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Cognitive–behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies

• Mutsuhiro Nakao 1 ,
• Kentaro Shirotsuki 2 &
• Nagisa Sugaya 3  

BioPsychoSocial Medicine volume  15 , Article number:  16 ( 2021 ) Cite this article

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Cognitive–behavioral therapy (CBT) helps individuals to eliminate avoidant and safety-seeking behaviors that prevent self-correction of faulty beliefs, thereby facilitating stress management to reduce stress-related disorders and enhance mental health. The present review evaluated the effectiveness of CBT in stressful conditions among clinical and general populations, and identified recent advances in CBT-related techniques. A search of the literature for studies conducted during 1987–2021 identified 345 articles relating to biopsychosocial medicine; 154 (45%) were review articles, including 14 systemic reviews, and 53 (15%) were clinical trials including 45 randomized controlled trials. The results of several randomized controlled trials indicated that CBT was effective for a variety of mental problems (e.g., anxiety disorder, attention deficit hypersensitivity disorder, bulimia nervosa, depression, hypochondriasis), physical conditions (e.g., chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, breast cancer), and behavioral problems (e.g., antisocial behaviors, drug abuse, gambling, overweight, smoking), at least in the short term; more follow-up observations are needed to assess the long-term effects of CBT. Mental and physical problems can likely be managed effectively with online CBT or self-help CBT using a mobile app, but these should be applied with care, considering their cost-effectiveness and applicability to a given population.

History of cognitive–behavioral therapy (CBT)

CBT is a type of psychotherapeutic treatment that helps people to identify and change destructive or disturbing thought patterns that have a negative influence on their behavior and emotions [ 1 ]. Under stressful conditions, some individuals tend to feel pessimistic and unable to solve problems. CBT promotes more balanced thinking to improve the ability to cope with stress. The origins of CBT can be traced to the application of learning theory principles, such as classical and operant conditioning, to clinical problems. So-called “first-wave” behavioral therapy was developed in the 1950s [ 2 ]. In the US, Albert Ellis founded rational emotive therapy to help clients modify their irrational thoughts when encountering problematic events, and Aaron Beck employed cognitive therapy for depressed clients using Ellison’s model [ 3 ]. Behavioral therapy and cognitive therapy were later integrated in terms of theory and practice, leading to the emergence of “second-wave” CBT in the 1960s. The first- and second-wave forms of CBT arose via attempts to develop well-specified and rigorous techniques based on empirically validated basic principles [ 4 ]. From the 1960s onward, the dominant psychotherapies worldwide have been second-wave forms of CBT. Recently, however, a third-wave form of CBT has attracted increasing attention, leading to new treatment approaches such as acceptance and commitment therapy, dialectical behavior therapy, mindfulness-based cognitive therapy, functional analytic psychotherapy, and extended behavioral activation; other forms may also exist, although this is subject to conjecture [ 4 ]. In a field of psychosomatic medicine, it has been reported that cognitive restructuring is effective in improving psychosomatic symptoms [ 5 ], exposure therapy is suitable for a variety of anxious disease conditions like panic disorder and agoraphobia [ 6 ], and mindfulness reduces stress-related pain in fibromyalgia [ 7 ]. Several online and personal computer-based CBT programs have also been developed, with or without the support of clinicians; these can also be accessed by tablets or smartphones [ 8 ]. Against this background, this review focused on the effectiveness of CBT with a biopsychosocial approach, and proposed strategies to promote CBT application to both patient and non-patient populations.

Research on CBT

Using “CBT “and “biopsychosocial” as PubMed search terms, 345 studies published between January 1987 and May 2021 were identified (Fig.  1 ); 14 of 154 review articles were systemic reviews, and 45 of 53 clinical trials were randomized controlled trials. Most clinical trials recruited the samples from patient populations in order to assess specific diseases, but some targeted at those from non-patient populations like a working population in order to assessing mind-body conditions relating to sick leave [ 9 ]. The use of biopsychosocial approaches to treat chronic pain is shown to be clinically and economically efficacious [ 10 ]; for example, CBT is effective for chronic low-back pain [ 11 ]. The prevalence of chronic low-back pain, defined as pain lasting for more than 3 months, was reported to be 9% in primary-care settings and 7–29% in community settings [ 12 ]. Chronic low-back pain is not only prevalent, but is a source of significant physical disability, role impairment, and diminished psychological well-being and quality of life [ 11 ]. Interestingly, according to the results of our own study [ 13 ], CBT was effective among hypochondriacal patients without chronic low-back pain, but not in hypochondriacal patients with chronic low-back pain. These group differences did not seem to be due to differences in the baseline levels of hypochondriasis. Although evidence has suggested that both hypochondriasis and chronic low-back pain can be treated effectively with CBT [ 10 , 11 , 14 ], this has not yet been validated. Chronic low-back pain may be associated with a variety of conditions, including anxiety, depression, and somatic disorders such as illness conviction, disease phobia, and bodily preoccupation. The core psychopathology of hypochondriacal chronic low-back pain should be clarified to promote adequate symptom management [ 13 ].

Number of articles per year identified by a PubMed search from 1989 to the present

Since 2000, Cochrane reviews have evaluated the effectiveness of CBT for a variety of mental, physical, and behavioral problems. Through a search of the Cochrane Library database up to May 2021 [ 15 ], 124 disease conditions were assessed to clarify the effects of CBT in randomized controlled trials; the major conditions for which CBT showed efficacy are listed in Table  1 . These include a broad range of medical problems such as psychosomatic illnesses (e.g., chronic fatigue syndrome, irritable bowel syndrome, and fibromyalgia), psychiatric disorders (e.g., anxiety, depression, and developmental disability), and socio-behavioral problems (drug abuse, smoking, and problem gambling). For most of these conditions, CBT proved effective in the short term after completion of the randomized controlled trial. Although the number of literature was still limited, some studies have reported significant and long-term treatment effects of CBT on some aspects of mental health like obsessive-compulsive disorder [ 16 ] 1 year after the completion of intervention. Future research should investigate the duration of CBT’s effects and ascertain the optimal treatment intensity, including the number of sessions.

Future directions for CBT application in biopsychosocial domains

In Japan, CBT for mood disorders was first covered under the National Health Insurance (NHI) in 2010, and CBT for the following psychiatric disorders was subsequently added to the NHI scheme: obsessive–compulsive disorder, social anxiety disorder, panic disorder, post-traumatic stress disorder, and bulimia nervosa [ 17 ]. The treatment outcomes and health insurance costs for these six disorders should be analyzed as the first step, for appropriate allocation of medical resources according to disease severity and complexity [ 18 ]. In Japan, health insurance coverage is provided only when physicians apply for remuneration. A system promoting nurse involvement in CBT delivery [ 19 ], as well as shared responsibility between the CBT instructor and certified psychologists (or even a complete shift from physicians to psychologists), has yet to be established. Information and communication technology (ICT) devices may allow CBT delivery to be shared between medical staff and psychologists, in medical, community and self-help settings [ 8 ]. The journal BioPsychoSocial Medicine published 334 relevant articles up to the end of May 2021, 112 (33.5%) of which specifically addressed CBT [ 20 ]. CBT is a hot topic in biopsychosocial medicine, and more research is required to encourage its application to clinical and general populations.

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Abbreviations

• Cognitive–behavioral therapy

Information and communication technology

National Health Insurance

Post-traumatic stress disorder

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Acknowledgments

The study was supported in part by a Research Grant (Kiban C) from the Japanese Ministry of Education, Culture, Sports, Science and Technology.

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Department of Psychosomatic Medicine, School of Medicine, International University of Health and Welfare, 4-3, Kozunomori, Narita-shi, Chiba, 286-8686, Japan

Mutsuhiro Nakao

Graduate School of Human and Social Sciences, Musashino University, Tokyo, Japan

Kentaro Shirotsuki

Unit of Public Health and Preventive Medicine, School of Medicine, Yokohama City University, Yokohama, Japan

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MN organized the project and wrote the entire manuscript. KS and NS conducted the literature search and were involved in the conceptualization of the review. All authors (MN, KS and NS) share final responsibility for the decision to submit the manuscript for publication. The authors read and approved the final manuscript.

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Nakao, M., Shirotsuki, K. & Sugaya, N. Cognitive–behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies. BioPsychoSocial Med 15 , 16 (2021). https://doi.org/10.1186/s13030-021-00219-w

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

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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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• Published: 18 November 2015

Global research challenges and opportunities for mental health and substance-use disorders

• Florence Baingana 1 ,
• Mustafa al'Absi 2 ,
• Anne E. Becker 3 &
• Beverly Pringle 4  

Nature volume  527 ,  pages S172–S177 ( 2015 ) Cite this article

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The research agenda for global mental health and substance-use disorders has been largely driven by the exigencies of high health burdens and associated unmet needs in low- and middle-income countries. Implementation research focused on context-driven adaptation and innovation in service delivery has begun to yield promising results that are improving the quality of, and access to, care in low-resource settings. Importantly, these efforts have also resulted in the development and augmentation of local, in-country research capacities. Given the complex interplay between mental health and substance-use disorders, medical conditions, and biological and social vulnerabilities, a revitalized research agenda must encompass both local variation and global commonalities in the impact of adversities, multi-morbidities and their consequences across the life course. We recommend priorities for research — as well as guiding principles for context-driven, intersectoral, integrative approaches — that will advance knowledge and answer the most pressing local and global mental health questions and needs, while also promoting a health equity agenda and extending the quality, reach and impact of scientific enquiry.

This article has not been written or reviewed by Nature editors. Nature accepts no responsibility for the accuracy of the information provided.

The global mental health landscape has transformed over the past 25 years because of the higher visibility of the burden of mental health and substance-use disorders 1 . These disorders comprise 7.4% of global disability-adjusted life years (DALYs) and 22.7% of global years lived with disability (YLDs) 2 (Supplementary Information) 3 . The main contributors worldwide are depression and dysthymia (9.6% of all YLDs); anxiety (3.5% of all YLDs); and schizophrenia, substance-use disorders and bipolar disorder (just over 2% of all YLDs). Alcohol and substance-use disorders come in second for most of the developing world, more so for southern Africa (drug use) and Eastern Europe (alcohol) 2 . The burden of mental health and substance-use disorders is predicted to increase worldwide in coming decades, and the steepest rise can be expected in low- and middle-income countries (LMICs) as a result of rising life expectancy, population growth and under-resourced health care 4 . For example, simulation models predict a 130% increase in associated health burden of alcohol and substance misuse in sub-Saharan Africa by 2050 as a result of population growth and ageing 5 . As substantial as they are, conventional health metrics do not capture additional social burdens attached to living with mental illness. Untreated mental health disorders are associated with a high economic burden 6 . Furthermore, pervasive stigma and human rights violations compound the suffering associated with these disorders and exacerbate social vulnerabilities 7 , 8 , 9 .

As the health, social, economic and human costs of mental and substance-use disorders become increasingly better documented, political will and multilateral commitments to scale up mental health care in LMICs have grown. The World Health Organization has introduced a series of policy initiatives that articulate both high-level aspirations and pragmatic guidance for mental health and substance-use services delivery in LMICs. The most recent, the Global Mental Health Action Plan 2013–2020, challenges member states, partners and the Secretariat to collectively meet ambitious goals by the year 2020, including increasing mental health care coverage by 20% for severe mental health illness and reducing national suicide rates by 10% (ref. 10 ). A consideration of the timeline of these landmark events — including the roll out of a number of key funding and policy initiatives that target the persisting resource gaps — illustrates the substantial momentum in integrating mental health into the broader global health agenda that has occured over the past few decades (See Supplementary Information).

An interactive map, depicting the broad geographical distribution of current, promising initiatives in global mental health is available at http://www.nimh.nih.gov/about/organization/gmh/global-research-on-mental-health-and-substance-abuse.shtml . Policy and programmatic initiatives have laid a foundation for strengthened global mental health services by developing an initial consensus scientific agenda that focuses energies and funding on the most crucial research for building an empirical base. Key funding initiatives have supported research to leverage scarce resources and improve access through task sharing, integration of mental health care into existing primary health-care infrastructure and enhancement of diagnostic assessment. Increasingly, resources have been allocated to build in-country research capacities and strengthen collaboration through institutional partnerships 11 . Complementary graduate-level training programmes in global mental health have also emerged, although mental health specialty training, as a track, remains relatively under-represented among other global health domains 12 , 13 .

Key research gaps and challenges

The global health burden of mental health disorders is exacerbated by the growing concurrent problems associated with substance misuse. Substance use and exposure to addictive drugs have chronic and profound effects on neurobehavioural and neurodevelopmental functions. In LMICs, the socioecology of poverty, malnutrition, political conflicts and poor health systems influence the epidemiology, as well as the adverse outcomes, that result from substance misuse. Additional challenges associated with co-morbidity stem from its augmentation of clinical burden, through increased risk for relapse, other infectious and medical complications, and economic hardship and homelessness. In this context, co-morbid substance use and mental illnesses in particular may contribute to increasing health burden. The prevalence of substance-use disorders has escalated in recent decades, reaching 5.4% of the total disease burden and 9.1% when tobacco use is included 14 .

Individuals with substance-use disorders are also likely to have other mental health problems, including depression and schizophrenia 4 , 15 . Similarly, a large proportion of people with mental illnesses also have substance-use disorders 16 , 17 . Research that investigates the relationship between mental illness and substance-use disorder has yielded mixed findings, with some support for causal relationships in both directions as well as for shared genetic, environmental, social and cultural risk factors. For example, cannabis use is linked to a risk of developing psychotic illness 18 . Conversely, mental illness may increase the risk of substance misuse; individuals may 'self-medicate' with alcohol, tobacco or amphetamines as a means of coping with distress and negative affects 19 , 20 . Some factors, including genetic vulnerabilities, traumatic exposures and stress, may confer risk for both conditions 21 , 22 . Diagnosis and treatment of co-morbid substance misuse and mental health illness remains a significant challenge, particularly in LMICs. The burden of this co-morbidity is further exacerbated by the increased clinical complexity that stems from resistance to treatment, risk of relapse, vulnerability to other infectious and medical complications, and increased economic hardship and homelessness.

The burden and configuration of risk associated with substance-use disorders and co-morbid mental illness seem to vary across the world ( Fig. 1 ) 14 . Although alcohol and opioid problems are escalating in Europe, Africa and Asia, problems associated with amphetamines and cannabis are more prevalent in Asia, North America and Europe. Cocaine use is prevalent in North America and Europe, whereas misuse of indigenous psychoactive substances is prevalent in other regions, such as the use of khat in parts of Africa and the Middle East and that of coca leaves in South America 23 . Notably, existing knowledge gaps may underestimate the impact of substance-use disorders 24 . The full extent of adverse mental health and social impacts of substance-use disorders such as alcohol use during pregnancy and fetal alcohol spectrum disorders 25 remain incompletely understood.

Reprinted with permission from ref. 4 .

Mental health and substance-use disorders also frequently co-occur with other diseases, increasing associated morbidity and mortality risk 26 , 27 . It is not uncommon for individuals with HIV/AIDS or non-communicable diseases such as hypertension, diabetes and cardiovascular disease to also have symptoms of depression or anxiety and to use alcohol or other drugs to excess. Attention deficit hyperactivity disorder has been associated with risky sexual behaviours that can result in transmission of HIV/AIDS. These interdependent illnesses stem from common risk factors, such as childhood adversity; and bidirectional influences, such as poor treatment adherence 28 and increased engagement in risky behaviour 29 , 30 , 31 . Growing awareness of the complex interplay between mental illness and the increasing burden of chronic disease globally has prompted research that examines the effects of depression on adherence to medical treatments and the effects of integrated care — co-treatment of high blood pressure and depression, for example — on the outcomes of both of the co-occurring illnesses (see for example refs 32 , 33 , 34 ). A life-course approach to risk reduction that takes into account risks that occur in childhood and early adulthood, and that promotes a healthy lifestyle, and early recognition and treatment of mental and substance-use disorders is essential to curtail the long-term negative impacts of many preventable health risks.

Treatment gap

The proportion of people who need, but do not receive care is especially high in LMICs 35 , 36 . The inadequate resourcing of mental health care in LMICs has been widely documented and critiqued. For example, on average less than 3% of public health resources are allocated to specific mental health care in LMICs, with even less (around 1%) in Africa and Asia 37 . Most LMICs have far fewer health-care professionals than they need to deliver mental health and substance-use interventions to everyone who needs them 38 , 39 . Scaling up services will require more than training additional psychiatrists, psychologists and psychiatric nurses, however, strategic leveraging of scarce resources will also be necessary. In particular, task shifting — delegating health-care tasks from specialists to various non-specialist health professionals and other health workers — has shown promise for certain mental health and substance-use interventions 40 , 41 , 42 , 43 . In addition, the integration of mental health services into primary health-care delivery settings through community-based and task-sharing approaches can both help to reduce burden on carers and improve access and the coordination of care. Mental health services and health-system strengthening, and in particular, task shifting, as well as organization and ways of delivering community-based mental health services in LMICs should be prioritized for research.

There is also a substantial gap in scientific knowledge for preventing and treating mental health and substance-use disorders. In addition, what is currently known is often not applicable to low-resource regions. Intervention strategies to address substance-use disorders have improved over recent decades, but have had limited success in achieving total recovery and have limited coverage in LMICs 15 . Moreover, resources for providing these interventions are constrained or lacking in most LMICs 15 , 24 . Models for improving availability and access to effective mental health care emphasize the integration of both prevention and treatment services within primary care systems. This has been a core approach taken by the WHO Mental Health Gap Action Program (mhGAP) 44 , 45 .

Most published clinical trial data on therapeutics for mental health disorders are based on research conducted in high-income countries 46 , 47 , 48 . In the absence of region-specific empirical data, deployment of these therapeutic strategies in LMICs is a reasonable pragmatic compromise in the short term when informed by local knowledge, and pending rigorous and systematic evaluation. Local research on clinical effectiveness of these treatments and implementation research on how to deliver these therapies and scale them up are urgently needed.

Priorities for advancing the global mental health agenda

Our recommendations build on the strong base of empirical evidence and previous consensus statements and reports that have articulated principles, needs and priorities that should inform a robust research agenda ( Table 1 ). The predominant focus of global mental health research is currently on health services and implementation research, areas that align well with efforts to close treatment gaps and that must continue to be strengthened. Whereas we regard these contributions as formative and arguably the most pragmatic and exigent in the short term, they should not pre-empt a more ambitious scope of scientific inquiry that ranges from basic sciences to health policy. Innovation should encompass much more than strategies to leverage scarce resources lest the scope of progress in the field be consigned to improving the efficiency of old models of care delivery. Instead, complementary and parallel lines of context-driven research should also aim to advance the scientific understanding of aetiology, population-specific phenotypic variation in presentation and course, and differential response to therapeutics through promising avenues in neuroscience, biomarkers, genetics and epigenomics.

Epidemiology

Epidemiological research is crucial to better understand the differential risk factors and burden of mental health and substance-use disorders across diverse geographical regions and social contexts. Refinement of approaches to diagnostic assessment that are both locally valid and relatable to global classification is essential to more effective and efficient case identification, particularly in the hands of non-specialists. Such advances will generate more accurate estimates of health burdens and salient risk factors on which local health policymakers can draw. In addition, research is needed to better define the health and social impacts of syndemic mental health disorders, substance-use disorders and medical diseases, as well as to understand how social adversities moderate and mediate risk of onset, severity and course. Such research will inform optimal strategies for prevention, treatment and follow-up care for individuals with these co-morbidities.

Basic science research

The research agenda to address the global burden of mental health and substance-use disorders should build on recent advances in the field of basic neuroscience, biomarkers, proteomics, and genetics and epigenetics. For example, research in the past decade has identified molecular and structural markers connected with mental health and substance-use disorders 49 . These include protein alterations in the form of upregulation of a 40-amino acid VGF-derived peptide and the downregulation of apoA1 protein in schizophrenia 50 . Hormonal and physiological alterations in stress- and appetite-related neuropeptides have also been pursued in the context of addiction and treatment outcome 51 , 52 , 53 . There has also been significant interest in epigenomics and how it could advance our understanding and use of biomarkers. Epigenomic modifications affect gene expression, and involve multiple molecular steps, including DNA methylation 54 . In light of evidence that indicates a role for epigenetic mechanisms in modifying genes that increase propensity for drug use and mental illness, it is important to develop a means by which this approach could be harnessed to improve the validity and reliability of diagnostic measures as well as to help to tailor interventions to the individual. Research that considers the diversity of environmental exposures and gene–environment interactions across different settings can advance the utility of these markers to confirm diagnosis and to predict treatment outcome. Furthermore, such markers may be useful in identifying those at high risk so that measures can be applied to prevent initial risk or onset, or slow down or prevent progression towards psychopathology. The use of such approaches should also parallel the development of conceptual models to guide understanding of the complex, multidimensional aetiology of mental health and substance-use disorders. To that end, global research that focuses on mental health and substance-use disorders should take into account how genetics and exposure to environmental toxins interact with social, cultural and environmental conditions to moderate the risk of these disorders.

Health delivery and implementation research

Four out of the top five research priorities identified in the grand challenges statement — developed by a consortium of researchers, advocates and clinicians with funding from the US National Institute of Mental Health (NIMH) and the Global Alliance for Chronic Diseases — fall in the domain of enhancing the quality of, and access to, mental health care 55 . This call to invest in health services and implementation research is in response to identified treatment gaps as well as their numerous antecedents, such as weak health systems, shortfalls in human and financial resources, and social structural barriers to care. There is ample evidence for science-based care and the integration of mental health services into primary health care. However, we still lack crucial knowledge on how best to disseminate and implement evidence-based mental health interventions in resource-poor contexts, including those characterized by the extreme social adversities associated with political conflict, displacement and destitution. Future research is therefore necessary to rigorously evaluate and optimize effectiveness of task sharing, integration of mental health into primary care, and deployment of the mhGAP algorithms at larger scale and across diverse social settings 41 , 56 .

Key strategies for expanding access to high-quality mental health care in LMICs come from models that are successful in leveraging scarce resources in other clinical domains. However, challenges unique to care delivery for mental health and substance-use disorders warrant special attention and innovation. These include how to improve diagnostic assessment and population health surveillance, given the heterogeneous and sometimes opaque presentations of signs and symptoms across diverse social and cultural contexts 57 , 58 ; how to address the social and cultural factors, especially stigma, that hinder access to care and may prevent patients with mental illnesses and substance-use problems from using the resources available for prevention and treatment; how to mitigate social vulnerabilities, such as poverty and gender-based violence that elevate risk of mental disorders, while building on sociocultural resources that promote coping and resilience; how to develop coordinated approaches to strategic preventive interventions, monitoring and targeted treatments over the life course and across disorders, given developmental trajectories of mental health and substance-use disorders, and their harmful symbiosis with other chronic conditions and vulnerabilities; and how to rapidly scale up effective interventions to close the treatment gap in resource constrained environments 59 , 60 , 61 . Priorities for global mental health research resonate with the global health agenda, with its focus on reducing health burdens 62 . In this respect, a globalizing framework aimed at developing approaches that are effective when scaled up and implemented across geographically and socially diverse settings and populations reflect pragmatic goals of responding to pressing needs. We emphasize, however, that closing the prevailing treatment gaps for mental health and substance-use disorders will also depend on fortifying scientific inquiry so that we can understand the, sometimes remarkable, local variation in manifestation and course of mental disorders 63 .

Translational and health-policy research

Ensuring that populations receive high-quality care that improves mental health is the purview of policymakers. Shaping sound public policies that are based on up-to-date research can be challenging, but promising examples exist. An experimental housing policy called Moving to Opportunity found that moving from a high-poverty to a lower-poverty neighbourhood improved adult physical and mental health and subjective wellbeing over 10–15 years, despite no change in average economic status 64 . Moving to Opportunity was able to capitalize on the fact that public policy decisions are interconnected — it is not just health policies that influence mental health, substance use and other public health outcomes, but also economic, housing and criminal justice policies, among others 65 . Rapid growth in mental health and substance-use research over the past decade, as well as appeals from researchers and advocates to apply the findings in policy and practice have not yet bridged the divide between what is known and what is done 66 , 67 . The intricacies of ensuring evidence-based health policy are not entirely understood 68 , but a few effective practices are being used. Advocacy organizations such as the National Alliance on Mental Illness have become trusted sources of digestible research findings 69 . Carefully planned links between researchers and decision makers — an approach increasingly encouraged by funders of mental health and substance-use research — can also be effective 69 . Such links often involve collaboration among researchers, government agencies, advocates and provider institutions to synchronize research activities with policies, health-care demands and community priorities, and to engage key stakeholders in the identification of pressing research questions and the use of study findings. In this way, policymakers have become partners in the research enterprise, helping researchers to understand what information is needed for developing or updating policies, making investment decisions, expanding access to care, improving care quality and monitoring system-level change over time. The long-term goal is that these partnerships will mobilize political will, inform policy development, and shed light on the essentials of shaping science-informed mental health and substance-use policies.

Inclusion of mental health as an explicit priority in the post-2015 development agenda (such as that included in the UN Open Working Group on Sustainable Development Goals, 2015; https://sustainabledevelopment.un.org/content/documents/7891TRANSFORMING%20OUR%20WORLD.pdf ) provides an opportunity to mobilize the requisite political will and resources at several levels so that this ambitious agenda for research and capacity building can be realized. Lessons learned from the positive health impact as a result of Millennium Development Goals 4, 5 and 6 illuminate how multisector and multilevel cohesion of effort and commitments are powerful levers for advancing health in low-resource settings, and an opportunity for the broad community of stakeholders and advocates to improve care for individuals living with mental health and substance-use disorders.

Collaborative capacity building

New commitments and additional resources will be needed to rapidly cultivate the in-country research capacity needed to respond to the global disease burden of mental health and substance-use disorders 70 . The most culturally sensitive, scientifically and ethically sound, and locally relevant research requires investigators who best understand and live among the populations that they study. Funding initiatives such as the Fogarty International Center's Global Brain and Nervous System Disorders Across the Lifespan programme ( http://www.fic.nih.gov/Programs/Pages/Brain-Disorders.aspx ), the NIMH's Collaborative Hubs for International Research in Mental Health ( http://www.nimh.nih.gov/about/organization/gmh/globalhubs/index.shtml ) as well as Grand Challenges Canada's Global Mental Health granting programme ( http://www.grandchallenges.ca/grand-challenges/global-mental-health/ ) that explicitly structure research capacity building into grant requirements, provide exemplary platforms to test and ultimately to systematize innovative strategies for training, mentorship and building a research culture and other infrastructural support for research in LMICs.

In addition, collaborative capacities to advance the mental health and substance-use research agenda must be developed. Capacity building in knowledge management is also integral to packaging accrued evidence so that it is accessible to policymakers and mental health technology specialists in LMICs. Platforms for knowledge sharing (for example, the Mental Health Innovation Network, http://mhinnovation.net/ ; and GHD Online, http://www.ghdonline.org/ ) can promote scientific discovery and help to harmonize the mental health and substance-use disorder research goals, processes and tools, and to catalyse the translational potential of research to policy and programmes 71 . Moreover, these platforms are needed to build and consolidate the community of advocates, consumers, investigators, clinicians and policymakers united in their commitment to mitigate the suffering associated with mental health and substance-use disorders, eliminate their attendant stigma, diminish their social and economic burdens, and erase the social and health disparities perpetuated by poor access to high-quality mental health care.

Conclusions

The formidable and rising health, economic and social burdens associated with mental health and substance-use disorders call for the prioritization of research that can inform a global response — through the development and enhancement of preventive and therapeutic strategies, health-system strengthening and policymaking — to alleviate suffering and stem the associated economic and social consequences of unmet needs. Indeed, the potential synergies among breakthroughs in basic neuroscience, epidemiological methods and implementation science, as well as the mobilization of resources and political will have generated optimism and catalysed a commitment to act among policymakers, advocates and the scientific community. Although the increase in mental health research initiatives over the past two decades are encouraging for the future challenges remain and patterns of progress have been inconsistent. We find, for example, that although response to the growing burden of depression in LMICs has led to an increase in the number of studies on effectiveness of treatments, delivery methods and task shifting to provide access to care for all populations, we do not see this same trajectory of efforts to address substance-use disorders. This occurs with the background of growing substance-use problems globally. Approaches to address substance-use disorders in LMICs are still limited, fragmented and not well vetted scientifically or culturally. On an optimistic note, the draft Social Development Goals to be passed by the UN General Assembly in September 2015 recognise mental health as integral to health and mental health is explicitly included within universal health coverage; in addition, the UN General Assembly will hold a special session on drugs in 2016. These developments have symbolic and substantive importance, and auger well for mental health within the Global Health agenda in the coming years.

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Acknowledgements

The authors thank J. Dewit, A. Garton, Y. Bodenstein and J. Nguyen at the National Institute of Mental Health for construction of the interactive map. M. A. was supported in part by the following grants: R01DA016351 and R01DA027232, and a BRAIN R21 grant (R21DA024626). F. B. was supported in part by Grand Challenges Canada Grant GMH 0094-04. We are grateful to B. Good for his insightful review and suggestions.

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Bipolar disorders

Affiliations.

• 1 Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Department of Pharmacology, University of Toronto, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada. Electronic address: [email protected].
• 2 Institute for Mental and Physical Health and Clinical Translation Strategic Research Centre, School of Medicine, Deakin University, Melbourne, VIC, Australia; Mental Health Drug and Alcohol Services, Barwon Health, Geelong, VIC, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia; Centre for Youth Mental Health, Florey Institute for Neuroscience and Mental Health, Melbourne, VIC, Australia; Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia.
• 3 Department of Psychiatry, Adult Division, Kingston General Hospital, Kingston, ON, Canada; Department of Psychiatry, Queen's University School of Medicine, Queen's University, Kingston, ON, Canada; Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.
• 4 Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Centre for Youth Bipolar Disorder, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
• 5 Department of Psychiatry, Faculty of Medicine, University of Antioquia, Medellín, Colombia; Mood Disorders Program, Hospital Universitario San Vicente Fundación, Medellín, Colombia.
• 6 Copenhagen Affective Disorders Research Centre, Psychiatric Center Copenhagen, Rigshospitalet, Copenhagen, Denmark; Department of Psychiatry, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
• 7 Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, NSW, Australia; Department of Academic Psychiatry, Northern Sydney Local Health District, Sydney, Australia.
• 8 Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
• 9 Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Dauten Family Center for Bipolar Treatment Innovation, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
• 10 Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada.
• 11 Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain.
• 12 Department of Psychiatry, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Psychiatric Research Unit, Psychiatric Centre North Zealand, Hillerød, Denmark.
• 13 Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London and South London and Maudsley National Health Service Foundation Trust, Bethlem Royal Hospital, London, UK.
• 14 Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
• PMID: 33278937
• DOI: 10.1016/S0140-6736(20)31544-0

Bipolar disorders are a complex group of severe and chronic disorders that includes bipolar I disorder, defined by the presence of a syndromal, manic episode, and bipolar II disorder, defined by the presence of a syndromal, hypomanic episode and a major depressive episode. Bipolar disorders substantially reduce psychosocial functioning and are associated with a loss of approximately 10-20 potential years of life. The mortality gap between populations with bipolar disorders and the general population is principally a result of excess deaths from cardiovascular disease and suicide. Bipolar disorder has a high heritability (approximately 70%). Bipolar disorders share genetic risk alleles with other mental and medical disorders. Bipolar I has a closer genetic association with schizophrenia relative to bipolar II, which has a closer genetic association with major depressive disorder. Although the pathogenesis of bipolar disorders is unknown, implicated processes include disturbances in neuronal-glial plasticity, monoaminergic signalling, inflammatory homoeostasis, cellular metabolic pathways, and mitochondrial function. The high prevalence of childhood maltreatment in people with bipolar disorders and the association between childhood maltreatment and a more complex presentation of bipolar disorder (eg, one including suicidality) highlight the role of adverse environmental exposures on the presentation of bipolar disorders. Although mania defines bipolar I disorder, depressive episodes and symptoms dominate the longitudinal course of, and disproportionately account for morbidity and mortality in, bipolar disorders. Lithium is the gold standard mood-stabilising agent for the treatment of people with bipolar disorders, and has antimanic, antidepressant, and anti-suicide effects. Although antipsychotics are effective in treating mania, few antipsychotics have proven to be effective in bipolar depression. Divalproex and carbamazepine are effective in the treatment of acute mania and lamotrigine is effective at treating and preventing bipolar depression. Antidepressants are widely prescribed for bipolar disorders despite a paucity of compelling evidence for their short-term or long-term efficacy. Moreover, antidepressant prescription in bipolar disorder is associated, in many cases, with mood destabilisation, especially during maintenance treatment. Unfortunately, effective pharmacological treatments for bipolar disorders are not universally available, particularly in low-income and middle-income countries. Targeting medical and psychiatric comorbidity, integrating adjunctive psychosocial treatments, and involving caregivers have been shown to improve health outcomes for people with bipolar disorders. The aim of this Seminar, which is intended mainly for primary care physicians, is to provide an overview of diagnostic, pathogenetic, and treatment considerations in bipolar disorders. Towards the foregoing aim, we review and synthesise evidence on the epidemiology, mechanisms, screening, and treatment of bipolar disorders.

Copyright © 2020 Elsevier Ltd. All rights reserved.

Publication types

• Research Support, Non-U.S. Gov't
• Anticonvulsants / therapeutic use
• Antidepressive Agents / therapeutic use
• Antimanic Agents / therapeutic use
• Antipsychotic Agents / therapeutic use
• Bipolar Disorder / classification*
• Bipolar Disorder / drug therapy*
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• Bipolar Disorder / psychology
• Carbamazepine / therapeutic use
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• Lamotrigine / therapeutic use
• Lithium / therapeutic use
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• Mania / psychology
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• Valproic Acid / therapeutic use
• Young Adult
• Anticonvulsants
• Antidepressive Agents
• Antimanic Agents
• Antipsychotic Agents
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• Valproic Acid
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Reasons for hope

Solutions for the mental health crisis emerge through innovative research, diagnostics and treatments

By Nina Bai

Illustration by Jules Julien

Photography by Leslie Williamson

It’s the spring of hope for mental health, astir with novel discoveries, life-changing therapies and more openness than ever before — yet, for many, it feels like the winter of despair. The pandemic years, that crucible of stress, isolation and uncertainty, fueled and exposed mental health problems. In 2022, nearly 1 in 4 American adults (about 59 million people) said they experienced a mental illness in the previous year, but only half of those afflicted reported receiving any mental health treatment.

Among children and adolescents, the prevalence of mental illness, which had been steadily creeping upward, jumped during the pandemic, according to the U.S. Substance Abuse and Mental Health Services Administration. In 2019, 15.7% of American adolescents aged 12-17 reported experiencing a major depressive episode in the past year. In 2022, that number was 19.5%. That same year, 13.4% of adolescents — just over 1 in 8 — seriously thought about killing themselves.   

And even as the pandemic has stoked demand for mental health care, it also has worn down the mental health workforce, already short-handed, with early retirements and widespread burnout. Access to affordable, effective interventions remains a daunting barrier. People face long waiting lists and lack of insurance coverage. Many treatable conditions remain undiagnosed because people lack a way to obtain assessments. 

Yet, below this perfect storm of mental health crisis, there is a strong undercurrent of hope that begins in the lab. Research is leading the way toward treatments that are more effective, more personalized and more accessible.

“The manner in which we know the brain now, compared with what we knew in previous decades, is incredibly different,” said Victor Carrión , MD, the John A. Turner, MD, Endowed Professor for Child and Adolescent Psychiatry and vice chair of the department of psychiatry and behavioral sciences.

Direct impact on patients

New imaging technologies allow researchers to see the neural circuitry that goes awry in neuropsychiatric disorders, lab-grown clumps of brain tissue — known as organoids — can simulate the impact of genetics in autism, and artificial intelligence can surmise signals that predict the onset of depression and anxiety.

Moreover, these discoveries, rather than moving slowly through specialist silos, can now rapidly inform new treatments. “Collaboration is vital for translation, and our departmental awards and programs promote and emphasize synergy between research and clinical practice,” said Laura Roberts , MD, the Katharine Dexter McCormick and Stanley McCormick Memorial Professor and chair of the department of psychiatry and behavioral sciences.

“Our bench scientists doing tremendous research also work alongside our clinicians to make sure that new knowledge translates to the clinical setting and has a direct impact on patient care,” she said.

Researchers developing transcranial magnetic stimulation, for example, work with clinicians who treat patients with severe depression to design clinical trials, and their techniques are informed by teams inventing new ways to measure the flow of brain signals and those building virtual reality models of the brain.

A clearer understanding of the biology of mental health disorders not only leads to breakthrough treatments — but just as powerfully, helps dissipate stigma.

“There’s been a large shift in stigma in the past 25 years,” said Heather Gotham , PhD, clinical professor of psychiatry and behavioral sciences, who leads the coordination of a nationwide network of centers dedicated to implementing evidence-based mental health care.

The Mental Health Technology Transfer Center Network, funded by the Substance Abuse and Mental Health Services Administration, offers training in preventing school violence, substance use in the workplace, adolescent depression and more, and it offers support for mental health providers seeing refugees and asylum seekers.

“Collaboration is vital for translation, and our departmental awards and programs promote and emphasize synergy between research and clinical practice.” Laura Roberts, the Katharine Dexter McCormick and Stanley McCormick Memorial Professor and chair of the department of psychiatry and behavioral sciences

“One thing that’s made a difference is the greater understanding that mental health disorders and substance use disorders are chronic, relapsing disorders of the body, just like diabetes and heart disease,” Gotham said.

With this new awareness, more people want to be mental health literate. In the past few years, Gotham has seen a surge of interest, from a broader community, in the network’s online courses — from teachers, for example, who want to be more responsive to the needs of students and reduce stigma in the classroom.

Less stigma also means more money for research and mental health services. Funding for mental health has become a rare bipartisan issue. In 2022, Congress passed the Bipartisan Safer Communities Act, which has provided $245 million to fund mental health services like training for school personnel, first responders and law enforcement and expanding the 988 suicide and crisis lifeline.

Stanford Medicine researchers know that to make the most impact with their discoveries they must reach those who need help the most — through online symptom screenings, virtual therapy, group therapy, inclusive clinical trials and community interventions.

They are training mental health professionals locally and globally in new evidence-based techniques. Providers in more than 38 countries, for example, have been trained in cue-centered therapy, a 15-week treatment program developed at Stanford Medicine to help children and teens recover from chronic trauma. Recently, pro bono training in cue-centered therapy was provided to clinicians in Ukraine.

What gives Roberts hope is that a more open conversation on mental health is drawing together experts from different fields with a shared purpose. “It used to be that clinicians would stay in their clinical practice and refer to journals for new research, and researchers would stay in the lab and never see a patient — and we don’t have that now,” she said. “I see more openness and more flexibility from the current generation of researchers and clinicians.”

Read on in this issue of Stanford Medicine to learn about some of the ways Stanford Medicine researchers and clinicians are advancing the understanding of mental health and sharing that knowledge.

Nina Bai is a science writer in the Stanford Medicine Office of Communications.

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What is Mental Disorder? An essay in philosophy, science, and values

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This resource by Derek Bolton tackles the problems involved in the definition and boundaries of mental disorder.

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Mental Health Stigma

How medical psychiatry may worsen mental-health stigma, challenging the received wisdom about mental health..

Posted April 25, 2024 | Reviewed by Gary Drevitch

• Seeing mental illness as having a biological cause tends to make stigma worse, not better.
• Trauma-based explanations of mental illness do not seem to have these negative effects.
• We should reconsider public messaging about mental health in light of these findings.

In the 1980s and 90s, an emerging theory was that mental disorders like depression , bipolar disorder , or schizophrenia were due to faulty brain chemicals, and ultimately, faulty genes.

This message was popularized by books like Nancy Andreasen’s 1985 The Broken Brain , Solomon Snyder’s 1986 Drugs and the Brain , and Jon Franklin’s 1987 Molecules of the Mind .

In this view, schizophrenia was due to dopamine imbalances. Depression involved serotonin imbalances. Bipolar disorder involved lithium imbalances. And drugs like Prozac worked by reversing these imbalances.

While simplistic versions of many of these theories were disproven , the “chemical imbalance” metaphor still has a powerful grip on the professional and public imagination .

Journalists, doctors, and activists thought that this messaging would help end stigma by showing that you’re not to blame for your mental health problems, any more than you’re to blame for breast cancer.

New research, however, is calling this received wisdom into question. This research is showing that medical framings of mental health problems actually make some kinds of stigma worse , not better.

Challenging the Received Wisdom

Over the last decade, a group of psychologists have investigated new questions about mental health stigma .

For example, if I think that your mental illness is caused by your brain or your genes, how does that affect my desire to interact with you? This is known as the desire for social distance .

Similarly, if I think that your mental illness is caused by your brain or your genes, how does that affect my belief that you will recover? This is known as prognostic optimism .

The upshot of this research is that biological explanations of mental illnesses have their own dangers. They tend to increase people’s desire for social distance . If I think your mental illness is caused by your brain or genes, I’m more likely to see you as potentially dangerous and unpredictable, and to want to keep my distance from you. They also decrease prognostic optimism: If I see your mental illness as having a biological cause, I have less hope that you’re going to recover.

On the plus side, these mindsets do reduce the perception of blame: If I think your schizophrenia or depression is caused by your genes, I’m less likely to blame you for it.

One of the most troubling findings in this new research is that, by several measures, stigma towards schizophrenia has actually gotten worse over the last 30 years, not better. This may be related to the greater acceptance of the medical paradigm.

Making Stigma Worse?

Research carried out last year, while confirming those main findings, raised new puzzles of its own. This research was led by sociologist Marta Elliott of the University of Nevada, Reno and published in August, 2023 in Psychiatric Services [1]. Elliott sought to better understand what happens when conditions like schizophrenia, depression, or addiction are presented as having a genetic, versus an environmental, cause. Her team also wanted to know what happens when we combine different sorts of explanations, such as biological and environmental ones.

As they put it, “to our knowledge, this study is the first of its kind to manipulate multiple attributions and treatability and to test their independent and interactive effects on stigma with a large sample representative of the U.S. adult population.”

To this end, they recruited over 1,600 participants and presented various hypothetical scenarios to them (“vignettes”). In one vignette, a man consults a physician and is told his mental disorder is genetic. In another, he is told his mental disorder is caused by trauma. In yet another, he is told his mental disorder is caused by both genes and trauma.

The participants were then asked questions, such as how willing they would be to spend an evening socializing with the man or making friends with him.

Predictably, biological explanations increase the desire for social distance, regardless of which mental illness is in question. The desire for social distance was far stronger for schizophrenia and addiction than for depression.

New Puzzles

Elliott's research, however, raised two new puzzles. First, she found no negative impact on public stigma when mental illness was presented as caused by life trauma. If I see your depression as the result of, say, profound grief , I’m just as likely to want to socialize with you or be friends with you. Knowing that your mental health problems stem from negative life events seems to have a powerful humanizing influence on how people think about those who suffer from mental illnesses.

Second, when offered an explanation that combined life trauma with genetics , participants’ desire for social distance increased almost as much as it did when the biological account was presented alone. It’s as if the “genetic” part of the explanation cancels out the humanizing impact of the traumatic event.

It seems to me that one possible explanation for these findings is that if I see your mental illness as a meaningful response to the problems of life, I’m less likely to see it as defining your very identity .

The authors note that these results may have implications for how psychiatrists and other mental health professionals, as well as the media, discuss mental illness: “Portraying mental illness in exclusively genetic terms may perpetuate stigma, encourage discrimination , and harm the mental health of people living with psychiatric diagnoses.”

As psychologists Eleanor Longden and John Read put the point, when it comes to mental illness, it may be time to start seeing “ people with problems ” rather than “patients with illnesses.”

Elliott, M., Ragsdale, J. M., and LaMotte, M. E. 2024. Causal Explanations, Treatability, and Mental Illness Stigma: Experimental Study. Psychiatric Services 75: 131-138. DOI: 10.1176/appi.ps.20230169

Justin Garson, Ph.D., is a philosopher and author of Madness: A Philosophical Exploration (Oxford, 2022) and The Biological Mind: A Philosophical Introduction, Second Edition (Routledge, 2022).

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Brain research shows the arts promote mental health

Associate Professor, Leadership, Policy & Governance, University of Calgary

Disclosure statement

Brittany Harker Martin owns Mindset Consulting Inc. and is the founder of Brain Smoothies, an art-based program.

University of Calgary provides funding as a founding partner of The Conversation CA.

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During self-isolation due to coronavirus, many are turning to the arts . Perhaps they seek a creative outlet or opportunity for expression; but it’s also possible that their attraction may be driven by an innate desire to use their brains in ways that make them feel good.

As a professor and arts educator for over 20 years, I have witnessed the mental benefits of an arts-rich life — but don’t take my word for it. There is a powerful and compelling case, supported by cutting-edge research, that the arts have positive effects on mental health .

Mental health issues affect nearly half of the global population, at some point, by age 40 . Add to that, recent challenges of the pandemic for maintaining mental wellness, managing fears and uncertainty , and one thing is clear: it’s time to think differently when it comes to how we engage our minds.

The arts offer an evidence-based solution for promoting mental health. While practising the arts is not the panacea for all mental health challenges, there’s enough evidence to support prioritizing arts in our own lives at home as well as in our education systems.

For managing well-being

The relationship between the arts and mental health is well established in the field of art therapy , which applies arts-based techniques (like painting, dancing and role play) as evidence-based interventions for mental health issues, such as anxiety and depression . There is also growing evidence that the arts can be used in non-therapy contexts for promoting mental health, such as using performing arts to learn about the core subject areas in schools or doing visual art with adults who are mentally well, and want to sustain that sense of wellness .

In other words, practising the arts can be used to build capacity for managing one’s mental and emotional well-being .

Neuroesthetics

With recent advances in biological, cognitive and neurological science, there are new forms of evidence on the arts and the brain. For example, researchers have used biofeedback to study the effects of visual art on neural circuits and neuroendocrine markers to find biological evidence that visual art promotes health, wellness and fosters adaptive responses to stress .

In another study, cognitive neuroscientists found that creating art reduces cortisol levels (markers for stress), and that through art people can induce positive mental states. These studies are part of a new field of research, called neuroesthetics : the scientific study of the neurobiological basis of the arts .

Neuroesthetics uses brain imaging, brain wave technology and biofeedback to gather scientific evidence of how we respond to the arts. Through this, there is physical, scientific evidence that the arts engage the mind in novel ways, tap into our emotions in healthy ways and make us feel good.

Mindfulness and flow

The arts have also been found to be effective tools for mindfulness, a trending practice in schools that is effective for managing mental health .

Being mindful is being aware and conscious of your thoughts and state of mind without judgement . The cognitive-reflective aspects of the arts, in addition to their ability to shift cognitive focus, make them especially effective as tools for mindfulness . Specifically, engaging with visual art has been found to activate different parts of the brain other than those taxed by logical, linear thinking; and another study found that visual art activated distinct and specialized visual areas of the brain .

Read more: Visual arts help marginalized youth learn mindfulness and self-compassion

In short: the arts create conditions for mindfulness by accessing and engaging different parts of the brain through conscious shifting of mental states. For those of us who practise regularly in the arts, we are aware of those states, able to shift in and out and reap the physiological benefits through a neurological system that delights in and rewards cognitive challenges. Neuroesthetic findings suggest this is not an experience exclusive to artists: it is simply untapped by those who do not practise in the arts.

Research shows that the arts can be used to create a unique cognitive shift into a holistic state of mind called flow, a state of optimal engagement first identified in artists, that is mentally pleasurable and neurochemically rewarding .

There is a wealth of studies on the relationship between the arts, flow and mental health , and flow-like states have been connected to mindfulness , attention , creativity and even improved cognition .

Benefits in education

Despite increasing evidence published in top, peer-reviewed journals, on the measurable benefits of the arts in education, such as increased academic performance and the development of innovative thinking , the arts continue to be marginalized in education .

Could the study of neuroesthetics finally provide the evidence decision-makers require to prioritize the arts in education? If so, we may be on the verge of a renaissance that remembers our human instinct to create.

One thing is certain: the mental health crisis affecting young people implicates a systematic failure to provide the right tools for success . That should not be acceptable to anyone.

Three tips for arts-based mindfulness

Make mistakes: Try something new and be willing to make mistakes to learn. Most artists practise for years before they are able to render something realistic, and they are willing to make many mistakes along the way, likely because the brain rewards learning. If you are trying this at home, don’t encourage anything messy with children unless you have time to oversee it. There is nothing worse for kids than getting in trouble for something you have encouraged — it can crush their love of art and inhibit creative exploration.

Reuse and repeat: Play and experiment with reusable materials, like dry-erase markers on windows that can be easily wiped away, or sculpting material, like playdough that can be squished and reshaped. This emphasizes practice and process over product and takes the pressure off to make something that looks good. If you really must keep a copy, snap a quick photo of the work, then let it go.

Limit language: Try not to talk when you are making art, and if you are listening to music, choose something without lyrics. The parts of the brain activated during visual art are different than those activated for speech generation and language processing. Give those overworked parts of the mind a break, and indulge in the calm relaxation that comes from doing so. The neurochemicals that are released feel good, and that is your brain’s way of thanking you for the experience.

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Mental Health and Substance Use Disorders Often Go Untreated for Parents on Medicaid

By Emily Baumgaertner

For parents struggling with mental health or substance use disorders, access to treatment can often mean the difference between keeping and losing their children. But a new analysis of health and child welfare records found that a significant portion of those who were eligible for Medicaid coverage for such treatment were not getting it.

The analysis, published Friday by researchers at the nonprofit institute RTI International and the Department of Health and Human Services, found that fewer than half of parents on Medicaid who had substance use disorders and had been referred to authorities over suspicions of child abuse or neglect had received treatment.

Some Context: Experts say bad situations can often be reversed with treatment.

Both mental health and drug addiction crises have been roiling the country, and the effects of parental drug use and mental illness can quickly trickle down to their children . Public health experts say substance use disorders can incapacitate a previously diligent parent and lead to the involvement of child protective services.

In 2021 alone, more than seven million children were referred to authorities over worries of maltreatment, according to a federal report , and more than 200,000 were removed from their homes. But research shows that when parents seek treatment for psychiatric and substance use disorders , they are far less likely to experience family separation.

The Numbers: What the researchers found.

To calculate treatment rates among parents on Medicaid, the health insurance program for low income people, Tami Mark, a health economist at RTI, who led the research, and her colleagues drew from a new publicly available data set that used de-identified social security numbers to link child welfare records in Florida and Kentucky with corresponding Medicaid claims records from 2020.

For comparison, they also analyzed a random sample of Medicaid recipients who had no records in the child welfare system. (The study didn’t capture any counseling or medication given outside the Medicaid system, nor any cases of mental health or substance use disorders that were undiagnosed.)

Among 58,551 parents who had a child referred to welfare services, more than half had a psychiatric or substance use diagnosis, compared to 33 percent of the comparison group. About 38 percent of those with referrals who had mental health disorders and 40 percent of those who had substance use disorders had received counseling; about 67 percent of people with mental health disorders and 38 percent of those with substance use disorders had received medication.

Norma Coe, an associate professor of medical ethics and health policy at the University of Pennsylvania, who was not involved in the research, said some of the rates were worse than general Medicaid treatment figures , suggesting that some barriers could be specific to parents.

“In general, the U.S. supports parents and caregivers less than many other countries,” Dr. Coe said, “which has numerous and lasting intergenerational effects on health and wealth.”

What Happens Next: Examining the barriers.

The study’s authors highlighted an array of roadblocks to receiving counseling and medication, including stigma, inconvenience and the fear of losing parental rights.

They called for better coordination between social programs, such as integrating the data systems of child welfare and Medicaid so that it would be clear when parents needed to be connected to specific services.

But Dr. Steven Woolf, a professor of family medicine and population health at Virginia Commonwealth University who studies inequity, said there was another challenge: a shortage of treatment providers that will accept patients on Medicaid, which pays lower reimbursement rates than private insurers.

“Access to behavioral health services is inadequate in the United States,” he said, “but it’s even worse for Medicaid beneficiaries.”

Emily Baumgaertner is a national health reporter for The Times, focusing on public health issues that primarily affect vulnerable communities. More about Emily Baumgaertner