research articles on depression and anxiety

Depression and anxiety

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• 1 University of Melbourne, Melbourne, VIC, Australia. [email protected].
• PMID: 25370281
• DOI: 10.5694/mja12.10628

Comorbid depression and anxiety disorders occur in up to 25% of general practice patients. About 85% of patients with depression have significant anxiety, and 90% of patients with anxiety disorder have depression. Symptomatology may initially seem vague and non-specific. A careful history and examination with relevant investigations should be used to make the diagnosis. Once the diagnosis is made, rating scales may identify illness severity and help in monitoring treatment progress. Both the depression disorder and the specific anxiety disorder require appropriate treatment. Psychological therapies, such as cognitive behaviour therapy, and antidepressants, occasionally augmented with antipsychotics, have proven benefit for treating both depression and anxiety. Benzodiazepines may help alleviate insomnia and anxiety but not depression. They have dependency and withdrawal issues for some people, and may increase the risk of falls in older people. Despite the availability of treatments, 40% of patients with depression or anxiety do not seek treatment, and of those who do, less than half are offered beneficial treatment.

• Anxiety / drug therapy
• Anxiety / epidemiology*
• Anxiety / therapy
• Benzodiazepines / adverse effects
• Benzodiazepines / therapeutic use
• Cognitive Behavioral Therapy
• Comorbidity
• Depression / drug therapy
• Depression / epidemiology*
• Depression / therapy
• Depressive Disorder / psychology
• Depressive Disorder / therapy
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Examining Coping Skills, Anxiety, and Depression Dynamics Amidst the COVID-19 Pandemic

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This cross-sectional study, conducted amid the COVID-19 pandemic, delves into the intricate connections between coping strategies and levels of anxiety and depression, presenting vital implications for medical, clinical, and broader societal contexts. As crises like the pandemic highlight the importance of adaptive coping, this investigation underscores the imperative to comprehend and address maladaptive coping strategies. The study utilized a diverse sample of 386 participants during the pandemic's peak, employing online platforms for recruitment and ensuring broad demographic representation. Data were collected through self-report measures, including the Patient Health Questionnaire-4 (PHQ-4) for depression and anxiety symptoms and the Brief Coping Orientation to Problems Experienced (COPE) inventory to assess coping skills across various domains. The coping skills assessment measured strategies such as Self-Distraction, Active Coping, Denial, Substance Use, Emotional and Instrumental Support, Behavioral Disengagement, Venting, Positive Reframing, Planning, Humor, Acceptance, Religion, and Self-Blame. The Colorado Multiple Institutional Review Board prioritized and approved ethical considerations, and participants provided informed consent. Data analysis involved rigorous cleaning, recoding, and quantitative analysis using SPSS. Descriptive statistics, regression analyses, and correlation analyses were employed to uncover nuanced relationships between coping strategies and mental health outcomes, contributing to understanding the phenomena under investigation within the context of the pandemic. The findings highlight the pivotal role of individualized approaches and the potential of humor as an essential coping mechanism, emphasizing the need for tailored interventions during crises.

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• Published: 24 April 2024

Discrimination is associated with depression, anxiety, and loneliness symptoms among Asian and Pacific Islander adults during COVID-19 Pandemic

• Cameron K. Ormiston   ORCID: orcid.org/0000-0002-3598-616X 1 , 2 ,
• Paula D. Strassle   ORCID: orcid.org/0000-0002-1072-1560 1 ,
• Eric Boyd 3 &
• Faustine Williams   ORCID: orcid.org/0000-0002-7960-2463 1  

Scientific Reports volume  14 , Article number:  9417 ( 2024 ) Cite this article

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In the United States, Asian and Pacific Islander (A/PI) communities have faced significant discrimination and stigma during the COVID-19 pandemic. We assessed the association between discrimination and depression, anxiety, and loneliness symptoms among Asian or Pacific Islander adults (n = 543) using data from a 116-item nationally distributed online survey of adults (≥ 18 years old) in the United States conducted between 5/2021–1/2022. Discrimination was assessed using the 5-item Everyday Discrimination Scale. Anxiety, depression, and loneliness symptoms were assessed using the 2-item Generalized Anxiety Disorder, 2-item Patient Health Questionnaire, and UCLA Loneliness Scale—Short form, respectively. We used multivariable logistic regression to estimate the association between discrimination and mental health. Overall, 42.7% of participants reported experiencing discrimination once a month or more. Compared with no discrimination, experiencing discrimination once a month was associated with increased odds of anxiety (Adjusted Odds Ratio [aOR] = 2.60, 95% CI = 1.38–4.77), depression (aOR = 2.58, 95% CI = 1.46–4.56), and loneliness (aOR = 2.86, 95% CI = 1.75–4.67). Experiencing discrimination once a week or more was associated with even higher odds of anxiety (aOR = 6.90, 95% CI = 3.71–12.83), depression, (aOR = 6.96, 95% CI = 3.80–12.74), and loneliness (aOR = 6.91, 95% CI = 3.38–13.00). Discrimination is detrimental to mental health, even at relatively low frequencies; however, more frequent discrimination was associated with worse mental health symptoms. Public health interventions and programs targeting anti-A/PI hate and reducing A/PI mental health burden are urgently needed.

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Introduction.

Since the start of the COVID-19 pandemic, the United States (US) has seen a dramatic rise in anti-Asian and Pacific Islander (A/PI) discrimination 1 , 2 . Within the first month of the Asian Pacific Policy and Planning Council’s public reporting center for discrimination being active, they received 1,497 reports of anti-A/PI discrimination from across the US 3 . Since the start of the pandemic, anti-Asian hate crimes have increased by 344% and over half of Asian adults report that anti-Asian discrimination is more frequent compared to before the pandemic 1 . In one nationally representative survey of US adults, 1 in 3 Asian adults reported experiencing COVID-related discrimination, and Asian adults were more likely to experience discrimination compared to Black/African American, Hawaiian/Pacific Islander, Hispanic/Latino, multiracial, and White adults, even though COVID-related discrimination was common across all racial and ethnic minoritized groups 4 . Furthermore, almost a third of US adults believe China or Chinese Americans are to blame for the COVID-19 pandemic 5 .

Experiences of discrimination can have extensive, adverse impacts on the health, including mental health, of racial and ethnic minoritized individuals 2 . For example, after the September 11, 2001 attacks, the US saw a rise in discrimination, hate crimes, and negative attitudes towards Muslim Americans, which resulted in increased depressive and post-traumatic stress disorder (PTSD) symptoms among Muslim Americans 6 , 7 , 8 . Worse mental health due to discrimination after the 9/11 attacks was also reported among other minoritized groups, including Latino adults and Asian Americans 9 , 10 . In fact, national emergencies and crises, such as 9/11 or the COVID-19 pandemic, likely provide opportunities for white supremacy and privileged groups to reassert hegemony over the country’s sociopolitical and ideological environment thereby facilitating the exclusion of non-White communities 9 .

Discrimination experiences are said to trigger stress and trauma responses that can lead to chronic mental and physical health conditions such as cardiovascular disease, PTSD, and depression 1 , 6 , 11 . Indeed, numerous studies predating the pandemic have linked discrimination with depression, suicidal ideation, loneliness, and psychological distress among A/PI adults 1 , 12 , 13 , 14 . Persistent anti-Asian rhetoric in the US news, social media, and general population, and terms such as “Kung flu,” “Chinese Virus,” and other derogatory terms toward Asian communities during the pandemic will have deleterious, far-reaching effects on A/PI mental health 2 , 6 , 15 . For example, witnessing anti-Asian discrimination in public or seeing images of discrimination towards Asian individuals on the news or social media has been linked to depressive and anxiety symptoms among Asian adults during the pandemic 16 . And although A/PI adults were less likely to report having poor mental health compared to White adults prior to the pandemic 2 , 17 , 18 , 19 , recent research has found higher levels of mental health symptoms compared with White adults during the pandemic 2 , 20 .

Presently, our knowledge on the impact of discrimination during the COVID-19 pandemic on A/PI mental health is still developing. Although depression, anxiety, and loneliness have been examined among A/PI individuals before, most studies have focused on specific populations (e.g. adolescents, older adults), predate the COVID-19 pandemic, did not control for pre-existing mental health conditions, or did not utilize a national sample 1 , 6 , 21 , 22 . Understanding this relationship is important given the drastic increase in discrimination faced by A/PI communities in the US, and the already high risk of mental health concerns during the pandemic. Thus, the purpose of this analysis was to examine the association between discrimination and depression, anxiety, and loneliness symptoms during the COVID-19 pandemic in a national sample of A/PI adults living in the United States. We hypothesized higher frequency of discrimination would confer higher odds of depression, anxiety, and loneliness.

Study data and population

We conducted a comprehensive 116-item online survey that was nationally distributed throughout the US, which focused on mental health during the COVID-19 pandemic. Qualtrics LLC, which uses a national survey panel to conduct online surveys, distributed ten thousand surveys to adults (≥ 18 years old) living in the US from May 13, 2021, to January 9, 2022. Upon completing the survey, participants were given a $5–10 gift card from Qualtrics. As we were interested in assessing mental health during the pandemic among African, Asian, Hispanic/Latino, and Middle Eastern immigrant individuals, this group was oversampled during recruitment. Low-income (< $25,000 annual household income) and rural adults were also oversampled.

Initial survey responses received by Qualtrics (n = 5938, 59.4% response rate) were assessed via Expert Review Fraud Detection to prevent multiple submissions and ensure data integrity. Participants were removed from the final survey sample if they completed < 80% of the survey after accounting for skip pattern items or if they took < 5 min to complete the survey. Overall, 5,413 surveys were ultimately included in the final sample. For this study, we restricted our cohort to participants who self-identified as Asian and/or Pacific Islander (n = 534, 9.9% of sample). Informed consent was obtained from all individual participants included in the study.

The research protocol for the study was reviewed by the National Institutes of Health (NIH) Institutional Review Board (IRB) and was approved on December 23, 2020 (IRB#000308) as an exempt study. The NIH Intramural Research Program IRB Human Research Protections Program Office of Human Subjects Research Protections determined that our protocol did not involve human subjects and was excluded from IRB review. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The data for the study is available upon request per the new Data Management and Sharing Agreement plan.

An adapted version of the 5-item Everyday Discrimination Scale 23 was used to assess for frequency of discrimination during the COVID-19 pandemic. Participants were asked, “Since the beginning of the Coronavirus/COVID-19 pandemic, how often have any of the following things happened to you? (1) You are treated with less courtesy or respect than other people; (2) You receive worse service than other people in restaurants or stores; (3) People act as though they think you are not intelligent; (4) People act as though they are afraid of you; and (5) You are threatened or assaulted”. For each scenario, participants had five answer options (Never, About once a month, About once a week, 2–3 times a week, and Daily or almost daily). Based on the responses, discrimination frequency was classified as having felt discrimination never, once a month, or once a week or more (About once a week/2–3 times a week/daily or almost daily). Participants were further asked to give the main reasons for their discrimination experiences. They could select all that apply from the following list of reasons: People think I have Coronavirus/COVID-19, Race, Ancestry or national origin, Immigration status, Gender, Age, Religion, Height, Weight, Sexual orientation, Education or income level, None of these or not applicable. The Everyday Discrimination Scale has been validated among a wide range of racial and ethnic groups, including Asian American adults 23 , 24 , 25 , 26 , 27 , 28 , 29 .

Anxiety, depression, and loneliness symptoms were assessed using the 2-item Generalized Anxiety Disorder (GAD-2) 30 , 2-item Patient Health Questionnaire (PHQ-2) 31 , and UCLA Loneliness 3-item Scale—Short form (ULS-3) 32 , respectively. The GAD-2 asks, “Over the last 2 weeks, how often have you been bothered by the following problems? (1) Feeling nervous, anxious, or on edge. (2) Not being able to stop or control worrying.” Respondents answered, Not at all (0), Several days (1), More than half the days (2), and Nearly every day (3) for each item. Response scores were summed, and a score of ≥ 3 indicated GAD (yes/present) and < 3 no/none 33 . The PHQ-2 asked, “Over the last 2 weeks, how often have you been bothered by the following problems? (1) Feeling nervous, anxious, or on edge. (2) Not being able to stop or control worrying”. Possible responses included Not at all (0), Several days (1), More than half the days (2), and Nearly every day (3) for each item. Response scores were summed, and a score of ≥ 3 indicated yes/present depression symptoms and < 3 no/none 31 , 34 . The ULS-3 asks participants, “How often do you feel that you lack companionship?”, “How often do you feel left out?”, “How often do you feel isolated from others?”. Response options included Hardly ever (1), Some of the time (2), and Often (3) 32 . Response scores were summed for each participant and a score of 3–5 = Not Lonely (no/none) and 6–9 = Lonely (yes/present) 32 . These scale cutoffs have been validated among a diverse range of populations 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 .

Other covariates were created from single questions from the questionnaire including age (18–44, 45–54, 55–64, ≥ 65 years old), country of birth (Born outside the US or Born in the US/US-born), income ($0–24,999; $25,000–34,999; $35,000–49,999; $50,000–74,999; ≥ $74,999), education (Less than high school, High school graduate, Technical or Some college, ≥ College degree), race (Asian or Pacific Islander), ethnicity (Hispanic/Latino or not Hispanic/Latino), sexual orientation (Bisexual, Else, Gay, Heterosexual, or Lesbian), gender identity (Man, Transgender and/or Non-binary, and Woman), marital status (Divorced/Separated, Married/Living with partner, Never married, Widowed), housing stability (Stable or Unstable) and employment (Employed [full or part-time] or Not employed).

Statistical analyses

Prevalence of reasons for discrimination, anxiety, depression, and loneliness symptoms, overall and by frequency of COVID-related discrimination, were estimated using descriptive statistics. Multivariable logistic regression was used to estimate the association between discrimination (once a week or more vs. never; and monthly vs. never) and depression, anxiety, and loneliness symptoms, respectively. All models adjusted for race, ethnicity, age, gender identity, sexual orientation, income, country of birth, marital status, education, employment, housing stability, and history of mental health conditions (Anxiety disorder, Depressive disorder, Other mental health diagnosis). All analyses were performed using SAS version 9.4 (SAS Inc., Cary, NC) and SUDAAN Release 11.0.1 (Research Triangle Institute: Research Triangle Park, NC).

Descriptive statistics of study sample

The majority of participants was Asian (91.9%), aged 18–44 years (61.0%), identified as woman (65.6%), heterosexual (89.5%), were employed (56.4%), and had a college degree or more (61.0%). Approximately 56.2% of the sample was born outside of the US. In terms of pre-existing mental health conditions, 10.7% had anxiety, 7.7% had depression, and 7.6% had a mental health diagnosis that was not anxiety or depression. See Table 1 .

Overall, 42.7% of participants reported experiencing discrimination (once a month: 23.4%; once a week or more: 19.3%). Differences in discrimination frequency were seen by race, age, sexual orientation, annual household income, marital status, region of birth, history of mental health conditions (anxiety, depression, and other mental health diagnosis), and housing stability. See Table 1 . When stratifying the overall sample by race, there were differences by sexual orientation, education, region of birth, history of mental health conditions (anxiety, depression, and other mental health diagnosis), and housing status. See Table 2 .

Among participants who reported discrimination, 25.4% said the discrimination was COVID-19-related, 60.8% said it was due to race, 25.0% due to ancestry, 20.7% due immigration status, and 21.6% due to gender. See Supplemental Table 1 . Participants who experienced discrimination more frequently were more likely to report the discrimination was due to religion (19.1% vs. 4.7%, p = 0.0006). See Supplemental Table 2 and Fig.  1 A.

( A – C ) Reasons for discrimination among individuals who reported experiencing discrimination during the pandemic (n = 232, 43.4%), stratified by ( A ) Discrimination frequency, ( B ) Race, and ( C ) Country of Birth. Participants were able to select more than one reason. ( A ) Reasons for discrimination stratified by discrimination frequency. ( B ) Reasons for discrimination stratified by race. ( C ) Reasons for discrimination stratified by place of birth.

When stratifying participants who experienced discrimination by race, no differences were found between Asian and Pacific Islander respondents. See Supplemental Table 3 and Fig.  1 B. After stratifying by place of birth (born outside US and US-born), people born outside US were more likely to report the discrimination was due to race (66.9% vs. 54.1%, p = 0.04) and ancestry (30.6% vs. 18.9%, p = 0.04). See Supplemental Table 4 and Fig.  1 C.

After adjusting for sociodemographic characteristics and history of mental health, we observed a dose–response between frequency of discrimination and increased odds of poor mental health. For example, compared with those reporting no discrimination, experiencing discrimination once a month was associated with almost three times the odds of anxiety (Adjusted Odds Ratio [aOR] = 2.60, 95% Confidence Interval [CI] = 1.38–4.77) and experiencing discrimination once a week or more was associated with over six times the odds of anxiety (aOR = 6.90, 95% CI = 3.71–12.83), Supplemental Table 5 and Fig.  2 A. Similar trends were observed for both depression (once a month: aOR = 2.58, 95% CI = 1.46–4.56; once a week or more: aOR = 6.96, 95% CI = 3.80–12.74) and loneliness (once a month: aOR = 2.86, 95% CI = 1.75–4.67; aOR = 6.91, 95% CI = 3.38–13.00). See Supplemental Table 5 and Fig.  2 B,C.

( A – C ) Adjusted association between discrimination and ( A ) anxiety, ( B ) depression, and ( C ) loneliness symptoms among Asian and Pacific Islander adults. ( A ) Adjusted association between discrimination and anxiety. ( B ) Adjusted association between discrimination and depression. ( C ) Adjusted association between discrimination and depression and loneliness. All models were adjusted for race, ethnicity, age, gender identity, sexual orientation, income, country of birth, marital status, education, employment, housing stability, and history of mental health conditions (Anxiety disorder, Depressive disorder, Other mental health diagnosis). N = 499 Asian and Pacific Islander adults. See Supplemental Table 5 for the values of each aOR and 95% CI.

Using a national sample of US A/PI adults, we found that almost 50% reported experiencing discrimination, and among those who experienced discrimination, 25% reported that it was related to COVID-19. We also found that even when discrimination is experienced at relatively low frequencies (monthly), it had a substantial and detrimental impact on mental health; moreover, among individuals who experienced discrimination more frequently (once a week or more) the odds of poor mental health was even greater. Overall, this study represents one of the most recent and comprehensive assessments of the impact of discrimination on mental health in the US A/PI community during the COVID-19 pandemic.

Since the start of the pandemic, depressive symptoms among US adults and global anxiety symptoms have both tripled, and global loneliness symptoms have significantly increased 39 , 40 , 41 . These trends may be due to a multitude of reasons, including diseases-related anxiety, isolation due to quarantine and stay-at-home orders, and stress from economic and financial instability 41 . A/PI individuals, however, may be doubly burdened during the pandemic, experiencing fear, stress, and isolation due to not only the pandemic, but also due to anti-Asian discrimination, stigmatization, and violence 2 , 6 .

The present study found the total prevalence of discrimination among A/PI, Asian, and Pacific Islander adults to be 42.7%, 41.1%, and 61.4%, respectively. These findings are comparable with existing research. For example, a study utilizing COVID-19 Effects on the Mental and Physical Health of Asian Americans and Pacific Islanders Survey Study data found 60.7% of A/PI adults reported discrimination 42 . An online survey of Asian adults in Florida found 56.5% experienced discrimination during the pandemic 6 . Other studies report the prevalence of COVID-19-related discrimination to be 20–67% among Asian adults 1 , 2 , 4 , 43 . Among Pacific Islander adults, the prevalence of discrimination during the pandemic is estimated to be 22.8–40.5% 4 , 42 . Research prior to the pandemic show the prevalence of discrimination among Asian and Pacific Islander adults living in the US was 13–50% and 48–52%, respectively 13 , 42 . Both the present study and prior studies therefore highlight the increase in discrimination among A/PI adults and an urgent need to address this issue given discrimination’s harmful effects on mental health.

Prior research has also shown anti-Asian discrimination during the pandemic has negative effects on mental health 2 , 43 and may have led to the Asian-White mental health gap now seen in the US 2 . Our findings also mirror existing research on the link between discrimination and A/PI mental health both prior to and during the pandemic 1 , 2 , 16 , 43 , 44 , 45 , 46 . A recent study on Asian/Asian American young adults found COVID-19-related discrimination to be significantly associated with PTSD symptoms after controlling for demographics, socioeconomic status, lifetime discrimination, and pre-existing mental health conditions 1 . Furthermore, an analysis of a national survey of 245 Asian/Asian American adults found discrimination during the pandemic was significantly associated with depressive symptoms as assessed using the 20-item Center for Epidemiologic Studies of Depression Scale 43 . Given A/PI adults report lower rates of using mental health services and discrimination has been previously associated with lower mental health service utilization among Asian adults, providing community-based, accessible, anti-racist, and culturally competent services is increasingly important 2 , 3 , 12 .

There are a number of limitations to consider for our study. First, our study is cross-sectional, meaning we cannot infer any directionality or causality of our findings. While we assume discrimination leads to mental health symptoms, individuals with mental health conditions experience significant barriers and stigmatization in society and report high levels of discrimination due to their mental health status, particularly those of racial and ethnic minoritized groups 47 , 48 , 49 , 50 . Second, given small sample sizes, we aggregated the Asian and Pacific Islander samples, and were unable to perform Asian and Pacific Islander analyses separately and among subgroups. Future research should aim disaggregate data and examine the link between discrimination and mental health outcomes across Asian and Pacific Islander subgroups and other intersectional identities (e.g., generational immigration status). The heterogenous experiences between these groups therefore may not be captured in our results. Additionally, the sample size for many of our cell counts were small, which may also introduce power issues that can impact the results and are likely to be unstable in adjusted models. Fourth, this was a convenience sample, which limits statistical inference, replication, and generalization of the results. Data integrity may also be a concern of convenience sampling; however we had several safeguards in place to prevent this issue. Fourth, the survey was conducted in English, thus individuals with limited English proficiency may have been underrepresented. Finally, the survey was online and individuals with limited access to the internet may not have been captured in the results.

Conclusions

Among a national sample of A/PI adults, discrimination was associated with anxiety, depression, and loneliness symptoms. Although odds of mental health symptoms increased with increased frequency of discrimination, our results highlight the deleterious impact of discrimination even at ‘low’ levels of frequency. The pandemic and discrimination will likely have far-reaching, sustained impacts on A/PI mental and physical health. As such, health practitioners need to be educated on the unique experiences of A/PI adults, prepared to effectively screen for and treat these issues, and utilize their unique positions as leaders in health and society to stand up to racism and discrimination. Interventions that both target anti-A/PI hate and disinformation and address the growing mental health burden among A/PI in the US will be essential to mitigating potential long-term, negative effects of the pandemic among A/PI communities.

Data availability

The data are available by making a request through Dr. FW per the new Data Management and Sharing Agreement plan.

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Physical Fitness Linked to Better Mental Health in Young People

A new study bolsters existing research suggesting that exercise can protect against anxiety, depression and attention challenges.

By Matt Richtel

Physical fitness among children and adolescents may protect against developing depressive symptoms, anxiety and attention deficit hyperactivity disorder, according to a study published on Monday in JAMA Pediatrics.

The study also found that better performance in cardiovascular activities, strength and muscular endurance were each associated with greater protection against such mental health conditions. The researchers deemed this linkage “dose-dependent,” suggesting that a child or adolescent who is more fit may be accordingly less likely to experience the onset of a mental health disorder.

These findings come amid a surge of mental health diagnoses among children and adolescents, in the United States and abroad, that have prompted efforts to understand and curb the problem.

The new study, conducted by researchers in Taiwan, compared data from two large data sets: the Taiwan National Student Fitness Tests, which measures student fitness performance in schools, and the National Insurance Research Databases, which records medical claims, diagnoses prescriptions and other medical information. The researchers did not have access to the students’ names but were able to use the anonymized data to compare the students’ physical fitness and mental health results.

The risk of mental health disorder was weighted against three metrics for physical fitness: cardio fitness, as measured by a student’s time in an 800-meter run; muscle endurance, indicated by the number of situps performed; and muscle power, measured by the standing broad jump.

Improved performance in each activity was linked with a lower risk of mental health disorder. For instance, a 30-second decrease in 800-meter time was associated, in girls, with a lower risk of anxiety, depression and A.D.H.D. In boys, it was associated with lower anxiety and risk of the disorder.

An increase of five situps per minute was associated with lower anxiety and risk of the disorder in boys, and with decreased risk of depression and anxiety in girls.

“These findings suggest the potential of cardiorespiratory and muscular fitness as protective factors in mitigating the onset of mental health disorders among children and adolescents,” the researchers wrote in the journal article.

Physical and mental health were already assumed to be linked , they added, but previous research had relied largely on questionnaires and self-reports, whereas the new study drew from independent assessments and objective standards.

The Big Picture

The surgeon general, Dr. Vivek H. Murthy, has called mental health “the defining public health crisis of our time,” and he has made adolescent mental health central to his mission. In 2021 he issued a rare public advisory on the topic. Statistics at the time revealed alarming trends: From 2001 to 2019, the suicide rate for Americans ages 10 to 19 rose 40 percent, and emergency visits related to self-harm rose 88 percent.

Some policymakers and researchers have blamed the sharp increase on the heavy use of social media, but research has been limited and the findings sometimes contradictory. Other experts theorize that heavy screen use has affected adolescent mental health by displacing sleep, exercise and in-person activity, all of which are considered vital to healthy development. The new study appeared to support the link between physical fitness and mental health.

“The finding underscores the need for further research into targeted physical fitness programs,” its authors concluded. Such programs, they added, “hold significant potential as primary preventative interventions against mental disorders in children and adolescents.”

Matt Richtel is a health and science reporter for The Times, based in Boulder, Colo. More about Matt Richtel

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Millions of children in the United States have received a diagnosis of A.D.H.D . Here is how their families can support them .

The condition is also being recognized more in adults . These are some of the behaviors  that might be associated with adult A.D.H.D.

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The disorder can put a strain on relationships. But there are ways to cope .

Though meditation can be beneficial to those with A.D.H.D., sitting still and focusing on breathing can be hard for them. These tips can help .

• Open access
• Published: 07 May 2024

The impact of the Systematic Assessment for Resilience (SAR) framework on students’ resilience, anxiety, depression, burnout, and academic-related stress: a quasi-experimental study

• Majed Wadi   ORCID: orcid.org/0000-0002-8117-770X 1 ,
• Ali Shorbagi   ORCID: orcid.org/0000-0002-2908-0281 2 ,
• Sarra Shorbagi   ORCID: orcid.org/0000-0001-9246-2904 3 ,
• Mohamed Hassan Taha   ORCID: orcid.org/0000-0003-0808-5590 4 &
• Muhamad Saiful Bahri Yusoff   ORCID: orcid.org/0000-0002-4969-9217 5  

BMC Medical Education volume  24 , Article number:  506 ( 2024 ) Cite this article

Metrics details

Medical students face significant psychological stress, impacting their academic performance and well-being. The Systematic Assessment for Resilience (SAR) framework is designed to enhance resilience and mitigate stress among medical students, addressing the need for interventions within the assessment system in medical education. The aim of this study was to evaluate the implementation of SAR framework on medical students’ resilience, anxiety, depression, burnout, and academic stress.

This study employed a quasi-experimental design with pre- and post-testing. It involved the training of course coordinators in implementing the SAR framework and its integration into the daily learning activities. Fourth-year medical students were assessed before and after the intervention using standardized measures of resilience, anxiety, depression, burnout, and academic stress. Data were analyzed using quantitative methods and thematic analysis for qualitative feedback.

Post-intervention, students demonstrated a significant increase in resilience scores ( p  < 0.001) and a notable decrease in measures of anxiety, depression, and academic stress ( p  < 0.001). The burnout types were also statistically different ( p  < 0.001) except client-related burnout ( p  > 0.05). Qualitative feedback of the course coordinators highlighted an improved learning environment, increased coping strategies, and a more supportive academic culture.

The SAR framework significantly contributes to enhancing medical students’ resilience and reducing psychological distress. Its implementation suggests a promising approach to fostering a supportive educational environment that not only addresses the psychological challenges faced by medical students but also enhances their academic performance and overall well-being. Further research is warranted to explore the long-term impacts of SAR across different medical education contexts.

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Introduction

Medical students perceive medical school as a demanding environment due to the nature and magnitude of the curriculum’s contents [ 1 ] and the pressure of numerous assessments that influence important decisions in their lives [ 2 ]. Systematic reviews and meta-analyses reveal alarming figures regarding the extent to which medical students suffer from stress and its consequences, such as anxiety and depression [ 3 , 4 , 5 ]. It has been found that 30% of medical students suffer from stress, anxiety, or depression [ 5 , 6 , 7 ]. Other studies have reported even higher rates of these problems (70%) [ 8 , 9 ]. Chronic stress aggravates other undesirable problems, such as poor academic performance, poor peer relationships, academic dishonesty, depression, and even sleep and eating disorders [ 10 , 11 ]. Additionally, chronic stress is connected to drug addiction, alcoholism, and suicide [ 3 , 4 , 5 ]. It has been found that doctors who suffer stress throughout their undergraduate education may develop a negative attitude toward their profession that could threaten patient care [ 5 , 6 , 7 ].

Based on these facts, it is sensible to identify the causes of stress and to implement interventions to alleviate this burden. Multiple studies have found that tests and exams are among the most identified causes [ 4 , 5 , 12 , 13 ]. Consequently, several interventions have been implemented to combat what is known in the literature as test anxiety [ 7 , 14 ]. In their systematic review, Soares and Woods [ 15 ] summarized several studies on test anxiety reduction and found a lack of collaboration between the identified interventions and the school site, which impeded the maximum benefit of intervention and the desired outcomes. Furthermore, the identified studies focus on a single aspect of the problem without addressing a solid theoretical framework or a holistic perspective on other factors that influence the situation [ 15 ]. Consequently, it has become vital to seek comprehensive approaches that incorporate both individual and systemic (organizational) factors [ 4 , 5 ]. With the expansion of resilience research, medical educators are increasingly interested in identifying interventions that foster resilience among medical students [ 3 , 16 , 17 ].

Resilience is a construct that cultivates a variety of characteristics necessary for adapting to the dynamic changes of life and maintaining well-being [ 18 ]. Resilience is no longer viewed as a set of inherited traits that enable an individual to overcome life’s challenges and adversities; rather, it is viewed as a dynamic process and an acquired trait, meaning that it can be taught and fostered [ 19 , 20 ]. Despite varying definitions of resilience, the general and agreed definition is the individual’s capacity to deal with and overcome adversity appropriately and effectively that boosts well-being [ 4 , 18 , 21 , 22 , 23 , 24 ]. Accordingly, resilient students are those who can maintain their abilities and continue to grow despite academic and life obstacles [ 3 , 25 , 26 , 27 ]. According to related literature, resilience can be fostered by working on multiple levels. The first level begins with internal factors, which means advancing the psychological process in the face of adversity and enhancing what are called “internal traits” [ 28 ]. The second level involves exposing individuals to simulated adversities and providing them with opportunities for reflection [ 21 , 29 ]. The third level derives from the extent of institutional or organizational efforts to provide protective factors and fertile resources (external protective factors) to equip individuals with the necessary protective factors to overcome life’s adversities [ 28 , 30 ].

In their recent research, Wadi et al. developed a framework for fostering resilience through the process of student assessment [ 31 ]. This framework is called the Systematic Assessment for Resilience (SAR) framework and encompasses numerous guidelines for fostering resilience and enhancing its four constructs: (1) self-control, in which students should be able to govern themselves and face adversity; (2) management, which describes the students’ ability to use available resources effectively to overcome obstacles; (3) engagement, which highlights the students’ ability to be involved and committed to pursuing challenges with perseverance; and (4) growth, which reflects the students’ ongoing development to face future challenges. The four constructs work together in a cycle to promote resilience through five phases of assessment: (i) direction, which focuses on improving the candidate’s understanding of the assessment’s scope and procedure; (ii) preparation, which emphases enhancing candidates’ cognitive, mental, and psychomotor readiness to optimize assessment performance; (iii) experience, which helps enhance the formative assessment component; (iv) examiner focus, which deals with improving examiner behavior to increase candidate performance and decrease candidate anxiety; and (v) student reflection, which encourages self-review [ 31 ]. The SAR framework presents a comprehensive approach that promises to foster a learning environment in medical schools that supports mental well-being and cultivates resilience in medical students. Therefore, this study aims to evaluate the impact of the SAR framework implementation on enhancing resilience and reducing anxiety, depression, and academic-related stress among medical students.

Study setting

The study was conducted at the University of Sharjah, College of Medicine (UoS-CoM), which offers a six-year MBBS program delivered in three phases: Phase I is the foundation year and Phase II is the pre-clerkship phase, which includes years 1, 2, and 3. This is followed by Phase III, a clerkship phase, that comprises years 4 and 5. In the clerkship phase, students receive clinical training in various departments in public and private hospitals in Sharjah. Year 4 consists of four clinical rotations (10 weeks each) in the four major divisions of Medicine, Surgery, Pediatrics, and Obstetrics & Gynecology, while in Year 5, the rotations include medicine and surgery sub-specialties such as Neurology, Dermatology, Cardiology, Nephrology, ENT, and Ophthalmology, as well as Family Medicine and Psychiatry [ 32 ].

Study population

For logistical considerations, Year 4 students were selected as study participants. All 149 fourth-year medical students registered for the academic year 2021–2022 at UoS-CoM were invited to participate in this study.

Course coordinators.

Eight Year 4 course coordinators, responsible for planning courses, organizing educational events, facilitating bedside training in teaching hospitals, and managing learning materials in the learning management system, were invited to participate in the study.

Eligibility criteria of participants

For students, only those who participated in both the pre- and post-stages of the study will be included in the analysis of the results. As for course coordinators, only those who agree to participate in the in-depth interview will be included in the analysis of results.

Study design

The study used a quasi-experimental design with one group pre- and post-test [ 33 ]. The decision to opt for a single-group design was driven by ethical considerations, as randomizing student participants into intervention and control groups posed ethical concerns related to potential unequal benefits [ 33 ]. Additionally, the feasibility of maintaining the integrity of training materials among course coordinators in the target group further supported the choice of a single-group pre-test and post-test design [ 34 ].

The design begins with training all course coordinators on how to use the SAR framework as a daily practice in their respective clerkships and then measuring its effect on students before and after its implementation. Furthermore, in-depth interviews were conducted with the course coordinators (Fig.  1 ). The purpose of this qualitative phase was to gain insights into the perceptions of the SAR guidelines among medical teachers, as well as to assess the feasibility and applicability of these guidelines in the clinical setting.

Study intervention

The intervention began with a training session on how to utilize and implement the SAR framework, which was completed before the clerkship rotation began. It was a five-hour online training workshop provided by Microsoft Teams for fourth-year medical educators (Appendix I ). The course coordinators were informed that SAR consists of guidelines that promote resilience throughout the various phases of assessment, from planning to implementation to evaluation. Participants were given a group activity consisting of a list of SAR guidelines presented in the form of a series of yes-or-no questions regarding how to apply the SAR guidelines (Appendix II ). To facilitate the effective implementation of the guidelines, they were tabulated, and each was accompanied by an example of how and when to use it (Appendix III ). In addition, the participants were supported/monitored through ongoing online communication (WhatsApp group, online meetings, email reminders) to discuss and clarify any concerns regarding SAR guidelines. They were not required to implement all of the framework’s guidelines; rather, they were free to decide which guidelines were feasible and applicable to their clerkships. As a result, all students received the intervention, which was tailored based on the guidelines implemented by their course coordinators.

Data collection

Quantitative data.

Quantitative data were gathered from Year 4 medical students whose course coordinators implemented the SAR guidelines in their respective courses. Before starting their respective clerkship rotations, all students were invited to complete the study’s measurement instruments through a Google form, distributed to them via their official email addresses. Four tools were used: (1) the Medical Professionals Resilience Scale (MeRS) to measure resilience, (2) the academic-related stressors (ARS) part of the Medical Students Stressor Questionnaire (MSSQ), (3) the depression and anxiety parts of the Depression and Anxiety Stress Scale (DASS), and (4) the Copenhagen Burnout Inventory (CBI). Appendix IV contains full details of study tools and how they were scored, however, a general overview of these tools is described below.

The Medical Professionals Resilience Scale (MeRS) [ 35 ] measures four domains of resilience based on the integrated resilience model [ 36 ]: control, resourcefulness, involvement, and growth dimensions. The MeRS is a valid and reliable scale with a Cronbach’s alpha of 0.914 [ 35 ]. It presents 37 items to rank according to a four-point Likert scale (1 Strongly disagree , 2 Disagree , 3 Agree , and 4 Strongly agree ). Six items assess the domain of control, which refers to medical professionals’ ability to remain calm and composed in the face of adversity, four assess resourcefulness—the ability to use available resources to overcome adversity—twelve assess commitment, and fifteen assess growth capability and resilience following adversity.

The Medical Student Stress Questionnaire (MSSQ) [ 37 ] contains 40 items covering six dimensions of stress unique to medical students—academic stressors, interpersonal stressors, teaching and learning stressors, social stressors, drive/desire stressors, and group activity stressors. The questionnaire is based on a four-point Likert scale and has a good level of validity and reliability, with a Cronbach’s alpha of 0.95 in the initial study [ 37 ], and its reliability has been consistently upheld across various contexts and cultures [ 38 , 39 ]. For the purpose of this study, only the items measuring academic-related stressors (ARS) were used.

The Depression, Anxiety, and Stress Scale (DASS-21) [ 40 ] is a widely used screening tool that utilizes a tripartite approach to assess three dimensions of emotional states: depression (low positive affect), anxiety (physiological hyperarousal), and stress (negative affect) [ 41 ]. Each dimension of the DASS-21 contains seven items. The respondents were asked to consider how much each statement applied to them in the previous week and rank each statement accordingly. A score of 0 means Did not apply to me at all , 1 =  Applied to some degree or some of the time , 2 =  Applied to me to a considerable degree or a good part of time , 3 =  Applied to me very much or most of the time ). DASS-21 has an overall Cronbach’s alpha of 0.93 [ 40 ] in the original study. This reliability has been mirrored in its global application [ 42 ].

The Copenhagen Burnout Inventory (CBI) [ 43 ] is a self-reporting inventory comprised of 19 items that assess personal-, work-, and client-related burnout. The personal-related burnout domain has six items and assesses respondents’ levels of physical and psychological fatigue or exhaustion independent of their work. The work-related burnout domain contains seven items and assesses respondents’ levels of physical and psychological fatigue or exhaustion as a result of their employment. The client-related burnout domain has six items and assesses the respondent’s bodily and psychological weariness or fatigue as a result of their clients. Client is a broad term that encompasses individuals, such as students, customers, and patients. In accordance with the CBI guide, the phrase “client-related burnout” should be used when referring to the sample’s participants, and this domain will henceforth be referred to as shown. It has been confirmed using Cronbach’s alpha values of 0.85 to 0.87 for each domain [ 43 ], the reliability of the instrument has been consistently evident in various studies utilizing the CBI [ 44 ].

For the purpose of analyzing and matching students’ responses in pre- and post-intervention, students were asked to include a distinct number in both surveys to facilitate the matching of pre- and post-intervention responses without compromising confidentiality.

Qualitative data

Qualitative data were collected at the end of the clinical courses via in-depth interviews with the course coordinators. The interview was conducted in person and recorded for verbatim transcription and analysis. Figure  1 is a flow chart illustrating the steps of the study.

Study flowchart

Data analysis

Initially, each participant’s pre- and post-intervention data were matched, and descriptive and inferential analyses were conducted using SPSS 23 with a 95% confidence interval and a significance level of 0.05. Based on the majority of measurement tools, the responses were calculated as means and standard deviations (SD). The paired t-test was used to compare the means of pre- and post-intervention results among students. McNemar test was used to analyze the difference of burnout cases pre- and post-intervention. Additionally, the Pearson correlation coefficient was used for pre- and post-intervention measurements to evaluate study parameters.

Braun and Clark’s six-phase thematic analysis method was used for the analysis of the transcripts of the interviews [ 45 ]. In the first step (data familiarization phase), the authors familiarized themselves with the data transcribed verbatim from the audio recordings, assigned pseudonyms to all identifiable individuals, and cross-checked the transcript against the audio recordings. In the second step (generating initial codes), the authors imported the transcript into Atlas.Ti (version 7.9) and began identifying open codes across the dataset, including the participants’ own words (in vivo) or a descriptor for their experience. Next, in the third step (searching for themes), the authors sought themes by combining several related codes to generate overarching themes. Then in the fourth step, reviewing the themes, the authors reviewed the themes and their coherence with the related quotes and defined and named the themes (fifth step) to write the report. Finally, as the sixth step, the authors wrote the report.

To ensure the trustworthiness of qualitative data, the researchers employed Guba’s four criteria: credibility, transferability, dependability, and confirmability [ 46 ]. Credibility (akin to internal validity) was enhanced through prolonged engagement during interview, ensuring participants fully expressed their experiences, and member checking, which involved validating summaries of discussion with participants “on the spot”. Transferability (comparable to external validity) was facilitated by providing detailed descriptions in the methodology section of the study’s context and participants, enhancing the applicability of findings across different settings. Dependability was secured through a code-recode strategy, involving periodic reevaluation of data coding to verify consistency. Lastly, confirmability was established by creating an audit trail, documenting the research process and analysis, thus offering a transparent record for external examination.

After matching students’ pre-and post-intervention responses, 78 students of 149 had participated in both phases. The characteristics of the students are shown in Table  1 .

Pre- and post-intervention scores of the measured parameters were compared for all students. Collectively, the mean differences in resilience (as a global score), as well as its underlying four constructs, showed negative values, indicating a significant increase in these parameters after the intervention, whereas the difference in the mean scores of depression, anxiety, and academic-related stressors showed positive values, indicating a significant reduction of these parameters after the intervention. There were statistically significant differences between the mean scores for all parameters (Table  2 ).

The analysis of student burnout pre- and post-intervention revealed significant shifts in two categories of burnout (Table  3 ). For personal-related burnout, all 21 participants initially classified as non-cases remained unchanged, highlighting the intervention’s stability in non-affected individuals. Conversely, 12 participants previously identified as cases transitioned to non-cases, showcasing a notable positive change ( p -value < 0.001). In the realm of work-related burnout, while 25 non-cases maintained their status, 11 cases shifted to non-cases, underscoring the intervention’s effectiveness ( p -value = 0.001). However, in client-related burnout, although a shift was observed with 6 moving from case to non-case, this change was not statistically significant ( p -value = 0.289) (Table  3 ).

The correlation matrix presented in Table  4 reveals substantial associations among the study variables pre- and post-intervention. Global resilience and its four domains consistently showed strong, positive correlations in both assessments. Depression, anxiety, and academic-related stress (ARS) were positively correlated with various burnout types. Inversely, global resilience and its subcomponents negatively correlated with these psychological stress indicators, suggesting that higher resilience is linked to lower levels of depression, anxiety, and stress.

Qualitative analysis of in-depth interviews

In-depth interviews were conducted with five course coordinators who agreed to participate to offer their perceptions of the SAR framework and its guidelines. Interviews were conducted through an online platform, each lasting around 35 min. The qualitative analysis of the interviews revealed the themes shown in Table  5 . Generally, all coordinators acknowledged the feasibility of implementing the SAR framework with their educational practices; for example, briefing the students about assessments, sharing the assessment rubrics with the students, implementing formative assessment and mock exams, providing supporting material about coping and study skills, encouraging peer and self-assessment, and orienting the examiners to create a less stressful environment during the exams. Concerning observed effectiveness, the coordinators stated that they noticed that students in the intervention were generally self-assured and were enjoying the rotation compared to other batches. Regarding the challenges faced with the SAR after its implementation, one coordinator expressed that some strategies could not be done without official approval from the curriculum committee; for instance, introducing collaborative assessment and open book exams. Almost all the coordinators emphasized that components included in the SAR framework should be obligatory as part of educational practices.

In contrast to other resilience interventions aimed at enhancing resilience at the individual level that use interventions with a limited perspective, the current study utilized a holistic approach to foster resilience as an integral part of daily assessment practices among medical students in their clinical years. Consequently, the purpose of applying the SAR framework is to sustain and foster resilience as part of the organization’s educational process [ 17 , 47 ]. The efficacy of the intervention was verified by measuring its impact on students’ psychological parameters (resilience, academic stress, anxiety, depression, and burnout), as well as by ascertaining the perspective of medical educators who used the framework. The analysis of psychological measurements yielded statistically significant results, and the qualitative analysis of the educators’ perspectives reported positive feedback. Below, we discuss the results based on study measurement tools and support the quantitative results with qualitative findings obtained from the participating educators.

The current study revealed that applying the SAR framework improved resilience significantly, reflecting the dramatic effect of SAR as an intervention. These findings can be explained from three aspects: (i) the approach of the SAR intervention, (ii) the nature of the guidelines, and (iii) the specific resilience measurement tool.

The SAR intervention approach is holistic and integrative. It incorporates resilience principles at multilevel steps across different stages of assessment, while simultaneously employing various preventive measures to counteract the opposite effect of anti-resilience constructs, particularly anxiety and stress. Indeed, the SAR framework utilized Huey and Palaganas [ 3 ] recommendation to combine organizational and individual factors to promote resilience in an HPE context. Furthermore, SAR promotes resilience at all stages of assessment: before, during, and after. The SAR guidelines aim to improve students’ protective factors during pre-assessment so that they can pursue the assessment with adequate resources and preparation. It has been demonstrated that providing students with adequate protective factors improves resilience [ 48 ]. During the assessment, the SAR guidelines aim to gradually expose students to uncertainty and difficulty through formative assessment or mock exams, so that they will engage in adversity but with support (feedback) to help them overcome difficulties and achieve their goals [ 49 , 50 ]. They will eventually develop confidence and belief in their own abilities (self-efficacy) [ 51 , 52 ]. As a result, they will be able to face similar struggles in the future [ 36 ]. The SAR framework provides opportunities for self-reflection following assessment. Students evaluate their performance based on constructive feedback, reformulate their goals [ 52 , 53 ], and benefit from the experience (growth and transformation) to face future challenges [ 53 ].

The nature of SAR guidelines is to make them part of daily practice as checklists facilitating their use. Checklists act as reminders of the most crucial steps that even highly qualified professionals might forget [ 54 ]. It has been demonstrated that using checklists is an easy and effective way to boost both individual and group performance [ 55 ]. Besides using checklists, SAR provides fertile resources explaining how every guideline can be applied. The courses’ coordinators acknowledged that they were pleasantly surprised by the way SAR could be integrated into assessment practice. They also commented on the richness of the provided resources, which facilitated the use of SAR in their practice, and the positive feedback they received from students (Table  5 ). Therefore, SAR can be described as a proactive and supportive framework for promoting resilience [ 56 ].

The last point supporting these findings was the result of a specific resilience measurement tool, the Medical Professionals Resilience Scale (MeRS) [ 35 ]. This tool was created based on the integrated resilience model [ 57 ]. The MeRS has specific items measuring a particular resilience construct. Even though this tool was validated for practicing doctors [ 35 ], the uniqueness of the items in measuring four resilience constructs—control, resourcefulness, involvement, and growth—supported its use in the current study. Several systematic reviews have recommended that using a specific measurement tool in resilience intervention is crucial for validating the intervention’s effectiveness [ 19 , 58 , 59 ].

Contrasting the current findings with previous research in terms of study design and the relationship between assessment and resilience is worthwhile. In terms of using an experimental design, the current study is comparable with certain studies identified in the systematic review that was done by Cleary, Kornhaber [ 58 ] in which numerous interventional studies using single-arm pre- and post-intervention measurement were very effective in promoting resilience among health professionals, and comparable with the findings of Kunzler, Helmreich [ 59 ] meta-analysis which found that several randomized controlled trials were very effective in promoting resilience among health professionals.

Regarding those studies’ attempts to explain the relationship between assessment and resilience, Berg and Pietrasz [ 60 ] used experiential classroom exercises (competitive activities) to help students develop resilience. Similarly, Clipa et al. [ 16 ] found that students’ resilience increases when they practice formative assessment, which reduces test anxiety. Although both studies have the same findings, the intervention proposed in the current study was developed based on a solid evidence-based framework [ 31 ].

The current findings are consistent with those of Liu et al. [ 61 ], who found that resilience mediated the relationship between emotion regulation and test anxiety and discovered that developing resilience improves emotional regulation, which automatically lowers test anxiety. The current study used SAR as an intervention not only to promote resilience but also to enhance emotional regulation. The employed approach targeted individual and environmental levels at various stages of assessment: pre-, during, and post-assessment to improve emotion regulation. The SAR contains guidelines focusing on emotion regulation, such as “advising students on exam skills” and “providing strategies for students to reduce test anxiety.” These guidelines principally aim to mitigate anxiety, thus fostering resilience. Cobbinah and Amoako [ 62 ] used a non-experimental study design to show that the assessment promotes resilience by causing students to manage and cope well with academic stress caused by “the assessment” without support and guidance, whereas the current study used an empirical study design (quasi-experimental) and designed a comprehensive assessment framework to promote resilience proactively. The current study provided protective factors (resources for assessment direction and preparation). These resources serve as enablers for achieving resilience and equip students with the resources they need to face adversity. In the absence of these resources, resilience will not grow. This works in the same way that adequate nutrition does after vaccination. Nutrition strengthens the immune system in the face of the vaccine [ 50 , 63 ].

Academic-related stress

The implementation of SAR significantly reduced academic stress, reflecting the effectiveness of the framework in improving psychological health. Obtaining this result may be due to the approach of the SAR framework. It adopts the implications of the transactional stress model of Lazarus and Folkman [ 64 ] and incorporates sets of guidelines at various levels to counteract stress and nurture the coping mechanisms of medical students. According to this model [ 64 ], there are three stages of stress development: (1) primary appraisal, influenced by stress antecedents; (2) secondary appraisal, influenced by stress mediators; and (3) reappraisal, influenced by stress consequences. Primary appraisal is the process by which an individual evaluates an event and decides whether it is positive, threatening (negative), or irrelevant [ 64 ]. This is influenced by personality traits (such as social evaluative trait anxiety, self-efficacy, and optimism) and environmental factors (such as the test atmosphere, the amount of social support available, and the nature of the cognitive task) [ 65 ]. The SAR framework encourages the personal traits and environment toward the positive side. It enhances self-efficacy and optimism through the frequency of formative assessment and feedback so that the students will acquire self-regulatory learning, which in turn enhances self-efficacy and optimism. Regarding the environment, it guides course coordinators to enrich the test environment with multiple factors to reduce the sources of test anxiety. The secondary appraisal appears if a negative event occurs. In this phase, the process starts when a person evaluates the resources available to deal with a situation. When a loss occurs, harm appraisal occurs. When a person anticipates harm, threat appraisal occurs; when they are confident in their ability to meet the demand of an event, challenge appraisal occurs [ 64 ]. Zeidner [ 65 ] described this psychological process as a stress mediator. The SAR framework was designed to empower the psychological process (stress mediators) so that the individual will have enough ability to appraise the harm event and overcome the loss if it occurs. This characteristic is the core of resilience [ 19 , 30 ]. Reappraisal occurs when new information or resources for dealing with an event become available. It is a continuous reevaluation of the event [ 64 , 66 ] influenced by individual characteristics and coping strategies [ 65 ]. The SAR is also designed to provide avenues for reappraisal and to strengthen personal characteristics and coping strategies in advance.

Another point to elucidate the findings is that the stress measurement instrument is primarily focused on academic-related stressors (ARS). ARS items are very specific to stressors arising from the academic context [ 37 ]. Because the SAR framework aims to promote resilience and simultaneously counteract other anti-resilience factors such as academic stress, the results are expected. The result is comparable with the randomized controlled trial (RCT) conducted by Yusoff and Esa [ 67 ], in which the same tool was used but the intervention was different. It was a workshop enhancing coping skills in the face of adversities. The current study utilized a holistic approach through daily practice of assessment and curriculum delivery. The SAR framework provides a range of advice on how to overcome test anxiety, how to manage time, and how to study properly (Appendix III ). All these skills were utilized as system-built approaches not only to foster resilience but also to enhance the protective factors of students and enhance medical teachers’ ability to provide a safe and healthy academic environment [ 48 ]. Notably, the medical educators reported a remarkable change in the students’ behavior exemplified by their favorable attitude toward the academic environment (Table  5 ).

Comparing the current findings with those of other studies that used resilience-focused intervention demonstrates that resilience intervention has an enduring effect on stress that can persist for six months after intervention [ 19 , 58 , 59 , 68 ]. The current study adds to this body of evidence by providing another empirical finding to support the nexus between reducing academic stress and improving resilience through assessment practice.

Nevertheless, the current study contradicts the findings of Lo et al. [ 69 ], who found that psychological interventions did not affect stress but that cognitive-behavioral, relaxation, and mindfulness interventions may improve the mental health of health profession students. The current study combines psychoeducation and cognitive interventions by providing students with useful links to a variety of resources based on these approaches and advising them to use them.

A significant reduction in anxiety symptoms was observed in the current study. This was not unexpected, as the intervention incorporates multiple components that not only reduce test anxiety and the negative impact of assessment but also reduce other anxieties arising from the burden of studying medicine, while simultaneously fostering self-efficacy, a strong predictor of resilience [ 51 , 70 ].

The guidelines provide medical educators with several practical tips for students to overcome academic challenges, including exam-taking strategies and self-care techniques, as well as advice on reducing test anxiety [ 71 ].

The current findings provide additional evidence for earlier systematic reviews [ 3 , 58 , 59 ] that discovered a significant effect of resilience interventions in lowering anxiety among HPE students and practitioners. The current study, however, diverges from the findings of Lo et al. [ 69 ], who found that while cognitive-behavior, relaxation, and mindfulness interventions may improve the mental health of health professional students, psychoeducational interventions did not affect stress. The SAR framework encompasses guidelines targeting these previous aspects and provides students with helpful links to a range of resources based on these approaches (Appendix III ).

The current study found that depressive symptoms decreased significantly after implementing SAR guidelines. The improvement in depressive symptoms may be attributed to the design of the SAR framework, which enhances resilience at multiple levels (personal and environmental) throughout the various assessment stages (pre, during, and post) [ 3 , 50 ]. The SAR framework’s “assessment preparation” and “student reflection” guidelines aim to improve personal assessment behavior (Appendix III ). During SAR implementation, students were advised to prepare thoroughly for the exam and were given strategies for improving self-care and reducing test anxiety. Furthermore, the other SAR guidelines, particularly “assessment direction” and “assessment experience,” focus on the assessment organizational process to boost motivation and self-efficacy. These can lead to a reduction in “rumination,” a cognitive response style that consists of a vicious cycle of ruminating on negative thoughts [ 72 ]. Regarding this quantitative finding, course coordinators supported it by observing and reporting that mental health improved after SAR implementation (Table 5 ).

The current study is comparable to a randomized controlled trial confined to a single medical school in which researchers used a workshop-based intervention to promote the mental health of students, and the results demonstrated a significant reduction in depressive symptoms [ 67 ]. Furthermore, this study is consistent with Kunzler, Helmreich [ 59 ] systematic review, which found that resilience interventions result in improving depression with a low effect size. It is worth noting that the systematic review by Cleary, Kornhaber [ 58 ] revealed that some interventional studies improved depression, but not resilience. They attributed this outcome to the nature of the intervention, which focused on specific psychological problems, such as depression, while ignoring other crucial constructs, such as resilience. The current intervention addressed both concepts—depression and resilience—demonstrating its strength as a comprehensive and holistic approach.

Three types of burnout were measured in the current study—personal, work (academic), and client (patients). Personal and work-related (academic) burnout were significantly reduced by the use of SAR guidelines, which is consistent with the findings of two RCTs that found a significant decline in burnout following resilience intervention [ 73 , 74 ]. This could be explained by the reciprocal mediating effect between resilience and burnout [ 4 , 75 , 76 ]. Moreover, the SAR guidelines were intended to improve personal and occupational factors (academic environment). SAR includes several guidelines aimed at personal factors, such as self-efficacy and motivation, as well as guidelines aimed at mitigating the negative effects of the academic environment, particularly the exam-related environment (Appendix III ). As a result of implementing the SAR guidelines (personal and academic environment), resilience increased while burnout declined.

The factor that contributes to burnout reduction is the use of SAR guidelines at the process and organizational levels of an assessment (pre, intra, and post). Multiple meta-analyses have found that organizationally targeted interventions have a greater effect size than individually targeted interventions [ 8 , 77 , 78 , 79 ]. This further supports the argument that burnout is likelier to be caused by organizational deficiencies than by individual factors [ 8 , 77 ]. This effect is clearly described by medical educators who observed that students were significantly more engaged in clinical rotations when SAR was utilized than in rotations when it was not (Table  5 ).

Client-related burnout did not differ significantly between pre- and post-intervention measures. This could be explained by the fact that participants who had just begun their clinical rotation lacked the full authority to interact with patients and make clinical decisions. These actions were performed by clinicians, so students were not yet exposed to hospital-related burnout [ 8 , 10 ].

Correlation among study tools

The correlation analysis of study tools in pre- and post-intervention elucidates the dynamic interplay between resilience and psychological stress indicators such as depression, anxiety, stress, and burnout among participants before and after the intervention. We discovered a significant negative correlation between resilience and these indicators, highlighting resilience’s critical role in protecting against psychological distress. Such findings are consistent with prior research by Hayat, Choupani [ 51 ], Putwain, Becker [ 80 ], which suggest that enhancing resilience can significantly mitigate the adverse effects of stress, anxiety, and depression.

The practical implications of these insights are profound. They suggest that interventions aimed at bolstering resilience may be effective strategies for reducing psychological distress. In educational settings, this could translate to a resilience-built-in system designed to equip students with coping mechanisms, thereby enhancing their well-being and academic performance.

Regarding the strong correlation of anxiety, depression, stress, and burnout that was noticed in this study, a previous systematic review by Koutsimani, Montgomery [ 78 ] found that such psychological constructs are highly correlated even when using different scales.

Nevertheless, the current study has several strengths, one of which is that it used an experimental design with pre- and post-intervention evaluations. The timing of the study intervention was optimal, as it occurred in the middle of the academic year when stress levels were at their peak [ 7 ]. This underscores its effectiveness. Moreover, it was evident that these guidelines are user-friendly and self-explanatory. In addition to providing a system-integrated approach to promoting resilience, the study also includes tools for assessing resilience levels along with other counteracting factors.

On the other hand, the study has some limitations. One of these is that a comparative control group is impractical because preventing intervention leakage cannot be guaranteed in a single-institution study. Additional research that includes a control group is necessary to evaluate the efficacy of the SAR framework. Another challenge was that follow-up measurements were not conducted due to logistical constraints. After implementing the intervention, multiple measurements should be taken in a future study. Additionally, qualitative feedback was gathered from five course coordinators, rendering the sample size insufficient for achieving saturation in a qualitative study. Future research should aim to include an acceptable sample size for the qualitative evaluation of the study. Finally, it was limited to a single institution and the sample size is small; further study including multicenter research with large sample size is suggested.

Based on the findings of the current study, the researchers propose several recommendations. First, it is strongly recommended that the SAR guidelines be incorporated into medical and HPE curricula daily due to their clarity, practicability, and feasibility. Teachers in the medical and HPE fields should be encouraged to utilize them and be provided training to ensure their proper application. Second, in the “new normal” following the COVID-19 pandemic and the massive transformations it occasioned, nearly all medical schools have adopted blended learning. It is feasible to apply the SAR framework with this modification. E-learning platforms are fertile ground for employing SAR guidelines and their associated resources, and students would have unlimited access to them. Additionally, these resources are simple to expand and update regularly. Finally, the nature of SAR guidelines is not limited to medical and HPE students; they can be applied to students in other disciplines in higher education, and even to students in secondary and elementary schools.

Resilience is a crucial attribute for students in the medical and health professions as it fosters the traits that graduates need to face future adversities. The current study presents a distinctive intervention using a quasi-experimental design with one group pre- and post-test for fostering resilience while simultaneously practicing the assessment. It uses what is called systematic assessment for resilience (SAR) to enhance resilience through a holistic approach across multiple levels. Comparing the results of pre- and post-intervention measurements yielded astounding results and showed significant improvement in resilience and a significant reduction in counteracting psychological parameters, such as stress, anxiety, depression, and burnout; thus, this study provides evidence-based guidance on how to promote resilience within an educational setting. By using this novel approach, the SAR framework, this research opens a new horizon for nurturing the mental well-being of future doctors who will provide better healthcare services to ensure patient safety. Future research is needed to monitor the impact of the SAR framework over time and broaden the scope of the intervention by including other HPE fields and students in higher education.

Data availability

Please email the corresponding author for a link to the de-identified datasets. However, due to privacy concerns, the in-depth interview transcripts are unavailable to the general public.

Abbreviations

Academic Related Stressors

Copenhagen Burnout Inventory

Confidence interval

Depression, Anxiety and Stress Scale 21

Degree of freedom

Direct Observation of the Clinical Examination Encounter

Health Professions Education

Inter Quartile Range

Medical Professionals Resilience Scale

Medical Students Stressor Questionnaire

Randomized Control Trials

Systematic Assessment for Resilience

Standard deviation

Statistical Package for Social Sciences

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Acknowledgements

Authors extend the deepest gratitude to the clerkship courses’ coordinators who participated in this study, dedicating their valuable time and providing essential insights that significantly enriched our research. Their cooperation and enthusiastic engagement were crucial in the successful completion of the data collection process. We also wish to thank the students at the College of Medicine, University of Sharjah, for their active participation and contributions. Their involvement was instrumental in enhancing the depth and breadth of our study. This work could not have been accomplished without the collective efforts of all parties involved.

This research is part of a larger project supported by Fundamental Research Grant Scheme (FRGS: 203.PPSP.6171219), Ministry of Education, Malaysia.

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Sarra Shorbagi

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Mohamed Hassan Taha

Medical Education Department, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia

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Each author has a substantial contribution in this paper. MW, MSBY, and AS initiated the research idea and wrote the research proposal. MW established the training program for the medical teachers. AS, SS and MHT collected data pre and post the training. MW and MHT analyze data. MW initiated writing the paper. Both MW and AS has refined the paper. MHT, SS and MSBY reviewed it carefully before submission.

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The study has received ethical approval (no. REC-21-11-03) from the Research Ethics Committee of the University of Sharjah, which followed the Belmont Report and Helsinki Declaration. All participants signed a written informed consent form containing clear information about the study’s purpose, methods, and secure data handling. They were also informed that they could withdraw from the study verbally or in writing. The standard rules for privacy and confidentiality were followed when conducting the study. Anonymity was maintained for participants for Year 4 clerkship rotations.

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Wadi, M., Shorbagi, A., Shorbagi, S. et al. The impact of the Systematic Assessment for Resilience (SAR) framework on students’ resilience, anxiety, depression, burnout, and academic-related stress: a quasi-experimental study. BMC Med Educ 24 , 506 (2024). https://doi.org/10.1186/s12909-024-05444-9

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The Power of Perception to Reduce Anxiety and Depression

Overcome the influence of the destructive normal mind to improve your life..

Posted April 30, 2024 | Reviewed by Davia Sills

• What Is Anxiety?
• Find a therapist to overcome anxiety
• The mind attempts to explain, solve problems, and protect.
• The normal activity of the mind can be turned into a destructive process.
• The more people value specific outcomes, the greater the risk of inflexible thinking.
• Observing mental activity is a step toward reducing its destructive power.

Why do we so easily upset ourselves? We wake up in the middle of the night and start worrying about the future, regretting the past, and asking, “What if...?” until we have made ourselves miserable.

Understanding the mind and how it works starts with knowing what the mind wants to accomplish.

The mind has three primary tasks. First, it attempts to make sense of all the information it receives by creating a reasonable explanation for our experience. Second, the mind is a problem-solving machine—it wants to determine how to meet our needs and overcome any barrier to making that happen. Finally, the mind needs to protect us from harm. It lets us know when there is a potential threat by creating negative emotions, adverse sensations, and physical symptoms that get our attention .

Explaining, problem-solving, and protecting are three skills we excel at beyond any other creature on Earth. This means we can survive in the cold, heat, desert, mountains, and jungles in the worst circumstances, including drought, floods, famines, and blizzards.

The Normal Mind

Our ability to link ideas and events together is lifesaving.

A farmer looks at the winter sky, tests the soil in the early spring, reads about regional weather patterns, and predicts that it will be drier than usual next summer. Based on this prediction, he can adjust how and when he plants, select different seeds, and modify how he cares for the crop while it grows. His ability to make comparisons, see events from a future perspective, and understand cause-and-effect relationships allows him to adapt, survive, and overcome problems that have not yet occurred.

The Destructive Normal Mind

Just like that farmer, we can use this fantastic language ability to either make our lives safe, pleasant, and satisfying or to create misery.

We can imagine our upcoming presentation at an important meeting going poorly. We can even sense, as if it is happening now, our embarrassment and the discomfort that others would feel in the room. After such a poor performance, we reason that a demotion within the company will follow, and we will eventually lose our job. Within the year, we will be unable to pay the mortgage and end up homeless.

Destructive normality means we can misuse the mind’s ability to explain, problem-solve, and protect and turn those same mental processes against ourselves. Without any evidence or facts at all, we can create tremendous misery in which we believe we are unlovable, our problems are unsolvable, everything is our fault, and life is unbearable. It is thoughts like these that create the mental environment for anxiety and depression to develop.

Our mind’s ability to predict outcomes and create unsolvable problems is not a sign that we are unhealthy or broken. It is simply what the mind does —it uses language to explain what we experience. This power of explanation is impressive, but we should not trust it.

It is our job to look at the activity of the mind and ask ourselves, “Is this helpful? Does this explanation and prediction help me go in the direction I want to go? Does it help me solve my problems, or does it make things worse?”

Anxious and Depressed Thinking

Among the many unhelpful activities of the mind, irrational beliefs are one of the more destructive. Irrational beliefs are inflexible demands that insist that we should conform to a certain standard of perfection. There are three core irrational beliefs that each insist that life must be a certain way:

• I must do well and have specific desirable characteristics.
• Other people should treat me well and approve of me.
• Life conditions absolutely must be easy, comfortable, predictable, secure, and essentially as I want them to be.

These core beliefs produce three secondary inflexible attitudes that compound our misery and interfere with our ability to solve problems:

• My experience is unbearable, intolerable, and too burdensome.
• On a rating scale, my experience would be the worst. It is awful, terrible, and the end of everything.
• I am not just a little bit bad, but totally bad. You are totally bad. Life is totally bad.

When put together, our core beliefs and inflexible attitudes lay the foundation for anxiety and depression. They also create an emotional rollercoaster of moments of happiness when we think we have measured up and found approval, followed by distress when our fortunes change:

• I must do well (or have specific desirable characteristics) and win others’ approval, and I am an inadequate, undeserving person when I don’t do as well as I must.
• Other people should treat me fairly and kindly. If they don’t, they are no good and deserve punishment .
• I ought to get what I want and not get what I don’t want from life. If I don’t get what I want, life is terrible, and I will be miserable.

Our minds are constantly making comparisons—this is normal. One person is taller, shorter, prettier, more intelligent, poorer, funnier, or quieter than another. The mind can then add a value rating to these comparisons—“I am not as smart as she is, and that is bad.”

According to Albert Ellis, Ph.D ., one of the founders of cognitive psychology, we have two flaws that make us vulnerable to irrational beliefs. The mind treats threats to our ego as if they are threats to our lives. The mind should warn us by producing anxiety and fear if a large dog is charging, but not treat the prospect of not sounding smart at a party as an actual threat. Similarly, we assume a threat occurs when life does not go as we expect. Rather than accepting life as it is, a mixture of good and bad, we insist that life ought to be as we would like it, not as we don’t. Unfortunately, there is no rule that states life should be a certain way. Life can be incredibility difficult, mildly inconvenient, and everything in between.

We simultaneously believe that we should be superhuman, outstanding, and perfect and that life should be as good as we can imagine that can be. According to the principles rational emotive behavior therapy , the more we value something, the greater our risk for irrational thinking.

When you catch yourself saying, “I must…” “Others should…” and “Life ought…” know you are in good company. We all do this. Your mind will make comparisons, and when it does, you will come up short. Others do have it better than you. You do mess up. Not everyone likes you.

Changing Perception

Knowing how our mind works against us will help tackle the problems the unhelpful mind creates. We can monitor, evaluate, and modify our mental activity, putting us back into the driver’s seat of our lives.

• Monitor — Get to know your observing self . You are not your thoughts; you contain them. Practice standing back and observing the mind’s activity for what it is—a powerful word-producing machine that creates stories, explanations, predictions, and judgments. Mindfulness skills can help.
• Evaluate — Look at your beliefs, the meaning you ascribe to situations, and the value you assign to what you experience. Where do your ideas of what is important, valuable, and worthwhile come from? Are these beliefs and values helpful? Do you tend to see yourself as a mistake if you make a mistake? If so, is that type of global rating helpful?
• Modify — Learn to accept yourself, others, and life unconditionally, a mixture of qualities you like and some you don’t. Change your demands to desires. You want to perform well and prefer that others treat you well. Who doesn’t? Change the script that goes through your mind: I would like to perform well, and it is disappointing when I don’t. I prefer the approval of others, but it is not terrible if I don’t receive it; it is just frustrating. I am a flawed, fallible human and a mixture of good and bad. I am unique but not special.

These steps are easier said than done, but you can start today. If that does not go well, start again tomorrow. You can keep starting until you have some momentum.

Evan Parks, Psy.D. , is a clinical psychologist at Kalkaska Memorial Health Center and an adjunct assistant professor at Michigan State University College of Human Medicine. He is the host of the Pain Rehab podcast.

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WBP indicates withdrawal by patient.

Data are presented as mean (SEM). Missing data for mean pain intensity are imputed with the last-observation-carried-forward method. The dark blue line represents patients with a Hospital Anxiety and Depression Scale (HADS) score ≥11 (definite case) (n = 123); orange dashed line, patients with a HADS score of 8-10 (suspected case) (n = 77); and light blue dotted line, patients with a HADS score ≤7 (not pathological) (n = 129).

a P < .05 between time (compared with baseline) and baseline depression status (Hospital Anxiety and Depression Scale scores ≤7 [not pathological] vs ≥11 [definite case]).

b P < .05 between time (vs baseline) and baseline depression status (Hospital Anxiety and Depression Scale scores ≤7 [not pathological] vs 8-10 [suspected case]).

A, Median cumulative dose of ketamine in each trajectory and at each time point. B, Pain trajectories obtained using semiparametric mixture models.

a P  < .05 vs baseline (intragroup analysis).

b P  < .05 between time (vs baseline) pain trajectories (trajectory 3 vs trajectory 1).

c P  < .05 between time (vs baseline) and pain trajectories (trajectory 2 vs trajectory 3).

d P  < .05 between time (vs baseline) and pain trajectories (trajectory 1 vs trajectory 2).

eMethods. Statistical Analysis

eFigure. One-Year Evolution of Numerical Pain Rating Scale

eTable 1. Initial Baseline Characteristics of Patients According to Pain Trajectories After Intravenous Ketamine (n = 279)

eTable 2. Concomitant Treatments Depending on Pain Trajectories During the Year of Follow-up After Intravenous Ketamine (n = 279)

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Voute M , Lambert C , Pereira B , Pickering G. Assessment of Initial Depressive State and Pain Relief With Ketamine in Patients With Chronic Refractory Pain. JAMA Netw Open. 2023;6(5):e2314406. doi:10.1001/jamanetworkopen.2023.14406

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Assessment of Initial Depressive State and Pain Relief With Ketamine in Patients With Chronic Refractory Pain

• 1 Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Institut National de la Santé et de la Recherche Médicale (INSERM) 1405, Centre d’Investigation Clinique 1405, Platform of Clinical Investigation, Clermont-Ferrand, France
• 2 CHU Clermont-Ferrand, Direction de la Recherche Clinique et de l’Innovation, Biostatistics Unit, Clermont-Ferrand, France
• 3 University Clermont Auvergne, INSERM 1107, Neuro-Dol, Clermont-Ferrand, France

Question   What are the mediators of repeated ketamine administration for chronic pain relief?

Findings   In this cohort study of 329 patients with treatment-resistant pain, pretreatment depression was the only mediator of chronic pain relief with ketamine.

Meaning   Depression as a mediator for refractory chronic pain relief provides radically new insights on how ketamine reduces pain primarily by dampening depression and reinforces the need for systematic depression assessment of patients with treatment-resistant pain.

Importance   Repeated ketamine administration is common in treatment-refractory chronic pain, but ketamine analgesic and antidepressant effects are poorly understood in patients with chronic pain with depression symptoms.

Objective   To determine clinical pain trajectories with repeated ketamine administrations, exploring whether ketamine dose and/or pretreatment depressive and/or anxiety symptoms may mediate pain relief.

Design, Setting, and Participants   This nationwide, multicenter, prospective cohort study included patients in France with treatment-refractory chronic pain who received repeated ketamine administration, over 1 year, according to ketamine use in their pain clinic. Data were collected from July 7, 2016, through September 21, 2017. Linear mixed models for repeated data, trajectory analysis, and mediation analysis were performed from November 15 to December 31, 2022.

Interventions   Ketamine administration in cumulative dose (milligrams) over 1 year.

Main Outcomes and Measures   Primary outcome was mean pain intensity (0-10 on the Numerical Pain Rating Scale [NPRS]), assessed every month for 1 year by telephone, after inclusion in the hospital. Depression and anxiety (Hospital Anxiety and Depression Scale [HADS]), quality of life (12-item Short Form Health Survey [SF-12]), cumulative ketamine dose, adverse effects, and concomitant treatments were secondary outcomes.

Results   A total of 329 patients (mean [SD] age, 51.4 [11.0] years; 249 women [75.7%] and 80 men [24.3%]) were enrolled. Repeated ketamine administration was associated with a decrease of NPRS (effect size = −0.52 [95% CI, −0.62 to −0.41]; P  < .001) and an increase of SF-12 mental health (39.7 [10.9] to 42.2 [11.1]; P  < .001) and physical health (28.5 [7.9] to 29.5 [9.2]; P  = .02) dimension scores over 1 year. Adverse effects were in the normal range. There was a significant difference between patients without and with depressive symptoms in pain diminution (regression coefficient, −0.04 [95% CI, −0.06 to −0.01]; omnibus P  = .002 for interaction of time × baseline depression [HADS score ≤7 or >7]). The mediation model showed that ketamine dose was not associated with pain diminution ( r  = 0.01; P  = .61) and not correlated with depression ( r = −0.06; P  = .32), and that depression was associated with pain diminution (regression coefficient, 0.03 [95% CI, 0.01-0.04]; P  < .001), whereas ketamine dose was not (regression coefficient, 0.00 [95% CI, −0.01 to 0.01]; P  = .67). The proportion of reduction of pain mediated by baseline depression was 64.6%.

Conclusions and Relevance   The findings of this cohort study on chronic refractory pain suggest that depression (and not ketamine dose or anxiety) was the mediator of the association of ketamine with pain diminution. This finding provides radically new insights on how ketamine reduces pain primarily by dampening depression. This reinforces the need for systematic holistic assessment of patients with chronic pain to diagnose severe depressive symptoms where ketamine would be a very valuable therapeutic option.

Drug management of chronic pain with antidepressants, antiepileptics, and opioids remains inconclusive, as 60% of patients show little improvement, experience adverse effects, and often require other treatment options. 1 , 2 Ketamine, a nonselective N -methyl- d -aspartate receptor (NMDAR) antagonist with anesthetic properties, can relieve chronic pain. 3 - 5 A recent clinical study 3 in patients with refractory chronic pain identified distinct pain relief trajectories with variables that are associated with the response to a single dose of ketamine according to pain characteristics, level of anxiety, depression, or quality of life.

Comorbid pain and depression are common. In treatment-resistant depression, a number of studies 6 - 9 have also reported ketamine to have rapid antidepressant and antisuicidal effects. Patients with chronic pain often experience depressive symptoms, as chronic pain-induced depression affects up to 85% of patients with chronic pain, depending on the clinical setting. 10 Likewise, the prevalence of pain among patients with depression ranges from 43% to 80%. 11 , 12 Both conditions are challenging and share clinical consequences of impaired function and decreased quality of life, 12 , 13 which are accentuated when both are present in a patient. Depression may also be more difficult to alleviate in persons with concomitant pain. 12 , 14

Pain and depression share common neurobiological elements in the central nervous system, at cerebral, brainstem, and spinal cord (descending inhibitory pathways) levels. This may explain concomitant decreased levels of pain and depression when ketamine is used. 15 , 16 Few studies have evaluated this bilateral action of ketamine. Oral ketamine for 6 weeks showed an alleviation of depressive symptoms in chronic pain, 17 and ketamine improved both depression and pain. 18 A recent study 12 evaluated the role of pretreatment pain symptoms in response to repeated ketamine infusions in individuals with depression and showed that patients with depressive symptoms and varying degrees of pain, especially severe pain, exhibited a significant and rapid improvement in depressive symptoms after 6 infusions of ketamine.

Conversely, there is limited information about the influence of pretreatment depressive symptoms on relief in patients with chronic pain treated with ketamine. To optimize the management of treatment-refractory chronic pain with ketamine, this 1-year study aimed to determine clinical pain trajectories with repeated ketamine administration, exploring whether racemic (R/S) ketamine dose and/or pretreatment depressive and/or anxiety symptoms mediate pain relief.

This prospective, multicenter cohort study was conducted in 30 French pain clinics. Patients were followed up with telephone calls over 1 year by the Clinical Research Center and Clinical Investigation Center of Institut National de la Santé et de la Recherche Médicale (INSERM) 1405, Clermont-Ferrand University Hospital, Clermont-Ferrand, France. The study was approved by the National Ethics committee (Comité Consultatif sur le Traitement de l’Information en Matière de Recherche dans le Domaine de la Santé, Commission Nationale de L'informatique et des Libertés, and Comité de Protection des Personnes Sud-Est), was registered on ClinicalTrials.gov, 19 and followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline for cohort studies. All participants provided written informed consent.

Male and female patients who were 18 years or older, had chronic pain for more than 6 months (peripheral or central neuropathic pain, fibromyalgia, complex regional pain syndrome, or other chronic pain), and required ketamine in their pain care pathway were eligible to participate in the pain clinic where they were usually treated. The clinician evaluated the eligibility criteria, explained the objectives of the study, gave an information and nonopposition form (approved by the National Ethics committee), and specified the patient could refuse to participate to the study.

This study included 585 patients. A previous publication 3 focused on the outcomes of 256 patients who received only 1 ketamine administration. The present study focuses on the 329 patients who received more than 1 ketamine infusion.

Pain clinics followed their own R/S ketamine protocols, and these varied in terms of dosage, duration, frequency, and route of administration (eg, a single dose of 0.2 mg/kg over 40 minutes or 0.1 mg/kg/d once a week for 8 weeks, intravenous or subcutaneous). Cumulative dose in milligrams was used; for example, for a 70-kg person, a dose of 0.5 mg/kg/d once a month for 3 months was equal to a cumulative dose of 105 mg.

After R/S ketamine administration, patients were called at 1 week and monthly for 1 year. Demographics, ketamine naivety, ketamine dosage, pain, comorbidities, questionnaires, concomitant analgesics, drug and nondrug treatments, and adverse effects were collected. The primary outcome, mean pain intensity, was assessed over 1 year with the Numerical Pain Rating Scale (NPRS) ranging from no pain (0) to maximal tolerable pain (10). Secondary outcomes included depression and anxiety scores measured using the Hospital Anxiety and Depression Scale (HADS), 20 with scores ranging from 0 to 21 (≤7 indicates not pathological; 8-10, suspected case; ≥11, definite case); quality of life, using the 12-item Short Form Health Survey (SF-12) 21 for mental and physical scores; cumulative ketamine dose (in milligrams); adverse effects; and concomitant treatments.

Data were analyzed from November 15 to December 31, 2022. Sample size estimation was determined sequentially according to rules of thumb for determining the minimum number of participants required for Cohen’s recommendations, 22 with effect size (ES) bounds defined as small (ES = 0.2), medium (ES = 0.5), and large (ES = 0.8 [“grossly perceptible and therefore large”]). Therefore, with at least 320 patients evaluated at baseline and month 12, an ES greater than 0.3 (ie, 1-point difference for an SD of 3) can be highlighted for NPRS change, with a 2-sided type I error at 0.001 (correction due to multiple comparisons), a 90% statistical power, an intraindividual correlation coefficient ( r value) of 0.5, and 15% lost to follow-up.

To analyze longitudinal data (NPRS and HADS), linear mixed models for repeated data were used, with time as a fixed effect and patient as a random effect, to account for between- and within-patient variability. Effect size and 95% CIs were calculated and interpreted according to Cohen’s recommendations. 22

To identify distinctive trajectories of pain, semiparametric mixture models were used to model the association between pain and time for each trajectory, the shape of the trajectory, and the estimated proportion of the population belonging to each trajectory. The baseline characteristics of the patients were then compared according to the trajectories using the χ 2 test or the Fisher exact test for categorical variables and analysis of variance or Kruskal-Wallis test for continuous variables. 23

A mediation analysis was conducted to assess the respective contributions of the treatment dose and baseline depression to evolution of pain. A mediation proportion was estimated, indicating how much of the whole increment value provided by an independent variable can be explained by the indirect path in which changes in this independent variable drive a change in the mediator (retention rate) and changes in the mediator are associated with outcome. A multilevel mediation analysis was performed with sex and age being integrated. Results were expressed as mediation proportion and significance of the mediation analysis associations.

Unless otherwise indicated, data are expressed as mean (SD). Statistical analyses were performed using Stata software, version 15 (StataCorp LLC). All tests were 2 sided, with an α level set at 5%. The analyses were performed after the last-observation-carried-forward imputation method for missing data, for NPRS, HADS, and SF-12 (eMethods in Supplement 1 ).

Between July 7, 2016, and September 21, 2017, 329 patients (mean [SD] age. 51.4 [11.0] years; 249 women [75.7%] and 80 men [24.3%]) were included in the analysis. Participants received at least 2 ketamine administrations ( Figure 1 and Table ).

Between baseline and month 12, the mean NPRS score decreased from 6.7 (1.8) to 5.6 (2.1), with a mean variation of −1.13 (2.22) (ES = −0.52 [95% CI, −0.62 to −0.41]; P  < .001) (eFigure, A in Supplement 1 ). The mean HADS depression score decreased from 8.8 (4.2) to 7.5 (4.9) (ES = −0.44 [95% CI, −0.54 to −0.33]; P  < .001), with 123 definite cases (37.4%; score ≥11) at baseline and 94 (28.6%) at month 12 (eFigure, B2 in Supplement 1 ). The mean HADS anxiety score decreased from 10.4 (4.3) to 8.7 (4.6) (ES = −0.58 [95% CI, −0.69 to −0.47]; P  < .001), with 163 definite cases (49.5%; score ≥11) at baseline and 109 (33.1%) at month 12 (eFigure, B1 in Supplement 1 ). At baseline, a combination of definite depression (score ≥11) and anxiety (score ≥11) affected 92 patients (28.0%), and 60 (18.2%) also had an NPRS score of greater than 7.

Evolution of pain over time according to baseline depression showed an overall decrease in pain for all patients, the benefits of repeated administrations of ketamine being observed in patients both with and without depression disorders. According to baseline depression level, there was a significant difference between depressive (HADS score >7) and nondepressive (HADS score ≤7) scores in pain diminution (regression coefficient, −0.04 [95% CI, −0.06 to −0.01]; omnibus P  = .002 for interaction of time × baseline depression status ≤7 or >7) ( Figure 2 ).

Evolution of pain over time according to anxiety at baseline showed an overall decrease in pain for all patients, the benefits of repeated infusions of ketamine being observed in patients both with and without anxiety disorders. There was no difference in pain evolution according to baseline anxiety level (regression coefficient, −0.01 [95% CI, −0.03 to 0.02]; omnibus P  = .56 for interaction of time × baseline anxiety status ≤7 or >7).

The mean mental health dimension scores of SF-12 increased between baseline and month 12, from 39.7 (10.9) to 42.2 (11.1) ( P  < .001). Mean physical health dimension scores increased from 28.5 (7.9) to 29.5 (9.2) ( P  = .02) (eFigure, C in Supplement 1 ).

At 1 week after ketamine administration, 123 of 297 patients (41.4%) experienced at least 1 adverse effect; at 1 month, 68 of 289 (23.5%); and for the rest of the year, between 28 of 220 (12.7%) and 59 of 277 (21.3%). The main adverse effects were fatigue (184 of 645 [28.5%] of all adverse effects collected), nausea (118 of 645 [18.3%]), headache (115 of 645 [17.8%]), and drowsiness (59 of 645 [9.1%]) (eFigure, D in Supplement 1 ).

Overall, concomitant treatments were not changed between baseline and month 12, except for acetaminophen (paracetamol) and/or nonsteroidal anti-inflammatory drugs (140 of 329 [42.6%] and 155 of 291 [53.3%], respectively; P  < .001), step 3 opioids (52 of 329 [15.8%] and 54 of 291 [18.6%], respectively; P  = .04), and antiepileptics (145 of 329 [44.1%] and 123 of 291 [42.3%], respectively; P  = .01). About half of patients had kinesiotherapy or mild physical activity during follow-up.

Three pain trajectories (T1, T2, and T3) were identified in 279 patients who received intravenous ketamine. Mean NPRS score at baseline was 5.3 (1.7) in T1 (lesser pain; 52 [18.6%]), 6.5 (1.5) in T2 (moderate pain; 134 [48.0%]), and 7.8 (1.5) in T3 (severe pain; 93 [33.3%]) ( Figure 3 ). There was a significant difference between pain trajectories about pain etiology, especially fibromyalgia (15 of 52 [28.8%] in T1, 83 of 134 [61.9%] in T2, and 45 of 93 [48.4%] in T3; P  < .001). Patients with neuropathic pain (18 of 52 [34.6%]) in T1 have alleviation of pain with NPRS scores less than 3 from month 3.

Concerning the HADS, mean baseline depression scores increased from T1 to T3 (7.9 [4.1] in T1, 8.7 [4.0] in T2, and 9.4 [4.2] in T3; P  = .09) and mean baseline anxiety scores increased significantly (9.6 [3.9] in T1, 10.1 [4.4] in T2, and 11.5 [4.1] in T3; P  = .009). Scores of mental and physical health dimensions of SF-12 decreased from T1 to T3 (eTable 1 in Supplement 1 ). Cumulative ketamine dose was not associated with pain trajectories, whatever the time of evaluation. There was a significant interaction between pain trajectories and time. The time point at which the variation from baseline started to be significantly different between the trajectories was at month 2 between T1 and T3 (regression coefficient, 1.51 [95% CI, 0.78-2.23]; P  < .001), at month 2 (until month 10) between T1 and T2 (regression coefficient, 1.03 [95% CI, 0.34-1.71]; P  = .003), and at month 4 between T2 and T3 (regression coefficient, 0.59 [95% CI, 0.03-1.16]; P  = .04) ( Figure 3 ). Finally, the baseline number of ketamine-naive patients, number of treatments, and the follow-up concomitant treatments did not differ between pain trajectories (eTable 2 in Supplement 1 ).

The multilevel mediation model method provided information from several path models. In path 1, ketamine dose was not associated with pain diminution ( r = 0.01; P  = .61). In path 2, ketamine dose was not correlated with depression ( r = −0.06; P  = .32). In path 3, multivariate analysis showed depression was associated with pain diminution (regression coefficient, 0.03 [95% CI, 0.01-0.04]; P  < .001), whereas ketamine dose was not (regression coefficient, 0.00 [95% CI, −0.01 to 0.01]; P  = .67). In other words, proportion of reduction of pain mediated by ketamine dose was 0% and 64.6% for baseline depression ( Figure 4 ).

In this 1-year clinical cohort study, repeated R/S ketamine treatment in chronic refractory pain was associated with pain relief for all patients with or without concomitant depression and/or anxiety. Ketamine was immediately associated with a diminution of pain, confirming results of some of the literature 3 , 24 and of a previous clinical study, 3 where a single subanesthetic dose of ketamine induced rapid and sustained pain relief. Likewise, ketamine was associated with rapid and sustained improvement of depression, as reported previously. 25 Concerning adverse effects, these were in the usual range described for ketamine use, and ketamine was overall well tolerated and associated with significantly improved quality of life.

Repetition of ketamine administration does not, however, provide more analgesia than the immediate relief at 1 week, suggesting a threshold beyond which ketamine cannot diminish pain any further and that the analgesic effects of ketamine occur mainly at the start of the treatment. Cumulative ketamine dose was not associated with pain relief and not involved in the mediation model, underlining that trajectories and profiles of responders are independent from the dose. However, with repeated ketamine administration, the percentage of patients in the trajectory with most severe pain was only 33.3% compared with the 48.0% we observed with a single dose, 3 suggesting that ketamine may globally have an analgesic effect on more patients with severe pain. The 3 pain trajectories allow the identification of different profiles that are rather similar to those with a single ketamine administration. 3 Patients with neuropathic pain (18 of 52 [34.6%]) in T1 have alleviation of pain with NPRS scores less than 3 from month 3, while diminution of pain in patients with fibromyalgia, who account for 83 of 134 (61.9%) in T2 and 45 of 93 (48.4%) in T3, occurs only briefly.

The total rate of depression at baseline in our study, 75 of 312 suspected cases (24.0%) and 119 of 312 definite cases (38.1%), is high (higher than what has been described in some studies 26 ), and 60 of 329 patients (18.2%), the most vulnerable of the cohort, combined highest depression and/or anxiety severity and highest pretreatment pain scores. We observed that patients with pretreatment depression (score >7) displayed more robust symptomatic pain improvement, with the amplitude of pain decrease associated with the severity of baseline depression. This mediation of depression in pain relief was not associated with the pain trajectories and occurred whatever the pain trajectory. Anxiety, however, does not present the same correlation as depression; this is in accordance with some published research, but ketamine effect on anxiety is still controversial. 27

The link between depression alleviation (especially for depression with suicidal ideations) 6 , 28 and pain relief 5 with ketamine treatment is complex. 24 , 29 Comorbid pain and depression are frequent, with a bidirectional interaction, 26 , 30 but a recent activation likelihood estimation meta-analysis 31 stresses that the direction of comorbidity (ie, pain with depression vs depression with pain) is rarely addressed and may concern different cerebral areas and neurobiology mechanisms. The analysis indicated that pain with concomitant depression was associated with the right amygdala, while depression with concomitant pain was related primarily to the left dorsolateral prefrontal cortex. The amygdala, its adjacent limbic structures such as the hippocampus, and the connectivity between the medial prefrontal cortex and these limbic structures are implicated in chronic pain. As depression appears in our study as the main mediator (64.6% of the mediation) of the analgesic effect of ketamine, this suggests that ketamine mode of action might be primarily directed toward the prefrontal cortex and probably involves and modulates the frontostriatal circuitry thereafter. 32

In effect, there are overlaps in the neurobiological and clinical aspects of these comorbidities, with the involvement of NMDAR, inflammation, and psychological elements. Ketamine mechanism of action involves numerous receptors, metabolites, and targets common to pain and depression, 33 , 34 with a number of downstream mechanisms that will regulate synaptic plasticity. Inhibition of NMDAR is pivotal for antidepressant and pain alleviation effects, with direct synaptic, extrasynaptic, and γ-aminobutyric acid–stimulating interneuron NMDAR inhibition. Ketamine may also modulate inflammation as shown when markers of inflammation and cytokines are elevated. 18 , 35 Another point concerns cognition, which is impaired in pain 36 and in depression. 37 - 39 Ketamine has an action at a cognitive level, with belief updating becoming more optimistically biased rapidly after the first ketamine infusion. 40

This study has some limitations. Depression was screened with HADS, as is commonly done in patients with chronic pain, and not with Montgomery-Åsberg Depression Rating Scale, which is used for depression evaluation. 7 As a clinical study, there is no placebo group, and the placebo effect of ketamine that is not negligible 24 has not been evaluated. Subjective psychopathology and neurocognitive performance after starting the infusion were not measured. It would be worth adding them in future trials. Furthermore, R/S ketamine was used, and it would be interesting to compare with other enantiomers, as differences have been described. 41

The findings of this cohort study suggest that depression (and not ketamine dose or anxiety) may be the mediator of the diminution of pain with repeated administrations of ketamine. This finding provides new insight into how ketamine may reduce pain primarily by dampening depression. This reinforces the need for systematic holistic assessment of patients with chronic pain to diagnose severe depressive symptoms where ketamine would be a very valuable therapeutic option. Further research is needed on the mechanistic, biological, and cognitive properties of ketamine in comorbid pain and depression.

Accepted for Publication: April 6, 2023.

Published: May 19, 2023. doi:10.1001/jamanetworkopen.2023.14406

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Voute M et al. JAMA Network Open .

Corresponding Author: Gisèle Pickering, MD, PhD, Plateforme d’Investigation Clinique/Centre d’Investigation Clinique, Institut National de la Santé et de la Recherche Médicale 1405, Bâtiment 3C, Centre Hospitalier Universitaire Clermont-Ferrand, F-63000 Clermont-Ferrand, France ( [email protected] ).

Author Contributions: Mr Pereira and Prof Pickering had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Voute, Pereira, Pickering.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Voute, Pereira, Pickering.

Critical revision of the manuscript for important intellectual content: Lambert, Pereira, Pickering.

Statistical analysis: Lambert, Pereira.

Administrative, technical, or material support: Voute, Pickering.

Supervision: Voute, Pickering.

Conflict of Interest Disclosures: None reported.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: We wish to acknowledge all the medical colleagues who referred their patients and the persons who participated in the follow-up of the patients from the Observational Study of the Management of Patients With Chronic Pain.

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