mental health crisis case study

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

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

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

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

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

Overcoming struggles

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

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

Let’s throw rocks together

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

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

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

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

Case studies

August 13, 2024

Finding Happiness At Sea As A Yacht Captain After Overcoming Depression and Anxiety

“If a situation is making you unhappy – a marriage, a job, a family member – anything – change the situation. You can leave, you can stop speaking to someone (yes, even a parent or another family member), and you can do so free of guilt because you are in charge of your own happiness, and life is too short to choose anything different for yourself.”

Struggled with: Anxiety Depression Suicidal

Helped by: Medication Therapy

August 6, 2024

Overcoming Neglect, Childhood Trauma and Abuse Through Careful Self-Improvement

“When I was 12 years old, my parents moved into their own place, along with my brother and sister. They left me with my grandparents. I could only see my family on weekends, and on Sunday evenings I would go back home. I was not able to build a normal relationship with my brother and sister. I even thought at one point that I was adopted, which was against all logic.”

Struggled with: Abuse Childhood

Helped by: Journaling Self-improvement

July 30, 2024

Overcoming a Rare Autoimmune Disease With a Careful Diet and Self-Improvement

“There were weeks when I wouldn’t leave my house, feeling too overwhelmed and exhausted to face the world. I tend to isolate myself rather than reaching out to others, which only compounded my feelings of loneliness and despair. I had to repattern my behavior and learn to ask for help or talk about my feelings, but it wasn’t easy. I internalized a lot of my pain and frustration, which made me feel even more isolated.”

Struggled with: Anxiety Autoimmune disease

Helped by: Self-improvement

July 23, 2024

Surviving The Boston Marathon Bombings While Facing TBI and Medical Gaslighting

“As I literally lived on his couch, with my port-a-potty in his living room, my partner eventually applied for permanent disability status for me. But, even the doctor gaslighted me, told me I was physically able to work, and reported the same to the government. In reality, I was so dizzy with vertigo, this same doctor refused to let me walk to and from our car, by myself, fearing I’d fall and sue!”

Struggled with: CPTSD Traumatic Brain Injury

Helped by: Treatment

July 16, 2024

Somatic Therapy Helped Me Heal From CPTSD After Years of Childhood Abuse

“At 22 years old, I knew that I was dying of alcoholism. I accepted that. The trauma symptoms I experienced were too overwhelming to stop drinking. When I was sober, I would sometimes experience 30 to 40 body memories of being sexually assaulted–again and again in succession. I drank to feel numb.”

Struggled with: Abuse Addiction CPTSD Suicidal

Helped by: Social support Therapy

July 9, 2024

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

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

Struggled with: Irritable Bowel Syndrome

Helped by: Therapy Treatment

July 4, 2024

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

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

Struggled with: Depression Suicidal Traumatic Brain Injury

Helped by: Medication Pets Volunteering

July 2, 2024

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

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

Struggled with: Feeling lost People-pleasing Self-doubt

Helped by: Self-acceptance Self-awareness

June 27, 2024

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

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

Struggled with: Breakup

Helped by: Self-Care Social support

June 19, 2024

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

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

Struggled with: Anxiety Bipolar Disorder Depression Suicidal

Vera Institute of Justice

Case study: cahoots.

Eugene, Oregon

Jackson Beck

Melissa Reuland

Amid national conversation in recent months about reducing policing’s footprint in behavioral health matters, the Crisis Assistance Helping out on the Streets (CAHOOTS) program in Eugene, Oregon, has received particular attention as a successful and growing alternative to on-scene police response. Staffed and operated by Eugene’s White Bird Clinic, the program dispatches two-person teams of crisis workers and medics to respond to 911 and non-emergency calls involving people in behavioral health crisis—calls that in many other communities are directed to police by default. CAHOOTS units are equipped to deliver “crisis intervention, counseling, mediation, information and referral, transportation to social services, first aid, and basic-level emergency medical care.” [ ] White Bird Clinic, “CAHOOTS FAQ,” accessed August 18, 2020, https://whitebirdclinic.org/ca... . All services are voluntary. If the situation involves a crime in progress, violence, or life-threatening emergencies, police will be dispatched to arrive as primary or co-responders. [ ] Ibid. CAHOOTS teams deliver person-centered interventions and make referrals to behavioral health supports and services without the uniforms, sirens, and handcuffs that can exacerbate feelings of distress for people in crisis. They reduce unnecessary police contact and allow police to spend more time on crime-related matters. Eugene police may also request assistance if they arrive on-scene and determine that a CAHOOTS team can help resolve a situation.

This case study explains how CAHOOTS teams are funded, dispatched, staffed, and trained—and how a long-term commitment between police and community partners has cemented the program’s success.

Funding CAHOOTS through the police

The City of Eugene has long supported CAHOOTS through the Eugene Police Department (EPD) budget as an essential part of the community’s crisis response system, beginning in 1989 when EPD funded the first CAHOOTS shift. [ ] Tatiana Parafiniuk-Talesnick, “In Cahoots: How the Unlikely Pairing of Cops and Hippies Became a National Model,” The Register-Guard , October 20, 2019, https://www.registerguard.com/... . In June 2016, the Eugene City Council increased the program’s funding by $225,000 per year to allow for 24/7 service. [ ] Ellen Meny, “CAHOOTS Starts 24-Hour Eugene Service in January 2017,” KVAL, December 12, 2016, https://kval.com/news/local/ca... . Funding increases have continued over the last few years to allow for overlapping, two-van coverage as the call volume for CAHOOTS has grown. [ ] City of Eugene Police Department, “CAHOOTS,” https://www.eugene-or.gov/4508/CAHOOTS .

After years of working with police in Eugene, White Bird expanded CAHOOTS services to the neighboring community of Springfield in 2015, when Lane County administered an Oregon Health and Human Services grant for the program. [ ] Parafiniuk-Talesnick, “In Cahoots,” 2019; Tim Black, operations coordinator, CAHOOTS, April 17, 2020, telephone call. Between Eugene and Springfield, CAHOOTS is now funded at around $2 million annually—about 2 percent of their police departments’ budgets. [ ] Anna V. Smith, “There’s Already an Alternative to Calling the Police,” High Country News , June 11, 2020, https://www.hcn.org/issues/52.... .

Dispatching CAHOOTS for ‘better customer service’

A key element of White Bird’s partnership with police is that CAHOOTS staff carry a police radio that emergency dispatchers use to request their response to people in crisis on a special channel. The channel can get “overwhelmed,” Eugene officer Bo Rankin explained, by the increasing number of requests for CAHOOTS teams. [ ] Officer Bo Rankin, Eugene Police Department, February 25, 2020, telephone call. Of the estimated 24,000 calls CAHOOTS responded to in 2019, only 311 required police backup, and in Eugene, CAHOOTS teams resolved almost 20 percent of all calls coming through the city’s public safety communications center. [ ] Black, September 10, 2020, email; and Trevor Bach, “One City’s 30-Year Experiment with Reimagining Public Safety,” U.S. News & World Report , July 6, 2020, https://www.usnews.com/news/ci... .

Of the estimated 24,000 calls CAHOOTS responded to in 2019, only 311 required police backup...

The center is housed in EPD and tasked with receiving and dispatching all police, fire, and CAHOOTS calls. [ ] Marie Longworth, communications supervisor, Eugene Police Department, May 4, 2020, telephone call. With the CAHOOTS program embedded in Eugene’s communications system, Eugene dispatchers are empowered to use this non-police alternative to handle non-police issues.

The police department and CAHOOTS staff collaboratively developed criteria for calls that might prompt a CAHOOTS team to respond primarily, continuing to adapt them based on experience; the protocol is used as a guide rather than a rule. For example, when a call arrives at Eugene’s communications center, through either 911 or the community’s non-emergency line, call-takers listen for details that might fit these criteria. As Eugene communications supervisor Marie Longworth put it, sending CAHOOTS rather than police is often regarded as “better customer service” for community members requesting assistance for themselves or others. [ ] Ibid.

Official Eugene communications protocol for CAHOOTS

Longworth also notes that CAHOOTS’s relationships in the community help dispatchers connect people with appropriate responders. The communications center sometimes gets direct requests for CAHOOTS. In other cases, because of their familiarity with community members and their specific needs, CAHOOTS teams have demonstrated comfort taking on calls that would otherwise go to police. [ ] Ibid.

Staffing and training

Robust recruitment and training underpin the success of CAHOOTS teams. CAHOOTS medics typically bring EMT certifications and experience within fire departments. CAHOOTS crisis workers may have undergraduate degrees in a human services field, but some people bring experience working crisis lines or in shelters, whereas others have lived experience with behavioral health conditions. Increasingly, the program has sought multilingual candidates who can help extend the reach of CAHOOTS services to Latinx communities. [ ] Black, April 17, 2020, call. CAHOOTS team members undergo a months-long training process, in cohorts whenever possible. In addition to at least 40 hours of class time, new staff complete 500 to 600 hours of field training—specific timelines depend on cohort needs—before they can graduate to exclusive, two-person CAHOOTS teams.

Although most EPD officers receive CIT training, CAHOOTS staff take on a more specialized set of issues and benefit from extensive field training focused on crisis incidents. [ ] Rankin, February 25, 2020, call; Rankin, September 10, 2020, email. The CAHOOTS training process is incremental, ranging from field observation to de-escalation to the nuts and bolts of working with police radios, writing reports, coordinating with service partners, and starting and ending shifts. [ ] Black, April 17, 2020, call.

White Bird also engages CAHOOTS trainees in a mentorship process that lasts throughout their careers with the organization, with the understanding that they take on difficult work and need outlets to process experiences together to carry out their jobs. [ ] Ibid. The practice demonstrates the importance of wellness for first responders and community members alike.

Sustained and inclusive collaboration

Over time, CAHOOTS and police have developed strategies for supporting one another as calls evolve on-scene and require real-time, frontline collaboration. As noted above, requests for service involving a potentially dangerous situation will require early police involvement, but officers may engage alternative responders once the scene is stabilized and they have gathered more information about what the person in crisis needs. For example, Eugene officers can request assistance when they determine that CAHOOTS-led de-escalation might resolve a situation safely for all parties involved, especially when a call appears to involve underlying substance use or mental health issues.

In addition to bringing expertise in behavioral health-related de-escalation to a scene, CAHOOTS teams can drive a person in crisis to the clinic or hospital. This transportation, which must be voluntary, eliminates the indignity of a police transport, which necessitates the use of handcuffs per standard police protocols. [ ] Rankin, February 25, 2020, call.

More rarely, CAHOOTS teams may determine that police involvement is needed when they gather more information, or as a situation evolves on-scene. If they respond to calls involving people who pose a danger to themselves or others, CAHOOTS teams may see the need for an involuntary hold without the authority to carry one out. [ ] Black, April 17, 2020, call. For example, a person may be so severely intoxicated that they cannot care for themselves and will not consent to a sobering center. [ ] American College of Emergency Physicians, “Sobering Centers,” https://www.acep.org/by-medica... . In this case, CAHOOTS staff might call in patrol officers to execute an emergency custody order. For mental health calls that end in involuntary hospitalizations such as these, CAHOOTS vans follow patrol vehicles to the emergency department to share their transfer sheet, which lists observations of and items discussed with the community member. This facilitates continuity of care for the client. [ ] Black, April 17, 2020, call.

Collaboration between EPD and CAHOOTS extends beyond emergency response. Over the last few years, EPD has introduced the Community Outreach Response Team program to deliver case management for people experiencing homelessness who often come to the attention of emergency services. [ ] Rankin, February 25, 2020, call; see also Cameron Walker, “Police Collaboration Effort Works to Keep Downtown Eugene Safe,” KVAL-TV, August 10, 2016, https://kval.com/news/local/po... . As part of this program, the police have partnered with CAHOOTS to bring their behavioral health expertise to bear on community members who continue to experience frequent contact with the police. EPD has found that this collaborative problem-solving work complements Eugene’s ongoing efforts to support alternative first responders. [ ] Sergeant Julie Smith, Eugene Police Department, March 11, 2020, telephone call.

Close collaboration among government and community partners—including schools, shelters, and behavioral health providers—enables CAHOOTS to respond to a wide variety of situations and to assist police and other agencies with behavioral health emergencies when appropriate. [ ] White Bird Clinic, “CAHOOTS FAQ.” Such partnerships during program planning and throughout program implementation are essential to the success of efforts to improve local crisis response systems. CAHOOTS Operations Coordinator Tim Black stressed that the organization’s success did not happen overnight; there were many small, but important, details to address and a wide range of stakeholders to engage for effective implementation. “You want to make sure you have everyone who could possibly have an opinion about this topic at the table,” he explained. [ ] Black, April 17, 2020, call. It is important to include detractors of the police department in program planning, as getting these partners’ input is critical to program success. Officer Rankin noted that CAHOOTS staff themselves can be “strongly against police in many ways,” but it is “nice having all the line people trying to come up with solutions together.” [ ] Rankin, February 25, 2020, call.

Still, the Eugene and Springfield communities are more than 80 percent white, making them racially homogeneous compared to many cities. [ ] United States Census Bureau, “Quickfacts Eugene, Oregon,” https://www.census.gov/quickfacts/eugenecityoregon; and United States Census Bureau, “Quickfacts Springfield, Oregon,” https://www.census.gov/quickfa... . “There’s a lot of privilege that comes along with having a healthy enough relationship with police that you can contact them,” Black acknowledged, and Eugene is now exploring a separate phone line for CAHOOTS that would be disconnected from the police department. [ ] Black, April 17, 2020, call; and Molly Harbarger, “Police Cuts Give Portland Alternative First Responder Program a Boost—But Can it Respond to the Moment?” The Oregonian , July 4, 2020, https://www.oregonlive.com/cri... . This is a vital consideration for implementing crisis response programs where relationships between police and communities of color are historically characterized by tension and distrust. Programs may find success by grappling with this distrust directly and engaging a wide variety of partners to reach communities with the greatest need. [ ] See for example Jumaane D. Williams, Improving New York City’s Responses to Individuals in Mental Health Crisis (New York: New York City Public Advocate, 2019), https://www.pubadvocate.nyc.go... .

CAHOOTS credits being embedded in the community’s emergency communications and public safety infrastructure for much of its impact, while stressing that the program’s ultimate objective is to reduce policing’s overall footprint. White Bird’s website states, “CAHOOTS is designed to provide an alternative to police action whenever possible for non-criminal substance abuse, poverty, and mental health crisis.” [ ] White Bird Clinic, “CAHOOTS FAQ.” According to Black, the program aims to reduce opportunities for people to become justice-involved and lose their rights. Working with the police has made this possible: “By no means do we [ignore] what other public safety personnel are doing,” he explains. “We try to use our privilege in the public safety system to fight for compassionate and responsive services.” [ ] Black, April 17, 2020, call.

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In This Section

The program has developed an extensive catalogue of case studies addressing crisis events. These cases serve as an important tool for classroom study, prompting readers to think about the challenges different types of crises pose for public safety officials, political leaders, and the affected communities at large.

The following cases, here organized into three broad categories, are available through the  Harvard Kennedy School Case Program ; click on a case title to read a detailed abstract and purchase the document. A selection of these cases are also available in the textbooks Managing Crises: Responses to Large-Scale Emergencies  (Howitt and Leonard, with Giles, CQ Press) and Public Health Preparedness: Case Studies in Policy and Management (Howitt, Leonard, and Giles, APHA Press), both of which contain fifteen cases as well as corresponding conceptual material to support classroom instruction.

Natural Disasters, Infrastructure Failures, and Systems Collapse

At the Center of the Storm: San Juan Mayor Carmen Yulín Cruz and the Response to Hurricane Maria (Case and Epilogue) This case profiles how Carmen Yulín Cruz, Mayor of San Juan, Puerto Rico, led her City’s response to Hurricane Maria, which devastated the island and neighboring parts of the Caribbean in the fall of 2017. By highlighting Cruz’s decisions and actions prior to, during, and following the storm’s landfall, the case provides readers with insight into the challenges of preparing for and responding to severe crises like Maria. It illustrates how several key factors—including San Juan’s pre-storm preparedness efforts, the City’s relationships with other jurisdictions and entities, and the ability to adapt and improvise in the face of novel and extreme conditions—shaped the response to one of the worst natural disasters in American history.

A Cascade of Emergencies: Responding to Superstorm Sandy in New York City (A and B) On October 29, 2012, Superstorm Sandy made landfall near Atlantic City, New Jersey. Sandy’s massive size, coupled with an unusual combination of meteorological conditions, fueled an especially powerful and destructive storm surge, which caused unprecedented damage in and around New York City, the country’s most populous metropolitan area, as well as on Long Island and along the Jersey Shore. This two-part case study focuses on how New York City prepared for the storm’s arrival and then responded to the cascading series of emergencies – from fires, to flooding, to power failures – that played out as it bore down on the region. Profiling actions taken at the local level by emergency response agencies like the New York City Fire Department (FDNY), the case also explores how the city coordinated with state and federal partners – including both the state National Guard and federal military components – and illustrates both the advantages and complications of using military assets for domestic emergency response operations.

Part B of the case highlights the experience of Staten Island, which experienced the worst of Sandy’s wrath. In the storm’s wake, frustration over the speed of the response triggered withering public criticism from borough officials, leading to concerns that a political crisis was about to overwhelm the still unfolding relief effort.

Surviving the Surge: New York City Hospitals Respond to Superstorm Sandy Exploring the experiences of three Manhattan-based hospitals during Superstorm Sandy in 2012, the case focuses on decisions made by each institution about whether to shelter-in-place or evacuate hundreds of medically fragile patients -- the former strategy running the risk of exposing individuals to dangerous and life-threatening conditions, the latter being an especially complex and difficult process, not without its own dangers. "Surviving the Surge" illustrates the very difficult trade-offs hospital administrators and local and state public health authorities grappled with as Sandy bore down on New York and vividly depicts the ramifications of these decisions, with the storm ultimately inflicting serious damage on Manhattan and across much of the surrounding region. (Included in Howitt, Leonard, and Giles, Public Health Preparedness)

Ready in Advance: The City of Tuscaloosa’s Response to the 4/27/11 Tornado On April 27, 2011, a massive and powerful tornado leveled 1/8 of the area of Tuscaloosa, AL. Doctrine called for the County Emergency Management Agency (EMA) to take the lead in organizing the response to the disaster – but one of the first buildings destroyed during the event housed the County EMA offices, leaving the agency completely incapacitated. Fortunately, the city had taken several steps in the preceding years to prepare for responding to a major disaster. This included having sent a delegation of 70 city officials and community leaders, led by Tuscaloosa Mayor Walter Maddox, to a week-long training organized by FEMA. “Ready in Advance” reveals how that training, along with other preparedness activities undertaken by the city, would pay major dividends in the aftermath of the tornado, as the mayor and his staff set forth to respond to one of the worst disasters in Tuscaloosa’s history.

The Deepwater Horizon Oil Spill: The Politics of Crisis Response (A and B) Following the sinking of the Deepwater Horizon drilling rig in late April 2010, the Obama administration organized a massive response operation to contain the oil spreading across the Gulf of Mexico. Attracting intense public attention, the response adhered to the Oil Pollution Act of 1990, a federal law that the crisis would soon reveal was not well understood – or even accepted – by all relevant parties.

This two-part case series profiles how senior officials from the U.S. Department of Homeland Security sought to coordinate the actions of a myriad of actors, ranging from numerous federal partners; the political leadership of the affected Gulf States and sub-state jurisdictions; and the private sector. Case A overviews the disaster and early response; discusses the formation of a National Incident Command (NIC); and explores the NIC’s efforts to coordinate the actions of various federal entities. Case B focuses on the challenges the NIC encountered as it sought to engage with state and local actors – an effort that would grow increasingly complicated as the crisis deepened throughout the spring and summer of 2010.

The 2010 Chilean Mining Rescue (A and B) On August 5, 2010, 700,000 tons of rock caved in Chile's San José mine. The collapse buried 33 miners at a depth almost twice the height of the Empire State Building-over 600 meters (2000 feet) below ground. Never had a recovery been attempted at such depths, let alone in the face of challenges like those posed by the San José mine: unstable terrain, rock so hard it defied ordinary drill bits, severely limited time, and the potentially immobilizing fear that plagued the buried miners. The case describes the ensuing efforts that drew the resources of countless people and multiple organizations in Chile and around the world.

The National Guard’s Response to the 2010 Pakistan Floods Throughout the summer of 2010, Pakistan experienced severe flooding that overtook a large portion of the country, displacing millions of people, causing extensive physical damage, and resulting in significant economic losses. This case focuses on the role of the National Guard (and of the U.S. military, more broadly) in the international relief effort that unfolded alongside that of Pakistan’s government and military. In particular it highlights how various Guard and U.S. military assets that had been deployed to Afghanistan as part of the war there were reassigned to support the U.S.’s flood relief efforts in Pakistan, revealing the successes and challenges of transitioning from a war-footing to disaster response. In exploring how Guard leaders partnered with counterparts from other components of the U.S. government, Pakistani officials, and members of the international humanitarian community, the case also examines how they navigated a set of difficult civilian-military dynamics during a particularly tense period in US-Pakistan relations.

Inundation: The Slow-Moving Crisis of Pakistan’s 2010 Floods (A, B, and Epilogue) In summer 2010, unusually intense monsoon rains in Pakistan triggered slow-moving floods that inundated a fifth of the country and displaced millions of people. This case describes how Pakistan’s Government responded to this disaster and highlights the performance of the country’s nascent emergency management agency, the National Disaster Management Authority, as well as the integration of international assistance.

"Operation Rollback Water": The National Guard’s Response to the 2009 North Dakota Floods   ( A ,  B , and   Epilogue ) In spring 2009, North Dakota experienced some of the worst flooding in the state’s history. The state's National Guard responded by mobilizing thousands of its troops and working in concert with personnel and equipment from six other states. This case profiles the National Guard’s preparations for and response to the floods and focuses on coordination within the National Guard, between the National Guard and civilian government agencies, and between the National Guard and elected officials.

Typhoon Morakot Strikes Taiwan, 2009 (A, B, and C) In less than four days, Typhoon Morakot dumped close to 118 inches of rain on Taiwan, flooding cities, towns, and villages; washing away roads and bridges; drowning farmland and animals; and triggering mudslides that buried entire villages. With the typhoon challenging its emergency response capacity, Taiwan’s government launched a major rescue and relief operation. But what began as a physical disaster soon became a political disaster for the President and Prime Minister, as bitter criticism came from citizens, the opposition party, and the President’s own supporters.

Getting Help to Victims of 2008 Cyclone Nargis: AmeriCares Engages with Myanmar's Military Government (Case and Epilogue) In May 2008, Cyclone Nargis in Myanmar (Burma) left 138,373 dead or missing and 2.4 million survivors’ livelihoods in doubt, making it the country’s worst natural disaster and one of the deadliest cyclones ever. Friendly Asian countries as well as western governments which previously had used economic sanctions to isolate Myanmar’s military government now sought to provide aid to Myanmar’s people. But they met distrust and faced adversarial relationships from a suspicious government, reluctant to open its borders to outsiders.

China's Blizzards of 2008 From January 10-February 6, a series of heavy snow storms intertwined with ice storms and subzero temperatures created China’s worst winter weather in 50 years. The storms closed airports and paralyzed trains and roads, damaged power grids and water supplies, caused massive black-outs, and left several cities in hard-hit areas isolated and threatened. The disruption of the power supply and transport also severely affected the production and flow of consumer goods and industrial materials, triggering a cascade of crisis nationwide. Coal reserves at power plants were nearly exhausted, production was significantly cut back at big factories, the chronic winter power shortage was exacerbated, and food prices spiked sharply in many areas because of shortages.

Thin on the Ground: Deploying Scarce Resources in the October 2007 Southern California Wildfires  When wildfires swept across Southern California in October 2007, firefighting resources were stretched dangerously thin. Readers are prompted to put themselves in the shoes of public safety authorities and consider how organizations can best address resource scarcities in advance of and during emergency situations.

"Broadmoor Lives:" A New Orleans Neighborhood’s Battle to Recover from Hurricane Katrina (A, B, and Sequel) Stunned by a city planning committee’s proposal to give New Orleans neighborhoods hard-hit by Hurricane Katrina just four months to prove they were worth rebuilding, the Broadmoor community organized and implemented an all-volunteer redevelopment planning effort to bring their neighborhood back to life.

Gridlock in Texas (A and B) As Hurricane Rita bore down on the Houston metro area in mid-September 2005, just a few weeks after Hurricane Katrina had devastated the Gulf Coast, millions of people flocked to the roadways. Part A details the massive gridlock that ensued, illustrating the challenges of implementing safe evacuations and of communicating effectively amidst great fear. Part B explores post-storm efforts to improve evacuation policies and procedures -- and how the resulting plans measured up in 2008, when the area was once again under threat, this time from Hurricane Ike.

Wal-Mart’s Response to Hurricane Katrina: Striving for a Public-Private Partnership (Case and Sequel) This case explores Wal-Mart's efforts to provide relief in the immediate aftermath of Hurricane Katrina, raising important questions about government’s ability to take full advantage of private sector capabilities during large-scale emergencies. (Included in Howitt & Leonard, Managing Crises)

Moving People out of Danger: Special Needs Evacuations from Gulf Coast Hurricanes (A and B ) In the face of Hurricanes Katrina and Rita, officials in Louisiana and Texas grappled with the challenging task of evacuating people with medical and other special needs to safety. The shortcomings of those efforts sparked major initiatives to improve evacuation procedures for individuals requiring transportation assistance – plans that got a demanding test when Hurricanes Gustav and Ike threatened the Gulf Coast in the fall of 2008. (Included in Howitt, Leonard, and Giles, Public Health Preparedness)

Hurricane Katrina:  (A) Preparing for the Big One , and  (B) Responding to an "Ultra-Catastrophe" in New Orleans Exploring the failed response to Hurricane Katrina and its implications for the greater New Orleans area, the case begins with a review of pre-event planning and preparedness efforts. Part B details the largely ineffective governmental response to the rapidly escalating crisis.  (Included in Howitt & Leonard, Managing Crises; Also available in abridged form.)

Rebuilding Aceh: Indonesia's BRR Spearheads Post-Tsunami Recovery (Case and Epilogue) The December 26, 2004, Indian Ocean tsunami caused tremendous damage and suffering on several continents, with Indonesia's Aceh Province, located on the far northern tip of Sumatra Island, experiencing the very worst. In the tsunami's wake, the Indonesian government faced a daunting task of implementing a large-scale recovery effort, and to coordinate the many reconstruction projects that soon began to emerge across Aceh, Indonesia's president established a national-level, ad hoc agency, which came to be known by its acronym BRR. This case examines the challenges encountered by BRR's leadership as it sought to implement an effective recovery process.

When Imperatives Collide: The 2003 San Diego Firestorm   (Case and Epilogue) In October 2003, multiple wildfires burned across southern California. Focusing on the response to the fires, this case explores what can happen when an operational norm — to fight fires effectively but safely — collides with the political imperative to override established procedures to protect the public.  (Included in Howitt & Leonard, Managing Crises)

"Almost a Worst Case Scenario:" The Baltimore Tunnel Fires of 2001 (A, B, and C) When a train carrying hazardous materials derailed under downtown Baltimore, a stubborn underground fire severely challenged emergency responders. Readers are prompted to give particular attention to the significant challenges of managing a multi-organizational response.  (Included in Howitt & Leonard, Managing Crises)

Safe But Annoyed: The Hurricane Floyd Evacuation in Florida When far more citizens than necessary evacuated in advance of Hurricane Floyd, Florida’s roadways were quickly overloaded and emergency management operations overwhelmed. In detailing these (and other) problems, the case highlights the challenges of managing evacuations in advance of potentially catastrophic events. (Included in Howitt & Leonard, Managing Crises)

The US Forest Service and Transitional Fires This case outlines the operational challenges of decision making in a high stress, high stakes situation – in this instance during rapidly evolving wildland fires, also known as "transitional fires." (Included in Howitt & Leonard, Managing Crises)

The Tzu Chi Foundation's China Relief Mission Tzu Chi is one of the largest charities in Taiwan, and one of the swiftest and most effective relief organizations internationally. Rooted in the value of compassion, the organization has many unusual operating features -- including having no long term plan. This case explores the basic operating approach of the organization and invites students to explain the overall effectiveness and success of the organization and its surprising success (as a faith-based, Taiwanese, direct-relief organization -- all of which are more or less anathema to the Chinese government) in securing an operating license in China.

Security Threats

Ce Soir-Là, Ils n'Arrivent Plus Un par Un, Mais par Vagues: Coping with the Surge of Trauma Patients at L'Hôpital Universitaire La Pitié Salpêtrière-Friday, November 13, 2015 On November 13, 2015, Dr. Marie Borel, Dr. Emmanuelle Dolla, Dr. Frédéric Le Saché, and Prof. Mathieu Raux were the doctors in charge of the trauma center at L'Hôpital de la Pitié Salpêtrière in Paris, where dozens of wounded and dying patients, most with severe gunshot wounds from military grade firearms, arrived in waves after a series of terrorist attacks across the city. The doctors had trained for a mass-casualty event but had never envisioned the magnitude of what they now saw. This case describes how they rapidly expanded the critical care capacity available so as to be able to handle the unexpectedly large number of patients arriving at their doors.

Into Local Streets: Maryland National Guard and the Baltimore Riots (Case and Epilogue) On April 19, 2015, Freddie Gray, a young African American male, died while in the custody of the Baltimore Police. In response to his death, protestors mobilized daily in Baltimore to vocalize their frustrations, including what they saw as law enforcement’s long-standing mistreatment of the African American community. Then, on April 27, following Gray’s funeral, riots and acts of vandalism broke out across the city. Overwhelmed by the unrest, the Baltimore police requested assistance from other police forces. Later that evening, Maryland Governor Larry Hogan declared a state of emergency and activated the Maryland National Guard. At the local level, Baltimore Mayor Stephanie Rawlings-Blake issued a nightly curfew beginning Tuesday evening.

“Into Local Streets” focuses on the role of the National Guard in the response to the protests and violence following Gray’s death, vividly depicting the actions and decision-making processes of the Guard’s senior-most leaders. In particular, it highlights the experience of the state’s Adjutant General, Linda Singh, who soon found herself navigating a complicated web of officials and agencies from both state and local government – and their different perspectives on how to bring an end to the crisis.

Defending the Homeland: The Massachusetts National Guard Responds to the 2013 Boston Marathon Bombings On April 15, 2013, Dzhokhar and Tamerlan Tsarnaev placed and detonated two homemade bombs near the finish line of the Boston Marathon, killing three bystanders and injuring more than two hundred others. This case profiles the role the Massachusetts National Guard played in the complex, multi-agency response that unfolded in the minutes, hours, and days following the bombings, exploring how its soldiers and airmen helped support efforts on multiple fronts – from performing life-saving actions in the immediate aftermath of the attack to providing security on the region’s mass transit system and participating in the search for Dzhokhar Tsarnaev several days later. It also depicts how the Guard’s senior officers helped manage the overall response in partnership with their local, state, and federal counterparts. The case reveals both the emergent and centralized elements of the Guard’s efforts, explores the debate over whether or not Guard members should have been armed in the aftermath of the bombings, and highlights an array of unique assets and capabilities that the Guard was able to provide in support of the response.

Recovery in Aurora: The Public Schools' Response to the July 2012 Movie Theater Shooting (A and B) In July 2012, a gunman entered a movie theater in Aurora, Colorado and opened fire, killing 12 people, injuring 58 others, and traumatizing a community. This two-part case briefly describes the shooting and emergency response but focuses primarily on the recovery process in the year that followed. In particular, it highlights the work of the Aurora Public Schools, which under the leadership of Superintendent John L. Barry, drew on years of emergency management training to play a substantial role in the response and then unveiled an expansive recovery plan. This included hiring a full-time disaster recovery coordinator, partnering with an array of community organizations, and holding mental health workshops and other events to support APS community members. The case also details the range of reactions that staff and community members had to APS' efforts, broader community-wide recovery efforts, and stakeholders' perspectives on the effectiveness of the recovery.

"Miracle on the Hudson" (A, B, and C) Case A describes how in January 2009, shortly after takeoff from LaGuardia Airport, US Airways Flight 1549 lost all power when Canada geese sucked into its engines destroyed them. In less than four harrowing minutes, Flight 1549’s captain and first officer had to decide whether they could make an emergency landing at a nearby airport or find another alternative to get the plane down safely. Cases B and C describe how emergency responders from many agencies and private organizations on both sides of the Hudson River – converging on the scene without a prior action plan for this type of emergency – effectively rescued passengers and crew from the downed plane.

Security Planning for the 2004 Democratic National Convention in  Boston (A, B, and Epilogue) When the city of Boston applied to host the 2004 Democratic Party presidential nominating convention, it hoped to gain considerable prestige and significant economic benefits. But convention organizers and local officials were forced to grapple with a set of unanticipated planning challenges that arose in the aftermath of the 9/11 terrorist attacks.  (Included in Howitt & Leonard, Managing Crises)

Command Performance: County Firefighters Take Charge of the 9/11 Pentagon Emergency This case describes how the Arlington County Fire Department – utilizing the Incident Management System – took charge of the large influx of emergency workers who arrived to put out a massive fire and rescue people in the Pentagon following the September 11, 2001, suicide jetliner attack.  (Included in Howitt & Leonard, Managing Crises)

Rudy Giuliani: The Man and His Moment Although not long before the September 11, 2001 terrorist attacks, New York Mayor Rudolph Giuliani had been under fire for aspects of his mayoralty, the post 9/11 Giuliani won national and international acclaim as a leader. This case recounts the details of Giuliani’s response such that students of effective public leadership can analyze both Giuliani’s decisions and style as examples.

Threat of Terrorism: Weighing Public Safety in Seattle (Case and Epilogue) When a terrorist was arrested in late December 1999 at the Canadian-Washington State border in a car laden with explosives, public safety officials worried that the city of Seattle had been a possible target. This case explores the debate that ensued concerning the seriousness of the threat and whether the city should proceed with its planned Millennium celebration.  (Included in Howitt & Leonard, Managing Crises)

Protecting the WTO Ministerial Conference of 1999 (Case and Epilogue) Two very different sets of actors made extensive preparations in advance of the World Trade Organization's Ministerial Conference of 1999 — protesters opposing international trade practices and public safety officials responsible for event security. This case examines the efforts of both, highlighting why security arrangements ultimately fell short.  (Included in Howitt & Leonard, Managing Crises)

The Shootings at Columbine High School: Responding to a New Kind of Terrorism (Case and Epilogue) Within minutes of the shootings at Columbine, numerous emergency response agencies – including law enforcement, fire fighters, emergency medical technicians, and others – dispatched personnel to the school site. Under intense media scrutiny and trying to coordinate their actions, they sought to determine whether the shooters were still active and rescue the injured.

To What End? Re-Thinking Terrorist Attack Exercises in San Jose (Case, Sequel 1, Sequel 2) In the late 1990s, a task force in San Jose, CA mounted several full-scale terrorist attack exercises, but—despite the best of intentions—found all of them frustrating, demoralizing, and divisive. In response, San Jose drew on several existing prototypes to create a new “facilitated exercise” model that emphasized teaching over testing, and was much better received by first responders.

Security Preparations for the 1996 Centennial Olympic Games (A, B, and C) This case describes efforts by state and federal government entities to plan in advance for security protection for the Atlanta Olympics. It also recounts the Centennial Park bombing and emergency response.  (Included in Howitt & Leonard, Managing Crises)

The Flawed Emergency Response to the 1992 Los Angeles Riots (A, B, and C) Following the announcement of the not guilty verdicts for the law enforcement officers accused of beating Rodney King, the City of Los Angeles was quickly overrun by severe rioting. This case reviews how local, county, state, and federal agencies responded and coordinated their activities in an effort to restore order.  (Included in Howitt & Leonard, Managing Crises)

Public Health Emergencies

Mission in Flux: Michigan National Guard in Liberia ( Case and Epilogue ) In summer and fall of 2014, thousands of individuals in Liberia, Sierra Leone, and Guinea contracted the Ebola virus. This outbreak of the deadly disease, which until then had been highly uncommon in West Africa, prompted a major (albeit delayed) public health response on the part of the international community, including an unprecedented commitment made by the United States, which sent almost 3,000 active military soldiers to Liberia. “Mission in Flux” focuses on the US military’s role in the Ebola response, emphasizing the Michigan National Guard’s eventual involvement. In particular, it provides readers with a first-hand account of the challenges the Michigan Guard faced as it prepared for and then deployed to Liberia, just as the crisis had begun to abate and federal officials in Washington began considering how to redefine the mission and footprint of Ebola-relief in West Africa. 

Fears and Realities: Managing Ebola in Dallas   ( Case   and  Epilogue ) “Fears and Realities” describes how public health authorities in Dallas, TX - along with their counterparts at the state and local levels, elected officials, and hospital administrators - responded to the first case of Ebola identified on U.S. soil during the 2014 outbreak of the disease. The hugely difficult tasks of treating the patient and mounting a response was made all the more challenging by confusion over the patient's background and travel history, and, eventually, by the intense focus and considerable concern on the part of the media and public at large. Efforts to curtail the spread of the disease were further complicated when two nurses who had cared for the patient also tested positive for Ebola, even though they apparently had followed CDC protocols when interacting with him. With three confirmed cases of the disease in Dallas – each patient with their own network of contacts – authorities scrambled to understand what was happening and to figure out a way to bring the crisis to an end before more people were exposed to the highly virulent disease.  (Included in Howitt, Leonard, and Giles, Public Health Preparedness)

Confronting a Pandemic in a Home Rule State: The Indiana State Department of Health Responds to H1N1 When Indiana State Health Commissioner Dr. Judy Monroe learned of the emergence of H1N1 in late April 2009, she had to quickly figure out how to coordinate an effective response within a highly balkanized public health system in which more than 90 local health departments wielded considerable autonomy. She would rely heavily on relationships she had worked hard to establish with local health officials upon becoming commissioner -- but she and her senior advisors would still have to scramble to find new ways to communicate and coordinate with their local partners.

On the Frontlines of a Pandemic: Texas Responds to 2009 Novel H1N1 Influenza A  As cases of a new strain of influenza strike in the spring of 2009, Texas, just over the border from the initial epicenter of the epidemic in Mexico, faces great uncertainty about the severity and extent of the epidemic. State officials, presiding over a highly decentralized public health and health care system and needing to work with school systems and other non-health actors, strive to improvise their response to reduce the spread of this disease, while providing anti-viral drugs and, ultimately, a new vaccine to its citizens. (Included in Howitt, Leonard, and Giles, Public Health Preparedness)

Tennessee Responds to the 2009 Novel H1N1 Influenza A Pandemic Tennessee, not so severely struck by H1N1 in the spring of 2009 as some other states, expects to encounter worse in the fall. Working through a hybrid state- and local government-run health system, as well as a network of privately run pharmacies, Tennessee officials mobilize to cope with the expected demand for anti-viral medications and to distribute an expected new vaccine. (Included in Howitt, Leonard, and Giles, Public Health Preparedness)

Harvard Encounters H1N1 In the spring of 2009, as the H1N1 epidemic was beginning to emerge, Harvard University’s medical, dental, and public health schools had to be shut down when a rash of cases and the possibility of widespread exposure emerged among the student body. The case tracks the decision-making by University officials as they cope with the uncertainties surrounding the outbreak of a potentially dangerous emergent infectious disease. (Included in Howitt, Leonard, and Giles, Public Health Preparedness)

Beijing’s Response to the 2009 H1N1 Pandemic In spring 2009, H1N1 emerged in North America and began to spread rapidly throughout the world. Municipal government officials in Beijing, China – who feared a repeat of their painful experience with SARS in 2003 – responded by conducting health screenings at the airport, quarantining people with flu-like symptoms, and scaling capacity at Beijing’s hospitals. The case describes Beijing’s expansive effort to combat H1N1 and is designed to teach students about Beijing’s government as well as China’s public health system.

Keeping an Open Mind in an Emergency: CDC Experiments with 'Team B'   ( Case   and  Epilogue ) In the early 2000s, the US Centers for Disease Control and Prevention (CDC) sought to adapt its protocols for coping with public health emergencies. This case examines the usefulness of one such method, "Team B," which was designed to provide the principal investigating team with alternative explanations for and approaches to the incident at hand.  (Included in Howitt & Leonard, Managing Crises; and Howitt, Leonard, and Giles, Public Health Preparedness)

X-Treme Planning: Ohio Prepares for Pandemic Flu With concern developing about the possibility of a worldwide pandemic of avian flu, the Ohio Department of Health developed plans for how it would handle such an emergency, while at the same time seeking to exercise its nascent incident management system and continue its efforts to develop as an emergency response agency. (Included in Howitt, Leonard, and Giles, Public Health Preparedness)

Emergency Response System Under Duress: Public Health Doctors Fight to Contain SARS in Toronto (A, B, and Epilogue) When an emergent infectious disease arrived in Toronto in 2003, the Canadian public health system struggled to bring it under control. This case explores the efforts of Canadian public health authorities to identify and understand the mysterious illness, which threatened the health — and lives — of Toronto’s residents and healthcare workers for months on end.  (Included in Howitt & Leonard, Managing Crises; and Howitt, Leonard, and Giles, Public Health Preparedness)

Hong Kong Copes with SARS, 2003: The Amoy Gardens (Case and Epilogue) In the last days of March 2003, the frightening new disease known as Severe Acute Respiratory Syndrome, or SARS, seemed to threaten to spread out of control in one of the world’s most densely-populated cities: Hong Kong. The SARS outbreak at Amoy Gardens became an exercise in crisis management for public health officials in Hong Kong—with their counterparts around the world either observing or actively advising.

When Prevention Can Kill: Minnesota and the Smallpox Vaccine Program (Case and Epilogue) Following the 2001 terrorist attacks, President Bush launched a program to vaccinate health workers and emergency responders against smallpox. This case describes that effort, placing particular emphasis on the difficulties that emerged in making that program work in Minnesota. (Included in Howitt, Leonard, and Giles, Public Health Preparedness)

Charting a Course in a Storm: US Postal Service and the Anthrax Crisis This case describes how the USPS responded when it was struck by devastating anthrax attacks through the mails. It covers the initial response to protect employees, efforts to keep the mails moving to the greatest extent possible, and early steps toward decontamination of facilities and recovery.  (Included in Howitt & Leonard, Managing Crises; and Howitt, Leonard, and Giles, Public Health Preparedness)

White Powders in Georgia: Responding to Cases of Suspected Anthrax After 9/11 Although no spore of real anthrax showed up in Georgia during the anthrax attack period, the state was inundated with thousands of calls about suspect white powders. The case describes efforts by local and state officials to develop appropriate procedures to triage and prioritize possible cases, conduct tests of possible anthrax, and protect and reassure worried first responders. (Included in Howitt, Leonard, and Giles, Public Health Preparedness)

The West Nile Virus Outbreak in New York City (A, B, and Sequel) Case A tells how in the summer of 1999 New York City public health officials discovered sentinel cases of a hitherto unknown disease and identified it with assistance from the state, CDC, veterinary pathologists at the Bronx Zoo, and university researchers. Case B and the Sequel describe how the city organized a massive mosquito spraying effort, first in a single borough and then citywide. (Included in Howitt, Leonard, and Giles, Public Health Preparedness)

Anthrax Threats in Southern California This case recounts how California officials responded (and over-responded) to an Anthrax hoax in late 1998, as well as how they then developed protocols of response and disseminated them to multiple jurisdictions. (Included in Howitt, Leonard, and Giles, Public Health Preparedness)

Coping with Crisis: Hong Kong Public Health Officials and the "Bird Flu"  In 1997, public health authorities in Hong Kong worked to identify and control a dangerous new flu virus not previously known to infect humans. The case focuses on the authorities' communication with the public, as they sought to quell public fears notwithstanding their own incomplete knowledge of the disease. The case, too, describes the crisis management decision to undertake a massive slaughter of Hong Kong chickens, once they were shown to be the host of the deadly but difficult-to-transmit virus.

The City of Chicago and the 1995 Heat Wave (A and B) During the summer of 1995, more than 700 people died of heat-related illness in Chicago, Illinois. With most deaths occurring before the city recognized that an “epidemic” was going on, this case explores the silent crisis that overtook the city. (Included in Howitt, Leonard, and Giles, Public Health Preparedness)

Case Examples

Examples of recommended interventions in the treatment of depression across the lifespan.

Children/Adolescents

A 15-year-old Puerto Rican female

The adolescent was previously diagnosed with major depressive disorder and treated intermittently with supportive psychotherapy and antidepressants. Her more recent episodes related to her parents’ marital problems and her academic/social difficulties at school. She was treated using cognitive-behavioral therapy (CBT).

Chafey, M.I.J., Bernal, G., & Rossello, J. (2009). Clinical Case Study: CBT for Depression in A Puerto Rican Adolescent. Challenges and Variability in Treatment Response. Depression and Anxiety , 26, 98-103.  https://doi.org/10.1002/da.20457

Sam, a 15-year-old adolescent

Sam was team captain of his soccer team, but an unexpected fight with another teammate prompted his parents to meet with a clinical psychologist. Sam was diagnosed with major depressive disorder after showing an increase in symptoms over the previous three months. Several recent challenges in his family and romantic life led the therapist to recommend interpersonal psychotherapy for adolescents (IPT-A).

Hall, E.B., & Mufson, L. (2009). Interpersonal Psychotherapy for Depressed Adolescents (IPT-A): A Case Illustration. Journal of Clinical Child & Adolescent Psychology, 38 (4), 582-593. https://doi.org/10.1080/15374410902976338

© Society of Clinical Child and Adolescent Psychology (Div. 53) APA, https://sccap53.org/, reprinted by permission of Taylor & Francis Ltd, http://www.tandfonline.com on behalf of the Society of Clinical Child and Adolescent Psychology (Div. 53) APA.

General Adults

Mark, a 43-year-old male

Mark had a history of depression and sought treatment after his second marriage ended. His depression was characterized as being “controlled by a pattern of interpersonal avoidance.” The behavior/activation therapist asked Mark to complete an activity record to help steer the treatment sessions.

Dimidjian, S., Martell, C.R., Addis, M.E., & Herman-Dunn, R. (2008). Chapter 8: Behavioral activation for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 343-362). New York: Guilford Press.

Reprinted with permission from Guilford Press.

Denise, a 59-year-old widow

Denise is described as having “nonchronic depression” which appeared most recently at the onset of her husband’s diagnosis with brain cancer. Her symptoms were loneliness, difficulty coping with daily life, and sadness. Treatment included filling out a weekly activity log and identifying/reconstructing automatic thoughts.

Young, J.E., Rygh, J.L., Weinberger, A.D., & Beck, A.T. (2008). Chapter 6: Cognitive therapy for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 278-287). New York, NY: Guilford Press.

Nancy, a 25-year-old single, white female

Nancy described herself as being “trapped by her relationships.” Her intake interview confirmed symptoms of major depressive disorder and the clinician recommended cognitive-behavioral therapy. 

Persons, J.B., Davidson, J. & Tompkins, M.A. (2001). A Case Example: Nancy. In Essential Components of Cognitive-Behavior Therapy For Depression (pp. 205-242). Washington, D.C.: American Psychological Association. http://dx.doi.org/10.1037/10389-007

While APA owns the rights to this text, some exhibits are property of the San Francisco Bay Area Center for Cognitive Therapy, which has granted the APA permission for use.

Luke, a 34-year-old male graduate student

Luke is described as having treatment-resistant depression and while not suicidal, hoped that a fatal illness would take his life or that he would just disappear. His treatment involved mindfulness-based cognitive therapy, which helps participants become aware of and recharacterize their overwhelming negative thoughts. It involves regular practice of mindfulness techniques and exercises as one component of therapy.

Sipe, W.E.B., & Eisendrath, S.J. (2014). Chapter 3 — Mindfulness-Based Cognitive Therapy For Treatment-Resistant Depression. In R.A. Baer (Ed.), Mindfulness-Based Treatment Approaches (2nd ed., pp. 66-70). San Diego: Academic Press.

Reprinted with permission from Elsevier.

Sara, a 35-year-old married female

Sara was referred to treatment after having a stillbirth. Sara showed symptoms of grief, or complicated bereavement, and was diagnosed with major depression, recurrent. The clinician recommended interpersonal psychotherapy (IPT) for a duration of 12 weeks.

Bleiberg, K.L., & Markowitz, J.C. (2008). Chapter 7: Interpersonal psychotherapy for depression. In D.H. Barlow (Ed.) Clinical handbook of psychological disorders: a treatment manual (4th ed., pp. 315-323). New York, NY: Guilford Press.

Peggy, a 52-year-old white, Italian-American widow

Peggy had a history of chronic depression, which flared during her husband’s illness and ultimate death. Guilt was a driving factor of her depressive symptoms, which lasted six months after his death. The clinician treated Peggy with psychodynamic therapy over a period of two years.

Bishop, J., & Lane , R.C. (2003). Psychodynamic Treatment of a Case of Grief Superimposed On Melancholia. Clinical Case Studies , 2(1), 3-19. https://doi.org/10.1177/1534650102239085

Several case examples of supportive therapy

Winston, A., Rosenthal, R.N., & Pinsker, H. (2004). Introduction to Supportive Psychotherapy . Arlington, VA : American Psychiatric Publishing.

Older Adults

Several case examples of interpersonal psychotherapy & pharmacotherapy

Miller, M. D., Wolfson, L., Frank, E., Cornes, C., Silberman, R., Ehrenpreis, L.…Reynolds, C. F., III. (1998). Using Interpersonal Psychotherapy (IPT) in a Combined Psychotherapy/Medication Research Protocol with Depressed Elders: A Descriptive Report With Case Vignettes. Journal of Psychotherapy Practice and Research , 7(1), 47-55.

Study Reveals Lack of Access as Root Cause for Mental Health Crisis in America

Mental health services in the U.S. are insufficient despite more than half of Americans (56%) seeking help. Limited options and long waits are the norm, but there are some bright spots, with 76% of Americans now seeing mental health as important as physical health.

Washington, D.C.

Today, Cohen Veterans Network (CVN), a national not-for-profit philanthropic organization, and National Council for Mental Wellbeing, the unifying voice of America’s health care organizations that delivers mental health and addiction treatment and services, issued the inaugural America’s Mental Health 2018 , a comprehensive study of access to mental health care, at the 2018 Cohen Veterans Care Summit in Washington D.C. The study, which assesses Americans’ current access to and attitudes towards mental health services, revealed American mental health services are insufficient, and despite high demand, the root of the problem is lack of access – or the ability to find care.

The study offers a comprehensive analysis of the state of mental health care in the U.S. It is comprised of a two-pronged research project that includes an online survey of 5,000 American adults, and a robust analysis of third-party data measuring patients’ access to mental health services in terms of four pillars – providers, facilities, funding and perceived satisfaction among patients.

“There is a mental health crisis in America. My experience establishing mental health clinics across the country, coupled with this study, shows that more needs to be done to give Americans much needed access to mental health services,” said Cohen Veterans Network President and Chief Executive Officer Dr. Anthony Hassan. “If we want to save lives, save families and save futures we must reimagine our behavioral health system and take concrete steps to improving consumers’ ability to find the care they need, when they need it, and on their terms.”

Despite Strong Demand for Mental Health Services, Common Barriers Remain

The demand for mental health services is stronger than ever, with nearly six in 10 (56%) Americans seeking or wanting to seek mental health services either for themselves or for a loved one. These individuals are skewing younger and are more likely to be of lower income and have a military background. The large majority of Americans (76%) also believe mental health is just as important as physical health.

“This study confirmed what we hear from our members every day, that individuals and families continue to struggle to find the help they desperately need,” said Linda Rosenberg, President and CEO of National Council for Mental Wellbeing. “Mental health and addiction providers need adequate funding to hire skilled staff, employ evidence-based practices and adopt innovative technologies – all of which will help us meet demand.”

Despite this strong demand and growing societal awareness of the importance of mental health in the U.S., the study revealed that the overwhelming majority of Americans (74%) do not believe such services are accessible for everyone, and about half (47%) believe options are limited.

These beliefs are driven by several perceived barriers in Americans’ ability to seek mental health treatment, including:

• High Cost and Insufficient Insurance Coverage : Forty-two percent of the population saw cost and poor insurance coverage as the top barriers for accessing mental health care. One in four (25%) Americans reported having to choose between getting mental health treatment and paying for daily necessities.

Several individuals blamed the U.S. government and insurers for not providing enough funding and support for access. Nearly one in five of Americans, or 17%, noted they have had to choose between getting treatment for a physical health condition and a mental health condition due to their insurance policy. The majority (64%) of Americans who have sought treatment believe the U.S. government needs to do more to improve mental health services.

• Limited Options and Long Waits : Access to face-to-face services is a higher priority for Americans seeking mental health treatment than access to medication. Ninety-six million Americans, or 38%, have had to wait longer than one week for mental health treatments. And nearly half of Americans, or 46%, have had to or know someone who has had to drive more than an hour roundtrip to seek treatment.

While most Americans have heard of telehealth as an option for treating mental health issues, only 7% have reported using it. When asked if they would be open to using it, almost half, or 45%, of Americans who have not already tried telehealth services said they would be open to the idea of trying a service to address a current or future mental health need.

• Lack of Awareness : While most Americans do try to seek out treatment, there also is a large portion of the population who have wanted to but did not seek treatment for themselves or loved ones (29%)– in part due to not knowing where to go if they needed this service. What’s more, fifty-three million American adults (21%) have wanted to see a professional but were unable to for reasons outside of their control.

Furthermore, younger Americans (i.e., Gen Z and Millennials) are less sure about resources for mental health services, compared to older generations. This younger generation was also more likely to find it too hard to figure out legitimate resources online. Instead, many turned to unreliable resources for information, including Facebook, YouTube and Twitter.

• Social Stigma: Nearly one-third of Americans, or 31%, have worried about others judging them when they told them they have sought mental health services, and over a fifth of the population, or 21%, have even lied to avoid telling people they were seeking mental health services. This stigma is particularly true for younger Americans, who are more likely to have worried about others judging them when they say they have sought mental health services (i.e. 49% Gen Z vs. 40% Millennials vs. 30% Gen X vs. 20% Boomers).

Stark Disparities in Accessibility at State and Income Levels

Based on the analysis of third-party data, states are struggling to keep up with demand due to lack of funding and facilities, and, to a lesser extent, providers. Texas, Wisconsin and Georgia ranked among the lowest in terms of lacking adequate number of providers, facilities and funding to support the states’ populations. Pennsylvania, New York and Minnesota ranked among the top.

There is also a large disparity in access to mental health care based on level of income and location. Individuals located in rural areas and of lower-income are less likely to say that mental health services are extremely accessible to them.

Compared to middle- and high-income households, low-income Americans are less likely to know where to go for treatment and more likely to use a community center verses a qualified mental health center. Of the Americans that have not sought mental health treatment, more than half, or 53%, were in low-income households.

In addition, compared to Americans living in urban and suburban areas, individuals living in rural areas are less likely to proactively seek mental health specialists they need, and instead go to their primary care doctor or community center for treatment. Rural Americans are also less accepting of mental health services and care.

The Path Forward

The Cohen Veterans Network and National Council for Mental Wellbeing believe that more must be done to improve access to care for everyday Americans. Specifically, younger Americans need more information on how and where to access care. There must also be a better understanding of the real cost of delivering mental health care and related reimbursement rates, which typically cover only a small portion of care. This is critical to help attract new providers into the field and more must be done to train and retain providers to help ensure people can get help when they need it. Finally, we must ensure standards of care are consistent through continued adoption of evidence-based practices.

For more information on the comprehensive study results and how CVN and National Council are working to address mental wellness and accessibly across the country, please visit www.cohenveteransnetwork.org/AmericasMentalHealth or www.TheNationalCouncil.org .

About America’s Mental Health 2018

Cohen Veterans Network and National Council for Mental Wellbeing partnered with Ketchum Analytics who conducted an online survey among 5,000 Americans, representative of the U.S. population based on age, gender, region, household income and race/ethnicity. The survey was conducted between July 31 – August 12, 2018, with a margin of error of +/- 1.38 at the 95% confidence level. Through the survey, the following groups were identified: veterans, active duty military and those with a secondary relationship with a veteran as well as those who have sought mental health treatment (Mental Health Treatment Seekers). A custom index was developed, ranking each state according to its mental health service access. Third-party data was gathered to determine access based on four pillars: providers, facilities, funding and satisfaction. Data was aggregated and averaged to each state, resulting in a score between 0 and 100, where 100 indicates the greatest access.

About Cohen Veterans Network

The Cohen Veterans Network (CVN) is a 501(c)(3) national not-for-profit philanthropic organization for post-9/11 veterans and their families. CVN focuses on improving mental health outcomes, with a goal to build a network of outpatient mental health clinics for veterans and their families in high-need communities, in which trained clinicians deliver holistic evidence-based care to treat mental health conditions. There are currently 10 Steven A. Cohen Military Family Clinics nationwide.

About The National Council

Founded in 1969, the National Council for Mental Wellbeing is a membership organization that drives policy and social change on behalf of over 3,400 mental health and substance use treatment organizations and the more than 10 million children, adults and families they serve. We advocate for policies to ensure equitable access to high-quality services. We build the capacity of mental health and substance use treatment organizations. And we promote greater understanding of mental wellbeing as a core component of comprehensive health and health care. Through our Mental Health First Aid (MHFA) program, we have trained more than 3 million people in the U.S. to identify, understand and respond to signs and symptoms of mental health and substance use challenges.

Media Contact

Sophia Majlessi [email protected] 202-621-1631

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Living Better

The truth about teens, social media and the mental health crisis.

Michaeleen Doucleff

For years, the research picture on how social media affects teen mental health has been murky. That is changing as scientists find new tools to answer the question. Olivier Douliery/AFP via Getty Images hide caption

For years, the research picture on how social media affects teen mental health has been murky. That is changing as scientists find new tools to answer the question.

Back in 2017, psychologist Jean Twenge set off a firestorm in the field of psychology.

Twenge studies generational trends at San Diego State University. When she looked at mental health metrics for teenagers around 2012, what she saw shocked her. "In all my analyses of generational data — some reaching back to the 1930s — I had never seen anything like it," Twenge wrote in the Atlantic in 2017.

Twenge warned of a mental health crisis on the horizon. Rates of depression, anxiety and loneliness were rising. And she had a hypothesis for the cause: smartphones and all the social media that comes along with them. "Smartphones were used by the majority of Americans around 2012, and that's the same time loneliness increases. That's very suspicious," Twenge told NPR in 2017.

But many of her colleagues were skeptical. Some even accused her of inciting a panic with too little — and too weak — data to back her claims.

Now, six years later, Twenge is back. She has a new book out this week, called Generations , with much more data backing her hypothesis. At the same time, several high-quality studies have begun to answer critical questions, such as does social media cause teens to become depressed and is it a key contributor to a rise in depression?

In particular, studies from three different types of experiments, altogether, point in the same direction. "Indeed, I think the picture is getting more and more consistent," says economist Alexey Makarin , at the Massachusetts Institute of Technology.

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In Generations , Twenge analyzes mental health trends for five age groups, from the Silent Generation, who were born between 1925 and 1945, to Gen Z, who were born between 1995 and 2012. She shows definitively that "the way teens spend their time outside of school fundamentally changed in 2012," as Twenge writes in the book.

Take for instance, hanging out with friends, in person. Since 1976, the number of times per week teens go out with friends — and without their parents — held basically steady for nearly 30 years. In 2004, it slid a bit. Then in 2010, it nosedived.

"It was just like a Black Diamond ski slope straight down," Twenge tells NPR. "So these really big changes occur."

At the same time, around 2012, time on social media began to soar. In 2009, only about half of teens used social media every day, Twenge reports. In 2017, 85% used it daily. By 2022, 95% of teens said they use some social media, and about a third say they use it constantly, a poll from Pew Research Center found .

"Now, in the most recent data, 22% of 10th grade girls spend seven or more hours a day on social media," Twenge says, which means many teenage girls are doing little else than sleeping, going to school and engaging with social media.

Not surprisingly, all this screen time has cut into many kids' sleep time. Between 2010 and 2021, the percentage of 10th and 12th graders who slept seven or fewer hours each night rose from a third to nearly one-half. "That's a big jump," Twenge says. "Kids in that age group are supposed to sleep nine hours a night. So less than seven hours is a really serious problem."

Teen girls and LGBTQ+ youth plagued by violence and trauma, survey says

On its own, sleep deprivation can cause mental health issues. "Sleep is absolutely crucial for physical health and for mental health. Not getting enough sleep is a major risk factor for anxiety and depression and self-harm," she explains. Unfortunately, all of those mental health problems have continued to rise since Twenge first sounded the alarm six years ago.

"Nuclear bomb" on teen social life

"Every indicator of mental health and psychological well-being has become more negative among teens and young adults since 2012," Twenge writes in Generations . "The trends are stunning in their consistency, breadth and size."

Across the board, since 2010, anxiety, depression and loneliness have all increased . "And it's not just symptoms that rose, but also behaviors," she says, "including emergency room visits for self-harm, for suicide attempts and completed suicides." The data goes up through 2019, so it doesn't include changes due to COVID-19.

All these rapid changes coincide with what, Twenge says, may be the most rapid uptake in a new technology in human history: the incorporation of smartphones into our lives, which has allowed nearly nonstop engagement with social media apps. Apple introduced the first iPhones in 2007, and by 2012, about 50% of American adults owned a smartphone, the Pew Research Center found .

The timing is hard to ignore, says data scientist Chris Said , who has a Ph.D. in psychology from Princeton University and has worked at Facebook and Twitter. "Social media was like a nuclear bomb on teen social life," he says. "I don't think there's anything in recent memory, or even distant history, that has changed the way teens socialize as much as social media."

Murky picture becomes clearer on causes of teen depression

But the timing doesn't tell you whether social media actually causes depression in teens.

In the past decade, scientists have published a whole slew of studies trying to answer this question, and those studies sparked intense debate among scientists and in the media. But, Said says, what many people don't realize is scientists weren't using — or didn't even have — the proper tools to answer the question. "This is a very hard problem to study," he says. "The data they were analyzing couldn't really solve the problem."

Mental Health

The mental health of teen girls and lgbtq+ teens has worsened since 2011.

So the findings have been all over the place. They've been murky, noisy, inconclusive and confusing. "When you use tools that can't fully answer the question, you're going to get weak answers," he says. "So I think that's one reason why really strong evidence didn't show up in the data, at least early on."

On top of it, psychology has a bad track record in this field, Said points out. For nearly a century, psychologists have repeatedly blamed new technologies for mental and physical health problems of children, even when they've had little — or shady — data to back up their claims.

For example, in the 1940s, psychologists worried that children were becoming addicted to radio crime dramas, psychologist Amy Orben at the University of Cambridge explains in her doctoral thesis. After that, they raised concerns about comic books, television and — eventually — video games. Thus, many researchers worried that social media may simply be the newest scapegoat for children's mental health issues.

A handful of scientists, including MIT's Alexey Makarin, noticed this problem with the data, the tools and the field's past failures, and so they took the matter into their own hands. They went out and found better tools.

Hundreds of thousands of more college students depressed

Over the past few years, several high-quality studies have come that can directly test whether social media causes depression. Instead of being murky and mixed, they support each other and show clear effects of social media. "The body of literature seems to suggest that indeed, social media has negative effects on mental health, especially on young adults' mental health," says Makarin, who led what many scientists say is the best study on the topic to date.

In that study, Makarin and his team took advantage of a once-in-a-lifetime opportunity: the staggered introduction of Facebook across U.S. colleges from 2004 to 2006. Facebook rolled out into society first on college campuses, but not all campuses introduced Facebook at the same time.

For Makarin and his colleagues, this staggered rollout is experimental gold.

"It allowed us to compare students' mental health between colleges where Facebook just arrived to colleges where Facebook had not yet arrived," he says. They could also measure how students' mental health shifted on a particular campus when people started to spend a bunch of their time on social media.

Luckily, his team could track mental health at the time because college administrators were also conducting a national survey that asked students an array of questions about their mental health, including diagnoses, therapies and medications for depression, anxiety and eating disorders. "These are not just people's feelings," Makarin says. "These are actual conditions that people have to report."

They had data on a large number of students. "The data comes from more than 350,000 student responses across more than 300 colleges," Makarin says.

This type of study is called a quasi-experiment, and it allows scientists to estimate how much social media actually changes teens' mental health, or as Makarin says, "We can get causal estimates of the impact of Facebook on mental health."

So what happened? "Almost immediately after Facebook arrives on campus, we see an uptick in mental health issues that students report," Makarin says. "We especially find an impact on depression rates, anxiety disorders and other questions associated with depression in general."

And the effect isn't small, he says. Across the population, the rollout of Facebook caused about 2% of college students to become clinically depressed. That may sound modest, but with more than 17 million college students in the U.S. at the time, that means Facebook caused more than 300,000 young adults to suffer from depression.

For an individual, on average, engaging with Facebook decreases their mental health by roughly 22% of the effect of losing one's job, as reported by a previous meta-analysis, Makarin and his team found.

Facebook's rollout had a larger effect on women's mental health than on men's mental health, the study showed. But the difference was small, Makarin says.

He and his colleagues published their findings last November in the American Economic Review . "I love that paper," says economist Matthew Gentzkow at Stanford University, who was not involved in the research. "It's probably the most convincing study I've seen. I think it shows a clear effect, and it's really credible. They did a good job of isolating the effect of Facebook, which isn't easy."

Of course, the study has limitations, Gentzkow says. First off, it's Facebook, which teens are using less and less. And the version of Facebook is barebones. In 2006, the platform didn't have a "like" button" or a "newsfeed." This older version probably wasn't as "potent" as social media now, says data scientist Chris Said. Furthermore, students used the platform only on a computer because smartphones weren't available yet. And the study only examined mental health impacts over a six-month period.

Nevertheless, the findings in this study bolster other recent studies, including one that Gentzkow led.

Social media is "like the ocean" for kids

Back in 2018, Gentzkow and his team recruited about 2,700 Facebook users ages 18 or over. They paid about half of them to deactivate their Facebook accounts for four weeks. Then Gentzkow and his team looked to see how a Facebook break shifted their mental health. They reported their findings in March 2020 in the American Economic Review.

This type of study is called a randomized experiment, and it's thought of as the best way to estimate whether a variable in life causes a particular problem. But with social media, these randomized experiments have big limitations. For one, the experiments are short-term — here only four weeks. Also, people use social media in clusters, not as individuals. So having individuals quit Facebook won't capture the effect of having an entire social group quit together. Both of these limitations could underestimate the impact of social media on an individual and community.

Nevertheless, Gentzkow could see how deactivating Facebook made people, on average, feel better. "Being off Facebook was positive across well-being outcomes," he says. "You see higher happiness, life satisfaction, and also lower depression, lower anxiety, and maybe a little bit lower loneliness."

Gentzkow and his team measured participants' well-being by giving them a survey at the end of the experiment but also asking questions, via text message, through the experiment. "For example, we sent people text messages that say, 'Right now, would you say you're feeling happy or not happy,'" he explains.

Again, as with Makarin's experiment, the effect was moderate. Gentzkow and his colleagues estimate that temporarily quitting Facebook improves a person's mental health by about 30% of the positive effect seen by going to therapy. "You could view that meaning these effects are pretty big," he explains, "or you could also see that as meaning that the effects of therapy are somewhat small. And I think both of those things are true to an extent."

Scientists still don't know to what extent social media is behind the rising mental health issues among teenagers and whether it is the primary cause. "It seems to be the case — like it's a big factor," says MIT's Alexey Makarin, "but that's still up for debate."

Still, though, other specifics are beginning to crystallize. Scientists are narrowing in on what aspects of social media are most problematic. And they can see that social media won't hurt every teen — or hurt them by the same amount. The data suggests that the more hours a child devotes to social media, the higher their risk for mental health problems.

Finally, some adolescents are likely more vulnerable to social media, and children may be more vulnerable at particular ages. A study published in February 2022 looked to see how time spent on social media varies with life satisfaction during different times in a child's life (see the graphic).

The researchers also looked to see if a child's present use of social media predicted a decrease of life satisfaction one year later. That data suggests two windows of time when children are most sensitive to detrimental effects of social media, especially heavy use of it. For girls, one window occurs at ages 11 through 13. And for boys, one window occurs at ages 14 and 15. For both genders, there's a window of sensitivity around age 19 — or near the time teenagers enter college. Amy Orben and her team at the University of Cambridge reported the findings in Nature Communications .

This type of evidence is known as a correlative. "It's hard to draw conclusions from these studies," Gentzkow says, because many factors contribute to life satisfaction, such as environmental factors and family backgrounds. Plus, people may use social media because they're depressed (and so depression could be the cause, not the outcome of social media use).

"Nevertheless, these correlative studies, together with the evidence from the causal experiments, paint a picture that suggests we should take social media seriously and be concerned," Gentzkow adds.

Psychologist Orben once heard a metaphor that may help parents understand how to approach this new technology. Social media for children is a bit like the ocean, she says, noting that it can be an extremely dangerous place for children. Before parents let children swim in any open water, they make sure the child is well-prepared and equipped to handle problems that arise. They provide safety vests, swimming lessons, often in less dangerous waters, and even then parents provide a huge amount of supervision.

Alyson Hurt created the graphic. Jane Greenhalgh and Diane Webber edited the story.

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Short stay unit for patients in acute mental health crisis: A case-control study of readmission rates

Affiliations.

• 1 Mental Health and Specialist Services, Gold Coast Hospital and Health Service, Southport, Queensland, Australia.
• 2 Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia.
• PMID: 31883230
• DOI: 10.1111/appy.12376

Introduction: Past evaluations of psychiatric short stay units have shown positive outcomes for patients, yet very little is known about the factors related to readmissions.

Methods: A Short Stay Pathway (SSP) has been introduced on the Gold Coast, Australia, for patients in acute mental health crisis with admissions of up to 3 days. Rates of readmissions within 28 days were compared for SSP patients (N = 678), and a diagnosis-matched control group of patients from acute mental health beds (N = 1356). Demographic and clinical factors were considered as predictors of subsequent readmissions.

Results: Average length of stay for SSP patients was 3.4 days, compared to 7.6 days in the control group. 10.6% of SSP patients and 18.4% of the control group were readmitted within 28 days (P < .001). For both groups, a 7-day follow up significantly reduced readmissions (P < .05). Indigenous patients on SSP had higher odds of readmissions than non-Indigenous patients (P < .05), and a diagnosis of a personality disorder increased readmission in the control group but not the SSP group (P < .001).

Discussion: SSP reduced repeated hospitalizations for patients in acute crisis by 42%. An identification of factors related to future admissions can inform future tailoring of this model of care to subgroups of patients.

Keywords: hospitalization; length of stay; mental health; patient readmission; psychiatry.

© 2019 John Wiley & Sons, Ltd.

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The Burden of Loss: Unexpected death of a loved one and psychiatric disorders across the life course in a national study

Katherine m. keyes.

1 Department of Epidemiology, Columbia University, New York, NY, USA.

Charissa Pratt

Sandro galea, katie a. mclaughlin.

2 Division of General Pediatrics, Department of Psychiatry, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA.

Karestan C. Koenen

M. katherine shear.

3 School of Social Work, Columbia University, New York, NY, USA.

Associated Data

Unexpected death of a loved one is common and associated with subsequent elevations in symptoms of multiple forms of psychopathology. Determining whether this experience predicts novel onset of psychiatric disorders and whether these associations vary across the life course has important clinical implications.

To examine associations of a loved one’s unexpected death with first onset of common anxiety, mood, and substance disorders in a population-based sample.

Relation between unexpected death and first onset of lifetime DSM-IV disorders estimated using a structured interview of adults in the US general population (analytic sample size=27,534). Models controlled for prior occurrence of any disorder, other traumatic event experiences, and demographics.

Unexpected death was the most common traumatic experience and most likely to be rated as the respondent’s worst, regardless of other traumatic experiences. Increased incidence after unexpected death was observed at every point across the life course for major depressive episodes, panic disorder, and post-traumatic stress disorder. Increased incidence was clustered in later adult age groups for manic episodes, phobias, alcohol disorders, and generalized anxiety disorder.

Conclusions

The bereavement period is associated with elevated risk for the onset of multiple psychiatric disorders, consistently across the life course and coincident with the experience of the loved one’s death. Novel associations between unexpected death and onset of several disorders, including mania, confirm multiple case reports and small studies, and suggest an important emerging area for clinical research and practice.

Introduction

Population-based studies in the US show that unexpected death of a loved one is the most frequently reported potentially traumatic experiences ( 1 , 2 ) making mental health consequences of unexpected death an important public health concern. Loss of a close relationship through death, especially one that is unexpected ( 3 ), is a stressful life event for both children and adults that is associated with the development of psychiatric disorders ( 4 – 7 ). Given the central role of close relationships through the life course ( 8 ), loss of close relationships is unique among stressful experiences. Close relationships influence a wide range of physical, cognitive, and emotional processes in everyday life ( 9 ). They can contribute importantly to a sense of identity and are often intertwined in a person’s self-concept, and as such, the death of a close loved one has unique psychological sequalae.

Although any death of a loved one can be emotionally devastating, unexpected deaths provoke especially strong responses, as there is less time to prepare for and adapt to the death ( 10 – 12 ). Throughout the lifespan, unexpected death of a loved one is associated with the development of depression and anxiety symptoms, substance use, as well as other psychiatric disorders ( 3 , 13 , 14 ) and heightened risk for prolonged grief reactions ( 15 ), Despite this evidence that death of a loved one is associated with common psychiatric disorders and substance use, however, the impact of unexpected death in the general population remains understudied. Central unresolved issues regarding the association between unexpected death and psychiatric morbidity include whether certain disorders are more likely than others to occur in the wake of a loved one’s death, whether death has different associations with mental disorders at different points across the life course, and whether a greater number of unexpected death experiences are associated with greater psychiatric disorder episodes. Studies to date have predominately examined death occurring in discrete developmental periods, such as early (e.g., ( 16 )) or late childhood (e.g., ( 6 )) or older adulthood (e.g., ( 3 , 7 )), yet traumatic experiences can have differential effects across developmental periods ( 17 ). Existing studies have considered a limited set of psychiatric outcomes, and outcomes such as mania have been rarely considered in population-based studies despite numerous case reports of onset during acute bereavement ( 18 – 26 ). Finally, it remains unclear whether a greater number of unexpected death experiences are associated with a greater number of psychiatric disorder episodes, or whether individuals become inoculated to the adverse effects of a loved one’s death after many experiences of loss. Given the high prevalence of unexpected death experiences in the population, greater knowledge of the nature, magnitude, and breadth of psychiatric outcomes is necessary.

The present study uses U.S. population-based data to examine the association of unexpected death of a loved one with onset of mood, anxiety, and alcohol use disorders. Unexpected death is ascertained in this study by self-report regarding whether someone very close to the respondent died unexpectedly, such as an accident or terrorist attack, murder, suicide, or through an acute medical condition such as a heart attack. We examine how the association between unexpected death and onset of common psychiatric disorders varies across different stages of the life course. Finally, we examine how the experience of multiple loved ones dying unexpectedly is associated with the number of psychiatric disorder episodes experienced across the life course.

Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, a face-to-face survey of non-institutionalized adults living in households and group quarters. There were two points of data collection: 2001–2001 (N=43,093) and 2004–2005 (N=34,653) (cumulative response rate: 70.2%); we include individuals who participated in the second wave, as lifetime unexpected death, other potentially traumatic experiences, and PTSD were assessed only at the second wave. We removed individuals from analysis for whom the worst traumatic event was related to 9/11 (see below) except if a loved one died, thus the total sample for the present analysis was 27,534. Sample demographics and distributions of study variables are provided in Online Tables 1 and 2

Potentially traumatic experiences

We considered exposure to unexpected death based on two questions: “Did someone very close to you ever die in a terrorist attack”, and “Not counting a terrorist attack, did someone very close to you ever die unexpectedly, for example, they were killed in an accident, murdered, committed suicide, or had a fatal heart attack?” Follow-up questions assessed the age of first exposure, the total number of exposures, and age of most recent exposure. The age of first unexpected death experience was on average 19.3 years prior to the time of the survey (SD=2.3, interquartile range 6–30). Other potentially traumatic experiences included interpersonal violence (e.g., rape, physical assault), accidents and injuries (e.g., auto accidents), network events (e.g., traumatic event to a loved one), and witnessing events (e.g., observing death or serious injury). Respondents were also asked to identify the experience that they considered to be the worst potentially traumatic experience. For the purpose of this study, respondents who endorsed any potentially traumatic experience other than unexpected death of a loved one are described as reporting “other potentially traumatic experiences.”

Other than death of a loved one during the terrorist attack on September 11, 2001 (9/11), we did not include other experiences related to 9/11 in our count of potentially traumatic experiences, as one-time large-scale traumatic experiences such as 9/11 can distort examinations of more general, ongoing traumatic experiences ( 27 ). For example, 76.5% of the sample reported indirect exposure to 9/11 (e.g., watching TV reports of the events), and 22.2% of the sample reported indirect exposure to 9/11 as their worst experience. Individuals for whom exposure to 9/11 was the worst traumatic event experienced were removed from the analysis.

Psychiatric disorders

The onset of nine lifetime DSM-IV mood, anxiety and alcohol use disorders was assessed by lay interviewers using the Alcohol Use Disorder and Associated Disabilities Interview, Schedule IV ( 28 – 30 ). Respondents who endorsed lifetime criteria for a disorder were asked to estimate age of onset of the first episode, the number of episodes, and the age of the most recent episode. Because age of each episode was not assessed, we focused on estimating risk of first episode onset by age.

Mood disorders included major depressive episode, dysthymia, and manic episodes. As per DSM-IV, major depressive episodes were diagnosed only if the respondent reported that symptoms did not occur within two months of a loved one’s death. Anxiety disorders included panic disorder (with or without agoraphobia), social phobia, specific phobia, generalized anxiety disorder, and PTSD. Alcohol use disorders included DSM-IV alcohol abuse or dependence. Test-retest reliability for these diagnoses range from fair (κ=0.42, panic disorder) to excellent (κ=0.84, alcohol dependence) ( 28 – 30 ). These estimates are similar to other large-scale psychiatric epidemiological surveys using lay-administered instruments ( 31 , 32 ).

For each disorder, among those with a diagnosis, respondents reported the age of onset of symptoms, and the number of distinct periods in which they experienced symptoms of the disorder. The average number of years between the age of the time of the survey and the age of reported onset of disorder symptoms ranged from 10.9 years (manic episodes) to 27.5 years (specific phobia). Clear instructions were given to instructed respondents to count disorder episodes that were separated by periods of improvement. A total count of the number of episodes of each disorder was created, as well as the total number of episodes of all psychiatric disorders for those with multiple disorders.

Socio-demographic Factors

Socio-demographic factors included as covariates included sex, race/ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian or Pacific Islander, non-Hispanic Native American or Alaska Native, and Hispanic), marital status (never married, widowed/separated/divorced, married), personal income at the time of interview (<$19,999, $20–$34,999, $35–$69,999, $70,000+), and highest level of completed education (less than high school, high school, or more than high school).

Statistical analysis

First, we examined the proportion of respondents who reported unexpected death of a loved one as their worst stressful experience, as a function of exposure to other potentially traumatic experiences. Second, we examined the association between timing of earliest unexpected death and first onset of each disorder. We grouped age into 5-year intervals ranging from age 5 to 69 years and 70+. We used a series of conditional logistic regressions to estimate the incidence of disorder at each five-year age interval, conditional on never having experienced the disorder at a prior age interval, as a function of exposure to the first unexpected death at the same age interval relative to those who did not experience unexpected death during that interval. Respondents for whom the age of onset of the focal psychiatric disorder was prior to first age of unexpected death were excluded from the analysis for that disorder. Models controlled for socio-demographic variables, onset of any disorder that was not the focal outcome of that model prior to the first experience of unexpected death, and number of lifetime potentially traumatic experiences (0, 1–2, 3–4, 5+). Sensitivity analyses explored the potential for retrospective reporting biases by limiting the sample to those who experienced their first unexpected death within 10 years of the interview (removing 8,218 individuals from the analysis). Finally, we examined how multiple deaths of loved ones contributes to the number of psychiatric disorder episodes experienced across the life course. Based on preliminary analyses, we divided the number of unexpected death experiences into four categories: 0 deaths (n=13,478), 1 death (n=7,872), 2–3 deaths (n=3,936), and 4+ deaths (n=1,949). We used Poisson regression with the count of episodes as the outcome after creating a sum of all episodes across mood, anxiety and alcohol use disorders (median=4.0 episodes). All analyses were conducted using SAS-callable SUDAAN software.

Experiences of unexpected death, other potentially traumatic events, and lifetime prevalence of psychiatric disorders

Respondent demographics are included in Online Table 1 . A total of 50.3% of respondents reported ever experiencing the unexpected death of a loved one (see Online Table 2 ). Exposure to other potentially trauma experiences ranged from 16.5% with no reported exposure to 15.7% with exposure to five or more events. The most common lifetime psychiatric disorder was alcohol use disorders (35.9%) and major depressive episode (23.7%), with mean age of onset 28.6 and 32.8 years, respectively. Lifetime prevalence estimates of psychiatric disorders are higher than in previous reports (e.g., ( 33 )), due to removal of individuals for whom the worst potentially traumatic experience was related to 9/11.

Worst experience: unexpected death compared to other potentially traumatic experiences

The proportion of individuals who report unexpected death as their worst experience across levels of total lifetime experiences is shown in Table 1 . Among those with at least four potentially traumatic experiences, more than 30% reported that unexpected death of a loved one was the worst event that they experienced. Among those with at least 5 and upwards of at least 11 potentially traumatic experiences, more than 20% reported unexpected death of a loved one as worst. A higher proportion reported unexpected death as their worst experience than for any other traumatic experience assessed in the survey, at every level of exposure (data not shown, available upon request).

Proportion of respondents reporting unexpected death of a loved one as the worst potentially traumatic experience in their lifetime

Incidence of mood, anxiety and alcohol use disorders in the context of unexpected death

Table 2 shows the conditional adjusted odds of disorder onset at each age, comparing those experiencing their first unexpected death experience at that age to those who did not experience unexpected death at that age. Incidence proportions and sample sizes that form the basis of comparison for each age group and each disorder are given in Online Table 3 .

Association between age of first unexpected death of a loved one and onset of major depressive episode, dysthymia, manic episode, and alcohol disorder compared with those who did not experience unexpected death of a loved one (N=27,534).

As shown in Table 2 , unexpected death was associated with increased odds of each mood and alcohol use disorder examined in at least one age group, with significant associations tending to cluster in older age groups. Increased odds of major depressive episodes were observed in 12 of 14 age groups, dysthymia in 6 age groups, manic episodes in 5 age groups, and alcohol disorders in the six age groups occurring after age 45.

Table 3 shows associations between age of first unexpected death experience and onset of anxiety disorders. Of the 14 age groups tested, odds of disorder onset was heightened in all 14 age groups for PTSD, 13 age groups for panic disorder, 7 age groups for generalized anxiety disorder (all after age 40), 5 age groups for specific phobia (all after age 40), and age groups for social phobia.

Association between age of first unexpected death of a loved one and onset of generalized anxiety disorder, PTSD, social phobia, specific phobia, and panic disorder compared with those who did not experience unexpected death of a loved one (N=27,534).

To assess the role of reporting bias in these associations, we conducted a sensitivity analysis by removing 8,218 individuals who reported their first unexpected death experience more than 10 years before the time of the survey. Results are shown in Online Table 4 . We could not estimate incidence for age 5–9, though for other age groups, results were robust and stronger associations were often observed compared with the results from the total sample.

Age-of-onset distributions for each disorder by age of first unexpected death experience

In the online supplementary figures , we show the proportion of respondents with a given psychiatric disorder onset at each age interval separately for respondents with no unexpected death experiences and for those with an experience at that same age interval. That is, among those who had a lifetime diagnosis of PTSD ( eFigure 1 ), for example, we show the proportion with onset at age 5–9, 10–14, 15–19, etc., among those with the first unexpected death of a loved one at age 5–9. We then show the distribution of onset by age among those with an unexpected death at age 10–14, and then the distribution among those with an unexpected death at age 15–19, continuing through age 70+. We also show the distribution among those with no unexpected death experience. We show these age-of-onset distributions for dysthymia ( efigure 2 ), depressive episode ( efigure 3 ), manic episodes ( efigure 4 ), panic disorder ( efigure 5 ), generalized anxiety disorder ( efigure 6 ), alcohol disorders ( efigure 7 ), social phobia ( efigure 8 ), and specific phobia ( efigure 9 ). For most disorders, a marked increase was observed in onset frequency in the time period during which the unexpected death occurred, with the exception of social and specific phobia for which little association with unexpected death was observed.

Associations between number of unexpected death experiences and number of episodes of psychiatric disorders

Table 4 shows the associations between number of unexpected deaths and number of episodes of each psychiatric disorder as well as total number of psychiatric disorder episodes across all disorders. Increasing exposure to unexpected death was associated with a monotonic increase in number of total psychiatric disorder episodes. Compared to those with no unexpected deaths, individuals with 1, 2–3, and 4+ deaths had 1.18 (95% C.I. 1.09–1.72), 1.25 (95% C.I. 1.12–1.41), and 1.72 (95% C.I. 1.44–2.04) times the number of total psychiatric disorder episodes, based on a Poisson distribution. When examined separately for each disorder, increases in episode frequency were particularly notable for major depression and PTSD episodes (see Table 4 ).

Association between number of unexpected deaths of loved ones and number of episodes of psychiatric disorders (N=27,534).

Unexpected death of a loved one is most frequently cited as the most severe potentially traumatic experience in one’s life, even among individuals with a high burden of lifetime stressful experiences. Unexpected death is associated with heightened vulnerability for onset of virtually all commonly occurring psychiatric disorders that we assessed. This heightened incidence risk is observable from childhood through late adulthood for major depression, PTSD, and panic disorder, and is particularly concentrated in older age groups for manic episodes, phobias, and alcohol use disorders. However, it is also notable that the majority of individuals in the present study did not have the onset of any disorder in the wake of unexpected death of a loved one.

There are several pathways through which experiencing a loved one’s death may influence psychiatric disorders. Bereavement is a major life stressor, and stressful life experiences in general are associated with later onset of many physical and mental disorders ( 34 – 36 ). A variety of cognitive, affective, and neurobiological mechanisms linking stress exposure to the onset of mental disorders have been identified ( 37 ) and work in this area in relation to death of a loved one is ongoing ( 11 ). There may also be mechanisms associated specifically with the consequences of bereavement, given that attachment relationships play a critical role in human experience ( 9 ). Available evidence indicates that lack of social support is an important predictor of depression ( 38 ); sudden loss of social support may thus engender increased psychiatric sequelae. Further, evidence indicates that bereavement following hospitalization of a loved one in an Intensive Care Unit has significant effects on a wide range of psychological and biological measures ( 39 ). Loss of a romantic partner regularly engenders separation distress, with yearning and longing for the loved one, disruption of self concept (e.g. ( 40 )) and these could potentially trigger the onset of a mood or anxiety disorder. Among children, in particular, the death of an attachment figure can have important maladaptive consequences ( 41 ). Sudden death of a loved one might therefore have consequences specific to attachment loss as well as those explainable by stress mechanisms. Death is the most obviously permanent and extreme form of loss, and sudden death is one of the more difficult forms of bereavement. It remains to be seen whether and how other types of loss, e.g. abandonment, incarceration, separation, deportation, might be similar or different from the response to sudden death. Moreover, several important time-varying constructs such as attachment loss, disruption of sense of self, loss of social support and stress reactivity likely interact to impact mental health and well-being; future research could be enhanced by explanatory models to guide us in understanding and testing intersecting associations among these important relationship-centered experiences.

We observed heightened risk for onset of a range of mood, anxiety and alcohol use disorders after the unexpected death of a loved one all along the life course. Previous research in children ( 6 ), widows ( 7 ), survivors of disasters ( 42 ), and older adults ( 43 ) suggests that the risk of depression and PTSD is elevated following the death of a loved one. However, the association between unexpected death and a range of psychiatric disorders across the life course has not previously been examined using population-based data. We found robust and pervasive associations between unexpected death and other mood and anxiety disorders as well as alcohol use disorders, with many of these associations clustered among those in older age groups. First incidence of a psychiatric disorder is relatively rare in old age compared with younger ages; these data indicate that psychiatric disorder onset in older age is commonly concomitant with the death of a loved one. The underlying developmental mechanisms that underlie this clustering of risk at older ages are an important area for future research. However, we note that unexpected death was associated consistently with elevated odds of new onsets of PTSD, panic disorder, and depressive episodes at all stages of the life course. It is particularly notable that these pervasive associations between unexpected death and onset of specific disorders are maintained even after adjustment for psychiatric comorbidity.

The present study also provides novel data supporting an association between unexpected death and onset of manic episodes in a general population sample across the life course. An increase in risk of manic episodes after death of a loved one has been suggested by a number of case reports ( 18 – 26 ), and a study based on the Danish psychiatric register found that suicide of a mother or sibling was strongly associated with increased risk for mania/mixed episodes ( 44 ). Our results suggest that unexpected death of a loved one may be a substantial risk factor for the onset of a manic episode, especially among older adults, and even among those with no prior history of mood, anxiety, or alcohol disorders. The observation of mania in response to traumatic events has been discussed in the literature for over a century ( 45 ), yet the specific mechanisms for this association remains unclear. Our findings should alert clinicians to the possible onset of mania after an unexpected death in otherwise healthy individuals.

We further document that the number of lifetime episodes of mood, anxiety, alcohol disorders increases as the number of unexpected deaths experiences increases. This suggests that prior unexpected death experiences do not offer protection from mental health problems following a later unexpected death experience; rather, each unexpected death experience is associated with similar elevations in risk for novel onsets of mood, anxiety, and alcohol disorder episodes ( 46 ).

We note several limitations to the present study that should be addressed in future research. Grief symptoms ( 47 ) were not assessed in the National Epidemiologic Survey on Alcohol and Related Conditions. A loved one’s death typically evokes a recognizable grief reaction, characterized by yearning and longing, intense sorrow and emotional pain, preoccupation with thoughts and memories of the deceased, a sense of disconnection from ongoing life, and disturbance of self concept and sense of self ( 8 , 47 ). Grief can resemble major depression and PTSD ( 48 ), and it is now clear that some bereaved individuals develop aberrant grief reactions ( 43 ). Further, we did not have information on the nature of the relationship between the respondent and the deceased loved one or the circumstances of the death. Grief intensity, frequency and duration as well as ensuing psychiatry morbidity might vary depending on the relationship to the deceased ( 49 ). For example, among children, death of a parent is especially difficult ( 50 ), and among adults, death of a child or a spouse is especially difficult ( 3 ). Therefore, it is possible that these specific types of close relationships account for the increased in risk observed in these data. Further, the assessment did not distinguish between violent and non-violent unexpected death. According to DSM-5, only unexpected violent death of a loved one can be coded as an inciting potential trauma. It is possible that violent death accounts for the relations we found between unexpected death and PTSD or other disorders. However, the literature indicates that PTSD symptoms do occur following nonviolent death ( 4 ). Future studies with information regarding between violent and non-violent death will be helpful in understanding these relations further; for example future research might contrast psychiatric sequalae after unexpected versus anticipated death to determine the extent to which the suddenness of a loved one’s death impacts psychiatric disorders. The description of a death as ‘unexpected,’ is a subjective judgment and we do not have information about reliability or validity of this judgment. However, a subjective judgment is commonly used in studies of unexpected death. The age of both unexpected death and onset of psychiatric disorder is retrospectively reported, which introduces reporting biases. However, analyses restricted to those who reported a first unexpected death experience within 10 years of the interview showed similar or slightly stronger results than among the whole sample, mitigating against reporting bias as an explanation for our findings. Finally, diagnoses were not confirmed by clinicians and were assessed with lay interviewers using structured questionnaires.

The diagnosis of PTSD in this data also deserves comment. Two issues are noteworthy. First, the National Epidemiologic Survey on Alcohol and Related Conditions followed DSM-IV and permitted unexpected death to qualify as a potential traumatic event. DSM-5 requires that the death be directly witnessed or both violent and unexpected, thus some cases identified here may not meet DSM-5 criteria. However, this has been a controversial issue in the field and we believe it is useful to know the prevalence of PTSD diagnoses after unexpected death more generally. The second issue is that not all respondents had a lifetime occurrence of an event that qualified as a potential trauma. A large majority of the sample (80%) did experience a potential trauma, though this was not consistent across different age groups. Therefore, our estimates of the association between unexpected death of a loved one and the development of PTSD include individuals who were not at risk for PTSD. However, the estimates we report in the present paper are overall population-average estimates of PTSD risk following unexpected death, thus of clinical interest.

In summary, we found a significant relationship between the onset of a mood, anxiety and alcohol use disorder and the unexpected death of a loved one. These results suggest bereavement may be a useful lens in examining the etiology of psychiatric illness. Clinically, our results highlight the importance of considering a possible role for loss of close personal relationships through death in assessment of psychiatric disorders, especially among older adults without a prior history of mental disorder. Clinicians should query the loss of key relationships through death over the patient’s life course, and especially around the period of onset of symptoms. It may be important to address the patient’s response to death of a loved one in order to optimize treatment outcome and reduce the likelihood of illness recurrence.

Supplementary Material

Supplemental figures and tables, acknowledgements.

This study was supported by National Institutes of Health Grants MH092526 (McLaughlin), MH093612 (Koenen), MH078928 (Koenen), MH60783 (Shear), MH70741 (Shear), and AA021511 (Keyes).

Financial disclosure/conflict of interest : The authors report no conflicts of interest and have no financial relationships with commercial interests.

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Part 2 Lucy’s Story

2.4 Lucy case study 3: Mental illness diagnosis

Nicole Graham

Introduction to case study

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

Learning Objectives

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

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

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

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

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

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

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

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

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

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

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

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

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

Case study questions

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

 Thinking point

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

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

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

Learning objectives.

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

Resources required

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

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

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

Role 1 – Clinician

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

Role 2 – Lucy who lives with bipolar

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

Post role play debrief

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

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

Additional resources that might be helpful

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

Key information and links to other resources

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

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

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

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

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

Organisations providing information relevant to this case study

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

 Case study 3 summary

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

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

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

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

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

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

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Case Studies

Through personal stories, these case studies illustrate various pathways to care for students and some of the processes that postsecondary service providers have followed to build on-and-off-campus partnerships, agreements and referrals. The aim of these case studies is to illustrate real-life examples of promising practices for supporting students with complex needs.

We also hope that they help stimulate creative ideas and allow for reflection on ways your campus can adopt some of these practices within your context. As much as possible, these case studies illustrate ways the different service models (i.e. case management, triage etc.) play out in practice. In addition, some of the case studies have also tried to exemplify specific challenges such as transitions, effective supports for Aboriginal  and International students, and early psychosis intervention.

• Lily’s Story

This case study highlights a pathway to the Early Psychosis Intervention (EPI) service… Read Lily’s Story

• Sally’s Story

This case study highlights the Successful Transitions Online and Mentoring Program (STOMP)… Read Sally’s Story

• David’s Story

This story showcases a Case Management approach to supporting student mental health… Read David’s Story

• Arjun’s Story

Arjun’s story highlights the Early Psychosis Intervention Ontario Network (EPION) service… Read Arjun’s Story

Campus-Community Connection

• Campus Check-in
• CACUSS Systematic Approach
• NASPA Ecological Approach
• Healthy Universities / Campuses Approach
• Case Management Model
• Stepped Care Approach
• Triage Model
• Connecting Students to Community-Based Expertise
• Referral Documentation Standards
• Referral and Documentation Resources and Tools
• Early Identification Resources and Tools
• From Cultural Competency to Health Equity
• Strategies & Tools to Integrate Health Equity
• Staff Training Resources
• Equity Resources and Tools
• Thinking About a Collaborative Partnership
• Steps to Building a Collaborative Partnership
• Characteristics of Successful Collaborations
• Partnership Challenges and Strategies
• Partnership Resources and Tools
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Are We Thinking About the Youth Mental Health Crisis All Wrong?

Global trends in economics, climate and technology are weighing on young adults, a report finds. It recommends overhauling how we approach mental health care.

By Christina Caron

Chloé Johnson, 22, has been feeling hopeless lately.

She’s struggling to focus on classes at her local community college in Dallas while also working full-time, making $18 an hour as a receptionist.

Her car broke down, so the $500 that she had managed to save will now go toward a down payment for a used vehicle.

And she was recently passed over for a promotion.

“Right now it just feels, like, very suffocating to be in this position,” said Ms. Johnson, who was diagnosed last year with bipolar II disorder, depression and A.D.H.D. “I’m not getting anywhere or making any progress.”

It’s an endless loop: Ms. Johnson’s mental health has worsened because of her financial difficulties and her financial problems have grown, partly because of the cost of mental health treatment but also because her disorders have made it more difficult to earn a college degree that could lead to a more lucrative job.

“I’ve failed several classes,” she said. “I burn out really easily, so I just give up.”

The mental health of adolescents and young adults has been on the decline and it’s partly because of “harmful megatrends” like financial inequality, according to a new report published on Tuesday in the scientific journal The Lancet Psychiatry. The global trends affecting younger generations also include wage theft , unregulated social media , job insecurity and climate change , all of which are creating “a bleak present and future for young people in many countries,” according to the authors.

Why focus on global trends?

The report was produced over the course of five years by a commission of more than 50 people, including mental health and economic policy experts from several continents and young people who have experienced mental illness.

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Navigating Mental Crises

My journey as a mom and a psychiatrist facing my son's bipolar illness..

Posted August 15, 2024 | Reviewed by Gary Drevitch

• What Is Psychosis?
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The purpose of this blog will be to describe aspects of the mental illness journey that my son “Bill” and I took together: the illness episodes, the emergency room visits, hospitalizations, medication issues, and interludes of stability and success. I will share my thoughts about aspects of his treatment that worked, treatment dilemmas that families face, legal decisions, and finally the tremendous strain that we all face confronting a terrible illness with inadequate resources.

In writing about my struggles, I hope to help others to understand mental illness better in themselves, or in their friends and loved ones. Every family’s situation is different, yet there are common elements, including recognizing the warning signs, getting help, understanding the different medications and their side effects, learning the ropes of the mental health system, and taking action to improve care. My ultimate goal is for this account to expand awareness and recognition that we are not alone in this struggle.

It has been almost three years since I found my son dead in his apartment in Madison, Wisconsin. I keep asking myself if I could have done more. If I could have saved him. His illness and death particularly haunt me because I am a professor of psychiatry at the University of Pennsylvania. Both my research and my clinical work focus on major depression and bipolar illness. Treating bipolar illness is what I do every day. So how could my own son have died from this terrible illness? How could I not save him?

Piecing together what happened with “Bill” involves several intertwined threads. One is the raw power of psychosis to dramatically change a person’s ability for self-direction and choice—in other words, free will . In classical philosophy , free will has two aspects: the freedom to do otherwise and the power of self-determination. In Bill’s case, and for many others with severe psychosis, it was questionable whether he had the power of self-determination once he started into a psychotic episode .

Because his psychosis was brought about by mania , it took the form of grandiose delusions and paranoia . He alternately thought he was auditioning to be Director of the CIA, that his thoughts were controlled by a computer, or that he was leading a rebel army against occupying forces. Some of these experiences naturally terrified him. But many were accompanied by an extremely elevated mood: “10,000 times higher than the highest marijuana high,” is how he once described it. He wrote about his drive to become manic again, to re-experience the high of mania.

This led to a third thread: his desire to avoid taking his medication, partly because of the side effects but even more because he simply wanted to feel better. I didn’t fully understand these different threads—the power of psychosis to undermine self-determination, the desire to re-experience the high of manic mood elevation, and the drive to avoid taking medicines—until it was too late.

Until I read his journal writings about his drive to avoid medication, I didn’t grasp how extremely ill he was, how there were repeated episodes when he was no longer himself once he’d been annihilated by illness. I didn’t realize he had a strong compulsion to invite the illness in again to feel high, something he described vividly as an addiction to mania, not dissimilar to opiate addiction.

Yvette Sheline, MD, is a professor of psychiatry at the University of Pennsylvania whose career has been devoted to understanding brain mechanisms of treatment effects, plasticity, and mood dysregulation. She is also the mother of a son with bipolar disorder who committed suicide.

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Revolutionizing the Study of Mental Disorders

March 27, 2024 • Feature Story • 75th Anniversary

At a Glance:

• The Research Domain Criteria framework (RDoC) was created in 2010 by the National Institute of Mental Health.
• The framework encourages researchers to examine functional processes that are implemented by the brain on a continuum from normal to abnormal.
• This way of researching mental disorders can help overcome inherent limitations in using all-or-nothing diagnostic systems for research.
• Researchers worldwide have taken up the principles of RDoC.
• The framework continues to evolve and update as new information becomes available.

President George H. W. Bush proclaimed  the 1990s “ The Decade of the Brain  ,” urging the National Institutes of Health, the National Institute of Mental Health (NIMH), and others to raise awareness about the benefits of brain research.

“Over the years, our understanding of the brain—how it works, what goes wrong when it is injured or diseased—has increased dramatically. However, we still have much more to learn,” read the president’s proclamation. “The need for continued study of the brain is compelling: millions of Americans are affected each year by disorders of the brain…Today, these individuals and their families are justifiably hopeful, for a new era of discovery is dawning in brain research.”

Still, despite the explosion of new techniques and tools for studying the brain, such as functional magnetic resonance imaging (fMRI), many mental health researchers were growing frustrated that their field was not progressing as quickly as they had hoped.

For decades, researchers have studied mental disorders using diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders (DSM)—a handbook that lists the symptoms of mental disorders and the criteria for diagnosing a person with a disorder. But, among many researchers, suspicion was growing that the system used to diagnose mental disorders may not be the best way to study them.

“There are many benefits to using the DSM in medical settings—it provides reliability and ease of diagnosis. It also provides a clear-cut diagnosis for patients, which can be necessary to request insurance-based coverage of healthcare or job- or school-based accommodations,” said Bruce Cuthbert, Ph.D., who headed the workgroup that developed NIMH’s Research Domain Criteria Initiative. “However, when used in research, this approach is not always ideal.”

Researchers would often test people with a specific diagnosed DSM disorder against those with a different disorder or with no disorder and see how the groups differed. However, different mental disorders can have similar symptoms, and people can be diagnosed with several different disorders simultaneously. In addition, a diagnosis using the DSM is all or none—patients either qualify for the disorder based on their number of symptoms, or they don’t. This black-and-white approach means there may be people who experience symptoms of a mental disorder but just miss the cutoff for diagnosis.

Dr. Cuthbert, who is now the senior member of the RDoC Unit which orchestrates RDoC work, stated that “Diagnostic systems are based on clinical signs and symptoms, but signs and symptoms can’t really tell us much about what is going on in the brain or the underlying causes of a disorder. With modern neuroscience, we were seeing that information on genetic, pathophysiological, and psychological causes of mental disorders did not line up well with the current diagnostic disorder categories, suggesting that there were central processes that relate to mental disorders that were not being reflected in DMS-based research.”

Road to evolution

Concerned about the limits of using the DSM for research, Dr. Cuthbert, a professor of clinical psychology at the University of Minnesota at the time, approached Dr. Thomas Insel (then NIMH director) during a conference in the autumn of 2008. Dr. Cuthbert recalled saying, “I think it’s really important that we start looking at dimensions of functions related to mental disorders such as fear, working memory, and reward systems because we know that these dimensions cut across various disorders. I think NIMH really needs to think about mental disorders in this new way.”

Dr. Cuthbert didn’t know it then, but he was suggesting something similar to ideas that NIMH was considering. Just months earlier, Dr. Insel had spearheaded the inclusion of a goal in NIMH’s 2008 Strategic Plan for Research to “develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures.”

Unaware of the new strategic goal, Dr. Cuthbert was surprised when Dr. Insel's senior advisor, Marlene Guzman, called a few weeks later to ask if he’d be interested in taking a sabbatical to help lead this new effort. Dr. Cuthbert soon transitioned into a full-time NIMH employee, joining the Institute at an exciting time to lead the development of what became known as the Research Domain Criteria (RDoC) Framework. The effort began in 2009 with the creation of an internal working group of interdisciplinary NIMH staff who identified core functional areas that could be used as examples of what research using this new conceptual framework looked like.

The workgroup members conceived a bold change in how investigators studied mental disorders.

“We wanted researchers to transition from looking at mental disorders as all or none diagnoses based on groups of symptoms. Instead, we wanted to encourage researchers to understand how basic core functions of the brain—like fear processing and reward processing—work at a biological and behavioral level and how these core functions contribute to mental disorders,” said Dr. Cuthbert.

This approach would incorporate biological and behavioral measures of mental disorders and examine processes that cut across and apply to all mental disorders. From Dr. Cuthbert’s standpoint, this could help remedy some of the frustrations mental health researchers were experiencing.

Around the same time the workgroup was sharing its plans and organizing the first steps, Sarah Morris, Ph.D., was a researcher focusing on schizophrenia at the University of Maryland School of Medicine in Baltimore. When she first read these papers, she wondered what this new approach would mean for her research, her grants, and her lab.

She also remembered feeling that this new approach reflected what she was seeing in her data.

“When I grouped my participants by those with and without schizophrenia, there was a lot of overlap, and there was a lot of variability across the board, and so it felt like RDoC provided the pathway forward to dissect that and sort it out,” said Dr. Morris.

Later that year, Dr. Morris joined NIMH and the RDoC workgroup, saying, “I was bumping up against a wall every day in my own work and in the data in front of me. And the idea that someone would give the field permission to try something new—that was super exciting.”

The five original RDoC domains of functioning were introduced to the broader scientific community in a series of articles published in 2010  .

To establish the new framework, the RDoC workgroup (including Drs. Cuthbert and Morris) began a series of workshops in 2011 to collect feedback from experts in various areas from the larger scientific community. Five workshops were held over the next two years, each with a different broad domain of functioning based upon prior basic behavioral neuroscience. The five domains were called:

• Negative valence (which included processes related to things like fear, threat, and loss)
• Positive valence (which included processes related to working for rewards and appreciating rewards)
• Cognitive processes
• Social processes
• Arousal and regulation processes (including arousal systems for the body and sleep).

At each workshop, experts defined several specific functions, termed constructs, that fell within the domain of interest. For instance, constructs in the cognitive processes domain included attention, memory, cognitive control, and others.

The result of these feedback sessions was a framework that described mental disorders as the interaction between different functional processes—processes that could occur on a continuum from normal to abnormal. Researchers could measure these functional processes in a variety of complementary ways—for example, by looking at genes associated with these processes, the brain circuits that implement these processes, tests or observations of behaviors that represent these functional processes, and what patients report about their concerns. Also included in the framework was an understanding that functional processes associated with mental disorders are impacted and altered by the environment and a person’s developmental stage.

Preserving momentum

Over time, the Framework continued evolving and adapting to the changing science. In 2018, a sixth functional area called sensorimotor processes was added to the Framework, and in 2019, a workshop was held to better incorporate developmental and environmental processes into the framework.;

Since its creation, the use of RDoC principles in mental health research has spread across the U.S. and the rest of the world. For example, the Psychiatric Ratings using Intermediate Stratified Markers project (PRISM)   , which receives funding from the European Union’s Innovative Medicines Initiative, is seeking to link biological markers of social withdrawal with clinical diagnoses using RDoC-style principles. Similarly, the Roadmap for Mental Health Research in Europe (ROAMER)  project by the European Commission sought to integrate mental health research across Europe using principles similar to those in the RDoC Framework.;

Dr. Morris, who has acceded to the Head of the RDoC Unit, commented: “The fact that investigators and science funders outside the United States are also pursuing similar approaches gives me confidence that we’ve been on the right pathway. I just think that this has got to be how nature works and that we are in better alignment with the basic fundamental processes that are of interest to understanding mental disorders.”

The RDoC framework will continue to adapt and change with emerging science to remain relevant as a resource for researchers now and in the future. For instance, NIMH continues to work toward the development and optimization of tools to assess RDoC constructs and supports data-driven efforts to measure function within and across domains.

“For the millions of people impacted by mental disorders, research means hope. The RDoC framework helps us study mental disorders in a different way and has already driven considerable change in the field over the past decade,” said Joshua A. Gordon, M.D., Ph.D., director of NIMH. “We hope this and other innovative approaches will continue to accelerate research progress, paving the way for prevention, recovery, and cure.”

Publications

Cuthbert, B. N., & Insel, T. R. (2013). Toward the future of psychiatric diagnosis: The seven pillars of RDoC. BMC Medicine , 11 , 126. https://doi.org/10.1186/1741-7015-11-126  

Cuthbert B. N. (2014). Translating intermediate phenotypes to psychopathology: The NIMH Research Domain Criteria. Psychophysiology , 51 (12), 1205–1206. https://doi.org/10.1111/psyp.12342  

Cuthbert, B., & Insel, T. (2010). The data of diagnosis: New approaches to psychiatric classification. Psychiatry , 73 (4), 311–314. https://doi.org/10.1521/psyc.2010.73.4.311  

Cuthbert, B. N., & Kozak, M. J. (2013). Constructing constructs for psychopathology: The NIMH research domain criteria. Journal of Abnormal Psychology , 122 (3), 928–937. https://doi.org/10.1037/a0034028  

Garvey, M. A., & Cuthbert, B. N. (2017). Developing a motor systems domain for the NIMH RDoC program.  Schizophrenia Bulletin , 43 (5), 935–936. https://doi.org/10.1093/schbul/sbx095  

Kozak, M. J., & Cuthbert, B. N. (2016). The NIMH Research Domain Criteria initiative: Background, issues, and pragmatics. Psychophysiology , 53 (3), 286–297. https://doi.org/10.1111/psyp.12518  

Morris, S. E., & Cuthbert, B. N. (2012). Research Domain Criteria: Cognitive systems, neural circuits, and dimensions of behavior. Dialogues in Clinical Neuroscience , 14 (1), 29–37. https://doi.org/10.31887/DCNS.2012.14.1/smorris  

Sanislow, C. A., Pine, D. S., Quinn, K. J., Kozak, M. J., Garvey, M. A., Heinssen, R. K., Wang, P. S., & Cuthbert, B. N. (2010). Developing constructs for psychopathology research: Research domain criteria. Journal of Abnormal Psychology , 119 (4), 631–639. https://doi.org/10.1037/a0020909  

• Presidential Proclamation 6158 (The Decade of the Brain) 
• Research Domain Criteria Initiative website
• Psychiatric Ratings using Intermediate Stratified Markers (PRISM)  

• Open access
• Published: 14 August 2024

Factors influencing nurse practitioner panel size in team-based primary care: a qualitative case study

• Ruth Martin-Misener 1 ,
• Faith Donald 2 ,
• Jennifer Rayner 3 , 4 ,
• Nancy Carter 5 ,
• Kelley Kilpatrick 6 ,
• Erin Ziegler 2 ,
• Ivy Bourgeault 7 &
• Denise Bryant-Lukosius 5  

BMC Primary Care volume  25 , Article number:  304 ( 2024 ) Cite this article

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Lack of access to health care is a worldwide public health crisis. In primary care it has led to increases in the implementation of nurse practitioners and heightened interest in their patient panel capacity. The aim of this study was to examine factors influencing nurse practitioner patient panel size in team-based primary care in Ontario, Canada.

We used a multiple case study design. Eight team-based primary care practices including rural and urban settings were purposively selected as cases. Each case had two or more nurse practitioners with a minimum of two years experience in the primary care setting. Interviews were conducted in-person, audio recorded, transcribed and analysed using content analysis.

Forty participants, including 19 nurse practitioners, 16 administrators (inclusive of executives, managers, and receptionists), and 5 physicians were interviewed. Patient, provider, organizational, and system factors influenced nurse practitioner patient panel size. There were eight sub-factors: complexity of patients’ health and social needs; holistic nursing model of care; nurse practitioner experience and confidence; composition and functioning of the multidisciplinary team; clerical and administrative supports, and nurse practitioner activities and expectations. All participants found it difficult to identify the panel size of nurse practitioners, calling it— “a grey area.” Establishing and maintaining a longitudinal relationship that responded holistically to patients’ needs was fundamental to how nurse practitioners provided care. Social factors such as gender, poverty, mental health concerns, historical trauma, marginalisation and literacy contributed to the complexity of patients’ needs. Participants indicated NPs tried to address all of a patient’s concerns at each visit.

Conclusions

Nurse practitioners have a holistic approach that incorporates attention to the social determinants of health as well as acute and chronic comorbidities. This approach compels them to try to address all of the needs a patient is experiencing at each visit and reduces their panel size. Multidisciplinary teams have an opportunity to be deliberate when structuring their services across providers to meet more of the health and social needs of empanelled patients. This could enable increases in nurse practitioner panel size.

Peer Review reports

Access to health care is a worldwide public health crisis. The supply and productivity of the primary care workforce, including nurse practitioners, (NPs) is critical to its resolution [ 1 , 2 , 3 ]. Panel size is a metric which refers to the number of patients receiving care from a single provider in one year [ 4 ]. Though commonly assessed in physician practices [ 5 , 6 , 7 , 8 ], its use in NP practice is less frequent but increasing [ 9 ]. Panel size and composition is also of interest in the context of primary care teams and is regarded as a key component of high-performing teams [ 10 , 11 , 12 ].

NPs are advanced practice nurses with graduate education that includes clinical training to assess, diagnose and manage patients with acute and or chronic illness [ 3 ]. NPs function as the most responsible provider for their own patient panels or provide care for patients in a collaborating physician’s panel [ 9 ]. Estimates of NP panel size range between 500 and 1000 patients [ 9 ]. These panel size numbers are less than what is typical for physician patient panels leading some to question the cost effectiveness of NPs [ 13 ].

Research has shown that the presence of an NP in a physician’s practice increases the physician’s patient panel size [ 4 , 5 , 6 ]. However few studies have investigated the nature of the patient panels of NPs or the factors that influence panel size and composition. Use of electronic databases, as well as validated disease burden scores, or first-voice perspectives in this research is sparse [ 9 ]. Since NPs are autonomous primary care providers in most of North America and many countries around the world [ 14 ], understanding the factors that influence their panel size is important for health workforce planning.

In Canada NPs are employed in all provinces and territories and their numbers are growing [ 15 ]. The province of Ontario was the first to formally introduce and regulate NPs 25 years ago and continues to have the largest number of NPs in the country [ 16 ]. It is also the province with the longest and most varied experience with various models of interprofessional team-based primary care [ 17 , 18 , 19 , 20 ].

Our study aim was to explore the factors influencing NP patient panel size in team-based primary care in Ontario, Canada.

Study design

We used a multiple case study design to enable understanding of the phenomena of panel size in the real-life context of rural and urban primary care practices [ 21 ]. Cases were defined as team-based primary care practices that included two or more NPs with at least two years experience in the setting.

Funding The study was funded by the Ontario Ministry of Health and Long-term Care. The grant number was 06695.

Recruitment of cases and participants

In consultation with an advisory panel of health care administrators and providers, we discussed the various team-based primary care models in Ontario and decided to include Aboriginal Health Access Centres, Community Health Centres, Family Health Teams and Nurse-Practitioner Led Clinics all of which had been in existence for at least 10 years [ 17 , 18 , 19 , 20 ]. The research team purposively selected eligible practices in rural and urban locations. To enable onsite data collection, practices were located within five hours driving from a large city.

An information letter explaining the study was emailed to the senior administrator in each potential case site. A follow-up telephone call confirmed the practice met eligibility criteria and obtained organizational permission to conduct the study, including the processes for participant recruitment. Each primary care setting and participant received a small honorarium.

Data collection and analysis

Individual interviews with providers and staff explored participants’ perceptions of the barriers and facilitators to increasing NP patient panel size. Interviews were conducted in-person by a research team member between March and November 2015. A small number of interviews were conducted by telephone when requested by participants. Interviews were 30 to 50 min in length and included member checking by summarising key points [ 22 ]. To promote data saturation, data collection occurred one case at a time [ 21 ]. Interviews were conducted in person at each site over two-to-three-days, recorded and transcribed. The interview guide is available as a supplemental file.

Transcripts were coded deductively and inductively using content analysis [ 23 ]. NVivo 12 was used to manage the data [ 24 ]. First, two research team members independently coded four transcripts, compared coding, and discussed emerging themes. Remaining transcripts were independently coded by four team members. Emerging and evolving themes were discussed and refined at research team meetings, including one with the advisory panel.

When reporting the findings, the descriptor “most participants” was used for approximately 75% or more participants, “many participants” for approximately 50–74%, “some participants” for approximately 25–49% and “few participants” for less than 25%. This approach protects participant confidentiality and provides an indication of how many participants expressed a viewpoint without making interpretations beyond the sample [ 25 ].

Forty participants including 19 NPs, 16 administrators (inclusive of executives, managers, and receptionists), and 5 physicians were interviewed. Their characteristics are reported in Table  1 . Many NPs (60%) had graduate education, most (72%) were employed fulltime, and, with one exception, had three or more years experience as an NP. Many self-identified as being female (56%) and their ages ranged from 39 to 46 years. NPs reported spending between 4 and 4.8 days per week providing direct patient care.

Factors influencing NP patient panel size were identified at patient, provider, organizational, and systems levels along with eight sub-factors (Table  2 ). Participants from Aboriginal Health Access Centres and NP-Led Clinics indicated NPs had their own patient panel whereas participants from Family Health Teams and Community Health Centres indicated NPs and physicians shared a patient panel.

All participants found it difficult to identify the number of patients in NPs’ panels commenting it was “a grey area.” Panel size estimates ranged from 300 to 1800 across the eight settings. Some participants assumed that expectations for NP panel sizes were externally determined, for example, by government or health service organizations. Others perceived panel size was determined at the primary care practice level and or by each provider individually.

All participants indicated that numbers alone could not capture the complexities of many of their patients’ lives, even when social factors were included as a diagnosis. As illustrated in the following quote, this, in combination with NPs’ deep commitment to patient-centred preventative care, inevitably meant longer appointment times and likely smaller panel sizes. These concepts are further considered in the following subfactor sections organized as Patient Factors, NP Factors, Organizational Factors and System Factors.

We really try hard here to put the diagnosis in and even poverty comes up or social isolation , so all of those factors. But even those things don’t capture the complexities. So , I think determining a panel size based on that and a philosophy of patient-centred preventative care— rather than acute episodic all the time. That means longer appointment times , less— maybe less patients [NP, Nurse Practitioner-Led Clinic].

Patient factors influencing NP Panel Size

The composition of the patient population and the complexity of their needs was the only patient related factor influencing NP panel size.

Complexity of health and social needs

Across all cases, most interview participants emphasized that the number one factor limiting NP panel sizes was the complexity of the health and social needs of patient populations. As one Family Health Team administrator explained; “ The more complex your patients are , the more time you’re spending with them , the higher their needs and then consequently it becomes more difficult to manage a larger panel .”

Many participants stressed that the length of appointment times was dependant on the needs of patients. Although the primary care receptionists knew most patients well and tried to predict the length of time needed for appointments, this was often not possible. The full extent of patients’ needs was often not disclosed or discovered until the time of the appointment with the NP. When this occurred, it required NPs to choose between staying on schedule or extending the length of the appointment in order to address the presenting patient’s needs. Participants indicated that NPs chose to capitalize on the opportunity to address the needs of the patient especially if the patient was unlikely or unable to return for regular follow up.

“You’re really only ready to give that injection but now you have 10 other issues , and you want to make sure you get through them because this patient may or may not come back for their follow up and it’s so important. I think that can really impact how your whole day looks”. [NP, Community Health Centre]

Participants recognized that health care funders wanted primary care practices to increase the size of NPs’ patient panels and the panels of the practice as a whole. However, participants indicated this was difficult to do without compromising their capacity to address the health and social needs of the patients already in NPs’ panels. As the following quote illustrates, they described this as the tension between providing quality care versus quantity. For participants, establishing and maintaining a supportive relationship with patients already in their practice was fundamental to providing quality care.

“I don’t know how you could have a relationship or how you could support the patient if they have 7 to 10 minutes or whatever the number might be. I recognize that they have expectations of us , being the funding body , that they need data , they need numbers. It’s a struggle with providing quality care versus quantity , especially when our patients come in with early onset aging and a higher representation of chronic diseases at an early age and issues with housing , financial , poverty —all those things. We manage health care , but in addition to health care , support for all the other areas— and it takes time.” [Administrator, Aboriginal Health Access Centre].

Participants identified that NPs provided primary care for patients with complex health and social needs. This included “patients with four or more chronic diseases with multiple complaints on any one day.” Most participants stressed that while multiple chronic illnesses were a component of the challenges patients were experiencing, mental health and substance use concerns and socioeconomic factors compounded the complexity of their lives. The following two quotes illustrate this.

“We draw from a range of socio-economic status areas in (city) and that affects many things. We have a high incidence or prevalence of mental illness , and a lot of issues are complicated through the presence of their mental illnesses {…} or make management more difficult. I’d say that’s a challenge for all our practitioners. {…} You know , you get it all just sort of wrapped together; complexities due to older patients or patients with multiple meds , and then you wrap that up with socioeconomics and mental illness— it’s huge .” [Administrator, Family Health Team] That just doesn’t mean the medical complexity , that also means the social complexity. If that client is substance-using , then I may give them a medication for an infection and they will go get that medication and then come back and say , you need to keep this medication , and then run away again , and I don’t know if they’ll come back or not. It’s totally the medical and behavioural complexity of that individual that certainly limits how many people I see in a day . [NP, Community Health Centre].

Participants further elaborated that gender, literacy, prior unattachment to a primary care provider, historical trauma and marginalisation also contributed to complexity and therefore the need for more support and more time.

“With the NPs , the responsibilities that they see and manage every day with complex patients. We have complex patients probably at a higher number and with early onset aging and historical trauma. Our patients come in with a lot more — they need a lot more support .” [Physician, Aboriginal Health Access Centre]. “We did have new families , and even with those patients , it was chronic issues. They were unattached and marginalized , and they’d never seen any primary care provider for years. And they were the frequent flyers between hospital emergency and the walk-in clinics .” [NP, NP-Led Clinic].

In summary, participants were united in their view that the complex health and social needs of patients in their primary care settings required longer appointment times with the NP, and this in turn reduced NPs’ panel size capacity.

Provider factors influencing NP panel size

Two provider factors influenced NP panel size: NPs’ holistic nursing model of care and their experience and confidence.

Holistic nursing model of care

Half of NP and administrator participants in all four models of team-based primary care identified that the holistic nature of the care NPs provide was an influence on their patient panel size. A physician explained that NPs’ ability to look at patients holistically originated from nursing culture and is a value-add that they bring to primary care.

“I think one of the great things NPs add to primary care , and it’s something that’s important to all of us , is something of value in nursing culture , which is to see people holistically as people who have needs and who come in with fears and anxieties. I think that’s a value that our whole health system needs more of.” [Physician, Community Health Centre].

Providing holistic care was linked to scheduling appointment times that enabled NPs to take time to nurture a relationship built on trust and to address the multiple health and social concerns of patients. An NP explained it as follows:

“If we can be patient-centred and take the time with people to address their issues , listen to them , you’re going to get more done. You spend a lot more money when a person ends up in crisis than doing prevention and really listening carefully to people and having that relationship with them. A lot of patients come here and the biggest thing they say they notice is that we spend the time—we listen. Their doctor may have had 10 minutes with them. So , they really appreciate that and they’re more apt to follow through on your suggestions because they feel you’ve listened to their problem and have some trust.” [NP, NP-Led clinic].

NP Experience and confidence

Most participants indicated that experience in the role and in primary care practice influenced NP panel size. This is illustrated in the following quotes from NP and administrator participants.

“When they first started , they had hour-long appointments with the clients because , first of all , they didn’t know the computer system , and their primary care skills weren’t as fresh.” [NP, Community Health Centre]. If an NP is more novice and really having to deal with a big pile of complexity with inter-related problems and symptoms—that really does affect panel size. It affects the amount of time that the NP takes and really having to lean on his or her colleague to get advice and support.” [Administrator, Community Health Centre].

Development of confidence occurred over time, and through application of theoretical knowledge and exposure to clinical issues in the practice setting. Having opportunities to discuss questions and decisions with a colleague enabled confidence. When patients presented with complexities that required NPs to consult other providers, these consultations impacted the number of patient appointments.

The connections between experience, confidence, and an ability to practice at a faster speed are summarised by an administrator in the following quote.

“What I have noticed is because of the comfort and confidence that a more experienced NP has , he or she will be able handle a situation around a prescription or diagnosis much more quickly .” [Administrator, Community Health Centre].

Organizational factors influencing NP panel size

There were three organisational factors influencing the panel size of NPs: multidisciplinary team roles; clerical and administrative supports, and expectations regarding NP activities.

Multidisciplinary team roles

Most NP and physician participants and many administrator participants identified that multidisciplinary teams enabled increases in NP panel size because patients could receive care from other team members. For example, dieticians provided nutrition counselling for patients with diabetes, pharmacists assisted patients with smoking cessation and social workers enabled patients to make connections with community resources and supports. Participants identified that it was important for the multidisciplinary team to think deliberately about each team member’s contribution to patient care. They indicated that when patient needs were matched with team members with the expertise to meet those needs, the panel size of NPs and the panel size of the entire practice could be increased.

If we involve more multidisciplinary team members, for instance, having a diabetic program in place or if you have a pharmacist, more registered practical nurses involved, and social work more involved, I can see NPs having more patients and expanding the panel size more. [Administrator, NP-Led Clinic].

Participants offered several examples of health care providers, who, through their education and team roles, provided specific skills and services to meet needs of patient groups. They discussed the importance of enabling all team members to practice to their full scope of practice and making deliberate decisions about involving providers with specific competencies in the care of specific patient populations. The following quote illustrates this concept.

“Truly using every provider to their full scope of practice and not booking tasks and activities that could go to another provider. So , when I think about our NPs , they’re a pretty hot commodity. We need them to see specific things with specific clients with specific issues and if they’re booking up their schedules with a blood pressure recheck or —name your episodic thing—it does take away time from being able to see other patients. So that full scope is really incredible.” [Administrator, Community Health Centre].

Some participants identified the importance of providers reflecting on their own professional and personal scope of practice as well as the scope of practice of other team members when planning how to address the needs of patients in the practice. As one NP explained

“I always think— what am I best able to provide the patient? I’m not a social worker , I’m not a great CBT (cognitive behavior therapy) counsellor— so why try to spend time counselling when I can send them to somebody else , find them resources.” [NP, Family Health Team].

Further to this, some participants indicated that multidisciplinary teams wanted opportunities to design, implement and evaluate new approaches to team collaboration. Many team members indicated that collaboration improved team building and that it enabled problem-solving that led to operational changes that contributed to panel size growth.

“What I’m seeing on our team , is really excellent team collaboration. If the team is really healthy , and functional , and can problem-solve and can do mutually supportive stuff—I think that’s a team that can handle a bigger panel size.” [Community Health Centre , Physician] .

Participants noted that with resources, such as dieticians, social workers, registered practical nurses and pharmacists, some of the health teaching previously done by NPs was now being carried out by other team members. This provided time for NPs to have more patient appointments.

“It evolves relative to practice size , the number of patients to be seen and to NP experience and confidence and availability of supports. An NP two years ago might have been doing smoking cessation on their own; now we have the support of the pharmacist to do that.” [Family Health Team , Administrator].

Clerical and administrative supports and activities

Most participants indicated that clerical, and administrative staff were essential for enabling NPs to increase their panel size. Many identified that their practices had standard times for different types of appointments. For example, patients needing a complete physical examination or who had mental health concerns would be booked for a one-hour appointment. Most other appointments were booked for 30 min. Participants noted that most patients were well known by clerical staff, and they knew how to adjust appointment duration times according to what patients were anticipated to need. The following quote exemplifies this perspective.

“I think each individual NP and the girls at the front have a background of all the patients— we know the patients well , and we know how to book them as far as time.” [NP -Led Clinic , Administrator] .

Many participants indicated that administrative responsibilities were a component of NPs’ workload and ranged from 0.5 to 7.5 h weekly.

“Of course , I have administrative time when I’m not seeing patients so during that time , I’m doing paperwork and reviewing labs and doing administrative things. If I had less administrative time , then maybe I would be able to see more clients but that’s part of the job” [NP, Family Health Team].

For others, administrative work included activities such as program planning, leading meetings, quality improvement and community education/outreach activities. Some participants indicated that the time NPs spent on administration lessened the available clinical time.

Expectations regarding NP activities

Most participants indicated appointment-based, direct care within the primary care practice setting was how NPs spent most of their time. In some practices NPs were expected to offer specific types of appointments that impacted their panel size, for example, same and next day patient appointments. In some practices NPs were responsible to do activities requiring more time, for example, completing the telephone follow-up calls or routine pelvic examinations for the patients of all providers in the practice.

Many participants indicated NPs did house calls or street calls noting these required more time because travel was entailed. For example, an Aboriginal Health Access Centre administrator said, “ I think we book 1 ½ hours .” The frequency of house-calls was on an as-needed basis, with one NP-Led Clinic NP reporting 28 in a year. Most NPs reported they did not have on-call responsibilities except for some who were on-call but only for critical lab results.

In summary, the three subfactors at the organizational level were composition and functioning of multidisciplinary healthcare provider teams, clerical and administrative supports and expectations regarding NP activities.

Systems Level factors influencing NP panel size

The systems level factors that influenced the panel size of NPs were restrictions on NP scope of practice and NP remuneration.

Restrictions on NP scope of practice

At the time of data collection, systems level factors that restricted scope of practice included barriers to referring patients to specialists, restrictions on ordering some diagnostic tests, and the inability to prescribe some medications. As one Family Health Team NP explained having these restrictions removed would save time because “having to ask can I order this or that— it just slows down the time .” The removal of the requirement for a physician’s co-signature on specialist referral requests had an impact on increasing panel size as illustrated in the following quote. “ Being able to refer now without a physician’s co-signing— that opened up a position for me in a satellite office in (location) to help with patients who didn’t have a family physician .

NP remuneration

Funding was also an important enabling factor identified by many NPs and physicians. One NP from a Community Health Centre summarized it as follows:

If we think of wages as a system thing and we think about how it impacts on recruitment and retention, you can’t grow your clinic if you don’t keep your staff. {…} So, if you support recruitment and retention with good wages, you can grow your panel size. But your NPs get a better offer, and they go off to a better paying organization, […], then you can’t grow primary care, you can’t grow your clinic.

Through this analysis we found that the most significant factor influencing NP panel size was the time needed to address the multiple complex health and social needs experienced by patients in their practice. To accommodate for this, NPs had appointment times that varied between 15 and 30 min and some that were booked for an hour or more. Participants identified that providing care for patients impacted by the social determinants of health was important. All participants supported the value of the principle of time allocation for NPs to address patients’ broader social needs—especially patients experiencing trauma, marginalization and high-risk environments. They emphasized that NPs were ideally suited to provide care for this patient population because of NPs’ holistic, comprehensive nursing approach that included taking the time to listen and fulsomely address patients’ concerns at each appointment. Participants emphasized that concerns about panel size should not compromise the comprehensiveness of the care NPs provide to patients with complex needs because it was important from a social justice standpoint, and it reduced the risk of adverse patient outcomes.

The association between the length of appointment time and complexity has been documented from patient [ 26 ] and provider [ 27 , 28 , 29 ] viewpoints. Patients impacted by social factors, such as poverty, are also disproportionately affected by medical comorbidities [ 30 ]. When discussing complexity, participants spoke briefly about patients’ multimorbidity and gave detailed accounts of the social determinants impacting patients for whom NPs provided care. It is possible that their focus on these factors was a confirmation bias of their knowledge of the nursing profession’s focus on social determinants of health. Similar findings from studies using patient profile [ 28 , 30 ] and task allocation studies [ 31 ] make this explanation unlikely. NPs in this study prioritized identifying and taking action to address the social needs of their patients regardless of the time it took or impact it had on panel size. Although not a concern of participants in our study, the cost effectiveness of NPs’ longer appointment times has been criticized [ 12 ]. However, recent studies indicate NP-provided primary care for patients with complex health needs results in savings in downstream costs associated with hospital use [ 32 , 33 ]. Primary care is the point in health care systems where these interventions should be provided - not in the emergency room or in hospital.

Participants in our study were mindful of the need to attend to NP panel size. However, they tended to regard panel size determination as an accountability required of funders, not a tool to improve how care delivery could be better organized in the practice [ 34 ]. They were cognizant of the challenges patients faced when accessing primary care, for example, transportation and childcare, and recognized the visit was a time-limited window of opportunity to address concerns. Therefore, participants prioritized giving patients the time required to have most or all of their needs met in a single appointment. This approach aligns with Levesque et al.’s [ 35 ] broad perspective on accessibility as an opportunity to identify healthcare needs and have those needs for services fulfilled. It is also consistent with the call to action of Browne and Tarlier, who said: “With even a small investment of time, NPs operating from a critical social justice perspective could for example, attend to the biomedical needs of patients and at the same time work towards countering or challenging the social or economic policies that affect biomedical issues” [ 36 , p. 90]. Participants in our study prioritized their time for these patients but did not discuss policy work they were doing related to the social determinants of health.

While participants valued and made efforts to optimize the roles of multidisciplinary team members including registered and practical nurses, for the most part they did not discuss how the team could take a more deliberate approach to maximizing optimal functioning of all team members’ roles and the impact this could have on NP panel size. Such planning requires data, and we did not specifically ask participants to what extent they could mine electronic medical record data to inform this planning. Research has shown that NPs use EMR data to plan their own clinics [ 37 ], however, few practices are using this data to inform financial and organizational planning for the services a primary care clinic could offer and the roles of team members [ 38 ]. This could enable improvements in accessibility and equity.

Limitations

Our study offers an in-depth description of the factors affecting NP patient panels in primary care in one Canadian province. Interview data were collected in 2015 before the COVID-19 pandemic and the increased use of virtual care in primary care. Future research should evaluate strategies for aligning team composition with patient population health and social needs as well as the potential impact of virtual care provision on NP panel size. Our study did not include patient interviews and not having their perspectives is a limitation. Detailed information about the structures and processes of these practice models other than what is presented in Table  1 was not obtained in our study and is a limitation to understanding the impact of context on panel size.

Multiple factors influence NP patient panel size, particularly the complexity of the health and social needs of patients. NPs have a patient-centred, holistic approach that aims to address the social determinants of health for each patient when they access primary care. Panel size concerns should not compromise the comprehensiveness and equity of the care NPs provide. Better utilization of practice-based data may enable multidisciplinary teams to optimize panel size without compromising equity and quality of care.

Data availability

The qualitative data that support the findings of this study are not openly available. Participants did not consent to have their data shared.

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R.M.M. collected and analyzed data and wrote the initial manuscript text and led subsequent revisions. FD, JR and KK collected and analyzed data and reviewed and contributed to revisions of the manuscript. DB, IB, NC and EZ analyzed data and reviewed and contributed to revisions of the manuscript.

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Martin-Misener, R., Donald, F., Rayner, J. et al. Factors influencing nurse practitioner panel size in team-based primary care: a qualitative case study. BMC Prim. Care 25 , 304 (2024). https://doi.org/10.1186/s12875-024-02547-6

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Received : 30 December 2023

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DOI : https://doi.org/10.1186/s12875-024-02547-6

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