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What Is a Good Thesis Statement About Depression?

Do you need to compose an informative or an argumentative essay on depression? One of the vital parts of your paper is a thesis statement on depression. Note there are various types of thesis statements, and what you use depends on the type of essay you are writing. A thesis summarizes the concept that you write on your research paper or the bottom line that you will write in your essay. It should elaborate more on the depression topics for the research paper you are working on. But at times, you might have a hard time writing your thesis statement.

Good Thesis Statement about Teenage Depression

Bipolar disorder thesis statements about depression, interesting thesis statements about depression, interesting thesis statement about diagnosis and treatment of depression, thesis statement about stress and depression, free thesis statements about depression and anxiety, get help with your depression research paper.

Here is a list of thesis statements to have an easier time writing your essay. They cover different topics, making it easy to select what excites you. Here we go!

Are you writing about teenagers and how they are always overthinking about their future, and they end up getting depressed? You need to write a good thesis statement for a depression research paper. That will help your depression argumentative essay stand out. Here are some thesis statement for depression to check out.

• There is a link between depression and alcohol among teenagers and the various ways to control it.
• Teenagers dealing with mood disorders eat and sleep more than usual, getting less interested in regular activities.
• Mediation is an effective way to reach out to adolescents that show heightened symptoms of depression.
• Self-blaming attributions are social cognitive mechanisms among adolescents.
• Peer victimization causes high-stress levels among adolescents and has negative psychological consequences.

Choosing a good depression thesis statement on bipolar disorder can be hectic. Research on bipolar will require a good thesis statement for mental health. Choose a thesis statement about mental health awareness here.

• People with Bipolar depression have more difficulties getting quality sleep.
• Bipolar disorder influences every aspect of a person’s life and changes their quality of life.
• Bipolar disorder causes depressive moods or lows of mental disorder.
• Bipolar is a severe mental issue that can negatively impact your moods, self-esteem, and behavior.
• Psychological evaluations play a significant role in diagnosing bipolar disorder.

When writing your essay, ensure that the thesis statement for mental health is fascinating. You will impress your professors if you get the right depression research paper outline as your thesis statement. Here is a depression thesis statement you can use.

• The effects of human psychology are viewed in the form of depression.
• Clinical psychology can help to bring outpatients who have depression.
• Treating long-term depression in bipolar patients is possible.
• Bipolar patients are drained to the roots of depression.
• Well-established rehabilitation centers can help bring drug addicts from depression.

Are you thinking of writing a thesis on depression and how to treat it? If so, you need to have an excellent thesis statement about mental health that will impress your professor. Read this list to find a thesis you need for your research paper.

• There are different ways to diagnose and treat depression from its early stage.
• People who show signs of depression from an early stage and seek treatment are likely to recover instead of those who do not show early signs.
• After you receive treatment for depression, putting the right measure in place is one of the best and effective ways to ensure that you do not get it again for the second time.
• Anxiety can interfere with daily living, and it can get anyone from children to adults.
• Besides medication, you need a lifestyle change and acceptance to treat depression.

Is your research about stress and how it can impact mental health? Getting a thesis statement for depression research paper that impresses your examiners can be challenging. Choose a thesis statement for your mental illness research paper below.

• Although it is normal for various situations to cause stress, having constant stress can have detrimental effects.
• To survive the modern industrial society, you need to have stress management strategies.
• The challenges of understanding and adapting to the changing environment can lead to stress.
• Lack of proper stress management will lead to inefficiency in everything people do.
• Stress does not come unless there are underlying stressors in your life.

Our team of writers is well-conversant about a free thesis statement about anxiety you can use. The best anxiety thesis statement will help you get the best grades. Here is a list of statements that stands out:

• Many factors can lead to early anxiety, but the leading cause of anxiety in adolescents is directly linked to families.
• Anxiety is a severe mental disorder that can occur without any apparent triggers.
• Long-term depression and anxiety can impact your mental health, but you can recover if you seek treatment.
• Depression and anxiety are not interlinked, and it is essential to learn how to differentiate them on practical grounds.
• Society has a role to play in helping people come out of depression and anxiety.

How do you write a research paper about depression and how it affects mental health? Before choosing a thesis statement on mental health, have a clear understanding of the essay that you are writing. That will help you get the best thesis to make our essay stand out.

But don’t keep stressing out about your thesis statement for mental illness research paper. We have your work cut out because our skilled writers have compiled a list of thesis statements about mental health and depression topics for research paper writing. We will also suggest correct thesis statements for your essay homework or assignment.

If you are still unsure of the statement to use, get in touch with us today. We have a team of skilled and experienced writers that can help you with your essay or research project and ensure that you get the best grades.

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10 New Thesis Statement about Depression & Anxiety | How to Write One?

Did you know according to the National Institute of Mental Health; it is estimated that approximately 8.4% of adults are patients of major depression in the US? Well, depression is a common illness globally that affects a lot of people. Yet, the reasons for this psychological sickness vary from person to person and numerous studies are being conducted to discover more about depression.

Therefore, college and university students are currently assigned to write research papers, dissertations, essays, and a thesis about depression. However, writing essays on such topics aims to increase the awareness of physical and mental well-being among youth and help them find solutions.

However, a lot of students find it pretty challenging to write a thesis statement about depression and seek someone to write my essay . No worries! In this article, you will learn about what is a good thesis statement about mental health and some effective methods and approaches to write a killer headline and compose an astonishing essay about depression.

5 Thesis Statement About Depression:

• “The complexity of depression, which includes biological, psychological, and environmental components, emphasizes the need for individualized treatment plans that consider each person’s particular requirements.”
• “Depression in the workplace not only affects an individual’s productivity but also carries economic implications, emphasizing the importance of fostering a mental health-friendly work environment.”
• “Alternative, holistic approaches to mental health care have the potential to be more successful as the link between creative expressions, such as art therapy, and depression management becomes more commonly recognized.”
• “It is critical to enhance geriatric mental health treatment and reduce the stigma associated with mental illness in older people since depression in senior populations is typically underdiagnosed and mistreated.”
• “The link between early childhood adversity and the risk of developing depression later in life accentuates the importance of early intervention and support systems for children exposed to adverse experiences.”

5 Thesis Statements about Anxiety & Depression :

• “Depression and anxiety Co-occurring disorders are a major concern in mental health, necessitating integrated treatment options that meet the unique challenges that co-occurring diseases provide.”
• “The utilization of technology-driven therapies, such as smartphone apps and telehealth services, is a realistic approach of addressing persons suffering from anxiety and depression, while also increasing access to mental health care.”
• “The examination of the gut-brain connection and its potential role in anxiety and depression showcases a burgeoning area of research that could lead to novel treatments emphasizing nutrition and gut health.”
• “Adolescents who experience both anxiety and depression face a serious issue that calls for comprehensive school-based mental health programs and preventative measures to promote young people’s mental health.”
• “Exploring the impact of sociocultural factors and the role of community support systems in the experience of anxiety and depression provides insights into the development of culturally sensitive mental health interventions.”

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Follow 7 Proven Methods to Compose Thesis Statement about Depression

A thesis is the overview of the concepts and ideas that you will write in your research paper or in the essay. Yet, a thesis statement about anxiety focuses more on the stress and depression topics for the paper you’re working on, which can be written by following the tips given below.

Nonetheless, you can compose an outline by covering the points mentioned below:

1. Pick a good study topic and perform a basic reading. Look for some intriguing statistics and try to come up with creative ways to approach your subject. Examine a few articles for deficiencies in understanding.

2. Make a list of your references and jot down when you come across a noteworthy quotation. You can cite them in your paper as references. Organize all of the information you’ve acquired in one location.

3. In one phrase, state the purpose of your essay. Consider what you want to happen when other people read your article.

4. Examine your notes and construct a list of all the key things you wish to emphasize. Make use of brainstorming strategies and jot down any ideas that come to mind.

5. Review and revise the arguments and write a thesis statement for a research paper or essay about depression.

6. Organize your essay by organizing the list of points. Arrange the points in a logical sequence. Analyze all elements to ensure that they are all relevant to your goal.

7. Reread all of your statements and arrange your outline in a standard manner, such as a bulleted list.

Final Words

So, what is an ideal way to write a thesis statement about depression for your research paper or essay? We hope you have a thorough idea of the essay you’re writing before picking a thesis statement about mental well-being. That will assist you in developing the greatest thesis for our essay.

But don’t get too worked up over your thesis statement for a research paper on mental disorders. Our professional subject experts have produced a list of thesis statements about mental health and depression themes for research paper writing, so you’ve got your job cut out for you. For your essay assignments or assignments, we will also offer appropriate thesis statements.

If you’re still confused about which statement to use, contact us right away. We have a staff of highly qualified and seasoned writers who can assist you with your essay or research work and guarantee that you receive the highest possible score.

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434 Depression Essay Titles & Research Topics: Argumentative, Controversial, and More

Depression is undeniably one of the most prevalent mental health conditions globally, affecting approximately 5% of adults worldwide. It often manifests as intense feelings of hopelessness, sadness, and a loss of interest in previously enjoyable activities. Many also experience physical symptoms like fatigue, sleep disturbances, and appetite changes. Recognizing and addressing this mental disorder is extremely important to save lives and treat the condition.

In this article, we’ll discuss how to write an essay about depression and introduce depression essay topics and research titles for students that may be inspirational.

• 🔝 Top Depression Essay Titles
• ✅ Essay Prompts
• 💡 Research Topics
• 🔎 Essay Titles
• 💭 Speech Topics
• 📝 Essay Structure

🔗 References

🔝 top 12 research titles about depression.

• How is depression treated?
• Depression: Risk factors.
• The symptoms of depression.
• What types of depression exist?
• Depression in young people.
• Differences between anxiety and depression.
• The parents’ role in depression therapy.
• Drugs as the root cause of depression.
• Dangerous consequences of untreated depression.
• Effect of long-term depression.
• Different stages of depression.
• Treatment for depression.

✅ Prompts for Essay about Depression

Struggling to find inspiration for your essay? Look no further! We’ve put together some valuable essay prompts on depression just for you!

Prompt for Personal Essay about Depression

Sharing your own experience with depression in a paper can be a good idea. Others may feel more motivated to overcome their situation after reading your story. You can also share valuable advice by discussing things or methods that have personally helped you deal with the condition.

For example, in your essay about depression, you can:

• Tell about the time you felt anxious, hopeless, or depressed;
• Express your opinion on depression based on the experiences from your life;
• Suggest a way of dealing with the initial symptoms of depression ;
• Share your ideas on how to protect mental health at a young age.

How to Overcome Depression: Essay Prompt

Sadness is a common human emotion, but depression encompasses more than just sadness. As reported by the National Institute of Mental Health, around 21 million adults in the United States, roughly 8.4% of the total adult population , faced at least one significant episode of depression in 2020. When crafting your essay about overcoming depression, consider exploring the following aspects:

• Depression in young people and adolescents;
• The main causes of depression;
• The symptoms of depression;
• Ways to treat depression;
• Help from a psychologist (cognitive behavioral therapy or interpersonal therapy ).

Postpartum Depression: Essay Prompt

The birth of a child often evokes a spectrum of powerful emotions, spanning from exhilaration and happiness to apprehension and unease. It can also trigger the onset of depression. Following childbirth, many new mothers experience postpartum “baby blues,” marked by shifts in mood, bouts of tears, anxiety, and sleep disturbances. To shed light on the subject of postpartum depression, explore the following questions:

• What factors may increase the risk of postpartum depression?
• Is postpartum depression predictable?
• How to prevent postpartum depression?
• What are the symptoms of postpartum depression?
• What kinds of postpartum depression treatments exist?

Prompt for Essay about Teenage Depression

Teenage depression is a mental health condition characterized by sadness and diminishing interest in daily activities. It can significantly impact a teenager’s thoughts, emotions, and behavior, often requiring long-term treatment and support.

By discussing the primary symptoms of teenage depression in your paper, you can raise awareness of the issue and encourage those in need to seek assistance. You can pay attention to the following aspects:

• Emotional changes (feelings of sadness, anger, hopelessness, guilt, etc.);
• Behavioral changes (loss of energy and appetite , less attention to personal hygiene, self-harm, etc.);
• New addictions (drugs, alcohol, computer games, etc.).

💡 Research Topics about Depression

• The role of genetics in depression development.
• The effectiveness of different psychotherapeutic interventions for depression.
• Anti-depression non-pharmacological and medication treatment .
• The impact of childhood trauma on the onset of depression later in life.
• Exploring the efficacy of antidepressant medication in different populations.
• The impact of exercise on depression symptoms and treatment outcomes.
• Mild depression: pharmacotherapy and psychotherapy .
• The relationship between sleep disturbances and depression.
• The role of gut microbiota in depression and potential implications for treatment.
• Investigating the impact of social media on depression rates in adolescents.
• Depression, dementia, and delirium in older people .
• The efficacy of cognitive-behavioral therapy in preventing depression relapse.
• The influence of hormonal changes on depression risk.
• Assessing the effectiveness of self-help and digital interventions for depression.
• Herbal and complementary therapies for depression .
• The relationship between personality traits and vulnerability to depression.
• Investigating the long-term consequences of untreated depression on physical health.
• Exploring the link between chronic pain and depression.
• Depression in the elderly male .
• The impact of childhood experiences on depression outcomes in adulthood.
• The use of ketamine and other novel treatments for depression.
• The effect of stigma on depression diagnosis and treatment.
• The conducted family assessment: cases of depression .
• The role of social support in depression recovery.
• The effectiveness of online support groups for individuals with depression.
• Depression and cognitive decline in adults.
• Depression: PICOT question component exploration .
• Exploring the impact of nutrition and dietary patterns on depression symptoms.
• Investigating the efficacy of art-based therapies in depression treatment.
• The role of neuroplasticity in the development and treatment of depression.
• Depression among HIV-positive women .
• The influence of gender on depression prevalence and symptomatology.
• Investigating the impact of workplace factors on depression rates and outcomes.
• The efficacy of family-based interventions in reducing depression symptoms in teenagers.
• Frontline nurses’ burnout, anxiety, depression, and fear statuses .
• The role of early-life stress and adversity in depression vulnerability.
• The impact of various environmental factors on depression rates.
• Exploring the link between depression and cardiovascular health .
• Depression detection in adults in nursing practice .
• Virtual reality as a therapeutic tool for depression treatment.
• Investigating the impact of childhood bullying on depression outcomes.
• The benefits of animal-assisted interventions in depression management.
• Depression and physical exercise .
• The relationship between depression and suicidal behavior .
• The influence of cultural factors on depression symptom expression.
• Investigating the role of epigenetics in depression susceptibility.
• Depression associated with cognitive dysfunction .
• Exploring the impact of adverse trauma on the course of depression.
• The efficacy of acceptance and commitment therapy in treating depression.
• The relationship between depression and substance use disorders .
• Depression and anxiety among college students .
• Investigating the effectiveness of group therapy for depression.
• Depression and chronic medical conditions .

Psychology Research Topics on Depression

• The influence of early attachment experiences on the development of depression.
• The impact of negative cognitive biases on depression symptomatology.
• Depression treatment plan for a queer patient .
• Examining the relationship between perfectionism and depression.
• The role of self-esteem in depression vulnerability and recovery.
• Exploring the link between maladaptive thinking styles (e.g., rumination, catastrophizing) and depression.
• Investigating the impact of social support on depression outcomes and resilience.
• Identifying depression in young adults at an early stage .
• The influence of parenting styles on the risk of depression in children and adolescents.
• The role of self-criticism and self-compassion in depression treatment.
• Exploring the relationship between identity development and depression in emerging adulthood.
• The role of learned helplessness in understanding depression and its treatment.
• Depression in the elderly .
• Examining the connection between self-efficacy beliefs and depression symptoms.
• The influence of social comparison processes on depression and body image dissatisfaction .
• Exploring the impact of trauma-related disorders on depression.
• The role of resilience factors in buffering against the development of depression.
• Investigating the relationship between personality traits and depression.
• Depression and workplace violence .
• The impact of cultural factors on depression prevalence and symptom presentation.
• Investigating the effects of chronic stress on depression risk.
• The role of coping strategies in depression management and recovery.
• The correlation between discrimination/prejudice and depression/anxiety .
• Exploring the influence of gender norms and societal expectations on depression rates.
• The impact of adverse workplace conditions on employee depression.
• Investigating the effectiveness of narrative therapy in treating depression.
• Cognitive behavior and depression in adolescents .
• Childhood emotional neglect and adult depression.
• The influence of perceived social support on treatment outcomes in depression.
• The effects of childhood bullying on the development of depression.
• The impact of intergenerational transmission of depression within families.
• Depression in children: symptoms and treatments .
• Investigating the link between body dissatisfaction and depression in adolescence.
• The influence of adverse life events and chronic stressors on depression risk.
• The effects of peer victimization on the development of depression in adolescence.
• Counselling clients with depression and addiction .
• The role of experiential avoidance in depression and its treatment.
• The impact of social media use and online interactions on depression rates.
• Depression management in adolescent .
• Exploring the relationship between emotional intelligence and depression symptomatology.
• Investigating the influence of cultural values and norms on depression stigma and help-seeking behavior.
• The effects of childhood maltreatment on neurobiological markers of depression.
• Psychological and emotional conditions of suicide and depression .
• Exploring the relationship between body dissatisfaction and depression.
• The influence of self-worth contingencies on depression vulnerability and treatment response.
• The impact of social isolation and loneliness on depression rates.
• Psychology of depression among college students .
• The effects of perfectionistic self-presentation on depression in college students.
• The role of mindfulness skills in depression prevention and relapse prevention.
• Investigating the influence of adverse neighborhood conditions on depression risk.
• Personality psychology and depression .
• The impact of attachment insecurity on depression symptomatology.

Postpartum Depression Research Topics

• Identifying risk factors for postpartum depression.
• Exploring the role of hormonal changes in postpartum depression.
• “Baby blues” or postpartum depression and evidence-based care .
• The impact of social support on postpartum depression.
• The effectiveness of screening tools for early detection of postpartum depression.
• The relationship between postpartum depression and maternal-infant bonding .
• Postpartum depression educational program results .
• Identifying effective interventions for preventing and treating postpartum depression.
• Examining the impact of cultural factors on postpartum depression rates.
• Investigating the role of sleep disturbances in postpartum depression.
• Depression and postpartum depression relationship .
• Exploring the impact of a traumatic birth experience on postpartum depression.
• Assessing the impact of breastfeeding difficulties on postpartum depression.
• Understanding the role of genetic factors in postpartum depression.
• Postpartum depression: consequences .
• Investigating the impact of previous psychiatric history on postpartum depression risk.
• The potential benefits of exercise on postpartum depression symptoms.
• The efficacy of psychotherapeutic interventions for postpartum depression.
• Postpartum depression in the twenty-first century .
• The influence of partner support on postpartum depression outcomes.
• Examining the relationship between postpartum depression and maternal self-esteem.
• The impact of postpartum depression on infant development and well-being.
• Maternal mood symptoms in pregnancy and postpartum depression .
• The effectiveness of group therapy for postpartum depression management.
• Identifying the role of inflammation and immune dysregulation in postpartum depression.
• Investigating the impact of childcare stress on postpartum depression.
• Postpartum depression among low-income US mothers .
• The role of postnatal anxiety symptoms in postpartum depression.
• The impact of postpartum depression on the marital relationship.
• The influence of postpartum depression on parenting practices and parental stress.
• Postpartum depression: symptoms, role of cultural factors, and ways to support .
• Investigating the efficacy of pharmacological treatments for postpartum depression.
• The impact of postpartum depression on breastfeeding initiation and continuation.
• The relationship between postpartum depression and post-traumatic stress disorder .
• Postpartum depression and its identification .
• The impact of postpartum depression on cognitive functioning and decision-making.
• Investigating the influence of cultural norms and expectations on postpartum depression rates.
• The impact of maternal guilt and shame on postpartum depression symptoms.
• Beck’s postpartum depression theory: purpose, concepts, and significance .
• Understanding the role of attachment styles in postpartum depression vulnerability.
• Investigating the effectiveness of online support groups for women with postpartum depression.
• The impact of socioeconomic factors on postpartum depression prevalence.
• Perinatal depression: research study and design .
• The efficacy of mindfulness-based interventions for postpartum depression.
• Investigating the influence of birth spacing on postpartum depression risk.
• The role of trauma history in postpartum depression development.
• The link between the birth experience and postnatal depression .
• How does postpartum depression affect the mother-infant interaction and bonding ?
• The effectiveness of home visiting programs in preventing and managing postpartum depression.
• Assessing the influence of work-related stress on postpartum depression.
• The relationship between postpartum depression and pregnancy-related complications.
• The role of personality traits in postpartum depression vulnerability.

🔎 Depression Essay Titles

Depression essay topics: cause & effect.

• The effects of childhood trauma on the development of depression in adults.
• The impact of social media usage on the prevalence of depression in adolescents.
• “Predictors of Postpartum Depression” by Katon et al.
• The effects of environmental factors on depression rates.
• The relationship between academic pressure and depression among college students.
• The relationship between financial stress and depression.
• The best solution to predict depression because of bullying .
• How does long-term unemployment affect mental health ?
• The effects of unemployment on mental health, particularly the risk of depression.
• The impact of genetics and family history of depression on an individual’s likelihood of developing depression.
• The relationship between depression and substance abuse .
• Child abuse and depression .
• The role of gender in the manifestation and treatment of depression.
• The effects of chronic stress on the development of depression.
• The link between substance abuse and depression.
• Depression among students at Elon University .
• The influence of early attachment styles on an individual’s vulnerability to depression.
• The effects of sleep disturbances on the severity of depression.
• Chronic illness and the risk of developing depression.
• Depression: symptoms and treatment .
• Adverse childhood experiences and the likelihood of experiencing depression in adulthood.
• The relationship between chronic illness and depression.
• The role of negative thinking patterns in the development of depression.
• Effects of depression among adolescents .
• The effects of poor body image and low self-esteem on the prevalence of depression.
• The influence of social support systems on preventing symptoms of depression.
• The effects of child neglect on adult depression rates.
• Depression caused by hormonal imbalance .
• The link between perfectionism and the risk of developing depression.
• The effects of a lack of sleep on depression symptoms.
• The effects of childhood abuse and neglect on the risk of depression.
• Social aspects of depression and anxiety .
• The impact of bullying on the likelihood of experiencing depression.
• The role of serotonin and neurotransmitter imbalances in the development of depression.
• The impact of a poor diet on depression rates.
• Depression and anxiety run in the family .
• The effects of childhood poverty and socioeconomic status on depression rates in adults.
• The impact of divorce on depression rates.
• The relationship between traumatic life events and the risk of developing depression.
• The influence of personality traits on susceptibility to depression.
• The impact of workplace stress on depression rates.
• Depression in older adults: causes and treatment .
• The impact of parental depression on children’s mental health outcomes.
• The effects of social isolation on the prevalence and severity of depression.
• The role of cultural factors in the manifestation and treatment of depression.
• The relationship between childhood bullying victimization and future depressive symptoms.
• The impact of early intervention and prevention programs on reducing the risk of postpartum depression.
• Treating mood disorders and depression .
• How do hormonal changes during pregnancy contribute to the development of depression?
• The effects of sleep deprivation on the onset and severity of postpartum depression.
• The impact of social media on depression rates among teenagers.
• The role of genetics in the development of depression.
• The impact of bullying on adolescent depression rates.
• Mental illness, depression, and wellness issues .
• The effects of a sedentary lifestyle on depression symptoms.
• The correlation between academic pressure and depression in students.
• The relationship between perfectionism and depression.
• The correlation between trauma and depression in military veterans.
• Anxiety and depression during childhood and adolescence .
• The impact of racial discrimination on depression rates among minorities.
• The relationship between chronic pain and depression.
• The impact of social comparison on depression rates among young adults.
• The effects of childhood abuse on adult depression rates.

Depression Argumentative Essay Topics

• The role of social media in contributing to depression among teenagers.
• The effectiveness of antidepressant medication: an ongoing debate.
• Depression treatment: therapy or medications ?
• Should depression screening be mandatory in schools and colleges?
• Is there a genetic predisposition to depression?
• The stigma surrounding depression: addressing misconceptions and promoting understanding.
• Implementation of depression screening in primary care .
• Is psychotherapy more effective than medication in treating depression?
• Is teenage depression overdiagnosed or underdiagnosed: a critical analysis.
• The connection between depression and substance abuse: untangling the relationship.
• Humanistic therapy of depression .
• Should ECT (electroconvulsive therapy) be a treatment option for severe depression?
• Where is depression more prevalent: in urban or rural communities? Analyzing the disparities.
• Is depression a result of chemical imbalance in the brain? Debunking the myth.
• Depression: a serious mental and behavioral problem .
• Should depression medication be prescribed for children and adolescents?
• The effectiveness of mindfulness-based interventions in managing depression.
• Should depression in the elderly be considered a normal part of aging?
• Is depression hereditary? Investigating the role of genetics in depression risk.
• Different types of training in managing the symptoms of depression .
• The effectiveness of online therapy platforms in treating depression.
• Should psychedelic therapy be explored as an alternative treatment for depression?
• The connection between depression and cardiovascular health: Is there a link?
• The effectiveness of cognitive-behavioral therapy in preventing depression relapse.
• Depression as a bad a clinical condition .
• Should mind-body interventions (e.g., yoga , meditation) be integrated into depression treatment?
• Should emotional support animals be prescribed for individuals with depression?
• The effectiveness of peer support groups in decreasing depression symptoms.
• The use of antidepressants: are they overprescribed or necessary for treating depression?
• Adult depression and anxiety as a complex problem .
• The effectiveness of therapy versus medication in treating depression.
• The stigma surrounding depression and mental illness: how can we reduce it?
• The debate over the legalization of psychedelic drugs for treating depression.
• The relationship between creativity and depression: does one cause the other?
• Cognitive-behavioral therapy for generalized anxiety disorder and depression .
• The role of childhood trauma in shaping adult depression: Is it always a causal factor?
• The debate over the medicalization of sadness and grief as forms of depression.
• Alternative therapies, such as acupuncture or meditation, are effective in treating depression.
• Depression as a widespread mental condition .

Controversial Topics about Depression

• The existence of “chemical imbalance” in depression: fact or fiction?
• The over-reliance on medication in treating depression: are alternatives neglected?
• Is depression overdiagnosed and overmedicated in Western society?
• Measurement of an individual’s level of depression .
• The role of Big Pharma in shaping the narrative and treatment of depression.
• Should antidepressant advertisements be banned?
• The inadequacy of current diagnostic criteria for depression: rethinking the DSM-5.
• Is depression a biological illness or a product of societal factors?
• Literature review on depression .
• The overemphasis on biological factors in depression treatment: ignoring environmental factors.
• Is depression a normal reaction to an abnormal society?
• The influence of cultural norms on the perception and treatment of depression.
• Should children and adolescents be routinely prescribed antidepressants?
• The role of family in depression treatment .
• The connection between depression and creative genius: does depression enhance artistic abilities?
• The ethics of using placebo treatment for depression studies.
• The impact of social and economic inequalities on depression rates.
• Is depression primarily a mental health issue or a social justice issue?
• Depression disassembling and treating .
• Should depression screening be mandatory in the workplace?
• The influence of gender bias in the diagnosis and treatment of depression.
• The controversial role of religion and spirituality in managing depression.
• Is depression a result of individual weakness or societal factors?
• Abnormal psychology: anxiety and depression case .
• The link between depression and obesity: examining the bidirectional relationship.
• The connection between depression and academic performance : causation or correlation?
• Should depression medication be available over the counter?
• The impact of internet and social media use on depression rates: harmful or beneficial?
• Interacting in the workplace: depression .
• Is depression a modern epidemic or simply better diagnosed and identified?
• The ethical considerations of using animals in depression research.
• The effectiveness of psychedelic therapies for treatment-resistant depression.
• Is depression a disability? The debate on workplace accommodations.
• Polysubstance abuse among adolescent males with depression .
• The link between depression and intimate partner violence : exploring the relationship.
• The controversy surrounding “happy” pills and the pursuit of happiness.
• Is depression a choice? Examining the role of personal responsibility.

Good Titles for Depression Essays

• The poetic depictions of depression: exploring its representation in literature.
• The melancholic symphony: the influence of depression on classical music.
• Moderate depression symptoms and treatment .
• Depression in modern music: analyzing its themes and expressions.
• Cultural perspectives on depression: a comparative analysis of attitudes in different countries.
• Contrasting cultural views on depression in Eastern and Western societies.
• Diagnosing depression in the older population .
• The influence of social media on attitudes and perceptions of depression in global contexts.
• Countries with progressive approaches to mental health awareness.
• From taboo to acceptance: the evolution of attitudes towards depression.
• Depression screening tool in acute settings .
• The Bell Jar : analyzing Sylvia Plath’s iconic tale of depression .
• The art of despair: examining Frida Kahlo’s self-portraits as a window into depression.
• The Catcher in the Rye : Holden Caulfield’s battle with adolescent depression.
• Music as therapy: how jazz artists turned depression into art.
• Depression screening tool for a primary care center .
• The Nordic paradox: high depression rates in Scandinavian countries despite high-quality healthcare.
• The Stoic East: how Eastern philosophies approach and manage depression.
• From solitude to solidarity: collective approaches to depression in collectivist cultures.
• The portrayal of depression in popular culture: a critical analysis of movies and TV shows.
• The depression screening training in primary care .
• The impact of social media influencers on depression rates among young adults.
• The role of music in coping with depression: can specific genres or songs help alleviate depressive symptoms?
• The representation of depression in literature: a comparative analysis of classic and contemporary works.
• The use of art as a form of self-expression and therapy for individuals with depression.
• Depression management guidelines implementation .
• The role of religion in coping with depression: Christian and Buddhist practices.
• The representation of depression in the video game Hellblade: Senua’s Sacrifice .
• The role of nature in coping with depression: can spending time outdoors help alleviate depressive symptoms?
• The effectiveness of dance/movement therapy in treating depression among older adults.
• The National Institute for Health: depression management .
• The portrayal of depression in stand-up comedy: a study of comedians like Maria Bamford and Chris Gethard.
• The role of spirituality in coping with depression: Islamic and Hindu practices .
• The portrayal of depression in animated movies : an analysis of Inside Out and The Lion King .
• The representation of depression by fashion designers like Alexander McQueen and Rick Owens.
• Depression screening in primary care .
• The portrayal of depression in documentaries: an analysis of films like The Bridge and Happy Valley .
• The effectiveness of wilderness therapy in treating depression among adolescents.
• The connection between creativity and depression: how art can help heal.
• The role of Buddhist and Taoist practices in coping with depression.
• Mild depression treatment research funding sources .
• The portrayal of depression in podcasts: an analysis of the show The Hilarious World of Depression .
• The effectiveness of drama therapy in treating depression among children and adolescents.
• The representation of depression in the works of Vincent van Gogh and Edvard Munch.
• Depression in young people: articles review .
• The impact of social media on political polarization and its relationship with depression.
• The role of humor in coping with depression: a study of comedians like Ellen DeGeneres.
• The portrayal of depression in webcomics: an analysis of the comics Hyperbole and a Half .
• The effect of social media on mental health stigma and its relationship with depression.
• Depression and the impact of human services workers .
• The masked faces: hiding depression in highly individualistic societies.

💭 Depression Speech Topics

Informative speech topics about depression.

• Different types of depression and their symptoms.
• The causes of depression: biological, psychological, and environmental factors.
• How depression and physical issues are connected .
• The prevalence of depression in different age groups and demographics.
• The link between depression and anxiety disorders .
• Physical health: The effects of untreated depression.
• The role of genetics in predisposing individuals to depression.
• What you need to know about depression .
• How necessary is early intervention in treating depression?
• The effectiveness of medication in treating depression.
• The role of exercise in managing depressive symptoms.
• Depression in later life: overview .
• The relationship between substance abuse and depression.
• The impact of trauma on depression rates and treatment.
• The effectiveness of mindfulness meditation in managing depressive symptoms.
• Enzymes conversion and metabolites in major depression .
• The benefits and drawbacks of electroconvulsive therapy for severe depression.
• The effect of gender and cultural norms on depression rates and treatment.
• The effectiveness of alternative therapies for depression, such as acupuncture and herbal remedies .
• The importance of self-care in managing depression.
• Symptoms of anxiety, depression, and peritraumatic dissociation .
• The role of support systems in managing depression.
• The effectiveness of cognitive-behavioral therapy in treating depression.
• The benefits and drawbacks of online therapy for depression.
• The role of spirituality in managing depression.
• Depression among minority groups .
• The benefits and drawbacks of residential treatment for severe depression.
• What is the relationship between childhood trauma and adult depression?
• How effective is transcranial magnetic stimulation (TMS) for treatment-resistant depression?
• The benefits and drawbacks of art therapy for depression.
• Mood disorder: depression and bipolar .
• The impact of social media on depression rates.
• The effectiveness of dialectical behavior therapy (DBT) in treating depression.
• Depression in older people .
• The impact of seasonal changes on depression rates and treatment options.
• The impact of depression on daily life and relationships, and strategies for coping with the condition.
• The stigma around depression and the importance of seeking help.

Persuasive Speech Topics about Depression

• How important is it to recognize the signs and symptoms of depression ?
• How do you support a loved one who is struggling with depression?
• The importance of mental health education in schools to prevent and manage depression.
• Social media: the rise of depression and anxiety .
• Is there a need to increase funding for mental health research to develop better treatments for depression?
• Addressing depression in minority communities: overcoming barriers and disparities.
• The benefits of including alternative therapies , such as yoga and meditation, in depression treatment plans.
• Challenging media portrayals of depression: promoting accurate representations.
• Two sides of depression disease .
• How social media affects mental health: the need for responsible use to prevent depression.
• The importance of early intervention: addressing depression in schools and colleges.
• The benefits of seeking professional help for depression.
• There is a need for better access to mental health care, including therapy and medication, for those suffering from depression.
• Depression in adolescents and suitable interventions .
• How do you manage depression while in college or university?
• The role of family and friends in supporting loved ones with depression and encouraging them to seek help.
• The benefits of mindfulness and meditation for depression.
• The link between sleep and depression, and how to improve sleep habits.
• How do you manage depression while working a high-stress job?
• Approaches to treating depression .
• How do you manage depression during pregnancy and postpartum?
• The importance of prioritizing employee mental health and providing resources for managing depression in the workplace.
• How should you manage depression while caring for a loved one with a chronic illness?
• How to manage depression while dealing with infertility or pregnancy loss.
• Andrew Solomon: why we can’t talk about depression .
• Destigmatizing depression: promoting mental health awareness and understanding.
• Raising funds for depression research: investing in mental health advances.
• The power of peer support: establishing peer-led programs for depression.
• Accessible mental health services: ensuring treatment for all affected by depression.
• Evidence-based screening for depression in acute care .
• The benefits of journaling for mental health: putting your thoughts on paper to heal.
• The power of positivity: changing your mindset to fight depression .
• The healing power of gratitude in fighting depression.
• The connection between diet and depression: eating well can improve your mood.
• Teen depression and suicide in Soto’s The Afterlife .
• The benefits of therapy for depression: finding professional help to heal.
• The importance of setting realistic expectations when living with depression.

📝 How to Write about Depression: Essay Structure

We’ve prepared some tips and examples to help you structure your essay and communicate your ideas.

Essay about Depression: Introduction

An introduction is the first paragraph of an essay. It plays a crucial role in engaging the reader, offering the context, and presenting the central theme.

A good introduction typically consists of 3 components:

• Hook. The hook captures readers’ attention and encourages them to continue reading.
• Background information. Background information provides context for the essay.
• Thesis statement. A thesis statement expresses the essay’s primary idea or central argument.

Hook : Depression is a widespread mental illness affecting millions worldwide.

Background information : Depression affects your emotions, thoughts, and behavior. If you suffer from depression, engaging in everyday tasks might become arduous, and life may appear devoid of purpose or joy.

Depression Essay Thesis Statement

A good thesis statement serves as an essay’s road map. It expresses the author’s point of view on the issue in 1 or 2 sentences and presents the main argument.

Thesis statement : The stigma surrounding depression and other mental health conditions can discourage people from seeking help, only worsening their symptoms.

Essays on Depression: Body Paragraphs

The main body of the essay is where you present your arguments. An essay paragraph includes the following:

• a topic sentence,
• evidence to back up your claim,
• explanation of why the point is essential to the argument;
• a link to the next paragraph.

Topic sentence : Depression is a complex disorder that requires a personalized treatment approach, comprising both medication and therapy.

Evidence : Medication can be prescribed by a healthcare provider or a psychiatrist to relieve the symptoms. Additionally, practical strategies for managing depression encompass building a support system, setting achievable goals, and practicing self-care.

Depression Essay: Conclusion

The conclusion is the last part of your essay. It helps you leave a favorable impression on the reader.

The perfect conclusion includes 3 elements:

• Rephrased thesis statement.
• Summary of the main points.
• Final opinion on the topic.

Rephrased thesis: In conclusion, overcoming depression is challenging because it involves a complex interplay of biological, psychological, and environmental factors that affect an individual’s mental well-being.

Summary: Untreated depression heightens the risk of engaging in harmful behaviors such as substance abuse and can also result in negative thought patterns, diminished self-esteem, and distorted perceptions of reality.

We hope you’ve found our article helpful and learned some new information. If so, feel free to share it with your friends. You can also try our free online topic generator !

• Pain, anxiety, and depression – Harvard Health | Harvard Health Publishing
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414 proposal essay topics for projects, research, & proposal arguments.

Anxiety Disorders and Depression Essay (Critical Writing)

Introduction, description section, feelings section, action plan, reference list.

Human beings become anxious in different situations that are uncertain to them. Depression and anxiety occur at a similar time. Anxiety is caused due to an overwhelming fear of an expected occurrence of an event that is unclear to a person. More than 25 million people globally are affected by anxiety disorders. People feel anxious in moments such as when making important decisions, before facing an interview panel, and before taking tests. Anxiety disorders are normally brained reactions to stress as they alert a person of impending danger. Most people feel sad and low due to disappointments. Feelings normally overwhelm a person leading to depression, especially during sad moments such as losing a loved one or divorce. When people are depressed, they engage in reckless behaviors such as drug abuse that affect them physically and emotionally. However, depression manifests in different forms in both men and women. Research shows that more women are depressed compared to men. This essay reflects on anxiety disorders and depression regarding from a real-life experience extracted from a publication.

“Every year almost 20% of the general population suffers from a common mental disorder, such as depression or an anxiety disorder” (Cuijpers et al. 2016, p.245). I came across a publication by Madison Jo Sieminski available who was diagnosed with depression and anxiety disorders (Madison 2020). She explains how she was first diagnosed with anxiety disorders and depression and how it felt unreal at first. She further says that she developed the need to get a distraction that would keep her busy so that she won’t embrace her situation. In her case, anxiety made her feel that she needed to do more, and everything needed to be perfect.

Madison further said that the struggle with anxiety is that it never seemed to happen, but it happened eventually. She always felt a feeling of darkness and loneliness. She could barely stay awake for more than 30 minutes for many days. Anxiety and depression made her question herself if she was good enough, and this resulted in tears in her eyes due to the burning sensation and overwhelmed emotions. In her own words, she said, “Do I deserve to be here? What is my purpose?” (Madison 2020). Anxiety made her lose confidence in herself and lowered her self-esteem. She could lay in bed most of the time and could not take any meal most of the days.

Madison said that since the sophomore year of high school, all was not well, and she suddenly felt someone in her head telling her to constantly worry and hold back from everything. She could wake up days when she could try a marathon to keep her mind busy. However, she sought help on 1 January 2020, since she felt her mental health was important, and she needed to be strong. She was relieved from her biggest worries, and what she thought was failure turned into a biggest achievement. She realized that her health needed to be her priority. Even after being diagnosed with depression disorders, she wanted to feel normal and have a normal lifestyle like other people.

Madison was happy with her decision to seek medical help even though she had her doubts. She was happy that she finally took that step to see a doctor since she was suffering in silence. She noted that the background of her depression and anxiety disorders was her family. It was kind of genetic since her mom also struggled with depression and anxiety disorders. Her mom was always upset, and this broke her heart. She said it took her years to better herself, but she still had bad days. Madison decided to take the challenge regarding her mother’s experience. Also, Madison said she was struggling to get over depression since her childhood friends committed suicide, and it affected her deeply. She also told the doctor how she often thought of harming herself. The doctor advised her on the different ways she could overcome her situation after discovering she had severe depression and anxiety disorders.

After going through Madison’s story, I was hurt by the fact that he had to go through that for a long time, and something tragic could have happened if she had not resorted to medical help. I felt emotional by the fact that she constantly blamed herself due to her friends who committed suicide, and she decided to accumulate all the pain and worries. The fact that I have heard stories of how people commit suicide due to depression and anxiety disorders made me have a somber mood considering her case. In this case, you will never know what people are going through in their private lives until they decide to open up. We normally assume every person is okay, yet they fight their demons and struggle to look okay. Hence, it won’t cost any person to check up on other people, especially if they suddenly change their social characters.

Madison’s story stood out for me since she had struggled since childhood to deal with depression and anxiety disorders. In her case, she was unable to seek help first even when she knew that she was suffering in silence (Madison 2020). However, most people find it hard to admit they need help regardless of what they are going through, like Madison. People who are depressed cannot work as they lack the motivation to do anything. In my knowledge, depression affects people close to you, including your family and friends. Depression also hurts those who love someone suffering from it. Hence, it is complex to deal with. Madison’s situation stood out for me since her childhood friends committed suicide, and she wished silently she could be with them. Hence, this leads to her constant thoughts of harming herself. Childhood friends at one point can become your family even though you are not related by blood due to the memories you share.

Depression and Anxiety disorders have been common mental health concerns globally for a long time. Depression and anxiety disorders create the impression that social interactions are vague with no meaning. It is argued by Cuijpers (2016, p.245) that people who are depressed normally have personality difficulties as they find it hard to trust people around them, including themselves. In this case, Madison spent most of her time alone, sleeping, and could not find it necessary to hang around other people. Negativity is the order of the day as people depressed find everything around them not interesting.

People who are depressed find it easy to induce negativity in others. Hence, they end up being rejected. Besides, if someone is depressed and is in a relationship, he/she may be the reason for ending the relationship since they would constantly find everything offensive. Research shows that people who are clinically depressed, such as Madison, prefer sad facial expressions to happy facial expressions. Besides, most teenagers in the 21 st century are depressed, and few parents tend to notice that. Also, most teenagers lack parental love and care since their parents are busy with their job routines and have no time to engage their children. Research has shown that suicide is the second cause of death among teenagers aged between 15-24 years due to mental disorders such as suicide and anxiety disorders.

Despite depression being a major concern globally, it can be controlled and contained if specific actions are taken. Any person needs to prioritize their mental health to avoid occurrences of depression and anxiety orders. Emotional responses can be used to gauge if a person is undergoing anxiety and depression. The best efficient way to deal with depression and anxiety is to sensitize people about depression through different media platforms (Cuijpers et al. 2016). A day in a month should be set aside where students in colleges are sensitized on the symptoms of depression and how to cope up with the situation. Some of the basic things to do to avoid anxiety and depression include; talking to someone when you are low, welcoming humor, learning the cause of your anxiety, maintaining a positive attitude, exercising daily, and having enough sleep.

Depression and anxiety disorders are different forms among people, such as irritability and nervousness. Most people are diagnosed with depression as a psychiatric disorder. Technology has been a major catalyst in enabling depression among people as they are exposed to many negative experiences online. Besides, some people are always motivated by actions of other people who seem to have given up due to depression. Many people who develop depression normally have a history of anxiety disorders. Therefore, people with depression need to seek medical attention before they harm themselves or even commit suicide. Also, people need to speak out about what they are going through to either their friends or people they trust. Speaking out enables people to relieve their burden and hence it enhances peace.

Cuijpers, P., Cristea, I.A., Karyotaki, E., Reijnders, M. and Huibers, M.J., 2016. How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta‐analytic update of the evidence . World Psychiatry 15(3), pp. 245-258.

Madison, J. 2020. Open Doors .

• Chicago (A-D)
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IvyPanda . 2022. "Anxiety Disorders and Depression." June 16, 2022. https://ivypanda.com/essays/anxiety-disorders-and-depression/.

1. IvyPanda . "Anxiety Disorders and Depression." June 16, 2022. https://ivypanda.com/essays/anxiety-disorders-and-depression/.

Bibliography

IvyPanda . "Anxiety Disorders and Depression." June 16, 2022. https://ivypanda.com/essays/anxiety-disorders-and-depression/.

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The Critical Relationship Between Anxiety and Depression

• Ned H. Kalin , M.D.

Search for more papers by this author

Anxiety and depressive disorders are among the most common psychiatric illnesses; they are highly comorbid with each other, and together they are considered to belong to the broader category of internalizing disorders. Based on statistics from the Substance Abuse and Mental Health Services Administration, the 12-month prevalence of major depressive disorder in 2017 was estimated to be 7.1% for adults and 13.3% for adolescents ( 1 ). Data for anxiety disorders are less current, but in 2001–2003, their 12-month prevalence was estimated to be 19.1% in adults, and 2001–2004 data estimated that the lifetime prevalence in adolescents was 31.9% ( 2 , 3 ). Both anxiety and depressive disorders are more prevalent in women, with an approximate 2:1 ratio in women compared with men during women’s reproductive years ( 1 , 2 ).

Across all psychiatric disorders, comorbidity is the rule ( 4 ), which is definitely the case for anxiety and depressive disorders, as well as their symptoms. With respect to major depression, a worldwide survey reported that 45.7% of individuals with lifetime major depressive disorder had a lifetime history of one or more anxiety disorder ( 5 ). These disorders also commonly coexist during the same time frame, as 41.6% of individuals with 12-month major depression also had one or more anxiety disorder over the same 12-month period. From the perspective of anxiety disorders, the lifetime comorbidity with depression is estimated to range from 20% to 70% for patients with social anxiety disorder ( 6 ), 50% for patients with panic disorder ( 6 ), 48% for patients with posttraumatic stress disorder (PTSD) ( 7 ), and 43% for patients with generalized anxiety disorder ( 8 ). Data from the well-known Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study demonstrate comorbidity at the symptom level, as 53% of the patients with major depression had significant anxiety and were considered to have an anxious depression ( 9 ).

Anxiety and depressive disorders are moderately heritable (approximately 40%), and evidence suggests shared genetic risk across the internalizing disorders ( 10 ). Among internalizing disorders, the highest level of shared genetic risk appears to be between major depressive disorder and generalized anxiety disorder. Neuroticism is a personality trait or temperamental characteristic that is associated with the development of both anxiety and depression, and the genetic risk for developing neuroticism also appears to be shared with that of the internalizing disorders ( 11 ). Common nongenetic risk factors associated with the development of anxiety and depression include earlier life adversity, such as trauma or neglect, as well as parenting style and current stress exposure. At the level of neural circuits, alterations in prefrontal-limbic pathways that mediate emotion regulatory processes are common to anxiety and depressive disorders ( 12 , 13 ). These findings are consistent with meta-analyses that reveal shared structural and functional brain alterations across various psychiatric illnesses, including anxiety and major depression, in circuits involving emotion regulation ( 13 ), executive function ( 14 ), and cognitive control ( 15 ).

Anxiety disorders and major depression occur during development, with anxiety disorders commonly beginning during preadolescence and early adolescence and major depression tending to emerge during adolescence and early to mid-adulthood ( 16 – 18 ). In relation to the evolution of their comorbidity, studies demonstrate that anxiety disorders generally precede the presentation of major depressive disorder ( 17 ). A European community-based study revealed, beginning at age 15, the developmental relation between comorbid anxiety and major depression by specifically focusing on social phobia (based on DSM-IV criteria) and then asking the question regarding concurrent major depressive disorder ( 18 ). The findings revealed a 19% concurrent comorbidity between these disorders, and in 65% of the cases, social phobia preceded major depressive disorder by at least 2 years. In addition, initial presentation with social phobia was associated with a 5.7-fold increased risk of developing major depressive disorder. These associations between anxiety and depression can be traced back even earlier in life. For example, childhood behavioral inhibition in response to novelty or strangers, or an extreme anxious temperament, is associated with a three- to fourfold increase in the likelihood of developing social anxiety disorder, which in turn is associated with an increased risk to develop major depressive disorder and substance abuse ( 19 ).

It is important to emphasize that the presence of comor‐bid anxiety symptoms and disorders matters in relation to treatment. Across psychiatric disorders, the presence of significant anxiety symptoms generally predicts worse outcomes, and this has been well demonstrated for depression. In the STAR*D study, patients with anxious major depressive disorder were more likely to be severely depressed and to have more suicidal ideation ( 9 ). This is consistent with the study by Kessler and colleagues ( 5 ), in which patients with anxious major depressive disorder, compared with patients with nonanxious major depressive disorder, were found to have more severe role impairment and more suicidal ideation. Data from level 1 of the STAR*D study (citalopram treatment) nicely illustrate the impact of comorbid anxiety symptoms on treatment. Compared with patients with nonanxious major depressive disorder, those 53% of patients with an anxious depression were less likely to remit and also had a greater side effect burden ( 20 ). Other data examining patients with major depressive disorder and comorbid anxiety disorders support the greater difficulty and challenge in treating patients with these comorbidities ( 21 ).

This issue of the Journal presents new findings relevant to the issues discussed above in relation to understanding and treating anxiety and depressive disorders. Drs. Conor Liston and Timothy Spellman, from Weill Cornell Medicine, provide an overview for this issue ( 22 ) that is focused on understanding mechanisms at the neural circuit level that underlie the pathophysiology of depression. Their piece nicely integrates human neuroimaging studies with complementary data from animal models that allow for the manipulation of selective circuits to test hypotheses generated from the human data. Also included in this issue is a review of the data addressing the reemergence of the use of psychedelic drugs in psychiatry, particularly for the treatment of depression, anxiety, and PTSD ( 23 ). This timely piece, authored by Dr. Collin Reiff along with a subgroup from the APA Council of Research, provides the current state of evidence supporting the further exploration of these interventions. Dr. Alan Schatzberg, from Stanford University, contributes an editorial in which he comments on where the field is in relation to clinical trials with psychedelics and to some of the difficulties, such as adequate blinding, in reliably studying the efficacy of these drugs ( 24 ).

In an article by McTeague et al. ( 25 ), the authors use meta-analytic strategies to understand the neural alterations that are related to aberrant emotion processing that are shared across psychiatric disorders. Findings support alterations in the salience, reward, and lateral orbital nonreward networks as common across disorders, including anxiety and depressive disorders. These findings add to the growing body of work that supports the concept that there are common underlying factors across all types of psychopathology that include internalizing, externalizing, and thought disorder dimensions ( 26 ). Dr. Deanna Barch, from Washington University in St. Louis, writes an editorial commenting on these findings and, importantly, discusses criteria that should be met when we consider whether the findings are actually transdiagnostic ( 27 ).

Another article, from Gray and colleagues ( 28 ), addresses whether there is a convergence of findings, specifically in major depression, when examining data from different structural and functional neuroimaging modalities. The authors report that, consistent with what we know about regions involved in emotion processing, the subgenual anterior cingulate cortex, hippocampus, and amygdala were among the regions that showed convergence across multimodal imaging modalities.

In relation to treatment and building on our understanding of neural circuit alterations, Siddiqi et al. ( 29 ) present data suggesting that transcranial magnetic stimulation (TMS) targeting can be linked to symptom-specific treatments. Their findings identify different TMS targets in the left dorsolateral prefrontal cortex that modulate different downstream networks. The modulation of these different networks appears to be associated with a reduction in different types of symptoms. In an editorial, Drs. Sean Nestor and Daniel Blumberger, from the University of Toronto ( 30 ), comment on the novel approach used in this study to link the TMS-related engagement of circuits with symptom improvement. They also provide a perspective on how we can view these and other circuit-based findings in relation to conceptualizing personalized treatment approaches.

Kendler et al. ( 31 ), in this issue, contribute an article that demonstrates the important role of the rearing environment in the risk to develop major depression. Using a unique design from a Swedish sample, the analytic strategy involves comparing outcomes from high-risk full sibships and high-risk half sibships where at least one of the siblings was home reared and one was adopted out of the home. The findings support the importance of the quality of the rearing environment as well as the presence of parental depression in mitigating or enhancing the likelihood of developing major depression. In an accompanying editorial ( 32 ), Dr. Myrna Weissman, from Columbia University, reviews the methods and findings of the Kendler et al. article and also emphasizes the critical significance of the early nurturing environment in relation to general health.

This issue concludes with an intriguing article on anxiety disorders, by Gold and colleagues ( 33 ), that demonstrates neural alterations during extinction recall that differ in children relative to adults. With increasing age, and in relation to fear and safety cues, nonanxious adults demonstrated greater connectivity between the amygdala and the ventromedial prefrontal cortex compared with anxious adults, as the cues were being perceived as safer. In contrast, neural differences between anxious and nonanxious youths were more robust when rating the memory of faces that were associated with threat. Specifically, these differences were observed in the activation of the inferior temporal cortex. In their editorial ( 34 ), Dr. Dylan Gee and Sahana Kribakaran, from Yale University, emphasize the importance of developmental work in relation to understanding anxiety disorders, place these findings into the context of other work, and suggest the possibility that these and other data point to neuroscientifically informed age-specific interventions.

Taken together, the papers in this issue of the Journal present new findings that shed light onto alterations in neural function that underlie major depressive disorder and anxiety disorders. It is important to remember that these disorders are highly comorbid and that their symptoms are frequently not separable. The papers in this issue also provide a developmental perspective emphasizing the importance of early rearing in the risk to develop depression and age-related findings important for understanding threat processing in patients with anxiety disorders. From a treatment perspective, the papers introduce data supporting more selective prefrontal cortical TMS targeting in relation to different symptoms, address the potential and drawbacks for considering the future use of psychedelics in our treatments, and present new ideas supporting age-specific interventions for youths and adults with anxiety disorders.

Disclosures of Editors’ financial relationships appear in the April 2020 issue of the Journal .

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• Published: 13 July 2021

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

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

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

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• Epidemiology
• Health policy
• Quality of life

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

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Introduction

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

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

Flowchart of included articles.

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

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

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

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

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

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

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

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

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

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

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

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

Risk of bias

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

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

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

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

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

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

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

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

Eligibility criteria

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

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

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

Search strategy and data extraction

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

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

Risk of bias assessment

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

Analysis and synthesis

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

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Acknowledgements

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

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

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

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

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Effects of the COVID-19 pandemic on mental health, anxiety, and depression

Ida kupcova.

1 Institute of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University in Bratislava, Sasinkova 4, Bratislava, 811 08 Slovakia

Lubos Danisovic

Martin klein.

2 Institute of Histology and Embryology, Faculty of Medicine, Comenius University in Bratislava, Sasinkova 4, Bratislava, 811 08 Slovakia

Stefan Harsanyi

Associated data.

The datasets generated and analyzed during the current study are not publicly available due to compliance with institutional guidelines but they are available from the corresponding author (SH) on a reasonable request.

The COVID-19 pandemic affected everyone around the globe. Depending on the country, there have been different restrictive epidemiologic measures and also different long-term repercussions. Morbidity and mortality of COVID-19 affected the mental state of every human being. However, social separation and isolation due to the restrictive measures considerably increased this impact. According to the World Health Organization (WHO), anxiety and depression prevalence increased by 25% globally. In this study, we aimed to examine the lasting effects of the COVID-19 pandemic on the general population.

A cross-sectional study using an anonymous online-based 45-question online survey was conducted at Comenius University in Bratislava. The questionnaire comprised five general questions and two assessment tools the Zung Self-Rating Anxiety Scale (SAS) and the Zung Self-Rating Depression Scale (SDS). The results of the Self-Rating Scales were statistically examined in association with sex, age, and level of education.

A total of 205 anonymous subjects participated in this study, and no responses were excluded. In the study group, 78 (38.05%) participants were male, and 127 (61.69%) were female. A higher tendency to anxiety was exhibited by female participants (p = 0.012) and the age group under 30 years of age (p = 0.042). The level of education has been identified as a significant factor for changes in mental state, as participants with higher levels of education tended to be in a worse mental state (p = 0.006).

Conclusions

Summarizing two years of the COVID-19 pandemic, the mental state of people with higher levels of education tended to feel worse, while females and younger adults felt more anxiety.

Introduction

The first mention of the novel coronavirus came in 2019, when this variant was discovered in the city of Wuhan, China, and became the first ever documented coronavirus pandemic [ 1 – 3 ]. At this time there was only a sliver of fear rising all over the globe. However, in March 2020, after the declaration of a global pandemic by the World Health Organization (WHO), the situation changed dramatically [ 4 ]. Answering this, yet an unknown threat thrust many countries into a psycho-socio-economic whirlwind [ 5 , 6 ]. Various measures taken by governments to control the spread of the virus presented the worldwide population with a series of new challenges to which it had to adjust [ 7 , 8 ]. Lockdowns, closed schools, losing employment or businesses, and rising deaths not only in nursing homes came to be a new reality [ 9 – 11 ]. Lack of scientific information on the novel coronavirus and its effects on the human body, its fast spread, the absence of effective causal treatment, and the restrictions which harmed people´s social life, financial situation and other areas of everyday life lead to long-term living conditions with increased stress levels and low predictability over which people had little control [ 12 ].

Risks of changes in the mental state of the population came mainly from external risk factors, including prolonged lockdowns, social isolation, inadequate or misinterpreted information, loss of income, and acute relationship with the rising death toll. According to the World Health Organization (WHO), since the outbreak of the COVID-19 pandemic, anxiety and depression prevalence increased by 25% globally [ 13 ]. Unemployment specifically has been proven to be also a predictor of suicidal behavior [ 14 – 18 ]. These risk factors then interact with individual psychological factors leading to psychopathologies such as threat appraisal, attentional bias to threat stimuli over neutral stimuli, avoidance, fear learning, impaired safety learning, impaired fear extinction due to habituation, intolerance of uncertainty, and psychological inflexibility. The threat responses are mediated by the limbic system and insula and mitigated by the pre-frontal cortex, which has also been reported in neuroimaging studies, with reduced insula thickness corresponding to more severe anxiety and amygdala volume correlated to anhedonia as a symptom of depression [ 19 – 23 ]. Speaking in psychological terms, the pandemic disturbed our core belief, that we are safe in our communities, cities, countries, or even the world. The lost sense of agency and confidence regarding our future diminished the sense of worth, identity, and meaningfulness of our lives and eroded security-enhancing relationships [ 24 ].

Slovakia introduced harsh public health measures in the first wave of the pandemic, but relaxed these measures during the summer, accompanied by a failure to develop effective find, test, trace, isolate and support systems. Due to this, the country experienced a steep growth in new COVID-19 cases in September 2020, which lead to the erosion of public´s trust in the government´s management of the situation [ 25 ]. As a means to control the second wave of the pandemic, the Slovak government decided to perform nationwide antigen testing over two weekends in November 2020, which was internationally perceived as a very controversial step, moreover, it failed to prevent further lockdowns [ 26 ]. In addition, there was a sharp rise in the unemployment rate since 2020, which continued until July 2020, when it gradually eased [ 27 ]. Pre-pandemic, every 9th citizen of Slovakia suffered from a mental health disorder, according to National Statistics Office in 2017, the majority being affective and anxiety disorders. A group of authors created a web questionnaire aimed at psychiatrists, psychologists, and their patients after the first wave of the COVID-19 pandemic in Slovakia. The results showed that 86.6% of respondents perceived the pathological effect of the pandemic on their mental status, 54.1% of whom were already treated for affective or anxiety disorders [ 28 ].

In this study, we aimed to examine the lasting effects of the COVID-19 pandemic on the general population. This study aimed to assess the symptoms of anxiety and depression in the general public of Slovakia. After the end of epidemiologic restrictive measures (from March to May 2022), we introduced an anonymous online questionnaire using adapted versions of Zung Self-Rating Anxiety Scale (SAS) and Zung Self-Rating Depression Scale (SDS) [ 29 , 30 ]. We focused on the general public because only a portion of people who experience psychological distress seek professional help. We sought to establish, whether during the pandemic the population showed a tendency to adapt to the situation or whether the anxiety and depression symptoms tended to be present even after months of better epidemiologic situation, vaccine availability, and studies putting its effects under review [ 31 – 34 ].

Materials and Methods

This study utilized a voluntary and anonymous online self-administered questionnaire, where the collected data cannot be linked to a specific respondent. This study did not process any personal data. The questionnaire consisted of 45 questions. The first three were open-ended questions about participants’ sex, age (date of birth was not recorded), and education. Followed by 2 questions aimed at mental health and changes in the will to live. Further 20 and 20 questions consisted of the Zung SAS and Zung SDS, respectively. Every question in SAS and SDS is scored from 1 to 4 points on a Likert-style scale. The scoring system is introduced in Fig.  1 . Questions were presented in the Slovak language, with emphasis on maintaining test integrity, so, if possible, literal translations were made from English to Slovak. The questionnaire was created and designed in Google Forms®. Data collection was carried out from March 2022 to May 2022. The study was aimed at the general population of Slovakia in times of difficult epidemiologic and social situations due to the high prevalence and incidence of COVID-19 cases during lockdowns and social distancing measures. Because of the character of this web-based study, the optimal distribution of respondents could not be achieved.

Categories of Zung SAS and SDS scores with clinical interpretation

During the course of this study, 205 respondents answered the anonymous questionnaire in full and were included in the study. All respondents were over 18 years of age. The data was later exported from Google Forms® as an Excel spreadsheet. Coding and analysis were carried out using IBM SPSS Statistics version 26 (IBM SPSS Statistics for Windows, Version 26.0, Armonk, NY, USA). Subject groups were created based on sex, age, and education level. First, sex due to differences in emotional expression. Second, age was a risk factor due to perceived stress and fear of the disease. Last, education due to different approaches to information. In these groups four factors were studied: (1) changes in mental state; (2) affected will to live, or frequent thoughts about death; (3) result of SAS; (4) result of SDS. For SAS, no subject in the study group scored anxiety levels of “severe” or “extreme”. Similarly for SDS, no subject depression levels reached “moderate” or “severe”. Pearson’s chi-squared test(χ2) was used to analyze the association between the subject groups and studied factors. The results were considered significant if the p-value was less than 0.05.

Ethical permission was obtained from the local ethics committee (Reference number: ULBGaKG-02/2022). This study was performed in line with the principles of the Declaration of Helsinki. All methods were carried out following the institutional guidelines. Due to the anonymous design of the study and by the institutional requirements, written informed consent for participation was not required for this study.

In the study, out of 205 subjects in the study group, 127 (62%) were female and 78 (38%) were male. The average age in the study group was 35.78 years of age (range 19–71 years), with a median of 34 years. In the age group under 30 years of age were 34 (16.6%) subjects, while 162 (79%) were in the range from 31 to 49 and 9 (0.4%) were over 50 years old. 48 (23.4%) participants achieved an education level of lower or higher secondary and 157 (76.6%) finished university or higher. All answers of study participants were included in the study, nothing was excluded.

In Tables  1 and ​ and2, 2 , we can see the distribution of changes in mental state and will to live as stated in the questionnaire. In Table  1 we can see a disproportion in education level and mental state, where participants with higher education tended to feel worse much more than those with lower levels of education. Changes based on sex and age did not show any statistically significant results.

Distribution of changes in mental state in the study group during the coronavirus pandemic depending on sex, age, and education

Distribution of affected will to live and thoughts about death in the study group during the coronavirus pandemic depending on sex, age, and education

In Table  2 . we can see, that decreased will to live and frequent thoughts about death were only marginally present in the study group, which suggests that coping mechanisms play a huge role in adaptation to such events (e.g. the global pandemic). There is also a possibility that living in times of better epidemiologic situations makes people more likely to forget about the bad past.

Anxiety and depression levels as seen in Tables  3 and ​ and4 4 were different, where female participants and the age group under 30 years of age tended to feel more anxiety than other groups. No significant changes in depression levels based on sex, age, and education were found.

Distribution of anxiety levels in the study group during the coronavirus pandemic depending on sex, age, and education

Distribution of depression levels in the study group during the coronavirus pandemic depended on sex, age, and education

Compared to the estimated global prevalence of depression in 2017 (3.44%), in 2021 it was approximately 7 times higher (25%) [ 14 ]. Our study did not prove an increase in depression, while anxiety levels and changes in the mental state did prove elevated. No significant changes in depression levels go in hand with the unaffected will to live and infrequent thoughts about death, which were important findings, that did not supplement our primary hypothesis that the fear of death caused by COVID-19 or accompanying infections would enhance personal distress and depression, leading to decreases in studied factors. These results are drawn from our limited sample size and uneven demographic distribution. Suicide ideations rose from 5% pre-pandemic to 10.81% during the pandemic [ 35 ]. In our study, 9.3% of participants experienced thoughts about death and since we did not specifically ask if they thought about suicide, our results only partially correlate with suicidal ideations. However, as these subjects exhibited only moderate levels of anxiety and mild levels of depression, the rise of suicide ideations seems unlikely. The rise in suicidal ideations seemed to be especially true for the general population with no pre-existing psychiatric conditions in the first months of the pandemic [ 36 ]. The policies implemented by countries to contain the pandemic also took a toll on the population´s mental health, as it was reported, that more stringent policies, mainly the social distancing and perceived government´s handling of the pandemic, were related to worse psychological outcomes [ 37 ]. The effects of lockdowns are far-fetched and the increases in mental health challenges, well-being, and quality of life will require a long time to be understood, as Onyeaka et al. conclude [ 10 ]. These effects are not unforeseen, as the global population suffered from life-altering changes in the structure and accessibility of education or healthcare, fluctuations in prices and food insecurity, as well as the inevitable depression of the global economy [ 38 ].

The loneliness associated with enforced social distancing leads to an increase in depression, anxiety, and posttraumatic stress in children in adolescents, with possible long-term sequelae [ 39 ]. The increase in adolescent self-injury was 27.6% during the pandemic [ 40 ]. Similar findings were described in the middle-aged and elderly population, in which both depression and anxiety prevalence rose at the beginning of the pandemic, during the pandemic, with depression persisting later in the pandemic, while the anxiety-related disorders tended to subside [ 41 ]. Medical professionals represented another specific at-risk group, with reported anxiety and depression rates of 24.94% and 24.83% respectively [ 42 ]. The dynamic of psychopathology related to the COVID-19 pandemic is not clear, with studies reporting a return to normal later in 2020, while others describe increased distress later in the pandemic [ 20 , 43 ].

Concerning the general population, authors from Spain reported that lockdowns and COVID-19 were associated with depression and anxiety [ 44 ]. In January 2022 Zhao et al., reported an elevation in hoarding behavior due to fear of COVID-19, while this process was moderated by education and income levels, however, less in the general population if compared to students [ 45 ]. Higher education levels and better access to information could improve persons’ fear of the unknown, however, this fact was not consistent with our expectations in this study, as participants with university education tended to feel worse than participants with lower education. A study on adolescents and their perceived stress in the Czech Republic concluded that girls are more affected by lockdowns. The strongest predictor was loneliness, while having someone to talk to, scored the lowest [ 46 ]. Garbóczy et al. reported elevated perceived stress levels and health anxiety in 1289 Hungarian and international students, also affected by disengagement from home and inadequate coping strategies [ 47 ]. Wathelet et al. conducted a study on French University students confined during the pandemic with alarming results of a high prevalence of mental health issues in the study group [ 48 ]. Our study indicated similar results, as participants in the age group under 30 years of age tended to feel more anxious than others.

In conclusion, we can say that this pandemic changed the lives of many. Many of us, our family members, friends, and colleagues, experienced life-altering events and complicated situations unseen for decades. Our decisions and actions fueled the progress in medicine, while they also continue to impact society on all levels. The long-term effects on adolescents are yet to be seen, while effects of pain, fear, and isolation on the general population are already presenting themselves.

The limitations of this study were numerous and as this was a web-based study, the optimal distribution of respondents could not be achieved, due to the snowball sampling strategy. The main limitation was the small sample size and uneven demographic distribution of respondents, which could impact the representativeness of the studied population and increase the margin of error. Similarly, the limited number of older participants could significantly impact the reported results, as age was an important risk factor and thus an important stressor. The questionnaire omitted the presence of COVID-19-unrelated life-changing events or stressors, and also did not account for any preexisting condition or risk factor that may have affected the outcome of the used assessment scales.

Acknowledgements

We would like to provide our appreciation and thanks to all the respondents in this study.

Authors’ contributions

IK and SH have produced the study design. All authors contributed to the manuscript writing, revising, and editing. LD and MK have done data management and extraction, SH did the data analysis. Drafting and interpretation of the manuscript were made by all authors. All authors read and approved the final manuscript.

This research project received no external funding.

Data Availability

Declarations.

Ethical permission was obtained from the Ethics Committee of the Institute of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University in Bratislava (Reference number: ULBGaKG-02/2022). The need for informed consent was waived by the Ethics Committee of the Institute of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University in Bratislava due to the anonymous design of the study. This study did not process any personal data and the dataset does not contain any direct or indirect identifiers of participants. This study was performed in line with the principles of the Declaration of Helsinki. All methods were carried out following the institutional guidelines.

Not Applicable.

The authors declare that they have no competing interests.

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COVID-19 Pandemic Effects on Depression, Anxiety, and Stress of Hemodialysis Patients

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• May 4, 2021
• Affiliation: School of Nursing
• Hemodialysis patients are disproportionally at risk for depression and anxiety due to changes in functional status and financial and practical concerns. More recently in the year 2020, the Coronavirus Disease (COVID-19) brought many behavioral and lifestyle changes related to quarantine policies. The purpose of this study was to evaluate changes in depression, anxiety, and stress among hemodialysis patients during the COVID-19 pandemic. This retrospective cohort study recruited 13 participants, ranging from age 18 to 60. Paper surveys were distributed to patients during treatment within an inpatient dialysis unit. This study used a modified version of the DASS-21 scale for depression, anxiety, and stress “before” the pandemic, as well as “during” the pandemic. A majority of participants’ final scores for depression and anxiety remained unchanged across the two time periods (53.8% and 69.2%, respectively). Of those participants, 53.8% demonstrated an increase in final stress scores with the emergence of the pandemic. Findings suggest that increases in stress among hemodialysis patients may be related to variables of the COVID-19 pandemic. In addition to personal risks and vulnerabilities, managing end stage renal disease and facing a global disease may explain the sample’s stress scores. Caregivers and healthcare providers should routinely assess hemodialysis patients’ cognitive, behavioral and emotional wellbeing. Further evaluation of exacerbating factors is needed to explore the overall effects of the COVID-19 pandemic among the population.
• April 29, 2021
• https://doi.org/10.17615/06z8-9h35
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• Bachelor of Science

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• UNC-Chapel Hill Coronavirus Research

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The burden of anxiety, depression, and stress, along with the prevalence of symptoms of PTSD, and perceptions of the drivers of psychological harms, as perceived by doctors and nurses working in ICUs in Nepal during the COVID-19 pandemic; a mixed method evaluation

• Shirish KC 1 ,
• Tiffany E. Gooden 2 ,
• Diptesh Aryal 1 ,
• Kanchan Koirala 1 ,
• Subekshya Luitel 1 ,
• Rashan Haniffa 3 , 4 ,
• Abi Beane 3 , 4 on behalf of

Collaboration for Research, Implementation, and Training in Critical Care in Asia and Africa (CCAA)

BMC Health Services Research volume  24 , Article number:  450 ( 2024 ) Cite this article

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The COVID-19 pandemic resulted in significant physical and psychological impacts for survivors, and for the healthcare professionals caring for patients. Nurses and doctors in critical care faced longer working hours, increased burden of patients, and limited resources, all in the context of personal social isolation and uncertainties regarding cross-infection. We evaluated the burden of anxiety, depression, stress, post-traumatic stress disorder (PTSD), and alcohol dependence among doctors and nurses working in intensive care units (ICUs) in Nepal and explored the individual and social drivers for these impacts.

We conducted a mixed-methods study in Nepal, using an online survey to assess psychological well-being and semi-structured interviews to explore perceptions as to the drivers of anxiety, stress, and depression. Participants were recruited from existing national critical care professional organisations in Nepal and using a snowball technique. The online survey comprised of validated assessment tools for anxiety, depression, stress, PTSD, and alcohol dependence; all tools were analysed using published guidelines. Interviews were analysed using rapid appraisal techniques, and themes regarding the drivers for psychological distress were explored.

134 respondents (113 nurses, 21 doctors) completed the online survey. Twenty-eight (21%) participants experienced moderate to severe symptoms of depression; 67 (50%) experienced moderate or severe symptoms of anxiety; 114 (85%) had scores indicative of moderate to high levels of stress; 46 out of 100 reported symptoms of PTSD. Compared to doctors, nurses experienced more severe symptoms of depression, anxiety, and PTSD, whereas doctors experienced higher levels of stress than nurses. Most (95%) participants had scores indicative of low risk of alcohol dependence. Twenty participants were followed up in interviews. Social stigmatism, physical and emotional safety, enforced role change and the absence of organisational support were perceived drivers for poor psychological well-being.

Nurses and doctors working in ICU during the COVID-19 pandemic sustained psychological impacts, manifesting as stress, anxiety, and for some, symptoms of PTSD. Nurses were more vulnerable. Individual characteristics and professional inequalities in healthcare may be potential modifiable factors for policy makers seeking to mitigate risks for healthcare providers.

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Introduction

Between January 2020 and December 2021, the COVID-19 pandemic led to an estimated 18.2 million deaths [ 1 ]. Globally, healthcare systems were overwhelmed during the pandemic, with intensive care units (ICUs) receiving an unprecedented burden of patients [ 2 ]. In Nepal, the government first declared a lockdown on March 24, 2020, that lasted until July 21, 2020, and the second lockdown was announced on April 29, 2021, which was fully lifted on September 1, 2021 [ 3 ]. The first wave of the COVID-19 pandemic reached a peak of over 5000 cases a day in October 2020, and the second wave reached a peak of more than 9000 cases a day in May 2021, which was almost double [ 4 ]. Prior to the pandemic, Nepal reported a capacity of 1595 ICU beds across 194 hospitals and around 840 ventilators, equating to 2.8 ventilator-equipped ICU beds per 100,000 people [ 5 ]. To cope with the influx of COVID-19 patients, several existing postoperative wards and other high-dependency units of the hospitals were converted into improvised critical care units [ 6 ]. Globally, healthcare professionals (HCPs) and specifically those working in ICU and critical care services, arguably were at the frontline of the healthcare response. These HCPs faced the uncertainty of managing this new condition, extended working hours, limited personal protective equipment (PPE), and an increased risk of infection as they provide essential lifesaving interventions, including intubation and non-invasive respiratory management [ 7 , 8 ].

The impacts of the COVID-19 pandemic on the mental health and well-being of HCPs who worked during and after this global emergency are slowly becoming apparent. Research emerging from China, the USA, and Europe [ 9 ] describes a significant burden of psychological distress and symptoms synonymous with mental health conditions in HCPs. This is also evident from the limited studies that have been conducted in Nepal. For instance, one study conducted among 150 HCPs from outpatient clinics and inpatient wards caring for COVID-19 patients in Nepal reported that 38% of participants suffered from anxiety and/or depression [ 10 ]. Another Nepali study revealed that the prevalence of anxiety and depression among HCPs, including health assistants and support staff was 47% and 41%, respectively [ 11 ]. A larger online survey of 475 HCPs including pharmacists, paramedics and public health practitioners reported similar findings (42% had anxiety) and noted that nurses had a higher proportion of symptoms compared to other HCPs [ 12 ].. Whilst these studies, in conjunction with a meta-analysis, indicate that depression, anxiety, and post-traumatic disorder (PTSD) are highly prevalent among HCPs during the pandemic [ 9 , 10 , 11 , 12 , 13 ], fewer studies have explored the disparities between professionals’ roles, specifically among ICU workers, a group exposed to more advanced cases of COVID-19. Indeed a small study in Nepal comprising 96 nurses revealed that nurses who worked directly with COVID-19 patients experienced more severe symptoms of depression and anxiety [ 13 ]. The nature and characteristics of mental health symptoms appear to vary geographically, the HCPs’ role, their individual characteristics (age, gender) along with health system’s pre-existing resource capacity and ability to respond to increasing demand placed by events such as a pandemic. Understanding the mental health impact of ICU workers, any disparities between professional roles and drivers behind poor mental health in Nepal will help to identify what support is needed for ICU workers for pandemic preparedness; thus, providing important directions for investment in health systems strengthening.

We aimed to investigate the burden of anxiety, depression, stress, PTSD, and alcohol dependence among doctors and nurses in Nepal that worked in the ICU during the COVID-19 pandemic. We further sought to identify the factors driving the self-reported burden of psychological distress by exploring the lived experiences of these two different professional groups, and how these experiences impacted their psychological health and well-being.

Study design

We undertook a mixed-methods cross-sectional study [ 14 ] in Nepal with ICU doctors and nurses, combining an online questionnaire consisting of validated self-assessment tools combined with semi-structured interviews. The following self-reporting psychological assessment tools were used, given they have been used in previous studies in other settings and their widely validated in a variety of settings: Beck Anxiety Inventory (BAI) [ 15 ], Beck Depression Inventory (BDI) [ 16 ], Perceived Stress Scale (PSS) [ 17 ], PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5 (PCL-5) [ 18 ] and Alcohol Use Disorder identification Tool (AUDIT) [ 19 ]. BDI, BAI, and AUDIT have been validated in Nepal [ 20 , 21 , 22 ] and the PSS has been tested for reliability and correlation in Nepal [ 23 ]. Whilst the PCL-5 has not been validated in a Nepali setting, it was piloted (along with all other assessment tools used) with 20 people before the study commenced. Participants were given the flexibility to complete the questionnaire in either Nepali or English language. Despite this option, all participants opted to respond in English.

Ethics approval

was granted from the Nepal Health Research Council (approval number: 176/2021 P). All participants provided informed consent electronically before completing the online questionnaire. Participants from the qualitative component provided further informed verbal consent before the interview commenced.

In 2020, Nepal reported a capacity of 1595 ICU beds across 194 hospitals and around 840 ventilators, equating to 2.8 ventilator-equipped ICU beds per 100,000 people [ 5 ]. A year later, Nepal was under a state of health emergency, with patients being turned down due to a lack of ICU beds, oxygen, and ventilators [ 24 ].

Participants and recruitment

Doctors and nurses with experience in caring for COVID-19 patients in Nepalese ICUs were eligible for participation. Initially doctors registered with the Nepalese Society of Critical Care Medicine (NSCCM) [ 25 ] and nurses registered with the Critical Care Nurses Association of Nepal (CCNAN) [ 26 ] were contacted and invited to participate. Both organisations consist of voluntary memberships and represent the doctors and nurses working in a critical care setting in Nepal. At the time of recruitment, there were 187 doctors and 104 nurses registered at these organisations. This initial purposive sampling was augmented by snowballing techniques, whereby respondents were invited to forward the questionnaire link to other doctors or nurses working in ICUs [ 27 ]. Following completion of the questionnaire, respondents were invited to participate in a virtual interview. A convenience sample of 20 participants (a number which, based on the literature, was likely to provide saturation of findings [ 28 ]) was subsequently scheduled for an interview.

Study materials and data collection

The questionnaire was developed using an online survey platform (Google Forms) [ 29 ]. The questionnaire was piloted for readability and responder reliability with twenty HCPs based in Nepal, prior to roll out, who did not participate in the final analysis. Questionnaire content included socio-demographic information; age, sex, professional role and experience, degree of schooling, and home living arrangements; factors which had been identified as being important in the burden of psychological distress and impact on family life in similar research conducted during the previous SARS pandemic as well as the current COVID-19 event [ 30 ]. Participants could opt out of the study at any time. Participants could only complete the questionnaire once, and all survey responses were anonymous. Participants were signposted to healthcare services available to them should they be suffering from any distressing, mild, moderate or severe mental health symptoms. Invitations to participate in the questionnaire were sent out from 20th May 2021, and the questionnaire was closed to responses on 2nd October 2021.

The semi-structured interview topic guide was co-developed between doctors and nurses working in ICUs in Kathmandu. Co-design was used to ensure the sensitivity and appropriateness of the questions. None of the doctors and nurses involved in the codesign of the topic guide participated in the study proper. The qualitative component was aimed to augment the quantitative findings by providing an understanding of what social, organisational, and environmental factors were related to HCPs’ mental health. Topic guide questions focused on HCPs’ perceptions of their experiences of working during the pandemic and explored social, organisational, and environmental factors that may have influenced their self-reported burden and symptoms of psychological distress. These factors were selected from a review of the findings of the previously published meta-analysis and other studies conducted in Nepal [ 9 , 10 , 11 , 12 , 13 ]. The interview questions were piloted with five HCPs for interpretability and interviewer consistency. All interviews were conducted via video conferencing (Zoom) [ 31 ] between September 2021 and March 2022. Five ICU nurses with experience in conducting interviews and mixed methods research led the data collection following training on the topic guide. To ensure there was no prior relationship between the interviewer and the participant, interviewers were assigned to participants that worked in different ICUs than themselves and were not known to the interviewee. No one other than the interviewer and the participant was present for each interview, and interviews were conducted at the time chosen by the interviewee. Rapid assessment procedure (RAP) sheets were used for note-taking during the interviews [ 32 ]. Commonly used in rapid evaluations - designed to improve the rapidity and replicability of research during public health emergencies - RAP sheets help reduce the need for long-form transcription and encourage reflexivity for both interviewers and researchers, reduce interviewer bias, and enable validation of internal consistency with coding [ 33 ]. The RAP sheet contained the summary of questions from the topic guide, and the interviewers took notes of what the participants said regarding each question during the interview.

Data analysis

Descriptive statistics were used to describe participants’ demographics and professional profiles. Psychological health and well-being assessment tools from the questionnaire were analysed using published guidelines. For the BDI, each of the 21 items corresponding to a symptom of depression was summed for each participant to give a single total score [ 16 ]. With each item ranging from 0 to 3 points, a total score of 13 or less was considered minimal to no depression, 14 to 19 as mild depression, 20 to 28 as moderate depression, and 29 to 63 as severe depression [ 16 ]. Data is also presented separately for suicidality (question 9 from the BDI) whereby anyone that said they have thoughts about or plans to kill themselves is said to have experienced suicidality. The BAI scores reported included the 21 symptoms of anxiety that ranged between 0 and 63 points [ 15 ]. The values for each symptom were summed, and a total score of 0 to 7 was interpreted as a minimal level of anxiety, 8 to 15 as mild, 16 to 25 as moderate, and 26 to 63 as severe anxiety [ 15 ]. Scores on the PSS ranged from 0 to 40, with higher scores indicating higher perceptions of stress [ 17 ]: scores ranging from 0 to 13 were considered low descriptors of stress; 14 to 26 moderate; and 27 to 40 were considered higher levels of perceived stress. For alcohol use disorder reported using AUDIT [ 19 ], a score of 0 indicated no previous or current alcohol use; a score of 1 to 7 suggested low-risk consumption; 8 to 14 hazardous or harmful alcohol consumption; 15 or higher indicated the likelihood of alcohol dependence (moderate to severe alcohol use disorder). The PCL-5 included 20 items with a score range of 0 to 80 and a score of 33 or higher, indicating the presence of PTSD [ 18 ]. A sensitivity analysis was conducted for the BDI, BAI and AUDIT scores based on local validation studies whereby a score of 15 or lower from the BDI indicated no depression [ 20 ], 12 or lower from the BAI indicated no anxiety [ 21 ], and a score of 11 or above from the AUDIT indicated discriminate dependent drinkers [ 22 ].

RAP sheets, along with interviewer notes, were reviewed by the research team before analysis to ensure information was complete. SK, KK and AB used a constant comparative method, coding data following each round of interviews and then reflecting back on the summary of the codes together with the interviewers to promote the accuracy of findings and reduce recall and interviewer bias. In addition, emerging themes identified following each round of coding were used to guide subsequent interviews [ 34 ]. The broader research team met following each coding round to review the findings and reflexivity [ 35 ]. Categories and the subsequent themes (‘drivers’) were developed through the iterative process of interviewing, coding, analysing, and reviewing.

We invited 120 doctors and 341 nurses to participate. A total of 21 doctors and 113 nurses responded, all of which completed the BDI, BAI, PSS, and AUDIT questions; 100 completed the PCL-5 (16 doctors and 84 nurses). Nearly all nurses were female (99%, n  = 112), whereas most doctors were male (81%, n  = 17). The characteristics of respondents are described in Table  1 .

50% ( n  = 67) of respondents reported experiencing symptoms associated with moderate to severe anxiety, and a further 27% ( n  = 36) scored for mild anxiety as a result of working in the ICU during the COVID-19 pandemic (Table  2 ). Anxiety levels (and associated symptoms) were more pronounced in nurses than doctors, with 55% ( n  = 62) of the former scoring moderate to severe on the anxiety scale, compared to 24% ( n  = 6) of the latter. 21% ( n  = 28) of respondents described symptoms associated with moderate to severe depression, with a near-even split between nurses and doctors. Three-quarters of respondents ( n  = 114; 85%) had scores indicative of moderate to high levels of stress; this proportion was higher among doctors ( n  = 19; 91%) compared to nurses ( n  = 95; 84%). Of the 100 individuals that completed the PCL-5 assessment (16 doctors and 84 nurses), 45% ( n  = 46) reported a constellation of symptoms closely associated with PTSD, with a higher prevalence among nurses ( n  = 40; 47%) compared to doctors ( n  = 6; 38%).

Using cut-off scores from Nepali validation studies, 45 (34%) participants were experiencing mild, moderate or severe depressive symptoms, 80 (60%) were experiencing mild, moderate or severe anxiety symptoms, and 3 (2%) were considered discriminate dependent drinkers. These results are in line with our main analysis, including that a greater proportion of nurses were still found to suffer from depression and anxiety symptoms (supplementary Table 1 ).

Forty-six respondents to the online questionnaire volunteered to participate in the subsequent semi-structured interviews. Twenty participants were approached and consented to an interview: 16 were nurses (all female), and 4 were doctors (1 female, 3 male). On average, each interview resulted in 45 to 60 min of qualitative data. Saturation was met within the first 15 interviews, and findings were consistent between the coders and the research team. Analysis and synthesis of the interviews revealed nine themes, which, when codified, can be described as three key drivers of the psychological symptoms and impacts on mental well-being experienced by the interviewees: social stigmatism, physical and emotional safety, and organisational support. (Fig.  1 ). During the interviews, HCPs further described some of the coping strategies that they found helpful in mitigating the impacts experienced and may provide insights for future pandemic preparedness. These three themes, the drivers, and coping strategies, are explored below, along with quotes from the respondents.

Coding tree for the four main drivers for psychological distress

Social stigmatism

Interviewees described experiencing feelings of social stigmatisation as a result of interactions with their families, peers, as well as from the wider public. Examples of stigmatism experienced included physical avoidance from neighbours and community members when the HCP travelled to and from and around their home, especially when dwellings were in shared buildings and common areas.

“My house owner avoided talking and meeting me because I worked with COVID patients.” [N]. “I have an elderly family member, and I was afraid and worried [for them] when I came back from duty.” [N].

Interviewees described how rumours would spread within the community, notably related to concerns of risk of co-infection or cross-infection, either directly from parent to child or indirectly via friends and extended family. Some HCPs were asked or elected to stay away from their home so as to reduce the stigma to them and their family and in an attempt to reduce the risk of co-infection, particularly when they had vulnerable family members. Interviewees described how this self-selected or enforced separation and isolation resulted in feelings of rejection, physically and emotionally heightened feelings of stress and anxiety, alongside the threat to physical and emotional safety.

Physical and emotional safety

Increased workload and an enforced change in working pattern/ shift structures were experienced by all the HCPs interviewed. These longer overall working hours, increased duration of shift patterns, and enforced working rotas were perceived as resulting in a loss of physical and emotional safety by the interviewees. Feelings of loss of control, insomnia, or disruption to sleep patterns, alongside physical discomfort through sustained working in personal protective equipment, often in hot and humid temperatures. This physical and mental endurance contributed to feelings of emotional stress and anxiety.

“Shift frequency was increased, and I only got one night off in a week. Sometimes I had to work extra hours, which was very stressful.” [N]. “My sleep pattern had changed, I felt restless and was afraid about COVID” [D].

The change in shift structure and in working patterns meant for some HCPs enforced separation from family and friends whereby HCPs sought accommodation away from family or in temporary lodgings. This again resulted in isolation and additional strain on other family members so as to provide care for HCP’s dependents.

“I had to involve other family members to arrange for the medication and care of my grandmother” [N].

Increased working hours and changes in working patterns further had physical impacts; participants described skipping meals or having limited time to eat. The need to wear personal protective equipment (PPE), and indeed the risks to safety when PPE was not available, associated risks of non-availability of equipment, brought with it a risk to physical and emotional safety. HCPs interviewed reported skin lacerations, irritation, and discomfort whilst wearing equipment in hot, humid working environments.

“We had to frequently change the PPE and masks, which has caused skin problems that still exist.” [N].

Organisational support

Interviewees found the COVID-19 pandemic brought new and often enforced work responsibilities, some of which were associated with high levels of professional anxiety, stress, and uncertainty. A professionally challenging situation, even for those with many years of ICU working experience. HCPs faced emotionally challenging tasks such as dealing with end-of-life situations (particularly without relatives of the patient present) and having to comfort relatives over the phone, of which they received limited to no training or support on handling such situations.

“I went through an emotional breakdown while dealing with the end of the life situation of patients without the presence of family members in the COVID ICU… I felt sad when a young patient lost their lives” [D]. “Accommodation or isolation facilities should be provided by the hospital” [D]. “If incentives were provided in time and staff were provided with health insurance it would motivate us” [N].

Ever-changing role and responsibilities created anxiety for HCPs as to what care to deliver, and the rapidity and uncertainty of care were associated with feelings of vulnerability. Interviewees expressed how they wished there was a need for greater organisational support to better cope with the frequent updates and changes to practice. Furthermore, HCPs expressed concerns regarding a shortage of staff and the lack of mental health counselling and support, accommodation on-site at the hospital, and transportation to and from work.

“Mental health support or counselling facilities were not provided. It should be there… seniors and hospital staff should also talk to the staff to know the situation.” [N]. “Safety of healthcare workers should be the priority and nurse-patient ratio should be maintained to provide quality care to the patients… hospital should have recruited more staff.” [N].

Coping strategies

Participants described various ways in which they coped with the emotional, physical, social, and professional impacts of working through the pandemic. This included speaking with family and friends about the pressures they were under, taking up activities in their off time, such as gardening and reading, and using media entertainment such as music, movies, and shows. A few participants also mentioned that comparing the situation in Nepal to other countries (i.e., keeping up-to-date with the news) also helped them cope. Others mentioned that detachment from social media and more self-awareness through meditation helped.

“I ventilated my feelings with friends and family. Listening to soothing music also helped me cope with the stress.” [N]. “I coped by gardening with my sister in my home.” [N]. “I… watched the news that compared the death rates, which was low compared to others.” [D].

The COVID-19 pandemic’s impact on healthcare services and population health internationally is unprecedented in recent times. As healthcare professionals, policymakers, and researchers work to strengthen services in preparation for future pandemics now and mitigate the long-term impacts on individual and population health, understanding the impact on and perspectives of doctors and nurses at the frontline of care can provide important learning regarding the individuals characteristics and professional, social and economic drivers which may increase the risk of psychological impacts.

Mandated and enforced changes in role, specifically in working hours and shift patterns, were a key driver of psychological anxiety and distress. Within hospitals in Nepal, many departments were closed, and stay-at-home orders meant that outpatient or clinical services all but ceased. This resulted in an increased role and scope for critical care trained staff, and in contrast to other health systems (such as the UK) where healthcare staff were redeployed to ICU, there was a separation for ICU staff even from their professional peers working in other specialties. The increased scope and uncertainty of the HCP’s role, along with limited choice in redeployment in the ICU was another driver of poor mental health- and dominated nursing participants’ experiences. Interviewees described how these changes impacted not only themselves but the multigenerational families for whom many cared for. This enforcement of role change, and the related descriptions of the drivers for these impacts as experienced by participants in this study point not only to the differences in roles between nurses and doctors; but also highlights disparities in autonomy, advocacy for role change during international emergencies, and the implications of work on home and family life [ 36 ].

Giving staff choice to select shift patterns and ensuring the opportunity to have periods of rest to reconnect with family and have self-care is needed. Consultation and shared decision-making, even in times of restricted choice, are associated with improved perceptions of work from staff and may result in reducing psychological distress and promoting emotional safety, which is, in turn, associated with better outcomes for patients [ 37 , 38 ]. However, nurses in Nepal, as with many health systems, may have less opportunity for strategic and organisational decision making in response to public health emergencies. The impact of ongoing disparities between professionals and their agency to advocate for wellbeing and safety warrants further research.

Nurses were disproportionately burdened by both occurrence and severity of symptoms of anxiety and depression as a result of their work during the pandemic when compared to doctors.

Nearly half of all respondents had symptoms of anxiety and PTSD (again more prevalent in nurses), and the burden of anxiety symptoms was higher than the reported 22–33% from a recent umbrella review [ 39 ]. The burden of stress we report was also higher than a smaller study conducted in Nepal during the pandemic, which reported stress among 53.2% of healthcare professionals working in hospitals, primary health centres, pharmacies, and health posts in Nepal [ 40 ]; it was also higher than a meta-analysis of published studies exploring the incidence of both stress (57%) and PTSD (22%) among all cadres of healthcare workers [ 41 ]. One reason for the higher reported symptoms in our study may be the focus on ICU workers and their role in the management of end-of-life care. Indeed, our results for depression and anxiety are comparable to a study involving nurses working directly with COVID-19 in Nepal [ 13 ]. Studies conducted elsewhere in Asia have highlighted this positive relationship between ICU experiences and poor mental health [ 42 ].

Nurses in Nepal, as with many other countries, are more likely to be female, younger in age, and have less opportunity for graduate study; and have lower earning potential than physician colleagues [ 43 ]; all characteristics associated with increased risk of poorer mental health outcomes [ 44 ]. Exploration into the disparities of the psychological and health impacts of COVID-19 on different cadres of healthcare workers is emerging. A systematic review conducted in 2020, identified 27 studies which sought to explore the disparity in impacts of the pandemic on HCP’s psychological well-being. The findings from the review are in line with ours, indicating that the burden of symptoms for anxiety, depression, and PTSD is higher in nurses compared to doctors [ 45 ]. Notably only a few of these studies used validated tools for assessment of specific symptoms of anxiety, depression, or substance misuse [ 45 ]. Our study serves to strengthen the evidence of the vulnerability of nurses.

Nepal, like many other lower and middle-income countries in South and Southeast Asia, enforced large-scale lockdowns and restrictions of movement for all but essential healthcare and municipal staff [ 46 ]. As such, social stigmatism, physical and emotional safety, and organisational support were key drivers behind the elevated symptoms of psychological distress in ICU HCPs and may be a key determinant of differences between health systems internationally. Furthermore, the family responsibilities and social circumstances for nurses, contributed to their experiences of isolation, rejection, vulnerability, physical discomfort, and strain. These drivers mirrored those reported from Europe; and may reflect differences experienced by nurses as a result of their gender, and role norms of primary family carers within society [ 44 ].

Interviewees from both professional groups expressed concern at the absence of preparedness and support they felt from their employing institutions. This is notable given the ongoing investment in pandemic preparedness and the potential to make changes now to prepare for the next pandemic or public health emergency. Interventions such as resilience training, scenario-based simulation training, and group exercises based on psychoeducation and cognitive behavioural therapy (CBT) principles have proved effective in reducing anxiety, depression, stress, and PTSD among doctors and nurses while simultaneously improving their ability to work in unprecedented situations in other sectors [ 47 ]. Similar provisions may be valuable for ICU-based healthcare professionals and are deliverable online, making rollout potentially more feasible.

Strengths and limitations

A strength of this study is the exploration of participants’ perspectives on the drivers behind the burden of poor mental health described in ICU HCPs. This mixed methods approach offers insights into doctors’ and nurses’ unique individual, social and professional characteristics that may be associated with increased risk of distress. These differences and their potential for disparity in impacts on health and wellbeing should be of interest to policymakers and healthcare facility managers involved in future pandemic preparedness. However, the study has some limitations to acknowledge. Given the use of the snowball technique, we were able to ensure a high number of respondents, but as a consequence, we were unable to track the number of respondents that came from using this technique compared to those initially invited from the NSCCM and CCNAN. Therefore, a response rate and, subsequently, a non-response rate could not be reported. We did not collect information on the level of training in critical care that participants received; trained health professionals are likely to have additional skills in how to handle the potential stressful environment in critical care settings. Also, due to the lack of validation of the PCL-5 in Nepal, the results of this assessment tool should be interpreted with caution. The survey tools used for this study have not been validated in an online format. However, given these tools were self-reporting, and were piloted and administered in English, the online format is thought to have minimal impact on the results. Additionally, participants for the qualitative component were recruited based on convenience sampling; therefore, the diversity of the sample may not be optimised. We acknowledge that recall bias may be present in the participants during the interview, given they were recalling their experiences throughout the pandemic for up to 24 months prior to the interview; however, we hope the piloting of the interviews, the use of multiple researchers to code the data, and the constant comparative nature of the evaluation will mitigate this potential.

The COVID-19 pandemic negatively impacted the mental health of HCPs worldwide. This study strengthens existing evidence that nurses were (and may remain) at increased risk of both cross infection and may also be more vulnerable to psychological impacts including anxiety, depression and PTSD than their professional colleagues. In addition, critical care staff may be at even greater risk, due to the uniqueness of their role which includes prolonged periods of time with infected patients, frontline role in managing end of life care, and as described here, limited ability to advocate for changing role and working patterns during an emergency. Professional hierarchies, and social-economic and gender profiles unique to nurses, may be potential drivers for these disparities, and warrants further research. Learning from the ICU HCPs’ experiences during the COVID-19 pandemic may inform future preparedness strategies e to mitigate short and long-term mental illness among ICU HCPs in future pandemics.

Data availability

The interview guide is available in the Figshare repository,

https://doi.org/10.6084/m9.figshare.24247384.v1 .

The data supporting the conclusions of this article are available in the Figshare repository, https://doi.org/10.6084/m9.figshare.23999790.v1 .

Abbreviations

Coronavirus disease 2019

Intensive care unit

Healthcare professional

Personal protective equipment

Post-traumatic stress disorder

Nepalese Society of Critical Care Medicine

Critical Care Nurses Association of Nepal

Beck Anxiety Inventory

Beck Depression Inventory

Perceived Stress Scale

PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5

Alcohol Use Disorder Identification Tool

Rapid assessment procedure

Cognitive behavioural therapy

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Acknowledgements

We thank the volunteers who took the time to interview the participants: Radhika Maharjan, Dipika Khadka, Anita Bashyal, Samina Amatya, and Roshani Kafle. We also want to thank Dr. Rohini Nepal and Jugmaya Chaudhary of Rhythm Neuropsychiatry Hospital and Research Centre for their contribution to advising and reviewing the self-reporting psychological assessment tools used in the questionnaire. We would also like to thank Transcultural Psychosocial Organisation (TPO) Nepal and Dr. Nabaraj Koirala for the permission to use the Nepali-validated version of BDI I and BAI for the study. We additionally thank Nilu Dullewe, who helped in coding the qualitative data. For the ongoing mutual support for improvements in ICU care, we would also like to acknowledge and thank members of the CCAA.

CCAA members

Diptesh Aryal, Shirish KC, Kanchan Koirala, Subekshya Luitel, Rohini Nepal, Sushil Khanal, Hem R Paneru, Subha K Shreshta, Sanjay Lakhey, Samina Amatya, Kaveri Thapa, Radhika Maharjan, Roshani Kafle, Anita Bashyal, Reema Shrestha, Dipika Khadka and Nilu Dullewe.

This study was funded by a Wellcome Innovations Flagship Programme grant (Wellcome grant number: 215522/Z/19/Z). They had no role in the design, analysis, or reporting of this protocol.

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Shirish KC, Diptesh Aryal, Kanchan Koirala & Subekshya Luitel

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Tiffany E. Gooden

Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK

Rashan Haniffa & Abi Beane

Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand

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• Diptesh Aryal
• , Shirish KC
• , Kanchan Koirala
• , Subekshya Luitel
• , Rohini Nepal
• , Sushil Khanal
• , Hem R Paneru
• , Subha K Shreshta
• , Sanjay Lakhey
• , Samina Amatya
• , Kaveri Thapa
• , Radhika Maharjan
• , Roshani Kafle
• , Anita Bashyal
• , Reema Shrestha
• , Dipika Khadka
•  & Nilu Dullewe

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All authors conceptualised this study. SK, DA, AB, RH, and SL developed the protocol, study methods, and materials. KK and SL facilitated the data collection, supervised by SK and DA. Data were analysed by SK, AB, KK, and TEG. SK and TEG wrote the drafts of the manuscript, and all authors reviewed the manuscript and consented to it being submitted. AB is the senior author.

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Ethics approval was granted from the Nepal Health Research Council (approval number: 176/2021 P). All participants provided informed consent electronically before completing the online questionnaire. Participants from the qualitative component provided further informed verbal consent before the interview commenced.

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KC, S., Gooden, T.E., Aryal, D. et al. The burden of anxiety, depression, and stress, along with the prevalence of symptoms of PTSD, and perceptions of the drivers of psychological harms, as perceived by doctors and nurses working in ICUs in Nepal during the COVID-19 pandemic; a mixed method evaluation. BMC Health Serv Res 24 , 450 (2024). https://doi.org/10.1186/s12913-024-10724-7

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BRIEF RESEARCH REPORT article

Exploring the relationships among music performance anxiety, teaching anxiety, and self-efficacy of chinese preservice music teachers.

• 1 College of Music and Dance, Guangzhou University, Guangzhou, Guangdong, China
• 2 School of Music, The Pennsylvania State University, State College, PA, United States
• 3 Allegheny Singer Research Institute, Allegheny Health Network, Pittsburgh, PA, United States

This quantitative study aimed to explore the relationships among music performance anxiety (MPA), teacher anxiety (TA), and self-efficacy (SE) through a survey study of Chinese preservice music teachers ( N  = 237). We also examined gender, grade, primary instrument, secondary instrument, music learning time length, and time spent in four activities: peer teaching, practicum, internship, and private teaching as potential predictors of MPA, TA, and SE. Results indicated that the higher the self-efficacy, the lower music performance anxiety and teaching anxiety; Simultaneously, the increased music performance anxiety was associated with an increased teaching anxiety. Partial correlation results indicated a significant but negative correlation between TA and SE with MPA controlled. Teaching anxiety, followed by primary piano, was the strongest predictor of MPA. MPA, followed by SE and peer teaching, was the strongest predictor of TA. TA, followed by grade level, was the strongest predictor of SE. The results from the multivariate analysis of variance revealed that the SE of male preservice music teachers were significantly higher than their female counterparts. As a study implication, music teacher educators may consider interventions and support mechanisms that address both types of anxiety simultaneously to improve overall teacher preparedness.

Introduction

The role of a music teacher is challenging and demanding. A qualified music teacher must possess various types of abilities, such as (a) administration, (b) classroom management, (c) musicianship, and (d) content and pedagogical knowledge ( Hourigan and Scheib, 2009 ). As required by the Ministry of Education, People’s Republic of China, (2021) , teacher candidates must teach ethically, comprehensively, independently, and practically ( Ministry of Education, People’s Republic of China, 2021 ). Chinese music scholars have further elaborated on the teaching practice abilities needed of music teachers, encompassing two aspects: musicianship and pedagogy ( Chen, 2016 ). These official standards serve as a testament to the critical importance of music teachers’ ability to demonstrate their musicianship while teaching effectively.

In essence, music teachers assume dual roles, facing the duality between the concepts of “musicians” and “teachers.” Extensive research has consistently highlighted the challenges faced by music teachers, particularly preservice music teachers, who encounter a significant discrepancy between their expectations and the reality of their teaching and musical modeling ( Ballantyne, 2007 ; Strong, 2013 ). This incongruity often leads to increased levels of anxiety, which, in turn, could impact their self-efficacy. It is noteworthy that previous studies have predominantly focused on preservice music teachers’ performance anxiety and self-efficacy beliefs individually ( Hargreaves et al., 2007 ; Egilmez, 2015 ). The complexity of music performance anxiety is closely linked with other forms of anxiety which are contextual, such as social anxiety and test anxiety ( Papageorgi et al., 2011 ). Our study assumed an interconnectedness between performance anxiety and teaching anxiety in the music classrooms, with their relationship potentially influenced by individual self-efficacy levels.

Key concepts

Parallel to the empirical investigation of music performance anxiety (MPA), self-efficacy (SE), and teaching anxiety (TA) as separate subjects, the underlying concepts have been developed separately. Specifically, we reviewed these three concepts and further examined and discussed the related literature.

Music performance anxiety

Music Performance Anxiety (MPA) refers to “the fear that grips individuals before or during a performance and is often likened to ‘stage fright’ or a fundamental fear of life itself” ( Goode, 2004 , p. 25). Research has indicated that several factors contribute to musicians’ performance anxiety, including gender ( Patston and Osborne, 2016 ), age ( Dempsey and Comeau, 2019 ), individual characteristics ( Smith and Rickard, 2004 ), personality traits ( Girgin, 2017 ), anxiety-related traits ( Hallam and Welsh, 2007 ), early childhood relationships ( Kenny, 2009 ), psychological vulnerability ( Kenny, 2009 , 2011 ), and proximal performance vulnerability ( Kenny, 2009 , 2011 ). Among these, factors such as low self-esteem, low self-efficacy, inadequate preparation, a surface approach to learning, and high task difficulty and values have negative effects on an individual’s experience of music performance anxiety. However, some researchers argue that a certain level of tension before an event is natural and may enhance the experience; in this context, music performance anxiety might be seen as a potential benefit for music students and musicians ( Kokotsaki and Davidson, 2003 ).

To date, music teachers, undergraduate music majors, and professional musicians continue to grapple with various physiological, psychological, emotional, and behavioral challenges when performing in front of others ( Ely, 1991 ; Kenny, 2009 , 2011 ; Papageorgi et al., 2011 ; Papageorgi and Welch, 2020 ; Papageorgi, 2021 ). Preservice music teachers, who are in the process of gaining experience in teaching and performing in front of students, may also be susceptible to the effects of music performance anxiety ( Taborsky, 2007 ).

Teacher self-efficacy

Self-efficacy (SE), a component of self-concept, refers to the perceived belief in one’s capabilities to organize and execute actions necessary for achieving specific goals ( Bandura, 1997 , p. 3). Teacher self-efficacy has a potential impact on teachers’ behaviors, and consequently, students’ behaviors, it has strong influence on teaching performance, instructional effectiveness, and student outcomes ( Bandura, 1997 ; Klassen and Tze, 2014 ).

Due to the multidimensional nature of teacher self-efficacy ( Biasutti et al., 2021 ), there are positive correlations between teacher self-efficacy and variables such as teaching experience ( Tschannen-Moran and Hoy, 2007 ; Potter, 2021 ), school context (urban, suburban, rural/small town) ( Tschannen-Moran and Hoy, 2007 ), and contextual familiarity during field placements ( Regier, 2021 ). Positive associations have also been noted between teacher self-efficacy and various aspects, including students’ academic adjustment, teacher behavior, and practices related to classroom quality ( Zee and Koomen, 2016 ).

Self-efficacy was found malleable ( Bandura, 1997 ); preservice music teachers’ self-efficacy can be formed by curricular experiences. Prichard (2017) found that teaching experiences, such as individualized mentoring, peer teaching, and structured field observations, positively influenced the pre-service music teachers’ efficacious beliefs. Bergee (2002) found that preservice music teachers’ self-efficacy for classroom management improved after viewing video recordings or applying learned classroom management strategies in the field. In Potter’s (2021) study, pre-service teachers’ self-efficacy was found to be impacted by teaching experience. Results further indicated that gains of the field application group lasted longer than those of the video-only group-a result that supports Bandura’s (1997) assertion that mastery experiences are often most impactful on efficacious beliefs.

Teaching anxiety

Teaching anxiety (TA), as defined by Gardner and Leak (1994) , relates to the anxiety experienced in connection with teaching activities, especially those involving the preparation and execution of classroom activities. In the realm of mathematics education, research has revealed that the content knowledge dimension of mathematics teaching anxiety can have a detrimental impact on various aspects of self-efficacy beliefs related to mathematics teaching. These aspects encompass teaching efficacy, motivation, taking responsibility, and teaching effectiveness. Additionally, studies have indicated that the teaching knowledge dimension of mathematics teaching anxiety negatively affected the dimension of effective teaching ( Peker, 2016 ). In a related study, Olson and Stoehr (2019) made an important discovery, highlighting that math anxiety and math teaching anxiety are not confined solely to evaluative contexts. Instead, when anxiety is triggered by thoughts of evaluation, preservice teachers may experience concerns not only about their own performance but also about the performance of their students. However, teaching anxiety is commonly observed in the general education field ( Patkin and Greenstein, 2020 ; Liu et al., 2022 ), there is limited literature addressing teaching anxiety in the field of music education.

Purpose and research questions

Previous studies concentrated on the relationship between music performance anxiety and self-efficacy in musicians and music teachers ( Hargreaves et al., 2007 ; Egilmez, 2015 ; Girgin, 2017 ; Dempsey and Comeau, 2019 ; MacAfee and Comeau, 2020 ). A few studies have explored teaching anxiety in relation to teaching other subjects ( Peker, 2009 ), such as math education ( Patkin and Greenstein, 2020 ) and linguistic education ( Liu et al., 2022 ). As far as can be determined, no existing study has placed a specific focus on examining the interconnections between music performance anxiety, teaching anxiety, and the self-efficacy of preservice music teachers. Prior research has primarily highlighted a significant, inverse association between musical performance anxiety scale scores and self-efficacy beliefs related to piano performance among Turkish student teachers ( Egilmez, 2015 ). Furthermore, only one study has delved into the relationships between music performance anxiety and teaching anxiety ( Strong, 2013 ).

The purpose of this study was to explore the relationships among music performance anxiety, teaching anxiety, and self-efficacy among preservice music teachers in China. Four main research questions are included: (1) What are the relationships among MPA, TA, and SE? (2) What variables (gender, grade, primary instrument, secondary instrument, music learning time length, and time spent in four activities: peer teaching, practicum, internship, and private teaching) predict MPA, TA, and SE? (3) To what extent do MPA, TA, and SE predict each other? (4) Is there a difference in gender, grade, primary instruments, and secondary instruments among MPA, TA, and SE?

Methodology

Participants.

Following approval from our affiliating universities’ institutional review boards, we recruited 246 third-and fourth-year undergraduate music education majors using purposive and snowball sampling methods. These participants were selected from seven universities located in seven areas in China: Zhejiang, Jiangsu, Hunan, Hainan, Guangdong, Anhui, and Shanghai. Out of the 246 students, 96.3% ( N  = 237) agreed to participate and completed the survey. Participants who were not identified as third or fourth year were excluded from subsequent analyses, resulting in the removal of nine participants.

The participants self-identified as 72.6% female and 27.4% male. Among them, 69.2% were third-year, while 30.8% were fourth-year. In terms of emphasis within their music studies, 43% were voice emphasis, followed by 38% in piano and 19% in other instruments. Participants also reported their secondary instruments as the piano (34.1%), voice (27%), other instruments (24.5%), choral conducting (1.3%), and none (13.1%). Most participants (32.9%) had been studying music for over 10 years, while only 5.9% had less than 3 years of music education experience.

Measurement instruments

Instruments in this study included a consent form, demographic information, and three surveys: the Kenny Music Performance Anxiety Inventory ( Kenny, 2009 ), the Preservice Music Teacher Self-Efficacy Scale ( Prichard, 2017 ), and the Teaching Anxiety Scale ( Parsons, 1973 ). In the demographic section, participants were asked to report their gender, grade level, primary instrument, secondary instrument, music learning time length, and time spent in four activities: peer teaching, practicum, internship, and private teaching. The objective was to investigate the relationships among performance anxiety, teacher self-efficacy, and teaching anxiety and assess the extent to which the first two variables could predict the third.

Preservice music teacher efficacy scale

Prichard’s (2017) Preservice Music Teacher Self-Efficacy Scale (PMTES) is a self-reported inventory consisting of two subscales with a total of 18 items. The first subscale, Music Teaching Efficacy Beliefs (MTE), comprises 11 items that focus on an individual’s beliefs regarding their effectiveness as a music educator. The second subscale, Classroom Management Efficacy Beliefs (CME), includes 7 items and is centered around an individual’s beliefs about their ability to manage behavioral and other non-content-area classroom situations. Both subscales demonstrated strong reliability (MTE, α = 0.93; CME, α = 0.91). To assess responses, a 6-point Likert scale ranging from 1 = strongly disagree to 6 = strongly agree was employed.

Kenny music performance anxiety inventory

The Kenny Music Performance Anxiety Inventory (K-MPAI) revised version (2009) comprises 8 subscales with 40 items, including proximal somatic anxiety and worry about performance (11 items, α = 0.91), worry/dread focused on self/other scrutiny (8 items, α = 0.86), depression/hopelessness (8 items, α = 0.85), parental empathy (4 items, α = 0.75), memory (2 items, α = 0.92), generational transmission of anxiety (3 items, α =0.72), anxious apprehension (3 items, α = 0.59) and biological vulnerability (1 item). Respondents would self-rate through a 7-point Likert scale from 0 to 6 (0 = strongly disagree, 6 = strongly agree). Among the 40 items, 8 items were reverse scored.

The teaching anxiety scale

The Teaching Anxiety Scale (TCHAS) is a self-reported inventory consisting of 25 items that was designed and established by Parsons (1973) . The TCHAS is still considered the most effective way of measuring teaching anxiety for both preservice and in-service teachers. In this measure, a 5-point scale is used: 1 = never, 2 = seldom, 3 = occasionally, 4 = frequently, and 5 = often.

After confirming the suitability of the three inventories and obtaining permission from the instrument designers, the first author, fluent in both English and Chinese, initially translated all three instruments from English to Chinese. Following this translation, the second author, also bilingual, conducted a backward translation of the instruments from Chinese to English. Subsequently, the two authors compared the translated versions and made further adjustments to the Chinese translations. Prior to distributing the survey instrument, three undergraduate and graduate students majoring in music education took part in a pre-study to refine the translation of the three survey instruments.

Data collection was carried out using a Chinese online-based survey company, wjx.cn, a platform that collects participants’ responses, stores, and manages data, and facilitates the export of raw data, similar to Qualtrics. The website provided a template that we customized to align with the design of this study. After completing the survey design, the website automatically generated a QR code for the survey instrument. To recruit participants, the second author created an electronic flyer containing inclusion criteria and the associated QR code. Prospective participants could scan the QR code if they wished to take part in the study.

This study employed purposeful snowball sampling to recruit potential participants via WeChat, a popular social media platform in China. Recruitment assistance was provided by (1) music educators from various universities, (2) individuals known to be third- and fourth-year music education majors, and (3) parents of third- or fourth-year music education students. Upon contact, participants were invited to participate if they met the study’s criteria and expressed interest. They were also encouraged to forward the flyer to potential participants who might be interested and meet the study’s inclusion criteria.

The interitem correlations of each instrument were computed via SPSS 27, with coefficients ranging from 0.13 to 0.74 (SE), −0.30 to 0.75 (MPA), and − 0.05 to 0.65 (TA). The item-total correlations of each instrument ranged from 0.38 to 0.75 (SE), 0.00 to 0.69 (MPA) and 0.20 to 0.59 (TA), respectively. We further calculated the internal consistency of each instrument, and the results revealed that all three instruments exhibited high reliability, with Cronbach’s alpha values of 0.93 (SE), 0.93 (MPA), and 0.88 (TA), respectively (see Table 1 ).

Table 1 . Descriptive statistics of the music performance anxiety, preservice music teacher self-efficacy, and teaching anxiety scales.

Due to the negative interitem correlations exhibited in music performance anxiety (MPA) and teaching anxiety (TA), we excluded items that were negatively correlated in subsequent analyses and recalculated the interitem correlation, item-total correlations, and coefficient alpha (see Table 2 ). The results indicated that 3 items (item 1, item 2, and item 4) in MPA and 2 items (item 1 and item 5) in TA were excluded (see Supplementary Appendix A ).

Table 2 . Descriptive statistics of recalculated music performance anxiety, preservice music teacher self-efficacy, and teaching anxiety.

Research Question 1: What are the relationships among MPA, TA, and SE?

Bivariate Pearson Product–Moment correlation coefficients were used to examine the relationships of music performance anxiety, preservice music teachers’ self-efficacy, and teaching anxiety. All correlations were statistically significant at the p  < 0.01 level. The results indicated a moderately strong and positive correlation between music performance anxiety and teaching anxiety ( r = 0 .59, p  < 0.001). However, a moderately negative correlation was found between preservice music teachers’ self-efficacy and teaching anxiety ( r  = −0.55, p  < 0.001). Additionally, a significant negative correlation was revealed between music performance anxiety and preservice music teachers’ self-efficacy ( r  = −0.28, p  < 0.000). In other words, results revealed that the higher the self-efficacy, the lower music performance anxiety and teaching anxiety; Simultaneously, the increased music performance anxiety was associated with an increased teaching anxiety.

In addition, we conducted partial correlation analyses to examine the relationships between (a) preservice music teachers’ self-efficacy and (b) teaching anxiety and performance anxiety, with MPA and TA being controlled, respectively. The results indicated that with MPA controlled, a significant negative correlation was found between teaching anxiety and preservice music teachers’ self-efficacy ( r = −0.49, p < 0.001).

Research Question 2: What variables (gender, grade, primary instrument, secondary instrument, music learning time length, and time spent in four activities: peer teaching, practicum, internship, and private teaching) predict MPA, TA, and SE?

Research Question 3: To what extent do MPA, TA, and SE predict each other?

Table 3 shows the results of three stepwise multiple regression analyses. To control for Type I errors, a Bonferroni correction was applied ( α  = 0.0167 instead of α  = 0.05). To determine the best prediction model for preservice music teachers’ music performance anxiety, we first conducted a stepwise multiple regression analysis using gender, grade, primary instrument, secondary instrument, music learning time length, time spent in four activities (peer teaching, practicum, internship, and private teaching), TA and SE as the predictors and music performance anxiety as the criterion variable. Preliminary analyses confirmed no violation of the assumptions of normality, linearity, multicollinearity, and homoscedasticity. The results of the first stepwise regression analysis reveal the best prediction model in which teaching anxiety, piano as primary instrument, and secondary instrument explained a total of 37.9% of the variance in music performance anxiety, F (3, 236) = 47.49. The results showed that with a one-unit increase in teaching anxiety, music performance anxiety increased by 1.57, β  = 0.1.57, p  < 0.001. Compared to students with other primary instruments, students who used piano as their primary instrument had an 11.75 higher music performance anxiety mean score, β  = 11.75, p  < 0.001. Teaching anxiety accounted for 35.1% of the variance. Primary instruments such as piano contributed an additional 1.7%.

Table 3 . Results of stepwise regression analyses for preservice music teachers’ music performance anxiety, teaching anxiety, and self-efficacy.

To test which variables significantly predicted preservice music teachers’ teaching anxiety, we conducted another stepwise regression analysis with the same 11 predictors except MPA. The TA score served as the criterion variable. This stepwise multiple regression analysis revealed that music performance anxiety, self-efficacy and peer teaching were significant predictors of preservice music teachers’ teaching anxiety. A model including these three predictors was the best prediction model, accounting for 51.9% of the variance in preservice music teachers’ teaching anxiety, which was significant, F (3, 236) = 83.96, p  < 0.001. The results showed that with each unit increase in music performance anxiety, teaching anxiety increased by 0.18, β  = 0.18, p  < 0.001, and it contributed 35.1% of the variance. With each unit increase in preservice music teachers’ self-efficacy, teaching anxiety decreased by 0.38, β  = −0.38, p  < 0.001, and it contributed an additional 15.5% of the variance. Teaching anxiety also decreased by 2.57 with every unit of peer teaching increase, β  = −2.57, p  < 0.01, and it shared 1.3% of the variance.

Preservice music teacher self-efficacy

In the third stepwise multiple regression analyses, we regressed preservice music teachers’ self-efficacy on 11 predictors, including gender, grade, primary instrument, secondary instrument, music learning time length, time spent in four activities (peer teaching, practicum, internship, and private teaching), MPA and TA. Preservice music teachers’ self-efficacy was the criterion variable. The results indicated that teaching anxiety and grade were significant predictors, and the best model explained a total of 31% of the variance in preservice music teachers’ self-efficacy, which was significant, F (2,236) = 54.13. With every unit increase in teaching anxiety, teachers’ self-efficacy decreased by 0.53, β  = −0.53, p  < 0.001, and it contributed 29.7% of the variance. Compared to participants at other grade levels, junior participants had 3.26 points lower teacher self-efficacy, β  = −3.26, p  < 0.01, which contributed an additional 1.9%.

Research Question 4: Is there a difference in gender, grade, primary instruments, and secondary instruments among MPA, TA, and SE?

We computed one mixed-design MANOVA with four between-subject variables (gender, grade level, primary instrument, secondary instrument) and three within-subject variables (MPA, TA, and SE). The primary instrument encompassed three groups: voice, piano and other instruments, while the secondary instrument included five groups: voice, piano, conducting, other instruments, and no instrument. Relationship strength was determined using partial eta squared (η 2 ), and an alpha level of 0.05 was set. Since the Box M test indicated the violation of the assumption of sphericity, the more robust Pillai’s trace was used. The results revealed that gender significantly differed for preservice music teachers’ self-efficacy p < 0.05, F (1,237) = 4.07, η 2 = 0.02, indicating that male participants ( M = 82.93, SD = 1.82) displayed a significantly higher mean score for teachers’ self-efficacy than female participants ( M = 78.88, SD = 1.48). Additionally, no significant differences or significant interactions were found for the other variables (see Table 4 ).

Table 4 . Results for MPA, TA and SE in gender, grade, primary instruments and secondary instruments.

We aimed to investigate the associations among music performance anxiety (MPA), self-efficacy (SE), and teaching anxiety (TA) among Chinese preservice music teachers. To the best of our knowledge, this study fills research gaps in the relationships among these three factors affecting preservice music teachers. Moreover, we further attempted to examine potential variables that could predict SE, MPA, and TA.

The primary result revealed a significant negative correlation between music performance anxiety and preservice music teachers’ self-efficacy, confirming that as MPA increased, self-efficacy decreased in preservice music teachers. This finding aligns with the study conducted by Dempsey and Comeau (2019) , however, it contrasts with the conclusion reached by MacAfee and Comeau (2020) , who found no observed relationships between music performance anxiety and self-efficacy. These differences may be attributed to variations in the research design and the target participants in these two studies. MacAfee and Comeau (2020) conducted a multiple case study over 6 weeks of intervention with five young musicians. Participants completed the Music Performance Anxiety Inventory for Adolescents (MPAI-A), Self-efficacy for Musical Performing, Performance evaluations, and Behavioral Anxiety Index in three stages (preintervention, baseline-intervention, and return to baseline). In our study, we implemented K-MPAI, PMTES, and TCHAS for 237 junior and senior preservice music teachers with diverse demographic backgrounds and various music teaching experiences. This relatively large sample size enhanced the reliability of our findings. Another potential reason for the disparities in findings might be due to the differences of the target participants. Our study focused on Chinese preservice music teachers, while MacAfee and Comeau (2020) analyzed performance anxiety and self-efficacy in Canadian adolescent young musicians. Thus, based upon discrepant research designs and diverse target participants, different studies may possess inconsistent results.

An intriguing finding is that there was an inconsistency observed between the results of the Pearson correlation analysis and the partial correlation analysis. The findings reveal that no significant correlation was found between MPA and SE through the partial correlation analysis, suggesting the presence of a confounding variable, TA. It became apparent that without controlling TA, MPA, and SE exhibited a significant correlation. One potential explanation for the inconsistency in the results could be that the role of a music teacher is multifaceted, encompassing not only teaching but also musicianship. The demonstration of musical skills is integral to the teaching process. This includes vocal demonstrations, piano accompaniment, conducting, and demonstrations on various instruments. Consequently, the factors of teaching anxiety and performance anxiety often interact in complex ways, which may influence the observed correlations.

In our study, teaching anxiety is one of the predictors of self-efficacy among preservice music teachers. In other words, preservice music teachers who experience high levels of teaching anxiety tend to have lower self-efficacy in music instruction; meanwhile, those who experience low levels of teaching anxiety tend to have higher self-efficacy in music instruction. This finding could be explained by Bandura’s theory ( Bandura, 1997 ), as he pointed out that one’s self-efficacy beliefs were influenced by four sources of efficacy: mastery experiences, vicarious experiences, social persuasion, and emotional states. Teaching anxiety maybe related to emotional states that might influence self-efficacy. It is not surprising that the current study confirmed that teaching anxiety could predict preservice music teachers’ self-efficacy. In addition, the broader literature confirmed the current results and suggested that the increased teaching anxiety may be due to pedagogy, evaluation, classroom management, and misbehavior of students ( Merç, 2015 ; Gorospe, 2022 ). These potential reasons would further affect preservice teachers’ self-efficacy.

The results of the current study indicated that no significant difference was observed between genders in music performance anxiety, which is congruent with the results of Dempsey and Comeau’s (2019) study. Nevertheless, Osborne and Kenny’s (2008) and Egilmez’s (2015) study revealed that there was a significant difference in gender and music performance anxiety. In their studies, females had higher scores on music performance anxiety than males. We assumed that one of the reasons for the lack of a specific difference in the current study could be attributed to the substantial imbalance in the male-to-female ratio in our sample. However, this imbalanced phenomenon mirrors the real-world demographic information on gender in Chinese music teacher preparation programs. In most institutions, the numbers of female students and male students in the music department are unequal: female music students are far more common than male music students, which impacted the data collection and analysis in this study.

Implication, limitation, and future research

Results of this study imply that teacher educators should consider interventions in MPA and TA, to improve overall teacher preparedness. Interventions available include teaching practicum, mental and visual rehearsal, peer support and parents’ support, etc. ( Kenny and Osborne, 2006 ; Prichard, 2017 ; Huang and Song, 2021 ). A limitation of this study is the small sample size and lack of gender diversity. This study recruited only 237 participants, with an unequal number of men and women. Although preservice male music teachers exhibited higher mean scores than preservice female music teachers in self-efficacy, that was not the case for music performance anxiety (MPA) and teaching anxiety (TA). In MPA and TA, no gender differences were found.

Furthermore, we propose several directions for future research. Firstly, considering the limitation of this study, it is advisable to expand the sample size to include participants with a broader range of demographic backgrounds and gender diversity. Secondly, we might consider conducting experimental research involving instructional interventions, such as field experiences and peer teaching, that could yield valuable insights into how Chinese pre-service music teachers can enhance their self-efficacy in music teaching and reduce teaching anxiety. Thirdly, we might consider a mixed methods study to explore the coping strategies of individual pre-service music teachers in dealing with teaching anxiety and music performance anxiety to gain insights on how these strategies influence their self-efficacy in teaching. Lastly, since self-efficacy is a complex and multidimensional construct ( Bandura, 1986 , 1997 ), influenced by personal traits as a variable ( Topoğlu, 2014 ; Biasutti and Concina, 2018 ; Biasutti et al., 2021 ), we might consider exploring the relationship between personal traits and the self-efficacy of pre-service music teachers in other cultural contexts.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by Guangzhou University and The Pennsylvania State University's institutional review boards (IRB-STUDY00021646). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants' legal guardians/next of kin because participants signed the electronic consent form.

Author contributions

CC: Data curation, Formal analysis, Investigation, Methodology, Validation, Writing – original draft, Writing – review & editing. XX: Writing – original draft, Writing – review & editing, Methodology. YY: Formal analysis, Software, Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This work was supported by the China Postdoctoral Science Foundation (Project No. 62216277).

Acknowledgments

We appreciated all the suggestions and feedback from C. Victor Fung.

Conflict of interest

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

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2024.1373454/full#supplementary-material

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Keywords: teaching anxiety, music performance anxiety, self-efficacy, relationships, preservice music teachers

Citation: Cui C, Xie X and Yin Y (2024) Exploring the relationships among music performance anxiety, teaching anxiety, and self-efficacy of Chinese preservice music teachers. Front. Psychol . 15:1373454. doi: 10.3389/fpsyg.2024.1373454

Received: 19 January 2024; Accepted: 03 April 2024; Published: 12 April 2024.

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*Correspondence: Xin Xie, [email protected]

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