000 medical students were enrolled in Medical schools) [ 18 ], there have been no studies to date that have simultaneously investigated the correlation and impact of sociodemographic, lifestyle, and program/training-related factors on the mental health of Jordanian medical students.

This study aimed to (1) examine the prevalence of depression, anxiety, stress, somatization, eating disorders and lifestyle practices (such as substance abuse, low/no physical activity, stress and coping strategies), and (2) assess the association of academic level (pre-clerkship/pre-clinical versus clerkship/clinical years of medical school) with MHPs (depression, anxiety, and somatization) while adjusting for lifestyle-related and sociodemographic factors. Our findings are of value to clinicians, educational experts, student advisors, and counselors seeking to improve Medical schooling in Jordan and similar countries in the Middle East. By gaining insights into the prevalence of depression, anxiety, somatic symptoms, and eating disorders as well as understanding what factors shape MHPs in medical students, appropriate interventions can be designed to prevent and effectively address mental health concerns within this student population.

Ethical review

The study was reviewed and approved by the Institutional Review Board of the King Hussein Cancer Center (study number 22 KHCC 69), an accredited body of the Association for the Accreditation of Human Research Protection Programs, Inc (AAHRPP).

Study design and setting

Our study was designed to examine differences between two naturalistic groups: medical students in basic years (pre-clerkship stage) and those in senior years (clerkship stage). Specifically, a cross-sectional study was conducted among undergraduate medical students at Yarmouk University School of Medicine in Irbid, Jordan. Yarmouk University's School of Medicine, founded in 2013, is among the six medical schools in the country. During the 2021/2022 academic year when the data collection for the study took place, Yarmouk University had an estimated total of 2,540 medical students enrolled (1,820 students in the pre-clerkship/pre-clinical stage and 720 students in the clerkship/clinical stage).

Sample size

To achieve a ± 5% accuracy and a confidence interval of 95%, with a power of 80%, a total sample size of 636 medical students (318 from each study level, i.e., pre-clerkship and clerkship) was required. This calculation was based on the number of students at the pre-clerkship group, which was 1820 students. The chosen 50% prevalence for depression was based on previous reports indicating a high prevalence of depression among medical students, ranging from 30 to 50% [ 19 , 20 , 21 ].

Recruitment strategy

A self-administered online Arabic questionnaire was created and distributed using the online platform QuestionPro ( https://www.questionpro.com/ ). In order to ensure students completed the survey when they were not experiencing acute stressors (examinations), we distributed the survey during non-examination periods. Each cohort of students [per year of enrollment] was subscribed to a WhatsApp and Facebook group, and the survey link was distributed to students through these groups. Given the variation in examination schedules by cohort, survey links were distributed in a stepwise manner.

Measurement instrument

The on-line questionnaire was designed to gauge various conditions (depression, anxiety, somatization, eating disorders) and their association with clerkship status of medical students while also accounting for lifestyle factors (tobacco use, alcohol use, exercise and diet, stress, coping). Before being distributed to participants, the survey was pilot tested on 7 students, and necessary modifications were made based on the feedback received. The final questionnaire specifically measured the following aspects:

Clerkship status

Clerkship status was our main independent variable of interest. Medical students in years 1 to 3 of medical school were categorized in the pre-clinical/pre-clerkship group, while those in years 4 to 6 of medical school were categorized in the clinical/clerkship group.

• Mental health

We sought to assess three specific mental health conditions: depression, anxiety and somatization. We employed the Arabic version of the Patient Health Questionnaire (PHQ) [ 22 ]. The PHQ is widely recognized as a reliable and valid diagnostic tool used in primary care settings to assesses six disorders (including depression, generalized anxiety, and somatization). Briefly, within each condition, subjects are asked to rate items (symptoms or problems) they experienced over the past few weeks. For example, when measuring depression or anxiety, subjects rate 9 symptoms or 7 symptoms (respectively) on a 4-point scale (ranging from "not at all" to "nearly every day"). When measuring somatization, subjects rate 15 symptoms on a 3-point scale (ranging from "not bothered at all" to "bothered a lot"). Raw scores are then generated for depression (scores range from 0 to 27), anxiety (scores range from 0 to 21) and somatization (scores range from 0 to 30) [ 23 , 24 , 25 ].

For the purpose of our study, the following specific modules in the Arabic PHQ were used: [ 22 ] depression (Patient Health Questionnaire-9 (PHQ9)), generalized anxiety disorder (General Anxiety Disorder-7 (GAD7)), and somatization (Patient Health Questionnaire-15 (PHQ15)). Raw scores of depression, anxiety and somatization were further categorized as follows:

✔ Depression (PHQ-9): A cutoff score of 10 or above (out of 27) was used to screen individuals at risk of depression (versus those at low risk). Five categories of severity of PHQ-9 scores were first generated: normal (scores of 0–4), mild depression (5–9), moderate depression (10–14), moderate to severe depression (15–19), and severe depression (20–27) [ 26 ]. However, due to limited cell counts in the two highest categories (moderate to severe depression and severe depression) we subsequently opted for a four-category approach similar to that for anxiety and somatization (i.e. normal, mild, moderate, and severe).

✔ Anxiety (GAD-7): A cutoff score of 10 or above (out of 21) was used to screen individuals at risk of anxiety (versus those at low risk). Categories of severity of GAD-7 scores also were generated: normal (scores of 0–4), mild anxiety (5–9), moderate anxiety (10–14), and severe anxiety (15–21) [ 27 ].

✔ Somatization (PHQ-15): A cutoff score of 10 or above (out of 30) was used to screen individuals at risk of experiencing somatic symptoms (versus those at low risk). Categories of severity of PHQ-15 scores also were generated: normal (0–4), mild somatization (5–9), moderate somatization (10–14), and severe somatization (15–30) [ 25 ].

Eating disorders

The Arabic version of SCOFF questionnaire, which was previously translated into Arabic and tested for validity and reliability, was used to assess eating disorders [ 28 ]. This questionnaire is comprised of five questions that specifically address the fundamental characteristics of anorexia nervosa and bulimia nervosa. Subjects are asked to respond with either "yes" or "no" for each question. Each "yes" response is assigned 1 point, and answering ‘yes’ to two or more questions of the five (i.e. a score of 2) indicates a probable diagnosis of anorexia nervosa or bulimia.

Perceived stress, the ability to handle stress, and sources of stress (stressors) were measured.

✔ Perceived stress and ability to handle stress were assessed using two previously studied single-item measures [ 29 ]. One item assesses the perceived amount of stress in a subject’s life on a scale of 1 (no stress) to 6 (extreme stress). The second item asks subjects to rate their ability to handle stress on a scale of 1 (“I can shake off stress”) to 6 ("stress eats away at me"). In our analysis, perceived amount of stress was categorized into three levels: low stress (score 1 or 2), moderate stress (score 3 or 4), and high stress (score 5 or 6). The ability to handle stress was categorized into three levels: Not at all able (scores 5 or 6), moderately able (scores 3 or 4), and extremely able (scores 1 or 2).

✔ Stressors among medical students were assessed using 31 items adapted from two sources: the Medical Student Stressors Questionnaire (MSSQ) and a tool employed by Amanya et. Al [ 30 , 31 ]. The 31 items were translated by our research team and face validity was confirmed by two experts. Participants were asked to rate the level of stress caused by each stressor on a 5-point scale (ranging from "does not cause any stress" to "causes severe stress").

Coping strategies employed by medical students in response to stress were assessed using the 28-item Arabic Brief Cope scale, which was previously tested for its validity and reliability [ 32 ]. Subjects are asked to rate the extent to which they utilize each listed coping strategy on a 4-point scale (ranging from “not at all” to “doing a lot”).

Lifestyle behaviors

✔ Diet: dietary habits were assessed using the Simple Lifestyle Indicator Questionnaire (SLIQ) [ 33 ]. The SLIQ is a concise measurement scale that evaluates five dimensions of lifestyle, including diet, physical activity, alcohol consumption, smoking, and stress. Each component is scored individually, and an overall lifestyle score is also calculated. The SLIQ/diet component consists of three questions that probe the weekly consumption of fruits, vegetables, and cereals. Subjects assign a value between 0 (less than once a week) and 5 (twice or more daily) to each question, and the scores are then summed to generate a raw score for diet, ranging from 0 to 15. The raw diet scores are then be categorized as follows: 0-5 ("unhealthy"), 6-10 ("average"), and 11-15 ("healthy"). These categories also were used in our study analysis.

In addition to the SLIQ, students were asked about their consumption of fish, energy drinks, beverages (including tea and coffee), and unhealthy snacks (sugary snacks, sodas, or chips); how often they had breakfast; and how often they consumed fast food.

✔ Physical activity: The physical activity section of the SLIQ was used to measure the weekly frequency of engaging in light, moderate, and vigorous physical activities [ 33 ]. In this section, each type of activity is assigned a score based on the weekly frequency reported) ranging from zero times per week to 8 or more times per week). The raw score for physical activity is then obtained by summing the scores for light, moderate, and vigorous activities. The resulting raw score is then categorized into three groups: 0 for individuals engaging in light exercise only, 1 for those participating in any moderate activity, and 2 for individuals involved in any vigorous activity [ 33 ]. These categories also were used in our study analysis.

✔ Tobacco forms: respondents were asked to report their use of tobacco forms (combustible cigarettes, electronic cigarettes, water pipes, and heated tobacco products). Age of initiation, frequency of use, and time to first use after waking (an item from the Fagerström Test for Nicotine Dependence) also were probed [ 34 ].

✔ Alcohol use/abuse: the Arabic version of the PHQ was used to measure alcohol use [ 22 ]. In the PHQ, subjects are first asked if they drink alcohol. Those who respond with a yes are asked whether or not they experience five events indicative of problematic alcohol use (e.g. missing work or school or had difficulties getting along with people because of alcohol). A yes response to any of these events indicates the likelihood of "probable alcohol abuse or dependence".

✔ Insomnia was assessed using the two-question Pittsburgh Insomnia Rating Scale (PIRS-2) [ 35 , 36 ]. The tool gauges individuals' perceived sleep quality and screens for insomnia risk. The PIRS-2 inquires about overall sleep satisfaction on a scale of 0 (“excellent”) to 3 (“poor”); and how much a person was bothered by lack of energy due perceived poor sleep in the past week on a scale of 0 (“not bothered at all”) to 3 (“severely bothered”). Each question carries a score from 0 to 3, with total scores ranging from 0 to 6. Higher scores correspond to a heightened potential for insomnia.

Other factors

Information was also collected on academic and sociodemographic attributes (age, gender, college year, marital status, place of residence, perceived financial situation of the family), perceived academic performance, perceived health status, weight, height, as well as the presence of any medical conditions.

Statistical analysis

All analyses were conducted using STATA 16 [ 37 , 38 ], and included:

Reliability analyses: Internal consistency estimates (Cronbach's alpha) were calculated for each scale to ensure the instruments used in the study were reliable. The following values were obtained for the instruments tested: PHQ-9: 0.885; GAD-7: 0.905; PHQ-15: 0.851; PHQ alcoholism: 0.702; Brief Cope scale: 0.875; Stressors: 0.936; SCOFF: 0.571; SLIQ-diet: 0.577; SLIQ-physical activity: 0.532.

Descriptive analyses: Levels of depression, anxiety, somatization, eating disorders, and lifestyle factors reported across pre-clinical and clinical years were examined through bivariate tests (Chi-square, Independent Samples T-test, One-Way ANOVA, Man-Whitney U, and Kruskal–Wallis).

Multivariable analyses: Three multivariable analyses were conducted to determine whether or not being in a pre-clinical (versus clinical) stage of medical school was associated with (1) depression, (2) anxiety, and (3) somatization levels, while adjusting for various sociodemographic and lifestyle factors. Ordinal logistic regressions were used due to the multiple ordered categories of depression, anxiety and somatization (four categories: normal, mild, moderate, and severe). To ensure the appropriateness of our method, the proportional odds assumption was tested in all the models [ 39 , 40 , 41 ]. In models where variables violated the proportionality assumption, a Partial Proportional Odds Model (PPOM) was used to allow relaxation of this assumption specifically with these variables.

Per outcome (depression, anxiety, or somatization), the PPOM generated three panels. The first panel compared the first level of the outcome variable with all other levels of the outcome (e.g. normal depression versus mild+moderate+severe depression). The second panel compared the first two levels of the outcome variable with the remaining levels of the outcome (e.g. normal+mild depression versus moderate+severe depression). Finally, the third panel compared the three successive levels of the outcome variable with the highest level of the outcome (e.g. normal+mild+moderate depression versus severe depression) [ 42 ]. When the proportional odds assumption was met, odds ratios were similar across panels.

Overall descriptive statistics and bivariate associations

A total of 618 students (representing approximately a quarter of all enrolled students) responded to the survey. Sociodemographic characteristics of the sample by clerkship group are included in Table  1 . Among students participating in the study, 312 (50.5%) were in their pre-clinical years (and 49.5% in their clinical years). The median age of the sample was 22. The majority of the sample of students were Jordanian, unmarried, and resided with their families. In terms of perceived financial situation at home, 84% of the students reported this as “average” (with a greater proportion of students in the pre-clinical years reporting “low” than those in the clinical years). With regards to academic performance, a greater proportion of students in pre-clinical years reported “poor to fair” academic performance than those in clinical years while a greater proportion in the latter group reported “very good” performance.

The association of health and lifestyle-related factors with clerkship status are displayed in Table  2 . Approximately 57% of students had a healthy body weight with a BMI (18.5 to < 25). The median raw score for dietary habits was 5 (interquartile range 3–7), placing 60.2% of students in the “unhealthy diet” category. Overall, 28.6% of students were identified as being at high risk for eating disorders, but a significantly greater proportion was observed in the pre-clerkship group (33.7% versus 23.5% in the clerkship group). In terms of physical activity, the median raw score was 6 (interquartile range 3–10), and only 17% of students engaged in vigorous activities. Only 1% of the sample screened positive for alcohol abuse or dependence. Finally with regards to health and lifestyle, roughly a quarter of the sample reported any tobacco use, with significantly higher rates of any tobacco use (29.1%) in the clerkship group. The most frequently used form of tobacco was the waterpipe (19.1% of students) while the least used form was heat-not-burn tobacco (used by 1.3%). Notable results not presented in the Tables was the dual use of combustible cigarettes and vapes – more than half of the students who smoked conventional cigarettes also used electronic cigarettes; and the higher rates of smoking in males for all tobacco products except for waterpipe.

With regards to MHPs (Table  2 ), 4.7% of students reported having a mental illness prior to joining medical school, with the proportion being significantly higher among students in the pre-clerkship group (6.7% versus 2.6% in the clerkship group). The percentage of students reporting a diagnosis of a mental illness post-enrollment at University was 10%. In terms of perceived stress, 63.6%, 30.6% and 5.8% of students reported high levels, moderate levels, and normal to low levels of stress, respectively. Approximately 24% stated that they were not at all able to handle the amount of stress they faced. Furthermore, 48.4%, 36.7%, and 55% of students screened positive for depression, anxiety and somatization, respectively. Specifically, 25.4% had severe depression and 15.4% had severe anxiety. Just over a quarter of the sample experienced severe somatic symptoms, with the most frequently reported symptoms being feeling tired, headaches, trouble sleeping, back pain, and pain in the arms and legs. In terms of significant differences when comparing pre-clerkship and clerkship groups, distributional differences were observed between “normal” and severe somatization levels and depression levels: significantly greater proportions of pre-clerkship students reported severe somatization and severe depression (and lower proportions reported no somatization or no depression). Finally with regards to MHPs prevalence, roughly 26% of students experienced suicidal ideation, with 36 students (5.8%) having such thoughts almost daily.

For further insight, supplemental Tables 1 , 2 and 3 (online supplement 1) provide the bivariate associations of the sociodemographic, lifestyle and academic factors measured in the study by reported levels of depression, anxiety and somatization, respectively.

Multivariable analyses

The results of the final multivariable analyses for each outcome (depression, anxiety, and somatization) are displayed in Table  3 .

Depression-related findings

With regards to depression, students in the clinical/clerkship group were 0.49 times less likely to experience any form of depression (mild, moderate, or severe) compared to their counterparts in the pre-clerkship status ( p  < 0.05). Any [moderate or extreme] ability to handle stress was significantly associated with lower odds of being in moderate to severe levels of depression (odds ratios ranged between 0.32 and 0.65 across panels). Our analysis also revealed a statistically significant association between physical activity and depression, indicating that for each unit increase in physical activity raw score, there was a 4% decrease in the odds of falling into higher depression categories (odds ratio 0.96, 95% confidence interval: 0.93-0.99, p value 0.011). Conversely, having a higher insomnia score, reporting an eating disorder, and being a cigarette smoker were associated with a 1.34, 1.93 and 1.8 times (respectively) greater odds of being in higher categories of depression.

Anxiety-related findings

Students who reported their academic performance as “very good” or “excellent” were 0.55 and 0.57 times less likely [than those reporting poor/fair performance] to fall in higher anxiety categories (respectively). Furthermore, ability to handle stress (i.e. moderate ability or extreme ability) was significantly associated with lower odds of being in moderate to severe levels of anxiety across most panels (odds ratios ranged between 0.37 and 0.59). Conversely, having a higher insomnia score, reporting an eating disorder, and being a cigarette smoker were significantly associated with a 1.37, 1.67 and 2.51 times (respectively) greater odds of being in higher categories of anxiety.

Somatization-related findings

Females had significantly higher odds of falling into the severe somatization category compared to males (odds ratios ranged between 2.54 and 6.07 across panels). High-perceived stress was significantly associated with moderate to severe somatization. Specifically, those perceiving moderate to high stress were 2.44 to 3.17 times (respectively) more likely to fall in categories indicative of greater somatization. Having a higher insomnia score, reporting an eating disorder, being a cigarette smoker, and being a waterpipe (or other forms of tobacco) smoker were significantly associated with a 1.31, 1.55, 2.78 and 1.65 times (respectively) greater odds of being in higher categories of somatization.

In our study, we examined the association of academic, sociodemographic and lifestyle-related factors with key MHPs, namely depression, anxiety and somatization, in medical students at Yarmouk University in Jordan. Our findings revealed few significant differences between pre-clinical and clinical years of study. Rather, across both groups of study, our findings revealed a high prevalence of depression, anxiety, somatic symptoms, eating disorders, and stress. Moreover, a considerable proportion of students experienced severe symptoms of MHPs.

Limited studies in Jordan have explicitly evaluated depression in medical students. The prevalence of depression in our study (48.4%) aligns with previous research conducted in the Arab world [ 10 , 14 , 20 , 43 ], but is significantly higher than the global rates [ 8 , 44 ]. This could be attributed to various factors: high-pressure academic environments and a conventional non-student-centered program and curriculum elements; limited access to mental health services and support; cultural norms that deter from healthy discussions about mental health; increasingly competitive opportunities to train abroad; and challenging employment prospects for physicians.

With regards to factors that influenced depression, we found that being in the pre-clerkship years of study negatively influenced depression. Findings in the literature have varied (some have found a similar association [ 16 , 19 , 45 , 46 ], some have found the converse [ 47 , 48 ], and some have found no association between depression and clerkship status [ 8 ]). Given the high prevalence of depression in our study, it is important to avail efforts to enhance mental well-being to all medical students, rather than assuming only in-coming students (or only students experiencing clinical work) require this.

Several studies have demonstrated that females are more likely than males to suffer from depression [ 14 , 20 , 44 , 49 ]. However, our results did not reveal an association between gender and the severity of depressive symptoms, a finding consistent with a systematic review of studies on depression in medical students [ 8 ]. Such inconsistencies also were observed with obesity: our findings, like others [ 50 , 51 ], indicated no association between obesity and depression, but some studies have reported greater psychological morbidity with obesity [ 52 ]. More importantly, we were able to confirm the protective potential of physical activity against depression, a finding which aligns with previous studies [ 10 , 53 ], and which can be used to encourage students to engage in active lifestyles.

We also observed a relatively high prevalence of eating disorders when compared to international studies [ 15 , 54 , 55 , 56 ]. There is a noticeable lack in the number and quality of research studies on eating disorders in Arab communities (let alone Jordanian medical students in particular). One review of studies in the Arab world revealed a wide variability in estimates of eating disorders (2% to 54.8%), and further emphasized the scarcity of and need for better-designed studies [ 57 ]. Nevertheless, we speculate that our finding is not unusual. In our view, eating disorders in Arab cultures may well be on the rise due to the clash of older sociocultural norms with the relatively rapid exposure to global Westernized norms that are now much more pervasive in Arab communities and tend to focus on being thin (in the case of females) or being more toned or muscular (in the case of males). There is a pressing need for national and epidemiological studies to examine the prevalence of eating disorders in Arab countries, particularly in Jordan, and to investigate why these rates are higher than in other countries worldwide.

Our findings (supplementary tables) suggest an association between the presence of eating disorders and the degree of depression among our sample of students.

With regards to the prevalence of anxiety observed in our study, it was comparable to the global prevalence of 33.8% reported in a meta-analysis [ 6 ], although individual studies have reported both higher, [ 20 , 45 , 47 , 58 , 59 ], and lower rates than ours [ 60 , 61 , 62 , 63 ]. Combustible cigarette smoking, insomnia, and the presence of indications of an eating disorder all were associated with higher anxiety; while ability to manage stress was protective. This finding aligns with similar findings in other studies [ 64 ].

The prevalence of somatization in our study was higher than rates reported in the literature [ 26 , 65 , 66 , 67 ]. Notably, amongst other factors, females were significantly more likely than males to experience somatization, suggesting that female students may process MHPs in a different manner than males.

Our study has certain limitations: our survey was a cross-sectional and we were therefore unable to capture any fluctuations in MHPs across time to better understand how MHPs developed. Our study also was solely quantitative, and did not probe in-depth experiences of students with regards to their MHPs. Furthermore, due to its cross-sectional nature, we were unable to conclude a temporal relation between the variables examined. In addition, our measurement tool was relatively long. We sought to gauge several important constructs that no single available pre-existing questionnaire could cover, and multiple items and tools were therefore included in the study questionnaire. While the briefest valid versions of measurements were used [per construct], and piloting of the questionnaire was conducted to ensure that the questionnaire was well-understood and was not burdensome, it arguable that some respondents may still have perceived it to be complex or long (of the 1,208 who began the survey, and 618 complete results were obtained). Non-responders may have had different experiences, and we could not assess their characteristics. Thus, while our sample represented approximately a quarter of students enrolled, nonresponse bias cannot be ruled out. Finally, our study was conducted in one Medical College, and arguably may not be generalizable to other colleges. To address these limitations, conducting longitudinal studies would be of value to chart the trajectory of MHPs throughout medical training, and identify both risk and protective factors over time. Moreover, harmonizing how these studies are conducted across all colleges (for example, by incorporating metrics of mental health and lifestyle in college-wide surveys) would allow for comparisons across campuses and specialties to provide generalizable insight with regards to how MHPs, lifestyle factors and academic environments interact during these formative years of professional and overall development. Qualitative research studies would also add a wealth of information regarding how MHPs develop in young medical professionals, and what interventions would resonate with this important subgroup of the community.

In summary with regards to our findings, MHPs were observed in considerable percentages of medical students. Ability to handle stress, a skill that can be taught to students, played a protective role across all MHPs, and physical activity appeared to have a positive effect on depression. Contrary to the common misconception that smoking may help manage MHPs, combustible cigarette smokers had a higher risk of falling in more severe categories of anxiety, a useful finding when educating young adults. Insomnia also was associated with higher levels of anxiety. Collectively, our results paint a compelling picture that can provide the rational to engage with medical students and empower them with skills to manage their well-being holistically (for example, incorporating sleep hygiene practices, being physically active, and learning stress management techniques).

Our study revealed concerning prevalence rates of depression, anxiety, somatic symptoms, stress, and eating disorders among undergraduate medical students at Yarmouk University. Key findings include the protective effects of ability to handle stress and having healthy lifestyles. However, only a small percentage of the participating students demonstrated healthy lifestyle practices relative to the higher proportion of students reporting tobacco use. Medical students need to be better educated about the interconnections between mental health, lifestyle, and stress; and more interventions need to be availed to build students’ skills in resilience and stress management.

Data availability

Data cannot be shared publicly because of institutional regulations. Data requests are reviewed and approved by the Institutional Review Board at King Hussein Cancer Center (contact Linda Kateb, at [email protected]). For researchers who meet the criteria for access to confidential data, data can then be shared.

Abbreviations

Mental health problems

Association for the Accreditation of Human Research Protection Programs

Patient Health Questionnaire

Patient Health Questionnaire-9

General Anxiety Disorder-7

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Yasmeen Dodin and Nour Obeidat contributed equally to this work.

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Cancer Control Office, King Hussein Cancer Center, Amman, 11941, Jordan

Yasmeen Dodin & Nour Obeidat

Department of Dermatology, St. George’s NHS Foundation Trust, London, UK

Razan Dodein

Department of Clinical Science, Faculty of Medicine, Yarmouk University, Irbid, Jordan

Razan Dodein & Khaled Seetan

Medical Student, Yarmouk University, Irbid, Jordan

Samah Alajjawe, Manar Awwad, Majd Adwan, Amal Alhawari, Arwa ALkatari, Amat Al-lateef Alqadasi & Ghaith Alsheyab

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YD and NO contributed to the conceptualization and design of the study, literature review, questionnaire development, formal data analysis, results interpretation, and manuscript development. RD and KS contributed to the conceptualization and design of the study, project supervision, results interpretation, and manuscript revision. SA, MA, MI, AA, AA, AA and GS contributed to the pilot testing, data collection, and manuscript revision. All authors have read and agreed to the published version of the manuscript.

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Dodin, Y., Obeidat, N., Dodein, R. et al. Mental health and lifestyle-related behaviors in medical students in a Jordanian University, and variations by clerkship status. BMC Med Educ 24 , 1283 (2024). https://doi.org/10.1186/s12909-024-06273-6

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• Data and Statistics on Children's Mental Health

Children's mental health data

Indicators of positive mental health are present in most children . National US data from 2021-2022 show that:

• 96% usually or always are affectionate and tender with parents or caregivers.
• 83% usually or always bounce back quickly when things do not go their way.
• 95% usually or always show interest and curiosity in learning new things.
• 99% usually or always smile and laugh.
• 83% usually or always show interest and curiosity in learning new things.
• 72% usually or always stay calm and in control when faced with a challenge.
• 81% usually or always work to finish tasks they start.

Childhood mental health conditions affect many children and families. In 2018-2019:

• 1 in 7 children ages 3 to 17 (13%) had a current, diagnosed mental or behavioral health condition. 2

Mental health conditions can begin in early childhood and the prevalence changes with age. Although there are some exceptions, most mental health conditions are more common with increased age (see figure below). 1

Anxiety problems, behavior disorders, and depression are the most commonly diagnosed mental disorders in children. Based on US data from 2021–2022: 1

• 10% of children ages 3-17 had current, diagnosed anxiety (9% of males and 11% of females).
• 7% of children ages 3-17 had current, diagnosed behavior disorders (10% of males and 5% of females)
• 4% of children ages 3-17 had current, diagnosed depression (3% of males and 6% of females).

Some of these mental health conditions commonly occur together. In 2018–2019, among children with a current mental health condition, more than 1 in 3 (37%) had two or more conditions . 2

Data on other co-occurring conditions are below:

Treatment varies among different mental disorders and by age. Based on US data from 2018–2019: 2

• Among children ages 3-17 with a current mental health condition, just over half (53%) received treatment or counseling from a mental health professional in the past year, and 43% took medication for an emotional, concentration, or behavioral condition.
• Among children with depression, 79% received treatment or counseling, compared with 59% of children with anxiety and 52% of children with behavior disorders.
• Receipt of treatment or counseling increased with age, from 36% of children ages 3-5 to 60% of children ages 12-17.

It's important to remember that diagnosed conditions do not tell the whole story about mental distress in children . This is because children can also experience some symptoms without meeting criteria for a condition, or they can meet criteria for diagnosis but remain undiagnosed.

Teen mental health, substance use, suicide

Among adolescents, mental health, substance use, and suicide are concerns. Data obtained directly from youth can tell us more about the scope of these problems.

Among US adolescents ages 12–17 in 2021-2022: 3

• 21% reported symptoms of anxiety in the past two weeks.
• 17% reported symptoms of depression in the past two weeks.

Among US high school students in 2023: 4

• 40% reported persistent feelings of sadness or hopelessness in the past year.
• 20% reported seriously considering attempting suicide in the past year.
• 16% reported making a suicide plan in the past year.
• 9% reporting attempting suicide in the past year.
• 22% report drinking alcohol in the past 30 days.
• 17% report using marijuana in the past 30 days.
• 4% report misusing prescription pain medication in the past 30 days.
• 10% report ever using illicit drugs.

Many adolescents discuss mental health with health care providers, and receive treatment, but there are still gaps in treatment to support youth. Using national data collected from adolescents during 2021-2022, in the past 12 months: 3

• More than half (55%) of US adolescents reported discussing their mental and emotional health with a health care professional.
• 14% of adolescents reported taking any prescription medication to help with their emotions, concentration, behavior, or mental health.
• 20% of adolescents reported receiving mental health therapy.
• 20% of adolescents ages 12-17 reported having unmet mental health care needs.

Childhood experiences

Children and adolescents may have experiences that support or harm their mental health.

• Adverse childhood experiences (ACEs) are potentially traumatic experiences in childhood that have a profound impact on physical and mental health. Learn more about ACEs , how they can be prevented, and their impacts on mental and physical health.
• Positive childhood experiences (PCEs) are experiences in childhood that support children’s ability to live and grow in safe, stable, nurturing relationships and environments. The more PCEs a child or adolescent has, the less likely they are to have diagnosed mental health conditions. 5

We all have a role to play in ensuring that all children and adolescents have positive experiences. There is more we can do to foster these experiences, so all children reach their full potential and live healthy lives.

Data from adolescents ages 12-17 in 2021-2022 indicate that: 3

• 59% report they always or usually receive social and emotional support.
• 50% report they receive peer support a lot of the time.
• 64% report they receive parent support a lot of the time.
• 81% report they have at least one adult in their life who makes a positive difference.

Children and adolescents may also engage in activities that promote wellbeing. These can include, but is not limited to, participating in activities that they enjoy, exercising and other physical activity.

• 61% report being physically active for at least an hour most days.
• 34% report strength training most days.
• 59% report playing on a sports team in the past year.
• 27% report meditating in the past year.
• 22% of adolescents report practicing yoga in the past year.

Children's mental health data sources

Health care providers, researchers, educators, policy makers, and others can get information about the prevalence of children's mental health and mental health conditions from a variety of sources in the United States.

National Health and Nutrition Examination Survey (NHANES) assesses health and nutritional status through interviews and physical examinations. Mental health topics include conditions, symptoms, and concerns associated with mental health and substance abuse, as well as the use and need for mental health services.

National Health Interview Survey (NHIS) collects data on children's mental health, conditions such as ADHD, autism spectrum disorder, depression, and anxiety problems, and the use and need for mental health services.

National Survey of Children's Health (NSCH) examines the health of children, with emphasis on wellbeing. It includes medical homes, family interactions, the health of parents, school and after-school experiences, and safe neighborhoods. This survey was redesigned in 2016.

National Survey of Family Growth (NSFG) gathers information on family life, marriage and divorce, pregnancy, infertility, use of contraception, and general and reproductive health. NSFG includes data on individuals ages 15-49. Mental health topics covered in NSFG include alcohol and drug use.

National Survey on Drug Use and Health (NSDUH) , administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), provides national- and state-level data on the use of tobacco, alcohol, and illicit drugs (including non-medical use of prescription drugs), as well as data on substance use disorders, major depressive disorder, any other mental health conditions, and access to treatment for depression. Participants include individuals ages 12 and older.

National Vital Statistics System (NVSS) contains vital statistics from the official records of live births, deaths, causes of death, marriages, divorces, and annulments recorded by states and independent registration areas.

National Youth Tobacco Survey (NYTS) is a nationally representative school-based survey on tobacco use by public school students in grades 6-12.

School Health Policies and Programs Study (SHPPS) is a national survey assessing school health policies and practices at the state, district, school, and classroom levels. Collected data includes mental health and social service policies.

Youth Risk Behavior Surveillance System (YRBSS) measures health-related behaviors and experiences that can lead to death and disability among youth and adults. The YRBSS monitors health-risk behaviors, including tobacco use, substance abuse, unintentional injuries and violence, sexual behaviors that contribute to unintended pregnancy, and sexually transmitted diseases.

Additional resources

Healthy People 2030 sets data-driven national objectives to improve health and well-being over the next decade, including children's mental health and well-being.

Web-based Injury Statistics Query and Reporting System (WISQARS) is an interactive database system that provides customized reports of injury-related data.

• Child and Adolescent Health Measurement Initiative. (2021-2022). National Survey of Children's Health. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved August 8, 2024 from https://nschdata.org/browse/survey?s=2&y=51&r=1&#home
• Health Resources and Services Administration. (October, 2020). National Survey of Children's Health Mental and Behavioral Health, 2018-2019. [Issue Brief]. https://mchb.hrsa.gov/sites/default/files/mchb/data-research/nsch-data-brief-mental-bh-2019.pdf
• National Center for Health Statistics. (2021-2022). National Health Interview Survey— Teen. Generated interactively: Aug 06 2024 from https://wwwn.cdc.gov/NHISDataQueryTool/NHIS_TEEN/index.html
• Centers for Disease Control and Prevention. (2024). Youth Risk Behavior Survey Data Summary & Trends Report: 2013–2023 . Retrieved from https://www.cdc.gov/yrbs/dstr/ .
• Anderson, K.N., et al. (2024). Prevalence of Positive Childhood Experiences and Associations with Current Anxiety, Depression, and Behavioral or Conduct Problems among U.S. Children Aged 6–17 Years. Adversity and Resilience Science. https://doi.org/10.1007/s42844-024-00138-z

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Children and Adolescents Mental Health: A Systematic Review of Interaction-Based Interventions in Schools and Communities

Rocío garcía-carrión, beatriz villarejo-carballido, lourdes villardón-gallego.

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Edited by: Isabel Menezes, Universidade do Porto, Portugal

Reviewed by: Sharinaz Hassan, Curtin University, Australia; Giovanna Bubbico, Department of Neuroscience, Imaging and Clinical Sciences, University of “G. d'Annunzio” Chieti-Pescara, Italy

*Correspondence: Beatriz Villarejo-Carballido [email protected]

This article was submitted to Educational Psychology, a section of the journal Frontiers in Psychology

Received 2018 Apr 24; Accepted 2019 Apr 5; Collection date 2019.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

Background: There is growing evidence and awareness regarding the magnitude of mental health issues across the globe, starting half of those before the age of 14 and have lifelong effects on individuals and society. Despite the multidimensional nature of this global challenge, which necessarily require comprehensive approaches, many interventions persist in seeking solutions that only tackle the individual level. The aim of this paper is to provide a systematic review of evidence for positive effects in children and adolescents' mental health resulting from interventions conducted in schools and communities in which interaction among different agents is an integral component.

Methods: An extensive search in electronic databases (Web of Knowledge, SCOPUS, ERIC, and PsycINFO) was conducted to identify interventions in which interactions between peers, teachers, families or other community members or professionals played a role. Their effects on children and adolescents' mental health were also reviewed. We carried out a systematic review of papers published from 2007 to 2017. Eleven studies out of 384 met the inclusion criteria. Seven of the articles reviewed focus on interventions conducted in schools and promote supportive interactions involving students, teachers, families and mental health professionals. Four of the articles develop interventions that engage community members in dialogic interactions with children and adolescents.

Results: Interventions in schools and communities implement strategies that foster supportive interactions among diverse actors including teachers, parents, community members, and other professionals. The effects of the mental health interventions reported on children and adolescents' problems include a decrease in disruptive behaviors and affective symptoms such as depression and anxiety, together with an increase in social skills, as well as an improvement in personal well-being.

Conclusions: There is evidence of a positive effect on the mental health of children and adolescents, both in decreasing symptoms of mental disorder and in promoting emotional well-being. Whereas, interactions among different actors seem to be a relevant aspect across the interventions, more research is needed to conclude its effect on the outcomes of the studies reviewed.

Keywords: interaction-based interventions, mental health, schools, communities, children, adolescence, systematic review

Introduction

Childhood and adolescence are critical periods to promote mental health as more than half of mental health problems start at these stages, and many of these persist throughout adult life (Kessler et al., 2005 ). Currently, this has become a priority as worldwide data shows an increase in the prevalence of mental health issues in childhood and adolescence (de la Barra M, 2009 ) and the percentage of those afflicted reaching nearly 20% (WHO, 2016 ). The situation is further exacerbated by the fact that many of these children and adolescents are not receiving the specialized care they require (Mills et al., 2006 ; Weist and Murray, 2008 ; Green et al., 2013 ).

Consequently, important efforts to bring together the best evidence about mental health have been done and raised the challenge of agreeing about fundamental issues in the field such as the definition of mental health and other related concepts (Mehta et al., 2015 ). According to WHO, mental health is understood not as a mere absence of illness, but rather, in a broader sense, as a state of well-being in which individuals develop their abilities, face the stress of daily life, perform productive and fruitful work, and contribute to the betterment of their community (WHO, 2004 ). This definition served as the basis for WHO Mental Health Action Plan, 2013–2020, which incorporates the concepts of mental health promotion, mental illness prevention and treatment, and rehabilitation. Particularly, developmental aspects of children and young people, including, for instance, the ability to manage thoughts, emotions, as well as to build social relationships, and the aptitude to learn, are emphasized in the plan as critical facets to be tackled in mental health interventions.

Mental health interventions conducted in schools and in the communities start from the premise that the problems experienced by adolescents are determined by the interaction of individual, environmental and family factors (Manjula, 2015 ). Accordingly, schools and communities offer an optimal context to intervene as children and adolescents grow and develop through social interaction. Schools and communities can make the most of its environment to foster child and youth development and to promote good mental health (Weist and Murray, 2008 ). Many of the mental health programs implemented in schools promote the development of social skills, socio-emotional competences, and learning outcomes while at the same time reducing disruptive behavior (Dowdy et al., 2010 ; Moreira et al., 2010 ; Durlak et al., 2011 ; Suldo et al., 2014 ). The school environment and climate can therefore play a critical role in encouraging the promotion of protective factors for mental health, such as social-emotional competences and skills (Osher et al., 2012 ).

Hence, social and cognitive development is enacted through social interactions in a particular cultural and social context (Vygotsky, 1978 ; Bronfenbrenner, 1979 ). Drawing on the contributions of Vygotsky's theory of cognitive development, human interaction that takes place in the social and cultural context enhances learning and is fundamental for psychological function. These cultural processes in which people learn and developed occur through interactions with others, including symmetrical (peer) as well as expert–novice (e.g., teacher–student) relations (Rogoff, 1990 ; Cole, 1996 ). Importantly, specific instruments have been produced to capture productive forms of dialogue across educational contexts (Hennessy et al., 2016 ).

Most of the research have been devoted to understanding the central role played by the quality of dialogue and interaction between students, in small group classrooms, or in whole class setting teacher-student interaction (see review by Howe and Abedin, 2013 ). Furthermore, research conducted in community-based schools has also reported the benefit of involving families and community members in learning interactions with elementary students, especially for those belonging to vulnerable populations (Flecha and Soler, 2013 ; Valls and Kyriakides, 2013 ). Accordingly, community plays a central role as human develop through their interactions in the sociocultural activities of their communities (Rogoff, 2003 ). Similar improvements have been reported among students with disabilities as a result of engaging in caring and supportive interactions among peers and with other adults when solving academic tasks in interactive groups (García-Carrión et al., 2018 ). The relevance of productive forms of dialogue and supportive interactions among peers, teachers and other community members, have also reported positive effects in 4th grade students prosocial behavior (Villardón-Gallego et al., 2018 ). These studies evidence the potential of educational interventions that draw on the potential of fostering interactions among different agents and promote productive dialogues as a tools for academic and social improvement.

However, when searching for mental health improvement through dialogic interactions, the research is scarce. The pioneering study carried out by Seikkula and Arnkil ( 2006 ) showed the psychological and social benefits of the therapy based on open and anticipation dialogues with adults and adolescents that also involved the family along with the professionals. Rather than focusing in the individual, facilitating supportive interactions among peers, professionals and family members might be an asset underpinning mental health interventions with children and adolescents. This study showed the critical role of collective interactions, which were very different from a dialogue between two individuals (Seikkula and Arnkil, 2006 ). They identified multi-system treatments (MST) characterized by engaging in close interaction professionals with adolescents, family, and other networks. Replication of these US studies in Norway found evidence of effectiveness, particularly, in the adolescents' social skills (Ogden and Halliday-Boykins, 2004 ). However, according to Seikkula and Arnkil ( 2006 , p. 181): “what ultimately caused the observed outcome was not revealed. After all, methods do not help or cure anyone as such. Psychological methods -and other interaction-based means- exist as they user activity.”

Whereas, determining the effect of the interaction itself in the outcomes obtained might be problematic, the authors of these paper aim to examine interaction-based mental health interventions, defined as those in which collective interactions, that involve professionals, family and community members with children and adolescents, are an integral component of the intervention. This systematic review focuses on those interventions conducted in schools and communities and its outcomes on children and adolescents' mental health. According to the WHO definition of mental health provided above, primary studies selected for this review will include positive outcomes in a broader sense, comprising not only the reduction of symptoms of mental disorder but also the promotion of emotional well-being.

The study carries out a systematic review (Gough et al., 2013 ), a methodology developed by the EPPI Centre of the UCL Institute of Education. We have also taken into account the recommendations by PRISMA (Moher et al., 2009 ) and checklist by Joanna Briggs Institute (JBI) (Lockwood et al., 2015 ), in order to offer transparency, validity, replicable, and updateable in this study.

Search Strategy

This systematic review has been focused and defined by the question: Do interaction-based mental health interventions in schools and communities have positive effects among children and adolescents? This question has been defined in terms of PICOS: In children and adolescents (Population) are interaction-based interventions (Intervention) effective in decreasing disruptive behaviors and affective symptoms such as depression and anxiety (in children and adolescents with mental health problems), and in increasing social skills, and improving well-being and academic engagement (in children and adolescents in general)? (Outcomes).

For the review, empirical articles published in international scientific journals in the areas of psychology, education, and mental health and focused on interventions among children and youth between 2007 and 2017 were searched and screened. To that effect, the following databases were analyzed: Web of Knowledge, SCOPUS, ERIC, and PsycINFO.

The articles were searched using the following keywords: “school-based,” “community-based,” “dialogue,” “mental health,” “well-being,” “emotional development,” “interventions,” “program,” “interaction,” and “prevention.” The exploration was completed with searches that employed synonyms or derivatives of the keywords. The keywords were also combined to refine the search. The publications containing the search criteria in the title, in the keywords and in the abstract were include.

Inclusion and Exclusion Criteria

In order to identify and select the studies most relevant to our research, inclusion and exclusion criteria were established.

The inclusion criteria were the following:

- Special population group: children and adolescents.

- Target age: 6 to 18 years of age, inclusive.

- Mental health interventions in which collective interactions, including professionals, families, and community members with children and adolescents, are an integral component.

- Studies reporting outcomes of the intervention in decreasing symptoms and/or promoting well-being.

The exclusion criteria were the following:

- Interventions focus on early childhood, youth, or adults.

- Target age is not specified, or the target population is below 5 or above 18 years.

- Mental health interventions focusing on one-to-one interactions (i.e., professional-child/professional-adolescent).

- The intervention is not described or assessed, as in trials, theoretical research or literature reviews.

Selection Process

The first part of the search yielded a total of 384 articles from indexed journals: 183 in published in the WOS database, 12 in Scopus, 33 in ERIC and 156 in PsycINFO. All these articles were entered into the Mendeley software for its screening and review. Basic information such as the title, year, authoring, and abstracts was obtained and introduced in a spreadsheet for a first screening.

From the 384 articles gathered in the initial search, the titles and their authors were subsequently revised in order to eliminate duplicates. This review was carried out by the members of the group independently in order to eliminate duplicate documents, specifically 83 were duplicates and were therefore discarded, resulting in a new total of 301 articles.

Abstracts of the 301 articles were reviewed according to the inclusion and exclusion criteria. As a result, 17 articles initially met the inclusion criteria and were eligible for the review (see Figure 1 ). The articles were downloaded for an in-depth review.

Flow diagram to show the process of study selection.

The three researchers examined the articles independently and extracted the most relevant information that was included in a spreadsheet. The information referred to: (a) study characteristics (author, country, selection criteria, design, data acquisition period), (b) population (target population, age and sample size), (c) settings, and (d) type of study. Once the articles were examined in depth against inclusion and exclusion criteria, discrepancies were discussed to reach a consensus in the final selection of the studies. This first review and discussion of the studies of the 11 articles lead to the elimination of a further six articles that did not adequately fit the inclusion criteria. Thus, a total of 11 articles were finally selected for analysis ( Figure 1 ).

Quality Assessment

The quality of the selected studies was assessed using a checklist following the methodological guidance for systematic reviews developed by the Joanna Briggs Institute (JBI) (Lockwood et al., 2015 ). The selected studies were checked against nine questions. The results of the evaluation are presented in the Table 1 .

Quality of studies.

Q1. Is there congruity between the stated philosophical perspective and the research methodology?

Q2. Is there congruity between the research methodology and the research question or objectives?

Q3. Is there congruity between the research methodology and the methods used to collect data?

Q4. Is there congruity between the research methodology and the representation and analysis of data?

Q5. Is there congruity between the research methodology and the interpretation of results?

Q6. Is the influence of the researcher on their search, and vice-versa, addressed?

Q7. Are participant, and their voices, adequately represented?

Q8. Is the research ethical according to current criteria or, for recent studies, and is there evidence of ethical approval by an appropriate body?

Q9. Do the conclusions drawn in the research report flow from the analysis or interpretation, of the data?

Data Analysis

For the analysis of the studies, the three researchers developed an analytical grid to systematize the most relevant information for the purpose of the review: study characteristics, interactions fostered during the intervention, positive effects and information for assessment of the risk of bias. Each researcher analyzed the studies independently aiming at identifying on the one hand, how the interventions promote interactions between different agents, and on the other hand, the effects of the interventions on the target population. Firstly, data was categorized following an inductive method. Secondly, researchers compared their analysis to reach a consensus to report main findings from the review.

The analysis of 11 mental health interventions targeting children and adolescents reported the benefits for both -students with mental health problems as well as healthy participants- resulting from their participation in the programs analyzed. Nine of the studies show the effects of preventive interventions aim to reduce future problems and to promote mental health among children and adolescents without mental health problems. Only two studies target children who had already contacted the school-based mental health service (Fazel, 2015 ) and adolescents who presented depressive symptoms (Connell and Dishion, 2008 ). Overall, the articles reviewed show a series of studies conducted mainly in the US context, seven out of ten, whereas the rest of the studies were carried out in the United Kingdom and Kenya. Seven of the interventions were conducted in schools and four of them were based in the community.

All the studies have shown to promote positive mental health in increasing well-being and preventing other related problems, as well as in reducing affective symptoms among those participants who were already affected. A detailed analysis of the strategies implemented across the mental health programs revealed an emphasis on fostering interactions among the children and adolescents engaging them in dialogues that involved different agents -teachers, families, community members, mental health professionals. An overview of the articles selected is provided in Table 2 .

Summary of included studies.

Sample size: total sample of the study; brackets indicate total number of children and youth .

Supportive Interactions in Mental Health Interventions

Interactions among students, teachers, family, and community members and other professionals play an important role in the interventions analyzed. The mental health programs developed in schools and communities include specific strategies that have an emphasis on enacting peer support, partnerships and dialogic spaces for the children and adolescents to engage in supportive interactions with other relevant peers or adults.

Collaborative Interactions Among Children, Teachers and Parents in the School Context

Interactions between teachers and students underpin the strategies of the mental health interventions in different specific ways, which include tutoring, interviews, consultation meetings, peer-assisted learning strategies, interactive games, cooperative non-competitive building games, among others. (Bradshaw et al., 2009 ; Houlston et al., 2011 ; Cappella et al., 2012 ; Ohl et al., 2013 ; Atkins et al., 2015 ; Fazel, 2015 ). Overall, five of the studies implement strategies aim at developing children social skills through interaction and collaboration.

Similarly, interventions focus on “group interactions” as a preventive strategy that seek to reduce future mental health problems and to promote well-being (McWhirter and McWhirter, 2010 ). Specifically, two group-oriented prevention programs—Project Family Rejuvenation Education and Empowerment and Group-Oriented Psychological Education Prevention- are characterized by small-group discussions among students and with their mothers; in both settings participants engage in dialogue in a nonthreatening climate while encouraging cultivation of feedback and support between them (McWhirter and McWhirter, 2010 ).

Moreover, three studies promoted collaborative interactions between parents, teachers, and mental health professionals (Bradshaw et al., 2009 ; McWhirter and McWhirter, 2010 ; Atkins et al., 2015 ). Interactive features of these mental health programs include building positive peer groups and partnerships, solving problems peacefully, and fostering parent-student interactions, among others. This aligns with the need for an integration of the school ecology into program planning and the implementation of effective programs, as observed in the Link to Learning (L2L) service model instituted in classrooms and homes to support children with disruptive behavior disorders living in urban low-income communities (Atkins et al., 2015 ). In the same vein, collaboration between parents and teachers in classrooms is at the heart of the Family-School Partnership Program (Bradshaw et al., 2009 ). Discussion-based interactions include parents reading aloud to their children, with a particular emphasis in the promotion of reasoning among the students. Interaction is guided-by open-ended questions after the reading or using other materials, such as videotapes. Parents reacted to and discussed the situations and problem-solved alternative approaches. Discussions were also held on problem situations arising at home.

Fostering Communicative Skills and Home–School Interaction

Communication skills and family communication practice are a central component of READY—a family-based intervention program to prevent HIV infection and mental health problems (Puffer et al., 2016 ). The interaction and the communication skills training involved families, caregivers, children, and the community, as the intervention was carried out in religious congregations. By improving family communication as a protective factor against mental health disorders, READY draws on a promising approach to strengthen protective family processes that may prevent future negative outcomes for adolescents (Puffer et al., 2016 ). In conjunction with these activities, and while the program was being implemented, interaction was also fostered, using a voicemail system to cultivate parents' involvement and to provide consultation on an as-needed basis, and asking parents to fill in and return comment sheets indicating whether they had completed the weekly home activities and whether they had encountered any problems.

For their part, Atkins et al. ( 2010 ) carried out an intervention that targeted home-school communication and home routines that support learning, homework support, and daily readings. They promoted interaction between parents and teachers by means of two techniques: Daily Report Cards and Good News Notes. Daily Reports Cards, on the one hand, consist of cards in which teachers and parents join efforts to identify, monitor, and reinforce behaviors that interfere with learning. Teachers and parents agree on a rating system to track behaviors, a reward schedule, and a plan for monitoring intervals that will enhance both direct feedback to students and home-school communication. Good News Notes, on the other hand, are certificates that teachers send to families detailing desirable behaviors exhibited by children, as a means to provide positive weekly feedback to parents. The Notes identify students' strengths, scaffold behavior improvement by reinforcing small achievements, and balance infraction reports with positive feedback.

Overall, these studies report a multilevel approach, tackling schools, families, communities, and mental health providers and services. The three articles include programs that evidence the crucial role of family and parental engagement in promoting mental health among adolescents (Connell and Dishion, 2008 ; Puffer et al., 2016 ) and children (Atkins et al., 2015 ). According to Connell and Dishion ( 2008 ), providing family-centered services in the school environment facilitated family engagement in the program.

Engaging in Dialogue With Community Members

Engaging in dialogue with the very community members who might be at risk of suffering mental health problems is essential for the success of the intervention. Some strategies for their involvement include the creation of a local Community Advisory Committee (Puffer et al., 2016 ) or a Community Advisory Board (Kia-Keating et al., 2017 ). The latter engage participants in reciprocal dialogues on solutions for issues ranging from violence exposure and health disparities to the difficulties encountered by youth people seeking to thrive, as exemplified by the HEROES Project (Kia-Keating et al., 2017 ).

There have been other community-based organizations studied in California, aimed at promoting “cultures of health” by engaging people in building social networks, by fostering solidarity and collective efficacy, or by promoting a shared commitment to the collective well-being (Puffer et al., 2016 ). Overall, these programs promote dialogic spaces in which the voices of the minorities, who have often been excluded, are instead given prominence and listened to, in order to look for solutions that will address the inequalities affecting their communities.

The effects of the interventions carried out in schools and communities with an emphasis on fostering supportive interactions as discussed above have benefited children and adolescents as reported in the following dimensions:

Internalizing symptomatology: Three studies include interventions that have had positive effects on the treatment and prevention of affective disorders such as depression and anxiety. Thus, Connell and Dishion ( 2008 ) ascertained, throughout 3 years, their potential to reduce and prevent the increase of depressive symptoms in at-risk early adolescents. Likewise, Ohl et al. ( 2013 ) confirmed the effectiveness of relationships for decreasing emotional symptoms. McWhirter and McWhirter ( 2010 ) garnered the results of the GOPEP intervention program (McWhirter et al., 1997 ), based on group sessions and on conjoint sessions, which entailed substantial collaboration between researchers and participants, and confirmed the effectiveness of the SOAR program (Student Optimistic Attitudes and Resilience Program) in reducing anxiety and depression. The FREE program, for its part, was effective in decreasing self-isolation among children and their mothers, survivors of domestic violence.

Externalizing symptomatology: Four articles present improvements in aspects related to aggression and behavioral issues. Ohl et al. ( 2013 ) confirmed that the Pyramid project helped improve peer problems; however, they did not find positive effects on behavioral problems. McWhirter and McWhirter ( 2010 ) gathered evidence confirming the effectiveness of the FREE project in decreasing family conflict, and of the SCARE (Student-Created Aggression Replacement Education) program, one of the GOPEP intervention programs, in decreasing and managing aggression, anger, and violent behaviors. However, Cappella et al. ( 2012 ) did not find significative differences in behavioral regulation as an effect of their BRIDGE intervention, although children identified as having behavioral problems benefitted more than their peers in the area of social relations. On the other hand, Bradshaw et al. ( 2009 ) confirmed the long-term positive effects in reducing behavioral and mental-health problems resulting of the CC intervention.

Personal well-being: Six of the studies reported positive effects on strengthening psychological-related aspects to well-being, including self-concept, self-esteem, self-efficacy, and empowerment, among others. Cappella et al. ( 2012 ) confirmed the existence of a positive effect of intervention on children's academic self-concept. Atkins et al. ( 2015 ) found a significantly greater improvement on social skills among children who had been involved in the intervention, whereas Ohl et al. ( 2013 ) ascertained its positive effect on prosocial behavior. Houlston et al. ( 2011 ) confirmed that peer support improves self-esteem in victims of bullying, as well as their perception of the support provided by friends and other students. Participants stated that peer support had a positive impact on students' relationships, improving and building peer networks with trained peer supporters and other students. More specifically, in bullying situations, students considered peer support to be helpful for a number of reasons, including being able to talk about it, having peers to interact with, or helping bullied students to tell others of their plight.

Bloemraad and Terriquez ( 2016 ) gathered the opinions of people taking part in activities organized by CBOs (Community-Based Organizations). Results provide evidence of the impact that involvement in CBOs has on participants, namely when preparing to enroll and succeed in college, as well as on their self-reported civic capacity developing skills, which encompass skills as diverse as communicating with others, understanding the impact that government decisions have on the community, speaking in public, or planning events. Besides, the involvement in CBOs improves personal empowerment and self-efficacy, as participants learn to stand up for their beliefs, become more aware of health issues impacting their communities, and learn about their own culture or ethnic group. As for health and education outcomes, participants became more informed about college and career options, took better care of their personal health, and improved their school grades.

McWhirter and McWhirter ( 2010 ) showed that the FREE project resulted in an increase in children's and women's emotional well-being, peer engagement and self-esteem in children, as well as women's self-efficacy.

Context: Five of the interventions reported improvements on the classroom climate and teacher-student and peer interactions. The study carried out by Cappella et al. ( 2012 ), based on BRIDGE intervention, demonstrates how classroom interactions generate a positive climate where emotional support and teacher sensitivity are prominent. These interactions also promote a positive classroom climate, characterized by optimal behavior management, productivity, and instructional learning formats. Furthermore, they have been verified to help develop instructional support, more positive teacher expectations regarding children's behavior, and a more responsive teacher-student relationship. The study by McWhirter and McWhirter ( 2010 ), based on group interventions, highlights that interacting with other people helps build positive peer/adult relationships. These conclusions are shared by Puffer et al. ( 2016 ), whose study focused on family communication, and who conclude that intra-family communication improves well-being. In a similar vein, Bloemraad and Terriquez ( 2016 ) find that the interactions fostered by the intervention improve well-being in the community.

The present systematic review of studies has fulfilled the objective of identifying evidence for positive effects of interaction-based interventions in schools and communities in children's and adolescents' mental health. We have shown that mental health interventions, in which supportive interactions are fostered among different actors, have a positive effect in decreasing affective symptoms and in increasing personal wellbeing among children and adolescents.

We detected in these programs an emphasis on engaging children and adolescents in supportive interactions with other relevant adults, such as teachers, family, community members, and other professionals. Overall it showcases the benefits children and adolescents without mental health problems can reap, particularly in preventive interventions as nine of the studies focused on. Only two studies target adolescents and children with mental health problems (Connell and Dishion, 2008 ; Fazel, 2015 ). The literature analyzed sheds light on the importance of preventive interventions where different agents work together toward the common goal of promoting children's and adolescents' mental health (Atkins et al., 2015 ; Kia-Keating et al., 2017 ).

Positive effects on mental health are achieved through interventions that are culturally appropriate and culturally grounded (Bloemraad and Terriquez, 2016 ; Puffer et al., 2016 ; Kia-Keating et al., 2017 ). This is particularly important in those interventions which require the active engagement of families and community members. The role of family and community members emerges as particularly relevant and providing them with communicative skills and fostering home-school communication are assets for the mental health interventions. Schools thus become an ideal space to facilitate family and community involvement, and they consequently present a great potential for enhancing positive parent-teacher, teacher-student and student-student interactions. This is consistent with other research that has focused on the benefits of school-based mental health interventions to help them develop cognitively, socially, and emotionally (Fazel et al., 2014 ).

There is enough supporting evidence on the potential of these interventions for schools to create a positive climate based on instructional and emotional support, solidarity and friendship that improves the well-being of children and communities (McWhirter and McWhirter, 2010 ; Bloemraad and Terriquez, 2016 ; Puffer et al., 2016 ). Available evidence on the effectiveness of these studies attests to the attainment of positive gains in students' academic achievement, which will also lead to other long-term positive effects that will help prevent behavioral and mental-health problems (Bradshaw et al., 2009 ). This positive effect is particularly strong in high poverty contexts (Atkins et al., 2015 ). Particularly relevant is the reduction of anxiety and depression, especially in light of the marked increase of the latter, currently ailing 4,4% of the world population (WHO, 2017 ).

Overall, we argue that interaction-based approaches in mental health interventions, that involve diverse actors in productive forms of dialogue and supportive interactions, are consistent with the benefits reported by the sociocultural approaches to learning and development (Vygotsky, 1978 ). However, in this systematic review we have not been able to determine the effect of the interaction on the effectiveness of the intervention. This is consistent with the literature, as effective mental health interventions, which include collective interactions among different agents as a central element of the intervention, did not revealed how those interactions were linked to the positive outcomes obtained (Seikkula and Arnkil, 2006 ). Similarly, the primary studies reviewed do not established a direct link of the interaction component of the intervention with the positive mental health outcomes. This question still remains.

Limitation and Future Directions

In this systematic review we have reviewed a set of interventions for both adolescents and children, without explicitly distinguishing within the two study groups. This raises a limitation as children and adolescents can potentially show different needs in terms of mental and behavioral support. Consequently, there could be potential differences in the outcomes that have not been considered in this review. In the same vein, this study only reviewed research in English and most research was conducted in the United States, which could also limit the generalizability of the results.

On the other hand, the concept of interaction we explored it is a broad concept that presents some limitations in providing a consistent definition within the interventions. Furthermore, the primary studies reported the effects of the intervention as a whole. Therefore, their methodological designs do not allow to identify the specific effect on mental health of the interaction itself. Still there is a gap to determine the effect of the interactions on the mental health outcomes. Further research is needed to explore the particular role and potential of social interaction to promote children and adolescents' mental health.

Conclusions

This systematic review of 11 studies has focused on mental health interventions in which interaction plays an important role. Supportive interactions carried out in the framework of mental health interventions involve various contexts, agents and systems, including teachers, parents, mental-health professionals, and members of the community.

There is evidence of a positive effect on the mental health of children and adolescents, both in decreasing internalizing and externalizing symptoms, and in promoting personal well-being. Factors that foster mental health as social support or engagement also increase with interventions programs that include interaction as a main feature.

However, more research is needed into the specific impact of interaction on the mental health of children and adolescents, as well as analyzing the type of interactions that have the most beneficial effect.

Author Contributions

RG-C wrote the proposal of this systematic review with the input and contributions of the research team BV-C and LV-G. RG-C and LV-G planned the search in databases and defined exclusion and inclusion criteria for the selection of the articles. BV-C carried out the search, screen the materials and proposed a selection. All the authors checked and refined the selection of the studies. Each author drafted a section of this manuscript. All authors reviewed the whole manuscript, read and approved the submitted version.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding. The work leading to this invention has received funding from the Spanish Research Grants EDU2017-88666-R and EDU2015-66395-R (MINECO/FEDER, UE).

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• 14 December 2021

Depression and anxiety ‘the norm’ for UK PhD students

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PhD students in the United Kingdom are more likely than other educated members of the general public to report symptoms of depression or anxiety, according to a survey.

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doi: https://doi.org/10.1038/d41586-021-03761-3

Hazell, C. M. et al. Humanit. Soc. Sci. Commun. 8 , 305 (2021).

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Levecque, K., Anseel, F., de Beuckelaer, A., van der Heyden, J. & Gisle, L. Res. Pol. 46 , 868–879 (2017).

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Satinsky, E. N. et al. Sci. Rep. 11 , 14370 (2021).

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