mental health disorders case study

159 Case Studies: Real Stories Of People Overcoming Struggles of Mental Health

At Tracking Happiness, we’re dedicated to helping others around the world overcome struggles of mental health.

In 2022, we published a survey of 5,521 respondents and found:

• 88% of our respondents experienced mental health issues in the past year.
• 25% of people don’t feel comfortable sharing their struggles with anyone, not even their closest friends.

In order to break the stigma that surrounds mental health struggles, we’re looking to share your stories.

Overcoming struggles

They say that everyone you meet is engaged in a great struggle. No matter how well someone manages to hide it, there’s always something to overcome, a struggle to deal with, an obstacle to climb.

And when someone is engaged in a struggle, that person is looking for others to join him. Because we, as human beings, don’t thrive when we feel alone in facing a struggle.

Let’s throw rocks together

Overcoming your struggles is like defeating an angry giant. You try to throw rocks at it, but how much damage is one little rock gonna do?

Tracking Happiness can become your partner in facing this giant. We are on a mission to share all your stories of overcoming mental health struggles. By doing so, we want to help inspire you to overcome the things that you’re struggling with, while also breaking the stigma of mental health.

Which explains the phrase: “Let’s throw rocks together”.

Let’s throw rocks together, and become better at overcoming our struggles collectively. If you’re interested in becoming a part of this and sharing your story, click this link!

Case studies

July 9, 2024

Learning To Live With Irritable Bowel Syndrome With Therapy And A Positive Mindset

“Raising four young children and battling a chronic illness with no cure was challenging for me. On the outside, I looked OK. But I wasn’t and in some ways today still have flare-ups and struggles, the difference is, I now know how to maintain it, especially knowing this will be the rest of my life regardless!”

Struggled with: Irritable Bowel Syndrome

Helped by: Therapy Treatment

July 4, 2024

How A Rescue Dog Helped Me Overcome TBI, Depression and Suicidal Ideation

“I sat on the summer-hot pavement, and no one stopped or asked me if I was okay. No one called the police. People walked around me as quickly as possible. When I was all cried out, I walked home to my empty house. I bought a set of knives, ostensibly for cooking, but that was not the reason. I had thought about pills, and every day I researched how many of each prescription drug I was on would I need to take to die. Using a sharp knife seemed so much easier.”

Struggled with: Depression Suicidal Traumatic Brain Injury

Helped by: Medication Pets Volunteering

July 2, 2024

Walking El Camino de Santiago Helped Me Reconnect With My Authentic Self

“Beneath the outward bravado, I battled with self-doubt and kept wondering why genuine connections seemed beyond my ability. Even though I put out valiant efforts to conceal it, my inner turmoil seeped out, leaving me feeling exposed and vulnerable. And, I knew they could tell.”

Struggled with: Feeling lost People-pleasing Self-doubt

Helped by: Self-acceptance Self-awareness

June 27, 2024

My Journey of Overcoming Heartbreak Thanks to Self-Care and The Support Of Friends

“I’ve learned that finding the right people to confide in, those who offer genuine support and empathy, can make a significant difference in navigating these challenges. It takes time and trust to build those connections, but they are invaluable.”

Struggled with: Breakup

Helped by: Self-Care Social support

June 19, 2024

How Therapy, Self-Help and Medication Help Me Live With Depression and Anxiety

“When the next depressive episode hit in 2018, I was devastated. How could this happen again when I thought I had it all figured out? I experienced some of the darkest moments of my life and a nearly complete loss of hope.”

Struggled with: Anxiety Bipolar Disorder Depression Suicidal

Helped by: Medication Therapy

June 11, 2024

Sharing My Journey From Alcohol and Substance Abuse to Sobriety and Happiness

“I felt prettier, smarter, funnier when alcohol entered my body so I simply continued numbing through the years. The progression of this disease of alcoholism turned into a nasty drug habit and those feelings of insecurity turned into deep darkness when I was “off my meds”. Or in other words, without alcohol or drugs.”

Struggled with: Addiction Depression Suicidal

Helped by: Rehab Therapy

June 4, 2024

Finding Happiness and Self-Love After Escaping Death From Burning 90% Of My Body

“It was like starting life over again, except you know how to do things you physically can’t do, which emotionally drains you. There was definitely a sense of resentment and feeling sorry for myself, I think that is natural. You wonder what you did to deserve that, you wonder if things are ever going to get better, you wonder how people will treat you. When you are confined to a bed for weeks on end, really all you can do is wonder.”

Struggled with: Physical trauma

Helped by: Self-improvement Social support

May 28, 2024

Cognitive Reframing and Mindfulness Helped Me Overcome Depression and Suicidal Ideation

“After exploring ways to end my life, I resolved to slash my wrist. I retrieved a steak knife from the kitchen and pressed it against my skin. Yet, an unexpected sensation washed over me—a profound sense of peace, love, and joy.”

Struggled with: Depression Suicidal

Helped by: Meditation Mindfulness Self-improvement

May 21, 2024

Learning To Live With Postpartum Depression (PPD) Through Self-Acceptance and Coaching

“I absolutely did not want to talk to anyone about this. I found it easier to tell a stranger about my struggles because I knew I would not see them again. I felt that telling family or friends made my struggle real. I felt that they would now be able to hold me accountable.”

Struggled with: Postpartum depression

Helped by: Self-acceptance Social support

May 14, 2024

I’m Finding Luck After Trauma and Abuse Through Mindfulness

“I never mentioned the accident to anyone until I met my future husband at 22. He was sympathetic and supportive, and helped me understand the enormity of what I had been through.I still have not talked to my siblings about it.”

Struggled with: Abuse Depression Eating disorder Suicidal

Helped by: Meditation Mindfulness Reinventing yourself

Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

• Theresa Cerulli, MD
• Tina Matthews-Hayes, DNP, FNP, PMHNP

Custom Around the Practice Video Series

Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.

EP: 1 . Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Ep: 2 . clinical significance of bipolar disorder, ep: 3 . clinical impressions from patient case #1, ep: 4 . diagnosis of bipolar disorder, ep: 5 . treatment options for bipolar disorder, ep: 6 . patient case #2: 47-year-old man with treatment resistant depression (trd), ep: 7 . patient case #2 continued: novel second-generation antipsychotics, ep: 8 . role of telemedicine in bipolar disorder.

Michael E. Thase, MD : Hello and welcome to this Psychiatric Times™ Around the Practice , “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.

Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.

Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.

We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.

Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.

On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.

At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.

Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.

So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.

Transcript Edited for Clarity

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

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Case Examples

Strongly Recommended Treatments

Jill, a 32-year-old Afghanistan War veteran

Jill had been experiencing PTSD symptoms for more than five years. She consistently avoided thoughts and images related to witnessing her fellow service members being hit by an improvised explosive device. This case example explains how Jill's therapist used a cognitive worksheet as a starting point for engaging in Socratic dialogue.

Tom, a 23-year-old Iraq War veteran

Several published CPT case examples exist in the literature but many find the one in this chapter to be especially helpful: 

Monson, C.M., Resick, P.A., & Rizvi, S.L. (2014). Posttraumatic stress disorder. In D.H. Barlow (Ed.), Clinical handbook of psychological disorders (5th ed., pp. 80-113). New York, NY: Guilford Press. 

Philip, a 60-year-old who was in a traffic accident (PDF, 294KB)

This case example from the European Journal of Psychotraumatology details an assisted self-study application of cognitive therapy for PTSD. Philip developed PTSD and comorbid major depression following a traffic accident. He was treated in six sessions of cognitive therapy with self-study modules completed in between sessions.

Terry, a 42-year-old earthquake survivor

Terry consistently avoided thoughts and images related to witnessing the injuries and deaths of others during an earthquake. He began spending more time at work and filling his days with hobbies and activities. However, whenever he had free time, he would have unwanted intrusive thoughts about the earthquake. In addition, he was having increasingly distressing nightmares. This case example is followed by an excerpt from an in-session imaginal exposure with a different client.

Conditionally Recommended Treatments

Mike, a 32-year-old Iraq War veteran

Mike was a 32-year-old flight medic who had completed two tours in Iraq and discharged from the Army due to his posttraumatic stress disorder.

Eric, a 24-year-old Rwandan refugee living in Uganda (PDF, 28KB)

This document from the Common Language for Psychotherapy Procedures summarizes narrative exposure therapy and includes a case example about a Rwandan civil war refugee living in a Ugandan settlement. Eric had recurring intrusive images and nightmares of seeing his family be shot by armed rebels.

Mental Health Case Study: Understanding Depression through a Real-life Example

Imagine feeling an unrelenting heaviness weighing down on your chest. Every breath becomes a struggle as a cloud of sadness engulfs your every thought. Your energy levels plummet, leaving you physically and emotionally drained. This is the reality for millions of people worldwide who suffer from depression , a complex and debilitating mental health condition.

Understanding depression is crucial in order to provide effective support and treatment for those affected. While textbooks and research papers provide valuable insights, sometimes the best way to truly comprehend the depths of this condition is through real-life case studies. These stories bring depression to life, shedding light on its impact on individuals and society as a whole.

In this article, we will delve into the world of mental health case studies, using a real-life example to explore the intricacies of depression. We will examine the symptoms, prevalence, and consequences of this all-encompassing condition. Furthermore, we will discuss the significance of case studies in mental health research, including their ability to provide detailed information about individual experiences and contribute to the development of treatment strategies.

Through an in-depth analysis of a selected case study, we will gain insight into the journey of an individual facing depression. We will explore their background, symptoms, and initial diagnosis. Additionally, we will examine the various treatment options available and assess the effectiveness of the chosen approach.

By delving into this real-life example, we will not only gain a better understanding of depression as a mental health condition, but we will also uncover valuable lessons that can aid in the treatment and support of those who are affected. So, let us embark on this enlightening journey, using the power of case studies to bring understanding and empathy to those who need it most.

Understanding Depression

Depression is a complex and multifaceted mental health condition that affects millions of people worldwide. To comprehend the impact of depression, it is essential to explore its defining characteristics, prevalence, and consequences on individuals and society as a whole.

Defining depression and its symptoms

Depression is more than just feeling sad or experiencing a low mood. It is a serious mental health disorder characterized by persistent feelings of sadness, hopelessness, and a loss of interest in activities that were once enjoyable. Individuals with depression often experience a range of symptoms that can significantly impact their daily lives. These symptoms include:

1. Persistent feelings of sadness or emptiness. 2. Fatigue and decreased energy levels. 3. Significant changes in appetite and weight. 4. Difficulty concentrating or making decisions. 5. Insomnia or excessive sleep. 6. feelings of guilt, worthlessness, or hopelessness. 7. Loss of interest or pleasure in activities.

Exploring the prevalence of depression worldwide

Depression knows no boundaries and affects individuals from all walks of life. According to the World Health Organization (WHO), an estimated 264 million people globally suffer from depression. This makes depression one of the most common mental health conditions worldwide. Additionally, the WHO highlights that depression is more prevalent among females than males.

The impact of depression is not limited to individuals alone. It also has significant social and economic consequences. Depression can lead to impaired productivity, increased healthcare costs, and strain on relationships, contributing to a significant burden on families, communities, and society at large.

The impact of depression on individuals and society

Depression can have a profound and debilitating impact on individuals’ lives, affecting their physical, emotional, and social well-being. The persistent sadness and loss of interest can lead to difficulties in maintaining relationships, pursuing education or careers, and engaging in daily activities. Furthermore, depression increases the risk of developing other mental health conditions, such as anxiety disorders or substance abuse.

On a societal level, depression poses numerous challenges. The economic burden of depression is significant, with costs associated with treatment, reduced productivity, and premature death. Moreover, the social stigma surrounding mental health can impede individuals from seeking help and accessing appropriate support systems.

Understanding the prevalence and consequences of depression is crucial for policymakers, healthcare professionals, and individuals alike. By recognizing the significant impact depression has on individuals and society, appropriate resources and interventions can be developed to mitigate its effects and improve the overall well-being of those affected.

The Significance of Case Studies in Mental Health Research

Case studies play a vital role in mental health research, providing valuable insights into individual experiences and contributing to the development of effective treatment strategies. Let us explore why case studies are considered invaluable in understanding and addressing mental health conditions.

Why case studies are valuable in mental health research

Case studies offer a unique opportunity to examine mental health conditions within the real-life context of individuals. Unlike large-scale studies that focus on statistical data, case studies provide a detailed examination of specific cases, allowing researchers to delve into the complexities of a particular condition or treatment approach. This micro-level analysis helps researchers gain a deeper understanding of the nuances and intricacies involved.

The role of case studies in providing detailed information about individual experiences

Through case studies, researchers can capture rich narratives and delve into the lived experiences of individuals facing mental health challenges. These stories help to humanize the condition and provide valuable insights that go beyond a list of symptoms or diagnostic criteria. By understanding the unique experiences, thoughts, and emotions of individuals, researchers can develop a more comprehensive understanding of mental health conditions and tailor interventions accordingly.

How case studies contribute to the development of treatment strategies

Case studies form a vital foundation for the development of effective treatment strategies. By examining a specific case in detail, researchers can identify patterns, factors influencing treatment outcomes, and areas where intervention may be particularly effective. Moreover, case studies foster an iterative approach to treatment development—an ongoing cycle of using data and experience to refine and improve interventions.

By examining multiple case studies, researchers can identify common themes and trends, leading to the development of evidence-based guidelines and best practices. This allows healthcare professionals to provide more targeted and personalized support to individuals facing mental health conditions.

Furthermore, case studies can shed light on potential limitations or challenges in existing treatment approaches. By thoroughly analyzing different cases, researchers can identify gaps in current treatments and focus on areas that require further exploration and innovation.

In summary, case studies are a vital component of mental health research, offering detailed insights into the lived experiences of individuals with mental health conditions. They provide a rich understanding of the complexities of these conditions and contribute to the development of effective treatment strategies. By leveraging the power of case studies, researchers can move closer to improving the lives of individuals facing mental health challenges.

Examining a Real-life Case Study of Depression

In order to gain a deeper understanding of depression, let us now turn our attention to a real-life case study. By exploring the journey of an individual navigating through depression, we can gain valuable insights into the complexities and challenges associated with this mental health condition.

Introduction to the selected case study

In this case study, we will focus on Jane, a 32-year-old woman who has been struggling with depression for the past two years. Jane’s case offers a compelling narrative that highlights the various aspects of depression, including its onset, symptoms, and the treatment journey.

Background information on the individual facing depression

Before the onset of depression, Jane led a fulfilling and successful life. She had a promising career, a supportive network of friends and family, and engaged in hobbies that brought her joy. However, a series of life stressors, including a demanding job, a breakup, and the loss of a loved one, began to take a toll on her mental well-being.

Jane’s background highlights a common phenomenon – depression can affect individuals from all walks of life, irrespective of their socio-economic status, age, or external circumstances. It serves as a reminder that no one is immune to mental health challenges.

Presentation of symptoms and initial diagnosis

Jane began noticing a shift in her mood, characterized by persistent feelings of sadness and a lack of interest in activities she once enjoyed. She experienced disruptions in her sleep patterns, appetite changes, and a general sense of hopelessness. Recognizing the severity of her symptoms, Jane sought help from a mental health professional who diagnosed her with major depressive disorder.

Jane’s case exemplifies the varied and complex symptoms associated with depression. While individuals may exhibit overlapping symptoms, the intensity and manifestation of those symptoms can vary greatly, underscoring the importance of personalized and tailored treatment approaches.

By examining this real-life case study of depression, we can gain an empathetic understanding of the challenges faced by individuals experiencing this mental health condition. Through Jane’s journey, we will uncover the treatment options available for depression and analyze the effectiveness of the chosen approach. The case study will allow us to explore the nuances of depression and provide valuable insights into the treatment landscape for this prevalent mental health condition.

The Treatment Journey

When it comes to treating depression, there are various options available, ranging from therapy to medication. In this section, we will provide an overview of the treatment options for depression and analyze the treatment plan implemented in the real-life case study.

Overview of the treatment options available for depression

Treatment for depression typically involves a combination of approaches tailored to the individual’s needs. The two primary treatment modalities for depression are psychotherapy (talk therapy) and medication. Psychotherapy aims to help individuals explore their thoughts, emotions, and behaviors, while medication can help alleviate symptoms by restoring chemical imbalances in the brain.

Common forms of psychotherapy used in the treatment of depression include cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and psychodynamic therapy. These therapeutic approaches focus on addressing negative thought patterns, improving relationship dynamics, and gaining insight into underlying psychological factors contributing to depression.

In cases where medication is utilized, selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed. These medications help rebalance serotonin levels in the brain, which are often disrupted in individuals with depression. Other classes of antidepressant medications, such as serotonin-norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants (TCAs), may be considered in specific cases.

Exploring the treatment plan implemented in the case study

In Jane’s case, a comprehensive treatment plan was developed with the intention of addressing her specific needs and symptoms. Recognizing the severity of her depression, Jane’s healthcare team recommended a combination of talk therapy and medication.

Jane began attending weekly sessions of cognitive-behavioral therapy (CBT) with a licensed therapist. This form of therapy aimed to help Jane identify and challenge negative thought patterns, develop coping strategies, and cultivate more adaptive behaviors. The therapeutic relationship provided Jane with a safe space to explore and process her emotions, ultimately helping her regain a sense of control over her life.

In conjunction with therapy, Jane’s healthcare provider prescribed an SSRI medication to assist in managing her symptoms. The medication was carefully selected based on Jane’s specific symptoms and medical history, and regular follow-up appointments were scheduled to monitor her response to the medication and adjust the dosage if necessary.

Analyzing the effectiveness of the treatment approach

The effectiveness of treatment for depression varies from person to person, and it often requires a period of trial and adjustment to find the most suitable intervention. In Jane’s case, the combination of cognitive-behavioral therapy and medication proved to be beneficial. Over time, she reported a reduction in her depressive symptoms, an improvement in her overall mood, and increased ability to engage in activities she once enjoyed.

It is important to note that the treatment journey for depression is not always linear, and setbacks and challenges may occur along the way. Each individual responds differently to treatment, and adjustments might be necessary to optimize outcomes. Continuous communication between the individual and their healthcare team is crucial to addressing any concerns, monitoring progress, and adapting the treatment plan as needed.

By analyzing the treatment approach in the real-life case study, we gain insights into the various treatment options available for depression and how they can be tailored to meet individual needs. The combination of psychotherapy and medication offers a holistic approach, addressing both psychological and biological aspects of depression.

The Outcome and Lessons Learned

After undergoing treatment for depression, it is essential to assess the outcome and draw valuable lessons from the case study. In this section, we will discuss the progress made by the individual in the case study, examine the challenges faced during the treatment process, and identify key lessons learned.

Discussing the progress made by the individual in the case study

Throughout the treatment process, Jane experienced significant progress in managing her depression. She reported a reduction in depressive symptoms, improved mood, and a renewed sense of hope and purpose in her life. Jane’s active participation in therapy, combined with the appropriate use of medication, played a crucial role in her progress.

Furthermore, Jane’s support network of family and friends played a significant role in her recovery. Their understanding, empathy, and support provided a solid foundation for her journey towards improved mental well-being. This highlights the importance of social support in the treatment and management of depression.

Examining the challenges faced during the treatment process

Despite the progress made, Jane faced several challenges during her treatment journey. Adhering to the treatment plan consistently proved to be difficult at times, as she encountered setbacks and moments of self-doubt. Additionally, managing the side effects of the medication required careful monitoring and adjustments to find the right balance.

Moreover, the stigma associated with mental health continued to be a challenge for Jane. Overcoming societal misconceptions and seeking help required courage and resilience. The case study underscores the need for increased awareness, education, and advocacy to address the stigma surrounding mental health conditions.

Identifying the key lessons learned from the case study

The case study offers valuable lessons that can inform the treatment and support of individuals with depression:

1. Holistic Approach: The combination of psychotherapy and medication proved to be effective in addressing the psychological and biological aspects of depression. This highlights the need for a holistic and personalized treatment approach.

2. Importance of Support: Having a strong support system can significantly impact an individual’s ability to navigate through depression. Family, friends, and healthcare professionals play a vital role in providing empathy, understanding, and encouragement.

3. Individualized Treatment: Depression manifests differently in each individual, emphasizing the importance of tailoring treatment plans to meet individual needs. Personalized interventions are more likely to lead to positive outcomes.

4. Overcoming Stigma: Addressing the stigma associated with mental health conditions is crucial for individuals to seek timely help and access the support they need. Educating society about mental health is essential to create a more supportive and inclusive environment.

By drawing lessons from this real-life case study, we gain insights that can improve the understanding and treatment of depression. Recognizing the progress made, understanding the challenges faced, and implementing the lessons learned can contribute to more effective interventions and support systems for individuals facing depression.In conclusion, this article has explored the significance of mental health case studies in understanding and addressing depression, focusing on a real-life example. By delving into case studies, we gain a deeper appreciation for the complexities of depression and the profound impact it has on individuals and society.

Through our examination of the selected case study, we have learned valuable lessons about the nature of depression and its treatment. We have seen how the combination of psychotherapy and medication can provide a holistic approach, addressing both psychological and biological factors. Furthermore, the importance of social support and the role of a strong network in an individual’s recovery journey cannot be overstated.

Additionally, we have identified challenges faced during the treatment process, such as adherence to the treatment plan and managing medication side effects. These challenges highlight the need for ongoing monitoring, adjustments, and open communication between individuals and their healthcare providers.

The case study has also emphasized the impact of stigma on individuals seeking help for depression. Addressing societal misconceptions and promoting mental health awareness is essential to create a more supportive environment for those affected by depression and other mental health conditions.

Overall, this article reinforces the significance of case studies in advancing our understanding of mental health conditions and developing effective treatment strategies. Through real-life examples, we gain a more comprehensive and empathetic perspective on depression, enabling us to provide better support and care for individuals facing this mental health challenge.

As we conclude, it is crucial to emphasize the importance of continued research and exploration of mental health case studies. The more we learn from individual experiences, the better equipped we become to address the diverse needs of those affected by mental health conditions. By fostering a culture of understanding, support, and advocacy, we can strive towards a future where individuals with depression receive the care and compassion they deserve.

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CASE STUDY Sarah (bipolar disorder)

Case study details.

Sarah is a 42-year-old married woman who has a long history of both depressive and hypomanic episodes.  Across the years she has been variable diagnoses as having major depression, borderline personality disorder, and most recently, bipolar disorder.  Review of symptoms indicates that she indeed have multiple episodes of depression beginning in her late teens, but that clear hypomanic episodes later emerged.  Her elevated interpersonal conflict, hyper-sexuality and alcohol use during her hypomanic episodes led to the provisional borderline diagnosis, but in the context of her full history, bipolar disorder appears the best diagnosis.  Sarah notes that she is not currently in a relationship and that she feels alienated from her family.  She has been taking mood stabilizers for the last year, but continues to have low level symptoms of depression.  In the past, she has gone off her medication multiple times, but at present she says she is “tired of being in trouble all the time” and wants to try individual psychotherapy.

• Alcohol Use
• Elevated Mood
• Impulsivity
• Mania/Hypomania
• Mood Cycles
• Risky Behaviors

Diagnoses and Related Treatments

1. bipolar disorder.

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Part 2 Lucy’s Story

2.4 Lucy case study 3: Mental illness diagnosis

Nicole Graham

Introduction to case study

Lucy has experienced the symptoms of mental illness during her lifespan; however, it was not until her early twenties that she was formally diagnosed with bipolar affective disorder. In the case study below, we explore the symptomology that Lucy experienced in the lead up to and post diagnosis. Lucy needs to consider her mental illness in relation to her work as a Registered Nurse and as she continues to move through the various stages of adulthood.

Learning Objectives

By the end of this case study, you should be able to:

• Identify and consider the symptoms of mental illness.
• Develop an understanding of contributing biopsychosocial stressors that may exacerbate the symptoms of mental illness as experienced by Lucy.
• Critically analyse the professional, ethical, and legal requirements and considerations for a registered health professional living with chronic illness.

Lucy’s small group of friends describe her as energetic and ‘a party person’. Although she sometimes disappears from her social group for periods of time, her friends are not aware that Lucy experiences periods of intense depression. At times Lucy cannot find the energy to get out of bed or even get dressed, sometimes for extended periods. As she gets older, these feelings and moods, as she describes them, get more intense. She loves feeling high on life. This is when she has an abundance of energy, is not worried about what people think of her and often does not need to sleep. These are the times when she feels she can achieve her goals. One of these times is when she decides to become a nurse. She excels at university, loves the intensity of study, practice and the party lifestyle. Emergency Nursing is her calling. The fast pace, the quick turnaround matches her endless energy. The fact that she struggles to stay focused for extended periods of time is something she needs to consider in her nursing career, to ensure it does not impact negatively on her care.

Unfortunately, Lucy has experienced challenges in her career. For example, her manager often comments on her mental illness after she had openly disclosed her diagnosis. It is challenging for her to hear her colleagues speak badly about a person who presents with mental illness. The stigma she hears directed at others challenges her. She is also very aware that it could be her presenting to the Emergency Department when she is unwell and in need of further support. Lucy is constantly worried that her colleagues will read her medical chart and think she is unsafe to practice.

While the symptoms that cause significant distress and disruption to her life began in her late teens, they intensified after she commenced antidepressant medication after the loss of her child. She subsequently ceased taking them due to side effects. These medications particularly impact on her ability to be creative and reduce her libido and energy. By the time she turns 18, she notices more frequent, intense mood swings, often accompanied by intense feelings of anxiety. During her high periods, Lucy enjoys the energy, the feeling of euphoria, the increased desire to exercise, her engagement with people, and being impulsive and creative. Lucas appreciates her increased libido. However, during these periods of high mood, Lucy also has impaired boundaries and is often flirtatious in her behaviour towards both friends and people she doesn’t know. She also increases her spending and has limited sleep. Lucas is often frustrated by this behaviour, leading to fights. On occasion Lucas slaps her and gets into fights with the people she is flirting with. These periods can last days and sometimes weeks, always followed by depressive episodes.

When she is in the low phases of her mood, Lucy experiences an overwhelming sense of hopelessness and emptiness. She is unable to find the energy to get out of bed, shower or take interest in simple daily activities. Lucas gets frustrated and dismisses Lucy’s statements of wanting to end her life as ‘attention seeking’. Lucy often expresses the desire to leave this world when she feels this way. When Lucas seeks support from the local general practitioner, nothing really gets resolved. The GP prescribes the medication; Lucy regains her desire to participate in life; then stops the medication due to side effects which extend to gastrointestinal upsets, on top of the decrease in libido and not feeling like herself. When Lucy is referred to a psychologist, she does not engage for more than one session, saying that she doesn’t like the person and feels they judge her lifestyle. When the psychologist attempts to explore a family history of mental illness, Lucy says no- one in her family has it and dismisses the concept.

The intense ups and downs are briefly interrupted with periods of lower intensity. During these times, Lucy feels worried about various aspects of her life and finds it challenging to let go of her anxious thoughts. There are times when Lucy has symptoms like racing heart, gastrointestinal update and shortness of breath. She spends a great deal of time wanting her life to be better. Her desire to move on from Lucas and to start a new life becomes more intense. Lucy is confident this is not a symptom of depression; it is just that she is unhappy in her relationship. Lucy starts to consider career options, feeling that not working affects her lifestyle, freedom and health. As she explores different options on the internet, Lucy comes across a chat room. Using the chat name ‘Foxy Lady 20’, she develops new friendships. She finds herself talking a lot with a man named Lincoln who lives on the Gold Coast.

After a brief but intense period talking with Lincoln online, Lucy abruptly decides to leave Lucas and her life in Bundaberg to move in with Lincoln. Lincoln, aged 26, 5 years older than Lucy, owns a modest home on the Gold Coast and has stable employment at the local casino. Their relationship progresses quickly and within a month Lincoln has proposed to Lucy. They plan to marry within 12 months.

Lucy is now happy with her life and feels stable. She decides to pursue a degree in nursing at the local university. Lucy enrols and makes many new friends, enjoying the intensity of study and a new social scene. Her fiancé Lincoln also enjoys the social aspects of their relationship. During university examination periods, Lucy experiences strong emotions. At the suggestion of an academic she respects, she makes an appointment with the university counselling service. After the first 3 appointments, Lucy self-discovers, with the support of her counsellor, that she might benefit from a specialist consultation with a psychiatrist. She comes to recognise that her symptoms are not within the normal range experienced by her peers. Lincoln is incredibly supportive and attends the appointments with Lucy, extending on the information she provides. Lucy reveals information about her grandmother, who was considered eccentric, and known for her periods of elevated mood and manic behaviour. The treating psychiatrist suggests Lucy may be living with bipolar affective disorder and encourages her to trial the medication lithium.

Lucy does not enjoy the side effects of decreased energy, nausea and feeling dazed and ceases taking the lithium during the university break period. This causes Lucy to again experience an intense elevation of her mood, accompanied by risk-taking behaviours. Lucy goes out frequently, nightclubbing and being flirtatious with her friends. She becomes aggressive towards a woman who confronts Lucy about her behaviour with her boyfriend in the nightclub. This is the first time Lucy exhibits this type of response, along with very pressured speech, pacing and an inability to calm herself. The police are called. They recommend Lucy gets assessed at the hospital after hearing from Lincoln that she has ceased her medication. Lucy is admitted for a brief period in the acute mental health ward. After stabilising and recommencing lithium, Lucy returns to the care of her psychiatrist in the community. The discharge notes report that Lucy had been previously diagnosed with bipolar disorder, may also be experiencing anxiety related symptoms, and have personality vulnerabilities.

Lucy is in the final year of her university studies when she has a professional experience placement in the emergency ward. Lucy really enjoys the fast pace, as well as the variety of complex presentations. Lucy feels it matches her energy and her desire for frequent change. After she completes her studies, Lucy applies and is successful in obtaining a position at the local hospital. Throughout her initial graduate year, Lucy balances life with a diagnosis of mental illness as well as a program of her own self-care. She finds the roster patterns in particular incredibly challenging and again becomes unwell. She goes through a period of depression and is unable to work. During this period, Lucy experiences an overwhelming sense of hopelessness and considers ending her life. Again, she requires a higher level of engagement from her treating team. Lucy agrees she is not fit to work during this time and has a period of leave without pay to recover. She has disclosed to her manager that she has been diagnosed with a mental illness and later discusses how shift work impacts her sleep and her overall mental wellbeing.

Over time, Lucy develops strategies to maintain wellness. However, she describes her relationship with the Nursing Unit Manager as strained, due to her inability to work night shift as her medical certificate shows. Lucy says she is often reminded of the impact that her set roster has on her colleagues. Lucy also feels unheard and dismissed when she raises workplace concerns, as her manager attributes her feelings to her mental health deteriorating. Lucy has a further period when her mental health deteriorates. However, this time it is due to a change in her medication.

As Lucy and Lincoln have a desire to have a child, Lucy was advised that she cease lithium in favour of lamotrigine, to reduce the risk of harm to the baby. Lucy ceases work during the period when her mental health deteriorates during the initial phase of changing medication. Lucy recommences lithium after she ceases breastfeeding their son at 4 months, with good effect and returns to work.

Case study questions

• Consider the symptoms that Lucy experiences and indicate whether they align with the suggested diagnosis.
• Identify the biopsychosocial contributing factors that could impact mental health and wellness.
• Review and identify the professional disclosure requirements of a Registered Nurse who lives with mental illness in your local area.
• Identify self-care strategies that Lucy or yourself as a health professional could implement to support mental health and wellbeing.

 Thinking point

Sometimes people do not agree with a diagnosis of mental illness, which can be incorrectly labelled as ‘denial’ by health professionals. It is possible that the person is unable to perceive or be aware of their illness. This inability of insight is termed anosognosia (Amador, 2023). The cause of anosognosia in simple terms can be due to a non-functioning or impaired part of the frontal lobe of the brain, which may be caused by schizophrenia, bipolar disorder or other diseases such as dementia (Kirsch et al., 2021).

As healthcare workers will likely care for someone who is experiencing anosognosia, it is important to reflect on how you may work with someone who does not have the level of insight you would have hoped. Below is a roleplay activity whereby you can experience what it might be like to communicate with someone experiencing anosognosia. Reflect on your communication skills and identify strategies you could use to improve your therapeutic engagement.

Role play activity – Caring for a person who is experiencing anosognosia

Learning objectives.

• Demonstrate therapeutic engagement with someone who is experiencing mental illness
• Identify effective communication skills
• Reflect on challenges and identify professional learning needs

Resources required

• Suitable location to act out scene.
• One additional person to play the role of service user.

Two people assume role of either service user or clinician. If time permits, switch roles and repeat.

• Lucy has been commenced on lithium carbonate ER for treatment of her bipolar disorder.
• Lucy is attending the health care facility every week, as per the treating psychiatrist’s requests.
• The clinician’s role is to monitor whether Lucy is experiencing any side effects.

Role 1 – Clinician

• Clinician assumes role of health care worker in a health care setting of choice.
• Lucy has presented and your role is to ask Lucy whether she is experiencing any side effects and whether she has noticed any improvements in her mental state.

Role 2 – Lucy who lives with bipolar

• Lucy responds that she does not understand the need for the tablets. She also denies having a mental illness. Lucy says she will do what she is told, but does not think there is anything wrong with her. Lucy thinks she is just an energetic person who at times gets sad, which she describes as ‘perfectly normal.’ Lucy is not experiencing any negative side effects, but says she would like clarification about why the doctor has prescribed this medication.

Post role play debrief

Reflect and discuss your experiences, both as Lucy and as the clinician. Identify and discuss what was effective and what were the challenges.

Identify professional development opportunities and develop a learning plan to achieve your goals.

Additional resources that might be helpful

• Australian Prescriber: Lithium therapy and its interactions
• LEAP Institute: The impact of anosognosia and noncompliance (video)

Key information and links to other resources

Fisher (2022) suggests there are large numbers of health professionals who live with mental illness and recognise the practice value that comes with lived experience. However, the author also notes that as stigma is rife within the health care environment, disclosing mental illness can trigger an enhanced surveillance of the health professional’s practice or impede professional relationships (Fisher, 2022).

It is evident that the case studies derived from Lucy’s life story are complex and holistic care is essential. The biopsychosocial model was first conceptualised in 1977 by George Engel, who suggests it is not only a person’s medical condition, but also psychological and social factors that influence health and wellbeing (Engel,2012).

Below are examples of what you as a health professional could consider in each domain.

• Biological: Age, gender, physical health conditions, drug effects, genetic vulnerabilities
• Psychological:  Emotions, thoughts, behaviours, coping skills, values
• Social:  Living situation, social environment, work, relationships, finances, education

Developing skills through engaging in reflective practice and professional development is essential. Each person is unique, which requires you as the professional to adapt to their particular circumstances. The resources below can help you develop understanding of both regulatory requirements and the diagnosis Lucy is living with.

Organisations providing information relevant to this case study

• Rethink Mental Illness: Bipolar disorder
• Australian Health Practitioner Regulation Agency (AHPRA): Resources – helping you understand mandatory notifications
• Australian Health Practitioner Regulation Agency (AHPRA): Podcast – Mental health of nurses, midwives and the people they care for
• Black Dog Institute: TEN – The essential network for health professionals
• Borderline Personality Disorder Community
• National Institute of Mental Health (NIMH): Anxiety disorders

 Case study 3 summary

In this case study, Lucy’s symptoms of mental illness emerge in her teenage years. Lucy describes periods of intense mood, both elevated and depressed, as well as potential anxiety-related responses. It is not until she develops a therapeutic relationship with a university school-based counsellor that she realises it might be beneficial to engage the services of a psychiatrist. After she is diagnosed with bipolar affective disorder she engages in treatment. Lucy shares her experience of both inpatient and community treatment as well as her professional practice requirements in the context of her mental illness.

Amador, X. (2023). Denial of anosognosia in schizophrenia. Schizophrenia Research , 252 , 242–243. https://doi.org/10.1016/j.schres.2023.01.009

Engel, G. (2012). The need for a new medical model: A challenge for biomedicine. Psychodynamic Psychiatry, 40 (3), 377–396. https://doi.org/10.1521/pdps.2012.40.3.377

Fisher, J. (2023). Who am I? The identity crisis of mental health professionals living with mental illness. Journal of Psychiatric and Mental Health Nursing . Advance online publication. https://doi.org/10.1111/jpm.12930

Kirsch, L. P., Mathys, C., Papadaki, C., Talelli, P., Friston, K., Moro, V., & Fotopoulou, A. (2021). Updating beliefs beyond the here-and-now: The counter-factual self in anosognosia for hemiplegia. Brain Communications , 3 (2), Article fcab098. https://doi.org/10.1093/braincomms/fcab098

Case Studies for Health, Research and Practice in Australia and New Zealand Copyright © 2023 by Nicole Graham is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

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A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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We are also grateful to patient’s legal guardian for their support in writing this manuscript.

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MR, AJM, JVV conceptualized and followed up the patient. MR, AJM, JVV did literature survey and wrote the report and took part in the scientific discussion and in finalizing the manuscript. All the authors read and approved the final document.

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Correspondence to Magdalena Romanowicz .

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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Received : 20 December 2016

Accepted : 01 September 2017

Published : 11 September 2017

DOI : https://doi.org/10.1186/s12888-017-1492-y

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• Polypharmacy
• Disinhibited social engagement disorder

BMC Psychiatry

ISSN: 1471-244X

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Mental health case studies

Driving up quality in mental health care.

Mental health care across the NHS in England is changing to improve the experiences of the people who use them. In many areas, a transformation is already under way, offering people better and earlier access as well as more personalised care, whilst building partnerships which reach beyond the NHS to create integrated and innovative approaches to mental health care and support.

Find out more through our case studies and films about how mental health care across the NHS is changing and developing to better meet people’s needs.

• Children and young people (CYP)
• Community mental health
• Crisis mental health
• Early intervention in psychosis (EIP)
• Improving access to psychological therapies (IAPT)
• Perinatal mental health
• Severe mental illness (SMI)
• Staff mental health and wellbeing
• Other mental health case studies
• Archived mental health case studies

Module 13: Disorders of Childhood and Adolescence

Case studies: disorders of childhood and adolescence, learning objectives.

• Identify disorders of childhood and adolescence in case studies

Case Study: Jake

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts. [1]

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.

Case Study: Kelli

Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.

• Kolaitis, G., Bouwkamp, C.G., Papakonstantinou, A. et al. A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability, and 47,XXY syndrome in combination with a 7q11.23 duplication, 11p15.5 deletion, and 20q13.33 deletion. Child Adolesc Psychiatry Ment Health 10, 33 (2016). https://doi.org/10.1186/s13034-016-0121-8 ↵
• Case Study: Childhood and Adolescence. Authored by : Chrissy Hicks for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability.... Authored by : Gerasimos Kolaitis, Christian G. Bouwkamp, Alexia Papakonstantinou, Ioanna Otheiti, Maria Belivanaki, Styliani Haritaki, Terpsihori Korpa, Zinovia Albani, Elena Terzioglou, Polyxeni Apostola, Aggeliki Skamnaki, Athena Xaidara, Konstantina Kosma, Sophia Kitsiou-Tzeli, Maria Tzetis . Provided by : Child and Adolescent Psychiatry and Mental Health. Located at : https://capmh.biomedcentral.com/articles/10.1186/s13034-016-0121-8 . License : CC BY: Attribution
• Angry boy. Located at : https://www.pxfuel.com/en/free-photo-jojfk . License : Public Domain: No Known Copyright
• Frustrated girl. Located at : https://www.pickpik.com/book-bored-college-education-female-girl-1717 . License : Public Domain: No Known Copyright

Providing Sustainable Mental and Neurological Health Care in Ghana and Kenya: Workshop Summary (2016)

Chapter: 4 case studies, 4 case studies.

Throughout the workshop, case studies were presented of some of the successful mental health projects in Ghana, Kenya, and around the world. Although each case study was multifaceted and addressed many challenges, the workshop participants focused on distilling lessons learned from each project that could be applied to potential mental health demonstration projects.

AFRICA MENTAL HEALTH FOUNDATION 1 : COMMUNITY PARTNERSHIPS

Founded in 2004, AMHF has stated the vision of being “the center of excellence in Africa for research, training, knowledge translation, and advocacy in mental health.” 1 AMHF uses a multidisciplinary, multisectoral approach to improve mental health through programs at all levels, from physician specialist training to community-based stigma reduction, including school-based programs. According to David Ndetei, AMHF’s greatest successes have been in creating community partnerships and joint ownership of programs. One partnership in particular that has been successful is the relationship AMHF has built with traditional and faith healers. AMHF works with them to build awareness of mental health disorders, to develop skills to screen for and refer cases of mental illness, and to deliver evidence-based, mhGAP-adapted psychosocial interventions. Other partnerships critical to the success of their programs, noted

_______________________

1 See http://www.africamentalhealthfoundation.org (accessed July 14, 2015).

Ndetei, include those with county government where health services have been devolved and with the government of Kenya.

BASICNEEDS 2

BasicNeeds was founded in 2000 with the goal of improving the lives of people around the world diagnosed with a mental illness or epilepsy, by ensuring that their basic needs are met and their rights are recognized and respected.

Ghana 3 : Building Capacity of NGOs

BasicNeeds’ Mid-Ghana Project is focused on the Ashanti and Brong Ahafo regions. It is a community-based model that seeks to ensure that people with mental illness or epilepsy can access their human rights. Specifically, BasicNeeds’ activities can be categorized into four main areas: identifying and supporting people who have treatment needs; training community health workers; creating awareness; and supporting service delivery through psychiatric outreach to communities. Since 2000, BasicNeeds Ghana has provided 7,800 women, men, and children with mental illness or epilepsy and caregivers access to mental health and development services through community-based mental health, and it has developed 130 self-help user groups as a mechanism for patients and caregivers to express their needs and claim their rights to inclusion and development. Peter Yaro, executive director of BasicNeeds Ghana, said that a key component of their work is training local partners such as NGOs. BasicNeeds trains and supports key local partners on their Mental Health and Development model to enable the organizations to gain accreditation as a BasicNeeds franchise partner. The components of the model include capacity building, community mental health, sustainable livelihoods (e.g., promoting social reintegration), research, advocacy, policy, and collaboration. The NGOs they work with are not necessarily mental health organizations: for the Mid-Ghana project, for instance, the organizations were focused on child labor, reproductive health care, education, and women’s issues. Yaro said that this type of collaboration among NGOs is a great way to align mental health activities with what

2 See http://www.basicneeds.org (accessed July 14, 2015).

3 See http://www.basicneeds.org/where-we-work/ghana (accessed July 14, 2015).

the NGOs are already doing. He cautioned, however, that even though many NGOs are interested in working in mental health, they “sometimes do not know how.” He said that if given the proper support and training, these NGOs can be valuable partners in improving community mental health. As a result, BasicNeeds Ghana established two regional mental health alliances that bring together more than 45 community-based organizations/NGOs and decentralized government ministries, departments, and agencies to foster these collaborations and implement work in mental health.

Kenya 4 : Patients as Ambassadors

BasicNeeds works at the community level to build the capacity of people with MNS disorders to participate in their own treatment and recovery, as well as to reduce stigma and prepare the rest of the community to help people with MNS disorders. Joyce Kingori reported that the critical partners of BasicNeeds are the adults and children with MNS disorders “who have taken the courage to come and get treatment, to share their stories, to provide their insights.” BasicNeeds uses mental health “ambassadors”: young people who have been treated and now work to create awareness among their peers, and to reach out to provide support to those in need. Kingori noted that in addition to the critical partnership with patients, BasicNeeds also has important partnerships with organizations such as KAWE and AMHF, as well as the MoH and local government and health officials.

DIRECT RELIEF 5 AND BREAST CARE INTERNATIONAL 6 : COLLABORATION

Founded in 1948, Direct Relief provides medical resources to areas affected by poverty or emergency situations. It focuses primarily on maternal and child health, disease prevention and treatment, emergency preparedness and response, and strengthening health systems. 5 In partnership with Breast Care International (BCI), a Ghanaian-based organization dedicated to breast cancer awareness, the two organizations conducted a mental

4 See http://www.basicneeds.org/where-we-work/kenya (accessed July 14, 2015).

5 See http://www.directrelief.org/about (accessed July 14, 2015).

6 See http://www.breastcareghana.com/about (accessed July 14, 2015).

health research project in the Ashanti region of Ghana. They are currently collecting data on the burden of mental health and examining what types of mental health services are available, with the purpose of using the data to recommend measures to address the challenges in the region. Andrew Schroeder, director of research and analytics for Direct Relief, and Samuel Kwasi Agyei, of BCI, stressed the importance of collaboration in their work. Schroeder noted that the collaboration with BCI was critical to the success of the project because they are a community-based organization that is trusted in the area in which they work. In addition, because of BCI’s interest in broad-based health care, the project is working to embed mental health care services in the general health care system, rather than operating as a stand-alone mental health program, thus making improvements that are systematic and sustainable.

EMERGING MENTAL HEALTH SYSTEMS IN LOW- AND MIDDLE-INCOME COUNTRIES (EMERALD) 7 : STRENGTHENING HEALTH SYSTEMS

EMERALD, or Emerging Mental Health Systems in Low- and Middle-Income Countries, is a 5-year program (2012–2017) that works in six countries (Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda) to improve mental health outcomes by improving health system performance, said Jibril Abdulmalik, Co-Investigator of EMERALD at the University of Ibadan in Nigeria. The program consists of six work packages: (1) project management and coordination; (2) capacity building in mental health systems research; (3) adequate, fair, and sustainable resourcing for mental health (health systems inputs); (4) integrated provision of mental health services (mental health system processes); (5) improved coverage and goal attainment in mental health (health system outputs); and (6) dissemination. EMERALD seeks to strengthen the system itself through activities such as holding trainings for policy makers, researchers, and service users; providing scholarships for students seeking advanced degrees in mental health; developing curricula for master’s training in public mental health; helping countries with cost projections; facilitating the integration of mental health into primary care; and improving health information systems. Abdulmalik added that having cultivated

7 See http://www.emerald-project.eu (accessed July 14, 2015).

relationships with policy makers and key stakeholders was useful to understanding health care systems hierarchy, as well as leveraging existing platforms. He acknowledged that some of these individual efforts are “droplets” in a bucket, but he hoped that the EMERALD project, as a whole, would result in a comprehensive template for strengthening mental health systems in low- and middle-income countries.

FIGHT AGAINST EPILEPSY 8 : STAKEHOLDER ENGAGEMENT

WHO and the Ghana MoH, with support from Sanofi Espoir Foundation, have teamed up for a 4-year project (2012–2015) to reduce the epilepsy treatment gap, using a variety of strategies: promoting training of all health care providers, improving community awareness to reduce stigma and increase demand for care, and integrating epilepsy care within the primary health care system. Since the initiation of the project:

• A national/district coordinating committee was established;
• A situation analysis report was developed at the national, regional, and district levels;
• 330 volunteers and 404 primary health care providers were trained in epilepsy management;
• Gradual scale up occurred, with coverage now in 10 districts in 5 regions;
• A monitoring and evaluation strategy was developed; and
• A draft model of epilepsy care was developed.

Cynthia Sottie, national coordinator of the Fight Against Epilepsy project at the Ghana Health Service, said that engaging with stakeholders at all levels, at all stages of the project, has been critical to the project’s success. She noted that they have involved the Minister of Health, representatives from the teaching hospitals, national and international NGOs, the Mental Health Society of Ghana, regional health directors, faith healers, and community members. By involving so many stakeholders from the beginning of the project, “everybody was involved [and] everybody knows what is going on at each time.” Sottie said that everyone’s in-

8 See http://fondation-sanofi-espoir.com/download/2012-10-22_CP_Ghana_EN.pdf (accessed July 14, 2015).

volvement was vital to getting the support and participation necessary to carry out the project.

KENYA ASSOCIATION FOR THE WELFARE OF PEOPLE WITH EPILEPSY 9 : PUBLIC EDUCATION

KAWE was founded in 1982 and seeks to improve the lives of those with epilepsy through a variety of efforts, including the training of primary health workers, awareness creation and stigma reduction through community projects, medical provision and support (e.g., epilepsy clinics, patient groups), and policy advocacy at the MoH in Kenya. Between 2000 and 2014, KAWE trained 1,814 clinical officers and nurses and 3,095 CHWs, and the organization’s awareness programs reached an estimated 254,000 people directly and more than 3 million through mass media, said Osman Miyanji. In addition, more than 25,000 patients have been registered throughout clinics in Nairobi, Kenya, as a result of KAWE’s community programs, and from a training perspective, the organization helped launch national epilepsy guidelines and developed a more comprehensive curriculum for medical training institutions. Miyanji reported that KAWE has demonstrated that they can close the treatment gap, and he noted that in 30 years of experience, public education to address social stigma and reduce ignorance has been a key element of their success.

THE KINTAMPO PROJECT 10 : FOCUS ON COMMUNITY- BASED CARE

The Kintampo Project, a collaboration between Ghana and the United Kingdom, is “training a new generation of mental health workers,” said Joseph B. Asare. The project trains clinical psychiatry officers (CPOs) and community mental health officers (CMHOs). CPOs can diagnose mental illness and prescribe medication, while CMHOs focus on detection of mental illness in the community, education of local people, and reducing stigma and discrimination. CMHOs work in part by developing relationships with local families, schools, prayer camps, and tradi-

9 See http://www.kawe-kenya.org (accessed July 14, 2015).

10 See http://www.thekintampoproject.org (accessed July 14, 2015).

tional healers. The organization’s objective is to have one CPO and two to three CMHOs in each of Ghana’s 216 districts by 2017. Through the Kintampo Project, workers have been trained and deployed all over Ghana, helping thousands of the most needy people. The project is on track to boost the mental health workforce by 60 percent and the number of patients treated per year by 500 percent. By focusing on community-based care, Kintampo is shifting the focus of mental health care away from large hospitals and into the community where it is most needed, Asare said.

PROGRAM FOR IMPROVING MENTAL HEALTH CARE (PRIME) 11 : BUY-IN, BUY-IN, BUY-IN

Tedla Wolde-Giorgis provided an overview of PRIME’s efforts to integrate mental health into the existing health delivery system in five countries (Ethiopia, India, Nepal, South Africa, and Uganda). The purpose of the 6-year study, launched in 2011, is to research the magnitude, impact, and tractability of mental disorders in low- and middle-income countries. Using Ethiopia as an example, Wolde-Giorgis reported that integration was an incredibly complex process (beyond the instructions in the mhGAP intervention guide [IG]) that required buy-in from decision makers at all levels—national, regional, and community—as well as support from health care facilities and NGOs. Wolde-Giorgis said that, regardless of the level of support at the top, a top-down approach will not work; ultimately, the day-to-day work is done in the community and facilities, so it must be led at this level. He also noted that stigma reduction is a critical part of getting buy-in at the community level. For an effort to be sustainable, the buy-in must be continuous—it is not a one-time effort. Leadership must be continuously reminded of the importance of mental health and how it aligns with national priorities because there are so many other competing health concerns and health initiatives (e.g., MDGs).

11 See http://www.prime.uct.ac.za (accessed July 14, 2015).

PROJECT FIVES ALIVE! 12 : SCALING UP

The goal of Project Fives Alive! is to reduce mortality rates among children below age 5. Sodzi Sodzi-Tettey said the project uses a quality improvement approach, which requires forming quality improvement teams, having the teams develop initiatives on how to change mortality rates, implementing these initiatives, and then using data to assess if there was a positive effect. The project started in 9 hospitals but has since been scaled up to 200 hospitals. Sodzi-Tettey said that the initial 9 hospitals were chosen because they were high-burden hospitals with high rates of mortality for children below age 5. By the end of the first 18 months of operation, 6 of the 9 hospitals showed significant improvement in mortality reduction. By learning what worked in these high-burden hospitals, the project created a “change package,” which consisted of data-driven initiatives that had led to improvement related to improving delay in seeking and providing care and to reliable use of protocols. Sodzi-Tettey said that of the 134 hospitals in which the project currently operates, nearly 70 percent have adopted ideas from the change package, while also developing their own initiatives (e.g., targeted health education on early care-seeking using interactive platforms, triage systems for screening and emergency treatment of critically ill children, and training staff on protocols, followed by regular coaching and mentoring) ( Twum-Danso et al., 2012 ). In these 134 hospitals, there has been a 31 percent reduction in facility-based mortality in children younger than age 5. Sodzi-Tettey reported on three lessons learned from the project. First, initiatives should be tested promptly and on a small scale; this creates data that management can use to decide whether or not to implement a change. Second, teams should be empowered to know and use their own data. Sodzi-Tettey said that many workers were used to reporting data to the top but had not been aware of their own performance. Once they had the ability to track their own progress, they became even more invested in improvement. Finally, Sodzi-Tettey said that sustainability is only possible if a project understands and works within the existing health system, rather than with its own schedule and priorities.

12 See http://www.ihi.org/engage/initiatives/ghana/pages/default.aspx (accessed July 14, 2015).

PARTNERS IN HEALTH IN RWANDA 13 : INTEGRATION OF MENTAL HEALTH INTO THE GENERAL CARE SYSTEM THROUGH PUBLIC-SECTOR COLLABORATION AND LEVERAGE OF EXISTING HEALTH PLATFORMS

Partners In Health strives “to bring the benefits of modern medical science to those most in need of them and to serve as an antidote to despair.” 13 The Partners In Health program in Rwanda focused on close collaboration within the public sector to integrate mental health care into the general community-based care system within the district. At each level (hospital, health centers, and community), health workers were trained in mental health care. Partners In Health’s primary mental health endeavor in Rwanda was the integration of mental health care into health centers using existing structure of intensive supported supervision and quality improvement following training. One challenge that the program faced was resistance from the staff to admitting and treating psychiatric patients in the general ward. Smith offered several reasons for the resistance, including stigma and discrimination. She said the most successful strategy for reducing stigma among the health care workers was effective treatment of patients. When staff saw people come in with very acute psychiatric conditions, receive treatment, and get better, the workers’ perspective on mental health was significantly changed. Smith recalled the story of a district hospital manager who unknowingly hired a former patient to work on the grounds of the hospital. When he learned that she had been admitted to his hospital as a psychiatric patient only 2 months earlier, and was now capable of holding a job, he “became a big advocate for the work.” Smith said, “It was the witnessing of people getting better that was the most destigmatizing.” In addition to reducing stigma, Smith said that another key element of successful integration was leveraging the existing system structures and human resources. Rather than restructuring or bringing in new people, they worked within the existing system by mapping skill sets and matching them to the skills needed for mental health care. Smith said that by using what was already available, a much more rapid and efficient integration into primary care was possible.

13 See http://www.pih.org (accessed July 14, 2015).

MENTAL HEALTH CARE IN TURKEY: POLICY DEVELOPMENT

Oğuz Karamustafalioğlu, professor of psychiatry at Üsküdar University, provided an overview of mental health care in Turkey. He noted the high treatment gap for schizophrenia, depression, and substance use problems, and the lack of human and material (i.e., psychiatric beds) resources needed to adequately meet the demands of patients. In 2006, the MoH in Turkey released a National Mental Health Policy (NMHP) 14 aimed at mobilizing resources to ensure that mental health care services are accessible and balanced. Karamustafalioğlu stated that the NMHP encouraged preventative methods to decrease the burden of mental disorders, to increase attainable mental health care and services at both primary and secondary care levels, to encourage the respect of human rights for those with a mental illness, and to support the necessary legislation to protect their rights. Although there have been some successes since the NMHP was released—including an increase in the outpatient mental health care units at the general hospitals, the number of adult and child psychiatrists, and public education and awareness programs about mental health to reduce stigma—he emphasized that there is still more to be done to provide care and treatment to all patients.

WORLD ASSOCIATION FOR SOCIAL PSYCHIATRY AND SANOFI: COUNTRY-SPECIFIC APPROACHES

Sanofi’s Access to Medicines department works in some of the world’s poorest countries, disseminating information about MNS disorders, improving diagnosis, and making treatment affordable and accessible to patients, said Francois Bompart. Programs are specifically tailored to each country in which they work, an approach that is critical to success. For example, Sanofi works in Comoros, a small group of islands off the coast of Mozambique. Bompart said that several issues complicate mental health care in Comoros: transportation is difficult and expensive, and there is only one psychiatrist in the country. In order to work within these confines, Sanofi is working to train primary health care providers to use telemedicine to connect to the one psychiatrist—a tailored ap-

14 See https://www.mindbank.info/item/69 (accessed August 13, 2015).

proach that works for the specific context of Comoros but might be wholly inappropriate elsewhere. Similarly, in Guatemala, Sanofi tailored its approach by choosing to partner with a local NGO instead of the MoH because of instability in the government. With regards to cultural and societal sensitivities, Bompart noted that in some areas in countries such as Morocco, traditional and faith healers were not involved in the awareness programs given the local contexts.

686 PROJECT IN CHINA: FOCUS ON GENERAL PRACTITIONERS

The 686 project was a 2004 initiative that launched mental health reform in China after the severe acute respiratory syndrome (SARS) epidemic. Prior to the reform, mental health institutions (565 hospitals) were worn and outdated, there were no community-based mental health care services, and medical insurance was provided only to employed people. Ma Hong, deputy director of mental health programs at the China MoH, stated that initially, the government granted 6.86 million Yuan (860,000 USD) to train providers in mental health, and as the program continued, it covered free hospital treatment for patients and out-of-pocket medical costs for impoverished patients. Hong noted that it was critical to learn how to express the need for funding and the overall burden of mental health in the language of the government. The project consisted of 60 demonstration projects reaching a population of 42.9 million people, in which providers were trained; hospital services were expanded to communities; and, when universal medical insurance was implemented in China, the project covered out-of-pocket costs for impoverished patients. One significant challenge was that while there was adequate funding for services, the human resources necessary to actually provide care lagged behind. Hong said, “Money does not equal service—human resources development is much slower than simply building a new hospital.” She proposed that too much reliance on specialists in rural areas is misguided, and that when building a mental health program, the focus should be on expanding general practitioners’ knowledge of mental health and building their capacity to diagnose and treat MNS disorders. Hong noted that a hospital–community continuous care system has since been established and 4.29 million patients have been registered in the health information system, including 3.41 million patients who have received community health care, 61.7 percent of whom are farmers.

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Mental, neurological, and substance use (MNS) disorders have a substantial impact on global health and well-being. Disorders such as depression, alcohol abuse, and schizophrenia constitute about 13 percent of the total burden of disease. Worldwide, MNS disorders are the leading cause of disability, and the 10th leading cause of death. Despite this high burden, there is a significant shortage of resources available to prevent, diagnose, and treat MNS disorders. Approximately four out of five people with serious MNS disorders living in low- and middle-income countries do not receive needed health services.

This treatment gap is particularly high in Sub-Saharan Africa (SSA). Challenges to MNS care in SSA countries include a lack of trained mental health professionals, few mental health facilities, and low prioritization for MNS disorders in budget allocations. African countries, on average, have one psychiatrist for every 2 million people, whereas European countries have one psychiatrist per 12,000 people.

Expanding on previous efforts to address the development and improvement of sustainable mental health systems in SSA, the Institute of Medicine convened this 2015 workshop series, bringing together key stakeholders to examine country-specific opportunities to improve the health care infrastructure in order to better prevent, diagnose, and treat MNS disorders. Providing Sustainable Mental and Neurological Health Care in Ghana and Kenya summarizes the presentations and discussions from these workshops.

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• Introduction
• Conclusions
• Article Information

Thick black line represents the model-estimated average trajectory over the course of treatment with 95% CIs in the shaded area around the black line. Thin colored lines represent each patient's observed data. Because not all patients provided data at the end of treatment, reliable change at 1 week posttreatment was estimated with mixed-effects logistic regression, which assigned each patient a probability of having achieved reliable change (yellow) or not (purple). GAD-7 indicates Generalized Anxiety Disorder questionnaire for anxiety; PHQ-9, Patient Health Questionnaire-9 for depression.

eMethods 1. Detailed Platform Methodology

eMethods 2. Elastic Net Regression

eMethods 3. Productivity-Related Savings

eMethods 4. Employee Retention

eResults 1. Results of Mixed-Effects Logistic Regression Models

eResults 2. Results of Elastic Net Model

eResults 3. Results of Employee Retention Analysis

eFigure 1. Variable Importances Extracted From Elastic Net Algorithm Trained on Patients With Depression

eFigure 2. Variable Importances Extracted From Elastic Net Algorithm Trained on Patients With Anxiety

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Bondar J , Babich Morrow C , Gueorguieva R, et al. Clinical and Financial Outcomes Associated With a Workplace Mental Health Program Before and During the COVID-19 Pandemic. JAMA Netw Open. 2022;5(6):e2216349. doi:10.1001/jamanetworkopen.2022.16349

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Clinical and Financial Outcomes Associated With a Workplace Mental Health Program Before and During the COVID-19 Pandemic

• 1 Spring Health, Spring Care Inc, New York, New York
• 2 Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
• 3 Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut

Question   Is participation in a comprehensive employer-sponsored mental health benefit associated with reduced symptoms for employees and positive financial return on investment for employers?

Findings   In this cohort study of 1132 employees participating in a workplace mental health program from 66 employers in the US, participants reported reduced symptoms of depression and anxiety. The program provided a positive return on investment for all salaries above the federal minimum wage.

Meaning   Results of this study suggest that employer-sponsored, evidence-based workplace mental health programs can be beneficial for both employers and employees.

Importance   Investment in workplace wellness programs is increasing despite concerns about lack of clinical benefit and return on investment (ROI). In contrast, outcomes from workplace mental health programs, which treat mental health difficulties more directly, remain mostly unknown.

Objective   To determine whether participation in an employer-sponsored mental health benefit was associated with improvements in depression and anxiety, workplace productivity, and ROI as well as to examine factors associated with clinical improvement.

Design, Setting, and Participants   This cohort study included participants in a US workplace mental health program implemented by 66 employers across 40 states from January 1, 2018, to January 1, 2021. Participants were employees who enrolled in the mental health benefit program and had at least moderate anxiety or depression, at least 1 appointment, and at least 2 outcome assessments.

Intervention   A digital platform that screened individuals for common mental health conditions and provided access to self-guided digital content, care navigation, and video and in-person psychotherapy and/or medication management.

Main Outcomes and Measures   Primary outcomes were the Patient Health Questionnaire-9 for depression (range, 0-27) score and the Generalized Anxiety Disorder 7-item scale (range, 0-21) score. The ROI was calculated by comparing the cost of treatment to salary costs for time out of the workplace due to mental health symptoms, measured with the Sheehan Disability Scale. Data were collected through 6 months of follow-up and analyzed using mixed-effects regression.

Results   A total of 1132 participants (520 of 724 who reported gender [71.8%] were female; mean [SD] age, 32.9 [8.8] years) were included. Participants reported improvements from pretreatment to posttreatment in depression ( b  = −6.34; 95% CI, −6.76 to −5.91; Cohen d  = −1.11; 95% CI, −1.18 to −1.03) and anxiety ( b  = −6.28; 95% CI, −6.77 to −5.91; Cohen d  = −1.21; 95% CI, −1.30 to −1.13). Symptom change per log-day of treatment was similar post–COVID-19 vs pre–COVID-19 for depression ( b  = 0.14; 95% CI, −0.10 to 0.38) and anxiety ( b  = 0.08; 95% CI, −0.22 to 0.38). Workplace salary savings at 6 months at the federal median wage was US $3440 (95% CI, $2730-$4151) with positive ROI across all wage groups.

Conclusions and Relevance   Results of this cohort study suggest that an employer-sponsored workplace mental health program was associated with large clinical effect sizes for employees and positive financial ROI for employers.

In the past few decades, the number of employers offering wellness benefits has increased considerably. A Centers for Disease Control and Prevention survey found, in 2017, that 92% of companies with more than 500 employees had some form of wellness program. 1 The increasing adoption of these programs is partly owing to tax breaks available to companies who offer these benefits and a genuine interest in reducing health care–related costs, increasing productivity and improving employee well-being. 2 Large randomized peer-reviewed studies have suggested that employee wellness programs improve health-related behavior (eg, daily step count) but do not deliver improvement in clinical outcomes, health care spending, or health care use. 3 , 4 An understanding of the types of mental health programming associated with improved employee wellness and the conditions under which they have the most utility may lead to scalable initiatives with population-level outcomes.

However, workplace wellness programs vary in design, scope, and intensity. Researchers have identified some components commonly present in successful programs, including educational interventions, supportive company culture and policies, reduced barriers to access, and systematic health risk assessments with tailored follow-up. 5 Such programs typically target modifiable risk factors of disease including nutrition, physical activity, and smoking cessation, and may deliver a measurable return on investment (ROI) only over a long period. At present, whether workplace wellness programs focused on physical health have delivered benefits to both employers and employees is unclear.

Workplace mental health programs that provide treatment for employee mental health difficulties may help close this gap. Mental illness is the leading cause of disability worldwide. 6 Consequently, employers face a high financial burden of mental illness via measures of productivity and absenteeism. To the extent that workplace mental health programs reduce the burden of mental illness, they may generate an ROI that provides for their widespread and sustained implementation. To date, few workplace mental health programs have reported clinical improvement, 7 , 8 and only 1 intervention has demonstrated both clinical and financial ROI. 9 Despite their potential to deliver both clinical and financial benefits, outcomes associated with workplace mental health programs remain mostly unknown.

The sustainability of workplace mental health programs may be enhanced by identifying when and for whom mental health programming is most effective. Program effectiveness may vary depending on individual characteristics such as age and gender (participant self-reported identity), 10 disease characteristics such as symptom severity or case complexity, 11 , 12 and environmental characteristics associated with or that sustain mental health difficulties. Recently, the COVID-19 pandemic has led to increases in depression and anxiety due to a range of chronic and relatively immutable environmental factors (routine disruption, social isolation, and financial difficulties), resulting in a surge in demand for mental health care. 13 Whether mental health care is equally effective in these conditions remains unknown.

In this study, we evaluated an employer-sponsored mental health program incorporating several evidence-based components, including a digital mental health screening platform, telephone and video appointments with care navigators who helped members find care matched to their needs, internet-based cognitive behavioral therapy resources, free or low-cost access to video or in-person psychotherapy and medication management, and a symptom tracking framework to support measurement-based care. We investigated the primary outcomes of clinical improvement in depression and anxiety symptoms, tested dose-response associations for each treatment component, and examined factors associated with clinical improvement including the COVID-19 pandemic. We also examined the secondary outcomes of increased time in the workplace, employee retention, and financial ROI.

This cohort study was categorized by the Yale Institutional Review Board as not human participant research and was therefore exempt from approval and the need for informed patient consent. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline for observational studies.

This study used data from an employer-sponsored online mental health benefit (Spring Health; Spring Care Inc). The program was implemented by 66 employers across 40 states in the US and was available to 282 960 eligible participants from January 1, 2018, through January 1, 2021. Employees were notified of their eligibility by their employer via email and on-site events and enrolled online for free.

The platform first invited participants to identify common mental health difficulties that have been bothering them (eg, stress, anxiety, sleeping, eating, or relationship difficulties) from a predetermined list. Depending on the issues that the participant identified, additional self-report questionnaires were triggered (eMethods 1 in the Supplement ). All participants completed the Patient Health Questionnaire-9 for depression (PHQ-9; range, 0-27) 14 , 15 and the Sheehan Disability Scale 16 for functional impairment. Screening results were shared with the participant’s care team via the electronic medical record. Follow-up assessments were completed at regular intervals chosen by participants with the default being every 2 weeks. Data were collected through 6 months of follow-up.

After taking an assessment, participants could schedule appointments with members of their care team, consisting of a care navigator, a therapist, and a medication manager. Participants who were deemed by their care team to need more intensive services were referred outside the online mental health benefit program by their clinicians. All care navigators were licensed masters degree–level mental health clinicians. All therapists had masters-level or doctoral-level licenses. All medication managers were medical doctors or doctors of osteopathic medicine. All 228 participating health care clinicians had at least 3 years of experience postsupervision before becoming a part of the network. In March 2020, due to the COVID-19 pandemic, in-person treatment was paused and care appointments were delivered via video, except when medically necessary.

To reduce financial barriers to accessing care, participants were able to book an unlimited number of free appointments with their care navigator. They could also schedule appointments with a program therapist and/or medication manager, the cost of which was either covered by their employer for all visits, a limited number of visits, as an in-network benefit via the participant’s insurance, or paid for by the participant, depending on the benefit design offered by the employer.

Participants were included if they were at least age 18 years, had a baseline PHQ-9 or Generalized Anxiety Disorder 7-item scale (GAD-7; range, 0-21) score above clinical cutoff points (PHQ-9 ≥ 10 or GAD-7 ≥ 10), 14 , 15 , 17 , 18 had at least 1 therapy appointment with an online therapist from the employer-sponsored mental health benefit, and completed at least 2 PHQ-9 or GAD-7 questionnaires during the 3-year period between January 1, 2018, and January 1, 2021. Baseline assessments were defined as an assessment less than 2 weeks before an individual’s first therapy appointment. Final assessments were defined as an individual’s latest assessment that occurred less than 6 months after their first assessment and less than 1 month after an appointment. An episode of care was defined as the time from the first assessment to the last appointment that happened within 6 months of the first assessment. Of 282 960 people eligible for the benefit, 20 351 enrolled in the program, resulting in a 7.19% enrollment rate. Of enrolled participants, 1132 met criteria for having at least 1 therapy session, 2 assessments, and a score above the cutpoint on the PHQ-9 or GAD-7.

The PHQ-9 and GAD-7 scores were the primary outcomes of this study. The PHQ-9 and GAD-7 are validated instruments for screening and diagnosing depression and anxiety. 15 , 18 They were used to calculate symptom change (continuous outcomes), reliable improvement 19 (5-point decrease in the PHQ-9 20 and 4-point decrease in the GAD-7 21 ), and reliable improvement with recovery (both reliable improvement and ending in the subclinical range, corresponding to a score <10). 15

Time spent back in the workplace was measured using the Sheehan Disability Scale. This scale is a self-report measure of family, work, and social functional impairment due to emotional symptoms. 16

To determine which treatment components were factors associated with overall change, the log-number of therapy and medication sessions in the previous month were added as time-varying covariates to the clinical outcome models. Use of care navigation (no/yes) was expected to lead to a more rapid trajectory of improvement and was added as a main outcome and care navigation × time interaction.

To identify participants with the strongest response to a given dose of treatment, a set of covariates and covariate × time interactions were added to the dose-response models. Time-invariant covariates were age, gender, number of positive screenings, and participant demographic characteristics. Age, gender, and demographic characteristics were provided on optional previsit questionnaires and coded as “declined to answer” if the participant did not complete the questionnaire. The main outcome of the COVID-19 pandemic was modeled with a time-varying indicator variable capturing whether the observation was pre–COVID-19 lockdown or post–COVID-19 lockdown. The association between the pandemic and participant trajectories was modeled with a piecewise log-linear model (coded as 0 prepandemic) and the log-days of treatment that occurred postlockdowns and was interpreted as the deviation from the main association of log-time that occurred during COVID-19 lockdowns. Additionally, an exploratory model was developed using a machine learning approach, elastic net regression. 22 Reliable improvement was used as the outcome, and candidate variables included sum scores and item scores for baseline questionnaires, number of positive screenings, and demographic variables (eMethods 2 in the Supplement ).

Employer cost of care for all participants was calculated based on outpatient fee-for-service rates (eMethods 3 in the Supplement ). Savings in 6 months were calculated using the changes in missed days per week and unproductive days per week estimated by the clinical outcome models and applying the following formula: (changes in absenteeism + changes in unproductive days)  ×  number of work weeks in 6 months × daily salary.

Employer break-even cost was calculated as the dollar amount per employee per month that equals the dollar amount generated from increased productivity and decreased absenteeism. The enrollment rate (the number of employees who enrolled in the benefit, whether or not they engaged in care) and rate of engagement in care (number of employees who completed at least 1 episode of care) are also reported.

To test whether platform use was associated with differential retention, group differences in retention rates were calculated between employees who enrolled in the program and those who did not (eMethods 4 in the Supplement ). This analysis was limited to 3 employers whose retention data were provided in an adequate form for this analysis.

Mixed-effects models were used to accommodate the multilevel data structure. Repeated observations (level 1) were nested within participants (level 2), and random intercepts and time effects were included at level 2. An identity link was used for continuous outcomes (depression, anxiety), a Poisson model with a log link for count data (productivity), and a logit link for categorical outcomes (reliable change, reliable recovery). Clinical rates of improvement were estimated using log-days in treatment as a level 1 covariate. Overall clinical outcomes were calculated using the delta method to estimate total change at 1 week posttreatment (84 days for depression, 85 days for anxiety). Cohen d effect sizes were calculated by dividing the overall effect size by the end point SD with commonly used thresholds to categorize effects as small ( d <0.50), medium ( d <0.8), and large ( d >0.8). 23 Reliable improvement and recovery were estimated using participant-specific random-effects models and treatment durations. Mean time to remission was calculated by the number of days needed to achieve a PHQ-9 score less than or equal to 5. All statistical tests were 2-sided with statistical significance set at α levels of .05. All analyses were conducted in R, version 4.1.2 (R Foundation for Statistical Computing).

A total of 1132 participants (mean [SD] age at enrollment, 32.9 [8.8] years; 515 of 721 who reported gender information [71.8%] were female; and 415 of 720 who reported demographic information [57.8%] were White) were included ( Table 1 ). Race and ethnicity are reported as a single measure to enable readers to gauge the generalizability of the current findings to the US population as a whole given known differences in mental health care use across racial and ethnic categories. Participants screened positive for a mean (SD) of 2.7 (1.3) mental health conditions and attended a mean (SD) of 5.6 (4.5) therapy sessions, with 86.8% (983 of 1132) attending at least 1 care navigator appointment and 30.0% (339 of 1132) attending at least 1 medication management appointment. For those who attended a medication appointment, the mean (SD) number of appointments was 2.1 (1.3). The median times to first available appointment were 1.2 days (IQR, 1.0-2.0 days) for psychotherapy and 1.0 days (IQR, 1.0-1.2 days) for medication management.

Employers consisted of 66 businesses from 40 states in the US. Company sizes ranged from commercial small businesses (<750 employees) to jumbo enterprises (>35 000 employees), with the median being a commercial large company (3001-5000 employees). There was a wide range of industries, with the most representation from software companies, business services, financial services, and manufacturing.

At baseline, participants had moderate to severe scores for both the PHQ-9 (mean [SD], 14.75 [3.9]) and GAD-7 (mean [SD], 14.27 [3.2]). PHQ-9 scores decreased with each log-day in treatment ( b  = −1.43; P  < .001) ( Table 2 and Figure ), for a total decrease over treatment of 6.34 points (95% CI, −6.76 to −5.91), corresponding to a large effect size ( d  = −1.11; 95% CI, −1.18 to −1.03). Results of mixed-effects logistic regression models (eResults 1 in the Supplement ) indicated that 69.3% (626 of 903) of participants reliably improved and 58.0% (524 of 903) achieved both reliable improvement and remission. Mean (SD) time to remission was 5.9 (5.0) weeks. Similarly, GAD-7 scores decreased with each log-day in treatment ( b  = −1.41; P  < .001), resulting in a total reduction of 6.28 points (95% CI, −6.77 to −5.91), corresponding to a large effect size ( d  = −1.21; 95% CI, −1.30 to −1.13). Reliable improvement was observed for 68.7% of participants (575 of 837) and both reliable improvement and remission for 60.5% of participants (506 of 837). Mean (SD) time to remission for GAD-7 was 6.0 (4.9) weeks.

Log-number of therapy sessions and medication sessions in the past month were significantly associated with lower scores for both the PHQ-9 and GAD-7 (therapy: PHQ-9, b  = −0.95; P  < .001 and GAD-7, b  = −0.89; P  < .001; medication: PHQ-9, b  = −1.13; P  = .002 and GAD-7, b  = −1.15; P  = .002) ( Table 2 ), indicating a positive dose-response association.

A significant age × log-days in treatment interaction indicated that each additional year of age was associated with more rapid depression symptom reduction, corresponding to a small difference by the end of treatment within the bounds of the data (eg, for a person 10 years older than the sample mean, Cohen d  = −0.12; 95% CI, −0.21 to −0.04). For GAD-7, the finding was not statistically significant. Rates of improvement during the COVID-19 pandemic were not significantly different than prepandemic rates for either depression or anxiety. Elastic net regression models did not explain reliable improvement above the base rate for either depression or anxiety (eResults 2, eFigure 1 and eFigure 2 in the Supplement ).

Log-days in treatment were associated with fewer missed days (incidence rate ratio = 0.94; 95% CI, 0.93-0.95) and fewer unproductive days (incidence rate ratio = 0.94; 95% CI, 0.92-0.95), corresponding to total posttreatment outcomes of missing 0.32 fewer days per week and being unproductive for 0.64 fewer days per week. A supplemental retention analysis (eResults 3 in the Supplement ) found that participants who enrolled in the program had 1.6 times the odds (95% CI, 1.3-1.9) of being retained as an employee than those who did not.

The median cost of care for participants with clinically significant depression or anxiety at baseline was $740 (IQR, $420-1065). Six-month salary savings for an employee at the federal median wage was $3440 (95% CI, $2730 to $4151) and ranged from $1442 for employees at the federal minimum wage to $19 125 for employees making at least $200 000 per year ( Table 3 ).

Accounting for costs of all enrolled employees, employers were estimated to break even based on workplace productivity alone across all salary levels and participation rates ( Table 4 ). In the most conservative case in which the mean annual salary was equal to the federal minimum wage and the participation rate was 0.4%, employers were estimated to break even at a per-employee per-month cost of $0.96.

Results of this cohort study found that an employer-sponsored mental health program was associated with large clinical improvements in depression and anxiety, fewer missed days of work, higher employee retention, and a positive financial ROI across all employee salary levels. Existing workplace mental health intervention research has focused on short-term, universal interventions 24 to reduce stress 25 and depression 26 and provide better management for employees with active mental illness. 27 Few studies have evaluated longer-term opt-in mental health programs, and those studies usually evaluated clinical outcomes alone. 7 , 8 To fill this gap, the current study evaluated clinical and financial outcomes of an opt-in mental health program that provided regular screening, care navigation, and outpatient psychotherapy and medication management. Notably, the findings suggest that employer-sponsored comprehensive mental health programming may be associated with a reduced burden of mental illness on the employee while providing financial ROI to the employer.

Participants reported clinical improvement in symptoms of both anxiety and depression. After treatment, 69.3% of participants showed reliable improvement for depression and 68.7% showed improvement for anxiety. Effect sizes were larger than those found in recent meta-analyses of psychotherapy (for depression, d  = 1.11 in the current study vs d  = 0.77 in meta-analysis 28 ; for anxiety, d  = 1.21 in the current study vs 0.76 in meta-analysis 29 ). The rates for both reliable improvement and recovery of 58% for depression and 60.5% for anxiety were substantially higher than the 43% rates found in meta-analyses of psychotherapy 30 and the medication response rate found, for example, in the large scale STAR*D (Sequential Treatment Alternatives to Relieve Depression) medication trial. 31 , 32 Although this was an observational study and benchmarking may be imperfect because of study-specific selection bias, the current study found dose-response associations for both psychotherapy and medication management sessions, suggesting that participant improvement was owing to treatment usage and not simply to the passage of time. Notably, the pandemic was not associated with reduced treatment effectiveness, as participant trajectories of recovery were similar before and after the onset of the pandemic. Each year of age was associated with more rapid symptom improvements during treatment, although effect sizes were large for all ages represented in the sample. Otherwise, neither traditional nor machine learning models identified participant characteristics associated with differential recovery rates. These results suggest that participants with a broad range of demographic and clinical characteristics experienced similar benefits, although the possibility that more informative variables or more complexly defined subgroups of participants had differential improvement rates cannot be ruled out. 33

One possible reason that participant outcome measures were higher than benchmark comparisons may have been the use of an ensemble of evidence-based care components. Whereas meta-analytic comparisons typically examined a single modality of treatment, the current program used screening, care navigation, access to psychotherapy and medication management, and clinical implementations of measurement-based care systems to monitor outcomes. Although not part of the study design, it is possible that the additive and interactive multiple care components were factors in the higher measures of clinical outcomes than any single intervention, suggesting that a flexible and multifaceted set of evidence-based care strategies may be important to the success of workplace mental health programs.

In addition to clinical outcomes, functional outcomes also improved. By the end of treatment, participants missed fewer days at work and reported higher productivity. This outcome may be expected, considering that depression and anxiety are estimated to cost the global economy 1.15 trillion USD annually, with one-third of that cost attributed to loss of workplace productivity. 34 The association of treatment with productivity gains compares favorably with the relatively low cost of appointments and became apparent within a short period, as the mean care episode was only 7 weeks in duration. Moreover, ROI was favorable at every income stratum including the federal minimum wage, highlighting that access to high-quality mental health care may be a financially viable benefit for all US employees.

The current study had several strengths. The study sample was heterogeneous. Participants were drawn from 66 employers across several industries in 40 US states. The study population was racially and ethnically diverse, with 42% being non-White. Participants were not compensated for participation. Comorbidity rates at baseline were similar to the general outpatient population. 35 , 36 Together, these factors suggest that the outcomes may be generalizable to other employers in the US.

Study limitations included that the study design cannot determine causality between improvements and the care provided. Although effect sizes were higher compared with benchmarks, subtle differences in the sampling strategy such as the ease of access to care may have increased the mean reversion effect sizes compared with what is typical in controlled trials. All assessments were self-reported for measurement-based care, raising the possibility of socially desirable responding.

In this cohort study evaluating an employer-sponsored mental health program, participants reported significant reductions in depression and anxiety symptoms and increased time in the workplace. The program delivered a positive ROI even when employees were compensated at the federal minimum wage. Together, these findings suggest that employer-sponsored workplace mental health programs may be beneficial for both employers and employees.

Accepted for Publication: April 22, 2022.

Published: June 9, 2022. doi:10.1001/jamanetworkopen.2022.16349

Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License . © 2022 Bondar J et al. JAMA Network Open .

Corresponding Author: Adam M. Chekroud, PhD, Department of Psychiatry, Yale University, New Haven, CT 06511 ( [email protected] ).

Author Contributions: Dr Bondar and Ms Babich Morrow had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of analysis. Dr Bondar and Ms Babich Morrow contributed equally to the manuscript.

Concept and design: Bondar, Babich Morrow, Brown, Krystal, Chekroud.

Acquisition, analysis, or interpretation of data: Bondar, Babich Morrow, Gueorguieva, Hawrilenko, Krystal, Corlett, Chekroud.

Drafting of the manuscript: Bondar, Babich Morrow, Hawrilenko, Corlett, Chekroud.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Bondar, Babich Morrow, Gueorguieva, Hawrilenko, Krystal, Chekroud.

Obtained funding: Krystal, Chekroud.

Administrative, technical, or material support: Babich Morrow, Brown, Krystal, Chekroud.

Supervision: Brown, Chekroud.

Conflict of Interest Disclosures: Dr Bondar and Ms Babich Morrow reported being employed by and holding equity in Spring Care. Dr Gueorguieva reported receiving royalties from the book Statistical Methods in Psychiatry and Related Fields published by CRC Press and being an inventor on US patent application 20200143922. Drs Brown and Hawrilenko reported being employed by and holding equity in Spring Care. Dr Krystal reported being a consultant for Aptinyx Inc; Atai Life Sciences; AstraZeneca Pharmaceuticals; Biogen Idec; Biomedisyn Corporation; Bionomics Limited (Australia); Boehringer Ingelheim International; Cadent Therapeutics Inc; Clexio Bioscience Ltd; COMPASS Pathways Limited, United Kingdom; Concert Pharmaceuticals Inc; Epiodyne Inc; EpiVario Inc; Greenwich Biosciences Inc; Heptares Therapeutics Limited (UK); Janssen Research & Development; Jazz Pharmaceuticals Inc; Otsuka America Pharmaceutical Inc; Perception Neuroscience Holdings Inc; Spring Care Inc; Sunovion Pharmaceuticals Inc; Takeda Industries; Taisho Pharmaceutical Co Ltd; being on the scientific advisory board of Biohaven Pharmaceuticals; BioXcel Therapeutics Inc; Cadent Therapeutics Inc; Cerevel Therapeutics LLC; EpiVario Inc; Eisai Inc; Jazz Pharmaceuticals Inc; Lohocla Research Corporation; Novartis Pharmaceuticals Corporation; PsychoGenics Inc; RBNC Therapeutics Inc; Spring Care Inc; Tempero Bio Inc; Terran Biosciences Inc; holding stock in Biohaven Pharmaceuticals; Sage Pharmaceuticals; Spring Care Inc; having stock options in Biohaven Pharmaceuticals Medical Sciences; EpiVario Inc; RBNC Therapeutics Inc; Terran Biosciences Inc; Tempero Bio Inc; being an inventor on 9 patents (patent numbers 5447948, 8778979, 9592207; patent application numbers 15379013, 61973961, 62444552, 62719935, 63/125,181; and USPTO docket number Y0087.70116US00); being an editor of Biological Psychiatry and receiving research support from AstraZeneca Pharmaceuticals and Novartis (both provide drugs for research related to NIAAA grant “Center for Translational Neuroscience of Alcoholism [CTNA-4]”). Dr Chekroud reported holding equity in Spring Care; Carbon Health Technologies Inc; Wheel Health Inc; Parallel Technologies Inc; Healthie Inc; and UnitedHealthcare; being the lead inventor on 3 patent submissions relating to treatment for major depressive disorder (US Patent and Trademark Office docket number Y0087.70116US00 and provisional application numbers 62/491 660 and 62/629 041); having done paid consultancy for Fortress Biotech about antidepressant drug development; and providing unpaid advisory services to health care technology startups. No other disclosures were reported.

Additional Contributions: Jessica Streeter, PhD (Spring Health), provided guidance on employee retention analysis. Dr Streeter receives a salary and holds equity.

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Introduction: Case Studies in the Ethics of Mental Health Research

Joseph millum.

Clinical Center Department of Bioethics/Fogarty International Center, National Institutes of Health, Bethesda, MD

This collection presents six case studies on the ethics of mental health research, written by scientific researchers and ethicists from around the world. We publish them here as a resource for teachers of research ethics and as a contribution to several ongoing ethical debates. Each consists of a description of a research study that was proposed or carried out and an in-depth analysis of the ethics of the study.

Building Global Capacity in Mental Health Research

According to the World Health Organization (WHO), there are more than 450 million people with mental, neurological, or behavioral problems worldwide ( WHO, 2005a ). Mental health problems are estimated to account for 13% of the global burden of disease, principally from unipolar and bipolar depression, alcohol and substance-use disorders, schizophrenia, and dementia. Nevertheless, in many countries, mental health is accorded a low priority; for example, a 2005 WHO analysis found that nearly a third of low-income countries who reported a mental health budget spent less than 1% of their total health budget on mental health ( WHO, 2005b ).

Despite the high burden of disease and some partially effective treatments that can be implemented in countries with weaker healthcare delivery systems ( Hyman et al., 2006 ), there exist substantial gaps in our knowledge of how to treat most mental health conditions. A 2007 Lancet Series entitled Global Mental Health claimed that the “rudimentary level of mental health-service research programmes in many nations also contributes to poor delivery of mental health care” ( Jacob et al., 2007 ). Its recommendations for mental health research priorities included research into the effects of interactions between mental health and other health conditions ( Prince et al., 2007 ), interventions for childhood developmental disabilities ( Patel et al., 2007 ), cost-effectiveness analysis, the scaling up of effective interventions, and the development of interventions that can be delivered by nonspecialist health workers ( Lancet Global Mental Health Group, 2007 ). All of these priorities require research in environments where the prevailing health problems and healthcare services match those of the populations the research will benefit, which suggests that research must take place all around the world. Similarly, many of the priorities identified by the Grand Challenges in Mental Health Initiative require focus on local environments, cultural factors, and the health systems of low- and middle-income countries. All the challenges “emphasize the need for global cooperation in the conduct of research” ( Collins et al., 2011 ).

Notwithstanding the need for research that is sensitive to different social and economic contexts, the trend of outsourcing to medical research to developing countries shows no sign of abating ( Thiers et al., 2008 ). Consequently, a substantial amount of mental health research will, in any case, take place in low- and middle-income countries, as well as rich countries, during the next few years.

The need for local research and the continuing increase in the international outsourcing of research imply that there is a pressing need to build the capacity to conduct good quality mental health research around the world. However, the expansion of worldwide capacity to conduct mental health research requires more than simply addressing low levels of funding for researchers and the imbalance between the resources available in rich and poor countries. People with mental health disorders are often thought to be particularly vulnerable subjects. This may be a product of problems related to their condition, such as where the condition reduces the capacity to make autonomous decisions. It may also result from social conditions because people with mental disorders are disproportionately likely to be poor, are frequently stigmatized as a result of their condition, and may be victims of human rights abuses ( Weiss et al., 2001 ; WHO, 2005a ). As a result, it is vitally important that the institutional resources and expertise are in place for ensuring that this research is carried out ethically.

Discussion at a special session at the 7th Global Forum on Bioethics in Research revealed the perception that many mental health researchers are not very interested in ethics and showed up a lack of ethics resources directly related to their work. This collection of case studies in the ethics of mental health research responds to that gap.

This collection comprises six case studies written by contributors from around the world ( Table 1 ). Each describes a mental health research study that raised difficult ethical issues, provides background and analysis of those issues, and draws conclusions about the ethics of the study, including whether it was ethical as it stood and how it ought to be amended otherwise. Three of the case studies are written by scientists who took part in the research they analyzed. For these cases, we have asked scholars independent of the research to write short commentaries on them. It is valuable to hear how the researchers themselves grapple with the ethical issues they encounter, as well as to hear the views of people with more distance from the research enterprise. Some of the ethical issues raised here have not been discussed before in the bioethics literature; others are more common concerns that have not received much attention in the context of international research. The case studies are intended to both expand academic discussion of some of the key questions related to research into mental health and for use in teaching ethics.

Case studies are an established teaching tool. Ethical analyses of such cases demonstrate the relevance of ethics to the actual practice of medical research and provide paradigmatic illustrations of the application of ethical principles to particular research situations. Concrete cases help generate and guide discussion and assist students who have trouble dealing with ethical concepts in abstraction. Through structured discussion, ethical development and decision-making skills can be enhanced. Moreover, outside of the teaching context, case study analyses provide a means to generate and focus debate on the relevant ethical issues, which can both highlight their importance and help academic discussion to advance.

People working in mental health research can benefit most from case studies that are specific to mental health. Even though, as outlined below, many of the same ethical problems arise in mental health research as elsewhere, the details of how they arise are important. For example, the nature of depression and the variation in effectiveness of antidepressive medication make a difference to how we should assess the ethics of placebo-controlled trials for new antidepressants. Moreover, seeing how familiar ethical principles are applied to one's own research specialty makes it easier to think about the ethics of one's own research. The cases in this collection highlight the commonalities and the variation in the ethical issues facing researchers in mental health around the world.

The current literature contains some other collections of ethics case studies that may be useful to mental health researchers. I note four important collections here, to which interested scholars may want to refer. Lavery et al.'s (2007) Ethical Issues in International Bio-medical Research provides in-depth analyses of ethically problematic research, mostly in low- and middle-income countries, although none of these cases involve mental health. Cash et al.'s (2009) Casebook on Ethical Issues in International Health Research also focuses on research in low- and middle-income countries, and several of the 64 short case descriptions focus on populations with mental health problems. Two further collections focus on mental health research, in particular. Dubois (2007) and colleagues developed short and longer US-based case studies for teaching as part of their “Ethics in Mental Health Research” training course. Finally, Hoagwood et al.'s (1996) book Ethical Issues in Mental Health Research with Children and Adolescents contains a casebook of 61 short case descriptions, including a few from outside the United States and Western Europe. For teachers and academics in search of more case studies, these existing collections should be very useful. Here, we expand on the available resources with six case studies from around the world with extended ethical analyses.

The remainder of this introduction provides an overview of some of the most important ethical issues that arise in mental health research and describes some of the more significant ethics guidance documents that apply.

Ethical Issues in Mental Health Research

The same principles can be applied in assessing the ethics of mental health research as to other research using human participants ( Emanuel et al., 2000 ). Concerns about the social value of research, risks, informed consent, and the fair treatment of participants all still apply. This means that we can learn from the work done in other areas of human subjects research. However, specific research contexts make a difference to how the more general ethical principles should be applied to them. Different medical conditions may require distinctive research designs, different patient populations may need special protections, and different locations may require researchers to respond to study populations who are very poor and lack access to health care or to significant variations in regulatory systems. The ethical analysis of international mental health research therefore needs to be tailored to its particularities.

Each case study in this collection focuses on the particular ethical issues that are relevant to the research it analyzes. Nevertheless, some issues arise in multiple cases. For example, questions about informed consent arise in the context of research with stroke patients, with students, and with other vulnerable groups. To help the reader compare the treatment of an ethical issue across the different case studies, the ethical analyses use the same nine headings to delineate the issues they consider. These are social value, study design, study population, informed consent, risks and benefits, confidentiality, post-trial obligations, legal versus ethical obligations, and oversight.

Here, I focus on five of these ethical issues as they arise in the context of international mental health research: (1) study design, (2) study population, (3) risks and benefits, (4) informed consent, and (5) post-trial obligations. I close by mentioning some of the most important guidelines that pertain to mental health research.

Study Design

The scientific design of a research study determines what sort of data it can generate. For example, the decision about what to give participants in each arm of a controlled trial determines what interventions the trial compares and what questions about relative safety and efficacy it can answer. What data a study generates makes a difference to the ethics of the study because research that puts human beings at risk is ethically justified in terms of the social value of the knowledge it produces. It is widely believed that human subject research without any social value is unethical and that the greater the research risks to participants, the greater the social value of the research must be to compensate ( Council for International Organizations of Medical Sciences [CIOMS], 2002 ; World Medical Association, 2008 ). However, changing the scientific design of a study frequently changes what happens to research participants, too. For example, giving a control group in a treatment trial an existing effective treatment rather than placebo makes it more likely that their condition will improve but may expose them to adverse effects they would not otherwise experience. Therefore, questions of scientific design can be ethically very complex because different possible designs are compared both in terms of the useful knowledge they may generate and their potential impact on participants.

One of the more controversial questions of scientific design concerns the standard of care that is offered to participants in controlled trials. Some commentators argue that research that tests therapeutic interventions is only permissible if there is equipoise concerning the relative merits of the treatments being compared, that is, there are not good reasons to think that participants in any arm of the trial are receiving inferior treatment ( Joffe and Truog, 2008 ). If there is not equipoise, the argument goes, then physician-researchers will be breaching their duty to give their patients the best possible care ( Freedman, 1987 ).

The Bucharest Early Intervention Project (BEIP) described in the case study by Charles Zeanah was a randomized controlled trial comparing foster care with institutional care in Bucharest, Romania. When designing the BEIP, the researchers wrestled with the issue of whether there was genuine equipoise regarding the relative merits of institutional and foster care. One interpretation of equipoise is that it exists when the professional community has not reached consensus about the better treatment ( Freedman, 1987 ). Childcare professionals in the United States were confident that foster care was superior, but there was no such confidence in Romania, where institutional care was the norm. Which, then, was the relevant professional community?

The equipoise requirement is justified by reference to the role morality of physicians: for a physician to give her patient treatment that she knows to be inferior would violate principles of therapeutic beneficence and nonmaleficence. As a result, the equipoise requirement has been criticized for conflating the ethics of the physician-patient relationship with the ethics of the researcher-participant relationship ( Miller and Brody, 2003 ). According to Miller and Brody (2003) , provided that other ethical requirements are met, including an honest null hypothesis, it is not unethical to assign participants to receive treatment regimens known to be inferior to the existing standard of care.

A subset of trial designs that violate equipoise are placebo-controlled trials of experimental treatments for conditions for which proven effective treatments already exist. Here, there is not equipoise because some participants will be assigned to placebo treatment, and ex hypothesi there already exists treatment that is superior to placebo. Even if we accept Miller and Brody's (2003) argument and reject the equipoise requirement, there remain concerns about these placebo-controlled trials. Providing participants with less effective treatment than they could get outside of the trial constitutes a research risk because trial participation makes them worse off. Moreover, on the face of it, a placebo-controlled trial of a novel treatment of a condition will not answer the most important scientific question about the treatment that clinicians are interested in: is this new treatment better than the old one? Consequently, in situations where there already exists a standard treatment of a condition, it has generally been considered unethical to use a placebo control when testing a new treatment, rather than using the standard treatment as an active-control ( World Medical Association, 2008 ).

Some psychiatric research provides scientific reasons to question a blanket prohibition on placebo-controlled trials when an effective intervention exists. For example, it is not unusual for antidepressive drugs to fail to show superiority to placebo in any given trial. This means that active-control trials may seem to show that an experimental drug is equivalent in effectiveness to the current standard treatment, when the explanation for their equivalence may, in fact, be that neither was better than placebo. Increasing the power of an active-control trial sufficiently to rule out this possibility may require an impractically large number of subjects and will, in any case, put a greater number of subjects at risk ( Carpenter et al., 2003 ; Miller, 2000 ). A 2005 trial of risperidone for acute mania conducted in India ( Khanna et al., 2005 ) was criticized for unnecessarily exposing subjects to risk ( Basil et al., 2006 ; Murtagh and Murphy, 2006 ; Srinivasan et al., 2006 ). The investigators' response to criticisms adopted exactly the line of argument just described:

A placebo group was included because patients with mania generally show a high and variable placebo response, making it difficult to identify their responses to an active medication. Placebo-controlled trials are valuable in that they expose the fewest patients to potentially ineffective treatments. In addition, inclusion of a placebo arm allows a valid evaluation of adverse events attributable to treatment v. those independent of treatment. ( Khanna et al., 2006 )

Concerns about the standard of care given to research participants are exacerbated in trials in developing countries, like India, where research participants may not have access to treatment independent of the study. In such cases, potential participants may have no real choice but to join a placebo-controlled trial, for example, because that is the only way they have a chance to receive treatment. In the Indian risperidone trial, the issue of exploitation is particularly stark because it seemed to some that participants were getting less than the international best standard of care, in order that a pharmaceutical company could gather data that was unlikely to benefit many Indian patients.

This is just one way in which trial design may present ethically troubling risks to participants. Other potentially difficult designs include washout studies, in which participants discontinue use of their medication, and challenge studies, in which psychiatric symptoms are experimentally induced ( Miller and Rosenstein, 1997 ). In both cases, the welfare of participants may seem to be endangered ( Zipursky, 1999 ). A variant on the standard placebo-controlled trial design is the withdrawal design, in which everyone starts the trial on medication, the people who respond to the medication are then selected for randomization, and then half of those people are randomized to placebo. This design was used by a Japanese research team to assess the effectiveness of sertraline for depression, as described by Shimon Tashiro and colleagues in this collection. The researchers regarded this design as more likely to benefit the participants because for legal reasons, sertraline was being tested in Japan despite its proven effectiveness in non-Japanese populations. Tashiro and colleagues analyze how the risks and benefits of a withdrawal design compare with those of standard placebo-controlled trials and consider whether the special regulatory context of Japan makes a difference.

Study Population

The choice of study population implicates considerations of justice. The Belmont Report, which lays out the ethical foundations for the United States system for ethical review of human subject research, says:

Individual justice in the selection of subjects would require that researchers … should not offer potentially beneficial research only to some patients who are in their favor or select only “undesirable” persons for risky research. Social justice requires that distinction be drawn between classes of subjects that ought, and ought not, to participate in any particular kind of research, based on the ability of members of that class to bear burdens and on the appropriateness of placing further burdens on already burdened persons. ( National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1978 )

Two distinct considerations are highlighted here. The first (“individual justice”) requires that the researchers treat people equally. Morally irrelevant differences between people should not be the basis for deciding whom to enroll in research. For example, it would normally be unjust to exclude women from a phase 3 trial of a novel treatment of early-stage Alzheimer disease, given that they are an affected group. Some differences are not morally irrelevant, however. In particular, there may be scientific reasons for choosing one possible research population over another, and there may be risk-related reasons for excluding certain groups. For example, a functional magnetic resonance imaging study in healthy volunteers to examine the acute effects of an antianxiety medication might reasonably exclude left-handed people because their brain structure is different from that of right-handed people, and a study of mood that required participants to forego medication could justifiably exclude people with severe depression or suicidal ideation.

The second consideration requires that we consider how the research is likely to impact “social justice.” Social justice refers to the way in which social institutions distribute goods, like property, education, and health care. This may apply to justice within a state ( Rawls, 1971 ) or to global justice ( Beitz, 1973 ). In general, research will negatively affect social justice when it increases inequality, for example, by making people who are already badly off even worse off. The quotation from the Belmont Report above suggests one way in which research might violate a requirement of social justice: people who are already badly off might be asked to participate in research and so be made worse off. For example, a study examining changes in the brain caused by alcohol abuse that primarily enrolled homeless alcoholics from a shelter near the study clinic might only put at further risk this group who are already very badly off. An alternative way in which research can promote justice or injustice is through its results. Research that leads to the development of expensive new attention deficit hyperactivity disorder medication is likely to do little, if anything, to make the world more just. Research on how to improve the cognitive development of orphaned children in poor environments (like the BEIP) is much more likely to improve social justice.

This last point suggests a further concern about fairness—exploitation—that frequently arises in the context of international collaborative research in developing countries. Exploitation occurs, roughly, when one party takes “unfair advantage” of the vulnerability of another. This means that the first party benefits from the interaction and does so to an unfair extent ( Wertheimer, 1996 ). These conditions may be met in international collaborative research when the burdens of research fall disproportionately on people and institutions in developing countries, but the benefits of research, such as access to new treatments, accrue to people in richer countries. A number of case studies in this collection raise this concern in one way or another. For example, Virginia Rodriguez analyzes a proposed study of the genetic basis of antisocial personality disorder run by US researchers but carried out at sites in several Latin American countries. One of the central objections raised by one of the local national research ethics committees with regard to this study was that there appeared to be few, if any, benefits for patients and researchers in the host country.

Risks and Benefits

Almost all research poses some risk of harm to participants. Participants in mental health research may be particularly susceptible to risk in several ways. First, and most obviously, they may be physically or psychologically harmed as a result of trial participation. For example, an intervention study of an experimental antipsychotic may result in some serious adverse effects for participants who take the drug. Less obvious but still very important are the potential effects of stopping medication. As mentioned above, some trials of psychoactive medications require that patients stop taking the medications that they were on before the trial ( e.g ., the Japanese withdrawal trial). Stopping their medication can lead to relapse, to dangerous behavior (like attempted suicide), and could mean that their previous treatment regimen is less successful when they attempt to return to it. Participants who were successfully treated during a trial may have similar effects if they do not have access to treatment outside of the trial. This is much more likely to happen in research conducted with poor populations, such as the Indian mania patients.

The harms resulting directly from research-related interventions are not the only risk to participants in mental health research. Participation can also increase the risks of psychosocial harms, such as being identified by one's family or community as having a particular condition. Such breaches of confidentiality need not involve gross negligence on the part of researchers. The mere fact that someone regularly attends a clinic or sees a psychiatrist could be sufficient to suggest that they have a mental illness. In other research, the design makes confidentiality hard to maintain. For example, the genetic research described by Rodriguez involved soliciting the enrollment of the family members of people with antisocial personality disorder.

The harm from a breach of confidentiality is exacerbated when the condition studied or the study population is stigmatized. Both of these were true in the case Sana Loue describes in this collection. She studied the co-occurrence of severe mental illnesses and human immunodeficiency virus risk in African-American men who have sex with men. Not only was there shame attached to the conditions under study, such that they were euphemistically described in the advertisements for the research, but also many of the participants were men who had heterosexual public identities.

Informed Consent

Many people with mental disorders retain the capacity (ability) and competence (legal status) to give informed consent. Conversely, potential participants without mental problems may lack or lose capacity (and competence). Nevertheless, problems with the ability to consent remain particularly pressing with regard to mental health research. This is partly a consequence of psychological conditions that reduce or remove the ability to give informed consent. To study these conditions, it may be necessary to use participants who have them, which means that alternative participants who can consent are, in principle, not available. This occurred in the study of South African stroke patients described by Anne Pope in this collection. The researcher she describes wanted to compare the effectiveness of exercises designed to help patients whose ability to communicate was compromised by their stroke. Given their communication difficulties and the underlying condition, there would inevitably be questions about their capacity. Whether it is permissible to enroll people who cannot give informed consent into a study depends on several factors, including the availability of alternative study populations, the levels of risk involved, and the possible benefits to participants in comparison with alternative health care they could receive.

In research that expects to enroll people with questionable capacity to consent, it is wise to institute procedures for assessing the capacity of prospective participants. There are two general strategies for making these assessments. The first is to conduct tests that measure the general cognitive abilities of the person being assessed, as an IQ test does. If she has the ability to perform these sorts of mental operations sufficiently well, it is assumed that she also has the ability to make autonomous decisions about research participation. A Mini-Mental State Examination might be used to make this sort of assessment ( Kim and Caine, 2002 ). The second capacity assessment strategy focuses on a prospective participant's understanding and reasoning with regard to the specific research project they are deciding about. If she understands that project and what it implies for her and is capable of articulating her reasoning about it, then it is clear that she is capable of consenting to participation, independent of her more general capacities. This sort of assessment requires questions that are tailored to each specific research project and cannot be properly carried out unless the assessor is familiar with that research.

Where someone lacks the capacity to give consent, sometimes a proxy decision maker can agree to trial participation on her behalf. In general, proxy consent is not equivalent to individual consent: unless the proxy was expressly designated to make research decisions by the patient while capacitated, the proxy lacks the power to exercise the patient's rights. As a result, the enrollment of people who lack capacity is only acceptable when the research poses a low net risk to participants or holds out the prospect of benefiting them. When someone has not designated a proxy decision maker for research, it is common to allow the person who has the power to make decisions about her medical care also to make decisions about research participation. However, because medical care is directed at the benefit of the patient, but research generally is not aimed at the benefit of participants, the basis for this assumption is unclear. Its legal basis may be weak, too. For example, in her discussion of research on South African stroke patients, Pope notes the confusion surrounding the legality of surrogate decision makers, given that the South African constitution forbids proxy decision making for adults (unless they have court-appointed curators), but local and international guidance documents seem to assume it.

Although it is natural to think of the capacity to give consent as an all-or-nothing phenomenon, it may be better conceptualized as domain-specific. Someone may be able to make decisions about some areas of her life, but not others. This fits with assumptions that many people make in everyday life. For example, a 10-year-old child may be deemed capable of deciding what clothes she will wear but may not be capable of deciding whether to visit the dentist. The capacity to consent may admit of degrees in another way, too. Someone may have diminished capacity to consent but still be able to make decisions about their lives if given the appropriate assistance. For example, a patient with mild dementia might not be capable of deciding on his own whether he should move in with a caregiver, but his memory lapses during decision making could be compensated for by having his son present to remind him of details relevant to the decision. The concept of supported decision making has been much discussed in the literature on disability; however, its application to consent to research has received little attention ( Herr, 2003 ; United Nations, 2007 ).

The ability to give valid informed consent is the aspect of autonomy that is most frequently discussed in the context of mental health research, but it is not the only important aspect. Several of the case studies in this collection also raise issues of voluntariness and coercion. For example, Douglas Wassenaar and Nicole Mamotte describe a study in which professors enrolled their students, which raises the question of the vulnerability of student subjects to pressure. Here, there is both the possibility of explicit coercion and the possibility that students will feel pressure even from well-meaning researchers. For various reasons, including dependence on caregivers or healthcare professionals and the stigma of their conditions, people with mental illnesses can be particularly vulnerable to coercion.

Post-Trial Obligations

The obligations of health researchers extend past the end of their study. Participants'data remain in the hands of researchers after their active involvement in a study is over, and patients with chronic conditions who enroll in clinical trials may leave them still in need of treatment.

Ongoing confidentiality is particularly important when studying stigmatized populations (such as men who have sex with men as discussed by Sana Loue) or people with stigmatizing conditions (such as bipolar disorder). In research on mental illnesses, as with many medical conditions, it is now commonplace for researchers to collect biological specimens and phenotypic data from participants to use in future research (such as genome-wide association studies). Additional challenges with regard to confidentiality are raised by the collection of data and biological specimens for future research because confidentiality must then be guaranteed in a long period of time and frequently with different research groups making use of the samples.

Biobanking also generates some distinctive ethical problems of its own. One concerns how consent to the future use of biological specimens should be obtained. Can participants simply give away their samples for use in whatever future research may be proposed, or do they need to have some idea of what this research might involve in order to give valid consent? A second problem, which arises particularly in transnational research, concerns who should control the ongoing use of the biobank. Many researchers think that biological samples should not leave the country in which they were collected, and developing country researchers worry that they will not be allowed to do research on the biobanks that end up in developed countries. This was another key concern with the proposed study in Latin America.

In international collaborative research, further questions arise as a result of the disparities between developing country participants and researchers and developed country sponsors and researchers. For example, when clinical trials test novel therapies, should successful therapies be made available after the trial? If they should, who is responsible for ensuring their provision, to whom should they be provided, and in what does providing them consist? In the case of chronic mental illnesses like depression or bipolar disorder, patient-participants may need maintenance treatment for the rest of their lives and may be at risk if treatment is stopped. This suggests that the question of what happens to them after the trial must at least be considered by those who sponsor and conduct the trial and the regulatory bodies that oversee it. Exactly on whom obligations fall remains a matter of debate ( Millum, 2011 ).

Ethics Guidelines

A number of important policy documents are relevant to the ethics of research into mental disorders. The WMA's Declaration of Helsinki and the CIOMS' Ethical Guidelines for Biomedical Research both consider research on individuals whose capacity and/or competence to consent is impaired. They agree on three conditions: a) research on these people is justified only if it cannot be carried out on individuals who can give adequate informed consent, b) consent to such research should be obtained from a proxy representative, and c) the goal of such research should be the promotion of the health of the population that the research participants represent ( Council for International Organizations of Medical Sciences, 2002 ; World Medical Association, 2008 ). In addition, with regard to individuals who are incapable of giving consent, Guideline 9 of CIOMS states that interventions that do not “hold out the prospect of direct benefit for the individual subject” should generally involve no more risk than their “routine medical or psychological examination.”

In 1998, the US National Bioethics Advisory Commission (NBAC) published a report entitled Research Involving Persons with Mental Disorders That May Affect Decision-making Capacity ( National Bioethics Advisory Commission, 1998 ). As the title suggests, this report concentrates on issues related to the capacity or competence of research participants to give informed consent. Its recommendations are largely consistent with those made in the Declaration of Helsinki and CIOMS, although it is able to devote much more space to detailed policy questions (at least in the United States context). Two domains of more specific guidance are of particular interest. First, the NBAC report considers the conditions under which individuals who lack the capacity to consent may be enrolled in research posing different levels of risk and supplying different levels of expected benefits to participants. Second, it provides some analysis of who should be recognized as an appropriate proxy decision maker (or “legally authorized representative”) for participation in clinical trials.

Finally, the World Psychiatric Association's Madrid Declaration gives guidelines on the ethics of psychiatric practice. This declaration may have implications for what is permissible in psychiatric research, insofar as the duties of psychiatrists as personal physicians are also duties of psychiatrists as medical researchers. It also briefly considers the ethics of psychiatric research, although it notes only the special vulnerability of psychiatric patients as a concern distinctive of mental health research ( World Psychiatric Association, 2002 ).

The opinions expressed are the author's own. They do not reflect any position or policy of the National Institutes of Health, U.S. Public Health Service, or Department of Health and Human Services.

Disclosure : The author declares no conflict of interest.

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• Neuropsychiatric disorders and the misguided emphasis on individual responsibility in public health interventions
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• http://orcid.org/0009-0004-9063-7984 Craig Waldence McFarland 1 ,
• http://orcid.org/0009-0004-5734-0441 Julia Pace 2 ,
• http://orcid.org/0000-0002-3878-5099 Emily Rodriguez 3 ,
• http://orcid.org/0009-0003-6364-417X Makenna Law 4 ,
• Ivan Ramirez 5
• 1 Harvard University , Cambridge , Massachusetts , USA
• 2 Northeastern University , Boston , Massachusetts , USA
• 3 Massachusetts General Hospital , Boston , Massachusetts , USA
• 4 Tufts University , Medford , Massachusetts , USA
• 5 Johns Hopkins University , Baltimore , Maryland , USA
• Correspondence to Craig Waldence McFarland, Harvard University, Cambridge, Massachusetts, USA; craigmcfarland{at}college.harvard.edu

https://doi.org/10.1136/jme-2024-110149

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• public policy
• ethics—medical
• mental disorders

Neuropsychiatric disorders such as drug addiction, depression and schizophrenia are often centrally implicated in public health challenges. These conditions impact the individuals affected and have widespread implications, contributing to related crises such as opioid epidemic, rising suicide rates and homelessness. Despite their influence, public health interventions frequently emphasise individual responsibility, overlooking the complex interplay of neurobiological and systemic factors that underpin these disorders.

Current public health frameworks, such as the Nuffield Council on Bioethics’ intervention ladder, prioritise efforts that encourage individual behaviour change. Paetkau critiques this emphasis on individual responsibility, emphasising the need to consider more systemic factors, such as social determinants of health, as targets of necessary intervention. 1 We aim to reinforce Paetkau’s critique of the intervention ladder by introducing three neuropsychiatric case studies, each highlighting the limitations of an individual-based framework in addressing psychopathology-involved public health issues. We argue that conditions like addiction, depression and serious mental illness undermine the emphasis on individual responsibility in public health and policy interventions. To this end, neuroscience demonstrates that effective public health interventions necessitate a shift from the long-standing emphasis on individual responsibility towards more comprehensive, systems-level interventions.

Addiction and the opioid crisis

Opioid overdose deaths in the USA have sextupled since 1999, with over 100,000 deaths in 2023 alone. 2 The opioid crisis has since remained one of the most pressing public …

Contributors CWMcF, JP, ER, ML and IR were directly involved in the creation of the article. CWMcF, as the lead author, was primarily responsible for conceptualising the main thesis, conducting the initial literature review and drafting the manuscript. JP, ER and ML assisted in the editing of the article and expanding initial ideas, ensuring clarity and coherence in the ideas presented. IR helped in the initial conceptualisation of the main thesis. All authors agreed to be accountable for all aspects of the work submitted.

Funding This study was funded by Lester Kissel Grant in Practical Ethics.

Competing interests None declared.

Provenance and peer review Not commissioned; internally peer reviewed.

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Artificial Intelligence enabled cognitive computer-centered digital analysis model for examination of the children’s mental health

• Research Paper
• Published: 11 July 2024

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• Jyoti Agarwal 1   na1 &
• Sachin Sharma 1   na1  

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Mental health plays an important role for how a person act, think and feel. Specially in the case of students it’s become very crucial and they suffer from various kind of mental disorders due to educational, emotional and societal pressure. This paper proposes an Artificial Intelligence enabled cognitive computer-centered digital analysis model for the examination of children’s mental health. The objective of children mental health analysis using vocal spectrogram, a pseudo-scientific technology, is to deduce deceit from mental health that is detected in the voice. With excessive stress being viewed as an indication of deceit, the technology seeks to distinguish between good mental health and bad mental health outputs in response to stimuli. In this study, we provide a Convolutional Neural network (CNN) based cognitive computer-based model for detecting children mental health based on speech cues and deep learning. Automatic children mental health detection is developing into an intriguing study topic since communication between intelligent systems and humans is demanded to happen more frequently. Although the level of particular hormones, like as cortisol, can be accurately measured to identify children’s mental health. Proposed CNN model validation is done using five different usability factors (learnability, efficiency, effectiveness, satisfaction and understandability) to assess its utility and effectiveness and the results of the initial tests indicate that the proposed model provides a promis- ing tool for the examination of children’s mental health. This paper also discusses how Reinforcement Learning (RL) and CNN algorithms can be used for continuous improvement of the proposed model.

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Jyoti Agarwal and Sachin Sharma contributed equally equally to this work.

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Department of Computer Science and Engineering, Graphic Era Deemed to be University, Dehradun, 248002, Uttarakhand, India

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Agarwal, J., Sharma, S. Artificial Intelligence enabled cognitive computer-centered digital analysis model for examination of the children’s mental health. Evol. Intel. (2024). https://doi.org/10.1007/s12065-024-00951-6

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Received : 25 March 2023

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Published : 11 July 2024

DOI : https://doi.org/10.1007/s12065-024-00951-6

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