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Filipino help-seeking for mental health problems and associated barriers and facilitators: a systematic review

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• Published: 20 August 2020
• Volume 55 , pages 1397–1413, ( 2020 )

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• Andrea B. Martinez   ORCID: orcid.org/0000-0002-4437-769X 1 , 2 ,
• Melissa Co 3 ,
• Jennifer Lau 2 &
• June S. L. Brown 2  

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This systematic review aims to synthesise the evidence on behavioural and attitudinal patterns as well as barriers and enablers in Filipino formal help-seeking.

Using PRISMA framework, 15 studies conducted in 7 countries on Filipino help-seeking were appraised through narrative synthesis.

Filipinos across the world have general reluctance and unfavourable attitude towards formal help-seeking despite high rates of psychological distress. They prefer seeking help from close family and friends. Barriers cited by Filipinos living in the Philippines include financial constraints and inaccessibility of services, whereas overseas Filipinos were hampered by immigration status, lack of health insurance, language difficulty, experience of discrimination and lack of acculturation to host culture. Both groups were hindered by self and social stigma attached to mental disorder, and by concern for loss of face, sense of shame, and adherence to Asian values of conformity to norms where mental illness is considered unacceptable. Filipinos are also prevented from seeking help by their sense of resilience and self-reliance, but this is explored only in qualitative studies. They utilize special mental health care only as the last resort or when problems become severe. Other prominent facilitators include perception of distress, influence of social support, financial capacity and previous positive experience in formal help.

We confirmed the low utilization of mental health services among Filipinos regardless of their locations, with mental health stigma as primary barrier, while resilience and self-reliance as coping strategies were cited in qualitative studies. Social support and problem severity were cited as prominent facilitators.

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Introduction

Mental illness is the third most common disability in the Philippines. Around 6 million Filipinos are estimated to live with depression and/or anxiety, making the Philippines the country with the third highest rate of mental health problems in the Western Pacific Region [ 1 ]. Suicide rates are pegged at 3.2 per 100,000 population with numbers possibly higher due to underreporting or misclassification of suicide cases as ‘undetermined deaths’ [ 2 ]. Despite these figures, government spending on mental health is at 0.22% of total health expenditures with a lack of health professionals working in the mental health sector [ 1 , 3 ]. Elevated mental health problems also characterise ‘overseas Filipinos’, that is, Filipinos living abroad [ 4 ]. Indeed, 12% of Filipinos living in the US suffer from psychological distress [ 5 ], higher than the US prevalence rate of depression and anxiety [ 1 ]. Long periods of separation from their families and a different cultural background may make them more prone to acculturative stress, depression, anxiety, substance use and trauma especially those who are exposed to abuse, violence and discrimination whilst abroad [ 6 ].

One crucial barrier to achieving well-being and improved mental health among both ‘local’ and overseas Filipinos is their propensity to not seek psychological help [ 7 , 8 ]. Not only are help-seeking rates much lower than rates found in general US populations [ 9 ], they are also low compared to other minority Asian groups [ 10 ]. Yet, few studies have been published on Filipino psychological help-seeking either in the Philippines or among those overseas [ 11 ]. Most available studies have focused on such factors as stigma tolerance, loss of face and acculturation factors [ 12 , 13 ].

To date, no systematic review of studies on Filipino psychological help-seeking, both living in the Philippines and overseas, has been conducted. In 2014, Tuliao conducted a narrative review of the literature on Filipino mental health help-seeking in the US which provided a comprehensive treatise on cultural context of Filipino help-seeking behavior [ 11 ]. However, new studies have been published since which examine help-seeking in other country contexts, such as Norway, Iceland, Israel and Canada [ 6 , 14 , 15 , 16 ]. Alongside recent studies on local Filipinos, these new studies can provide basis for comparison of the local and overseas Filipinos [ 7 , 8 , 12 , 17 ].

This systematic review aims to critically appraise the evidence on behavioural and attitudinal patterns of psychological help-seeking among Filipinos in the Philippines and abroad and examine barriers and enablers of their help-seeking. While the majority of studies undertaken have been among Filipino migrants especially in the US where they needed to handle additional immigration challenges, studying help-seeking attitudes and behaviours of local Filipinos is important as this may inform those living abroad [ 10 , 13 , 18 ]. This review aims to: (1) examine the commonly reported help-seeking attitudes and behaviors among local and overseas Filipinos with mental health problems; and (2) expound on the most commonly reported barriers and facilitators that influence their help-seeking.

The review aims to synthesize available data on formal help-seeking behavior and attitudes of local and overseas Filipinos for their mental health problems, as well as commonly reported barriers and facilitators. Formal psychological help-seeking behavior is defined as seeking services and treatment, such as psychotherapy, counseling, information and advice, from trained and recognized mental health care providers [ 19 ]. Attitudes on psychological help-seeking refer to the evaluative beliefs in seeking help from these professional sources [ 20 ].

Eligibility criteria

Inclusion criteria for the studies were the following: (1) those that address either formal help-seeking behavior OR attitude related to a mental health AND those that discuss barriers OR facilitators of psychological help-seeking; (2) those that involve Filipino participants, or of Filipino descent; in studies that involve multi-cultural or multi-ethnic groups, they must have at least 20% Filipino participants with disaggregated data on Filipino psychological help-seeking; (3) those that employed any type of study designs, whether quantitative, qualitative or mixed-methods; (4) must be full-text peer-reviewed articles published in scholarly journals or book chapters, with no publication date restrictions; (5) written either in English or Filipino; and (6) available in printed or downloadable format. Multiple articles based on the same research are treated as one study/paper.

Exclusion criteria were: (1) studies in which the reported problems that prompted help-seeking are medical (e.g. cancer), career or vocational (e.g., career choice), academic (e.g., school difficulties) or developmental disorders (e.g., autism), unless specified that there is an associated mental health concern (e.g., anxiety, depression, trauma); (2) studies that discuss general health-seeking behaviors; (3) studies that are not from the perspective of mental health service users (e.g., counselor’s perspective); (4) systematic reviews, meta-analyses and other forms of literature review; and (5) unpublished studies including dissertations and theses, clinical reports, theory or methods papers, commentaries or editorials.

Search strategy and study selection

The search for relevant studies was conducted through electronic database searching, hand-searching and web-based searching. Ten bibliographic databases were searched in August to September 2018: PsychInfo, Global Health, MedLine, Embase, EBSCO , ProQuest , PubMed , Science Direct, Scopus and Emerald Insight. The following search terms were used: “help-seeking behavior” OR “utilization of mental health services” OR “access to mental health services” OR “psychological help-seeking” AND “barriers to help-seeking” OR “facilitators of help-seeking” AND “mental health” OR “mental health problem” OR “mental disorder” OR “mental illness” OR “psychological distress” OR “emotional problem” AND “Filipino” OR “Philippines”. Filters were used to select only publications from peer-reviewed journals. Internet searches through Google Scholar and websites of Philippine-based publications were also performed using the search term “Filipino mental health help-seeking” as well as hand-searching of reference lists of relevant studies. A total of 3038 records were obtained. Duplicates were removed and a total of 2659 records were screened for their relevance based on their titles and abstracts.

Preliminary screening of titles and abstracts of articles resulted in 162 potentially relevant studies, their full-text papers were obtained and were reviewed for eligibility by two reviewers (AM and MC). Divergent opinions on the results of eligibility screening were deliberated and any further disagreement was resolved by the third reviewer (JB). A total of 15 relevant studies (from 24 papers) published in English were included in the review and assessed for quality. There were seven studies with multiple publications (two of them have 3 papers) and a core paper was chosen on the basis of having more comprehensive key study data on formal help-seeking. Results of the literature search are reported in Fig.  1 using the PRISMA diagram [ 21 ]. A protocol for this review was registered at PROSPERO Registry of the Centre for Reviews and Dissemination of the University of York ( https://www.crd.york.ac.uk/PROSPERO ; ID: CRD42018102836).

PRISMA flow diagram

Data extraction and quality assessment

Data extracted by the main author were crosschecked by a second reviewer (JB). A data extraction table with thematic headings was prepared and pilot tested for two quantitative and two qualitative studies to check data comparability. Extraction was performed using the following descriptive data: (1) study information (e.g. name of authors, publication date, study location, setting, study design, measurement tools used); (2) socio-demographic characteristics of participants (e.g. sample size, age, gender); and (3) overarching themes on psychological help-seeking behavior and attitudes, as well as barriers and facilitators of help-seeking.

Two reviewers (AM and MC) did quality assessment of the studies separately, using the following criteria: (1) relevance to the research question; (2) transparency of the methods; (3) robustness of the evidence presented; and (4) soundness of the data interpretation and analysis. Design-specific quality assessment tools were used in the evaluation of risk of bias of the studies, namely: (1) Critical Appraisal Skills Programme Qualitative Checklist [ 22 ]; and (2) Quality Assessment Tool for Quantitative Studies by the Effective Public Health Practice Project [ 23 ]. The appraisals for mixed-methods studies were done separately for quantitative and qualitative components to ensure trustworthiness [ 24 ] of the quality of each assessment.

For studies reported in multiple publications, quality assessment was done only on the core papers [ 25 ]. All the papers ( n  = 6) assessed for their qualitative study design (including the 4 mixed-methods studies) met the minimum quality assessment criteria of fair ( n  = 1) and good ( n  = 5) and were, thus, included in the review. Only 11 out of the 13 quantitative studies (including the 4 mixed-methods studies) satisfied the minimum ratings for the review, with five getting strong quality rating. The two mixed-methods studies that did not meet the minimum quality rating for quantitative designs were excluded as sources of quantitative data but were used in the qualitative data analysis because they satisfied the minimum quality rating for qualitative designs.

Strategy for data analysis

Due to the substantial heterogeneity of the studies in terms of participant characteristics, study design, measurement tools used and reporting methods of the key findings, narrative synthesis approach was used in data analysis to interpret and integrate the quantitative and qualitative evidence [ 26 , 27 ]. However, one crucial methodological limitation of studies in this review is the lack of agreement on what constitutes formal help-seeking. Some researchers include the utilization of traditional or indigenous healers as formal help-seeking, while others limit the concept to professional health care providers. As such, consistent with Rickwood and Thomas’ definition of formal help-seeking [ 19 ], data extraction and analysis were done only on those that reported utilization of professional health care providers.

Using a textual approach, text data were coded using both predetermined and emerging codes [ 28 ]. They were then tabulated, analyzed, categorized into themes and integrated into a narrative synthesis [ 29 ]. Exemplar quotations and author interpretations were also used to support the narrative synthesis. The following were the themes on barriers and facilitators of formal help-seeking: (1) psychosocial barriers/facilitators, which include social support from family and friends, perceived severity of mental illness, awareness of mental health issues, self-stigmatizing beliefs, treatment fears and other individual concerns; (2) socio-cultural barriers/facilitators, which include the perceived social norms and beliefs on mental health, social stigma, influence of religious beliefs, and language and acculturation factors; and (3) systemic/structural and economic barriers/facilitators, which include financial or employment status, the health care system and its accessibility, availability and affordability, and ethnicity, nativity or immigration status.

Study and participant characteristics

The 15 studies were published between 2002 and 2018. Five studies were conducted in the US, four in the Philippines and one study each was done in Australia, Canada, Iceland, Israel and Norway. One study included participants working in different countries, the majority were in the Middle East. Data extracted from the four studies done in the Philippines were used to report on the help-seeking behaviors and attitudes, and barriers/facilitators to help-seeking of local Filipinos, while the ten studies conducted in different countries were used to report on help-seeking of overseas Filipinos. Nine studies were quantitative and used a cross-sectional design except for one cohort study; the majority of them used research-validated questionnaires. Four studies used mixed methods with surveys and open-ended questionnaires, and another two were purely qualitative studies that used interviews and focus group discussions. Only three studies recruited participants through random sampling and the rest used purposive sampling methods. All quantitative studies used questionnaires in measures of formal help-seeking behaviors, and western-standardized measures to assess participants’ attitudes towards help-seeking. Qualitative studies utilized semi-structured interview guides that were developed to explore the psychological help-seeking of participants.

A total of 5096 Filipinos aged 17–70 years participated in the studies. Additionally, 13 studies reported on the mean age of participants, with the computed overall mean age at 39.52 (SD 11.34). The sample sizes in the quantitative studies ranged from 70 to 2285, while qualitative studies ranged from 10 to 25 participants. Of the participants, 59% ( n  = 3012) were female which is probably explained by five studies focusing on Filipino women. Ten studies were conducted in community settings, five in health or social centre-based settings and 1 in a university (Table 1 ).

Formal help-seeking behaviors

12 studies examined the formal help-seeking behaviors of Filipinos (Table 2 ), eight of them were from community-based studies and four were from centre-based studies. Nine studies reported on formal help-seeking of overseas Filipinos and three reported on local Filipinos.

Community-based vs health/social centres Data from quantitative community studies show that the rates of formal help-seeking behaviors among the Filipino general population ranged from 2.2% [ 30 ] to 17.5% [ 6 ]. This was supported by reports from qualitative studies where participants did not seek help at all. The frequency of reports of formal help-seeking from studies conducted in crisis centres and online counseling tended to be higher. For instance, the rate of engagement in online counseling among overseas Filipinos was 10.68% [ 31 ], those receiving treatment in crisis centers was 39.32% [ 17 ] while 100% of participants who were victims of intimate partner violence were already receiving help from a women’s support agency [ 8 , 32 ].

Local vs overseas Filipinos’ formal help-seeking The rate of formal psychological help-seeking of local Filipinos was at 22.19% [ 12 ] while overseas rates were lower and ranged from 2.2% of Filipino Americans [ 30 ] to 17.5% of Filipinos in Israel [ 6 ]. Both local and overseas Filipinos indicated that professional help is sought only as a last resort because they were more inclined to get help from family and friends or lay network [ 7 , 16 ].

Attitudes towards formal help-seeking

13 studies reported on participants’ attitudes towards seeking formal help. Seven studies identified family and friends as preferred sources of help [ 7 , 14 , 16 ] rather than mental health specialists and other professionals even when they were already receiving help from them [ 17 , 32 ]. When Filipinos seek professional help, it is usually done in combination with other sources of care [ 13 ] or only used when the mental health problem is severe [ 14 , 16 , 33 ]. Other studies reported that in the absence of social networks, individuals prefer to rely on themselves [ 32 , 33 ].

Community-based vs health/social centres Community-based studies reported that Filipinos have negative attitudes marked by low stigma tolerance towards formal help-seeking [ 7 , 14 , 16 ]. However, different findings were reported by studies conducted in crisis centres. Hechanova et al. found a positive attitude towards help-seeking among users of online counseling [ 31 ], whereas Cabbigat and Kangas found that Filipinos in crisis centres still prefer receiving help from religious clergy or family members, with mental health units as the least preferred setting in receiving help [ 17 ]. This is supported by the findings of Shoultz and her colleagues who reported that Filipino women did not believe in disclosing their problems to others [ 32 ].

Local vs overseas Filipinos Filipinos, regardless of location, have negative attitudes towards help-seeking, except later-generation Filipino migrants who have been acculturated in their host countries and tended to have more positive attitudes towards mental health specialists [ 10 , 13 , 15 , 34 ]. However, this was only cited in quantitative studies. Qualitative studies reported the general reluctance of both overseas and local Filipinos to seek help.

Barriers in formal help-seeking

All 15 studies examined a range of barriers in psychological help-seeking (Table 3 ). The most commonly endorsed barriers were: (1) financial constraints due to high cost of service, lack of health insurance, or precarious employment condition; (2) self-stigma, with associated fear of negative judgment, sense of shame, embarrassment and being a disgrace, fear of being labeled as ‘crazy’, self-blame and concern for loss of face; and (3) social stigma that puts the family’s reputation at stake or places one’s cultural group in bad light.

Local vs overseas Filipinos In studies conducted among overseas Filipinos, strong adherence to Asian values of conformity to norms is an impediment to help-seeking but cited only in quantitative studies [ 10 , 13 , 15 , 34 ] while perceived resilience, coping ability or self-reliance was mentioned only in qualitative studies [ 14 , 16 , 33 ]. Other common barriers to help-seeking cited by overseas Filipinos were inaccessibility of mental health services, immigration status, sense of religiosity, language problem, experience of discrimination and lack of awareness of mental health needs [ 10 , 13 , 18 , 34 ]. Self-reliance and fear of being a burden to others as barriers were only found among overseas Filipinos [ 6 , 16 , 32 ]. On the other hand, local Filipinos have consistently cited the influence of social support as a hindrance to help-seeking [ 7 , 17 ].

Stigmatized attitude towards mental health and illness was reported as topmost barriers to help-seeking among overseas and local Filipinos. This included notions of mental illness as a sign of personal weakness or failure of character resulting to loss of face. There is a general consensus in these studies that the reluctance of Filipinos to seek professional help is mainly due to their fear of being labeled or judged negatively, or even their fear of fueling negative perceptions of the Filipino community. Other overseas Filipinos were afraid that having mental illness would affect their jobs and immigration status, especially for those who are in precarious employment conditions [ 6 , 16 ].

Facilitators of formal help-seeking

All 15 studies discussed facilitators of formal help-seeking, but the identified enablers were few (Table 4 ). Among the top and commonly cited factors that promote help-seeking are: (1) perceived severity of the mental health problem or awareness of mental health needs; (2) influence of social support, such as the presence/absence of family and friends, witnessing friends seeking help, having supportive friends and family who encourage help-seeking, or having others taking the initiative to help; and (3) financial capacity.

Local vs overseas Filipinos Studies on overseas Filipinos frequently cited financial capacity, immigration status, language proficiency, lower adherence to Asian values and stigma tolerance as enablers of help-seeking [ 15 , 30 , 32 , 34 ], while studies done on local Filipinos reported that awareness of mental health issues and previous positive experience of seeking help serve as facilitator [ 7 , 12 ].

Community-based vs health/social centres Those who were receiving help from crisis centres mentioned that previous positive experience with mental health professionals encouraged their formal help-seeking [ 8 , 17 , 31 ]. On the other hand, community-based studies cited the positive influence of encouraging family and friends as well as higher awareness of mental health problems as enablers of help-seeking [ 12 , 14 , 16 ].

To the best of our knowledge, this is the first systematic review conducted on psychological help-seeking among Filipinos, including its barriers and facilitators. The heterogeneity of participants (e.g., age, gender, socio-economic status, geographic location or residence, range of mental health problems) was large.

Filipino mental health help-seeking behavior and attitudes The rate of mental health problems appears to be high among Filipinos both local and overseas, but the rate of help-seeking is low. This is consistent with findings of a study among Chinese immigrants in Australia which reported higher psychological distress but with low utilization of mental health services [ 35 ]. The actual help-seeking behavior of both local and overseas Filipinos recorded at 10.72% ( n  = 461) is lower than the 19% of the general population in the US [ 36 ] and 16% in the United Kingdom (UK) [ 37 ], and even far below the global prevalence rate of 30% of people with mental illness receiving treatment [ 38 ]. This finding is also comparable with the low prevalence rate of mental health service use among the Chinese population in Hong Kong [ 39 ] and in Australia [ 35 ], Vietnamese immigrants in Canada [ 30 ], East Asian migrants in North America [ 41 ] and other ethnic minorities [ 42 ] but is in sharp contrast with the increased use of professional help among West African migrants in The Netherlands [ 43 ].

Most of the studies identified informal help through family and friends as the most widely utilized source of support, while professional service providers were only used as a last resort. Filipinos who are already accessing specialist services in crisis centres also used informal help to supplement professional help. This is consistent with reports on the frequent use of informal help in conjunction with formal help-seeking among the adult population in UK [ 44 ]. However, this pattern contrasts with informal help-seeking among African Americans who are less likely to seek help from social networks of family and friends [ 45 ]. Filipinos also tend to use their social networks of friends and family members as ‘go-between’ [ 46 ] for formal help, serving to intercede between mental health specialists and the individual. This was reiterated in a study by Shoultz et al. (2009) in which women who were victims of violence are reluctant to report the abuse to authorities but felt relieved if neighbours and friends would interfere for professional help in their behalf [ 32 ].

Different patterns of help-seeking among local and overseas Filipinos were evident and may be attributed to the differences in the health care system of the Philippines and their host countries. For instance, the greater use of general medical services by overseas Filipinos is due to the gatekeeper role of general practitioners (GP) in their host countries [ 47 ] where patients have to go through their GPs before they get access to mental health specialists. In contrast, local Filipinos have direct access to psychiatrists or psychologists without a GP referral. Additionally, those studies conducted in the Philippines were done in urban centers where participants have greater access to mental health specialists. While Filipinos generally are reluctant to seek help, later-generation overseas Filipinos have more positive attitudes towards psychological help-seeking. Their exposure and acculturation to cultures that are more tolerant of mental health stigma probably influenced their more favorable attitude [ 41 , 48 ].

Prominent barrier themes in help-seeking Findings of studies on frequently endorsed barriers in psychological help-seeking are consistent with commonly reported impediments to health care utilization among Filipino migrants in Australia [ 49 ] and Asian migrants in the US [ 47 , 50 ]. The same barriers in this review, such as preference for self-reliance as alternative coping strategy, poor mental health awareness, perceived stigma, are also identified in mental health help-seeking among adolescents and young adults [ 51 ] and among those suffering from depression [ 52 ].

Social and self-stigmatizing attitudes to mental illness are prominent barriers to help-seeking among Filipinos. Social stigma is evident in their fears of negative perception of the Filipino community, ruining the family reputation, or fear of social exclusion, discrimination and disapproval. Self-stigma manifests in their concern for loss of face, sense of shame or embarrassment, self-blame, sense of being a disgrace or being judged negatively and the notion that mental illness is a sign of personal weakness or failure of character [ 16 ]. The deterrent role of mental health stigma is consistent with the findings of other studies [ 51 , 52 ]. Overseas Filipinos who are not fully acculturated to the more stigma-tolerant culture of their host countries still hold these stigmatizing beliefs. There is also a general apprehension of becoming a burden to others.

Practical barriers to the use of mental health services like accessibility and financial constraints are also consistently rated as important barriers by Filipinos, similar to Chinese Americans [ 53 ]. In the Philippines where mental health services are costly and inaccessible [ 54 ], financial constraints serve as a hindrance to formal help-seeking, as mentioned by a participant in the study of Straiton and his colleagues, “In the Philippines… it takes really long time to decide for us that this condition is serious. We don’t want to use our money right away” [ 14 , p.6]. Local Filipinos are confronted with problems of lack of mental health facilities, services and professionals due to meager government spending on health. Despite the recent ratification of the Philippines’ Mental Health Act of 2018 and the Universal Health Care Act of 2019, the current coverage for mental health services provided by the Philippine Health Insurance Corporation only amounts to US$154 per hospitalization and only for acute episodes of mental disorders [ 55 ]. Specialist services for mental health in the Philippines are restricted in tertiary hospitals located in urban areas, with only one major mental hospital and 84 psychiatric units in general hospitals [ 1 ].

Overseas Filipinos cited the lack of health insurance and immigration status without health care privileges as financial barrier. In countries where people have access to universal health care, being employed is a barrier to psychological help-seeking because individuals prefer to work instead of attending medical check-ups or consultations [ 13 ]. Higher income is also associated with better mental health [ 56 ] and hence, the need for mental health services is low, whereas poor socio-economic status is related to greater risk of developing mental health problems [ 57 , 58 ]. Lack of familiarity with healthcare system in host countries among new Filipino migrants also discourages them from seeking help.

Studies have shown that reliance on, and accessibility of sympathetic, reliable and trusted family and friends are detrimental to formal help-seeking since professional help is sought only in the absence of this social support [ 6 , 8 ]. This is consistent with the predominating cultural values that govern Filipino interpersonal relationships called kapwa (or shared identity) in which trusted family and friends are considered as “hindi-ibang-tao” (one-of-us/insider), while doctors or professionals are seen as “ibang-tao” (outsider) [ 59 ]. Filipinos are apt to disclose and be more open and honest about their mental illness to those whom they considered as “hindi-ibang-tao” (insider) as against those who are “ibang-tao” (outsider), hence their preference for family members and close friends as source of informal help [ 59 ]. For Filipinos, it is difficult to trust a mental health specialist who is not part of the family [ 60 ].

Qualitative studies in this review frequently mentioned resilience and self-reliance among overseas Filipinos as barriers to help-seeking. As an adaptive coping strategy for adversity [ 61 ], overseas Filipinos believe that they were better equipped in overcoming emotional challenges of immigration [ 16 ] without professional assistance [ 14 ]. It supports the findings of studies on overseas Filipino domestic workers who attributed their sense of well-being despite stress to their sense of resilience which prevents them from developing mental health problems [ 62 ] and among Filipino disaster survivors who used their capacity to adapt as protective mechanism from experience of trauma [ 63 ]. However, self-reliant individuals also tend to hold stigmatizing beliefs on mental health and as such resort to handling problems on their own instead of seeking help [ 51 , 64 ].

Prominent facilitator themes in help-seeking In terms of enablers of psychological help-seeking, only a few facilitators were mentioned in the studies, which supported findings in other studies asserting that factors that promote help-seeking are less often emphasized [ 42 , 51 ].

Consistent with other studies [ 44 , 49 ], problem severity is predictive of intention to seek help from mental health providers [ 18 , 30 ] because Filipinos perceive that professional services are only warranted when symptoms have disabling effects [ 5 , 53 ]. As such, those who are experiencing heightened emotional distress were found to be receptive to intervention [ 17 ]. In most cases, symptom severity is determined only when somatic or behavioral symptoms manifest [ 13 ] or occupational dysfunction occurs late in the course of the mental illness [ 65 ]. This is most likely due to the initial denial of the problem [ 66 ] or attempts at maintaining normalcy of the situation as an important coping mechanism [ 67 ]. Furthermore, this poses as a hindrance to any attempts at early intervention because Filipinos are likely to seek professional help only when the problem is severe or has somatic manifestations. It also indicates the lack of preventive measure to avert any deterioration in mental health and well-being.

More positive attitudes towards help-seeking and higher rates of mental health care utilization have been found among later-generation Filipino immigrants or those who have acquired residency status in their host country [ 10 , 15 ]. Immigration status and length of stay in the host country are also associated with language proficiency, higher acculturation and familiarity with the host culture that are more open to discussing mental health issues [ 13 ], which present fewer barriers in help-seeking. This is consistent with facilitators of formal help-seeking among other ethnic minorities, such as acculturation, social integration and positive attitude towards mental health [ 43 ].

Cultural context of Filipinos’ reluctance to seek help Several explanations have been proposed to account for the general reluctance of Filipinos to seek psychological help. In Filipino culture, mental illness is attributed to superstitious or supernatural causes, such as God’s will, witchcraft, and sorcery [ 68 , 69 ], which contradict the biopsychosocial model used by mental health care professionals. Within this cultural context, Filipinos prefer to seek help from traditional folk healers who are using religious rituals in their healing process instead of availing the services of professionals [ 70 , 71 ]. This was reaffirmed by participants in the study of Thompson and her colleagues who said that “psychiatrists are not a way to deal with emotional problems” [ 74 , p.685]. The common misconception on the cause and nature of mental illness, seeing it as temporary due to cold weather [ 14 ] or as a failure in character and as an individual responsibility to overcome [ 16 , 72 ] also discourages Filipinos from seeking help.

Synthesis of the studies included in the review also found conflicting findings on various cultural and psychosocial influences that served both as enablers and deterrents to Filipino help-seeking, namely: (1) level of spirituality; (2) concern on loss of face or sense of shame; and (3) presence of social support.

Level of spirituality Higher spirituality or greater religious beliefs have disparate roles in Filipino psychological help-seeking. Some studies [ 8 , 14 , 16 ] consider it a hindrance to formal help-seeking, whereas others [ 10 , 15 ] asserted that it can facilitate the utilization of mental health services [ 15 , 73 ]. Being predominantly Catholics, Filipinos had drawn strength from their religious faith to endure difficult situations and challenges, accordingly ‘leaving everything to God’ [ 74 ] which explains their preference for clergy as sources of help instead of professional mental health providers. This is connected with the Filipino attribution of mental illness to spiritual or religious causes [ 62 ] mentioned earlier. On the contrary, Hermansdottir and Aegisdottir argued that there is a positive link between spirituality and help-seeking, and cited connectedness with host culture as mediating factor [ 15 ]. Alternately, because higher spirituality and religiosity are predictors of greater sense of well-being [ 75 ], there is, thus, a decreased need for mental health services.

Concern on loss of face or sense of shame The enabler/deterrent role of higher concern on loss of face and sense of shame on psychological help-seeking was also identified. The majority of studies in this review asserted the deterrent role of loss of face and stigma consistent with the findings of other studies [ 51 ], although Clement et al. stated that stigma is the fourth barrier in deterring help-seeking [ 76 ]. Mental illness is highly stigmatized in the Philippines and to avoid the derogatory label of ‘crazy’, Filipinos tend to conceal their mental illness and consequently avoid seeking professional help. This is aligned with the Filipino value of hiya (sense of propriety) which considers any deviation from socially acceptable behavior as a source of shame [ 11 ]. The stigmatized belief is reinforced by the notion that formal help-seeking is not the way to deal with emotional problems, as reflected in the response of a Filipino participant in the study by Straiton et. al., “It has not occurred to me to see a doctor for that kind of feeling” [ 14 , p.6]. However, other studies in this review [ 12 , 13 ] posited contrary views that lower stigma tolerance and higher concern for loss of face could also motivate psychological help-seeking for individuals who want to avoid embarrassing their family. As such, stigma tolerance and loss of face may have a more nuanced influence on help-seeking depending on whether the individual avoids the stigma by not seeking help or prevent the stigma by actively seeking help.

Presence of social support The contradictory role of social networks either as helpful or unhelpful in formal help-seeking was also noted in this review. The presence of friends and family can discourage Filipinos from seeking professional help because their social support serves as protective factor that buffer one’s experience of distress [ 77 , 78 ]. Consequently, individuals are less likely to use professional services [ 42 , 79 ]. On the contrary, other studies have found that the presence of friends and family who have positive attitudes towards formal help-seeking can promote the utilization of mental health services [ 8 , 80 ]. Friends who sought formal help and, thus, serve as role models [ 14 ], and those who take the initiative in seeking help for the distressed individual [ 32 ] also encourage such behavior. Thus, the positive influence of friends and family on mental health and formal help-seeking of Filipinos is not merely to serve only as emotional buffer for stress, but to also favourably influence the decision of the individual to seek formal help.

Research implications of findings

This review highlights particular evidence gaps that need further research: (1) operationalization of help-seeking behavior as a construct separating intention and attitude; (2) studies on actual help-seeking behavior among local and overseas Filipinos with identified mental health problems; (3) longitudinal study on intervention effectiveness and best practices; (4) studies that triangulate findings of qualitative studies with quantitative studies on the role of resilience and self-reliance in help-seeking; and (5) factors that promote help-seeking.

Some studies in this review reported help-seeking intention or attitude as actual behaviors even though they are separate constructs, hence leading to reporting biases and misinterpretations. For instance, the conflicting findings of Tuliao et al. [ 12 ] on the negative association of loss of face with help-seeking attitude and the positive association between loss of face and intention to seek help demonstrate that attitudes and intentions are separate constructs and, thus, need further operationalization. Future research should strive to operationalize concretely these terms through the use of robust measurement tools and systematic reporting of results. There is also a lack of data on the actual help-seeking behaviors among Filipinos with mental illness as most of the reports were from the general population and on their help-seeking attitudes and intentions. Thus, research should focus on those with mental health problems and their actual utilization of healthcare services to gain a better understanding of how specific factors prevent or promote formal help-seeking behaviors.

Moreover, the majority of the studies in this review were descriptive cross-sectional studies, with only one cohort analytic study. Future research should consider a longitudinal study design to ensure a more rigorous and conclusive findings especially on testing the effectiveness of interventions and documenting best practices. Because of the lack of quantitative research that could triangulate the findings of several qualitative studies on the detrimental role of resilience and self-reliance, quantitative studies using pathway analysis may help identify how these barriers affect help-seeking. A preponderance of studies also focused on discussing the roles of barriers in help-seeking, but less is known about the facilitators of help-seeking. For this reason, factors that promote help-seeking should be systematically investigated.

Practice, service delivery and policy implications

Findings of this review also indicate several implications for practice, service delivery, intervention and policy. Cultural nuances that underlie help-seeking behavior of Filipinos, such as the relational orientation of their interactions [ 81 ], should inform the design of culturally appropriate interventions for mental health and well-being and improving access and utilization of health services. Interventions aimed at improving psychological help-seeking should also target friends and family as potential and significant influencers in changing help-seeking attitude and behavior. They may be encouraged to help the individual to seek help from the mental health professional. Other approaches include psychoeducation that promotes mental health literacy and reduces stigma which could be undertaken both as preventive and treatment strategies because of their positive influence on help-seeking. Strategies to reduce self-reliance may also be helpful in encouraging help-seeking.

This review also has implications for structural changes to overcome economic and other practical barriers in Filipino seeking help for mental health problems. Newly enacted laws on mental health and universal healthcare in the Philippines may jumpstart significant policy changes, including increased expenditure for mental health treatment.

Since lack of awareness of available services was also identified as significant barrier, overseas Filipinos could be given competency training in utilizing the health care system of host countries, possibly together with other migrants and ethnic minorities. Philippine consular agencies in foreign countries should not merely only resort to repatriation acts, but could also take an active role in service delivery especially for overseas Filipinos who experience trauma and/or may have immigration-related constraints that hamper their access to specialist care.

Limitations of findings

A crucial limitation of studies in this review is the use of different standardized measures of help-seeking that render incomparable results. These measures were western-based inventories, and only three studies mentioned using cultural validation, such as forward-and-back-translations, to adapt them to cross-cultural research on Filipino participants. This may pose as a limitation on the cultural appropriateness and applicability of foreign-made tests [ 73 ] in capturing the true essence of Filipino experience and perspectives [ 74 ]. Additionally, the majority of the studies used non-probability sampling that limits the generalizability of results. They also failed to measure the type of assistance or actual support sought by Filipinos, such as psychoeducation, referral services, supportive counseling or psychotherapy, and whether or not they are effective in addressing mental health concerns of Filipinos. Another inherent limitation of this review is the lack of access to grey literature, such as thesis and dissertations published in other countries, or those published in the Philippines and are not available online. A number of studies on multi-ethnic studies with Filipino participants do not provide disaggregated data, which limits the scope and inclusion of studies in this review.

This review has confirmed the low utilization of mental health services among Filipinos regardless of their locations, with mental health stigma as a primary barrier resilience and self-reliance as coping strategies were also cited, especially in qualitative studies, but may be important in addressing issues of non-utilization of mental health services. Social support and problem severity were cited as prominent facilitators in help-seeking. However, different structural, cultural and practical barriers and facilitators of psychological help-seeking between overseas and local Filipinos were also found.

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Martinez, A.B., Co, M., Lau, J. et al. Filipino help-seeking for mental health problems and associated barriers and facilitators: a systematic review. Soc Psychiatry Psychiatr Epidemiol 55 , 1397–1413 (2020). https://doi.org/10.1007/s00127-020-01937-2

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Genetic Architectures of Adolescent Depression Trajectories in 2 Longitudinal Population Cohorts

• 1 Division of Psychiatry, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
• 2 Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
• 3 School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
• 4 School of Medical Sciences, Örebro University, Örebro, Sweden
• 5 Generation Scotland, Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
• 6 MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom

Question   Could multitrait polygenic risk scores be used to strengthen genetic prediction of longitudinal depression across adolescence?

Findings   In this longitudinal cohort replication study of 14 112 adolescents, stronger effect sizes of multitrait polygenic risk association with adverse depression trajectories were found compared with unitrait genetic risk.

Meaning   Longitudinal depression has a robust genetic underpinning, and leveraging shared genetic information across multiple psychiatric traits may strengthen prediction models of depression in adolescence.

Importance   Adolescent depression is characterized by diverse symptom trajectories over time and has a strong genetic influence. Research has determined genetic overlap between depression and other psychiatric conditions; investigating the shared genetic architecture of heterogeneous depression trajectories is crucial for understanding disease etiology, prediction, and early intervention.

Objective   To investigate univariate and multivariate genetic risk for adolescent depression trajectories and assess generalizability across ancestries.

Design, Setting, and Participants   This cohort study entailed longitudinal growth modeling followed by polygenic risk score (PRS) association testing for individual and multitrait genetic models. Two longitudinal cohorts from the US and UK were used: the Adolescent Brain and Cognitive Development (ABCD; N = 11 876) study and the Avon Longitudinal Study of Parents and Children (ALSPAC; N = 8787) study. Included were adolescents with genetic information and depression measures at up to 8 and 4 occasions, respectively. Study data were analyzed January to July 2023.

Main Outcomes and Measures   Trajectories were derived from growth mixture modeling of longitudinal depression symptoms. PRSs were computed for depression, anxiety, neuroticism, bipolar disorder, schizophrenia, attention-deficit/hyperactivity disorder, and autism in European ancestry. Genomic structural equation modeling was used to build multitrait genetic models of psychopathology followed by multitrait PRS. Depression PRSs were computed in African, East Asian, and Hispanic ancestries in the ABCD cohort only. Association testing was performed between all PRSs and trajectories for both cohorts.

Results   A total sample size of 14 112 adolescents (at baseline: mean [SD] age, 10.5 [0.5] years; 7269 male sex [52%]) from both cohorts were included in this analysis. Distinct depression trajectories (stable low, adolescent persistent, increasing, and decreasing) were replicated in the ALSPAC cohort (6096 participants; 3091 female [51%]) and ABCD cohort (8016 participants; 4274 male [53%]) between ages 10 and 17 years. Most univariate PRSs showed significant uniform associations with persistent trajectories, but fewer were significantly associated with intermediate (increasing and decreasing) trajectories. Multitrait PRSs—derived from a hierarchical factor model—showed the strongest associations for persistent trajectories (ABCD cohort: OR, 1.46; 95% CI, 1.26-1.68; ALSPAC cohort: OR, 1.34; 95% CI, 1.20-1.49), surpassing the effect size of univariate PRS in both cohorts. Multitrait PRSs were associated with intermediate trajectories but to a lesser extent (ABCD cohort: hierarchical increasing, OR, 1.27; 95% CI, 1.13-1.43; decreasing, OR, 1.23; 95% CI, 1.09-1.40; ALSPAC cohort: hierarchical increasing, OR, 1.16; 95% CI, 1.04-1.28; decreasing, OR, 1.32; 95% CI, 1.18-1.47). Transancestral genetic risk for depression showed no evidence for association with trajectories.

Conclusions and Relevance   Results of this cohort study revealed a high multitrait genetic loading of persistent symptom trajectories, consistent across traits and cohorts. Variability in univariate genetic association with intermediate trajectories may stem from environmental factors. Multitrait genetics may strengthen depression prediction models, but more diverse data are needed for generalizability.

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Grimes PZ , Adams MJ , Thng G, et al. Genetic Architectures of Adolescent Depression Trajectories in 2 Longitudinal Population Cohorts. JAMA Psychiatry. Published online May 15, 2024. doi:10.1001/jamapsychiatry.2024.0983

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• Open access
• Published: 16 May 2024

Procrastination, depression and anxiety symptoms in university students: a three-wave longitudinal study on the mediating role of perceived stress

• Anna Jochmann 1 ,
• Burkhard Gusy 1 ,
• Tino Lesener 1 &
• Christine Wolter 1  

BMC Psychology volume  12 , Article number:  276 ( 2024 ) Cite this article

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It is generally assumed that procrastination leads to negative consequences. However, evidence for negative consequences of procrastination is still limited and it is also unclear by which mechanisms they are mediated. Therefore, the aim of our study was to examine the harmful consequences of procrastination on students’ stress and mental health. We selected the procrastination-health model as our theoretical foundation and tried to evaluate the model’s assumption that trait procrastination leads to (chronic) disease via (chronic) stress in a temporal perspective. We chose depression and anxiety symptoms as indicators for (chronic) disease and hypothesized that procrastination leads to perceived stress over time, that perceived stress leads to depression and anxiety symptoms over time, and that procrastination leads to depression and anxiety symptoms over time, mediated by perceived stress.

To examine these relationships properly, we collected longitudinal data from 392 university students at three occasions over a one-year period and analyzed the data using autoregressive time-lagged panel models.

Procrastination did lead to depression and anxiety symptoms over time. However, perceived stress was not a mediator of this effect. Procrastination did not lead to perceived stress over time, nor did perceived stress lead to depression and anxiety symptoms over time.

Conclusions

We could not confirm that trait procrastination leads to (chronic) disease via (chronic) stress, as assumed in the procrastination-health model. Nonetheless, our study demonstrated that procrastination can have a detrimental effect on mental health. Further health outcomes and possible mediators should be explored in future studies.

Peer Review reports

Introduction

“Due tomorrow? Do tomorrow.”, might be said by someone who has a tendency to postpone tasks until the last minute. But can we enjoy today knowing about the unfinished task and tomorrow’s deadline? Or do we feel guilty for postponing a task yet again? Do we get stressed out because we have little time left to complete it? Almost everyone has procrastinated at some point when it came to completing unpleasant tasks, such as mowing the lawn, doing the taxes, or preparing for exams. Some tend to procrastinate more frequently and in all areas of life, while others are less inclined to do so. Procrastination is common across a wide range of nationalities, as well as socioeconomic and educational backgrounds [ 1 ]. Over the last fifteen years, there has been a massive increase in research on procrastination [ 2 ]. Oftentimes, research focuses on better understanding the phenomenon of procrastination and finding out why someone procrastinates in order to be able to intervene. Similarly, the internet is filled with self-help guides that promise a way to overcome procrastination. But why do people seek help for their procrastination? Until now, not much research has been conducted on the negative consequences procrastination could have on health and well-being. Therefore, in the following article we examine the effect of procrastination on mental health over time and stress as a possible facilitator of this relationship on the basis of the procrastination-health model by Sirois et al. [ 3 ].

Procrastination and its negative consequences

Procrastination can be defined as the tendency to voluntarily and irrationally delay intended activities despite expecting negative consequences as a result of the delay [ 4 , 5 ]. It has been observed in a variety of groups across the lifespan, such as students, teachers, and workers [ 1 ]. For example, some students tend to regularly delay preparing for exams and writing essays until the last minute, even if this results in time pressure or lower grades. Procrastination must be distinguished from strategic delay [ 4 , 6 ]. Delaying a task is considered strategic when other tasks are more important or when more resources are needed before the task can be completed. While strategic delay is viewed as functional and adaptive, procrastination is classified as dysfunctional. Procrastination is predominantly viewed as the result of a self-regulatory failure [ 7 ]. It can be understood as a trait, that is, as a cross-situational and time-stable behavioral disposition [ 8 ]. Thus, it is assumed that procrastinators chronically delay tasks that they experience as unpleasant or difficult [ 9 ]. Approximately 20 to 30% of adults have been found to procrastinate chronically [ 10 , 11 , 12 ]. Prevalence estimates for students are similar [ 13 ]. It is believed that students do not procrastinate more often than other groups. However, it is easy to examine procrastination in students because working on study tasks requires a high degree of self-organization and time management [ 14 ].

It is generally assumed that procrastination leads to negative consequences [ 4 ]. Negative consequences are even part of the definition of procrastination. Research indicates that procrastination is linked to lower academic performance [ 15 ], health impairment (e.g., stress [ 16 ], physical symptoms [ 17 ], depression and anxiety symptoms [ 18 ]), and poor health-related behavior (e.g., heavier alcohol consumption [ 19 ]). However, most studies targeting consequences of procrastination are cross-sectional [ 4 ]. For that reason, it often remains unclear whether an examined outcome is a consequence or an antecedent of procrastination, or whether a reciprocal relationship between procrastination and the examined outcome can be assumed. Additionally, regarding negative consequences of procrastination on health, it is still largely unknown by which mechanisms they are mediated. Uncovering such mediators would be helpful in developing interventions that can prevent negative health consequences of procrastination.

The procrastination-health model

The first and only model that exclusively focuses on the effect of procrastination on health and the mediators of this effect is the procrastination-health model [ 3 , 9 , 17 ]. Sirois [ 9 ] postulates three pathways: An immediate effect of trait procrastination on (chronic) disease and two mediated pathways (see Fig.  1 ).

Adopted from the procrastination-health model by Sirois [ 9 ]

The immediate effect is not further explained. Research suggests that procrastination creates negative feelings, such as shame, guilt, regret, and anger [ 20 , 21 , 22 ]. The described feelings could have a detrimental effect on mental health [ 23 , 24 , 25 ].

The first mediated pathway leads from trait procrastination to (chronic) disease via (chronic) stress. Sirois [ 9 ] assumes that procrastination creates stress because procrastinators are constantly aware of the fact that they still have many tasks to complete. Stress activates the hypothalamic-pituitary-adrenocortical (HPA) system, increases autonomic nervous system arousal, and weakens the immune system, which in turn contributes to the development of diseases. Sirois [ 9 ] distinguishes between short-term and long-term effects of procrastination on health mediated by stress. She believes that, in the short term, single incidents of procrastination cause acute stress, which leads to acute health problems, such as infections or headaches. In the long term, chronic procrastination, as you would expect with trait procrastination, causes chronic stress, which leads to chronic diseases over time. There is some evidence in support of the stress-related pathway, particularly regarding short-term effects [ 3 , 17 , 26 , 27 , 28 ]. However, as we mentioned above, most of these studies are cross-sectional. Therefore, the causal direction of these effects remains unclear. To our knowledge, long-term effects of trait procrastination on (chronic) disease mediated by (chronic) stress have not yet been investigated.

The second mediated pathway leads from trait procrastination to (chronic) disease via poor health-related behavior. According to Sirois [ 9 ], procrastinators form lower intentions to carry out health-promoting behavior or to refrain from health-damaging behavior because they have a low self-efficacy of being able to care for their own health. In addition, they lack the far-sighted view that the effects of health-related behavior only become apparent in the long term. For the same reason, Sirois [ 9 ] believes that there are no short-term, but only long-term effects of procrastination on health mediated by poor health-related behavior. For example, an unhealthy diet leads to diabetes over time. The findings of studies examining the behavioral pathway are inconclusive [ 3 , 17 , 26 , 28 ]. Furthermore, since most of these studies are cross-sectional, they are not suitable for uncovering long-term effects of trait procrastination on (chronic) disease mediated by poor health-related behavior.

In summary, previous research on the two mediated pathways of the procrastination-health model mainly found support for the role of (chronic) stress in the relationship between trait procrastination and (chronic) disease. However, only short-term effects have been investigated so far. Moreover, longitudinal studies are needed to be able to assess the causal direction of the relationship between trait procrastination, (chronic) stress, and (chronic) disease. Consequently, our study is the first to examine long-term effects of trait procrastination on (chronic) disease mediated by (chronic) stress, using a longitudinal design. (Chronic) disease could be measured by a variety of different indicators (e.g., physical symptoms, diabetes, or coronary heart disease). We choose depression and anxiety symptoms as indicators for (chronic) disease because they signal mental health complaints before they manifest as (chronic) diseases. Additionally, depression and anxiety symptoms are two of the most common mental health complaints among students [ 29 , 30 ] and procrastination has been shown to be a significant predictor of depression and anxiety symptoms [ 18 , 31 , 32 , 33 , 34 ]. Until now, the stress-related pathway of the procrastination-health model with depression and anxiety symptoms as the health outcome has only been analyzed in one cross-sectional study that confirmed the predictions of the model [ 35 ].

The aim of our study is to evaluate some of the key assumptions of the procrastination-health model, particularly the relationships between trait procrastination, (chronic) stress, and (chronic) disease over time, surveyed in the following analysis using depression and anxiety symptoms.

In line with the key assumptions of the procrastination-health model, we postulate (see Fig.  2 ):

Procrastination leads to perceived stress over time.

Perceived stress leads to depression and anxiety symptoms over time.

Procrastination leads to depression and anxiety symptoms over time, mediated by perceived stress.

The section of the procrastination-health model we examined

Materials and methods

Our study was part of a health monitoring at a large German university Footnote 1 . Ethical approval for our study was granted by the Ethics Committee of the university’s Department of Education and Psychology. We collected the initial data in 2019. Two occasions followed, each at an interval of six months. In January 2019, we sent out 33,267 invitations to student e-mail addresses. Before beginning the survey, students provided their written informed consent to participate in our study. 3,420 students took part at the first occasion (T1; 10% response rate). Of these, 862 participated at the second (T2) and 392 at the third occasion (T3). In order to test whether dropout was selective, we compared sociodemographic and study specific characteristics (age, gender, academic semester, number of assessments/exams) as well as behavior and health-related variables (procrastination, perceived stress, depression and anxiety symptoms) between the participants of the first wave ( n  = 3,420) and those who participated three times ( n  = 392). Results from independent-samples t-tests and chi-square analysis showed no significant differences regarding sociodemographic and study specific characteristics (see Additional file 1: Table S1 and S2 ). Regarding behavior and health-related variables, independent-samples t-tests revealed a significant difference in procrastination between the two groups ( t (3,409) = 2.08, p  < .05). The mean score of procrastination was lower in the group that participated in all three waves.

The mean age of the longitudinal respondents was 24.1 years ( SD  = 5.5 years), the youngest participants were 17 years old, the oldest one was 59 years old. The majority of participants was female (74.0%), 7 participants identified neither as male nor as female (1.8%). The respondents were on average enrolled in the third year of studying ( M  = 3.9; SD  = 2.3). On average, the students worked about 31.2 h ( SD  = 14.1) per week for their studies, and an additional 8.5 h ( SD  = 8.5) for their (part-time) jobs. The average income was €851 ( SD  = 406), and 4.9% of the students had at least one child. The students were mostly enrolled in philosophy and humanities (16.5%), education and psychology (15.8%), biology, chemistry, and pharmacy (12.5%), political and social sciences (10.6%), veterinary medicine (8.9%), and mathematics and computer science (7.7%).

We only used established and well evaluated instruments for our analyses.

• Procrastination

We adopted the short form of the Procrastination Questionnaire for Students (PFS-4) [ 36 ] to measure procrastination. The PFS-4 assesses procrastination at university as a largely stable behavioral disposition across situations, that is, as a trait. The questionnaire consists of four items (e.g., I put off starting tasks until the last moment.). Each item was rated on a 5-point scale ((almost) never = 1 to (almost) always = 5) for the last two weeks. All items were averaged, with higher scores indicating a greater tendency to procrastinate. The PFS-4 has been proven to be reliable and valid, showing very high correlations with other established trait procrastination scales, for example, with the German short form of the General Procrastination Scale [ 37 , 38 ]. We also proved the scale to be one-dimensional in a factor analysis, with a Cronbach’s alpha of 0.90.

Perceived stress

The Heidelberger Stress Index (HEI-STRESS) [ 39 ] is a three-item measure of current perceived stress due to studying as well as in life in general. For the first item, respondents enter a number between 0 (not stressed at all) and 100 (completely stressed) to indicate how stressed their studies have made them feel over the last four weeks. For the second and third item, respondents rate on a 5-point scale how often they feel “stressed and tense” and as how stressful they would describe their life at the moment. We transformed the second and third item to match the range of the first item before we averaged all items into a single score with higher values indicating greater perceived stress. We proved the scale to be one-dimensional and Cronbach’s alpha for our study was 0.86.

Depression and anxiety symptoms

We used the Patient Health Questionnaire-4 (PHQ-4) [ 40 ], a short form of the Patient Health Questionnaire [ 41 ] with four items, to measure depression and anxiety symptoms. The PHQ-4 contains two items from the Patient Health Questionnaire-2 (PHQ-2) [ 42 ] and the Generalized Anxiety Disorder Scale-2 (GAD-2) [ 43 ], respectively. It is a well-established screening scale designed to assess the core criteria of major depressive disorder (PHQ-2) and generalized anxiety disorder (GAD-2) according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). However, it was shown that the GAD-2 is also appropriate for screening other anxiety disorders. According to Kroenke et al. [ 40 ], the PHQ-4 can be used to assess a person’s symptom burden and impairment. We asked the participants to rate how often they have been bothered over the last two weeks by problems, such as “Little interest or pleasure in doing things”. Response options were 0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day. Calculated as the sum of the four items, the total scores range from 0 to 12 with higher scores indicating more frequent depression and anxiety symptoms. The total scores can be categorized as none-to-minimal (0–2), mild (3–5), moderate (6–8), and severe (9–12) depression and anxiety symptoms. The PHQ-4 was shown to be reliable and valid [ 40 , 44 , 45 ]. We also proved the scale to be one-dimensional in a factor analysis, with a Cronbach’s alpha of 0.86.

Data analysis

To test our hypotheses, we performed structural equation modelling (SEM) using R (Version 4.1.1) with the package lavaan. All items were standardized ( M  = 0, SD  = 1). Due to the non-normality of some study variables and a sufficiently large sample size of N near to 400 [ 46 ], we used robust maximum likelihood estimation (MLR) for all model estimations. As recommended by Hu and Bentler [ 47 ], we assessed the models’ goodness of fit by chi-square test statistic, root mean square error of approximation (RMSEA), standardized root mean square residual (SRMR), Tucker-Lewis index (TLI), and comparative fit index (CFI). A non-significant chi-square indicates good model fit. Since chi-square is sensitive to sample size, we also evaluated fit indices less sensitive to the number of observations. RMSEA and SRMR values of 0.05 or lower as well as TLI and CFI values of 0.97 or higher indicate good model fit. RMSEA values of 0.08 or lower, SRMR values of 0.10 or lower, as well as TLI and CFI values of 0.95 or higher indicate acceptable model fit [ 48 , 49 ]. First, we conducted confirmatory factor analysis for the first occasion, defining three factors that correspond to the measures of procrastination, perceived stress, and depression and anxiety symptoms. Next, we tested for measurements invariance over time and specified the measurement model, before testing our hypotheses.

Measurement invariance over time

To test for measurement invariance over time, we defined one latent variable for each of the three occasions, corresponding to the measures of procrastination, perceived stress, and depression and anxiety symptoms, respectively. As recommended by Geiser and colleagues [ 50 ], the links between indicators and factors (i.e., factor loadings and intercepts) should be equal over measurement occasions; therefore, we added indicator specific factors. A first and least stringent step of testing measurement invariance is configural invariance (M CI ). It was examined whether the included constructs (procrastination, perceived stress, depression and anxiety symptoms) have the same pattern of free and fixed loadings over time. This means that the assignment of the indicators to the three latent factors over time is supported by the underlying data. If configural invariance was supported, restrictions for the next step of testing measurement invariance (metric or weak invariance; M MI ) were added. This means that each item contributes to the latent construct to a similar degree over time. Metric invariance was tested by constraining the factor loadings of the constructs over time. The next step of testing measurement invariance (scalar or strong invariance; M SI ) consisted of checking whether mean differences in the latent construct capture all mean differences in the shared variance of the items. Scalar invariance was tested by constraining the item intercepts over time. The constraints applied in the metric invariance model were retained [ 51 ]. For the last step of testing measurement invariance (residual or strict invariance; M RI ), the residual variables were also set equal over time. If residual invariance is supported, differences in the observed variables can exclusively be attributed to differences in the variances of the latent variables.

We used the Satorra-Bentler chi-square difference test to evaluate the superiority of a more stringent model [ 52 ]. We assumed the model with the largest number of invariance restrictions – which still has an acceptable fit and no substantial deterioration of the chi-square value – to be the final model [ 53 ]. Following previous recommendations, we considered a decrease in CFI of 0.01 and an increase in RMSEA of 0.015 as unacceptable to establish measurement invariance [ 54 ]. If a more stringent model had a significant worse chi-square value, but the model fit was still acceptable and the deterioration in model fit fell within the change criteria recommended for CFI and RMSEA values, we still considered the more stringent model to be superior.

Hypotheses testing

As recommended by Dormann et al. [ 55 ], we applied autoregressive time-lagged panel models to test our hypotheses. In the first step, we specified a model (M 0 ) that only included the stabilities of the three variables (procrastination, perceived stress, depression and anxiety symptoms) over time. In the next step (M 1 ), we added the time-lagged effects from procrastination (T1) to perceived stress (T2) and from procrastination (T2) to perceived stress (T3) as well as from perceived stress (T1) to depression and anxiety symptoms (T2) and from perceived stress (T2) to depression and anxiety symptoms (T3). Additionally, we included a direct path from procrastination (T1) to depression and anxiety symptoms (T3). If this path becomes significant, we can assume a partial mediation [ 55 ]. Otherwise, we can assume a full mediation. We compared these nested models using the Satorra-Bentler chi-square difference test and the Akaike information criterion (AIC). The chi-square difference value should either be non-significant, indicating that the proposed model including our hypotheses (M 1 ) does not have a significant worse model fit than the model including only stabilities (M 0 ), or, if significant, it should be in the direction that M 1 fits the data better than M 0 . Regarding the AIC, M 1 should have a lower value than M 0 .

Table  1 displays the means, standard deviations, internal consistencies (Cronbach’s alpha), and stabilities (correlations) of all study variables. The alpha values of procrastination, perceived stress, and depression and anxiety symptoms are classified as good (> 0.80) [ 56 ]. The correlation matrix of the manifest variables used for the analyses can be found in the Additional file 1: Table  S3 .

We observed the highest test-retest reliabilities for procrastination ( r  ≥ .74). The test-retest reliabilities for depression and anxiety symptoms ( r  ≥ .64) and for perceived stress ( r  ≥ .54) were a bit lower (see Table  1 ). The pattern of correlations shows a medium to large but positive relationship between procrastination and depression and anxiety symptoms [ 57 , 58 ]. The association between procrastination and perceived stress was small, the one between perceived stress and depression and anxiety symptoms very large (see Table  1 ).

Confirmatory factor analysis showed an acceptable to good fit (x 2 (41) = 118.618, p  < .001; SRMR = 0.042; RMSEA = 0.071; TLI = 0.95; CFI = 0.97). When testing for measurement invariance over time for each construct, the residual invariance models with indicator specific factors provided good fit to the data (M RI ; see Table  2 ), suggesting that differences in the observed variables can exclusively be attributed to differences of the latent variables. We then specified and tested the measurement model of the latent constructs prior to model testing based on the items of procrastination, perceived stress, and depression and anxiety symptoms. The measurement model fitted the data well (M M ; see Table  3 ). All items loaded solidly on their respective factors (0.791 ≤ β ≤ 0.987; p  < .001).

To test our hypotheses, we analyzed the two models described in the methods section.

The fit of the stability model (M 0 ) was acceptable (see Table  3 ). Procrastination was stable over time, with stabilities above 0.82. The stabilities of perceived stress as well as depression and anxiety symptoms were somewhat lower, ranging from 0.559 (T1 -> T2) to 0.696 (T2 -> T3) for perceived stress and from 0.713 (T2 -> T3) to 0.770 (T1 -> T2) for depression and anxiety symptoms, respectively.

The autoregressive mediation model (M 1 ) fitted the data significantly better than M 0 . The direct path from procrastination (T1) to depression and anxiety symptoms (T3) was significant (β = 0.16; p  < .001), however, none of the mediated paths (from procrastination (T1) to perceived stress (T2) and from perceived stress (T2) to depression and anxiety symptoms (T3)) proved to be substantial. Also, the time-lagged paths from perceived stress (T1) to depression and anxiety symptoms (T2) and from procrastination (T2) to perceived stress (T3) were not substantial either (see Fig.  3 ).

To examine whether the hypothesized effects would occur over a one-year period rather than a six-months period, we specified an additional model with paths from procrastination (T1) to perceived stress (T3) and from perceived stress (T1) to depression and anxiety symptoms (T3), also including the stabilities of the three constructs as in the stability model M 0 . The model showed an acceptable fit (χ 2 (486) = 831.281, p  < .001; RMSEA = 0.048; SRMR = 0.091; TLI = 0.95; CFI = 0.95), but neither of the two paths were significant.

Therefore, our hypotheses, that procrastination leads to perceived stress over time (H1) and that perceived stress leads to depression and anxiety symptoms over time (H2) must be rejected. We could only partially confirm our third hypothesis, that procrastination leads to depression and anxiety over time, mediated by perceived stress (H3), since procrastination did lead to depression and anxiety symptoms over time. However, this effect was not mediated by perceived stress.

Results of the estimated model including all hypotheses (M 1 ). Note Non-significant paths are dotted. T1 = time 1; T2 = time 2; T3 = time 3. *** p  < .001

To sum up, we tried to examine the harmful consequences of procrastination on students’ stress and mental health. Hence, we selected the procrastination-health model by Sirois [ 9 ] as a theoretical foundation and tried to evaluate some of its key assumptions in a temporal perspective. The author assumes that trait procrastination leads to (chronic) disease via (chronic) stress. We chose depression and anxiety symptoms as indicators for (chronic) disease and postulated, in line with the key assumptions of the procrastination-health model, that procrastination leads to perceived stress over time (H1), that perceived stress leads to depression and anxiety symptoms over time (H2), and that procrastination leads to depression and anxiety symptoms over time, mediated by perceived stress (H3). To examine these relationships properly, we collected longitudinal data from students at three occasions over a one-year period and analyzed the data using autoregressive time-lagged panel models. Our first and second hypotheses had to be rejected: Procrastination did not lead to perceived stress over time, and perceived stress did not lead to depression and anxiety symptoms over time. However, procrastination did lead to depression and anxiety symptoms over time – which is in line with our third hypothesis – but perceived stress was not a mediator of this effect. Therefore, we could only partially confirm our third hypothesis.

Our results contradict previous studies on the stress-related pathway of the procrastination-health model, which consistently found support for the role of (chronic) stress in the relationship between trait procrastination and (chronic) disease. Since most of these studies were cross-sectional, though, the causal direction of these effects remained uncertain. There are two longitudinal studies that confirm the stress-related pathway of the procrastination-health model [ 27 , 28 ], but both studies examined short-term effects (≤ 3 months), whereas we focused on more long-term effects. Therefore, the divergent findings may indicate that there are short-term, but no long-term effects of trait procrastination on (chronic) disease mediated by (chronic) stress.

Our results especially raise the question whether trait procrastination leads to (chronic) stress in the long term. Looking at previous longitudinal studies on the effect of procrastination on stress, the following stands out: At shorter study periods of two weeks [ 27 ] and four weeks [ 28 ], the effect of procrastination on stress appears to be present. At longer study periods of seven weeks [ 59 ], three months [ 28 ], six months, and twelve months, as in our study, the effect of procrastination on stress does not appear to be present. There is one longitudinal study in which procrastination was a significant predictor of stress symptoms nine months later [ 34 ]. The results of this study should be interpreted with caution, though, because the outbreak of the COVID-19 pandemic fell within the study period, which could have contributed to increased stress symptoms [ 60 ]. Unfortunately, Johansson et al. [ 34 ] did not report whether average stress symptoms increased during their study. In one of the two studies conducted by Fincham and May [ 59 ], the COVID-19 pandemic outbreak also fell within their seven-week study period. However, they reported that in their study, average stress symptoms did not increase from baseline to follow-up. Taken together, the findings suggest that procrastination can cause acute stress in the short term, for example during times when many tasks need to be completed, such as at the end of a semester, but that procrastination does not lead to chronic stress over time. It seems possible that students are able to recover during the semester from the stress their procrastination caused at the end of the previous semester. Because of their procrastination, they may also have more time to engage in relaxing activities, which could further mitigate the effect of procrastination on stress. Our conclusions are supported by an early and well-known longitudinal study by Tice and Baumeister [ 61 ], which compared procrastinating and non-procrastinating students with regard to their health. They found that procrastinators experienced less stress than their non-procrastinating peers at the beginning of the semester, but more at the end of the semester. Additionally, our conclusions are in line with an interview study in which university students were asked about the consequences of their procrastination [ 62 ]. The students reported that, due to their procrastination, they experience high levels of stress during periods with heavy workloads (e.g., before deadlines or exams). However, the stress does not last, instead, it is relieved immediately after these periods.

Even though research indicates, in line with the assumptions of the procrastination-health model, that stress is a risk factor for physical and mental disorders [ 63 , 64 , 65 , 66 ], perceived stress did not have a significant effect on depression and anxiety symptoms in our study. The relationship between stress and mental health is complex, as people respond to stress in many different ways. While some develop stress-related mental disorders, others experience mild psychological symptoms or no symptoms at all [ 67 ]. This can be explained with the help of vulnerability-stress models. According to vulnerability-stress models, mental illnesses emerge from an interaction of vulnerabilities (e.g., genetic factors, difficult family backgrounds, or weak coping abilities) and stress (e.g., minor or major life events or daily hassles) [ 68 , 69 ]. The stress perceived by the students in our sample may not be sufficient enough on its own, without the presence of other risk factors, to cause depression and anxiety symptoms. However, since we did not assess individual vulnerability and stress factors in our study, these considerations are mere speculation.

In our study, procrastination led to depression and anxiety symptoms over time, which is consistent with the procrastination-health model as well as previous cross-sectional and longitudinal evidence [ 18 , 21 , 31 , 32 , 33 , 34 ]. However, it is still unclear by which mechanisms this effect is mediated, as perceived stress did not prove to be a substantial mediator in our study. One possible mechanism would be that procrastination impairs affective well-being [ 70 ] and creates negative feelings, such as shame, guilt, regret, and anger [ 20 , 21 , 22 , 62 , 71 ], which in turn could lead to depression and anxiety symptoms [ 23 , 24 , 25 ]. Other potential mediators of the relationship between procrastination and depression and anxiety symptoms emerge from the behavioral pathway of the procrastination-health model, suggesting that poor health-related behaviors mediate the effect of trait procrastination on (chronic) disease. Although evidence for this is still scarce, the results of one cross-sectional study, for example, indicate that poor sleep quality might mediate the effect of procrastination on depression and anxiety symptoms [ 35 ].

In summary, we found that procrastination leads to depression and anxiety symptoms over time and that perceived stress is not a mediator of this effect. We could not show that procrastination leads to perceived stress over time, nor that perceived stress leads to depression and anxiety symptoms over time. For the most part, the relationships between procrastination, perceived stress, and depression and anxiety symptoms did not match the relationships between trait procrastination, (chronic) stress, and (chronic) disease as assumed in the procrastination-health model. Explanations for this could be that procrastination might only lead to perceived stress in the short term, for example, during preparations for end-of-semester exams, and that perceived stress may not be sufficient enough on its own, without the presence of other risk factors, to cause depression and anxiety symptoms. In conclusion, we could not confirm long-term effects of trait procrastination on (chronic) disease mediated by (chronic) stress, as assumed for the stress-related pathway of the procrastination-health model.

Limitations and suggestions for future research

In our study, we tried to draw causal conclusions about the harmful consequences of procrastination on students’ stress and mental health. However, since procrastination is a trait that cannot be manipulated experimentally, we have conducted an observational rather than an experimental study, which makes causal inferences more difficult. Nonetheless, a major strength of our study is that we used a longitudinal design with three waves. This made it possible to draw conclusions about the causal direction of the effects, as in hardly any other study targeting consequences of procrastination on health before [ 4 , 28 , 55 ]. Therefore, we strongly recommend using a similar longitudinal design in future studies on the procrastination-health model or on consequences of procrastination on health in general.

We chose a time lag of six months between each of the three measurement occasions to examine long-term effects of procrastination on depression and anxiety symptoms mediated by perceived stress. However, more than six months may be necessary for the hypothesized effects to occur [ 72 ]. The fact that the temporal stabilities of the examined constructs were moderate or high (0.559 ≤ β ≤ 0.854) [ 73 , 74 ] also suggests that the time lags may have been too short. The larger the time lag, the lower the temporal stabilities, as shown for depression and anxiety symptoms, for example [ 75 ]. High temporal stabilities make it more difficult to detect an effect that actually exists [ 76 ]. Nonetheless, Dormann and Griffin [ 77 ] recommend using shorter time lags of less than one year, even with high stabilities, because of other influential factors, such as unmeasured third variables. Therefore, our time lags of six months seem appropriate.

It should be discussed, though, whether it is possible to detect long-term effects of the stress-related pathway of the procrastination-health model within a total study period of one year. Sirois [ 9 ] distinguishes between short-term and long-term effects of procrastination on health mediated by stress, but does not address how long it might take for long-term effects to occur or when effects can be considered long-term instead of short-term. The fact that an effect of procrastination on stress is evident at shorter study periods of four weeks or less but in most cases not at longer study periods of seven weeks or more, as we mentioned earlier, could indicate that short-term effects occur within the time frame of one to three months, considering the entire stress-related pathway. Hence, it seems appropriate to assume that we have examined rather long-term effects, given our study period of six and twelve months. Nevertheless, it would be beneficial to use varying study periods in future studies, in order to be able to determine when effects can be considered long-term.

Concerning long-term effects of the stress-related pathway, Sirois [ 9 ] assumes that chronic procrastination causes chronic stress, which leads to chronic diseases over time. The term “chronic stress” refers to prolonged stress episodes associated with permanent tension. The instrument we used captures perceived stress over the last four weeks. Even though the perceived stress of the students in our sample was relatively stable (0.559 ≤ β ≤ 0.696), we do not know how much fluctuation occurred between each of the three occasions. However, there is some evidence suggesting that perceived stress is strongly associated with chronic stress [ 78 ]. Thus, it seems acceptable that we used perceived stress as an indicator for chronic stress in our study. For future studies, we still suggest the use of an instrument that can more accurately reflect chronic stress, for example, the Trier Inventory for Chronic Stress (TICS) [ 79 ].

It is also possible that the occasions were inconveniently chosen, as they all took place in a critical academic period near the end of the semester, just before the examination period began. We chose a similar period in the semester for each occasion for the sake of comparability. However, it is possible that, during this preparation periods, stress levels peaked and procrastinators procrastinated less because they had to catch up after delaying their work. This could have introduced bias to the data. Therefore, in future studies, investigation periods should be chosen that are closer to the beginning or in the middle of a semester.

Furthermore, Sirois [ 9 ] did not really explain her understanding of “chronic disease”. However, it seems clear that physical illnesses, such as diabetes or cardiovascular diseases, are meant. Depression and anxiety symptoms, which we chose as indicators for chronic disease, represent mental health complaints that do not have to be at the level of a major depressive disorder or an anxiety disorder, in terms of their quantity, intensity, or duration [ 40 ]. But they can be viewed as precursors to a major depressive disorder or an anxiety disorder. Therefore, given our study period of one year, it seems appropriate to use depression and anxiety symptoms as indicators for chronic disease. At longer study periods, we would expect these mental health complaints to manifest as mental disorders. Moreover, the procrastination-health model was originally designed to be applied to physical diseases [ 3 ]. Perhaps, the model assumptions are more applicable to physical diseases than to mental disorders. By applying parts of the model to mental health complaints, we have taken an important step towards finding out whether the model is applicable to mental disorders as well. Future studies should examine additional long-term health outcomes, both physical and psychological. This would help to determine whether trait procrastination has varying effects on different diseases over time. Furthermore, we suggest including individual vulnerability and stress factors in future studies in order to be able to analyze the effect of (chronic) stress on (chronic) diseases in a more differentiated way.

Regarding our sample, 3,420 students took part at the first occasion, but only 392 participated three times, which results in a dropout rate of 88.5%. At the second and third occasion, invitation e-mails were only sent to participants who had indicated at the previous occasion that they would be willing to participate in a repeat survey and provided their e-mail address. This is probably one of the main reasons for our high dropout rate. Other reasons could be that the students did not receive any incentives for participating in our study and that some may have graduated between the occasions. Selective dropout analysis revealed that the mean score of procrastination was lower in the group that participated in all three waves ( n  = 392) compared to the group that participated in the first wave ( n  = 3,420). One reason for this could be that those who have a higher tendency to procrastinate were more likely to procrastinate on filling out our survey at the second and third occasion. The findings of our dropout analysis should be kept in mind when interpreting our results, as lower levels of procrastination may have eliminated an effect on perceived stress or on depression and anxiety symptoms. Additionally, across all age groups in population-representative samples, the student age group reports having the best subjective health [ 80 ]. Therefore, it is possible that they are more resilient to stress and experience less impairment of well-being than other age groups. Hence, we recommend that future studies focus on other age groups as well.

It is generally assumed that procrastination leads to lower academic performance, health impairment, and poor health-related behavior. However, evidence for negative consequences of procrastination is still limited and it is also unclear by which mechanisms they are mediated. In consequence, the aim of our study was to examine the effect of procrastination on mental health over time and stress as a possible facilitator of this relationship. We selected the procrastination-health model as a theoretical foundation and used the stress-related pathway of the model, assuming that trait procrastination leads to (chronic) disease via (chronic) stress. We chose depression and anxiety symptoms as indicators for (chronic) disease and collected longitudinal data from students at three occasions over a one-year period. This allowed us to draw conclusions about the causal direction of the effects, as in hardly any other study examining consequences of procrastination on (mental) health before. Our results indicate that procrastination leads to depression and anxiety symptoms over time and that perceived stress is not a mediator of this effect. We could not show that procrastination leads to perceived stress over time, nor that perceived stress leads to depression and anxiety symptoms over time. Explanations for this could be that procrastination might only lead to perceived stress in the short term, for example, during preparations for end-of-semester exams, and that perceived stress may not be sufficient on its own, that is, without the presence of other risk factors, to cause depression and anxiety symptoms. Overall, we could not confirm long-term effects of trait procrastination on (chronic) disease mediated by (chronic) stress, as assumed for the stress-related pathway of the procrastination-health model. Our study emphasizes the importance of identifying the consequences procrastination can have on health and well-being and determining by which mechanisms they are mediated. Only then will it be possible to develop interventions that can prevent negative health consequences of procrastination. Further health outcomes and possible mediators should be explored in future studies, using a similar longitudinal design.

Data availability

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

University Health Report at Freie Universität Berlin.

Abbreviations

Comparative fit index

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Generalized Anxiety Disorder Scale-2

Heidelberger Stress Index

Hypothalamic-pituitary-adrenocortical

Robust maximum likelihood estimation

Short form of the Procrastination Questionnaire for Students

Patient Health Questionnaire-2

Patient Health Questionnaire-4

Root mean square error of approximation

Structural equation modeling

Standardized root mean square residual

Tucker-Lewis index

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Conceptualization: A.J., B.G., T.L.; methodology: B.G., A.J.; validation: B.G.; formal analysis: A.J., B.G.; investigation: C.W., T.L., B.G.; data curation: C.W., T.L., B.G.; writing–original draft preparation: A.J., B.G.; writing–review and editing: A.J., T.L., B.G., C.W.; visualization: A.J., B.G.; supervision: B.G., T.L.; project administration: C.W., T.L., B.G.; All authors contributed to the article and approved the submitted version.

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Jochmann, A., Gusy, B., Lesener, T. et al. Procrastination, depression and anxiety symptoms in university students: a three-wave longitudinal study on the mediating role of perceived stress. BMC Psychol 12 , 276 (2024). https://doi.org/10.1186/s40359-024-01761-2

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Factors Associated with Depressive Symptoms among Filipino University Students

Romeo b. lee.

1 Department of Behavioral Sciences, de la Salle University, Manila, The Philippines

Susana Estanislao

3 Office of Counselling and Career Services, de la Salle University, Manila, The Philippines

Cristina Rodriguez

Conceived and designed the experiments: RBL MS SE CR. Analyzed the data: RBL MS SE CR. Wrote the manuscript: RBL MS SE CR.

Depression can be prevented if its symptoms are addressed early and effectively. Prevention against depression among university students is rare in the Philippines, but is urgent because of the rising rates of suicide among the group. Evidence is needed to systematically identify and assist students with higher levels of depressive symptoms. We carried out a survey to determine the social and demographic factors associated with higher levels of depressive symptoms among 2,436 Filipino university students. The University Students Depression Inventory with measures on lethargy, cognition-emotion, and academic motivation, was used. Six of the 11 factors analyzed were found to be statistically significantly associated with more intense levels of depressive symptoms. These factors were: frequency of smoking, frequency of drinking, not living with biological parents, dissatisfaction with one’s financial condition, level of closeness with parents, and level of closeness with peers. Sex, age category, course category, year level and religion were not significantly related. In identifying students with greater risk for depression, characteristics related to lifestyle, financial condition, parents and peers are crucial. There is a need to carry out more surveys to develop the pool of local knowledge on student depression.

Introduction

Depression is a major source of the burden of disease throughout the world [ 1 ]. In much of the developing world, however, depression is largely unexplored as a research topic. A social mapping revealed that, even though the mental disorder has been recognized as a research priority, only a sparse number of relevant studies have been carried out in low- and middle-income countries [ 2 ]. Roughly 60% of these countries have contributed fewer than five articles to the international mental health indexed literature [ 2 ]. Strategic evidence is needed in order to prevent the occurrence of depression, including its pernicious effects and prohibitive treatment cost.

Prevention of depression, particularly among university students in developing countries, is urgent. With their large student populations and the developmental propensity of students for depression [ 3 ], the burden of the mental disorder is heavy on this demographic sector [ 4 – 6 ]. Preventive efforts in the developing world, however, are rare. Consistent with observations elsewhere [ 7 , 8 ], depression is widely perceived in this part of the world as innocuous and as part and parcel of normal adolescent development. Students with the mental disorder are not only suffering in silence, but are also placing their academic and future life goals in peril. Depression can be averted if students with depressive symptoms, comprising not only physical but also non-physical conditions (e.g., cognition-emotion and motivation) [ 9 ], are promptly and properly identified and helped.

Extant studies suggest that students with higher levels of symptoms tend to be women [ 10 , 11 ], older and in their senior year [ 5 ], and Catholics and/or Jews [ 12 , 13 ]. Moreover, research indicates that highly symptomatic students do not reside with their parents in one household [ 14 ], and are smoking [ 15 ] and drinking alcohol [ 16 ], and belong to the low-income bracket [ 6 ]. Furthermore, students with more severe levels of depressive symptoms have lower levels of closeness with their parents or with friends [ 7 ].

The context of the present study

The Philippines has a total population of 92.3 million that is very young (median age: 23) and growing at 1.9% annually. In 2009-2010, 2.8 million university students were enrolled in the country’s 2,247 higher education institutions. Of every 10 Filipino students, 6 and 4 are enrolled in private and public universities, respectively. Of these students, 26% are enrolled in business, 16% in medicine and allied programs, and 13% each are in engineering, information science and education [ 17 ]. In contrast to their counterparts throughout most of the world, Filipino students commence their university education at the age of 15 or 16 years.

Filipinos place a high premium on formal education; a university degree is strongly regarded as a primary requirement for social and economic mobility. In the context of the collective aspirations of Filipinos to go abroad for lucrative employments, the need for university education is even more compelling. Individual students are thus pressured to excel or complete a degree, lest they bring dishonor to their family and friends, and endanger their employment and life prospects. In this respect, academic-related matters are salient issues for individual students and in their relationships and conflicts with parents; these, too, can induce higher levels of depressive symptoms in students.

We carried out this research as part of our community engagement activities to help in the prevention of mental disorders, and subsequently, of suicide among Filipino university students. The connection between depression and suicide is well-established [ 18 ]. The spate of suicide events among local students had served as the impetus to conceive and implement this study. There is paucity of data on university student depressive symptomatology in the Philippines, and in the absence of published relevant articles in indexed journals, little is understood about depressive symptoms among Filipino university students at the international level. This survey examined the social and demographic factors associated with higher levels of depressive symptoms among Filipino university students. The University Student Depression Inventory (USDI), a newly-developed and psychometrically sound scale with measures on academic motivation in addition to lethargy and cognition-emotion, was used.

Participants

Data were derived from a complete enumeration survey undertaken in 2012 covering all 67 undergraduate classes in general social sciences (e.g., introductory sociology) at a large private university (total student population: >16,000) in Manila, the Philippines. Roughly half of the 67 classes were surveyed in the middle of Term 1 and the other half in the middle of Term 2. A total of 2,591 Filipino students anonymously completed the 10-page self-accomplished questionnaire. Only the questionnaires of 2,436 students were considered for the purpose of this report (126 questionnaires of international students were excluded and 29 questionnaires with at least 10 unanswered items were invalidated). Our sample represents about 15% of the university’s total undergraduate student population.

We utilized the USDI to measure depressive symptoms as a continuous variable. The USDI, developed by Khawaja & Kelly [ 9 ], measures the academic motivational aspect of depressive symptoms in addition to physical and cognitive-emotive dimensions. The USDI has 3 sub-scales having a total of 30 statements: lethargy (9 statements on lethargy, concentration difficulties and task performance); cognitive-emotional (14 statements on suicide ideation, worthlessness, emotional emptiness and sadness); and academic motivation (7 statements on class attendance and motivation to study) ( Table 1 ). Statements have score-bearing response options ranging from “none at all” (1) to “all the time” (5). The USDI has a high level of internal consistency (Cronbach α=0.95) [ 9 ].

The socio-demographic characteristics include sex, age category, course category, year level, religion, frequency of smoking, frequency of drinking, living/not living with both biological parents, level of satisfaction with one’s financial condition, level of closeness with parents, and level of closeness with peers. The last 2 variables were measured using a series of 8 statements on parents and 9 statements on peers. The statements were drawn from published studies on parental and peer relationships among adolescents [ 7 , 19 ]. Each series had 4 score-bearing response options: definitely not true (1), mostly not true (2), mostly true (3), and definitely true (4) ( Table 1 ).

Ethical standards

The study was approved by the ethics review committee of the university. After evaluating the contents of the survey instrument, the Committee assessed that the study would have no known risk to research participants. Verbal consent was thus obtained; however, students were informed that they could decline participation and that they could stop completing the questionnaire if they wished to. The benefits of the study (i.e., findings would be used to draw attention towards mental health in Filipino students) were especially stressed in order to trigger a sense of social responsibility and citizenship, and therefore, research participation among students. These instructions were written on the cover page of the survey instrument that was administered. On the same cover page, we also included our full names and contact numbers in which we enjoined students to ask us questions about the study and related matters.

We did not seek the consent of the students’ parents anymore. The survey focused on real-life conditions (e.g., feeling bored and having low energy) which are normally shared between and among Filipino students. During our pre-test of the questionnaire, student-respondents perceived the topic of the study as personally acceptable, one they felt they would not be asking their parents for permission should they decide to discuss it. The foregoing ethical standards, especially with respect to studies with no known harmful risks and the waiving of a signed certification of consent, are in line with the practices of most Institutional Review Boards elsewhere.

We conducted the survey in classrooms during the first quarter of the 90-minute classes. Each class was informed about the importance and rationale, and the anonymity and confidentiality of the study. Afterwards, students were invited to participate and were each given a questionnaire to accomplish. Students were reminded not to write any mark in the instrument that would identify them. Whether completely accomplished or not, all questionnaires were collected. Students were thanked for their participation. No incentive of any form was given.

Using the Statistical Package for the Social Sciences Version 20, differences in the mean depressive symptoms scores were examined based on social and demographic characteristics. The characteristics that were statistically significantly related with higher levels of depressive symptoms were further examined at the sub-scale levels. The analysis of variance was used.

The independent variables, except for sex (male, female), were recoded into variables with 2-3 categories each ( Table 2 ). The levels of closeness with parents and with peers were constructed by adding the scores corresponding to responses given to the series of statements. For level of closeness with parents, the score range is 8 to 32 (low-moderate, 8-23; high, 24-32); and for level of closeness with peers, the range is 9 to 36 (low-moderate, 9-26; high, 27-36). Our analyses revealed a high level of internal consistency for both series (parents: α=0.77; peers α=0.79).

* p<.05**p<.01

The dependent variable (levels of depressive symptoms) was constructed by adding the scores corresponding to the responses given to the series of statements. The scale score ranges from 30 to 150 while the sub-scale scores range from 9 to 45 for lethargy, 14 to 70 for cognition-emotion, and 7 to 35 for academic motivation; higher scores suggest higher levels of depressive symptoms Our analyses revealed a high level of internal consistency for the USDI (α=0.93).

Profile of respondents

The majority were female while 43.6% were male. 42.5% were 16 years of age or younger, 29.8% were 17 years old and a similar number were older. 39.0% were in social sciences/humanities; 29.6% were in business/economics/management and 23.2% were in engineering/natural/computer sciences. Seven of every 10 were first year students. Most were Catholic (80.9%) and reported not having smoked in the past 30 days prior to the survey. In the past 30 days, about 6 of every 10 students had taken alcohol for more than 10 days, while 4 for ≤10 days. Most respondents (77.9%) currently lived with both biological parents. About 70% were satisfied and very satisfied with their financial condition; the rest were not or were only somewhat satisfied. Most had high levels of closeness with parents (82.5%) and peers (88.1%).

Differences in mean scale scores based on social and demographic characteristics

The means and standard deviations for depressive symptoms scale scores are shown in Table 2 . Higher means suggest higher or more severe levels of depressive symptoms. Results indicate that male and female students did not differ in their symptoms levels. No significant differences were observed across age groups. The level of depressive symptoms statistically significantly varied according to course category but only marginally (F (3,2410) =2.54, p<.06). Means were not significantly dissimilar across year level and religion.

Means comparison related to frequency of smoking suggests significant differences among the categories (F (2,2411) =9.65, p<.01). Results of post-hoc Tukey test indicate that those who smoked for ≤10 days had a higher level of depressive symptoms than those who did not smoke in the past 30 days (p<.01). Significant means differences were observed based on frequency of drinking (F (1,2424) =14.31, p<.01). Students not living with both parents had a significantly higher level of symptoms compared to those living with parents (F (1,2432) =4.87, p<.05). Moreover, depressive symptoms level significantly varied according to satisfaction with one’s financial condition (F (3,2423) =52.03, p<.01). Based on post-hoc Tukey test findings, students who were not satisfied with their financial status had a more elevated level of depressive symptoms than those who were somewhat satisfied (p<.05), satisfied (p<.01) and very satisfied (p<.01).

Students with a low to a moderate level of closeness with parents had a significantly higher level of depressive symptoms than students with a high level of closeness with parents (F (1,2431) =165.76, p<.01). Students with a low-moderate level of closeness with peers had a significantly higher level of symptoms than those with a high level of closeness with peers (F (1,2425) =176.91, p<.01).

The 6 independent variables with statistically significant relationships with higher levels of depressive symptoms were further examined for their interactions. The two-way analysis of variance results indicate an absence of any interaction.

Differences in mean sub-scale scores based on statistically significant social and demographic factors

Additional analyses using the one-way analysis of variance were performed to determine if the statistically significant associations of the 6 independent variables (i.e., frequency of smoking, frequency of drinking, living/not living with both biological parents, level of satisfaction with financial condition, level of closeness with parents, and level of closeness with peers) would hold at the sub-scale level. The means, F-values and p-values are given in Table 3 .

* p<.05**p<.01. SS=sum of squares. MS=mean squares. NS=not significant

Results indicate that the associations of the 5 variables (i.e., frequency of drinking, level of satisfaction with financial condition, and levels of closeness with parents and with peers) persisted at all sub-scales of depressive symptoms (p-values at <0.01 or <0.05). The significant sub-scale association of the remaining variable (i.e., living/not living with both biological parents) was confined only to the cognitive-emotional sub-scale.

This survey identified a set of social and demographic factors that are statistically significantly associated with higher levels of depressive symptoms among Filipino university students. The aim is to help prevent depression among the domestic university student population. If students with elevated risks are known and assisted early, their depression would be promptly averted. Data suggest that the factors with significant associations with depressive symptoms, mostly at both the scale and sub-scale levels, were frequency of smoking, frequency of drinking, living/not living with both biological parents, level of satisfaction with one’s financial condition, and levels of closeness with parents and with peers.

The significant associations of frequencies of smoking and of drinking with depressive symptoms are aligned with extant empirical findings [ 20 , 21 ]. The present study revealed that Filipino students who smoked for some days (against those who did not smoke) and who took alcohol for some days (against those who consumed alcohol for longer durations) had higher depressive symptoms levels. In explaining the associations of smoking and drinking, some studies tend to highlight the psychopharmacological [ 20 ] and symbiotic [ 22 ] dimensions of these bivariate relationships. This implies that students could have smoked or taken alcohol as an escape route from the burdens of psychosocial difficulties. In the case of drinking, in particular, the use of alcohol usually precedes the symptoms of lethargy and social difficulties associated with depression [ 23 , 24 ]. Caution should be taken in appreciating these interpretations, however. The variables were measured in this study based on the number of days of smoking and drinking rather than the quantities of cigarettes and alcohol consumed (these two are not necessarily equivalent indicators). Considering that the rates of smoking and drinking among the Filipino youth are relatively high (21.0% and 41.4%, respectively) [ 25 ], these twin behaviors, specifically their frequencies, need closer examination vis-à-vis depressive symptoms.

The association between not living in the household with both biological parents and having more serious levels of depressive symptoms has ample empirical support [ 14 , 26 ]. Across the country, many Filipino students do not reside with both parents while pursuing their university education, because they live away from home in dormitories and/or their biological parents are single, separated, or are working abroad. Either as a permanent or a temporary condition, not living with both biological parents may induce depressive symptoms, primarily in cognitive-emotive terms as this study revealed, probably as a result of having restricted access to parental presence and support.

Satisfaction or dissatisfaction with one’s financial condition is well-confirmed in several other investigations for its significant role in mental health [ 27 ]. It is usually expensive to study in a private Philippine university compared to studying in the country’s state colleges and universities. Students in private universities would generally belong to higher levels of socioeconomic status and may influence a peer culture that promotes greater awareness of a person’s socioeconomic standing in society. Such an educational environment is, in turn, likely to enhance sensitivities about one’s own social status in comparison to one’s peers. Those who perceive themselves as higher in status also have higher levels of optimism and perceived control, and therefore, are also likely to exhibit lower levels of depressive symptoms [ 28 , 29 ].

The current study findings on the significant associations between the levels of closeness with parents and peers and depressive symptoms are to be expected; these are within the realm of the evidence widely reported in other investigations [ 7 , 30 ]. That most of the Filipino university students who participated in this study had high closeness levels with their parents and peers is hardly unexpected. Parents and friends are basic yet very significant primary groups for Filipino adolescents. Their provisions, including the immediate care, security and support that they bestow and the secure attachments that they consequently foster, are effective protectors and buffers of university students against depressive symptoms [ 31 , 32 ].

In the absence of high level of closeness of Filipino students with parents, in which the parent-child relationship would be characterized by communication problems, excessive parental control, low levels of cohesion, and high levels of conflict in the families, adolescents are bound to experience depressive symptoms [ 33 , 34 ]. Without high level of closeness with peers, local students are also predisposed to be at risk. Students are in a stage when they mostly need their peers for emotional support. Peer acceptance is important to the growing individual and is therefore associated with depressive symptoms [ 35 ]. Compared to the association of the lack of parental warmth and acceptance with adolescents’ depressive symptoms, which is largely unidirectional, the association between depressive symptoms and peer-relational problems tends to be bidirectional [ 36 ]. Filipino students exhibiting depressive symptoms are likely to be spending less time interacting with their peers and are prone to relate with them aggressively. This interaction pattern, in turn, is likely to cultivate further peer rejection and neglect.

Sex, age category, course category, year level and religion were not statistically significant factors as our analyses revealed. As a general rule, females show higher rates of depression than males [ 37 , 38 ] due to their tendency to be more expressive and more sensitive to the support provided by their social networks [ 39 ]. However, this normative rule on gender differences does not seem to hold true for university students [ 37 ]. The exception may be accounted for by the homogeneous university life experiences, similarities in parental education, or common socio-demographic conditions among the youth in general [ 37 , 39 ]. The lack of significant associations of age category, course category and year level among Filipino students could be due to this homogeneity factor as well, particularly that most of them were young, freshmen and completing general education rather than major subjects at the time of their interview. Religion was not significantly associated with depressive symptoms and this is to be expected: the Filipino youth, including university students, are largely nominal Catholics who seldom practice their faith [ 40 ]. Elsewhere, one’s religiousness rather than religious affiliation per se has been observed to be significantly related with lower levels of depressive symptoms in students [ 41 ].

The survey has some limitations. Since the study’s respondents were from general education classes with mostly first year students from middle- and high-income backgrounds, the findings cannot be generalized to the entire student population of the university surveyed or student populations from other universities in the Philippines. Another limitation of the survey is that it did not include other factors that may have potential relationships with higher levels of depressive symptoms. For instance, since completing a university degree is culturally valued among Filipinos, the academic performance of students could be a critical factor for assessing depressive symptoms. Also, the study is cross-sectional, and as such, its conclusions only refer to associations rather than causal relationships between the independent and dependent variables. Moreover, the level of depressive symptoms measured through the USDI pertains not to the sequence of the occurrence of high levels of depressive symptoms, but to the amount of depressive symptoms weighted by frequency of occurrence students experienced in the past fortnight.

More surveys using the USDI are needed in the Philippines. Future studies have to involve representative samples of Filipino university students from other socio-economic backgrounds. If feasible, longitudinal studies, which will provide repeated observations of the levels and associated factors of depressive symptoms, are a better alternative. Variables related to students’ academic performance should be included as well. Some variable measures (e.g., frequency of smoking) need to capture more nuanced dimensions of the social and demographic conditions of students at greater risk, For example, variables related to smoking and drinking should ask follow-up questions regarding the specific quantities of cigarettes and alcohol consumed by students in a given period. In addition, the association of religion with depressive symptoms will be better understood by a follow-up question on religiousness.

The present survey is a pioneering large-scale research on the social and demographic factors of higher levels of depressive symptoms among Filipino university students. These initial findings can help guide the development of a campus-based prevention program at the university surveyed. Towards addressing depressive symptoms and depression in students, lifestyle and factors related to financial condition and parental and peer relationships are important considerations for identifying those at greater risk. More research is needed towards building additional local knowledge on the topic.

Funding Statement

The authors have no support or funding to report. The study was carried out as part of the community engagement activities of the authors.

Unilateral and Bilateral Theta Burst Stimulation for Treatment-Resistant Depression: Follow up on a Naturalistic Observation Study

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Background: Theta burst stimulation (TBS) is a novel and faster modality of transcranial magnetic stimulation, which is showing promise as a treatment-resistant depression (TRD) treatment. Though TBS can be applied unilaterally or bilaterally, few studies have compared the effectiveness of both approaches in a naturalistic clinical sample. Objectives: In this retrospective chart review, we aimed to: (1) replicate previous bilateral sequential TBS effectiveness in a larger cohort of patients at a single centre, (2) present treatment outcome data between unilateral and bilateral TBS approaches, (3) investigate baseline factors associated with our observed outcomes, and (4) examine the sustainability of response, with follow-up data up to 6 months from patients. Methods: We included 161 patients who received TBS (unilateral: n = 64 (40%), 45.55 ± 14.25 years old, 55% females; bilateral: n = 97 (60%), 47.67 ± 15.11 years old, 58% females). Results: Firstly, we observed 47% response and 34% remission in the bilateral group, replicating findings from a smaller naturalistic study from our group; patients receiving unilateral TBS displayed 36% response and 26% remission, with no significant differences found between unilateral and bilateral TBS in remission and response rates. Secondly, bilaterally stimulated patients needed fewer treatments than those stimulated unilaterally (27 vs 29 on average respectively, t [159] = 3.31, p = .001), and had significantly lower anxiety symptoms post treatment (GAD-7) relative to patients receiving unilateral stimulation, F (1,148) = 3.95, p =0.049. Thirdly, no baseline factors were found to predict treatment outcomes. Lastly, after six months, 69% of patients who met the response criteria did not require additional treatment or a change in medication. Conclusions: Our findings support the efficacy and tolerability of TBS in TRD and indicate that bilateral TBS may have a superior anxiolytic effect and offer a slightly faster time to response.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

This study was funded by the St. Joseph's Health Care Foundation.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

This retrospective study has been approved by the Western University office of Human Research Ethics Board at St. Joseph's Health Care London in compliance with the Declaration of Helsinki.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Data Availability

To protect participant privacy, the data analyzed during the current study are available from the corresponding author on request.

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• Published: 14 May 2024

Exploring predictors and prevalence of postpartum depression among mothers: Multinational study

• Samar A. Amer   ORCID: orcid.org/0000-0002-9475-6372 1 ,
• Nahla A. Zaitoun   ORCID: orcid.org/0000-0002-5274-6061 2 ,
• Heba A. Abdelsalam 3 ,
• Abdallah Abbas   ORCID: orcid.org/0000-0001-5101-5972 4 ,
• Mohamed Sh Ramadan 5 ,
• Hassan M. Ayal 6 ,
• Samaher Edhah Ahmed Ba-Gais 7 ,
• Nawal Mahboob Basha 8 ,
• Abdulrahman Allahham 9 ,
• Emmanuael Boateng Agyenim 10 &
• Walid Amin Al-Shroby 11  

BMC Public Health volume  24 , Article number:  1308 ( 2024 ) Cite this article

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Postpartum depression (PPD) affects around 10% of women, or 1 in 7 women, after giving birth. Undiagnosed PPD was observed among 50% of mothers. PPD has an unfavorable relationship with women’s functioning, marital and personal relationships, the quality of the mother-infant connection, and the social, behavioral, and cognitive development of children. We aim to determine the frequency of PPD and explore associated determinants or predictors (demographic, obstetric, infant-related, and psychosocial factors) and coping strategies from June to August 2023 in six countries.

An analytical cross-sectional study included a total of 674 mothers who visited primary health care centers (PHCs) in Egypt, Yemen, Iraq, India, Ghana, and Syria. They were asked to complete self-administered assessments using the Edinburgh Postnatal Depression Scale (EPDS). The data underwent logistic regression analysis using SPSS-IBM 27 to list potential factors that could predict PPD.

The overall frequency of PPD in the total sample was 92(13.6%). It ranged from 2.3% in Syria to 26% in Ghana. Only 42 (6.2%) were diagnosed. Multiple logistic regression analysis revealed there were significant predictors of PPD. These factors included having unhealthy baby adjusted odds ratio (aOR) of 11.685, 95% CI: 1.405–97.139, p  = 0.023), having a precious baby (aOR 7.717, 95% CI: 1.822–32.689, p  = 0.006), who don’t receive support (aOR 9.784, 95% CI: 5.373–17.816, p  = 0.001), and those who are suffering from PPD. However, being married and comfortable discussing mental health with family relatives are significant protective factors (aOR = 0.141 (95% CI: 0.04–0.494; p  = 0.002) and (aOR = 0.369, 95% CI: 0.146–0.933, p  = 0.035), respectively.

The frequency of PPD among the mothers varied significantly across different countries. PPD has many protective and potential factors. We recommend further research and screenings of PPD for all mothers to promote the well-being of the mothers and create a favorable environment for the newborn and all family members.

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Introduction

Postpartum depression (PPD) is among the most prevalent mental health issues [ 1 ]. The onset of depressive episodes after childbirth occurs at a pivotal point in a woman’s life and can last for an extended period of 3 to 6 months; however, this varies based on several factors [ 2 ]. PPD can develop at any time within the first year after childbirth and last for years [ 2 ]. It refers to depressive symptoms that a mother experiences during the postpartum period, which are vastly different from “baby blues,” which many mothers experience within three to five days after the birth of their child [ 3 ].

Depressive episodes are twice as likely to occur during pregnancy compared to other times in a woman’s life, and they frequently go undetected and untreated [ 4 ]. According to estimates, almost 50% of mothers with PPD go undiagnosed [ 4 ]. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for PPD include mood instability, loss of interest, feelings of guilt, sleep disturbances, sleep disorders, and changes in appetite [ 5 ], as well as decreased libido, crying spells, anxiety, irritability, feelings of isolation, mental liability, thoughts of hurting oneself and/or the infant, and even suicidal ideation [ 6 ].

Approximately 1 in 10 women will experience PPD after giving birth, with some studies reporting 1 in 7 women [ 7 ]. Globally, the prevalence of PPD is estimated to be 17.22% (95% CI: 16.00–18.05) [ 4 ], with a prevalence of up to 15% in the previous year in eighty different countries or regions [ 1 ]. This estimate is lower than the 19% prevalence rate of PPD found in studies from low- and middle-income countries and higher than the 13% prevalence rate (95% CI: 12.3–13.4%) stated in a different meta-analysis of data from high-income countries [ 8 ].

The occurrence of postpartum depression is influenced by various factors, including social aspects like marital status, education level, lack of social support, violence, and financial difficulties, as well as other factors such as maternal age (particularly among younger women), obstetric stressors, parity, and unplanned pregnancy [ 4 ]. When a mother experiences depression, she may face challenges in forming a satisfying bond with her child, which can negatively affect both her partner and the emotional and cognitive development of infants and adolescents [ 4 ]. As a result, adverse effects may be observed in children during their toddlerhood, preschool years, and beyond [ 9 ].

Around one in seven women can develop PPD [ 7 ]. While women experiencing baby blues tend to recover quickly, PPD tends to last longer and severely affects women’s ability to return to normal function. PPD affects the mother and her relationship with the infant [ 7 ]. The prevalence of postpartum depression varies depending on the assessment method, timing of assessment, and cultural disparities among countries [ 7 ]. To address these aspects, we conducted a cross-sectional study focusing on mothers who gave birth within the previous 18 months. Objectives: to determine the frequency of PPD and explore associated determinants or predictors, including demographic, obstetric, infant-related, and psychosocial factors, and coping strategies from June to August 2023 in six countries.

Study design and participants

This is an analytical cross-sectional design and involved 674 mothers during the childbearing period (CBP) from six countries, based on the authors working settings, namely Egypt, Syria, Yemen, Ghana, India, and Iraq. It was conducted from June to August 2023. It involved all mothers who gave birth within the previous 18 months, citizens of one of the targeted countries, and those older than 18 years and less than 40 years. Women who visited for a routine postpartum follow-up visit and immunization of their newborns were surveyed.

Multiple pregnancies, illiteracy, or anyone deemed unfit to participate in accordance with healthcare authorities, mothers who couldn’t access or use the Internet, mothers who couldn’t read or speak Arabic or English and couldn’t deal with the online platform or smart devices, mothers whose babies were diagnosed with serious health problems, were stillborn, or experienced intrauterine fetal death, and participants with complicated medical, mental, or psychological disorders that interfered with completing the questionnaire were all exclusion criteria. There were no incentives offered to encourage participation.

Sample size and techniques

The sample size was estimated according to the following equation: n = Z 2 P (1-P)/d 2 . This calculation was based on the results of a systematic review and meta-analysis in 2020 of 17% as the worldwide prevalence of PPD and 12% as the worldwide incidence of PPD, as well as a 5% precision percentage, 80% power of the study, a 95% confidence level, and an 80% response rate [ 11 ]. The total calculated sample size is 675. The sample was diverse in terms of nationality, with the majority being Egyptian (16.3%), followed by Yemeni (24.3%) and Indian (19.1%), based on many factors discussed in the limitation section.

The sampling process for recruiting mothers utilized a multistage approach. Two governorates were randomly selected from each country. Moreover, we selected one rural and one urban area from each governorate. Through random selection, participants were chosen for the study. Popular and officially recognized online platforms, including websites and social media platforms such as Facebook, Twitter, WhatsApp groups, and registered emails across various health centers, were utilized for reaching out to participants. Furthermore, a community-based sample was obtained from different public locations, including well-baby clinics, PHCs, and family planning units.

Mothers completed the questionnaire using either tablets or cellphones provided by the data collectors or by scanning the QR code. All questions were mandatory to prevent incomplete forms. Once they provided their informed consent, they received the questionnaire, which they completed and submitted. To enhance the response rate, reminder messages and follow-up communications were employed until the desired sample size was achieved or until the end of August. To avoid seasonal affective disorders, the meteorological autumn season began on the 1st day of September, which may be associated with Autum depressive symptoms that may confound or affect our results.

Data collection tool

Questionnaire development and structure.

The questionnaire was developed and adapted based on data obtained from previous studies [ 7 , 8 , 9 , 10 , 11 , 12 ]. Initially, it was created in English and subsequently translated into Arabic. To ensure accuracy, a bilingual panel consisting of two healthcare experts and an externally qualified medical translator translated the English version into Arabic. Additionally, two English-speaking translators performed a back translation, and the original panel was consulted if any concerns arose.

Questionnaire validation

To collect the data, an online, self-administered questionnaire was utilized, designed in Arabic with a well-structured format. We conducted an assessment of the questionnaire’s reliability and validity to ensure a consistent interpretation of the questions. The questionnaire underwent validation by psychiatrists, obstetricians, and gynecologists. Furthermore, in a pilot study involving 20 women of CBA, the questionnaire’s clarity and comprehensibility were evaluated. It is important to note that the findings from the pilot study were not included in our main study.

The participants were asked to rate the questionnaire’s organization, clarity, and length, as well as provide a general opinion. Following that, certain questions were revised in light of their input. To check for reliability and reproducibility, the questionnaire was tested again on the same people one week later. The final data analysis will not include the data collected during the pilot test. We calculated a Cronbach’s alpha of 0.76 for the questionnaire.

The structure of the questionnaire

After giving their permission to take part in the study. The questionnaire consisted of the following sections:

Study information and electronic solicitation of informed consent.

Demographic and health-related factors: age, gender, place of residence, educational level, occupation, marital status, weight, height, and the fees of access to healthcare services.

Obstetric history: number of pregnancies, gravida, history of abortions, number of live children, history of dead children, inter-pregnancy space (y), current pregnancy status, type of the last delivery, weight gain during pregnancy (kg), baby age (months), premature labor, healthy baby, baby admitted to the NICU, Feeding difficulties, pregnancy problems, postnatal problems, and natal problems The nature of baby feeding.

Assessment of postpartum depression (PPD) levels using the Edinburgh 10-question scale: This scale is a simple and effective screening tool for identifying individuals at risk of perinatal depression. The EPDS (Edinburgh Postnatal Depression Scale) is a valuable instrument that helps identify the likelihood of a mother experiencing depressive symptoms of varying severity. A score exceeding 13 indicates an increased probability of a depressive illness. However, clinical discretion should not be disregarded when interpreting the EPDS score. This scale captures the mother’s feelings over the past week, and in cases of uncertainty, it may be beneficial to repeat the assessment after two weeks. It is important to note that this scale is not capable of identifying mothers with anxiety disorders, phobias, or personality disorders.

For Questions 1, 2, and 4 (without asterisks): Scores range from 0 to 3, with the top box assigned a score of 0 and the bottom box assigned a score of 3. For Questions 3 and 5–10 (with asterisks): Scores are reversed, with the top box assigned a score of 3 and the bottom box assigned a score of 0. The maximum score achievable is 30, and a probability of depression is considered when the score is 10 or higher. It is important to always consider item 10, which pertains to suicidal ideation [ 12 ].

Psychological and social characteristics: received support or treatment for PPD, awareness of symptoms and risk factors, experienced cultural stigma or judgment about PPD in the community, suffer from any disease or mental or psychiatric disorder, have you ever been diagnosed with PPD, problems with the husband, and financial problems.

Coping strategies and causes for not receiving the treatment and reactions to PPD, in descending order: social norms, cultural or traditional beliefs, personal barriers, 48.5% geographical or regional disparities in mental health resources, language or communication barriers, and financial constraints.

Statistical analysis

The collected data was computerized and statistically analyzed using the SPSS program (Statistical Package for Social Science), version 27. The data was tested for normal distribution using the Shapiro-Walk test. Qualitative data was represented as frequencies and relative percentages. Quantitative data was expressed as mean ± SD (standard deviation) if it was normally distributed; otherwise, median and interquartile range (IQR) were used. The Mann-Whitney test (MW) was used to calculate the difference between quantitative variables in two groups for non-parametric variables. Correlation analysis (using Spearman’s method) was used to assess the relationship between two nonparametric quantitative variables. All results were considered statistically significant when the significant probability was < 0.05. The chi-square test (χ 2 ) and Fisher exact were used to calculate the difference between qualitative variables.

The frequency of PPD among mothers (Fig.  1 )

The frequency of PPD among the studied mothers

The frequency of PPD in the total sample using the Edinburgh 10-question scale was 13.5% (Table S1) and 92 (13.6%). Which significantly ( p  = 0.001) varied across different countries, being highest among Ghana mothers 13 (26.0%) out of 50 and Indians 28 (21.7%) out of 129. Egyptian 21 (19.1) out of 110, Yemen 14 (8.5%) out of 164, Iraq 13 (7.7%) out of 168, and Syria 1 (2.3%) out of 43 in descending order. Nationality is also significantly associated with PPD ( p  = 0.001).

Demographic, and health-related characteristics and their association with PPD (Table  1 )

The study included 674 participants. The median age was 27 years, with 407 (60.3%) of participants falling in the >25 to 40-year-old age group. The majority of participants were married, 650 (96.4%), had sufficient monthly income, 449 (66.6%), 498 (73.9%), had at least a preparatory or high school level of education, and were urban. Regarding health-related factors, 270 (40.01%) smoked, 645 (95.7%) smoked, 365 (54.2%) got the COVID-19 vaccine, and 297 (44.1%) got COVID-19. Moreover, 557 (82.6%) had no comorbidities, 623 (92.4%) had no psychiatric illness or family history, and they charged for health care services for themselves 494 (73.3%).

PPD is significant ( p  < 0.05). Higher among single or widowed women 9 (56.3%) and mothers who had both medical, mental, or psychological problems 2 (66.7%), with ex-cigarette smoking 5 (35.7%) ( p  = 0.033), alcohol consumption ( p  = 0.022) and mothers were charged for the health care services for themselves 59 (11.9%).

Obstetric, current pregnancy, and infant-related characteristics and their association with PPD (Table  2 )

The majority of the studied mothers were on no hormonal treatment or contraceptive pills 411 (60.9%), the current pregnancy was unplanned and wanted 311 (46.1%), they gained 10 ≥ kg 463 (68.6%), 412 (61.1%) delivered vaginal, a healthy baby 613 (90.9%), and, on breastfeeding, only 325 (48.2%).

There was a significant ( P  < 0.05) association observed between PPD, which was significantly higher among mothers on contraceptive methods, and those who had 1–2 live births (76.1%) and mothers who had interpregnancy space for less than 2 years. 86 (93.5%), and those who had a history of dead children. Moreover, among those who had postnatal problems (27.2%).

The psychosocial characteristics and their association with PPD (Table  3 )

Regarding the psychological and social characteristics of the mothers, the majority of mothers were unaware of the symptoms of PPD (75%), and only 236 (35.3%) experienced cultural stigma or judgment about PPD in the community. About 41 (6.1%) were diagnosed with PPD during the previous pregnancy, and only 42 (6.2%) were diagnosed and on medications.

A p -value of less than 0.001 demonstrates a highly statistically significant association with the presence of PPD. Mothers with PPD were significantly more likely to have a history of or be currently diagnosed with PPD, as well as financial and marital problems. Experienced cultural stigma or judgment about PPD and received more support.

Coping strategies and causes for not receiving the treatment and reaction to PPD (Table  3 ; Fig.  2 )

Causes for not receiving the treatment and reaction to PPD

Around half of the mothers didn’t feel comfortable discussing mental health: 292 (43.3%) with a physician, 307 (45.5%) with a husband, 326 (48.4%) with family, and 472 (70.0%) with the community. Moreover, mothers with PPD felt significantly more comfortable discussing mental health in descending order: 46 (50.0%) with a physician, 41 (44.6%) with a husband, and 39 (42.3%) with a family (Table  3 ).

There were different causes for not receiving the treatment and reactions to PPD, in descending order: 65.7% social norms, 60.5% cultural or traditional beliefs, 56.5% personal barriers, 48.5% geographical or regional disparities in mental health resources, 47.4% language or communication barriers, and 39.7% financial constraints.

Prediction of PPD (significant demographics, obstetric, current pregnancy, and infant-related, and psychosocial), and coping strategies derived from multiple logistic regression analysis (Table  4 ).

Significant demographic predictors of ppd.

Marital Status (Married or Single): The adjusted odds ratio (aOR) among PPD mothers who were married in comparison to their single counterparts was 0.141 (95% CI: 0.04–0.494; p -value = 0.002).

Nationality: For PPD Mothers of Yemeni nationality compared to those with Egyptian nationality, the aOR was 0.318 (95% CI: 0.123–0.821, p  = 0.018). Similarly, for Syrian nationality in comparison to Egyptian nationality, the aOR was 0.111 (95% CI: 0.0139–0.887, p  = 0.038), and for Iraqi nationality compared to Egyptian nationality, the aOR was 0.241 (95% CI: 0.0920–0.633, p  = 0.004).

Significant obstetric, current pregnancy, and infant-related characteristics predictors of PPD

Current Pregnancy Status (Precious Baby—Planned): The aOR for the occurrence of PPD among women with a “precious baby” relative to those with a “planned” pregnancy was 7.717 (95% CI: 1.822–32.689, p  = 0.006).

Healthy Baby (No-Yes): The aOR for the occurrence of PPD among women with unhealthy babies in comparison to those with healthy ones is 11.685 (95% CI: 1.405–97.139, p  = 0.023).

Postnatal Problems (No–Yes): The aOR among PPD mothers reporting postnatal problems relative to those not reporting such problems was 0.234 (95% CI: 0.0785–0.696, p  = 0.009).

Significant psychological and social predictors of PPD

Receiving support or treatment for PPD (No-Yes): The aOR among PPD mothers who were not receiving support or treatment relative to those receiving support or treatment was 9.784 (95% CI: 5.373–17.816, p  = 0.001).

Awareness of symptoms and risk factors (No-Yes): The aOR among PPD mothers who lack awareness of symptoms and risk factors relative to those with awareness was 2.902 (95% CI: 1.633–5.154, p  = 0.001).

Experienced cultural stigma or judgement about PPD in the community (No-Yes): The aOR among PPD mothers who had experienced cultural stigma or judgment in the community relative to those who have not was 4.406 (95% CI: 2.394–8.110, p  < 0.001).

Suffering from any disease or mental or psychiatric disorder: For “Now I am suffering—not at all,” the aOR among PPD mothers was 12.871 (95% CI: 3.063–54.073, p  = 0.001). Similarly, for “Had a past history but was treated—not at all,” the adjusted odds ratio was 16.6 (95% CI: 2.528–108.965, p  = 0.003), and for “Had a family history—not at all,” the adjusted odds ratio was 3.551 (95% CI: 1.012–12.453, p  = 0.048).

Significant coping predictors of PPD comfort: discussing mental health with family (maybe yes)

The aOR among PPD mothers who were maybe more comfortable discussing mental health with family relatives was 0.369 (95% CI: 0.146–0.933, p  = 0.035).

PDD is a debilitating mental disorder that has many potential and protective risk factors that should be considered to promote the mental and psychological well-being of the mothers and to create a favorable environment for the newborn and all family members. This multinational cross-sectional survey was conducted in six different countries to determine the frequency of PDD using EPDS and to explore its predictors. It was found that PPD was a prevalent problem that varied across different nations.

The frequency of PPD across the studied countries

Using the widely used EPDS to determine the current PPD, we found that the overall frequency of PPD in the total sample was 92 (13.6%). Which significantly ( p  = 0.001) varied across different countries, being highest among Ghana mothers 13 (26.0%) out of 50 and Indians 28 (21.7%) out of 129. Egyptian 21 (19.1) out of 110, Yemen 14 (8.5%) out of 164, Iraq 13 (7.7%) out of 169, and Syria 1 (2.3%) out of 43 in descending order. This prevalence was similar to that reported by Hairol et al. (2021) in Malaysia (14.3%) [ 13 ], Yusuff et al. (2010) in Malaysia (14.3%) [ 14 ], and Nakku et al. (2006) in New Delhi (12.75%) [ 15 ].

While the frequency of PPD varied greatly based on the timing, setting, and existence of many psychosocial and post-partum periods, for example, it was higher than that reported in Italy (2012), which was 4.7% [ 16 ], in Turkey (2017) was 9.1%/110 [ 17 ], 9.2% in Sudan [ 18 ], Eritrea (2020) was 7.4% [ 19 ], in the capital Kuala Lumpur (2001) was (3.9%) [ 20 ], in Malaysia (2002) was (9.8%) [ 21 ], and in European countries. (2021) was 13–19% [ 22 ].

Lower frequencies were than those reported; PPD is a predominant problem in Asia, e.g., in Pakistan, the three-month period after childbirth, ranging from 28.8% in 2003 to 36% in 2006 to 94% in 2007, while after 12 months after childbirth, it was 62% in 2021 [ 23 – 24 ]. While in 2022 Afghanistan 45% after their first labour [ 25 ] in Canada (2015) was 40% [ 26 ], in India, the systematic review in 2022 was 22% of Primipara [ 27 ], in Malaysia (2006) was 22.8% [ 28 ], in India (2019) was 21.5% [ 29 ], in the Tigray zone in Ethiopia (2017) was 19% [ 30 ], varied in Iran between 20.3% and 35% [ 31 – 32 ], and in China was 499 (27.37%) out of 1823 [ 33 ]. A possible explanation might be the differences in the study setting and the type of design utilized. Other differences should be considered, like different populations with different socioeconomic characteristics and the variation in the timing of post-partum follow-up. It is vital to consider the role of culture, the impact of patients’ beliefs, and the cultural support for receiving help for PPD.

Demographic and health-related associations, or predictors of PPD (Tables  1 and 4 )

Regarding age, our study found no significant difference between PPD and non-PPD mothers with regard to age. In agreement with our study [ 12 , 34 , 35 ], other studies [ 36 , 37 , 38 ] found an inverse association between women’s age and PPD, with an increased risk of PPD (increases EPDS scores) at a younger age significantly, as teenage mothers, being primiparous, encounter difficulty during the postpartum period due to their inability to cope with financial and emotional difficulties, as well as the challenge of motherhood. Cultural factors and social perspectives of young mothers in different countries could be a reason for this difference. [ 38 – 39 ] and Abdollahi et al. [ 36 ] reported that older mothers were a protective factor for PPD (OR = 0.88, 95% CI: 0.84–0.92].

Regarding marital status, after controlling for other variables, married mothers exhibited a significantly diminished likelihood of experiencing PPD in comparison to single women (0.141; 95% CI: 0.04–0.494; p  = 0.002). Also, Gebregziabher et al. [ 19 ] reported that there were statistically significant differences in proportions between mothers’ PPD and marital status.

Regarding the mother’s education, in agreement with our study, Ahmed et al. [ 34 ] showed that there was no statistically significant difference between PPD and a mother’s education. While Agarwala et al. [ 29 ] showed that a higher level of mother’s education. increases the risk of PPD, Gebregziabher et al. [ 19 ] showed that the housewives were 0.24 times less likely to develop PPD as compared to the employed mothers (aOR = 0.24, 95% CI: 0.06–0.97; p  = 0.046); those mothers who perceived their socioeconomic status (SES) as low were 13 times more likely to develop PPD as compared to the mothers who had good SES (aOR = 13.33, 95% CI: 2.66–66.78; p  = 0.002).

Regarding the SES or monthly income, while other studies [ 18 , 40 ] found that there was a statistically significant association between PPD mothers and different domains of SES, 34% of depressed women were found to live under low SES conditions in comparison to only 15.4% who were found to live in high SES and experienced PPD. In disagreement with our study, Hairol et al. [ 12 ] demonstrated that the incidence of PPD was significantly p  = 0.01 higher for participants from the low-income group (27.27%) who were 2.58 times more likely to have PDD symptoms (OR: 2.58, 95% CI: 1.23–5.19; p  = 0.01 compared to those from the middle- and high-income groups (8.33%), and low household income (OR = 3.57 [95% CI: 1.49–8.5] increased the odds of PPD [ 41 ].

Adeyemo et al. (2020),and Al Nasr et al. (2020) revealed that there was no significant difference between the occurrence of PPD and socio-demographic characteristics. This difference may be due to a different sample size and ethnicity [ 42 , 43 ]. In agreement with our findings, Abdollahi et al. [ 36 ] demonstrated that after multiple logistic regression analyses, there were increased odds of PPD with a lower state of general health (OR = 1.08 [95% CI: 1.06–1.11]), gestational diabetes (OR = 2.93 [95% CI = 1.46–5.88]), and low household income (OR = 3.57 [95% CI: 1.49–8.5]). The odds of PPD decreased.

Regarding access to health care, in agreement with studies conducted at Gondar University Hospital, Ethiopia [ 18 ], North Carolina, Colorado [ 21 ], Khartoum, Sudan [ 44 ], Asaye et al. [ 45 ], the current study found that participants who did not have free access to the healthcare system were riskier for the development of PPD. the study results may be affected by the care given during the antenatal care (ANC) visits. This can be explained by the fact that PPD was four times higher than that of mothers who did not have ANC, where counseling and anticipatory guidance care are given that build maternal self-esteem and resiliency, along with knowledge about normal and problematic complications to discuss at care visits and their right to mental and physical wellness, including access to care. The increased access to care (including postpartum visits) will increase the diagnosis of PPD and provide guidance, reassurance, and appropriate referrals. Healthcare professionals have the ability to both educate and empower mothers as they care for their babies, their families, and themselves [ 46 ].

Regarding nationality, for PPD mothers of Yemeni nationality compared to those of Egyptian nationality, the aOR is 0.318 (95% CI: 0.123–0.821, p  = 0.018). Similarly, for Syrian nationality in comparison to Egyptian nationality, the aOR is 0.111 (95% CI: 0.0139–0.887, p  = 0.038), and for Iraqi nationality compared to Egyptian nationality, the aOR is 0.241 (95% CI: 0.0920–0.633, p  = 0.004). These findings indicated that, while accounting for other covariates, individuals from the aforementioned nationalities were less predisposed to experiencing PPD than their Egyptian counterparts. These findings can be explained by the fact that, in Egypt, the younger age of marriage, especially in rural areas, poor mental health services, being illiterate, dropping out of school early, unemployment, and the stigma of psychiatric illnesses are cultural factors that hinder the diagnosis and treatment of PPD [ 40 ].

Obstetric, current pregnancy, and infant-related characteristics and their association or predictors of PPD (Tables  2 and 4 )

In the present study, the number of dead children was significantly associated with PPD. This report was supported by studies conducted with Gujarati postpartum women [ 41 ] and rural southern Ethiopia [ 43 ]. This might be because mothers who have dead children pose different psychosocial problems and might regret it for fear of complications developing during their pregnancy. Agarwala et al. [ 29 ] found that a history of previous abortions and having more than two children increased the risk of developing PPD due to a greater psychological burden. The inconsistencies in the findings of these studies indicate that the occurrence of postpartum depression is not solely determined by the number of childbirths.

In obstetric and current pregnancy , there was no significant difference regarding the baby’s age, number of miscarriages, type of last delivery, premature labour, healthy baby, baby admitted to the neonatal intensive care unit (NICU), or feeding difficulties. In agreement with Al Nasr et al. [ 42 ], inconsistent with Asaye et al. [ 45 ], they showed that concerning multivariable logistic regression analysis, abortion history, birth weight, and gestational age were significant associated factors of postpartum depression at a value of p <  0.05.

However, a close association was noted between the mode of delivery and the presence of PPD in mothers, with p  = 0.107. There is a high tendency towards depression seen in mothers who have delivered more than three times (44%). In disagreement with what was reported by Adeyemo et al. [ 41 ], having more than five children ( p  = 0.027), cesarean section delivery ( p  = 0.002), and mothers’ poor state of health since delivery ( p  < 0.001) are associated with an increase in the risk of PPD [ 47 ]. An increased risk of cesarean section as a mode of delivery was observed (OR = 1.958, p  = 0.049) in a study by Al Nasr et al. [ 42 ].

We reported breastfeeding mothers had a lower, non-significant frequency of PPD compared to non-breast-feeding mothers (36.6% vs. 45%). In agreement with Ahmed et al. [ 34 ], they showed that with respect to breastfeeding and possible PPD, about 67.3% of women who depend on breastfeeding reported no PPD, while 32.7% only had PP. Inconsistency with Adeyemo et al. [ 41 ], who reported that unexclusive breastfeeding ( p  = 0.003) was associated with PPD, while Shao et al. [ 40 ] reported that mothers who were exclusively formula feeding had a higher prevalence of PPD.

Regarding postnatal problems, our results revealed that postnatal problems display a significant association with PPD. In line with our results, Agarwala et al. [ 29 ] and Gebregziabher et al. [ 19 ] showed that mothers who experienced complications during childbirth, those who became ill after delivery, and those whose babies were unhealthy had a statistically significant higher proportion of PPD.

Hormone-related contraception methods were found to have a statistically significant association with PPD, consistent with the literature [ 46 ]; this can be explained by the hormones and neurotransmitters as biological factors that play significant roles in the onset of PPD. Estrogen hormones act as regulators of transcription from brain neurotransmitters and modulate the action of serotonin receptors. This hormone stimulates neurogenesis, the process of generating new neurons in the brain, and promotes the synthesis of neurotransmitters. In the hypothalamus, estrogen modulates neurotransmitters and governs sleep and temperature regulation. Variations in the levels of this hormone or its absence are linked to depression [ 19 ].

Participants whose last pregnancy was unplanned were 3.39 times more likely to have postpartum depression (aOR = 3.39, 95% CI: 1.24–9.28; p  = 0.017). Mothers who experienced illness after delivery were more likely to develop PPD as compared to their counterparts (aOR = 7.42, 95% CI: 1.44–34.2; p  = 0.016) [ 40 ]. In agreement with Asaye et al. [ 45 ] and Abdollahi et al. [ 36 ], unplanned pregnancy has been associated with the development of PPD (aOR = 2.02, 95% CI: 1.24, 3.31) and OR = 2.5 [95% CI: 1.69–3.7] than those of those who had planned, respectively.

The psychosocial characteristics and their association with PPD

Mothers with a family history of mental illness were significantly associated with PPD. This finding was in accordance with studies conducted in Istanbul, Turkey [ 47 ], and Bahrain [ 48 ]. Other studies also showed that women with PPD were most likely to have psychological symptoms during pregnancy [ 43 , 44 , 45 , 46 , 47 , 48 , 49 ]. A meta-analysis of 24,000 mothers concluded that having depression and anxiety during pregnancy and a previous history of psychiatric illness or a history of depression are strong risk factors for developing PPD [ 50 , 51 , 52 ]. Asaye et al. [ 45 ], mothers whose relatives had mental illness history were (aOR = 1.20, 95% CI: 1.09, 3.05 0) be depressed than those whose relatives did not have mental illness history.

This can be attributed to the links between genetic predisposition and mood disorders, considering both nature and nurture are important to address PDD. PPD may be seen as a “normal” condition for those who are acquainted with relatives with mood disorders, especially during the CBP. A family history of mental illness can be easily elicited in the ANC first visit history and requires special attention during the postnatal period. There are various risk factors for PPD, including stressful life events, low social support, the infant’s gender preference, and low income [ 53 ].

Concerning familial support and possible PPD, a statistically significant association was found between them. We reported that mothers who did not have social support (a partner or the father of the baby) had higher odds (aOR = 5.8, 95% CI: 1.33–25.29; p  = 0.019) of experiencing PPD. Furthermore, Al Nasr et al. [ 42 ] revealed a significant association between the PPD and an unsupportive spouse ( P value = 0.023). while it was noted that 66.5% of women who received good familial support after giving birth had no depression, compared to 33.5% who only suffered from possible PPD [ 40 ]]. Also, Adeyemo et al. [ 41 ] showed that some psychosocial factors were significantly associated with having PPD: having an unsupportive partner ( p  < 0.001), experiencing intimate partner violence ( p  < 0.001), and not getting help in taking care of their baby ( p  < 0.001). Al Nasr et al. (2020) revealed that the predictor of PPD was an unsupportive spouse (OR = 4.53, P  = 0.049) [ 48 ].

Regarding the perceived stigma, in agreement with our study, Bina (2020) found that shame, stigma, the fear of being labeled mentally ill, and language and communication barriers were significant factors in women’s decisions to seek treatment or accept help [ 53 ]. Other mothers were hesitant about mental health services [ 54 ]. It is noteworthy that some PPD mothers refused to seek treatment due to perceived insufficient time and the inconvenience of attending appointments [ 55 ].

PPD was significantly higher among mothers with financial problems or problems with their husbands. This came in agreement with Ahmed et al. [ 34 ], who showed that, regarding stressful conditions and PPD, there was a statistically significant association with a higher percentage of PPD among mothers who had a history of stressful conditions (59.3%), compared to those with no history of stressful conditions (40.7%). Furthermore, Al Nasr et al. (2020) revealed that stressful life events contributed significantly ( P value = 0.003) to the development of PPD in the sample population. Al Nasr et al. stressful life events (OR = 2.677, p  = 0.005) [ 42 ].

Coping strategies: causes of fearing and not seeking

Feeling at ease discussing mental health topics with one’s husband, family, community, and physician and experiencing cultural stigma or judgment regarding PPD within the community was significantly associated with the presence of PPD. In the current study, there were different reasons for not receiving the treatment, including cultural or traditional beliefs, language or communication barriers, social norms, and geographical or regional disparities in mental health resources. Haque and Malebranche [ 56 ] portrayed culture and the various conceptualizations of the maternal role as barriers to women seeking help and treatment.

In the present study, marital status, nationality, current pregnancy status, healthy baby, postnatal problems, receiving support or treatment for PPD, having awareness of symptoms and risk factors of PPD, suffering from any disease or mental or psychiatric disorder, comfort discussing mental health with family, and experiencing cultural stigma or judgment about PPD in the community were the significant predictors of PPD. In agreement with Ahmed et al. [ 34 ], the final logistic regression model contained seven predictors for PPD symptoms: SES, history of depression, history of PPD, history of stressful conditions, familial support, unwanted pregnancy, and male preference.

PPD has been recognized as a public health problem and may cause negative consequences for infants. It is estimated that 20 to 40% of women living in low-income countries experience depression during pregnancy or the postpartum period. The prevalence of PPD shows a wide variation, affecting 8–50% of postnatal mothers across countries [ 19 ].

Strengths and limitations

Strengths of our study include its multinational scope, which involved participants from six different countries, enhancing the generalizability of the findings. The study also boasted a large sample size of 674 participants, increasing the statistical power and reliability of the results. Standardized measures, such as the Edinburgh Postnatal Depression Scale (EPDS), were used for assessing postpartum depression, ensuring consistency and comparability across diverse settings. Additionally, the study explored a comprehensive range of predictors and associated factors of postpartum depression, including demographic, obstetric, health-related, and psychosocial characteristics. Rigorous analysis techniques, including multiple logistic regression analyses, were employed to identify significant predictors of postpartum depression, controlling for potential confounders and providing robust statistical evidence.

However, the study has several limitations that should be considered. Firstly, its cross-sectional design limits causal inference, as it does not allow for the determination of temporal relationships between variables. Secondly, the reliance on self-reported data, including information on postpartum depression symptoms and associated factors, may be subject to recall bias and social desirability bias. Thirdly, the use of convenience sampling methods may introduce selection bias and limit the generalizability of the findings to a broader population. Lastly, cultural differences in the perception and reporting of postpartum depression symptoms among participants from different countries could influence the results.

Moreover, the variation in sample size and response rates among countries can be attributed to two main variables. (1) The methodology showed that the sample size was determined by considering several parameters, such as allocating proportionately to the mothers who gave birth and fulfilling the selection criteria during the data collection period served by each health center. (2) The political turmoil in Syria affects how often and how well people can use the Internet, especially because the data was gathered using an online survey link, leading to a relatively low number of responses from those areas. (3) Language barrier in Ghana: as we used the Arabic and English-validated versions of the EPDS, Ghana is a multilingual country with approximately eighty languages spoken. Although English is considered an official language, the primarily spoken languages in the southern region are Akan, specifically the Akuapem Twi, Asante Twi, and Fante dialects. In the northern region, primarily spoken are the Mole-Dagbani ethnic languages, Dagaare and Dagbanli. Moreover, there are around seventy ethnic groups, each with its own unique language [ 57 ]. (4) At the end of the data collection period, to avoid seasonal affective disorders, the meteorological autumn season began on the 1st day of September, which may be associated with autumm depressive symptoms that may confound or affect our results. Furthermore, the sampling methods were not universal across all Arabic countries, potentially constraining the generalizability of our findings.

Recommendations

The antenatal programme should incorporate health education programmes about the symptoms of PPD. Health education programs about the symptoms of PPD should be included in the antenatal program.

Mass media awareness campaigns have a vital role in raising public awareness about PPD-related issues. Mass media.

The ANC first visit history should elicit a family history of mental illness, enabling early detection of risky mothers. Family history of mental illness can be easily elicited in the ANC first visit history.

For effective management of PPD, effective support (from husband, friends, and family) is an essential component. For effective management of PPD effectiveness of support.

The maternal (antenatal, natal, and postnatal) services should be provided for free and of high quality The maternal (antenatal, natal, postnatal) services should be provided free and of high quality.

It should be stressed that although numerous studies have been carried out on PPD, further investigation needs to be conducted on the global prevalence and incidence of depressive symptoms in pregnant women and related risk factors, especially in other populations.

Around 14% of the studied mothers had PPD, and the frequency varies across different countries and half of them do not know. Our study identified significant associations and predictors of postpartum depression (PPD) among mothers. Marital status was significantly associated with PPD, with married mothers having lower odds of experiencing PPD compared to single mothers. Nationality also emerged as a significant predictor, with Yemeni, Syrian, and Iraqi mothers showing lower odds of PPD compared to Egyptian mothers. Significant obstetric, current pregnancy, and infant-related predictors included the pregnancy status, the health status of the baby, and the presence of postnatal problems. Among psychological and social predictors, receiving support or treatment for PPD, awareness of symptoms and risk factors, experiencing cultural stigma or judgment about PPD, and suffering from any disease or mental disorder were significantly associated with PPD. Additionally, mothers who were maybe more comfortable discussing mental health with family relatives had lower odds of experiencing PPD.

These findings underscore the importance of considering various demographic, obstetric, psychosocial, and coping factors in the identification and management of PPD among mothers. Targeted interventions addressing these predictors could potentially mitigate the risk of PPD and improve maternal mental health outcomes.

Data availability

Yes, I have research data to declare.The data is available when requested from the corresponding author [email protected].

Abbreviations

Adjusted Odds Ratio

• Postpartum depression

Primary Health Care centers

Socioeconomic Status

program (Statistical Package for Social Science

The Edinburgh Postnatal Depression Scale

The Neonatal Intensive Care Unit

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Acknowledgements

We would like to express our deep thanks to Rovan Hossam Abdulnabi Ali for her role in completing this study and her unlimited support. Special thanks to Dr. Mohamed Liaquat Raza for his role in reviewing the questionnaire. Moreover, we would like to thank all the mothers who participated in this study.

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Department of Public Health and Community Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Samar A. Amer

Department of Family Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Nahla A. Zaitoun

Department of Psychiatry, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Heba A. Abdelsalam

Faculty of Medicine, Al-Azhar University, Damietta, Egypt

Abdallah Abbas

Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Mohamed Sh Ramadan

Hammurabi Medical College, University of Babylon, Al-Diwaniyah, Iraq

Hassan M. Ayal

Hardamout University College of Medicine, Almukalla, Yemen

Samaher Edhah Ahmed Ba-Gais

Department of General Medicine, Shadan Institute of Medical Science, Hyderabad, India

Nawal Mahboob Basha

College of Medicine, Sulaiman Alrajhi University, Albukayriah, Al-Qassim, Saudi Arabia

Abdulrahman Allahham

Department of Virology, Noguchi Memorial Institute for Medical Research, University of Ghana Legon, Accra, Ghana

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Contributions

Conceptualization: Samar A. Amer (SA); Methodology: SA, Nahal A. Zaitoun (NZ); Validation: Mohamed Ramadan Ali Shaaban (MR), Hassan Majid Abdulameer Aya (HM), Samaher Edhah Ahmed Ba-Gais (SG), Nawal Mahboob Basha (NB), Abdulrahman Allahham (AbAl), Emmanuael Boateng Agyenim (EB); Formal analysis: Abdallah Abbas (AA); Data curation: MR, HM, SG, NB, AbAl, NZ, and EB; Writing original draft preparation: SA, Heba Ahmed Abdelsalam (HAA), and NZ; Writing review and editing: MR, AA, Walid Amin Elshrowby (WE); Visualization: SA, AA; Supervision: SA; Project administration: AA. All authors have read and agreed to the published version of the manuscript.

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All participants were provided with electronic informed consent after receiving clear explanations regarding the study’s objectives, data confidentiality, voluntary participation, and the right to withdraw. The questionnaire did not contain any sensitive questions, and data collection was performed anonymously. We affirm that all relevant ethical guidelines have been adhered to, and any necessary approvals from the ethics committee have been obtained. Approval was received from the ethical committee of the family medicine department, the faculty of medicine at Zagazig University, and from the patients included in the study. IRP#ZU-IRP#11079-8/10-2023.

Practicing ethical decision-making is crucial for providing clinical treatment. Such decisions are frequently made challenging due to a lack of knowledge and the mother’s ability to handle the associated complexities and uncertainties that affect the patient’s current level of functioning and ability to take care of her child. At the end of the survey, we raised concerns regarding the red flags, such as suicidal thoughts, and called for a revisit for the psychiatrist’s evaluation of the discussion of the risks, benefits, and alternatives to using medication.

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Amer, S.A., Zaitoun, N.A., Abdelsalam, H.A. et al. Exploring predictors and prevalence of postpartum depression among mothers: Multinational study. BMC Public Health 24 , 1308 (2024). https://doi.org/10.1186/s12889-024-18502-0

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Prevalence of depression and associated symptoms among patients attending primary healthcare facilities: a cross-sectional study in Nepal

• Nagendra P. Luitel 1 , 2 , 3 ,
• Bishnu Lamichhane 2 ,
• Pooja Pokhrel 2 ,
• Rudrayani Upadhyay 2 ,
• Tatiana Taylor Salisbury 4 ,
• Makhmud Akerke 4 ,
• Kamal Gautam 2 , 3 ,
• Mark J. D. Jordans 2 , 4 ,
• Graham Thornicroft 4 , 5 &
• Brandon A. Kohrt 2 , 3  

BMC Psychiatry volume  24 , Article number:  356 ( 2024 ) Cite this article

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Depression is a prevalent mental health condition worldwide but there is limited data on its presentation and associated symptoms in primary care settings in low- and middle-income countries like Nepal. This study aims to assess the prevalence of depression, its hallmark and other associated symptoms that meet the Diagnostic and Statistical Manual (DSM-5) criteria in primary healthcare facilities in Nepal. The collected information will be used to determine the content of a mobile app-based clinical guidelines for better detection and management of depression in primary care.

A total of 1,897 adult patients aged 18–91 (63.1% women) attending ten primary healthcare facilities in Jhapa, a district in eastern Nepal, were recruited for the study between August 2, 2021, and March 25, 2022. Trained research assistants conducted face-to-face interviews in private spaces before the consultation with healthcare providers. Depression symptoms, including hallmark symptoms, was assessed using the validated Nepali version of the Patient Health Questionnaire (PHQ-9).

One in seven (14.5%) individuals attending primary health care facilities in Jhapa met the threshold for depression based on a validated cut-off score ( > = 10) on the PHQ-9. The most commonly reported depressive symptoms were loss of energy and sleep difficulties. Approximately 25.4% of women and 18.9% of men endorsed at least one of the two hallmark symptoms on the PHQ-9. Using a DSM-5 algorithm (at least one hallmark symptom and five or more total symptoms) to score the PHQ-9, 6.3% of women and 4.3% of men met the criteria for depression. The intra-class correlation coefficient for PHQ-9 total scores by health facility as the unit of clustering was 0.01 (95% confidence interval, 0.00-0.04).

Depression symptoms are common among people attending primary healthcare facilities in Nepal. However, the most common symptoms are not the two hallmark criteria. Use of total scores on a screening tool such as the PHQ-9 risks overestimating the prevalence and generating false positive diagnoses. Compared to using cut off scores on screening tools, training health workers to first screen for hallmark criteria may increase the accuracy of identification and lead to better allocation of treatment resources.

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Introduction

Depression is a significant global health issue, particularly in low- and middle-income countries (LMICs) where the majority of people with depression live [ 1 ]. However, it often goes unnoticed in these countries. To address this, the task-sharing approach has been proposed [ 2 ], which involves training non-specialist healthcare providers to deliver mental health interventions in community settings. The World Health Organization (WHO) has developed the mental health gap action program (mhGAP) and implementation guide [ 3 ] to support this approach, which has been successfully implemented in over 90 countries [ 4 ]. Despite this, the detection rate of mental disorders by trained primary healthcare providers remains low, both in LMICs [ 5 ] and high-income countries [ 6 ].

In Nepal, only 24% of depression cases were detected by trained primary healthcare workers immediately after mhGAP-based training [ 7 ]. This raises concerns about the effectiveness of integrating mental health services into primary healthcare systems, especially considering that depression is a common condition in primary care [ 8 ]. To improve detection rates, routine screening for depression in primary care has been shown to be effective [ 9 ]. Various screening tools, such as the Patient Health Questionnaires (PHQ-9, PHQ-2) and the WHO Well-Being Index (WHO-5), have been recommended for use in primary care. However, their sensitivity in cross-cultural settings has not been widely evaluated [ 10 ]. Additionally, using PHQ-9 as a universal screener may not be feasible in LMICs due to limited resources. Using a mobile app-based clinical guide could be a potential strategy to enhance the detection of depression in primary care. Moreover, the severity of the individual item of PHQ-9 could help to determine the content of the mobile application because the DSM-PHQ algorithm closely aligns with the functionality of the app.

The purpose of this paper is to examine the prevalence of depression, its hallmark symptoms (depressed mood and anhedonia), and other related symptoms (e.g., fatigue, worthlessness, sleep disturbances) that meet Diagnostic and Statistical Manual (DSM-5) criteria in primary healthcare facilities in Nepal. The paper also seeks to identify factors associated with depression in order to estimate the target population in need of clinical services. Furthermore, the paper will investigate the most frequently reported symptoms of depression to inform the development of a mobile app-based clinical guideline for improved detection and management of depression in primary care.

This study was conducted as part of the Emilia (E-mhGAP Intervention guide in Low and middle-income countries: proof-of-concept for Impact and Acceptability) project, funded by UK Medical Research Council. The project aims to develop and test the feasibility and acceptability of a mobile-app-based clinical guide to improve the detection of depression in primary care [ 11 ]. The mobile app provides healthcare providers with the necessary information to assess, treat, and follow- up with individuals with depression. It follows the same protocol and decision trees as the paper version of the WHO mhGAP-IG V2 [ 12 ].

This study was a population-based cross-sectional health facility survey conducted prior to training primary health care workers in mobile app-based clinical guidelines. It was conducted between August 2, 2021 and March 25, 2022 in Jhapa, a district in eastern Nepal. The total population of Jhapa district is 998,054, with females accounting for more than half (52.1%) [ 13 ]. Nepal is one of the poorest countries in South-Asia, ranking 143rd out of 191 countries on the United Nations’ Human Development Index [ 14 ]. The country has a total population of approximately 29.1 million with 6, 666, 937 households.

In Nepal, Community Health Units (CHUs), Basic Health Service Centers (BHCs) in rural areas and Urban Health Centers (UHCs) in urban areas serve as the initial point of contact for basic health services. Health Posts (HPs) are the next level in the health care system. The third tier of health care consists of Primary Health Care Centers (PHCCs), which are higher- level facilities established in each electoral area as the first referral point. The municipal and district hospital are the highest-level healthcare institution within a district. The District Public Health Office (DPHO) or District Health Office (DHO) is responsible for coordinating health care activities in a specific district area [ 15 ]. There are 6 hospitals, 4 PHCCs, 42 HPs, 5 CHUs, 18 UHCs, 61 BHSCs in Jhapa district [ 16 ]. The study was conducted in two municipal hospitals, three PHCCs and five HPs. These health facilities offer primary healthcare services under the local government’s control. These health facilities were selected based on factors such as patient flow, accessibility, reasonable travel distance and availability of internet connectivity and electricity supply.

Sample size and sampling

The study was conducted with randomly selected adults who attended primary health care facilities during the data collection period. The sample size was determined to allow the detection of change in diagnosis of depression in the primary health facilities between the baseline and subsequent follow-up studies. The sample size was determined based on previous data regarding primary care service utilization and depression screening rates [ 7 ]. We aim to screen approximately 50% of adult patients in primary care, with the potential to increase this percentage depending on patient flow. Our plan is to screen around 200 patients per arm per month, totaling 400 patients in the 1-month pre-training enrollment period and 1200 patients per country in the 3-month post-training enrollment period. This sample size will allow us to detect a 43% increase in the clinical case identification rate within each arm using the e-mhGAP-IG, with 90% power at a 5% significance level, assuming an intra-class correlation coefficient of 0.02 [ 11 ].

The inclusion criteria for participation in the study were: 18 years of age or above, fluent in Nepali language, time and availability to complete full survey which was administered orally by research assistants, and willingness to provide informed consent. Those who were incapable of providing informed consent because of an acute medical cause were excluded from the study.

We invited all eligible individuals at the health facility to participate in the study. The inclusion criteria for participation were being 18 years or older, fluent in Nepali, residents of selected municipalities/rural municipalities, and able to provide informed consent. We interviewed all eligible adults who entered into the health facilities and randomly selected one participant when multiple individuals were present simultaneously. Field research assistants created a list of eligible participants upon entering the clinic and then randomly selected a participant by drawing a name from the list using a piece of paper. Interviews were conducted with the selected participant before their consultation. Due to low client flow caused by COVID-19 restrictions, with only one participant visiting at a time, most participants were recruited individually without the need for randomization. Exclusion criteria included the inability to provide informed consent or currently experiencing an acute medical issue. Field research assistants conducted interviews with the consenting participants while they were waiting for health-care services.

Instruments

The nine-item Patient Health Questionnaire (PHQ-9), a widely used tool for assessing depression, was used to assess depression [ 17 ]. Participants score nine common symptoms of depression based on their experience over the previous 2 weeks. It has a 4-point rating scale that ranges from 0 ‘not at all’ to 3 ‘always’. The first two items are the depression hallmark symptoms (depressed mood and anhedonia). At least one of these symptoms is required according to the DSM-5 to make a diagnosis of major depressive episode. The remaining seven items on the PHQ-9 are associated symptoms (e.g., fatigue, worthlessness, sleep disturbances). To meet DSM-5 criteria on the PHQ-9, at least one hallmark symptoms is required and 5 of the 9 total symptoms are required. The PHQ-9 has been culturally adapted, translated, and validated in Nepal [ 18 ]. The validation study determined that sum score cutoff of ≥ 10 had sensitivity = 0.94, specificity = 0.80, positive predictive value (PPV) = 0.42, negative predictive value (NPV) = 0.99, positive likelihood ratio = 4.62 and negative likelihood ratio = 0.07 when compared with a diagnosis of depression made using the Composite International Diagnostic Interview (CIDI) [ 18 ].

Data collection

A two-and-a-half-week training was provided to nine field research assistants for data collection. The training focused on the basics of structured interviewing, study population, sample size and sampling procedure. The training also focused on instruments, scoring, referral system and inclusion/exclusion criteria. Various pre-tests and mock interviews were conducted during the training period to assess the confidence level of the research assistants and whether the instruments correctly measured the symptoms of depression and impact in daily functioning. The research assistants visited each health facility, gauged inclusion/exclusion criteria, obtained written informed consent, and conducted the interviews in a confidential space, either in a spare room within the health facilities or an open ground. Android tablet with a questionnaire application was used for data collection.

Data was collected using an Android tablet with a system in place to minimize missing data and outliers. As a result, there were no missing data points in the dataset. Descriptive statistics were used to report on the socio-demographic characteristics such as age, sex, education, caste/ethnicity, occupation, marital status, religion, number of family members in the household and sufficiency of foods. We presented percentages of the patients who met threshold level for depression based on the Nepali validated cut-off score of PHQ-9 [ 18 ], DSM hallmark symptoms (depressed mood or anhedonia) on the PHQ-9 and DSM algorithm. We tested associations between depression with pre-defined risk factors such as age, sex, education, occupation, caste/ethnicity, marital status, number of family members in the household and food sufficiency in the family. We performed bi-variate and multivariate logistic regression to assess the association between depression and socio-demographic and economic characteristics of the participants. The statistical analysis was performed using the Statistical Package for Social Science IBM SPSS-28 [ 19 ].

In total, 1,914 people were approached for participation in the study. 1,897 participants consented to participate and completed the assessments. The majority were female (63.1%). The age of the participants ranged from 18 to 91 years with a mean age of 48.8 years. Most of the participants were between the age of 25 to 59 (58.3%), having secondary or higher level of education (29.5%), currently married (79.6%), and were Brahman/Chhetri (60.8%).

Table  1 shows that the prevalence of depression was higher among female (16.5%), illiterate (17.1%), unemployed (22.6%) and widow/widower/separated (24.5%) participants, as well as those from Janajati (ethnic minority groups, 18.2%); and smaller household size (participants having 1 to 4 members in the family (17.6%).

Prevalence of depression

Figure  1 presents the percentage of participants who met threshold for depression based on the locally validated PHQ-9 cut-off sum score, DSM major depressive disorder (MDD) hallmark symptoms and DSM MDD criteria (anhedonia symptoms). The result shows that 14.5% of the participants met threshold for depression based on the PHQ-9 cut-of scores. Hallmark symptoms of depression (depressed mood or anhedonia) were reported by 25.4% of women and 18.9% of men. The prevalence of depression was higher among women in all three measurements i.e. PHQ-9 cut-off (16.5%), hallmark symptoms (25.4%) and DSM-algorithm scoring of PHQ-9 (6.3%).

Table  2 presents item analysis of each PHQ-9 item and DSM hallmark symptoms for male and female participants. The most commonly experienced symptoms (most of the time or always) of depression reported by both male and female patients were little energy (female, 34.1%, and male, 29.3%), sleep difficulties (female, 20.7% and male, 16.6%), and little interest or pleasure/anhedonia (female, 15.1%, and male, 11.7%). These symptoms were significantly more frequent among females. Similarly, DSM hallmark symptoms were also frequent among female patients.

Table  3 presents the variables associated with depression in bivariate and multivariate logistic regression models. The prevalence rate of depression varied based on sex, level of education, caste/ethnicity, marital status and number of family members in the household in the bivariate model. Level of education lost its significance level in the multivariate model. Females (OR 1.65) and people from Janajati ethnic minority groups (OR 1.48) had significantly higher risk of depression compared to males and Brahman/Chhetri, respectively. On the other hand, participants who were married (OR 0.57), had 5 to 7 members in the family (OR 0.70) or had more than 7 members in the family (OR 0.54) had a reduced risk for depression (Table  3 ).

Intra-class correlation

The intra-class correlation coefficient (ICC) for the PHQ-9 was calculated with the health facility as the unit of clustering. The ICC was calculated to inform sample size calculations for determining the number of health facilities and number of participants for evaluating the effectiveness of the e-mhGAP app in a future fully-powered trial. The ICC for PHQ-9 total scores across the ten health facilities with the participants collected at baseline (n=537) was 0.01 (95% CI, 0.00-0.04). 

The results of this study indicate that one in seven people attending primary health care facilities in Jhapa met threshold for depression when using a total sum approach with all items of the PHQ-9 based on a locally validated cut-off. The prevalence of depression using sum scores was significantly higher among females compared to males. The most commonly reported symptoms of depression were low energy, sleep difficulties and lack of interest or pleasure. There was a significant difference in the reported symptoms of depression between males and females with females reporting depressive symptoms more frequently. At least one DSM-5 hallmark symptom (depressed mood or anhedonia) was reported by one out of four women and one out of five men. When using the DSM-5 algorithm for scoring the PHQ-9, the prevalence of depression was approximately one out of 20 patients in primary care. This raises a concern that using a total sum score on a screening tool to make a diagnosis could lead to a three-fold overestimation of the prevalence of depression in primary care.

The prevalence rate of depression reported in our study (14.5%) is consistent with or slightly higher than the rates reported in a recent systematic review of studies conducted with patients in primary care settings in low- and middle-income countries using the same PHQ-9 cut-off score [ 5 ]. However the prevalence rate in our study is much lower than the prevalence reported among people attending primary healthcare services in Saudi Arabia [ 20 ], Malawi [ 21 ], India [ 22 , 23 ], Nigeria [ 24 ] and Sri Lanka [ 25 ], all of which use a PHQ-9 sum score approach.

The prevalence of depression in our study is comparable to the prevalence of depression identified among people attending primary care [ 26 ] and general adults in Chitwan, Nepal [ 27 ]. However, it is much lower than the prevalence reported among populations in Nepal affected by natural disasters [ 28 ] and conflict [ 29 , 30 , 31 ]. Similarly, the prevalence rate reported in our study is slightly lower or comparable to the prevalence rate reported among a nationally representative sample of the adult population in Nepal [ 32 ]. However, our prevalence rate is higher than the prevalence of depression reported in the national mental health survey in Nepal, which was only 2.9%; this national prevalence study used the Mini International Neuropsychiatric Interview (MINI) which was not culturally adapted or clinically validated in Nepal [ 33 ]. The discrepancy in reported prevalence rates of depression between our study and the national mental health survey may be attributed to the use of a non-validated tool in the national survey and the study setting differences. Our study is facility-based, whereas the national mental health survey is community-based. Additionally, factors such as sample size, sampling strategies, and cultural sensitivity of the instruments used to assess depression may have contributed to the wide variation in the prevalence of depression in Nepal [ 34 ].

There were no significant associations between age, occupation, religion and food sufficiency in the family and the prevalence of depression. The Janajati caste/ethnic group had a significantly higher prevalence of depression compared to Brahman/Chhetri. Similarly, married participants and those with more than five members in the family had a lower prevalence of depression. Female participants (16.5%) had a significantly greater risk of depression than males (11.1%) which is consistent with previous studies conducted with the general population [ 29 , 30 , 35 ] and the population seeking care from primary healthcare facilities in Nepal [ 26 ]. The higher prevalence of depression among females could be due to the nature and amount of work females perform. In Nepal, males often do not involve themselves in domestic work while women are expected to look after the family and perform household chores even if they are employed [ 36 ]. Our results are consistent with studies conducted among primary healthcare attendees in Delhi and Haryana, India [ 22 , 23 ], Nigeria [ 24 ] and Sri Lanka [ 37 ].

Other factors associated with depression were the number of family members, marital status and caste/ethnicity. Married participants had a lower risk for depression which is consistent with a previous study conducted in Chitwan, Tanahu and Dang [ 29 ]. Our findings are consistent with the study in Saudi Arabia [ 20 ]. There was no significant association between depression and age, occupation and religion of the participants which is consistent with the study conducted among the help-seeking population in Chitwan [ 26 ].

The results of this study have several implications for improving the detection and management of depression in primary healthcare facilities in Nepal.

First, the results of this study can be used as baseline data for evaluating the services provided by trained primary health care workers. Similarly, the intra-class correlation coefficient reported in this study can be used to estimate the sample size (i.e., number of health facilities, number of patients) for future randomized controlled trial to evaluate the effectiveness of mobile app-based clinical guides.

Second, the results show that some symptoms of depression included in the PHQ-9 are highly prevalent among participants, and there was a significant difference in reporting those symptoms between males and females. If the mobile app-based clinical guide includes the commonly reported symptoms, this could help to increase patient engagement, overall detection, and the accuracy of detection of depression across all primary healthcare facilities in Nepal. The mobile app should also ensure that primary care workers screen for the hallmark symptoms to avoid over-diagnosis of depression.

Third, prior evidence shows that people with depression are more likely to contact primary healthcare workers rather than mental health specialists [ 8 ]. The low detection rate of depression by the trained primary healthcare workers in Nepal could be because of the words used by the healthcare workers during consultations. In our previous study, we found a significant increase in the prevalence of depression after changing the wording in the consent form (i.e. using heart-mind problems instead of mental health problems or mental illness) [ 38 ]. The idioms related to mental illness (manasik rog or manasik samasya) are understood as problems associated with the brain-mind, and are often perceived as incurable. Therefore, individuals may be less likely to endorse symptoms out of fear of stigma. On the other hand, the idioms related to the heart-mind (man ko samasya) are understood as something that can be healed and are generally socially acceptable to discuss [ 39 ]. Detection of depression might be increased if more culturally acceptable idioms are included in the mobile application.

Finally, the results of this study can be helpful to policy makers responsible for planning and implementing mental health services in primary care. The prevalence rate reported in this study can be used to allocate resources for training and supervision of healthcare workers and procurement of psychotropic medications in different municipalities.

There are several limitations to our study that should be acknowledged. First, the study was conducted in 10 primary healthcare facilities in Jhapa district with high patient flow; therefore, the results may not be generalizable to the entire population of Nepal. Second, the PHQ-9 which was used to screen patients for depression, has been found to have a high rate of false positives (6 false positives for every 10 patients screening positive for depression) [ 18 ]. Therefore, the prevalence rate reported in our study may be higher than the actual prevalence in the population. To minimize false positive cases, it is recommended to use tiered algorithms and provide regular clinical supervision to trained primary healthcare workers [ 18 ]. Third, our study was conducted during the COVID-19 pandemic, which may have influenced the prevalence of depression. Finally, we relied on self-report measures which may have increased the likelihood of bias. Self-report measures have been shown to predict inflated rates of mental health problems [ 34 ].

Depression symptoms are common among people attending primary healthcare facilities in Nepal. However, the most common symptoms do not always align with the two hallmark criteria. Relying solely on total scores from screening tools like the PHQ-9 may lead to an overestimation of prevalence and false positive diagnoses. Training health workers to first screen for hallmark criteria could improve accuracy and help allocate treatment resources more effectively. Additionally, enhancing the capacity of healthcare providers to identify and manage depression in primary healthcare facilities using a mobile app-based clinical guide may increase the detection rate of depression if the app includes the most commonly reported symptoms of depression by the participants in this study.

Data availability

Interested parties may notify the EMILIA (E-mhGAP Intervention guide in Low and middle-income countries: proof-of-concept for Impact and Acceptability) investigators of their interest in collaboration, including access to the data-set analyzed here, through the following email: [email protected].

Abbreviations

Basic Health Service Center

Community Health Unit

District health office

Diagnostic and Statistical Manual

Health Post

Low and Middle Income Countries

Major Depressive Disorder

mental health Gap Action Program

Primary Health Care Center

Patient Health Questionnaire

Urban Health Center

United Kingdom

World Health Organization

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Acknowledgements

We want to thank Mr. Gobinda Koirala, and research assistants of TPO Nepal for their support in data collection. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. NPL is supported by National Institute for Health Research (NIHR) and Wellcome Trust under the NIHR-Wellcome Partnership for Global Health Research [grant reference 222001/Z/20/Z]. GT is supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London) at King’s College Hospital NHS Foundation Trust. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. TTS is funded by UK Research and Innovation [MR/T019662/1]. GT and TTS are also supported by the UK Medical Research Council (UKRI) for the Indigo Partnership (MR/R023697/1) awards. For the purpose of open access, the author has applied a Creative Commons Attribution (CC BY) licence (where permitted by UKRI, ‘Open Government Licence’ or ‘Creative Commons Attribution No-derivatives (CC BY-ND) licence’ may be stated instead) to any Author Accepted Manuscript version arising.

This study is funded by the UK Medical Research Council in relation to the Emilia Project (MR/S001255/1). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The authors had full control of all primary data.

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Nagendra P. Luitel, Bishnu Lamichhane, Pooja Pokhrel, Rudrayani Upadhyay, Kamal Gautam, Mark J. D. Jordans & Brandon A. Kohrt

Center for Global Mental Health Equity, Department of Psychiatry and Behavioural Health, George Washington University, Washington, D.C, USA

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NPL, GT, BAK, MJD and TTS were responsible for the study design. NPL, PP and BL were responsible for supervision of data collection. NPL and BL performed data analysis. NPL, BL and RU drafted the first version of the manuscript; all authors reviewed and revised the manuscript. All authors read and approved the final manuscript.

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Luitel, N.P., Lamichhane, B., Pokhrel, P. et al. Prevalence of depression and associated symptoms among patients attending primary healthcare facilities: a cross-sectional study in Nepal. BMC Psychiatry 24 , 356 (2024). https://doi.org/10.1186/s12888-024-05794-0

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A Systematic Review of Grief and Depression in Adults

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

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Olivia Guy-Evans, MSc

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Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

Although grief is a normal response to loss, it is a complex and multidimensional process that can involve a wide range of distressing symptoms and significantly affect an individual’s functioning. People respond to death in diverse ways, both adaptively and maladaptively, and these reactions are highly personalized. During this time, bereaved individuals engage in tasks such as accepting the reality of the loss, managing emotional distress, adjusting to life without the deceased, and eventually letting go of the emotional attachment to the person who has died.

• This systematic review synthesized findings on depression and grief in adults, aiming to identify specificities of depression in grief and whether grief varies based on the type of loss.
• Factors like gender, education level, socioeconomic status, age of the deceased, cause of death, and time since loss significantly affect grief outcomes and the development of depression.
• The research, while enlightening, has limitations, such as the inability to isolate depression from other grief symptoms in some studies and variation in the types of losses examined.
• Understanding the relationship between grief and depression is universally relevant, as most people will experience the loss of a loved one and may be at risk for negative mental health outcomes.

Grief is a profound life experience that can lead to complications like depression for bereaved individuals. Depressive symptoms place a heavy burden on societal resources (Moreira et al., 2023).

Previous research has shown significant overlap between grief and depression in terms of symptoms, characteristics, family history, and response to medication (Kendler et al., 2008; Lamb et al., 2010; Zisook & Kendler, 2007; Zisook et al., 2001, 2007).

Increasing evidence indicates losing a loved one can lead to prolonged grief disorder and depressive symptoms/syndromes (Bonanno et al., 2007; Prigerson et al., 2009; Shear et al., 2011).

This systematic review aimed to synthesize findings on depression and grief to identify specificities of depression in grief and factors influencing grief outcomes.

Understanding the distinctions between grief and depression has important implications for the mental and physical health of bereaved individuals.

This systematic review followed PRISMA guidelines. Studies were identified through searching EBSCO, PubMed, and Web of Science databases.

• Search terms included variations of “depression,” “grief,” “bereavement,” and “mourning.”
• Inclusion criteria were having a grief sample and depression measures.
• Exclusion criteria included case studies, theoretical essays, reviews, instrument validations, not examining grief and depression, non-bereaved samples, and low study quality.

41 studies published between 1939-2021 were included. Two independent reviewers selected studies with almost perfect agreement (Cohen’s κ = .86). Study quality was assessed with the Quantitative Research Assessment Tool.

The search equation used variations of the key terms in the databases:

• EBSCO: TI (depress* OR mood disorder) AND TI (mourn* OR grief OR bereave* OR death OR loss)
• PubMed: (depress [Title] OR mood disorder[Title]) AND (mourn [Title] OR grief[Title] OR bereave* OR death[Title] OR loss)
• Web of Science: TI=(depress* OR mood disorder) AND TI=(mourn* OR grief OR bereave* OR death OR loss)

Studies can be grouped into two categories based on time of loss, namely grief during pregnancy or grief of a close relative

• After spontaneous abortion, women experienced more grief and depressive symptoms than their male partners. Childless women and those with infertility had higher grief.
• After miscarriage, 26.6% of women who met grief criteria also had depressive episodes.
• Grief symptoms decreased over a year after pregnancy loss, but depressive symptoms increased around 6 months for women who experienced sudden losses.
• Negative cognitions predicted grief 16-19 months after a perinatal death. Having more children was associated with less depression.

Early Childhood

• Infant death was associated with increased depression and psychosis-like experiences in mothers.
• 34% of caregivers had clinically significant depressive symptoms 3 months after losing a loved one.

Childhood/Adolescence

• 30% of bereaved parents had depression 5 years after a child’s cancer death vs. 14% of parents whose child survived. Mothers had more depression than fathers.
• Parental grief was predicted more by couple-level factors while depression was predicted more by individual factors. Traumatic child deaths led to more parental grief.

Adults/Elderly

• In gay men who lost a friend to AIDS, grief and depression were distinct. Depression was predicted by negative affect, health concerns, and loneliness. Grief was predicted by number of AIDS losses.
• 16% met criteria for complicated grief (CG) 1-2 years after losing a friend/relative. Relationship depth predicted CG while dependence predicted depression.
• Pre-loss grief, being a partner, and low education predicted post-loss CG and depression in caregivers.
• Violent deaths led to more depression, especially in females. CG and depression decreased over time after loss. More years since loss was associated with less depression in elders.

This review provides insights into the complex relationship between grief and depression after different types of losses.

While there is overlap, they emerge as distinct responses – certain factors uniquely predict grief (e.g., relationship depth, couple-level factors), while others uniquely predict depression (e.g., personal vulnerabilities, less time since loss).

Gender, education level, socioeconomic status, age of the deceased, cause of death, and time since loss are significant factors that influence grief outcomes and the development of depression following bereavement.

Research has shown that women often experience more intense grief and depressive symptoms compared to men, particularly in cases of miscarriage or child loss. Lower levels of education and socioeconomic status have been associated with a higher risk of complicated grief and difficulty coping with loss.

The age of the deceased also plays a role, with the loss of a child or younger individual often leading to more severe grief reactions compared to the loss of an older person.

Sudden, traumatic, or violent causes of death, such as accidents, homicide, or suicide, can result in more complicated grief and depression compared to losses due to natural causes or prolonged illness.

Finally, the time elapsed since the loss is a significant factor, as grief and depressive symptoms tend to decrease over time as individuals adjust to their new reality.

However, for some, grief may remain intense and prolonged, leading to complicated grief or persistent depression. Understanding these factors can help identify individuals at higher risk for adverse grief outcomes and inform targeted interventions.

Future research could further examine how the predictors of grief and depression vary depending on kinship to the deceased and expand to include more diverse causes of death.

• Followed PRISMA guidelines for systematic reviews
• Broad search of multiple databases
• Rigorous inclusion/exclusion criteria
• Independent reviewer selection of studies with high inter-rater reliability
• Assessed study quality with a standardized tool
• Examined grief and depression in response to various types of losses across the lifespan

Limitations

• Some included studies could not statistically isolate depression from other grief symptoms
• High variability in the types of losses and kinship of bereaved individuals across studies
• Conclusions may be limited by the demographics of study samples and countries where research was conducted
• Cross-sectional and retrospective designs of some studies prevent causal conclusions

Clinical Implications

The results have significant real-world implications, especially for clinical practice.

Understanding risk factors for intense, prolonged grief and depression can help practitioners identify bereaved clients who may need more support.

For example, those with prior depression/mental health issues, traumatic losses, or fewer coping resources may be more vulnerable.

Screening for complicated grief (CG) is important since it is underpinned more by interpersonal factors and may not respond to depression treatments.

Distinguishing between grief and depression is important for intervention and treatment, as grief is a normal response while depression may be more likely in individuals with certain vulnerabilities. However, some individuals with vulnerabilities may have a decreased ability to grieve.

The findings also suggest value in dyadic and family interventions since couple/family dynamics can influence grief. Gender differences imply the potential benefits of tailoring treatments.

Broadly, the review underscores the need to recognize the long-term impacts of bereavement, as grief and depressive symptoms can persist for years. Societal resources should be allocated to make bereavement support accessible.

More public education on the range of normal grief responses may help destigmatize the grief experience.

Primary reference

Moreira, D., Azeredo, A., Moreira, D. S., Fávero, M., & Sousa-Gomes, V. (2022). Why Does Grief Hurt?.  European Psychologist, 28 (1), 35–52. https://doi.org/10.1027/1016-9040/a000490

Other references

Bonanno, G. A., Neria, Y., Mancini, A., Coifman, K. G., Litz, B., & Insel, B. (2007). Is there more to complicated grief than depression and posttraumatic stress disorder? A test of incremental validity. Journal of Abnormal Psychology, 116 (2), 342–351. https://doi.org/10.1037/0021-843x.116.2.342

Kendler, K. S., Myers, J., & Zisook, S. (2008). Does bereavement-related major depression differ from major depression associated with other stressful life events? American Journal of Psychiatry, 165 (11), 1449-1455. https://doi.org/10.1176/appi.ajp.2008.07111757

Lamb, K., Pies, R., & Zisook, S. (2010). The bereavement exclusion for the diagnosis of major depression: To be or not to be. Psychiatry, 7 (7), 19-25.

Moreira, D., Azeredo, A., Moreira, D.S., Fávero, M., & Sousa-Gomes, V. (2023). Why does grief hurt? A systematic review of grief and depression in adults. European Psychologist, 28 (1), 35-52. https://doi.org/10.1027/1016-9040/a000490

Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, K., Raphael, B., Marwit, S. J., Wortman, C., Neimeyer, R. A., Bonanno, G. A., Block, S. D., Kissane, D., Boelen, P., Maercker, A., Litz, B. T., Johnson, J. G., First, M. B., & Maciejewski, P. K. (2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine, 6 (8), Article e1000121. https://doi.org/10.1371/journal.pmed.1000121

Shear, M. K., Simon, N., Wall, M., Zisook, S., Neimeyer, R., Duan, N., Reynolds, C., Lebowitz, B., Sung, S., Ghesquiere, A., Gorscak, B., Clayton, P., Ito, M., Nakajima, S., Konishi, T., Melhem, N., Meert, K., Schiff, M., O’Connor, M., … Keshaviah, A. (2011). Complicated grief and related bereavement issues for DSM-5. Depression and Anxiety, 28 (2), 103–117. https://doi.org/10.1002/da.20780

Zisook, S., & Kendler, K. S. (2007). Is bereavement-related depression different than non-bereavement-related depression?. Psychological Medicine, 37 (6), 779-794. https://doi.org/10.1017/S0033291707009865

Zisook, S., Shuchter, S. R., Pedrelli, P., Sable, J., & Deaciuc, S. C. (2001). Bupropion sustained release for bereavement: Results of an open trial. Journal of Clinical Psychiatry, 62 (4), 227-230. https://doi.org/10.4088/jcp.v62n0403

Zisook, S., Shear, K., & Kendler, K. S. (2007). Validity of the bereavement exclusion criterion for the diagnosis of major depressive episode. World Psychiatry, 6 (2), 102-107.

Keep Learning

• What factors do you think might influence how an individual responds to and copes with the death of a loved one? How could cultural background play a role?
• This review found some gender differences in grief and depression. Why do you think men and women may respond differently to loss? What are the implications for providing support?
• Imagine someone close to you experienced a significant loss one year ago. Based on the findings, what signs might indicate they are struggling with complicated grief and could benefit from professional help?
• The results suggest grief and depression are distinct but overlapping responses. How would you explain the difference between grief and depression to a friend who recently lost a loved one?
• Many of the studies used self-report measures of grief and depression symptoms. What are the strengths and limitations of this type of data? What other methods could provide useful insights?
• No single theory can fully explain the range of grief responses. What are some different theoretical perspectives on the grieving process? How could integrating them help us better understand the complexity of coping with loss?

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Incidence of depression among community-dwelling older adults: A systematic review

Affiliations.

• 1 Postgraduate Program in Collective Health, Federal University of Rio Grande do Norte (UFRN), Natal, Brazil.
• 2 Multicampi School of Medical Sciences, Federal University of Rio Grande do Norte (UFRN), Caicó, Brazil.
• 3 Department of Collective Health, Graduate Program in Collective Health, Federal University of Rio Grande do Norte, Natal, Brazil.
• 4 Graduate Program in Health Sciences, Federal University of Rio Grande do Norte, Natal, Brazil.
• 5 Research group on Methodology, Methods, Models and Outcomes of Health and Social Sciences (M3O), Faculty of Health Sciences and Welfare, Center for Health, and Social Care Research (CESS), University of Vic-Central University of Catalonia (UVic-UCC), Vic, Spain.
• 6 Institute for Research and Innovation in Life and Health Sciences in Central Catalonia (IRIS-CC), Vic, Spain.
• PMID: 38263357
• DOI: 10.1111/psyg.13081

We aimed to synthesise information related to the incidence of depression and depressive symptoms (DDS) in a community-dwelling older adult population at a global level. In this systematic review, we included articles with a cohort study design that evaluated the incidence of depression or depressive symptoms in older adults aged 60 years or more in a community-dwelling environment. Six databases were used: Web of Science, PubMed, Scopus, LILACS, SciELO, and Cochrane, and the entire selection process was independently performed by peers. We divided the included articles into subgroups according to the DDS assessment instrument: (i) Geriatric Depression Scale; (ii) Center for Epidemiologic Studies Depression Scale; (iii) miscellaneous scales; and (iv) diagnostic interviews. Each cumulative incidence value obtained per item was adjusted for a 1-year follow-up period, which generated an annual cumulative incidence (AcI). From 46 articles, 42 used scales to evaluate the depressive variable, with an AcI estimate of around 4.5%. The articles that assessed depression categorically observed a variation in AcI between 0.2% and 7.0%. Among all the materials included, the group that used the Geriatric Depression Scale observed the lowest and the highest AcI, 1.3% and 26.6% respectively. Most of the productions were from countries in the Asian continent (52.2%), followed by Europe (30.4%), the Americas (13%), and Oceania (4.4%). Despite the variation of AcI, we found a frequent occurrence of DDS in older adults in the community-dwelling environment, which highlights the need for preventive actions and better-targeted early care, especially in terms of primary health care.

Keywords: aged; cohort studies; depression; depressive disorder; incidence; systematic review.

© 2024 The Authors. Psychogeriatrics published by John Wiley & Sons Australia, Ltd on behalf of Japanese Psychogeriatric Society.

Publication types

• Systematic Review
• Depression* / diagnosis
• Depression* / epidemiology
• Independent Living*
• Social Environment

Grants and funding

• "Coordenação de Aperfeiçoamento de Pessoal de Nível Superior" - Brasil (CAPES)
• 308168/2020-8/CNPq (Brazilian National Council for Scientific and Technological Development)

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• 12 May 2024

Is the Internet bad for you? Huge study reveals surprise effect on well-being

• Carissa Wong

You can also search for this author in PubMed   Google Scholar

People who had access to the Internet scored higher on measures of life satisfaction in a global survey. Credit: Ute Grabowsky/Photothek via Getty

A global, 16-year study 1 of 2.4 million people has found that Internet use might boost measures of well-being, such as life satisfaction and sense of purpose — challenging the commonly held idea that Internet use has negative effects on people’s welfare.

US TikTok ban: how the looming restriction is affecting scientists on the app

“It’s an important piece of the puzzle on digital-media use and mental health,” says psychologist Markus Appel at the University of Würzburg in Germany. “If social media and Internet and mobile-phone use is really such a devastating force in our society, we should see it on this bird’s-eye view [study] — but we don’t.” Such concerns are typically related to behaviours linked to social-media use, such as cyberbullying, social-media addiction and body-image issues. But the best studies have so far shown small negative effects, if any 2 , 3 , of Internet use on well-being, says Appel.

The authors of the latest study, published on 13 May in Technology, Mind and Behaviour , sought to capture a more global picture of the Internet’s effects than did previous research. “While the Internet is global, the study of it is not,” said Andrew Przybylski, a researcher at the University of Oxford, UK, who studies how technology affects well-being, in a press briefing on 9 May. “More than 90% of data sets come from a handful of English-speaking countries” that are mostly in the global north, he said. Previous studies have also focused on young people, he added.

To address this research gap, Pryzbylski and his colleagues analysed data on how Internet access was related to eight measures of well-being from the Gallup World Poll , conducted by analytics company Gallup, based in Washington DC. The data were collected annually from 2006 to 2021 from 1,000 people, aged 15 and above, in 168 countries, through phone or in-person interviews. The researchers controlled for factors that might affect Internet use and welfare, including income level, employment status, education level and health problems.

Like a walk in nature

The team found that, on average, people who had access to the Internet scored 8% higher on measures of life satisfaction, positive experiences and contentment with their social life, compared with people who lacked web access. Online activities can help people to learn new things and make friends, and this could contribute to the beneficial effects, suggests Appel.

The positive effect is similar to the well-being benefit associated with taking a walk in nature, says Przybylski.

However, women aged 15–24 who reported having used the Internet in the past week were, on average, less happy with the place they live, compared with people who didn’t use the web. This could be because people who do not feel welcome in their community spend more time online, said Przybylski. Further studies are needed to determine whether links between Internet use and well-being are causal or merely associations, he added.

The study comes at a time of discussion around the regulation of Internet and social-media use , especially among young people. “The study cannot contribute to the recent debate on whether or not social-media use is harmful, or whether or not smartphones should be banned at schools,” because the study was not designed to answer these questions, says Tobias Dienlin, who studies how social media affects well-being at the University of Vienna. “Different channels and uses of the Internet have vastly different effects on well-being outcomes,” he says.

doi: https://doi.org/10.1038/d41586-024-01410-z

Vuorre, M. & Przybylski, A. K. Technol. Mind Behav . https://doi.org/10.1037/tmb0000127 (2024).

Article   Google Scholar  

Heffer, T. et al. Clin. Psychol. Sci. 7 , 462–470 (2018).

Coyne, S. M., Rogers, A. A., Zurcher, J. D., Stockdale, L. & Booth, M. Comput. Hum. Behav . 104 , 106160 (2020).

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