MHGCJ – 2021

Mental Health: Global Challenges Journal

Published from

the year 2017

Founders

Publication frequency

1-2 issue/year

Issue status

National/International

The MHGCJ was originally founded by NDSAN Network (MFC – Coordinator of the NDSAN)

Issue language

English

Media environment

Abbreviation key title

International

MHGCJ

Target audience

Scientists/researchers (medical, social, educational fields and etc.), mental health (MH) practitioners, policy-

makers, researchers, lawyers.

Major objectives

Mental Health: Global Challenges Journal is an open access peer-reviewed journal, whose main aim is to

promote dialogue and debate on topics such as Mental Health, Mental Health Care Systems and etc.Mental

Health: Global Challenges Journal is a journal dedicated to international studies on MHC systems in the

context of global social challenges, Mental health and migration, Mental health in times of military conflicts,

Mental health and community, Specific issues of MHC, Higher Education and MHC, Interdisciplinary and

transdisciplinary approaches in MHC, and related topics, therefore we will encourage those papers which

focus on the specific particularities from these topics, and /or authors coming from these areas. The journal

considers with a special attention the manuscripts which can be of interest for policy makers and/or

practitioners.The journal accepts manuscripts such as theoretical articles, research articles, case studies,

reviews, abstracts

2

Field of study and special focus

Medicine, Social Sciences, Education, Economics, Law, Inter- and Transdisciplinary studies

DOI: http://doi.org/10.32437/mhgcj.v4i2

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Mental Health: Global Challenges Journal

CONTENT

Paul Illingworth

COVID-19 the Trigger for SDG

Solutions in a Revised WHO Mental

Health Action Plan

4

Antony Laban-Sharman, Anne

Majumdar

Self-Care practices for anxiety during 9

the COVID-19 pandemic in the UK in

adults

Ana-Maria Vioreanu

The psychological impact of

infertility. Directions for the

21

development of interventions

Mental health sequelae of bone

cancer: A narrative review

Clinical case of catatonic stupor

Christos Tsagkaris, Dimitra Desse,

Emmanouela Dionysia Laskaratou

Komarovskyi М. S., Mykytenko R. V.,

35

39

Onofreichuk Kh. О., Hryshchenkova О. developed as a result of acute

S.,Podhorna А. D., Kosolapov О. P.,

Zolotarov P. V.

respiratory disease COVID-19

3

Larysa Bakhmutova

Main features of

42

49

expeditioners’personality traits in

Antarctic conditions

Sayang Ajeng Mardhiyah

Mental health literacy and

psychological distress as predictors

psychological well-being of collage

students in Sriwijaya university

Iryna B. Romash, Ivan R. Romash

Dynamics of quality of life indicators

in patients with gastroesophageal

reflux disease comorbid with

59

connective tissue dysplasia under

the influence of complex treatment.

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COVID-19 the Trigger for SDG Solutions in a

Revised WHO Mental Health Action Plan

Paul Illingworth

Leicester School of Allied Health Sciences, Faculty of Health and Life Sciences, De Montfort University, Leicester, England

Abstract

Introduction. This paper explores COVID-19 impact on Global attempts to achieve Sustainable

Development Goal 3, specifically Target 3.4.

Purpose. Suggest a new WHO Mental Health Action Plan needs to be refocused to help achieve

universal mental health.

Approach. The author discusses the context of COVID-19s impact on Governments inability to

progress the UN Sustainable Development Goals, specifically Target 3.4, reviewing this against

the WHO Mental Health Action Plan (MHAP) 2013-2020 (WHO 2013). Utilizing relevant

publications, progress/lack of progress are discussed, suggestions made as to how, by refocusing

the MHAP to one more culturally sensitive and localized, to progress towards universal mental

health.

Discussion. Contextualizing the lack of specific Sustainable Development Goals mental health

target. The continual use by the WHO of promoting western medical approaches to achieve

universal global mental health is explored, while using COVID-19 pandemic as a means of

triggering change in how localized, culturally specific non-medical approaches could be

championed.

Limitation/Strengths. The paper does not involve an extensive literature search. However,

subject matter is timely and relevant. It challenges traditional approaches of how Global Mental

Health has been addressed by organizations led by the UN/WHO. It identifies positive ways of

progressing global mental health, by utilizing localized and culturally sensitive approaches.

4

Practical/Social value. The suggestions made are cost effective, given the financial challenges

COVID-19 has brought, that is a practical and social value in its own right. Additionally, the

practical local and culturally sensitive solutions can be used globally. They could be undertaken

on their own or in conjunction with traditional western/medical models. The potential social value

could be considerable, should it be the focus of the latest WHO Mental Health Action Plan.

Conclusion. Any new WHO Mental Health Action Plan must ensure non-traditional interventions

are central and increasingly used to achieve universal mental health for all

Keywords

COVID-19, Mental Health, cultural sensitivity, cost effectiveness, resilience, SDGs.

Address for correspondence:

Paul Illingworth, Head of the Leicester School of Allied Health Sciences, Faculty of Health and

Life

Sciences,

De

Montfort

University,

Leicester,

England.

e-mail:

paul.illingworth@dmu.ac.uk

Submitted for publication: 12

March 2021

Received: 12 March 2021

Accepted for publication: 21

May 2021

This work is licensed under a Creative Commons Attribution-

NonCommercial 4.0 International License (CC BY-NC 4.0).

©Copyright: Illingworth, 2021

Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy

doi: https://doi.org/10.32437/mhgcj.v4i1.103

The COVID-19 pandemic has brought about

great disturbance for the global health community.

Governments and all the other different

Introduction

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organizations involved with the fight to control it, is

having to do so on many fronts. These include

identifying people who test positive through test

and trace, directly fighting the disease by caring

for those needing acute in-patient care, plus

vaccination and where needed resultant end of life

care. Increasingly care is undertaken, in many

countries, by Primary Care staff and this can

include helping people with the so called long

COVID and also those having also recovered but

who have been left with post COVID anxiety.

Additionally, this ‘fight’ involves supporting health

and social care workers, and any others involved

directly or in directly, as well as protecting

children’s learning and people’s livelihoods. This

is the focus of the world’s attention. However, this

work has often been hampered by challenges of

access, safety, supplies, and financial stress and

increasingly the isolation and mental anguish, the

likes of which has never been seen before, at

least as far as can be remembered or on record.

This global challenge has resulted in short-

publications, progress and lack of progress are

discussed and suggestions are made as to how,

by refocusing the MHAP away from the traditional

Western medical model to one more culturally

sensitive and localized, could help to bring about

great progress towards universal mental health.

Sustainable Development Goals

The Sustainable Development Goals are the

recovery framework developed by the United

Nations/World Health Organization (UN/WHO)

(UN 2021). Their aim is to make everyone globally

have an improved and more maintainable life. The

UN/WHO see this being accomplished by

addressing major global challenges, which they

see as; poverty, inequality, climate change,

environmental degradation, peace and justice.

These challenges are to be addressed globally by

governments through the 17 SDGs included in

Table 1. Each Goal is broken down into targets

relating to specific areas.

Table 1. The Seventeen Sustainable

Development Goals

term

consequences

which

are

evident

everywhere, but the long-term costs of the

pandemic have only recently started to emerge

and be considered. Just how COVID19 will

reconfigure health and social care, organizations

operating practices, (and not just health and social

care organizations, but also schools plus further

and higher education establishments, to name a

few), livelihoods, professions and priorities is only

beginning to emerge

There is now an opportunity to refocus and

reform how we do things. This paper suggests

that by using the COVID-19 pandemics impact on

people’s mental health globally, the WHO

The 17 Sustainable Development Goals

1: No Poverty 2: Zero Hunger 3: Good Health

and Well-being

4: Quality

Education

5: Gender

Equality

6: Clean Water

and Sanitation

7: Affordable 8: Decent

9: Industry,

Innovation and

Infrastructure

5

and Clean

Energy

Work and

Economic

Growth

10: Reduced

Inequality

11: Sustainable 12: Responsible

Sustainable

specifically

Development

Target

Goals

(SDGs),

3.4,

Cities and

Communities

14: Life Below

Water

Consumption

and Production

15: Life on Land

https://sdgs.un.org/goals/goal3 could be better

achieved and that a revised and reconfigured

WHO Mental Health Action Plan needs updating

and refocusing. By doing so, it will greatly assist to

get the globe back on track, from a mental health

perspective.

13: Climate

Action

16: Peace

and Justice

Strong

17:

Partnerships to

achieve the

Goal

Institutions

Purpose

COVID-19 Pandemic

This paper explores the impact of COVID-19

on Global attempts to achieve Sustainable

Development Goal 3, specifically Target 3.4 and

suggest how a new WHO Mental Health Action

Plan needs to be refocused to help achieve

universal mental health.

Millions of lives have been and continue to be

affected globally as a result of the COVID-19

pandemic, it is very likely many more will be

before the acute phase as run its course. At the

time of writing, it is just over 12 months since the

COVID-19 virus had become more widely known.

However, the Public Health community had been

predicting a similar SARS type virus would strike

again, much earlier. Devi Sridhar, Professor of

Global Public Health at Edinburgh University, had

Approach

The author discusses the current context of

COVID-19s impact on Governments ability to

progress the UN Sustainable Development Goals,

in particular Target 3.4 and reviews this against

the he WHO Mental Health Action Plan (MHAP)

2013-2020 (WHO 2013). Utilizing relevant

predicted

a

coronavirus-like crisis in 2018.

Speaking at the launch of her book, co-authored

with Chelsea Clinton, at the Hay Book Festival in

Hay-on-Wye in Wales, she not only predicted it,

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but said it would most likely come from animal to

human transfer in China and then be brought to

the West by airline (Allen-Mills & Gregory 2020).

Estimates of how many will eventually be

directly impacted vary, but there is no doubt, there

will be few globally not impacted. Lives have been

and will continue to be disrupted, people losing

their jobs many forced into poverty, some into

extreme poverty. While those with jobs and

money and developed countries are and will

continue to find this all a great challenge, the

impact will be even greater in low-middle income

countries (LMICs) and among vulnerable groups

everywhere.

It is, and will be for the foreseeable future,

challenging for any country to attain the SDGs,

but they can and must be achieved. Prior to the

COVID-19 pandemic, the majority of countries

had begun to make advances towards the SDGs,

the Sustainable Development Report 2020 (SDG

2020). The report exposed that there was no

country on course to achieve all of the SDGs, but

the majority were continuing to progress towards

their goals. It is interesting to note that Sach et al.

(2020) identified that East and South Asia have

progressed more than any other area, with Latin

America and the Caribbean progressing the least.

However, Sach et al. (2020) cautioned that

despite the progress made to date, any further

progress has been negatively impacted by

COVID-19.

relating to the negative impact COVID-19 has had

on the mental health of people across different

age ranges, for example; perinatal and offspring in

Spain (Caparros-Gonzalez et al., 2020), children

and adolescents in China (Duan et al., 2020) and

adults in Indonesia (Siste et al., 2020). While

Girdar et al. (2020) cautioned that the elderly in

India was at risk from social isolation as a result of

COVID-19, García-Fernández et al. (2020) found

that elderly people in Spain had significantly less

emotional distress than other age groups. No

longer should countries be delaying their

response to the SDGs in relation to this, and other

areas. Given the ensuing mental ill-health

pandemic, action needs to be enhanced to

address SDG 3 which is all encompassing

“Ensure healthy lives and promote well-being for

all at all ages”.

The SDG declaration emphasizes that to

achieve the overall health goal, 'we must achieve

universal health coverage (UHC) and access to

quality health care” (WHO 2019). However, this is

not specific enough. SDG3 Target 3.4 mentions

mental health but does not even give it its own

target. Instead it states; “By 2030, reduce by one

third premature mortality from non-communicable

diseases through prevention and treatment and

promote mental health and well-being. Within

Target 3.4, suicide rate is an indicator (3.4.2). One

has to question why such an important and

growing global concern has not got its own target.

Why does the WHO not build on work already

being undertaken to strengthen mental health

resilience, rather than focusing on traditional

western medical intervention, as it does in the

Mental Health Action Plan (MHAP) 2013-2020

(WHO, 2013)? Clearly it was not on track before

the COVID-19 pandemic struck. There is growing

evidence that non-medical, local and culturally

aware interventions are successful (Doukani et

al., 2021, Jakovljevic (2018) and Raghavan et al.,

2020).

6

In respect of mental health, there is growing

evidence that the pandemic has, is and will

continue to impact on the mental health of the

world’s population across the age range, (Girdhar

et al 2020; Shuja et al 2020 and Tanaka &

Okamoto 2021). The next pandemic is already

with us and it is the mental health pandemic.

Discussion

Had SDGs and especially Target 3.D,

https://sdgs.un.org/goals/goal3 which asks for

“early warning, risk reduction and management of

national and global health risks,” been fully

operationalized by now, countries globally would

have been in a better position and been able to

react and thereby control the COVID-19 pandemic

better than they have. As mentioned earlier, there

was clearly early warnings. Had there been better

forethought and greater decisiveness, by

Governments globally, many more lives would

likely have been saved. It is worth noting that

several low-income countries, such as Cambodia

and Vietnam, for example, have for the most part

stifled it with very little financial cost.

However, one has to be careful and a

distinction made between non-medical and

medical or professional interventions, for example,

a very good review was undertaken by Rathod et

al. (2018) into “culturally adapted interventions for

mental health disorders”. They concluded, there

was value in cultural adaptation but there was not

strong evidence of what adaptation and for whom.

In

other

words,

traditional,

westernized

interventions that had been adapted to address

cultural differences., can work but more research

is needed to ascertain what exactly works and

what does not.

What this paper calls for, is not a western

medical or psychological model that has been

culturally adapted for local needs. Instead it asks

for non-medical interventions that emerge from

cultures within which there are people with mental

health problems, where the ‘medical model’ is not

accepted for whatever reason or not working. This

At the time of writing COVID-19 continues to

have a major impact globally, it has also seriously

resulted in increased inequalities. One area that

has especially being affected is the mental health

of communities globally. A wealth of publications

globally has emerged since the pandemic began,

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could be that the cost is prohibitive, or more likely

availability is scarce. In many LMICs the ratio of

mental health professional to the population is

high and that what care provided is in urban

areas. A non-medical intervention could be

something as simple as a bench (Chibamba and

medicines.

Despite

recommendations

and

guidance from the UN and WHO and countries

responding to those, the mental health pandemic

is growing. The concern is once the viral aspects

of COVID-19 are beginning to be better controlled,

the mental health pandemic will hit. There are

increasing numbers of publications demonstrating

that locally based, culturally sensitive and non-

traditional interventions are having a significant

impact on improving mental ill-health. Any new

WHO Mental Health Action Plan should, indeed

must, ensure these non-traditional interventions

are central and increasingly used to achieve

universal mental health for all.

London,

2019)

or

religious

involvement

(Iheanacho et al., 2021), or theatre (Crossley et

al., 2019).

To ensure this is prioritized, we require a

robust framework for guiding governments to

move away from the costly medical and

pharmacological models, to one where immediate

post-pandemic recovery and long-term strategies

focus attention on low cost, localized, culturally

sensitive and effective means of building mental

health resilience. However, both the UN (2020)

policy brief on the need for action on mental

health in relation to COVID-19 and the WHO

(2021) report into how preparedness and

response to COVID-19 into mental health,

emphasize a more traditional medical model

response.

Conflict of interest

The author declares no conflict of interests

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the study:

The paper does not involve an extensive

literature search and has been undertaken by a

sole author. However, the subject matter is timely

and highly relevant. It challenges traditional

approaches of how Global Mental Health has

been addressed by organizations led by the

UN/WHO and who have championed the

western/medical model over other approaches. It

identifies positive ways of progressing global

mental health, by utilizing localized and culturally

sensitive approaches.

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Self-Care practices for anxiety during the COVID-

19 pandemic in the UK in adults

Antony Laban-Sharman¹, Anne Majumdar²

¹Faculty of Sport, Allied Health & Performance Sciences, St. Mary’s University, London, United Kingdom

²Department of Psychology & Pedagogic Science, St. Mary’s University, London, United Kingdom

Abstract

Introduction. The National Health Service cannot chronically sustain the overwhelming demands

being placed on it due to financial cuts, staff numbers and presence of Covid-19. As a result,

anxiety levels are on the rise thus increasing the need for effective self-care behaviors.

Purpose: The purpose of this study was to comprehend and acknowledge the profound influence

Covid-19 has had on anxiety levels and explore what behaviors people engage in to manage their

perceived stress levels themselves.

Methodology: This study was an exploratory mixed-methods design consisting of 110 self-

referred adults aged 18-65 with anxiety completed an online survey guided by the “Harvard

Anxiety and Depression Scale”. Data collected from the free-text questions were analyzed using

the thematic analyses method to evoke the most relevant themes and generate an evidence-

based narrative.

Results and Discussion: Self-care behaviors used for anxiety self-management pre and during

lockdown were walks, virtual family/social peer support, cooking and aerobic exercise.

Additionally, it was apparent that a lack of ongoing family/social support was a key predictor for

the proclivity of anxiety-inducing thoughts to be experienced. Interestingly, individuals who

continually engaged in activity experienced positive mood states irrespective of the current

lockdown environment.

9

Conclusion: This study adds to novel literature on the current anxiety levels of adults living in the

UK under the Covid-19 pandemic and what self-care behaviors people implement to self-manage

their anxiety levels. This study stresses the significance of ongoing peer support as a self-care

behavior that can act as a positive meditator for healthy cognitive processes to ensue. Therefore,

future self-care programs advocating this strategy may, if not prevent, slow down the rising cases

of anxiety and ill mental health due to the uncertain environment of Covid-19

Keywords

Anxiety, Mental Health, Self-Care, Covid-19, Qualitative.

Address for correspondence:

Dr. Anne Majumdar, Department of Psychology & Pedagogic Science, St. Mary’s University,

London, United Kingdom. e-mail: anne.majumdar@stmarys.ac.uk

Submitted for publication: 18

April 2021

Received: 21 April 2021

Accepted for publication: 28

This work is licensed under a Creative Commons Attribution-

Noncommercial 4.0 International License (CC BY-NC 4.0).

June 2021

©Copyright: Laban-Sharman, Majumdar, 2021

Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy

doi: https://doi.org/10.32437/mhgcj.v4i1.105

Acknowledged in literature as a “feeling of

unease, such as a worry or fear, that can be mild

Introduction

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or severe depended on the perceived

threat/outcome” (National Health Service [NHS],

2018a), anxiety is ongoing problem for the NHS in

England. Currently, 1 in 6 adults, aged 18 - 65,

experience some form of anxiety with an

additional 2.1 million individuals accessing the

NHS Mental Health Service (MHS) in 2018/19

(Baker, 2020).Additionally, the NHS at present

spends £13 billion yearly on MHS which equates

to a total of 14% economic distribution from local

NHS resources (Baker, 2020).

mental health of individuals living in the UK post

pandemic (Connor & Kirtley, 2018).

Additionally, access to ongoing support for

MHS across the country have been significantly

reduced due to the significant change in work

environment and growing demand thus further

increasing the levels of concern for health

practitioners as it is reported that less than a third

of individuals who commit suicide are usually in

contact with a MHS within the last 12 months

before death (Appleby, Shaw, & Amos, 1997).

Hence, increased ongoing access to MHS is

Moreover, these issues are now further

amplified by the presence of the Coronavirus

Disease 2019 (COVID-19). Despite its recent

paramount

post

pandemic

however,

alternative/complementary health-promoting “self-

care” (SC) behaviors may be an appropriate cost-

effective approach to not only reduce the demand

on the MHS but to also support and evoke

individuals to develop a sustainable “toolkit” of

behaviors that will enable adults to manage their

anxiety themselves.

The need for SC in the UK. At present, SC is

defined as “the ability of individuals, families and

communities to promote health, prevent disease,

maintain health, and to cope with illness and

disability with or without the support of a

healthcare provider” (World Health Organization

existence, Covid-19 has had

a

significant

influence on all the domains of society, including

physical and mental health in the United Kingdom

(UK) (Holmes et al., 2020; Romash.2020). For

instance, Kef (2021) and Sahu and Kumar (2020)

suggest that social media platforms are spreading

pseudo claims about the severity of Covid-19 and

amplifying already high tended levels of anxiety.

More importantly, literature suggests that ill

psychological consequences from the pandemic

are expected to be profound due to numerous

social determinants of health being influenced by

the pandemic such as education attainment

(Public Health England, 2018), inequitable income

distribution (Department of Work & Pensions

[DWP], 2019) and unemployment issues (Foley,

2020). Moreover, the “stay home, protect the

NHS, save lives” initiative (Freedman, 2020) may

induce further consequences of ill mental health

as even though the government initiative was

created to reduce the prevalence of infectivity, the

“by-products” of such an approach led towards

increased levels of loneliness, social isolation,

loss of work due to the economic crisis and the

media generating distress around the virus that all

contributes towards the probable development of

depression, anxiety and even self-harm (Holmes

et al., 2020; Mahase, 2020). Specifically, as

revealed in Holmes et al. (2020) survey of the

general population in the UK capturing the “mental

health concerns due to the impact of Covid-19”,

social isolation, loneliness and personal economic

difficulties seem to be the primary concerns for

people that are also key predictors for anxiety,

depression, stress and negative feelings

(Elovainio et al., 2017; Frasquilho et al., 2015;

Matthews et al., 2019).

[WHO], 2019). In

a

concise manner, SC

represents an idea and philosophy for people to

be more proactive about their own health

(Bhuyan, 2004; Dean & Kickbursch, 1995).

In other words, SC can act as an embodying

philosophy to help people prevent and

management the onset of anxiety and co-

morbidities that not only improves their quality of

life but simultaneously, would reduce cost,

pressure and stress on the NHS.

10

There are numerous behaviors categorized as

SC

however,

the

most

common

SC

approaches/activities presented in literature to

manage anxiety in adults are yoga (NHS, 2018b;

Stussman, Black, Barnes, Clarke, & Nahin, 2015),

mindfulness (Aherne et al., 2016; Decker, Brown,

Ashley, & Lipscomb, 2019), exercise (ACSM,

2016; Mikkelsen, Stojanovska, Polenakovic,

Bosevski,

& Apostolopoulos, 2017), cooking

(Farmer, Leonard, & Ross, 2018; Utter, J., Denny,

Lucassen, & Dyson, 2016) and peer support

(Gillard, 2019; Puschner, 2018).

Thus far, it seems that peer support, through

the phenomenon of “socialization”, may be the

most reliable and valid method of SC for anxiety

management as positive outcomes can be seen in

a variety of settings such as substance addiction

and abuse (O’Connell, Flanagan, Delphin-

Rittmon, & Davidson, 2017), clinical populations

with mental health disorders (Bocking et al.,

2018), ongoing mental health peer support for

students (Byrom, 2018), war veterans (Weir,

Cunningham, Abraham, & Allanson Oddy, 2019)

and peer support within communities to reduce

mental health hospital admissions (Lawn, Smith,

& Hunter, 2008).

Additionally, the fear of relationship loss,

thoughts of uncertainty about the future,

bereavement and lack of contact with family

members were all common themes amplifying the

overall feeling of anxiety (Holmes et al., 2020;

Mahase, 2020).

Thus, it is paramount to implement cost-

effective practices that will inhibit the sustained

feelings of loneliness/anxiety and support feelings

of belonging and engagement to preserve the

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Peer support is a practice where individuals

vicariously share lived experiences of discomfort

and suffering, form an interpersonal connection,

and collectively learn and support one another

ongoing (Gillard, 2019; Puschner, 2018). It isn’t

clear what precise mechanism is responsible for

such outcomes however, the phenomenon of

“socialization” and “empathy” (Smith, 2006) in

accordance with the social cognitive theory (SCT)

(Bandura, 2004) may offer some explanation; as

individuals who engage in socialization, spark a

dialogue where individuals can “vicariously share

emotions and thoughts” fostering interpersonal

Study Design, Participant Characteristics &

Recruitment

This study was an exploratory study with a

mixed-methods design with the primary focus

being on the qualitative findings. Following full

ethical approval from the St Mary’s University

ethics committee, this study aimed towards a

purposeful snowball sampling plan. Kotrlik and

Higgins (2001) suggested that the minimum

appropriate number of participants required for a

survey analysis is 100 therefore this volume was

aimed for and 110 was attained.

Furthermore, such a sample size ensured data

saturation was achieved (Tracy, 2013).

Additionally, all participants were given the

opportunity to read the generic information about

the study, survey and give their consent to prior to

participating.

closeness (Smith, 2006) leading towards

a

positive mood state in conjunction with a positive

behavioral feedback loop (Bandura, 2004)

increasing the probability for these individuals to

re-engage in socialization and further reducing the

chance for negative thoughts and feelings to be

experienced. Relating this to Covid-19, it is highly

probable that people who did not experience

ongoing social or familial support would be at risk

of experiencing negative cognitive processes

fueled by anxiety.

Furthermore, participants were recruited

through “word of mouth” (snowball sample)

(Tracy, 2013).

Lastly, all participants were either male or

female, based in the UK, aged 18-65 with self-

referred levels of anxiety.

Still, it is necessary to understand the influence

Covid-19 has had on anxiety levels and explore

what behaviors people engage in to manage their

perceived stress levels themselves as it’ll guide

future interventions to focus on SC behaviors that

individuals choose and perform consistently and

competently. This is important as future

interventions focused on SC behaviors that

people enjoy reduces the threat of autonomy, in

Consequently, participants who did not meet

the previous criteria were excluded from the

study.

Instruments and Procedures

A specifically designed online survey was

developed for this study guided by the Harvard

Anxiety and Depression Scale with the purpose of

achieving deep exploration of experiences as the

study idea in its nature was novel and specific.

Additionally, prior to dissemination, a pilot test

survey was carried out to ensure the questions

were trustworthy and reliable.

11

conjunction

with

perceived

behavioral

competence that has been associated with

improved self-efficacy which is a strong predictor

for behavior adoption and adherence (Bandura,

1997; Ryan & Deci, 2000). Furthermore, this

approach should help with the sustained self-

management of anxiety levels in the future

Subsequently, the online survey was

disseminated with elements of closed-ended,

multiple-choice,

scale-based

and

free-text

questions in order to best answer the research

question and capture people’s feelings, emotions

and thoughts.

Purpose

To explore the perceived effect of Covid-19 on

anxiety levels and what SC behaviors adults use

to manage it. The research question is as follows:

Data analysis.

The thematic analysis method (Braun &

Clarke, 2006) was used to analyze the free-text

questions, uncover the most relevant themes and

generate an evidence-based narrative.

A 6-phase guide to performing the analyses

was performed to ensure the research question

was best answered. Themes were data driven

(inductive) through the following phases:

•

To explore the anxiety experienced by

adults during the covid-19 pandemic and

approaches used to manage it?

Further objectives:

•

To explore the experiences of people

during lockdown and their impact on wellbeing.

To identify peoples’ self-care approaches

during the lock-down period.

•

“Familiarizing yourself with the data”

–

to

•

To inform healthcare practitioners on

submerge the researcher into the themes situated

in the text; “Generating initial codes” – articulating

small titles to best capture what being articulated;

“Searching for themes” – grouping relevant code;

“Reviewing themes” – refinement developed;

“Defining and naming themes” and “Producing the

report”.

areas of focus and potential self-care approaches

that could be encouraged in the future

management of patients who face similar

circumstances.

Methodology

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Closed-ended questions were analyzed using

the Statistical Package for Social Sciences

(SPSS) software where descriptive statistics were

conducted to best contextualize the findings.

lockdown with participants illustrating that “the

high point of the lockdown was certainly more

time for myself and my family as well as a slowly

paced life in general” in addition to “high points

when spending time with people virtually and

physically throughout lockdown”. One individual

who worked in a hospital provided an insightful

reflection on just how important family/social

support was:

Results

Quantitative analyses revealed that 62% of the

study’s sample size were female, 79% from a

white background in conjunction with 52%

being between the ages of 18-29 (Table 1).

Additionally, 51% of the study’s sample size

experienced heightened levels of anxiety due to

Covid-19 alongside 59% of individuals who

reported consistent worrying thoughts (Table 1).

Furthermore, feelings of isolation were not as

high among the sample although still not trivial

(32%) (Table 1).

“Working for the NHS during the pandemic has

been extremely stressful. We are doing more

cases and people are more anxious than usual

because of the risk of being infected. Due to the

short staffing, we have been given more work.

Night-time is even worse because we get more

serious emergencies then, which makes me

physically and mentally exhausted. Having said

that, I am able to get through it because I have a

good support system at home, being with my

family and spending time with them. This allows

me to calm my anxieties. Moreover, cooking and

baking acts as a good stress reliever

Table 1. Illustrating important demographic

characteristcs, anxiety and isolation percentages

of study participants.

Categorical data

Percentag

e (%)

before I go for my shifts at the hospital.” (Chloe)

Primary age range (18-29)

Male

Female

52

38

62

79

7

Furthermore, another participant articulated that

having a collaborative environment at work was

the key determinant in providing psychological

reassurance:

White

Mixed / Multiple ethnic groups

Asian / Asian British

Black / African / Caribbean /

“I was also able to appreciate teamwork and

camaraderie at work, which I experienced working

in the hospital. Knowing that somebody has my

back and supports me through difficult shifts is a

great reassurance during this uncertain time. I

was able to focus on my physical wellbeing also,

pushing myself to be healthier in the way I eat and

exercise.” (Georgia)

5

12

Black British

Other (e.g. Arab)

Feelings of anxiety

Experiencing

4

51

59

worrying

thoughts

Feeling isolated

32

Despite the differences in context, family/social

support seems to be a key psychological variable

for providing intrinsic reassurance and inhibiting

the feelings of worry and unease associated with

anxiety.

In regards to the qualitative analyses, several

connected themes and sub-themes emerged

from the analyses with “family/social support”

seemingly being the most significant factor for

the management of anxiety and ill mental health

alongside “positive feelings due to an activity” (e.

g. exercise) (Table 2).

Benefits of personal development. Another high

point for individuals during lockdown was the

opportunity for personal development and self-

reflection. Many people expressed that “time for

self-improvement” and “highs have been having

time to work on yourself” were of significance.

Other high points for people have been to allocate

their free time towards activity and movement to

achieve their self-defined goals such as “losing

weight, cooking meals from scratch, daily walks

have been good” and “highpoints have been

increased exercise activities and total control of

my diet”.

Themes.

High Points During the Lockdown. In this

theme, participants emphasized just how

significant it was to be able to see family and

friends during the lockdown and that the extra

time available allowed individuals to engage in

personal development. The sub-themes included

the importance of Family/Social Support and

Benefits of Personal Development:

One individual illustrated that having more time

for themselves since recovering (from Covid-19)

played an important role through the process of

returning to full health and normality:

Importance of family/social support. Seeing

family and friends acted as a “coping mechanism”

for stress and anxiety management during

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“Since recovering, I felt more relaxed and being

able to go for walks and be in the sunshine has

helped, being in furlough has helped ease the

worry, recovery from illness has enabled me to

get life back on track, improvement in diet and

reconnecting with people has helped find

normality again.” (Arthur)

also changed my mindset, appreciating simpler

things in life, being content with what you have

and finding happiness in whatever you have.”

(Venessa)

Thus, perhaps acting as “blessing in disguise”,

some individuals found that having ample free

time and self-reflection sparked up dormant

elements of self-development that occupied

people’s minds enough to engage in a journey of

self-discovery and meaning; also inhibiting

feelings of discomfort associated with anxiety.

“I was able to improve skills for home such as

gardening and cooking. Through this, I was also

able to spend more time with my family and better

my communication with them. This lockdown has

Table 2. A summary of relevant themes and sub-themes generated from the thematic analyses

Themes

Sub-themes

1.1 Importance

the Family/Social support

Selected quotation

High points have been speaking to family and

friends. (Sam)

1. High points

during

of

lockdown

1.2 Benefits of Personal

Development

A high point of lockdown was being able to

focus more on myself. (Matthew)

2. Low points

2.1 Lack of Family/Social

Feelings of isolation and loss of personal

during

lockdown

the support

isolation

&

Feelings

of contact with others. (Zoe)

2.2 I mostly missed family

Not being able to see friends and family from

different places in the UK. (Jake)

13

3.

Drivers

more to an activity

3.1 Positive feelings due

Therapeutic! Done a small amount of gardening

and cooking. (Mary)

towards

positive feelings

4. Feelings of

anxiety

4.1 Loneliness & isolation

5.1 Uncertainty about the

Being cut off from family and friends and feeling

alone. (Nancy)

5. Exacerbating

anxiety

Have felt tearful at times due to the uncertainty

of things and not being able to maintain a regular

routine. (Katrina)

future

5.2 Fear of 2^ndwave

N/A

Covid returning and being ill again as I don’t feel

I have the strength to face it again. (Natalie)

6.

Facilitating

Self-Care

Talking to my family for reassurance and

support. (Michelle)

Low Points During the Lockdown

Lack of family/social support and

feelings of isolation. In contrast to the

significance of family/social support in the

previous section, people who experienced a lack

of such support and prolonged duration indoors

underwent low mood states, feelings of

depression, stress and generalized anxiety about

the current environment and uncertainty about the

future. Quotations such as “feelings of isolation,

In this theme, individuals expressed their

feelings of isolation, loneliness and lack of

family/social support as the primary factors for

increasing their anxiety levels during the Covid-19

period. The sub-theme of this was isolation,

especially among those who lacked family/social

support, missing family and friends and anxiety.

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feeling low in general”, “a low point is being

isolated from friends and family”, “intermittent

anxiety and depression”, and “feeling stressed

about the uncertainty of the future” provided

insightful snapshots in respect to how people felt

and why. One individual managed to portray all of

these concerns in their response with the lack of

family support being something that “let them

down”:

Certain aspects were reported by

participants to generate positivity. Sub-themes

within this included participating in an activity,

seeking peer support and connecting with friends

and family.

Positive feelings due to an activity. In

this theme, individuals who engaged in multiple

activities throughout the day such as exercise,

cooking, walking and virtual social meetups

reported positive mood states. In general,

individuals who “kept themselves busy” did not

feel unworthy or unproductive thus reducing the

chance for self-critical thoughts to ensue. Quotes

that best portray this are as follows:

“Worried not coping with sickness, fear of dying

alone, trying to get correct medication because

symptoms unclear whether COVID or just flu, lack

of support while sick, isolation was difficult,

depression not knowing how long this was going

to last, feeling exhausted from simple tasks,

having to wash, shop and cook during sickness

was hard, difficult not being able to order

groceries online while sick, feeling anxiety from

listening to news and updates of people dying was

frightening, unable to tell neighbors I was sick in

case they panicked, feeling let down by family

because they were too scared to help out, losing

my job and worried about finances, also loss of 3

family and friends made it upsetting and real.

Spent 2 months living in fear and anxiety.” (Leah)

“Yesterday was a very busy day, I did tasks such

as DIY around the house, shopping and

exercising. I felt happy throughout the day and

productive. By the end

I was exhausted!”

(Jessica)

“I've had an extremely fulfilled day with activities

that occupied both my physical and mental needs.

I've studied for an exam, went to a bar with my

girlfriend and took a walk with my dog. I can easily

say that I’ve felt relaxed and happy throughout the

whole day.” (Adam)

Another individual also revealed that sustained

lack of contact led to feelings of anxiety and

depression:

“Yesterday I woke up early & went for a 3km run

followed by a 30-minute strength workout. I ate

healthy but nutritious good food & met with some

of my friends who I haven’t seen in a while

(socially distanced). I feel really positive & grateful

that the world has slowed down & we can really

enjoy spending time with each other & being in

the moment rather than constantly rushing about.”

(Taylor)

“Video calls, with friends and family. When I never

got any contact for a few days, then I would start

getting feelings of terrible loneliness, and would

start feeling a bit depressed.” (Emma)

14

Thus, it is evident that sustained absence of

family/social support increases the chance for

anxiety, feelings of depression and negative

“Woke up, did gardening, exercised and felt very

good relaxed in evening and watched a movie and

did some reading. Kept myself busy and

minimized sedentary activity. Ate three meals with

fruit as snacks cooked myself so felt very good

doing that as felt healthy too and was extremely

calm and relaxed, no stress apart from during

exercise pushing my limits but I enjoy that.” (Jake)

cognitive

deprecating thoughts).

processes

(self-critical

&

self-

I mostly missed family. The last key

theme was the emphasis from participants that

they most missed seeing and talking to their

families and friends for psychological reassurance

and emotional support during the Covid-19

pandemic. The quotations on this theme were

short but plentiful in volume:

Thus although this outcome is of no surprise, it

does illustrate the importance of engaging in

multiple activities though out the day as a strategy

for SC programs to encourage individuals to

preoccupy themselves and not allow self-

deprecating thoughts and worries to “creep in”.

“Company of people, being able to hug people I

care about.” (Vicky)

“Being able to see my family and friends.”

(Jeremy)

Feelings of Anxiety

“Human contact, I love being around people, and

socializing.” (Alex)

In contrast to those who felt positive,

numerous people during lockdown felt “sluggish”

and unmotivated to partake in regular daily

activities due to feelings of isolation, loneliness,

uncertainty about the future and fear of a second

Covid-19 wave all fueling a generalized feeling of

unease and fear. Some people felt “near

Thus, it is clear from the themes that a lack of

family/social support is a determinant for the

increased risk of anxiety levels and ill mental

health.

Drivers Towards More Positive Feelings

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breakdown” whilst others described their feelings

as “felt slightly down but hopefully things will get

better soon”.

that were occurring in people’s minds. Further

quotations include:

“Fears that there may be a second wave and i or

Loneliness and isolation. Loneliness and

isolation were feelings that people experienced

during the lockdown period that contributed

towards the generalized feeling of worry, unease

and thus anxiety. Quotations such as “feeling

lonely sometimes” and “being alone, feeling

restricted” provided insight that people felt

helpless and trapped. Further quotations were:

people I know may get ill and/or die.” (Marva)

“Fears - a second wave of the virus.” (Pam)

“That people have and are still not taking the

Pandemic seriously and that a second one may

occur. I worry that I could go out and bring Covid

19 back to my husband.” (Finola)

“Fear of a second wave of infections.” (Daniel)

“Excess free time, isolated from family.” (Ben)

Thus, this sub-theme may have acted as an

adjunct contributing towards the proclivity for

generalized anxiety to be experienced. Despite

this, it is clear that the reasons for increased

anxiety during lockdown are multifactorial and

situation specific in respect to how it is developed

for each person. More importantly, irrespective of

individual intention and activity, environmental

influence plays a significant role in changing

behavior and consequently, SC programs that

reduce environmental variance should be

facilitated.

“Day passed o.k. But then I would get feelings of

loneliness, I get this more than I did, before

lockdown.” (Alex)

“During the day I am able to cope, in evenings,

feelings of depression, unable to talk to someone

because people feel overburdened hearing about

my health. Daytime been out walking and to get

fresh air for change of environment, seeing people

with friends and loved ones, feel isolation even

more, having to socially distance. People don’t

want me to visit because I have been ill and they

are worried of me being asymptomatic and a

carrier.” (Sonia)

Facilitating Self-Care

Family/social support acted as a “coping

mechanism” for the management of anxiety levels

however, this theme illustrates that ongoing

family/social support was not only a “coping

mechanism” but also acted as a determinant for

positive mental health outcomes and inhibition of

anxiety and ill-related thoughts. Quotations such

as “support from family and friends” and “being

able to have virtual contact with friends through

face time” are just a couple of insights vocalized

by participants. One person explained how

ongoing support provided intrinsic reassurance

and due to such a phenomenon allowed her to

stay calm through such an uncertain time:

Exacerbating Anxiety

Another key theme was that it was clear

that participants were faces with troubled thoughts

during the pandemic that exacerbated their

anxiety. Subt-themes within this included

Uncertainty about the future and Fear of 2nd

wave.

15

Uncertainty about the future. In

conjunction with the previous sub-theme,

individuals reported a sense of “future uncertainty”

and “fear of the unknown” as mechanisms driving

ill thought and worry. Quotations such as “the

uncertainty of all our futures scares me “and“ what

will the future look like, fear of the unknown”

illustrate the gravity of how fearful people were

about future events. Due to the environment being

so volatile and negative, this could potentially

explain why individuals felt so insecure about the

future in conjunction with personal specific

circumstances that further amplified this feeling

increasing the risk of anxiety and health-

debilitating behaviors.

“Family and friends has been a great support

network for me to move through this lockdown.

Through the help of social media, I am able to

communicate with friends and family even from

my native home in Philippines. It reassured me

that I am not alone during this time.” (Sarah)

Others provided less depth and insight but

emphasized the same principle from different

perspectives:

Fear of 2^ndwave. Due to the infectious

nature of the virus and chaotic environment that

transpired after, many people felt frightened of the

possibility for a second wave unfolding with more

Covid-19 deaths. Quotations such as “dreading a

second wave of covid” and “I fear the virus may

return and kill more people” briefly illustrates the

severity of fear and negative cognitive processes

“Feeling supported but my family that allowed be

to stay calm about life and accept that what was

going on was out of my control.” (Debbie)

“Focusing on my faith and reuniting virtually with

family and friends.” (Ally)

“Talking to family and friends about how I am

feeling.” (Natalie)

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“Support from friends and family.” (Ryan)

this, individuals in warzones who lacked

community acknowledgement and support felt

rejected, abandoned and isolated that increased

the inclination of antisocial behaviours and

depressive thoughts (Puspoky et al., 2006;

Summerfield, 2000) which can also be seen in the

context of Covid-19 as individuals who received a

lack of peer support and sense of belonging

emphasised similar feelings. Comparable findings

can also be found during the Ebola virus outbreak

where survivors at an individual level, who felt

rejected, stigmatised and abandoned by their

community experienced feelings of anxiety,

depression, isolation, self-harm, worthlessness,

sadness and self-stigmatisation (Bortel et al.,

2016; James, Wardle, Steel, & Adams, 2019). In

conjunction with this, and similar to the

environment of Covid-19, the economy of West

Africa plummeted due to the Ebola virus outbreak

which further influenced the social fabric and

rapport between communities and consequently

creating a “breeding ground” for anxiety and self-

destructive behaviours to ensue (Huber, Finelli, &

Stevens, 2018). However, despite the severity

and death toll of the Ebola virus outbreak,

behavioural coping strategies to tackle and

recover from past traumatic experiences involved

socialisation/peer support and a commitment to

faith as a collective identity to foster a sense of

belonging (Bortel et al., 2016; James et al., 2019)

which again, is somewhat replicable to the coping

strategies of people during the Covid-19

pandemic. Acting as an adjunct to the previous

findings, data collected from the previous SARS

outbreak, in an hospital environment, confirmed

that nurses who lacked the peer support from their

physicians/doctors, felt burned out, less informed

about the development of SARS, less involved in

decision making, rejected and consequently,

experienced feelings of worry that affected moral,

job satisfaction and fulfilment (Tolomiczenko,

2005). This finding is useful as the environment of

the previous SARS outbreak in the hospital

domain is likely to be replicable to the current

hospital environment of Covid-19 and also

confirms the need for peer support to ensure staff

are nurtured for and that patient centred care isn’t

compromised. Thus, despite the differences in

environment, there is a universal theme that

ongoing peer support as a SC behaviour for

anxiety management is beneficial in the context of

social upheaval however, a tailored SC strategy

for anxiety self-management in the context of

Covid-19 is still warranted.

“Seeing a therapist, going for walks and speaking

to friends and family most days and avoiding the

news.” (Louise)

“Lots of family contact with phone and video

calls.” (George)

Despite the lack of depth, there was an

overwhelming emphasis on just how significant

ongoing family/social support played for

individuals during the Covid-19 pandemic towards

their mental wellbeing. It is clear that a SC

program facilitating a therapeutic environment

through dialogue where individuals can vicariously

share emotion and experience is paramount

Discussion

From the results presented, areas of interested

can be identified. Firstly, it is apparent that both a

lack of and a sustained reciprocation of ongoing

family/social support is a key predictor for the

proclivity of anxiety-inducing thoughts to be

experienced; secondly, in this study the “by-

products” of reduced family/social support led to

negative thought processes and feelings such as

isolation, loneliness and uncertainty about the

future; and lastly, individuals who continually

engaged in activity experienced positive mood

states irrespective of the current lockdown

environment.

As Covid-19 is a global pandemic and crisis,

the findings from this study, particularly around

the importance of peer support as a mediator for

positive mental health outcomes, is supported by

literature that has captured the psychological

impact of global crisis events on individual,

community and international levels such as the ill

16

mental

health

experienced

in

warzones

(Summerfield, 2000), coping mechanisms derived

from individuals who had experienced the Ebola

virus outbreak in Africa in 2014 (Bortel et al.,

2016) and the previous Coronavirus disease

(SARS) that occurred in China in 2003

(Tolomiczenko, 2005). Summerfield, (2000)

emphasises that “personal recovery is grounded

in social recovery” and that “rights and social

justice shape collective healing”. Although the

environment of warzones may compound the

feelings of anxiety more due to its violent nature,

ill-related thoughts and feelings of bereavement,

guilt, mistrust of public services, generalised

anxiety and fear about the uncertainty of future

events (Summerfield, 2000) are all relatable

findings to this dissertation. Additionally, even in

this traumatic context, peer support groups, where

people share insight, experiences, thoughts and

emotion, seem to facilitate an environment of trust

and rapport that helps nurture and develop health-

promotion strategies (Coatswroth, Forchuk, &

Griffin, 2006; Summerfield, 2000). In contrast to

Wu, Connors and Everly, (2020) looked at the

previous response to SARS in the context of

hospitals and emphasised the need for

leadership, cohesion and ongoing support for staff

to ensure they felt resilient enough to bare the

overwhelming responsibility of Covid-19; whilst

new research looking into the mental health

consequences of Covid19 advocate the need for

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“population-level interventions targeted at the

prevention and treatment of mental health

symptoms (e.g. anxiety) and at boosting coping

and resilience (e.g. exercise)” (Holmes et al.,

2020). Perhaps the most promising strategy for

successful adherence towards an anxiety self-

management intervention post pandemic is online

SC (self-help) programmes (Sahni, Singh,

Sharma, & Garg, 2021), in particular “self-help

guidance on demand” (Brog, Hegy, Berger, &

Znoj, 2021). Firstly, integrating self-help

programmes for anxiety online concur with current

social distancing measures, do not require

physical contant, facilitate peer support and are

scalable (Brog et al., 2021; Rosen, Glassman, &

authors knowledge, no studies have been carried

out this way that would be of use to the area of

anxiety

self-management.

Furthermore,

in

addition to the benefits from peer support, simply

moving would already provide additive benefits

both physically and psychologically (ACSM, 2016,

2017) as sedentary behaviour would be reduced.

In summary, a SC programme that encompasses

peer support with an activity such as walking,

cooking or even aerobic exercise should be a

cost-effective suitable strategy for helping

individuals self-manage their anxiety more

competently and reducing the proclivity to submit

to negative cognitive processes and engagement

in self-destructive behaviours.

Morland, 2020). Secondly,

a

“guidance on

demand” approach imples that patients can

request therapist assistance when needed whilst

still being able to experience unguided

(automated) self-help thus promoting cost

effectivness (Brog et al., 2021) and preserving

Impact of Findings

The findings of this study are influential,

insightful and pragmatic in guiding future health

care professionals, from both primary and

secondary care services, in producing a program

or self-help materials for anxiety. Consequently, in

doing so should act as the first step towards

reduced NHS pressure and costs. Secondary

community health services (e.g. talking groups,

weight management, exercise referral) in

particular benefit from this study as it would be

useful to facilitated SC programs fueled with

social support and activity in an attempt to

manifest socialization, rapport building, hedonism

and thus adherence towards this mode of

behavior.

autonomy,

establihsing rapport (Bandura, 2004). Most

importantly, randomised controlled trials

an

important

mechanism

for

assessing the effectivness of “guidance on

demand” on anxiety have been conducted with

“guidance on demand” showing similar positive

reductions to that of usual care (in person) or

“guided self-help” (online with therapist). For

instance, Krieger et al. (2019) carried out a 8-

week, compassion focused intervention with usual

care combined with “guidance on demand” and

usual care alone on individuals who experienced

overly self-critical cognitions and found significant

medium-large effect sized reductions in self-

deprecating thoughts in favour of the intervention

group. Similarly, Kleiboer et al. (2015) conducted

a 6-week online intervention based on problem

solving therapy with the “guidance on demand”

group showing identical reductions in anxiety

symptoms as the unguided mode of the

programme. Likewise, both Krieger et al. (2019)

and Kleiboer et al. (2015) findings can be

strengthened by additional evidence (Berger et

al., 2011; Rheker, Andersson, & Weise, 2015).

Thus, it would be safe to assume that best mode

of SC for anxiety moving forwards could be online

“guidance on demand”.

In the final analysis, amalgamating online,

“guidance on demand”, with an activity such as

walks (virtual walking groups) or cooking due to its

popularity might be an appropriate strategy.

Specifically, the “guidance on demand” aspect

can promote peer support that acts as a

“environmental mechanism” for rapport building

through the phenomenon of socialisation and

empathy (Smith, 2006) in conjunction with the

positive behavioural feedback loop, explained

through the SCT (Bandura, 2004), fostering an

hedonistic experience and increasing the

inclination for adherence towards this pattern of

behaviour. Additionally, and to the best of the

17

Limitations of the study\Strengths of

the study:

This study adds to novel literature and is one

of the first of its kind to obtain insight into people’s

perceptions, feelings, worries and thoughts about

the current uncertain environment of Covid-19 and

how people self-manage their anxiety however,

this study isn’t without its limitations. By its nature,

surveys only provide limited insight as it is difficult

to portray true feelings and emotions via this

mode of data collection. Additionally, some

questions were left unanswered in conjunction

with individuals potentially providing dishonest

answers or just answering the questions with what

“the researcher wanted to hear”. Furthermore,

some questions may have been comprehended

and interpreted differently between each

participant despite the researcher’s best efforts. It

is also important to acknowledge that the findings

of this study are only applicable to adults and thus

cannot apply to any population outside this age

range. Still, despite this both quantitative and

qualitative methods were used to facilitate a

holistic approach and absorb as much of the

relevant findings where possible to generate a

useful valid evidence-base narrative. Additionally,

as more than 100 individuals completed the

survey some trustworthiness, reliability and

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saturation can be established. In respect to future

research suggestions, it would be useful to focus

on the quantitative analyses for this research topic

and compare different age groups towards anxiety

levels in terms of severity; as this research

focused on the qualitative aspect, this analyses

was deemed outside the remit for this particular

study. Furthermore, as peer support presented

itself as being the most influential element of

anxiety management, future SC interventions

amalgamating peer support with an activity such

as walking (walking groups) or cooking (virtual or

in person) and using the HADS scale pre, during

and post intervention alongside qualitative

interviews may be one of many appropriate

research strategies acting as a “stepping stone”

towards a future SC program promoting anxiety

self-management.

by people with mental illness. The British

Journal of Psychiatry, 170(2), 101-102.

Byrom, N. (2018). An evaluation of a peer support

intervention for student mental health. Journal

of Mental Health, 27(3), 240-246.

Bortel, T., Basnayake, A., Wurie, F., Jambai, M.,

Koroma, A. S., Muana, A. T., ... & Nellums, L.

B. (2016). Psychosocial effects of an Ebola

outbreak at individual, community and

international levels. Bulletin of the World

Health Organization, 94(3), 210.

Bocking, J., Ewart, S. B., Happell, B., Platania-

Phung, C., Stanton, R., & Scholz, B. (2018).

“Here if you need me”: exploring peer support

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Baker, C. (2020). Mental health statistics for

England: prevalence, services and funding.

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Bandura, A. (2004). Health promotion by social

Conclusion

cognitive

means. Health

education

&

In conclusion, the findings from this study adds

to current novel literature on the current anxiety

levels of adults living in the UK under the Covid-

19 pandemic and what behaviors people adopt to

self-manage their anxiety levels. Furthermore, this

study highlights the significance of ongoing peer

support as a SC behavior that can act as a

positive meditator for healthy cognitive processes

to ensure that inherently reduces the risk of

anxiety levels and ill mental health. Thus, future

health care initiatives that seek to facilitate SC

and promoting this strategy may, if not prevent, at

least slow down the rising cases of anxiety and ill

mental health due to the uncertain environment

Covid-19 plus other future pandemics might

produce.

behavior, 31(2), 143-164.

Bandura, A. (1997). Self-efficacy: The exercise of

control. New York, NY: Freeman.

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analysis in psychology. Qualitative Research in

Psychology, 3(2), 77-101.

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self-care

and

community

participation:

elements of a proposed programme in the

developing countries. BMC public health, 4(1),

11.

18

Brog, N. A., Hegy, J. K., Berger, T., & Znoj, H.

(2021). An internet-based self-help intervention

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Kneubühler, B., Sutter, D., & Andersson, G.

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Conflict of interest

The author declare no conflict of interests

phobia:

a

randomized controlled trial

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The psychological impact of infertility. Directions

for the development of interventions

Ana-Maria Vioreanu

University of Bucharest, Bucharest, Romania

Abstract

Introduction: Infertility represents a major health problem that oftentimes is experienced as a

crisis situation. Because it interposes with achieving an important life goal, that of having children,

its implications on the psycho-emotional level are robust.

Purpose: The present article aimed at exploring the multidimensional effects of infertility on

mental health, as well as suitable psychological intervention strategies for patients both at an

individual and couple level.

Methodology: An extensive literature review was conducted to select the most relevant

information. Articles included were searched in PubMed, Google Scholar and other similar

databases within a seven years interval (2014-2021) to assure the up-to-date quality of the paper.

The main criteria of inclusion were: studies about the consequences of infertility on mental health,

epidemiology, risk and protective factors, psychological models for infertility, psychological

evaluation, established instruments, psycho-social and therapeutic interventions, intervention

protocols used in public health for infertility patients.

Results and Discussion: Infertility is often experienced as a crisis situation, in which the most

common consequences are visible at the level of mood disorders (e.g. anxiety, depression,

marked distress) and at the social level (stigma, divorce, social isolation, financial difficulties).

Psychological counseling is needed throughout medical treatment and therapeutic interventions

(e.g. cognitive-behavioral therapy) have shown favorable results in managing the emotional

balance of the individual/couple and reducing the risk of psychopathology.

21

Conclusions: Research highlights the beneficial effects of psychological interventions on

reducing levels of stress related to infertility, anxiety and depressive symptoms and on improving

the quality of life and couple dynamics.

Keywords

infertility, risk factors, protective factors, psychological interventions, infertility-related stress

Address for correspondence:

Ana-Maria Vioreanu. University of Bucharest. 90 Panduri Str., 050663, Bucharest, Romania

E-mail: ana.vioreanu8@gmail.com

Submitted for publication: 10

August 2021

This work is licensed under a Creative Commons Attribution-

Revised: 07 October 2021

Accepted for publication: 24

October 2021

NonCommercial 4.0 International License (CC BY-NC 4.0).

©Copyright: Vioreanu, 2021

Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy

doi: https://doi.org/10.32437/mhgcj.v4i1.128

public health problem worldwide, affecting around

48 million couples and 186 million individuals of

reproductive age. A distinction is made between

primary infertility - the inability to have a

pregnancy - and secondary infertility - the inability

to have another pregnancy after a previous

successful one. The impact of infertility can have

Introduction

According to the World Health Organization,

infertility is the inability of a couple to obtain a

pregnancy after twelve months of regular

unprotected sex or after repeated attempts by the

woman to become pregnant. Infertility is a major

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major consequences both psychologically and

socio-economically. The first to suffer from these

are women, as they are prone to stigma, an

increased risk of domestic violence, divorce, acute

distress, anxiety, depression and social isolation

(WHO, 2020).

• N97.0 Female infertility associated with

anovulation;

• N97.1 Female infertility of tubal origin;

o Associated with congenital anomaly of the

fallopian tube:

- locked;

One of the strongest predictors of infertility is

the advanced age of the woman, but an equally

important role is played by environmental factors

and lifestyle. Factors influencing reproductive

capacity may be gender specific, but this is not a

condition (Hart, 2016).

- occlusion;

- stenosis;

• N97.2 Female infertility of uterine origin;

o

Associated

abnormality;

o Non-implantation of ovum;

with

congenital

uterine

There are several terminologies explaining this

issue, so it is necessary to distinguish between

them. First, infertility "is defined as a disease

characterized by failure to establish a clinical

pregnancy after 12 months of regular and

unprotected sexual intercourse due to a person's

impairment of reproductive capacity either

individually or as a couple." (Borght & Wyns,

2018, p. 2). Infertility is a disease that causes

disability as an impairment of the function.

Subfertility is also the effort of couples to

achieve a pregnancy, associated with any low

degree of fertility. According to the International

Classification of Functioning, Disability and Health

(ICF), it is coded b660, affecting procreation

functions (functions associated with fertility,

pregnancy, birth and lactation) - b6600 fertility-

related functions with impairments such as

• N97.3 Female infertility of cervical origin;

• N97.4 Female infertility associated with male

factors;

• N97.8 Female infertility of other origin;

• N97.9 Female infertility, unspecified (World

Health Organization, 2002).

Going further and analyzing demographics

around the world, there are six important facts

about demography:

1) Millions of people worldwide suffer from this

condition;

2) The highest infertility rates are those of

secondary infertility and are found mainly in

contexts poor in resources;

3) Africa is the region with the most alarming

infertility rates globally;

4) Africa suffers from a demographic paradox:

high infertility rates coexist with high fertility rates;

5) Although this issue is a major global crisis,

there is an acute lack of prevention programs and

treatment services - the main justification being

directly linked to a form of control of over-

popularization, especially in regions with a very

high birth rate (e.g. sub-Saharan Africa);

6) The regions that suffer the most from

infertility are the same that offer the fewest

options of diagnosis and access to treatment

(Inhorn & Patrizio, 2015).

subfertility

and

sterility

(World

Health

22

Organization, 2001)

.

The terms infertility/

subfertility are used interchangeably.

Second, while infertility is a limited condition

over a period of time, sterility indicates a

permanent stage of infertility (Zegers-Hochschild,

et al., 2017).

Regarding the prevalence of infertility, it is

estimated to affect one in seven couples of

reproductive age in Western countries and one in

four couples in developing countries. There are

regions around the world that are more prone to

infertility such as South Asia, the Middle East,

North Africa, Eastern and Central Europe, where

the index can reach 30%. The contribution of

female and male factors differs: men are involved

in 50% of cases, with differences between certain

regions of the world. Globally, infertility affects

between 8 and 12% of couples, with secondary

infertility being the most common. One

explanation for this is the risky methods of

abortion, the lack of adequate care in maternity

wards, which can lead to dangerous infections

after birth or abortion (Borght & Wyns, 2018).

Female factors that contribute to infertility may

be related to other biological disorders. The

International Statistical Classification of Diseases

and Related Health Problems (ICD-10-AM)

classifies infertility as follows: N97 female infertility

(inability to complete a pregnancy) with the

following etiologies:

Purpose

The main objective of this paper was to explore

and analyze the psychological impact of the

infertility condition, with all its multidimensional

effects. More and more recent research draws

attention to the risk factors for infertility and to the

widespread effects of this condition at the bio-

psycho-social level. That is why psychological

intervention in managing this issue is urgently

needed, and the literature suggests scientifically

validated methods that can restore psychological

balance. Starting from psycho-education and

understanding the medical condition, to evaluation

and psychological intervention, each step must be

followed in order to bring the patient back to the

psychological safety zone, to help him face the

challenges that follow and to support him in taking

those better informed decisions. Therefore,

psychological support is essential from the

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moment of diagnosis until the end of treatment,

regardless of its results.

polycystic ovary syndrome (between 30-70% of

women with this syndrome are obese) the risk of

infertility is exacerbated (Tsai, et al., 2013).

- Sexual violence: research indicates that

women who have a history of psychological

trauma caused by sexual abuse have a three

times higher risk of infertility (Deyhoul,

Mohamaddoost, & Hosseini, 2017).

Methodology

The present study is a literature review

intended to serve as a practical guide for mental

health specialists for the development of

individualised interventions for infertility patients.

Articles included were searched in PubMed,

Google Scholar and other similar databases within

a seven years interval (2014-2021) to assure the

up-to-date quality of the paper using keywords

such as: „Infertility-related stress”, „Risk factors”,

- Testicular dysfunction and sperm quality;

- Negative life experiences and stress: studies

in mice show how systematic stress affects

reproductive function by inhibiting a key hormone

in the reproductive system. Moreover, life history

theory provides a frame of reference that explains

the impact of adverse early life experiences on

fertility from an evolutionary perspective.

Specifically, people who experience unfavorable

childhood conditions (e.g. lack of resources,

family imbalances) are more likely to approach a

fast life history strategy characterized by impulsive

„Psychological

impact”,

„Counseling”,

„Interventions”. The main criteria of inclusion

were: studies about the consequences of infertility

on mental health, epidemiology, risk and

protective factors, psychological models for

infertility, psychological evaluation, established

instruments, psycho-social and therapeutic

interventions, intervention protocols used in public

health for infertility patients. The exclusion criteria

were the year of publication (older than 2014) and

the source of publication (low impact factor).

behaviors,

early

reproduction,

prolonged

physiological activation, and poor mental health

management. All this translates into a major risk

of infertility in adulthood (Schweiger, Schweiger, &

Schweiger, 2018).

Infertility itself does not show a certain somatic

symptomatology, except when it is associated

with other clinical conditions. Instead, perhaps the

most common symptomatology of infertility is at a

psychological level, as mental health can be

affected in a proportion of 30 to 80% depending

on the cause and duration of infertility (Luk &

Loke, 2015). The main symptoms can range from

stress and an inferiority complex, to anxiety and

major depression (Yusuf, 2016). Stress levels are

much higher among women, for various reasons.

Perhaps one of the most important reasons is the

status of being a mother, a fundamental role in the

life of a woman, which for many of them is

considered defining and therefore an essential

purpose in life. The inability to achieve this goal

comes with many emotional imbalances, and can

Results

Risk factors and consequences of infertility

According to the literature, there are many factors

that can influence the spontaneous fertility of the

couple. These include:

- Reproductive system disorders: congenital

disorders, muscle tissue gland, endometriosis,

polyps and anatomical problems;

23

- Genital infections or sexually transmitted

diseases;

- Old age: the quality of fertility begins to

deteriorate at the age of 25-30 years in women

and studies show that most of them are not aware

that postponing a pregnancy increases the risk of

infertility. Moreover, it is erroneously considered

that medical treatments used to have and

maintain a pregnancy can solve the problem of

declining fertility caused by old age. The

prognosis is all the more unfavorable as the

woman's age is over 35 years, and the duration of

infertility exceeds 3 years (Eijkemans, 2014);

- Hormonal dysfunctions (e.g. hypothyroidism,

hyperprolactinemia);

- Smoking and alcohol consumption: studies

show that 40% of men suffering from infertility are

smokers. The impact of smoking is also great in

women, as nicotine works by destroying eggs

faster. A lost egg cannot be recovered, which is

why women who smoke reach menopause up to 4

years earlier than normal age. Alcohol

consumption in men indicates a reduction in

sperm count (Sabarre, Khan, Whitten, Remes, &

Phillips, 2013);

be

a

crisis situation that threatens the

psychological well-being of women. In addition,

some studies have suggested that among women

suffering from infertility, the initial level of stress

caused by the condition is compounded by

additional stress, at least as strong, caused by

medical treatments. The level of stress caused by

infertility treatment is the second highest intensity

of a stressor, after the death of a family member

or divorce (Wiweko, Anggraheni, Elvira, & Lubis,

2017).

The consequences of infertility extend to the

family, social and economic level, the damage

given by this condition being multi-dimensional.

Next, some of the dimensions of this issue will be

analyzed.

a) The psychological dimension: as

mentioned above, perhaps the most

affected area of life is the psychological

one. The most common reactions

- Obesity and nutrition: because the most

common complication of obesity in women is

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observed among individuals and couples

roles further. For such cultures, the

when they hear the news are the shock

reaction, denial (which if prolonged can

prevent access to early intervention),

anger (perception of an injustice), the

feeling of losing control (weakening

coping mechanisms), social isolation, guilt

(which can lead to depression), anxiety

(Kırca & Pasinlioğlu 2013; Sezgin &

Hocaoğlu 2014).

b) The socio-cultural dimension:

culture, traditions and beliefs play a very

important role in certain societies, putting

their mark on issues related to the

subjectivity of each person's health. For

example, in developing societies, infertility

can be a real social problem, with couples

facing stigma and experiences that lead to

shame and marginalization. These things

happen because of the emphasis on

various values, especially those related to

family life, namely: social pressure to

have children as soon as possible after

marriage, portrayal of the child in the form

of a supreme achievement that brings

pride and prestige, the attribution of the

parent to transfer certain norms and social

inability to fulfill their “mission” and social

and

family

expectations

defect,

can

a

be

major

categorized as

a

disadvantage or can be understood as a

bad will to have a child. Therefore, if they

are unable to achieve their social roles

defined by their own culture (women, the

role of mother and men, the role of male

example), people suffering from infertility

are at risk of developing feelings of lack of

self-worth, decreased self-esteem and the

perception that there is something wrong

with them as a family unit (Patel et al.,

2018; Pinar & Yildirim, 2016).

The

economical

dimension:

infertility

treatments are expensive and long-lasting, which

is why couples who are part of resource-poor

areas may be unable to gain access to treatment.

Moreover, in some cultures (mainly in developing

countries) the inability to give birth to a child

comes with a breakdown of a woman's economic

security, caused by various consequences:

divorce, alienation from family members,

withholding of any financial resources provided by

the family until then and even confiscation of the

inheritance

(Rouchou,

2013).

24

Fig 1. Treatment options for infertility

Unfortunately, most people only start to inform

about this when they are directly confronted with

the problem, and worries and feelings of fear have

already set in, putting pressure on the

effectiveness of treatments. Therefore, the role of

prevention is to meet the educational needs of

people who want children, to protect them from

the psychological shock of a potential diagnosis of

infertility, but also to promote good health

practices overall. The promotion of psycho-

educational programs on this topic, but also free

access to scientific information, are two key points

of primary prophylaxis (Öztürk, Siyez, Esen, &

Kağnici, 2020).

Primary prophylaxis is the most useful method

of reducing the frequency of infertility, but most of

the time it is not applied. In order for the

prevention to be effective, access to information

about the disease and risk factors is needed.

Research has indicated that, including among

women with a high level of education, the

significant impact of advanced age on infertility or

the risks associated with reproductive assistance

technology remain unknown (Hammerberg, et al.,

2017). Since a crucial step in preventing infertility

is to implement change into lifestyle and certain

deleterious habits, being informed about what to

do in order to achieve a healthy pregnancy is the

basis for active strategies of help seeking and

preventing the secondary effects of a possible

diagnosis (e.g. distress, anxiety).

Psychological aspects involved in infertility

issues

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The psychology of infertility began to take

shape in 1930, with the introduction of the

psychogenic model of infertility by Berg and

Wilson, in which it was postulated that a major

cause of infertility unexplained medically is

represented by psychopathology. More precisely,

the etiological factor of unexplained infertility

would be a psychic conflict of different nature:

conflicting sexual identity, conflicting relationship

between mother and child (Berg & Wilson, 1991).

Over time and with the advancement of

research and technology in gynecology, the

psychogenic model has lost its validity, proving

that the probability that unexplained infertility is

caused exclusively by psychological problems is

extremely low and that, in most cases, it is

factors is what contributes to the client's healthy

behavior. Shortly, clients present two important

sets of variables, namely, background variables -

demographics, social influences, medical history,

environmental resources - and dynamic variables

- intrinsic motivation, affective response, cognitive

appraisal - where the firsts are relatively stable

over time, and the dynamic ones are influenced

by environmental factors. Therefore, dynamic

variables are intrapersonal, and due to their

modifiable nature, are targeted in behavioral

interventions designed to support health-oriented

behavior (Cox, 1982). This model has a major

impact in promoting behavioral tactics designed to

reduce the risk of poor health (for example, by

changing lifestyle and trying to eliminate vicious

behaviors).

basically

a biomedical problem (e.g. pelvic

pathology). However, the contribution of the

psychogenic model has been considerable,

setting the starting point for psychological

research in the field of obstetrics and gynecology

(Boivin & Gameiro, 2015).

A major influence in the psychological study of

infertility was launched by the advancement of

multifactorial models, one of the best known being

the bio-psycho-social model. It attests to the

contribution of various factors (biological,

psychological, social, environmental) in the

etiology of somatic diseases. Thus, there may be

several determining factors and consequences of

diseases, which manifest themselves differently

from person to person, depending on the personal

Most often, infertility takes the form of a crisis

situation, putting in danger the psychological well-

being of the individual/couple, life satisfaction and

other aspects of mental health. It is useful to

conceptualize the crisis so that we understand

how to deal with the problem in the most effective

way (Fig.2).

Summing up the above, we can make a

general observation on the areas of research in

infertility. Two main directions are those of

medicine and clinical psychology and those of

social models. From this point of view, infertility

research is a vast, eclectic field, focusing on the

essential aspects of each field. For example, the

clinical perspective turns its attention to

psychological distress as a direct result of

infertility, coping mechanisms and effective

methods to identify those who need prompt

intervention. On the other hand, the social

perspective draws attention to several concepts

such as health-oriented behavior, seeking help,

the social role of being a parent, stigma, marital

dynamics, gender differences, culture, and

individual/dyadic differences (Johnson, Greil ,

Shreffler, & McQuillan, 2018).

Anxiety and depression are the most common

psychopathologies in infertile couples for several

reasons: uncertainty about the cause of infertility

and the success rate of treatment, uncertain

duration of treatment, financial difficulties and

social pressure. Of all these, the strongest

predictor of depression is the duration of

treatment. On the one hand, because a long

duration of treatment can lead to trial failures and

a possible chronicity of the disease. On the other

hand, the longer the duration of treatment, the

greater the risk that the identity of the disease will

be known to more friends and family members,

which can lead to social pressure, stigma or

feelings of shame (Maroufizadeh, et al., 2018). A

current review of the literature indicates that the

symptoms of clinical intensity manifested occur in

25 to 60% of people affected by infertility (De

Berardis, et al., 2014). Moreover, research draws

attention to the fact that high levels of depression

25

history,

individual

differences,

various

developmental environments, etc. (Lipowski,

1984).

One current direction of research that

continues to receive much attention is the link

between stress and infertility. This field is

developed through a solid body of studies that

focuses on many aspects starting from individual

characteristics (such as gender, type of stressor,

life events), explanatory mechanisms (lifestyle,

hormones, compliance with treatment) and

reaching up to protection factors and intervention

models (such as counseling, psycho-education,

help-seeking behavior). Another aspect that

deserves a glimpse of change it is the excessive

focus on female infertility, losing sight of the male

factors that can contribute to this issue. Especially

in the psychiatric debate of infertility, men tend to

be included much less often in research and

therefore neglected during treatment. That is why

recent studies recommend shifting attention to the

area of dyadic models of conceptualization and

intervention (Boivin & Gameiro, 2015).

Continuing along the lines of psychological

models of infertility, we review a theoretical

framework that discusses several variables that

can lead to the development of specific

intervention models. The Interaction Model of

Client Health Behavior (IMCHB) argues that the

interaction between intrapersonal and contextual

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in women are associated with avoiding medical

treatment and increasing dropout rates after the

first cycle of treatment. Consequently, the reasons

for giving up treatment or refusing specialized

help are explained by psychological factors (Rich

& Domar, 2016).

Unfortunately, the complications of depressive

symptoms and acute stress have effects on the

success rate of treatment, forming a kind of

vicious circle. In short, stress produces harmful

effects on the hormonal system, with implications

on sexual functions and the body's response to

treatment (Ergin, et al., 2018). Therefore,

psychological interventions concomitant with

medical treatment specific to infertility are a

necessary condition in restoring the equilibrium of

the individual/couple and in removing obstacles to

the success of treatment.

26

Fig.2 The four-step model of crisis response (Caplan, 1964).

The literature emphasizes a person-centered

Psychological evaluation in infertility

approach to counseling, and the U.S. Institute of

Medicine has even provided a definition of what it

means to provide patient-centered health care:

"Providing care that respects and responds to the

patient's individual preferences, needs and values

and ensuring that patient values guide all clinical

decisions" (Institute of Medicine, 2001). Taking

into account the specific needs of the patient, the

risk factors for high distress can be analyzed,

depending on his history and individual

differences: pre-existing psychological disorders,

attitudes towards parental status, coping

mechanisms, quality of couple relationship, social

support network and treatment-related factors

such as side effects, success rate and others

(Doyle & Carballedo, 2014).

When it comes to estimating the impact of a

diagnosis of infertility on the functionality and

psycho-emotional balance, it is important to

analyze the aspect of psychological evaluation.

Psychological evaluation should be done both in

the initial stage, immediately after the diagnosis

and before the start of medical treatment, and

after the implementation of the treatment plan and

throughout it.

When the patient is in the initial stage, that of

learning about the diagnosis, one of the

therapeutic goals should focus on exploring his

concerns and fears about what is to come and on

psychological preparation, strengthening internal

resources for treatment requirements. An

important first step in this process is the correct

information of the patient about the condition he

suffers from, the treatment possibilities and the

expected results. Thus, the patient will know the

details necessary to form realistic expectations

and will lay the foundations for informed decision

making.

The main objective of the psychological

evaluation of the patient with infertility will capture

the emotional status and reactions/attitudes

towards infertility before starting treatment. For

the evaluation to be as valid as possible, it needs

to be structured on several levels:

a) Gathering information

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-

from the personal, medical, professional,

infertility. It consists of two parts, namely:

FertiQoL Central and an optional treatment

module that measures quality of life levels

throughout medical treatment.

FertiQoL Central consists of 4 scales totaling

24 items that measure the emotional, mind-body,

relational and social dimensions. The treatment

module contains 10 items plus 2 more general

items that measure the well-being of physical

health and of life in total. FertiQoL also presents

the necessary psychometric qualities, being

psychiatric history, both of the individual and of

couple;

- Establishing the current level of functionality;

- Checking the impact of infertility on mental

health, marital stability, reproductive and sexual

history;

- Administration of psychological tests.

b) Clinical interview

validated

in

several

countries

(see

www.fertiqol.org ) (Aarts et al., 2011; Donarelli et

al., 2016).

- Necessary for completing the clinical picture,

favoring the evaluation and construction of an

intervention plan;

COMPI

(Copenhagen

Multi-Center

Psychosocial Infertility) - Fertility Problem Stress

Scales (FPSS) is a key tool used in assessing

infertility related stress on a global level. It was

built on the basis of the Fertility Problem Stress

Inventory (Abbey et al., 1991) and patient

interviews (Schmidt, 2010) in order to determine

risk factors for infertility distress that may interfere

with treatment, but also protective factors and

gender differences (Sobral, Costa, Schmidt, &

Martins, 2017).

The other two mentioned instruments,

SCREENIVF and FertiSTAT, are two very useful

screening tools in the rapid evaluation of the

patient immediately after diagnosis. SCREENIVF

(Ockhuijsen et al., 2017) indicates the patient's

risk of developing a psychopathology at the end of

infertility treatment, and FertiSTAT (Blanchet et

al., 2019) provides support in assessing

knowledge about the pathology and helps

increase awareness of associated risk factors for

infertility. The latter consists of a list of indicators

representing the main risk factors for low fertility in

women and men, where each indicator is coded

by a color signifying the severity of the factor

(blue, yellow, orange and red - for more details

see http://www.fertistat.com/).

- Combining psychological testing with the clinical

interview provides an appropriate assessment and

identification of the patient's psychopathology and

immediate needs.

Therefore, a correct psychological assessment

will include theoretical, clinical and therapeutic

principles, so as to ensure the quality of services

provided, the implementation of effective

treatment and / or the application of counseling

sessions to support the patient / couple in the

medical process (Covington & Burns, 2006).

When it comes to psychometric assessment,

the main indicators to consider are stress /

distress, coping strategies, social support, quality

of life, adaptation to treatment, helplessness,

acceptance, anxiety and depression. An important

aspect here refers to the use of instruments to

measure the specific valences of infertility, as

general psychological scales cannot provide

sensitivity and specificity for infertility. Thus, more

than ten instruments have been developed to

measure the impact of infertility at the

psychological level and to capture vulnerable

areas or protective factors (Pedro, et al., 2016).

These include: Fertility Problem Inventory (FPI;

Newton et al., 1999), Fertility Quality of Life Tool

(FertiQoL; Boivin et al., 2011), COMPI - Fertility

Problem Stress Scales (COMPI-FPSS; Schmidt ,

2006), SCREENIVF (Verhaak et al., 2010),

FertiSTAT (Bunting et al., 2010).

27

Discussion

Psychological intervention strategies for

patients with infertility – Opportunities and

Challenges

Fertility Problem Inventory (FPI) is one of the

first multidimensional questionnaires built to

capture the most relevant aspects to consider in

the therapeutic process in patients with infertility.

It is a self-report questionnaire and can be

completed by both members of the couple. The

tool shows considerable gender differences in the

effect of stress on perceived anxiety and

depression symptoms, self-reported resilience

levels, and marital satisfaction, both from a female

and male perspective (Zurlo, Cattaneo Della

Volta, & Vallone, 2017).

The role of psychological counseling in

infertility highlights essential issues both

individually and as a couple or group. Counseling

should be a step that every patient with infertility

goes through, as the implications at the

psychological level, but also at the level of the

treatment plan, are essential.

In the initial stage of psychological counseling,

the patient benefits from a framework based on

unconditional acceptance, empathy and active

listening, so as to be motivated to seek and find

the most appropriate solutions for him. The

European Society of Human Reproduction and

Embryology (ESHRE, 2002) explains how the

process of psychological counseling gives the

Fertility Quality of Life Instrument (FertiQoL) is

a tool that focuses primarily on measuring the

quality of life of patients with infertility and is a

standard in the psychological assessment of

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patient the opportunity of making informed

decisions when it comes to medical treatment for

infertility. Basically, the counselor prepares the

person to start treatment, provides support

throughout the treatment and helps them adapt to

the different outcomes that treatment procedures

may have. Moreover, the counselor facilitates the

consideration and adoption of alternatives in case

of treatment failure (e.g., adopting a child or

In order to create a clearer picture of how CBT

sessions are conducted, we can take as an

example the randomized control study of Karaca

et al. (2019), in which a classic CBT intervention

protocol was followed. In this study, the

experimental group benefited from a group

cognitive-behavioral therapy program over 11

weeks. The sessions lasted on average, two

hours, only the first and last one having 20 extra

minutes to complete the pre and post intervention

questionnaires. The first session focused on the

patient's psycho-education both on the disease

(with the help of an obstetrician) and on drug and

psychological treatment options. The next two

sessions focused on clinical assessment

(assessment of the patient's condition and needs)

accepting

a

happy child-free life) (Joy

&

McCrystal, 2015).

There is a growing trend in research to identify

the most effective types or strategies of

psychosocial intervention. This imposes

a

challenge for the mental health practitioner as

research in recent years has failed to establish a

clear methodology due to mixed results. For

example, some meta-analyzes (Ying et al., 2016;

Chu et al., 2017) have suggested that

psychological interventions lead to a significant

reduction in negative affect caused by infertility,

help increase the likelihood of becoming pregnant,

and improve marital function ( Frederiksen et al.,

2015). On the other hand, there have been meta-

analyzes that have indicated the lack of significant

effects of psychological interventions on the

chance of becoming pregnant and on the

decrease in stress levels (Boivin, 2003).

Therefore, it is imperative to investigate the

effectiveness of psychological interventions in

managing the stress caused by infertility and their

possible effects on the pregnancy rate and

satisfaction in the couple. Next, it is important to

describe the psychological interventions that the

literature indicates to be the most useful to apply

to patients with infertility.

and

conceptualization

of

the

case

(a

comprehensive explanation of the patient's clinical

picture). The next six sessions were key to

therapy, implementing cognitive-behavioral stress

management methods and techniques such as

progressive muscle relaxation, breathing control

techniques, planning and goal setting, methods

for identifying and disputing negative thoughts and

ways to replace them with adaptive ones that

contribute

to

psychological

well-being.

Furthermore, the participants were supported in

exploring the maladaptive coping mechanisms

they used until then to cope with the symptoms of

anxiety and depression, in order to improve them

and to become more effectively. Participants were

given homework after each session, as they help

to strengthen the skills learned in therapy.

Session ten aimed to address other issues

specific to infertility, namely the couple's sexual

28

problems. In the last session,

a

general

One of the interventions that has enjoyed

significant positive results in reducing distress

caused by infertility is cognitive-behavioral therapy

(CBT). Numerous studies have suggested that

CBT techniques are useful in managing perceived

stress and infertility-related mood disorders (such

as anxiety) (Zhou, Cao, Liu, & Xiao, 2021). Such

techniques include relaxation methods (autogenic

training, progressive relaxation), stress inoculation

training (SIT), cognitive restructuring (techniques

for identifying and modifying distorted cognitions

induced by automatic thoughts about infertility;

conclusion was made based on the summary of

the key points of each meeting and indications

were given for strategies that can be adopted to

prevent relapses.

The results of this study suggest that group

cognitive-behavioral therapy has significant

positive effects on the control group, on infertility

related stress, symptoms of anxiety and

depression and on general health. These results

are conclusive with other studies, which point to

the high efficacy of CBT (individual) in reducing

global stress caused by infertility, with post-test

results indicating a considerable decrease in

e.g.

catastrophization,

global

evaluation),

problem-solving and decision-making techniques,

and lifestyle-related education (nutrition, exercise,

sleep and work schedule) (David, 2017). Some

studies included in this meta-analysis (Greil et al.,

2014) and which used CBT as a psychological

intervention, showed that patients report

significant improvements in mood, stress

management and marital satisfaction at 6 months

post-intervention. Moreover, progress tends to be

sustained over time, with participants indicating

stress and anxiety

compared to the initial results (Faramarzi et al.,

2013; Springer et al., 2018).

/

depressive symptoms

Another therapeutic intervention very often

used in the areas of health psychology is based

on the principles of mindfulness meditation. The

fundamental principle of mindfulness meditation is

the awareness of the present moment, sustained

attention, giving up judging what is happening

here and now (negative thoughts / emotions) and

practicing gratitude (Bai, et al., 2019). Evidence

from the literature shows the effectiveness of

mindfulness-based interventions in reducing

lower scores for depression

treatment.

1

year after

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anxiety and depressive symptoms (Eisendrath, et

al., 2016) reducing chronic pain (Morone, et al.,

2016) and increasing quality of life (Montgomery

et al., 2016). The ability to be flexible and shift

your attention to what you are experiencing right

now helps to integrate and accept thoughts and

emotions, ultimately leading to detachment from

their negative valences (e.g., in case of

depression, feelings lack of self-worth and lack of

hope) (Creswel, 2017).

Therefore, interventions such as those based

on mindfulness are useful and should be applied

in reproductive medicine, as in addition to the

long-term benefits specific to the patient, they may

have other benefits such as limited costs and

conservation of limited resources for infertility

treatment.

A new therapeutic technique derived from the

CBT area, belonging to the third wave of

cognitive-behavioral therapies, is Acceptance and

Commitment Therapy (ACT), which shows

promising results in recent studies. This technique

is based on certain essential processes such as

acceptance, mindfulness (contact with the present

moment), cognitive diffusion and actions

accompanied by commitment, which aim to

achieve and develop psychological flexibility

(Hosseinpanahi, et al., 2020). Through this

therapy, the patient learns to accept subjective

experiences with all his thoughts, feelings, and

perceptions, to limit excessive attention to himself

as a victim, and, perhaps most importantly, the

person learns how to identify his own qualities and

internal resources and how to translate them into

behavioral goals, to use them for easy adaptation

to life experiences (Samadi & Doustkam, 2014).

ACT has been shown to be effective in

interventions targeting mental disorders, but also

chronic medical conditions (e.g. chronic pain). The

main effects act on reducing psychological pain

(suffering) and improving psychological well-being

(Gloster, Walder, Levin, Twohig, & Karekla, 2020).

To sum up, the literature captures three of the

most useful therapeutic strategies that can be

used in patients with infertility: cognitive-

behavioral therapy, therapy based on mindfulness

and therapy through acceptance and commitment.

It comes as a challenge for the therapist to find

and use the therapeutic strategy that best fits the

client, as every person has its individual

differences.

Briefly, the first section contains the necessary

information on the medical consultations to be

performed and how they differ from other types of

consultations in the field of obstetrics and

gynecology. The second section introduces the

role of counseling the patient with infertility and

highlights the most common challenges, who is

more likely to need counseling, who can do

counseling and what it entails. Section three,

recalls patient-centered good practices and

indicates ways to incorporate counseling into the

medical treatment scheme. Section four focuses

on factors that may determine the urgent need for

counseling such as treatment failure, worsening

psychological distress, or sexual dysfunction.

Section five considers different ways of

reproduction and discusses the ethical and moral

issues they may impose (e.g. donating gametes,

choosing a surrogate mother, or adoption for both

heterosexual and homosexual couples). Section

six mentions additional ways of psycho-social help

that can be integrated with counseling in fertility

clinics such as the delivery of psycho-educational

materials, online / telephone counseling, help

groups, self-help strategies. To illustrate as clearly

as possible the content of this practice guide, the

following examples can be provided:

• For example, in the case of psycho-

educational materials, they must be written in a

comprehensive way and in such a way that the

patient does not feel excluded if he cannot identify

with the situations described as an example. At

the same time, it is important that the information

provided is empirically supported, to capture the

essential aspects of the issue (risk / protective

factors, coping / resilience mechanisms) and to

normalize the psychological consequences.

29

• In the case of support groups, social support

is facilitated, options are offered to strengthen a

meaningful life (child-free or by resorting to

alternative methods of forming

a

family),

strengthening coping strategies so that patients

face the inter and intra-personal problems they

may encounter.

• In the case of patients with high levels of

psychological distress, clinical evaluation is

performed

and

methods

of

therapeutic

intervention are established in order to reduce the

level of risk to psychopathology.

• In the case of patients who are at the end of

medical treatment, the perceived effects of losing

an important goal in the couple's life are

addressed in therapy or counseling and the

present condition of the partners is analyzed to

observe the level of preparation before the end of

treatment.

These are some of the essential examples for

counseling the infertility patient exposed in this

guide (Boivin, et al., 2001).

Furthermore, it is important to follow the

instructions in the established practice guidelines

to ensure the quality and efficiency of psycho-

social services provided to patients with infertility.

Such an example of guidelines is the guide by

Boivin and collaborators (2001), which is divided

into six sections that describe the objectives,

purpose, communication skills required and

potential problems that may arise in the

psychosocial counseling of patients with infertility.

National Institute for Health and Care

Excellence (NICE) in the United Kingdom is an

international benchmark for good practice based

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Mental Health: Global Challenges Journal

on scientific evidence. The recommendations

regarding the care of the patient with fertility

problems emphasize the central role of the effects

at the psychological level and how the information

should be provided so as to be helpful to the

patient. It mentions the need to inform both

partners about the effects of stress caused by

fertility problems, how it can affect sexual function,

leading to reduced sexual contact and, therefore,

to the spread of fertility problems. Furthermore,

people suffering from fertility problems are

encouraged to consult a mental health specialist,

as addressing problems, investigations and

medical treatments can exacerbate psychological

medical care that should be implemented in any

clinic. If up until now, the role of the counselor was

Related Health Problems. Sydney: WHO.

Ying, L., Wu, L., & Loke, A. (2015). Gender

Zegers-Hochschild, F., Adamson, D., Dyer, S.,

Racowsky, C., de Mouzon, J., Sokol, R., . . .

van der Poel, S. (2017). The International

Glossary on Infertility and Fertility Care.

Fertility and Sterility, 108(3), 393-406.

Zhou, R., Cao, Y., Liu, D., & Xiao, J. (2021).

Pregnancy or Psychological Outcomes of

Psychotherapy Interventions for Infertility: A

Meta-Analysis. Frontiers in Psychology, 12.

doi:10.3389/fpsyg.2021.643395

Zurlo, M., Cattaneo Della Volta, M., & Vallone, F.

(2017). Factor structure and psychometric

properties of the Fertility Problem Inventory–

Short Form. Health Psychology Open, 1-11.

doi:10.1177/2055102917738657

Zurlo, M., Cattateno Della Volta, M., & Vallone, F.

(2018). Predictors of quality of life and

psychological health in infertile couples: the

moderating role of duration of infertility. Quality

differences

in

experiences

with

and

adjustments to infertility : A literature review.

International Journal of Nursing Studies, 1640-

1652.

Ying, L., Wu, L., & Loke, A. (2016). he effects of

psychosocial interventions onthe mental

health, pregnancy rates, and marital function of

of

Life

Research

,

27,

945-954.

34

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Mental health sequelae of bone cancer: A

narrative review

Christos Tsagkaris ¹, Dimitra Desse ², Emmanouela Dionysia Laskaratou ³

1

Novel Global Community Educational Foundation, 2270 Hebersham, Australia ; Faculty of Medicine, University of Crete, Heraklion,

2

3

Greece ; University Hospital of Heraklion, Department of Orthopedics, Heraklion, Greece .

Abstract

Introduction: Bone cancer causes a significant mental health burden. Although the mental health

implications of cancer as a whole have been widely discussed, there is limited evidence regarding

the psychiatric and psychological sequelae of malignant and benign bone neoplasms in particular.

Purpose: To summarize the scientific literature, present relevant knowledge gaps and discuss a

number of recommendations. Methodology: The authors searched Pubmed/Medline and Google

Scholar with keywords (mental health, bone cancer, musculoskeletal neoplasms, psychiatric

comorbidities). When appropriate, MeSH terms and Boolean operators were used. Relevant peer

reviewed studies published in English, French or German until 05 May 2021 were included.

Results and Discussion: Loss of mobility, decrease of physical activity, chronic pain and

amputations in combination with patient’s previous psychiatric history, socioeconomic conditions,

cancer biology and treatment-related side effects undermine the mental wellbeing of patients and

carers. Since March 2020, the COVID-19 pandemic has posed an additional burden, which is yet

to be comprehensively evaluated.

Conclusion: More research and solid action towards the integration of mental health care into the

management of bone cancer is crucial.

35

Keywords

cancer, bone cancer, osteosarcoma, mental health, depression, anxiety

Address for correspondence:

Christos Tsagkaris, Novel Global Community Educational Foundation, 2270 Hebersham,

Australia. chriss20x@gmail.com

Submitted for publication: 5

This work is licensed under a Creative Commons Attribution-

NonCommercial 4.0 International License (CC BY-NC 4.0).

May 2021

Revised: 26 August 2021

Accepted for publication: 16

October 2021

©Copyright: Tsagkaris, Desse, Laskaratou, 2021

Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy

doi: https://doi.org/10.32437/mhgcj.v4i1.129

cell bone tumor and malignant fibrous

Introduction

histiocytoma,

are

rarer

(Franchi,

2012).

Secondary bone tumors usually derive from

breast, lung and prostate primary tumors. Bones

constitute the third most common metastatic sites

(Jayarangaiah , Kemp, Theetha Kariyanna, 2021).

Mental health conditions are quite prevalent

among patients with cancer affecting at least 30%

of them. Cancer associated emotional distress,

loss of functionality, change of body image,

uncertainty, treatment side effects, chronic pain

and disease progression contribute to the

development of mental health conditions such as

anxiety disorder, depression, dementia and

Bone malignancies are among the least

common types of cancer. In terms of incidence,

they have accounted for approximately 0.2% of all

new cancer cases in 2021. 0.3% of all cancer

mortality is associated with bone and joint tumors

according to the Surveillance, Epidemiology, and

End Results (SEER) Program of the National

Cancer Institute of the United States of America

(NCI, 2021). Malignant bone cancers are either

primary or secondary. Primary bone tumors,

namely chondrosarcoma, osteosarcoma, Ewing’s

sarcoma, chondrofibrosarcoma, malignant giant

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substance use among patients with cancer

(Niedzwiedz, Knifton, Robb, Katikireddi, Smith,

2019). On top of these, cancer-induced alterations

in neurotransmission, hormone secretion and

hepatic function can affect patients’ conscious and

unconscious mental activity (Dai et al., 2020).

Although, several aspects of mental health have

been investigated in the context of particular types

of cancer or neoplastic disease as a whole, to

date little is known about mental health and bone

cancer.

reported pain remission and improved self–

confidence following amputation (Gil et al, 2019).

The psychobiological aspects of bone cancer

have been addressed by He and colleagues

(2019) in an 84-months long clinicolaboratory

study investigating the expression of mental

health–related proteins in chondrosarcoma tissue

samples. Their study showed that death-domain-

associated (DAXX) protein, dopamine D3 receptor

(DRD3) and disrupted-in-schizophrenia-1 (DISC1)

protein were highly expressed in moderately,

poorly differentiated and metastatic osteosarcoma

tumors. On the contrary, their expression was

significantly lower in tissue samples of

Purpose

osteochondroma,

a

benign tumor. Further

The purpose of this review is to provide an

overview of the available research in the fields,

present the knowledge gaps, discuss their

implications in contemporary research and clinical

practice and outline relevant recommendations.

analysis associated the presence of these

proteins with worse survival rates and outcomes

and suggested them as potential chondrosarcoma

biomarkers (He et al, 2019).

A recent study by Groot et al. (2021) analyzed

the responses of 47 patients – patient cohabitants’

pairs to a series of questionnaires with an eye on

quality of life, pain, depression, and anxiety.

Patients and their cohabitants – who presumably

acted as informal carers – scored similarly for

quality of life. Nevertheless, higher levels of

depression and anxiety linked with an

overestimation of the patients’ burden were

detected among the patients’ cohabitants (Groot

et al, 2021). Finally, Bartels et al. (2021)

attempted to map the impact of the COVID-19

pandemic on the emotional status of patients with

bone metastases in a sub-study of the PRESENT

cohort. Statistical analysis of the responses of 169

patients to a structured questionnaire indicated

that 28% of patients experienced significant levels

stress and anxiety associated with the course of

the pandemic and the related restrictive

measures. 39% of the patients had similar

feelings regardless of the lockdown situation,

while 29% did not mention such feelings. On

these grounds the researchers concluded that the

pandemic has affected the psychosocial wellbeing

of the majority of patients with bone metastases

(Bartels, 2021).

Results and Discussion

Aspects of mental health in bone cancer

During the last years, a limited number of

clinical, observational and cross-sectional studies

have evaluated the impact of bone cancer on

mental wellbeing of patients and patients’

cohabitants, the biological underpinnings and

certain clinical aspects of bone cancer.

Sachsenmaier

and

colleagues

(2015)

36

assessed the mental health implications of bone

sarcoma by means of a structured questionnaire.

In a total of 66 eligible participants, 53% of

patients reported an optimistic attitude and 37.5%

reported emotional steadiness. Female patients

and patients with less than two offsprings were

more prone to pessimistic ideas. Well-educated

and married patients were more likely to seek

psychological consultation. Elderly patients had a

higher likelihood to experience feelings of

isolation, while relationship trouble within families

was common (Sachsenmaier, Ipach, Kluba, 2015;

Storey et al, 2019). In a critical review of evidence

published until 2017, Storey and colleagues

investigated the effect of bone sarcoma in mental

health and quality of life of 8,823 patients reported

in a sum of 12 studies. Their analysis indicated

that relapse rates was the most common cause of

anxiety and depression. Painful tumors were

strongly associated with psychiatric comorbidity

leading to worse quality of life, higher levels of

perceived stress and even marginalization.

Amputations were identified as a key factor in

mental health deterioration, although a limited

number of patients reported self– esteem

improvement following amputation procedures

(Storey et.al., 2019). The latter was consistent

with the findings of Gil et al. (2018), who assessed

the mental health implications of amputations by

means of a retrospective study involving 46

patients with metastatic osteosarcoma and

Knowledge gaps and the way forward

It appears that the interest in the mental health

implications of bone cancer has increased in the

last 5 years. Nevertheless, the available evidence

is still scarce and heterogeneous. Most studies

agree that bone cancer leads to a quality of life

deterioration and undermines patients’ and carers’

mental wellbeing (Sachsenmaier, Ipach, Kluba,

2015; Storey, 2019; Gil, 2019). Interestingly, it

seems that amputations can affect patients’

mental wellbeing positively, to the extent that they

relieve them of chronic pain and discomfort

(Sachsenmaier, Ipach, Kluba, 2015; Storey,

2019). On top of these, biomolecules implicated in

mental health disorders have been associated

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with bone cancer and are further assessed as

biomarkers.

Conclusions (and Future Work)

Evidently, there is a lack of clinical studies

assessing the effectiveness of psychosocial

interventions (individual or group oriented

psychotherapy and counseling, psychiatric

medication, ergotherapy sessions etc) in

supporting bone cancer patients’ and carers’

mental wellbeing (Lingens, Schulz, Bleich;. 2021).

Mental health increases the burden of bone

cancer. Recent studies have illustrated the

psychosocial implications of bone cancer towards

patients and carers and its potential biological

underpinnings. More research and solid action

towards the integration of mental health care into

the management of bone cancer is crucial.

During

the

COVID-19

pandemic

digital

psychosocial interventions can be implemented

and assessed. Telehealth has already been used

to perform neuropsychological tests and monitor

patients with dementia, who did not have access

to physical healthcare facilities due to COVID-19

Conflict of interest

The authors declares that they has no conflict

of interests.

restrictions

(Carotenuto,

Traini,

Fasanaro,

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amputations and other forms of treatment, such

as radiotherapy and chemotherapy, should be

assessed in the mental wellbeing of specific

vulnerable patients’ groups such as children and

refugees. Taking into account the cultural factors

contributing to pain and disease perception, it is

also important to compare patients and carers’

attitudes in different continents, countries and

social contexts. The aforementioned should also

be investigated among healthcare workers.

Simultaneously, there is a clear need for more

research about the biological interconnection of

bone cancer and mental health disorders. Such

research can yield biomarkers and potential

therapeutic targets with multiple applications in

oncology and psychiatry.

Currently, the way forward appears twofold

encompassing research and clinical interventions.

Research needs to address the knowledge gaps,

preferably by means of large-scale studies.

Retrospective research appears as the optimal

means to assess the potential effects of particular

mental health indicators and interventions.

Intention – to – treat analysis can be used to

evaluate the potential effects of mental health

oriented treatment strategies across different

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S., Al-Jabri, K., Elshamy, K., Ghrayeb, I.,

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479(4),

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Verhoeff, J., Verlaan, J. J., & Verkooijen, H. M.

(2021). Impact of the COVID-19 pandemic on

quality of life and emotional wellbeing in

patients with bone metastases treated with

38

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Clinical case of catatonic stupor developed as a

result of acute respiratory disease COVID-19

Komarovskyi М. S., Mykytenko R. V., Onofreichuk Kh. О., Hryshchenkova О. S.,

Podhorna А. D., Kosolapov О. P., Zolotarov P. V.

Starokostiantyniv Military Hospital. Starokostiantyniv, Ukraine

Abstract

The aim of this work is to demonstrate and analyze a clinical case of catatonic stupor as a

consequence of the complex effect of the infectious process, namely systemic inflammation and

direct neurotoxicity of the SARS-CoV-2 virus on the nervous system. A retrospective analysis of

outpatient and inpatient medical records was performed. . Analysis of clinical case proves the

possibility of catatonic syndrome due to acute respiratory disease COVID-19. 2. Given that

catatonia is an urgent condition, it is necessary to be vigilant about its occurrence.

Keywords

COVID-19, post-infectious catatonia, mental disorders, clinical case.

Address for correspondence:

Komarovskyi М. S.

captain of the medical service, the head of the medical department. Starokostiantyniv Military

Hospital. Starokostiantyniv, Ukraine, e-mail m.komarovskyi@gmail.com

39

Submitted for publication: : 26

April 2021

Revised: 17 September 2021

Accepted for publication 15

October 2021

This work is licensed under a Creative Commons Attribution-

NonCommercial 4.0 International License (CC BY-NC 4.0).

©Copyright: Komarovskyi, Mykytenko, Onofreichuk, Hryshchenkova, Podhorna, Kosolapov,

Zolotarov, 2021

Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy

doi: https://doi.org/10.32437/mhgcj.v4i1.130

infectious origin due to the acute coronavirus

disease COVID-19 in patient P., 40 years old, who

from 25.03.2021 to 30.04.2021 underwent

examination, treatment and rehabilitation in

Starokostiantyniv military hospital.

Introduction

Despite the fact that COVID-19 primarily

damages the respiratory system, as the pandemic

continues, the number of patients in whom the

infection affected the nervous system and

neuropsychiatric disorders such as hyposmia,

stroke, insomnia, neurotic disorders or delirium

increases. One of the potential post-infectious

disorders may be catatonia. Only sporadic cases

of it are described, and reliable data on

observations about it are absent. At the same

time, careful attention is paid to post-infectious

catatonia caused by COVID-19, because in the

absence of timely recognition and treatment of

this urgent condition there are serious

complications that can be fatal.

Materials and methods.

A retrospective analysis of outpatient and

inpatient medical records was performed.

Results and discussion

Catatonic stupor is

a

psychopathological

syndrome characterized by immobility combined

with lack of verbal contact and increase of muscle

tone. Catatonia has traditionally been regarded as

a sign of endogenous psychosis, especially

schizophrenia. However, this syndrome is not

nosologically specific and can occur in many

diseases: up to 20-25% of its cases are

somatogenously caused (Dunaievskiy. Kuznetsov,

2019). Constantine von Economo was the first

The aim of the work

The aim of the work is to demonstrate and

analyze a clinical case of catatonic stupor of post-

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who described catatonic syndrome after acute

respiratory disease in detail in the structure of

lethargic encephalitis, which affected some

patients after the Spanish flu during the pandemic

of 1918-1920. In May 2020, during the COVID-19

pandemic, Italian doctors were among the first to

report an atypical curative case of "akinetic

mutism". In retrospect, it was regarded as a

catatonic stupor (Cooper, Ross, 2020). In the

same month, British doctors reported a case of

catatonia, manifested by stupor and accompanied

by disorders of perception, in a man with COVID-

19 (Caan, Lim, Howard, 2020). In the systematic

review of the literature as of 20.04.2021, in

addition to the above, there are 7 more relevant

cases of catatonia due to COVID-19 (Schneider,

Smith, Wohlleber, Malone, Schwartz, 2021). The

lethargic, anxious, suspicious, for example, many

times a day measured the saturation of oxygen in

the blood. Despite the improvement in somatic

condition, general weakness, fatigue and anxiety

aggravated. Obvious changes in mental status

from 22.03.2021: he spoke in a quiet, hoarse

voice, became retarded, tense, reacted sluggishly

to others, decreased appetite, and almost stopped

sleeping at night. On March 23, 2021, due to the

expiration of the term of outpatient treatment, he

tried to start military service, due to severe

asthenia; his release from duty was extended. On

March 24, 2021, stereotypical movements

appeared the patient stared straight ahead, could

not pay attention to anything. 25.03.2021

consulted a psychiatrist, recommended MRI of the

brain. In the process of preparation for MRI in the

X-ray room finally stopped moving, did not

respond to painful stimuli, and did not respond to

the spoken language. MRI of the brain from

25.03.2021: "MR data for the presence of

changes in the volume of the substance in the

brain at the time of the examination was not

detected. MR signs of focal process of the brain,

most likely against the background of

neuroinfection. Hospitalization with a diagnosis of

catatonic syndrome is recommended. On

admission to the hospital, examined while lying on

a couch, his face tense, with his eyes tightly

closed, he resisted the attempt to open them. On

the language, painful stimuli did not respond;

muddy. He showed waxy flexibility in the muscles

of the upper extremities, there were elements of

passive submission: he allowed himself to sit on

the couch, stuck in this position with his arms

outstretched. Body T = 37.4 ° C, blood pressure =

130/100 mm PC, Ps = 120 / min., Sp O2 = 97%.

Laboratory tests within normal limits (leukocyte

count 7.9 x 109 cells / l). Delivered to the

department on a stretcher. Introduced solution of

Diazepam 5 mg / ml 4.0 ml v./m. About 30

minutes after the injection of Diazepam, opened

his eyes, followed the interlocutor's gaze,

responded to the spoken language, and made

verbal contact. The patient answered in terms of

the respondent, but in one word, in a quiet, low-

authors consider its appearance as

a

consequence of the complex impact of the

infectious process, namely systemic inflammation

and direct neurotoxicity of SARS-CoV-2 virus on

the nervous system, as well as psychosocial

factors leading to post-traumatic stress, anxiety

and depression. Differential diagnosis with

hypokinetic delirium is proposed, which in

particular consists in a rapid positive response to

benzodiazepines: patients quickly, significantly

improved after their prescription, which is not

typical for delirium.

Below is our own clinical case of catatonic

stupor, which developed in a patient as a result of

COVID-19.

40

In the life history, the burden of heredity on

mental illnesses is remarkable: the father is

"commissioned" from armed forces after the

transferred TBI on a line of psychiatry, the aunt on

a line of the father suffers from depression. The

patient underwent regular medical examinations

during military service and was considered

healthy. At work, family and friends are

characterized positively. Patient does not smoke,

denies the abuse of psychoactive substances.

Case history: from 08.03.2021 there was a

general weakness, increased body T to 38.0 ° C.

10.03.2021 performed PCR with real-time

detection, during study of nasopharyngeal lavage

revealed RNA of SARS-CoV-2 virus. Outpatient

treatment was started: hepacef, moxifloxacin,

xarelto, pulmobriz, serrata, vitamin therapy, tonic

therapy, physiotherapy. D-dimer from 12.03.2021

103.0 ng FEU / ml. CT of the chest from

16.03.2016: "CT signs of viral pneumonia. High

probability of COVID-19. CT-I (area of the affected

parenchyma up to 15%)". Antibiotic therapy was

continued. Feelings began to improve, the body's

T decreased, staying in the range of 35.9-36.5 °

C. From 21.03.2021 due to the fact that the

condition was regarded as recovery, treatment

was canceled.

modulated

voice.

Attention

is

unstable,

exhausting. Oriented comprehensively enough,

productive psychotic symptoms, gross cognitive

impairment did not show. Patients followed the

instructions as much as possible. According to the

Bush-Francis catatonia scale, the patient scored

20 points, which convincingly indicates the

presence of catatonia. Subsequently, on the

background of treatment and rehabilitation, the

patient's condition continued to improve, followed

by discharge in a state of stable compensation.

Conclusions and suggestions

During the illness there was a pronounced

somatopsychic asthenia, in particular, weight loss

of 7 kg, complained of fatigue, patient was weak,

1. Analysis of the above clinical case proves

the possibility of catatonic syndrome due to acute

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respiratory disease COVID-19. 2. Given that

catatonia is an urgent condition, it is necessary to

be vigilant about its occurrence. Based on this

case, it is necessary to consider the possibility of

its occurrence not only at the height of the

infectious process, but also as it resolves, i.e. to

show increased vigilance to convalescents and

not leave them unaccompanied in outpatient and

family medicine. If catatonic stupor is suspected, it

should be diagnosed with other similar conditions,

including hypokinetic delirium, taking into account

the difference in subsequent treatment tactics.

Patients with pre-existing psychiatric pathology

are likely to be at risk, especially if catatonic

syndrome is present. It is possible that the

development of catatonia in the patient described

by us contributed to the burden of heredity in

psychiatry, which was realized after the

transferred somatopsychic extreme factor. 3.

Prevention of anxiety among the population

should be carried out, as the neurotization of

society on the background of a pandemic comes

up with to the emergence of mental disorders.

Obviously, that the characterological anxious

thinking of the patient, considered in the clinical

case, in stressful conditions was one of the factors

that led to the deterioration of the mental state.

Conflict of interest

The authors declares that they have no conflict

of interests.

References

Dunaievskiy V.V., Kuznetsov A.V. (2019).

Catatonia evolution of views and modern

concepts (literature review)

.

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psychiatry and medical psychology. 4-2:29-40.

Cooper, J. J., Ross, D. A. (2020). COVID-19

Catatonia – Would We Even Know? Biological

Psychiatry, 88 (5), e19-e21.

Caan, M. P., Lim, C. T., Howard, M. (2020). A

Case of Catatonia in a Man With COVID-19.

Psychosomatics, 61, 556-560.

Schneider, N. S., Smith, A. K., Wohlleber, M.,

Malone, C., Schwartz, A. C. (2021). COVID-19

and Catatonia: A Case Series and Systematic

Review of Existing Literature. Journal of the

Academy of Consultation-Liaison Psychiatry

41

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Main features of expeditioners’personality traits in

Antarctic conditions

Larysa Bakhmutova

National Antarctic Scientific Center, Ministry of Education and Science of Ukraine, Kyiv, Ukraine.

Abstract

Introduction. Determining the benefits of basic human personality traits is one of the main

components of the selection and staffing of small groups of peoples that are working in extreme

environmental conditions and socio-spatial isolation. These groups include teams of polar

explorers, scientists from outlying research bases, ship and submarine crews, and aircraft and

space shuttles teams.

Purpose. To identify the prevailing type of temperament of and personal changes in people

working on the Antarctic station during a one-year period of isolation to develop measures to

maintain their mental and physical health.

Methodology. A total of 48 people (46 men and 2 women aged from 23 to 63 years) from four

wintering teams of the Ukrainian Antarctic station (UAS) “Akademik Vernadsky” were voluntarily

interviewed according to the Eysenck Personality Questionnaire (EPQ). The poll was conducted

twice – before the departure to the Antarctic station and after their return after a year. Participants

were studied in two groups (24 peoples) once again after a 6-month stay on the Antarctic station,

to determine the level of psychoticism. The research was based on the analysis of preferences

and changes in personality traits: Extraversion/Introversion, Neuroticism/Stability, and

Psychoticism/Socialization.

Results. Based on the analysis of indicators such as Extraversion/Introversion,

Neuroticism/Stability, and Psychoticism/Socialization, we determined the general structure of the

personal characteristics of the expeditioners. Indicators of these characteristics showed that more

than a third of the expeditioners (36.1%) were pronounced extroverts. A majority (61.1%) of the

respondents were characterized by an intermediate between extraversion and introversion, and

only 2.8% were pronounced introverts. 58.4% of the respondents were characterized by a low

level of neuroticism, while 33.3% were characterized by medium level of neuroticism. Only 8.3%

were found to have a high level of neuroticism. Low levels of psychoticism were predominant in

56.3% of the respondents while the remaining 43.7% had medium levels of psychoticism. A high

level of psychoticism was absent in the respondents which indicates a psychologically correct

selection of the team. Analysis of the dynamics of psychoticism revealed that there were higher

growth rates (+0.97) of average indexes of psychoticism during the first 6 months of the

expeditioners’ stay at the Antarctic station than at the end of the activity. This was due to the

“acute adaptation” period when the respondent fit in the natural conditions of Antarctica.

Furthermore, there was a development of psychoticism in the expeditioners during the “polar

night”; the growth rates of psychoticism decreased after adaptation.

42

Conclusions. To maintain people’s mental health at the Antarctic station, it is optimal to select

candidates for a one-year expedition with average rates of extraversion-introversion, and mostly

low rates of neuroticism and psychoticism. These personal characteristics must be taken into

account when forming an expedition team. The level of psychoticism during the expedition

increases under the influence of the adverse environmental conditions of Antarctica and the socio-

spatial isolation.

Keywords

adaptation, Antarctic expeditioners, extraversion, introversion, mental health, neuroticism,

psychological changes, psychoticism, personality traits, socio-spatial isolation, winter-over

syndrome, wintering teams.

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Address for correspondence:

Larysa Bakhmutova, Ph.D., National Antarctic Scientific Center, Ministry of Education and

Science of Ukraine, Kyiv, Ukraine.

e-mail bakhml@meta.ua

Submitted for publication: 03

April 2021

Revised: 10 August 2021

Accepted for publication: 25

September 2021

This work is licensed under a Creative Commons Attribution-

NonCommercial 4.0 International License (CC BY-NC 4.0).

©Copyright: the Author(s), 2021

Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy

doi: https://doi.org/10.32437/mhgcj.v4i1.131

Lee, & Bak, 2017). The influence of seasonality

(polar day and polar night) and long-term isolation

was studied among the winterers of the Indian

expedition to Antarctica (Bhagava, Mukerji, &

Sachdeva, 2000).

Introduction

On extreme conditions of the Antarctic

environment, Palinkas (2002) wrote that

«Antarctica is the highest, driest, coldest, and

windiest of the earth's continents». The vast

majority of this continent is an ice desert, where

people are exposed to prolonged low

temperatures, high solar radiation (due to opening

in the ozone hole), strong geomagnetic

disturbances, and the effects of polar day and

polar night. Thus, the Antarctic continent is not

suitable for human life and activity. These natural

factors significantly affect the functional and

psychological state of people who work at polar

stations under extreme conditions for a long time.

As a result, this leads to negative consequences

in their physical and psychological state such as

deterioration in health, well-being, mood, and

performance; and weakening of cognitive

functions. The signs of psycho-physiological and

psycho-emotional disorders such as chronic

stress, anxiety, grumpiness, depression, fatigue,

low activity, reduced performance, and violations

in the social sphere appear (Romash, 2019;

2020). These disorders are called “winter-over

syndrome”. Studying the impact of the “winter-

over syndrome:” on human health has been

repeatedly investigated by many authors: Alfano

et al. (2021); Chen, Wu, Li, Zhang, and Xu (2016);

Cravalho (1996); Miroshnychenko et al. (2020);

Palinkas (2002; 2017); Palinkas, Reed, and Do

(1997); Sandal, van deVijver, and Smith (2018);

Steinach and Gunga (2021); Suedfeld (1998);

Chengli et al. (2003) etc.

Some of them, for example, Chen et al. (2016)

and Kuwabara et al. (2021), study the processes

of human adaptation to polar conditions. It was

universally defined that sleep disorders in

members of winter teams increase. The study of

the regime, quality, and duration of sleep at the

Antarctic station are described in Collet et al.

(2015); Folgueira et al. (2019); Sandal, van

deVijver, and Smith (2018); Shylo, Lutsenko, D.,

Lutsenko, O., Babiychuk, and Moiseyenko (2020).

Polar expeditioners often note the unwarranted

occurrence of headaches and vegetative-vascular

reactions, and the deterioration of mood and well-

being, mostly during the Antarctic winter (Temp,

The team’s psychological climate is negatively

affected by the limited number of people who are

in a small space of the base during the entire

year. At the same time, the processes of chronic

stress and fatigue progress while the processes of

adaptation of psychophysiological functions slow

down (Bakhmutova (2020); Mohapatra, Anand,

and Raju (2020); Nirwan et al. (2020); Palinkas

(1992). This increases the risk of psycho-

emotional disorders and contravention of

interpersonal interaction. The psychological

consequences of isolation and prolonged stays in

small expeditionary groups have been studied in

Oliver (1979); Mullin (1960); Suedfeld and Steel

(2000); Tortello et al. (2020).

43

The

relationship

between

individual

psychological characteristics of people and the

emergence of psychosocial issues in small group

during isolation on the Antarctic station are

presented by Kokun and Bakhmutova (2020; 2021

and Palinkas and Suedfeld (2021).

One of the main components of the

psychological selection of a candidate to the UAS

“Akademik Vernadsky” is to determine the

benefits of individual psychological characteristics

of the expeditioners.

Here, the main criteria are the indicators

Extraversion/Introversion,

Neuroticism/Stability,

Psychoticism/Socialization. The concept of

Extraversion/Introversion was developed by

Eysenck H. J. (Eysenck, S. B. G., Eysenck, H. J.

& Barrett, 1985; Eysenck, H. J. & Eysenck, S. B.

G., 1993), where the physiological interpretation

of the benefits of Extraversion or Introversion was

defined. It is a feature of the central nervous

system, which depends on the balance between

the processes of excitation and inhibition.

Extraversion/Introversion balance together with

more pronounce factor Neuroticism/Stability

(emotional-volitional stability or instability) is

considered as the main characteristic of the

personality. Jung (1995) defined introversion as

an “attitude-type characterized by orientation in

life through subjective psychic contents”, and

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extraversion as “an attitude-type characterized by

concentration of interest on the external object.”

Neuroticism is one of the more than well-

established and empirically validated personality

traits. Widiger and Oltmanns (2017) noted that

“Persons with elevated levels of neuroticism

respond poorly to environmental stress, interpret

ordinary situations as threatening, and can

experience minor frustrations as hopelessly

overwhelming”. Numerous studies are currently

being conducted to establish the links between

these personal qualities and the peculiarities of

mental processes (including cognitive processes).

Psychoticism is the third personality trait in the

Eysenck personality model and is defined as a

personality type that is prone to risk-taking,

possibly engaging in anti-social behaviors,

impulsiveness, or non-conformist behaviour

(Eysenck, S. B. G., Eysenck, H. J., & Barrett,

1985).

of personal changes under the influence of

extreme environmental conditions of Antarctica

and socio-spatial isolation. Usually, these

indicators are recorded using various scales and

questionnaires.

Design/Methodology/Approach

An Eysenck Personality Questionnaire (EPQ)

was used for the expeditioners of the Ukrainian

Antarctic

Vernadsky” station. The scales measured by the

EPQ are: Extraversion/Introversion,

expeditions

at

the

“Akademik

Neuroticism/Stability, Psychoticism/Socialization

in addition to the Lie Scale (Timo Lajunena &

Hanna R. Scherler (March 1999). Extraversion

and introversion are typically viewed as a single

continuum; therefore, being high in one

necessitates being low in the other. This version

has 100 Yes/No questions.

Participants and Procedure

Taking such characteristics into account in the

recruitment processes to work at the Antarctic

station allows to make an optimal selection of

team members and the rational use of individual

characteristics to effectively perform tasks by

each of the expeditioners. Moreover, the presence

of high levels of neuroticism and psychoticism can

adversely affect the mental health of people.

This study involved 48 expeditioners (46 men

and 2 women; aged 23 to 63 years) from the the

Ukrainian Antarctic “Akademik Vernadsky” station

who participated in four annual expeditions (12

people in each group) between 2016 and 2020.

This Antarctic station is located in West Antarctica

on Galindez Island.

The research was conducted on the basis of

the State Institution National Antarctic Scientific

Center of the Ministry of Education and Science of

Ukraine (http://uac.gov.ua/en/) that organizes the

annual scientific expeditions to the Ukrainian

Therefore,

we

recommend

the

Eysenck

Personality Questionnaire (EPQ) as a necessary

tool to maintain the mental and physical health in

extreme environmental conditions.

In addition, considered such psychological

preliminaries in Antarctica could be demand in the

preservation of the mental and psychological

health of people in long term cosmic missions

(Tortello et al., 2018). Antarctica is seen as a

natural laboratory analogue of a space for

44

Antarctic

According to State Special-Purpose Research

Program in Antarctica for 2011-2023

station

“Akademik

Vernadsky”.

(http://uac.gov.ua/en/research-program-en/), this

is main operator in Ukraine for coordination of

logistic operation and scientific research in

Antarctica.

Statistical Analysis

The Statistical Package for the Social Sciences

version 22.0.0.0 was used for statistical analysis.

psychological

Suedfeld and Weiss (2000) (as cited in

Mohapatra, Anand, and Raju, 2020) stated that

research.

Suedfeld

(2018);

“Understanding

of

human

behavior

and

performance in isolated and confined environment

(ICE) has been the area of interest for all those

involved in human space program”. All of the

above confirm the importance of defining and

studying the structure of individual psychological

personality traits in polar expeditions as a factor of

human mental health.

Descriptive

statistics

(frequencies,

mean,

standard deviation) and a paired sample t-test

were used. We used paired samples because

data distributions for all indicators were close to

normal (modulo sum of skewness and kurtosis <

1).

Purpose

Results

The exploration of the predominant type of

fundamental

(Extraversion/Introversion, Neuroticism/Stability,

Psychoticism/Socialization) is aimed at

maintaining mental health, and understanding and

predicting changes in the psychological and

physiological state of expeditioners.

The aim of study was the assessment of the

predominant type of the temperament of people

working in Antarctic expeditions and identification

personality

traits

According to the EPQ, we diagnosed the

severity of individual psychological personality

traits after the type of temperament. Based on the

analysis of the frequencies of the dichotomous

indicators

Extraversion/Introversion,

Neuroticism/Stability, Psychoticism/Socialization,

we determined the general structure and severity

of personal characteristics in the sample (Table

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1). More than a third of the expeditioners (36.1%)

were pronounced extroverts. The majority of

respondents (61.1%) were characterized by an

intermediate position between extraversion and

introversion, and only 2.8% were pronounced

introverts (Table 1).

extreme conditions of group isolation. We found

that most of the UAE winterers—56.3%—had a

low level of psychosis, and 43.7% possessed a

medium level of psychosis (Table 1). High levels

of psychoticism were completely absent in the

expeditioners. This indicates a psychologically

correct selection of the team.

Table 1

An analysis of the dynamics of psychoticism in

two groups (24 people) found that during the first

6 months of the period of “acute adaptation”,

which coincides with the “polar night” (study D1-

D2; Table 2), a higher growth rate (+0.97) of the

average indicators (M1-M2) of psychoticism was

observed than in the previous 6 months (study

D2-D3). This indicates the significant influence of

the Antarctic environment and the effect of the

body’s adaptation processes on the mental health

of expeditioners.

The structure of personal characteristics in

expeditioners

Vernadsky”

at

the

UAS

“Akademik

The structure of

personal

characteristics

Levels of personal

characteristics (%)

Low Middle High

Extraversion/Intr 2,8

oversion

Neuroticism/Sta 58,4

bility

Psychoticism/So 56,3

cialization

61,1

33,3

43,7

36,1

8,3

0

In the second half of the year,

psychoticism increased at a slow rate (+0.45)

(Table

2)

because

the

period

of

psychophysiological adaptation to Antarctic

conditions had passed. It should be noted that at

the end of the year, the growth of psychoticism

remained within the average, which indicates a

quality selection of the expeditioners to the team

and effective psychological support throughout

their period of stay at the UAS “Akademik

Vernadsky”. Psychological support is provided to

prevent the significant progress of psychoticism

among team members, as it is one of the methods

of maintaining the mental, physical, and

psychological health of people living in extreme

environmental conditions and long-term socio-

spatial isolation.

It is well known that neuroticism is

a

fundamental domain of personalities with huge

public health implications. It was proved that the

people with high levels of neuroticism respond

poorly to environmental stress, interpret ordinary

situations as threatening, and can experience

minor frustrations as hopelessly overwhelming

(Widiger & Oltmanns, 2017). That is, the benefits

of Neuroticism/Stability (a characteristic of

emotional instability or resilience) as a personality

trait feature that maintains purposeful behavior in

normal and stressful (extreme) conditions, which

is especially important to consider when selecting

expeditioners for long Antarctic expeditions.

According to our results, 58.4% of the Ukrainian

expeditioners had a low level of neuroticism,

33.3% were characterized by a medium level of

neuroticism, and only 8.3% had a high level of

neuroticism (Table 1).

45

Table 2

Dynamics of psychoticism in the group of

expeditioners at the UAS “Akademik

Vernadsky”

Indicators of psychoticism in the

group

Psychoticism determines the presence of

personality traits that are manifested in

Dynamics

Mean (М)

Standard

Deviation

(σ)

(+; -)

interpersonal

relationships:

aggression,

impulsivity, aloofness, and antisocial behaviour,

indicating

psychopathic

(https://dictionary.apa.org/psychoticism ).

a

susceptibility to psychosis and

disorders

D

1

М

1

4,58 σ1

2,67

–

Psychoticism is associated not only with antisocial

behaviour, but also with aggression. Human

psychotic behaviour is characterized by severity,

conflict, inattention, carelessness, hostility, anger,

egocentrism, and impulsiveness in interpersonal

interaction. The psychoticism scale study was

conducted only for two groups of UAE winterers

with a total of 24 people. This indicator may show

the respondent’s antisocial behavior, inadequate

emotional reactions, high levels of conflict, non-

contact, which is unacceptable for work in

D

2

М

2

5,55 σ2

2,42 +0,97

2,45 +0,45

D

3

М

3

6,00 σ3

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Acta Astronautica, 181, 405

https://doi.org/10.1016/j.actaastro.2021.01.051

–

413.

Conclusions (and Future Work)

Bakhmutova,

L.

(2020).

Peculiarities

of

One of the components of successful

interpersonal relationships of

Ukrainian

preservation

of

the

mental

and

Antarctic expeditions participants. Mental

Health: Global Challenges Journal, 3(2), 50–

55.

https://www.mhgcj.org/index.php/MHGCJ/articl

e/view/96

psychophysiological health of people at the

Antarctic station is the knowledge of the structure

of personal characteristics of the selected

personnel. The predominant group characteristic

of the Antarctic expeditioners is extraversion and

most of the people in the year-long residence in

socio-spatial isolation are extroverts. The last

ones contribute to the effective establishment of

interpersonal relationships within the group,

communication both within the group and with the

outside world, demonstrate enthusiasm in

professional activities and interaction with the

extreme environment of Antarctica.

Bhagava, R, Mukerji, S, & Sachdeva, U. (2000).

Psychological impact of the Antarctic winter on

Indian

Behaiorv,

expeditioners.

32(1),

Environment

and

111–127.

https://doi.org/10.1177/00139160021972450

Chen, N., Wu, Q., Li, H., Zhang, T., & Xu, C.

(2016). Different adaptations of Chinese

winter-over expeditioners during prolonged

Antarctic

and

sub-Antarctic

residence.

In

well-formed

groups

of

Antarctic

International journal of biometeorology, 60(5),

737–747. https://doi.org/10.1007/s00484-015-

1069-8

expeditioners, a high level of neuroticism is quite

rare (8.3% of people). Psychoticism does not

reach a high level in spite of growing by the end of

a year of wintering. To maintain the expeditioners’

mental health, selecting candidates with average

rates of extraversion-introversion and low rates of

neuroticism and psychoticism is optimal. These

personal characteristics must be taken into

account at the phase of group formation. The level

of psychoticism during wintering is a variable

characteristic. Its growth is associated with

changes in the individual’s psycho-emotional state

during the adaptation and influence of the extreme

environmental conditions and socio-spatial

isolation. The current research has practical and

social value, as it is aimed at preventing the

development of negative mental states of

participants in long-term Antarctic expeditions and

the formation of positive social relations in a small

isolated group.

Chen, N., Wu, Q., Xiong, Y., Chen, G., Song, D.,

& Xu, C. (2016). Circadian rhythm and sleep

during prolonged antarctic residence at

chinese Zhongshan station. Wilderness &

Environmental Medicine, 27(4), 458–467.

https://doi.org/10.1016/j.wem.2016.07.004

Chengli, X., Guangjin, Z., Quanfu, X., Shandong,

Z., Guoyuan, D., Yanzhen, X., & Palinkas, LA.

(2003) Effect of the Antarctic environment on

hormone levels and mood of Chinese

46

expeditioners,

Circumpolar

https://doi.org/10.3402/ijch.v62i3.17562

International

Health, 62:3,

Journal

of

255-267.

Collet, G., Mairesse, O., Cortoos, A., Tellez, H. F.,

Neyt, X., Peigneux, Ph., … Pattyn, N. (2015).

Altitude and seasonality impact on sleep in

Antarctica. Aerospace Medicine and Human

Performance,

86(4),

392-396.

Future research may reveal relationships

between personality traits and changes in other

influences on the freight forwarders’ mental

health. These are indicators of the emotional

state, social relationships, professional vitality,

etc. We believe that is advisable to continue to

study the peculiarities in psychophysiological

changes in the dynamics between those people

whose professional activities take place in

extreme environmental conditions and expand the

methodological basis of research.

https://doi.org/10.3357/AMHP.4159.2015

Cravalho, M. A. (1996). Toast on Ice: The

Ethnopsychology

of

the

Winter-Over

Experience in Antarctica. Ethos, 24(4), 628–

656.

https://doi.org/10.1525/eth.1996.24.4.02a0003

0

Eysenck, H. J., & Eysenck, S. B. G. (1993).

Eysenck Personality Questionnaire-Revised

(EPQ-R) [Database record]. APA PsycTests.

https://doi.org/10.1037/t05461-000

Eysenck, S. B. G., Eysenck, H. J. & Barrett,

P.(1985). A revised version of the psychoticism

scale. Personality and Individual Differences.

6(1), 21–29. doi:10.1016/0191-8869(85)90026-

1.

Conflict of interest

The author declares that she has no conflict of

interests.

Folgueira, A., Simonelli, G., Plano, S., Tortello, C.,

Cuiuli,JM., Blanchard, A., … Vigo, D. E.

(2019). Sleep, napping and alertness during an

overwintering mission at Belgrano II Argentine

Antarctic station. Scientific Reports, 9, Article

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Mental health literacy and psychological distress

as predictors psychological well-being of collage

students in Sriwijaya university

Sayang Ajeng Mardhiyah

Psychology Departement, Medical Faculty Universitas Sriwijaya

Abstract

Introduction. This research focused on answering questions: how mental health literacy and

psychological distress act as predictors of psychological well-being in Sriwijaya university

students.

Methodology.This research used quantitative method, by conducting instrument preparation,

data collection, and analysis of data results to see the role of the independent variables on the

dependent variable. Psychological well-being was measured using an instrument in a form of

psychological scale referred to Psychological Scale by Ryff & Keyes (1995). Meanwhile,

psychological distress was measured using WHO Self-Reporting Questionnaire 20 (SRQ-20)

Indonesian version, and Mental Health Literacy measurement was adapted from O’Connor and

Casey (2015). The participants of this research were consisted of 418 college students.

Results.The analysis results show that there is a role of mental health literacy and psychological

distress together on psychological well-being, thus the hypothesis is accepted. Major hypothesis

test was done using multiple linear regression which shows a correlation value (R) of 0.586 and a

significance of 0.001 (p<0.05). For the results of minor hypothesis test, it is known that the beta

value is 0.143 and the P value is 0.022 (p>0.05), this indicates that there is a role for mental

health literacy on psychological well-being, thus the hypothesis is accepted. In addition, it is

known that psychological well-being and psychological distress show a beta value of -1.945 and a

P value of 0.001 (p>0.05), this indicates that there is a role for psychological distress on

psychological well-being thus the hypothesis is accepted.

49

Conclusions.The percentage of mental health literacy and psychological pressure influences on

psychological well-being (R adjusted) is 0.343, this also shows that the contribution of mental

health literacy and psychological distress together on psychological well-being is 34.3%, while the

rest is the contribution of other variables not examined in this study.

Keywords

mental health literacy, psychological distress, psychological well being

Address for correspondence:

Sayang Ajeng Mardhiyah, Psychology Departement, Medical Faculty Universitas

Sriwijaya. email : ajeng_mardhiyah.psi@fk.unsri.ac.id

Submitted for publication: 25

This work is licensed under a Creative Commons Attribution-

NonCommercial 4.0 International License (CC BY-NC 4.0).

August 2021

Revised: 03 October 2021

Accepted for publication: 24

October 2021

Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy

doi: https://doi.org/10.32437/mhgcj.v4i1.132

person realizes their abilities, able to deal with

normal stressors, able to work productively and

pleasantly, and able to contribute to the

community (WHO, 2005). It can be said that, if

Introduction

The World Health Organization (WHO),

describes mental health as a state in which a

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there are obstacles in carrying out these

functions, the individual may have problems with

their mental health.

psychological distress, such as depression,

anxiety and somatic complaints (Mardhiyah,

2019).

The increase in mental disorders obtained from

Basic Health Research Indonesian Ministry of

Health (riskesdas) in 2018, shows a significant

increase compared to Riskesdas in 2013, which

increase from 1.3% to 7% (Indonesian Ministry of

Health, 2018). This increase was revealed from

the increase in the prevalence of households with

people with mental disorders (ODGJ) in

Indonesia.

Low mental health literacy and psychological

distress are considered predictors of low

psychological well-being (Farrer, Leach, Griffiths,

Christensen, & Jorm, 2008; Burns & Rapee, 2006)

and even dropping out of college (NAMI, 2012).

Mental health literacy is knowledge and beliefs

about mental disorders related to recognition,

management, or prevention (Jorm, 2000). This

means that individuals with mental health literacy

have knowledge about mental disorders, their

causes, symptoms, and treatments. Mental health

literacy (Jorm, 2000) consists of several

components including: 1) the ability to recognize

specific disorders or differences in types of

psychological distress, 2) knowledge and beliefs

about risk factors and causes, 3) knowledge and

understanding of self-help interventions, 4)

knowledge and beliefs about mental health

disorders.

Johanna Jarcho, Ph.D., a postdoctoral at

National Institute of Mental Health, said that most

mental health disorders appear in their teens or

early 20s. The symptoms usually begin in

childhood or adolescence and will continue into

adulthood. Most people don’t realize that they had

an anxiety disorder when they were teenagers,

and realize it as an adult. Teenagers have the

potential to experience mental health problems

such as school problems, college, lack of sleep,

and romance, so it is not uncommon for them to

choose drugs and alcohol to forget about those

problems (Women’s Brain Health Initiative, 2015) .

It is estimated that mental disorders in children

and adolescents will become one of the five

problems that cause disability, morbidity, or even

mortality in the next 20 years (WHO, 2013).

Mental health problems in children and

adolescents can affect their functioning in

important domains in their lives now and the

future, such as functioning at school, at home,

with friends, and in the community (Jaycox et al.,

2009).

Based on the background of the study, the

researcher was interested to analyze mental

health literacy and psychological distress as

predictors for psychological well-being of collage

students in Sriwijaya University.

Purpose

This research focused on answering questions

as below:

1. Is there a role of mental health literacy

and psychological distress on the psychological

well-being of collage students in Sriwijaya

University?

2. Is there a role of mental health literacy on

the psychological well-being of collage students in

Sriwijaya University?

3. Is there a role of psychological stress on

the psychological well-being of collage students in

Sriwijaya University?

50

Likewise, when teenagers enter university,

students’ mental health issues become a very

common discussion (Blanco C. et al., 2008). In

general, it is known that every individual has the

potential to experience mental health disorders,

from children to adults. In children, it is too early

for them to understand mental health, so research

has focused more on adolescents. This is

Design/Methodology/Approach

because

in

adolescence,

the

cognitive

development has finally able to receive

information abstractly and rationally, it also can

process this information in everyday life.

Furthermore, for early prevention before mental

disorders occur in adulthood, adolescents also

need to understand about mental health itself. In

this context, many students experience the onset

of mental health problems or even worsen initial

conditions that students have experienced before

entering university (Burns & Rapee, 2006; Pedrelli

et al., 2014;).

Screening results on 147 Unsri students

conducted by researcher at the time of community

service in 2019, found 56.5% of the students

experienced mild symptoms of psychological

distress, 40.1% experienced symptoms of high

psychological distress (needs to be wary of), and

only 3.4% did not show symptoms of

This research used quantitative method, by

conducting

instrument

preparation,

data

collection, and analysis of data results to see the

role of the independent variables on the

dependent variable.

Research Population and Sample

The population in this study are active students

in Sriwijaya University. The sampling technique

used is the incidental sampling which is a

sampling technique based on respondents who

are met and meet the criteria. In this study,

samples were taken based on individual’s

willingness to fill out the research scale.

The selection of the number of samples in this

study refers to Roscoe’s theory (Sugiyono, 2016).

Roscoe suggested a suitable sample size for

research ranging from 30 to 500 (Sugiyono,

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2016). In this study, the participants were 418

college students.

Indonesian population, which aims to determine

mental health status. One of the reasons is

because this questionnaire has good validity in

terms of sensitivity of 88%, and specificity of 81%

(Hartono, 1995).

Data collecting methods

Psychological well-being was measured using

an instrument in a form of psychological scale

referred to the psychological concept proposed by

Ryff and Keyes (1995), which describes individual

functioning to be independent, realize their

potential, able to master their environment, able to

accept themselves, have a purpose in life, and

able to have a positive relationship with others.

The Indonesian version of the Ryff and Keyes

(1995) psychological well-being scale developed

by Rachmayani and Rachmadani (2014) was

modified and a try out was carried out to 50

respondents before being distributed. This was

done to measure the validity and reliability of the

measuring instrument. The reliability before try-out

with 86 items was 0.871 and after try-out with 43

items was 0.923 (data attached).

Meanwhile, mental health literacy concept is

defined as knowledge and beliefs about mental

disorders that aid in the recognition, management,

or prevention. Mental health literacy includes the

ability to recognize specific disorders; knowing

how to seek mental health information; knowledge

of risk factors and causes; knowledge of self-

treatments; knowledge of professional help

available; and attitudes that promote recognition

and appropriate help-seeking (O’Connor & Casey,

2014). To measure mental health literacy, a

standardized scale was adapted from O’Connor

and Casey (2015) which was translated into

Bahasa, with permission and guidance from

O’Connor.

Furthermore, the concept of psychological

distress is used as an indicator of mental health

which is defined as a multifactorial and unpleasant

emotional experience of psychological (cognitive,

behavioral, emotional), social, and spiritual traits

that may interfere with the ability to effectively

cope with illness, physical symptoms, and

treatments (Reis et al., 2014). In this case, the

researcher measured psychological distress using

the Indonesian version of the WHO Self-Reporting

Questionnaire 20 (SRQ-20), with a scoring scale

of Yes (1) and No (0). This instrument has been

used in Basic Health Research (Riskesda) of

Results

Description of Participants

The number of participants in this study were

418 college students.

Based on the gender data, it is known that

there are 129 male participants (30.9%) and 289

female participants (69.1%). Meanwhile for the

age data, there are 150 adolescent participants

(35.9%) and 268 young adult participants (64,1%)

51

Individual Characteristics

Frequen

cy

Percentage

Gender

Age

Male

Female

Adolescence

129

289

150

30,9%

69,1%

35,9%

Early

adulthood

268

64,1%

Participate in Non-

Academic Activities

Semester

Yes

No

2

4

6

8

10

12

264

154

153

85

108

52

63,4%

36,6%

20,3%

25,8%

12,5%

3,8%

16

2

0,5%

Description of Research Data

This study was analyzed descriptively on each

variable. The following is a description of each

variable

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Hypothetical Data

Empirical Data

Variable

Max Min

Mean

SD

Max

Min

Mean

SD

Mental

Health

Literacy

175

35

105

23,3

137

77

109,775

9,478

Psychological

Distress

20

6

13

2,3

20

0

7,175

4,401

Psychological

Well-Being

172

43

107,5

21,5

163

82

123,077

14,867

Description: Min: Minimum Total Score; Max: Maximum Total Score; Mean: Mean Score; SD:Standard

Deviation.

Besides that, researcher also classified the

participants into certain categories for variable of

mental health literacy and psychological well-

being. This categorization serves a purpose to

place individuals into groups in which positions

are tiered according to a continuum based on the

measured attributes. Classification of participants

was done through three kinds of categories,

namely: low, average, and high.

Meanwhile, for psychological distress, the

Indonesian version of WHO Self-Reporting

Questionnaire

20

(SRQ-20)

was

used.

Specifically, the interpretation of SRQ-20 total

score is (Medhin, Hanlon, Dewey, Alem, Tesfaye,

Lakew,

et

al,

2010):

Table of SRQ-20 Total Score Categorization

SRQ-20 Total Score

Categorization

No symptoms of psychological distress, such as depression, anxiety

and somatic complaints

52

0

1 – 5

There are mild symptoms of psychological distress

Experiencing symptoms of high psychological distress (needs to be

wary of)

6 or above

Based on the formula above, the categorization

each variable is as follows:

for

Table of Categorization of Participants’: Mental Health Literacy, Psychological Distress and Psychological Well-Bein

Categorization

Frequen

Percentage

cy

Mental

Literacy

Health X < 81,7

81,7 ≤ X <

Low

2

402

0,5%

96,2%

Average

128,3

X ≥ 128,3

High

14

21

3,3%

5,0%

Psychological

Distress

No

symptoms

of

X < 1

psychological distress

Showing

symptoms

psychological distress

Showing symptoms

of high psychological

distress

mild

of

140

257

33,5%

61,5%

1 ≤ X < 6

X ≥ 6

Psychological Well- X < 86

Being

Low

4

263

151

1%

62,9%

36,1%

86 ≤ X < 129 Average

X ≥ 129 High

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recognized or detected by looking at the

distribution of data (dots) on the diagonal axis of

the plot graph and its residuals. Data can be said

to be normally distributed if the dots spread

around the diagonal line and follow the direction of

the diagonal line.

Based on the plot graph output, the dots follow

and approach the diagonal line thus it can be

concluded that the data are normally distributed.

Results

Data analysis results

Assumption test

1) Normality test

Before testing the hypothesis, the researcher

conducted a normality test first, because to test

the hypothesis, the data are required to be

normally distributed. Normality of a data can be

53

2) Linearity test

between variables. To find out whether there is a

linear relationship or not between each variables,

a linearity test was carried out. The results of the

linearity test are as follows:

One of the other requirements before testing

the hypothesis is that there is a linear relationship

Table of Linearity Test Results

Linearity

Variables

Description

Linear

Pearson’s r p-value.

Psychological Well-

Being -- Mental Health

Literacy

0,110

0,025

Psychological Well-

Being -- Psychological

Distress

-0,578

< 0,001

Linear

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Based on the linearity test, the significance

value of psychological well-being and mental

health literacy variables is 0.025; while

psychological distress is 0.001 (p<0.05), thus it

can be concluded that the variables have a linear

relationship.

regression model should not have a perfect

correlation between the independent variables.

Multicollinearity test was carried out by looking at

the Variance Inflation Factor (VIF).

According to Ghozali (in Purnomo, 2016), if the

VIF value is <10 then there is no symptom of

multicollinearity among the independent variables,

and if the VIF value is >10 then multicollinearity

occur among the independent variables. The

results of the multicollinearity test can be seen in

3) Multicollinearity test

Multicollinearity test is used to see whether the

independent variables have a perfect or near

the

following

table:

perfect linear relationship, because

a good

Table of Multicollinearity Test Results Summary

Collinearity Statistics

Tollerance VIF

Description

Variables

Psychological

Well-

0,999

1,001 No multicollinearity

Being -- Mental Health

Literacy

Psychological

Well-

Being -- Psychological

Distress

From the results of heteroscedasticity test, it can

be seen that the dots spread above and below the

number 0 on the Y axis, which means that there is

no symptom of heteroscedasticity.

From these results, it can bee seen that the

variable of mental health literacy and

psychological well-being has a VIF of 1.001,

meaning that the VIF value is smalled than 10

(1.001<10), thus it can be conclude that there is

no symptom of multicollinearity among the

independent variables.

54

4) Heteroscedasticity test

This test is carried out to see whether the

variance of the variables is not the same for all

observation, because heteroscedasticity should

not occur in a good regression. In this study, to

see whether there is heteroscedasticity, the

researcher used scatterplots; namely by looking at

the pattern of dots on the regression scatterplots.

The method is to create a plot or scatter graph

between Standardized Predicted Value (ZPRED)

and Studentized Residual (SRESID). Whether or

not there is a certain pattern on the scatterplot

graph between SRESID and ZPRED can be seen

from the Y axis which has been predicted and the

X axis which is the residual (predicted Y – true Y).

Hypothesis testing

To test the hypothesis, the researcher used

regression analysis. In this study, multiple

regression analysis is used to determine the role

of mental health literacy and psychological

distress on psychological well-being. The result of

the regression analysis is as follows:

Table of Major Hypothesis Testing Results

Variables

R

R Square

F

Sig

Description

Significant

Mental Health Literacy -

Psychological Distress -

Psychological Well-Being

0,586

0,343

108,416 < 0,001

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The percentage of mental health literacy and

psychological distress influences on psychological

well-being (R adjusted) is 0.343, this also shows

that the role of mental health literacy and

psychological distress together on psychological

well-being is 34.3%, while the rest is the

contribution of other variables not examined in this

study.

Based on the table, it is known that the

significance value of psychological well-being,

mental health literacy, and psychological distress

is 0.001 (p<0.05) with a correlation coefficient (R)

of 0.586. These results show that there is a role of

mental health literacy and psychological distress

together on psychological well-being, thus the

hypothesis is accepted.

Table of Minor Hypothesis Testing Results

Variables

Beta

p

Significance

Significant

Mental Health Literacy -

Psychological Well-Being

0,143

0,022

Psychological Distress -

Psychological Well-Being

-1,945

< 0,001

Significant

psychological

well-being,

the

researcher

Based on the table above, it can be seen that

psychological well-being and mental health

literacy show a beta value of 0.143 and a P value

of 0.022 (p<0.05), this indicates that there is a role

for mental health literacy on psychological well-

being, thus the hypothesis is accepted.

conducted an analysis to find the effective

contribution of the variables. By using the

following formula:

It can also be seen that psychological well-

being and psychological distress show a beta

value of -1.945 and a P value of 0.001 (p<0.05),

this indicates that there is a role for psychological

distress on psychological well-being, thus the

hypothesis is accepted.

Thus it is known that the effective contribution

of mental health literacy is 1.001% and

psychological distress is 33.35% on mental

health.

To determine how big the role of mental health

55

literacy

and

psychological

distress

on

Table of Effective Contribution Data of Mental Health Literacy and Psychological Distress on

Psychological Well-Being

Variable

Beta

0,091

-0,576

Zero Order

0,110

Mental Health

Literacy

Psychological Distress

-0,579

Table of Effective Contribution Summary

Variables

Effective Contribution

1,001%

Mental Health Literacy

- Psychological Well-

Being

Psychological Distress -

Psychological Well-

Being

(0,091) x (0,110) x 100%

(-0,576) x (-0,579) x 100%

33,35%

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mental disorders, so the promotion of mental

health literacy becoming important to promote

psychological well-being and prevent mental

Discussion

In this study, the major hypothesis testing was

carried out using multiple linear regression which

showed correlation value (R) of 0.586 and a

significance of 0.001 (p<0.05). These results show

that there is a role of mental health literacy and

psychological distress together on psychological

well-being, thus the hypothesis is accepted.

Meanwhile, the percentage of mental health

literacy and psychological distress influences on

psychological well-being (R adjusted) is 0.343,

this also shows that the role of mental health

literacy and psychological distress together on

psychological well-being is 34.3%, while the rest

is the contribution of other variables not examined

in this study. According to Ryff (1995), several

factors that may affect psychological well-being

are age, gender, and culture. Then Ryff et al.

(2002) also added several more factors including

educational status and personality.

health problems (Inchaithep, Punsawat,

Nuntana, 2018).

&

Ashfield and Smith (Male Suicide Prevention

Australia, 2018) through their discussion of

suicide prevention, also explained that it is not

only important to reach an approach on how to

respond to psychological distress and mental

health disorders, but also to be involved in

preventive promotion (in this case suicide

prevention), improvement on psychological well-

being, and mental health literacy. Moreover, one

of the components of mental health literacy

mentioned by Jorm (2000) is the ability to

recognize specific disorders or differences in

various psychological distresses. Thus, both

mental health literacy and psychological distress

are considered having a role in improving

psychological well-being.

The results and discussion above indicate that

the hypothesis which states there is a role of

mental health literacy and psychological distress

on psychological well-being can be accepted.

Given that there are still 65.7% of other factors

unidentified in this study, for further research,

other variables can be added as predictors of

psychological well-being, including adjustment,

emotion, personality type, stress management,

social support, and others.

The results also show that 61.5% students

have high psychological distress, 33.5% on

average level, and another 5% on low level of

psychological distress. This is in line with what

Jarcho (Womens Brain Health Initiative (2015)

said that most adolescents in university

experience psychological distress.

Psychological distress is a state of emotional

distress that affects psychological well-being, this

condition is characterized by symptoms of

depression (e.g. loss of interest, sadness,

hopelessness) and anxiety (e.g. restlessness,

feeling tense) (Mirowsky & Ross, 2003). The level

of psychological distress can be caused by two

influences, namely: intrapersonal, such as

personality traits; and situational influences, such

as life events (Matthews, 2000). Situational

factors from the environment that encourage

psychological distress include traumatic events,

physical factors, social factors, and poor health

(Matthews, 2000). Therefore, there should be

preventative efforts that universities can come up

with in this regard.

In this study, the researcher also conducted

additional analysis by conducting difference tests

on variables of psychological well-being, mental

health literacy, and psychological distress based

on gender, age, participation in non-academic

activities and semester of lectures. From those

tests, differences are found in age for all variables

and both in gender and semester for the variables

For the results of the minor hypothesis testing,

it is known that the beta value is 0.143 and the P

value is 0.022 (p>0.05), this indicates that there is

a role for mental health literacy on psychological

well-being, thus the hypothesis is accepted.

In addition, psychological well-being and

psychological distress show a beta value of -1.945

and a P value of 0.001 (p<0.05), this indicates that

there is a role for psychological distress on

psychological well-being, thus the hypothesis is

accepted. Specifically, the effective contribution of

56

mental

health

literacy

is

1.001%

and

psychological distress is 33.35% on mental

health.

Several previous researches indicate that

university should planning intervention and

promotion of psychological well-being, to increase

awareness and ability to conceptualize mental

and emotional health for collage students

(Vazquez, 2016). Learning and adopting

knowledge related to health promotion and

behavior during adolescence can improve healthy

decision making and health literacy in collage,

including mental health literacy, which in particular

also has a component of knowledge around

mental health itself (Bjørnsen et al., 2019).

Therefore, mental health literacy interventions are

suggested in promoting psychological well-being

as the result itself rather than focusing solely on

curative mental disorders (Vazquesz, 2016).

Adolescence is also a period when individuals

are vulnerable to psychological distress, and so

this period is an important time to promote

psychological well-being and early intervention for

mental health, as an effort to avoid the occurrence

of mental health problems (Pengpid, & Peltzer,

2020). One of the interventions that can be done

is mental health literacy intervention as described

above. Research on mental health literacy will

lead to planning for mental health promotion in

order to reduce the occurrence and severity of

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Mental Health: Global Challenges Journal

of mental health literacy and psychological

distress. The difference in gender and mental

health literacy variables is in line with several

previous studies (Dias et al., 2018; Cotton et al.,

2006), where women have higher mental health

literacy scores than men. Gender differences

found in psychological distress variable are also in

line with several previous studies (Campbell,

Bann, & Patalay, 2021; Tian et al., 2021), where

women have higher mental health problems than

men, and the biggest difference is in life

satisfaction and psychological distress (Campbell,

Bann, & Patalay, 2021).

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The percentage of mental health literacy and

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pressure

influences

on

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Future work, it is important that university

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health for collage students. Learning and adopting

knowledge related to health promotion and

behavior during in collage; can improve healthy

decision making and health literacy in

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knowledge around mental health itself. Research

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mental health promotion in order to reduce the

occurrence and severity of mental disorders.

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This research is expected to be able to

contribute to the development of knowledge in the

field of mental health regarding mental health

literacy, psychological distress, and psychological

well-being of collage students in Sriwijaya

University.

Conflict of interest

Author declares that she has no conflict of

interests

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Dynamics of quality of life indicators in patients

with gastroesophageal reflux disease comorbid

with connective tissue dysplasia under the

influence of complex treatment

Iryna B. Romash, Ivan R. Romash

Ivano-Frankivsk National Medical University, Ukraine.

Abstract

Introduction. In the case of gastroesophageal reflux disease (GERD) on the background of

undifferentiated connective tissue dysplasia (UCTD) causes an even more significant deterioration

in the QOL, including sleep disturbances and the onset of excessive daytime sleepiness (EDS).

Thus, the study of the peculiarities of GERD on the background of connective tissue dysplasia

and determining the impact of comorbid pathology on the QOL of patients with GERD is a topical

issue in internal medicine. It has significant socio-economic significance. We believe that

monitoring the most important variables that affect the quality of life of patients with GERD can

help raise public awareness in this regard. In addition, it can guide the health care system to

address these issues.

Purpose. The purpose of the work is to increase the awareness of medical workers about the

scale of the problem and ways to solve it. to study the features of the dynamics of quality of life in

patients with gastroesophageal reflux disease comorbid with connective tissue dysplasia under

the influence of the proposed complex therapy.

59

Methodology. 120 patients were included: 65 men and 55 women. In 75 of them (Study Group)

GERD was in the background of UCTD, in 45 (Сomparison Group ) - developed as an

independent disease. The Study Group was divided into three groups. Сomparison Group - 45

patients with GERD without UCTD, received basic standard therapy, which included PPI

"Panocid" 40 mg once a day and alginate-antacid formulation (Gaviscon Double Action Liquid) 20

ml, 3 times per day after meals and before bedtime. I Group - 25 patients with GERD +UCTD,

which to the standard basic therapy was added "Magne-B6" for 2 tablets 3 times per day. II Group

- 25 patients with GERD +UCTD, which to the standard basic therapy was added "Calcium-D3

Nicomed" 1 tablet 3 times per day. III Group - 25 patients with GERD +UCTD, who used the drug

"Magne-B6" 2 tablets 3 times per day and "Calcium-D3 Nicomed" 1 tablet 3 times per day on the

background of standard basic therapy. The Medical Outcomes Study 36-Item Short-Form Health

Status (SF-36), the Gastrointestinal Symptom Rating Scale (GSRS), and the scale of "Personal

and social performance" (PSP) - were used to study patients in detail. A comprehensive

examination of patients was performed twice: before and after 30 days of comprehensive

treatment.

Results and Discussion. Under the influence of the basic therapy in Comparison Group the

General Health (GH) improved by 33.03%. While in the groups on the background of complex

treatment is increased by 42.52% in patients of the I Group, by 13.10% in patients of the II Group,

and 46.28% in patients of the III Group (p1, p2, p3 <0.05).Physical Functiong Scale (PF) improved

by 17.9% in patients of the Comparison Group (p <0.05) and by 30.38%; 27.47%, 29.17%,

respectively (p1, p2, p3 <0.05). Role Physical Scale (RP) scores improved by 25.14% in

Comparison Group (p <0.05) and by 33.6 %, 22.58% and 40.20% respectively (p1, p2, p3 <0.05).

Dynamics of data in Body Pain (BP) scale improved by 21.84% in patients of the Comparison

Group (p <0.05) and by 37.28%, 25.46%, 35.92% (p1, p2, p3 <0.05).As can be seen from it,

under the influence of complex therapy, the values of the Vitality (VT) increased by 17.18% in

patients of Group I, by 21.93% – in Group II, by 37.87%– in Group III (p1, p2, p3 <0.05). Among

patients of the Comparison Group, the influx of strength and energy felt 9.50% (p <0.05). Data of

Social Functioning Scale (SF) improved by 8.8% in patients of the Comparison Group (p <0 , 05)

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and by 22.7%, 29.6%, 29.31%, respectively(p1, p2, p3 <0.05). Mental Health Scale (MH)

improved by 17.23% in patients of Group I, by 22.41% – in Group II, by 21.96% – in Group III (p1,

p2, p3 <0.05) and 14.22% - in the Comparison Group (p <0.05). Also in patients were positive

dynamics of the Role Emotional functioning scale (RE): by 27.37% in patients of Group I, by

12.36%– in Group II, by 15.7% – in the Group III (p1, p2, p3 <0.05) and 9.05% - in patients of the

Comparison Group (p < 0.05).

Conclusions. Thus, the inclusion in the standard therapy of gastroesophageal reflux disease in

patients with its development on the background of undifferentiated connective tissue dysplasia of

magnesium lactate dihydrate in combination with pyridoxine hydrochloride ("Magne -B6 ") and

calcium carbonate in combination with cholecalciferol ("Calcium-D3 Nicomed") contributed to a

significant improvement in their quality of life.

Keywords

quality of life, gastroesophageal reflux disease, comorbidity, connective tissue dysplasia, complex

treatment.

Address for correspondence:

Romash Iryna Bohdanіvna, MD, Ph.D., assistant of professor Department

propaedeutics of internal medicine, Ivano-Frankivsk National Medical University.

76010 Ivano-Frankivsk, Ukraine.e-mail: iromash@ukr.net ;

iromash@ifnmu.edu.ua

Submitted for publication: 23

April 2021

Revised: 17 August 2021

Accepted for publication: 24

October 2021

This work is licensed under a Creative Commons Attribution-

NonCommercial 4.0 International License (CC BY-NC 4.0).

Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy

60

doi: https://doi.org/10.32437/mhgcj.v4i2.1 2 8

including acid regurgitation, epigastralgia, non-

cardiac chest pain, chronic cough, asthma.

Symptoms of nocturnal acid regurgitation may

interfere with sleep. Therefore, patients with

GERD may experience a loss of quality of life

(QOL) much more often than the general

population. (Salome Satya Vani P et al., 2018).

And this in turn affects the ability of people to

perform daily activities, which closely affects the

state of their well-being.

The urgency of the problem of GERD in

addition to a serious impact on QOL and social

functioning is the development of dangerous to

the health and life of patients complications:

esophageal stricture, peptic ulcer, Barrett's

esophagus, adenocarcinoma. Therefore, early

diagnosis of the underlying disease and comorbid

conditions is important to prevent the above

complications. By the way, digestive disorders are

increasingly recognized as one of the leading

causes of disability worldwide. In 2019, these

diseases took third place after cardiovascular and

cancer diseases

Introduction

The problem of comorbid pathology in the

patient XXI century becomes the rule rather than

the exception. It causes significant costs for the

diagnosis and treatment of such patients, and

ultimately high disability and mortality.

Epidemiological studies in recent years have

shown that gastroesophageal reflux disease

(GERD) occupies a leading position among other

acid-dependent gastrointestinal diseases and is a

significant factor in health care costs. Depending

on the study population, its prevalence is in the

range of 10-30% and tends to increase (Charles

Hill et al. 2020). Over the past 40 years, the

incidence of GERD has increased significantly

and has become one of the main clinical problems

in gastroenterology. In North America, it is noted

in 18.1-27.8%, in Europe - in 2.5-7.8%, in the

Middle East - in 8.7-33.2% of cases. GERD is also

increasingly found in Asians, where its prevalence

averages about 8%.

According to research by Gorczyca R et al.

(2019) and Iudici M et.al. (2017) already in

patients with GERD without concomitant

pathology, the quality of life deteriorates due to

In the case of GERD on the background of

undifferentiated connective tissue dysplasia

(UCTD) causes an even more significant

deterioration in the QOL, including sleep

disturbances and the onset of excessive daytime

sleepiness (EDS). This dependence is indicated

functional

limitations,

emotional

disorders,

increased frequency of reflux. Patients with GERD

usually suffer from a variety of symptoms,

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by our previous correlation analysis and the

establishment of direct close relationship

a

120 patients have included 65 men and 55

women. In 75 of them (Stady Group) GERD was

in the background of UCTD, in 45 (Comparison

Group) - developed as an independent disease.

Depending on the treatment regimen, the

experimental group was divided into three.

Comparison Group consisted of 45 patients

with GERD without connective tissue disorders,

who received basic standard therapy, which

included PPI "Panocid" and alginate-antacid

formulation (Gaviscon Double Action Liquid) 20 ml

3 times per day after meals and before bedtime.

I Group consisted of 25 patients with GERD in

combination with UCTD, which was added to the

basic therapy "Magne-B6" for 2 tablets 3 times per

day.

I Group consisted of 25 patients with GERD on

the background of UCTD, which was added to the

basic therapy "Calcium-D3 Nicomed" 1 tablet 3

times per day.

IІІ Group consisted of 25 patients with GERD in

combination with UCTD, which was added to the

basic therapy "Magne-B6" in 2 tablets. 3 times per

day and "Calcium-D3 Nicomed" 1 tablet 3 times

per day.

between the indicator of pathological acidification

of the esophagus (acid exposure time - AET) and

EDS in both groups. In our previous study, we

found a significant decrease in QOL and social

functioning (Romash, 2019, 2020). In particular,

patients with a combination of GERD and UCTD

significantly more often worried about heartburn,

impaired quality of sleep, and life on 1.4 times (p

<0.05). They increased the frequency of

gastroesophageal reflux with pH <4, increased the

number of acid reflux in the supine and standing

positions.

Thus, the study of the peculiarities of GERD on

the background of connective tissue dysplasia

and determining the impact of comorbid pathology

on the QOL of patients with GERD is a topical

issue in internal medicine. It has significant socio-

economic significance

We believe that monitoring the most important

variables that affect the quality of life of patients

with GERD can help raise public awareness in

this regard. In addition, it can guide the health

care system to address these issues

The Medical Outcomes Study 36-Item Short-

Form Health Status (SF-36), the Gastrointestinal

Symptom Rating Scale (GSRS), and the scale of

"Personal and social performance" (PSP) - were

used to study patients in detail.

A comprehensive examination of patients was

performed twice: before and after 30 days of

comprehensive treatment

Purpose

The purpose of the work is to increase the

awareness of medical workers about the scale of

the problem and ways to solve it. to study the

features of the dynamics of quality of life in

patients with gastroesophageal reflux disease

comorbid with connective tissue dysplasia under

the influence of the proposed complex therapy.

61

The sample of patients was representative by

age and gender ( Table 1).

Design/Methodology/Approach

Table 1.

Distribution patients by age and sex

Сomparison

Group

Indexes

Age

І

ІІІ

(n=25)

III

(n=25)

(n=45)

46.2±3.03

36.2±3.03

32.2±3.03

29.2±3.03

Gender

(abs. number,%)

Male

23

51.2

48.8

14

11

56.0

44.0

15

9

60.0

40.0

13

12

52.0

48.0

Female 22

After reviewing the examination procedure and

the principle of treatment, all patients voluntarily

signed written agreements following the protocol

of the clinical trial approved by the Bioethics

Commission of Ivano-Frankivsk National Medical

University. To assess the dynamics of quality of

life (QOL) of the examined patients under the

influence of complex treatment, each patient was

asked to fill out a short form of the questionnaire

Medical Outcomes Study 36-Item Short-Form

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Health Status (SF-36) Ware et al. (1993) and the

Gastrointestinal Symptom Rating Scale.

scores of each scale vary between 0 and 100,

where 100 is a completely healthy, and the results

are in the form of scores compiled in such a way

that a higher score indicates a higher QOL level.

The SF-36 questionnaire consists of 36

questions grouped into eight domains: physical

functioning (PF), social functioning (SF), role

limitation related to physical problems (RP), role

limitation, gender associated with emotional

problems (RE), mental health (MH), vitality (VT),

body pain (VP) and perception of general health

(GH). The indicators of each scale are compiled

as follows: the higher the value of the indicator

(from 0 to 100), the better the score on the

selected scale. They form two parameters that

evaluate the eight concepts of health:

psychological and physical components. The

physical components are: GH - general perception

of health, PF - limitations in physical activity due

to health problems, RP - limitations in normal role-

playing activities due to physical health problems,

BP - physical pain. Mental components include:

SF - limitations in social activity due to physical or

emotional problems, MH - general mental health

(psychological distress and well-being, RE -

limitations in normal role activity due to emotional

problems, VT - viability (energy and fatigue) The

The general questionnaire is

a

general

questionnaire that can be used for patients with

various pathologies as well as for population-

based studies. of 15 questions grouped into five

clusters for

a detailed study of symptoms

reflecting reflux, abdominal pain, indigestion,

diarrhea, and constipation. GSRS has a seven-

point Likert-type scale, where "1" means no

problem symptoms and "7" means no very

problematic symptoms. The reliability and validity

of this questionnaire are well documented, the

values of the norms for the general population are

available (Kulich et.al., 2008).

Results and Discussion

The dynamics of the physical components of

quality of life under the influence of the proposed

comprehensive treatment in our examined

patients is presented in Figure 1.

62

Fig. 1. Dynamics of quality of life indicators (physical component) in the examined patients

Note: * - (p <0,05) data are reliable for indicators before and after treatment.

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Under the influence of the basic therapy

among the patients of the Comparison Group the

General Health (GH) improved by 33.03%,

changing from 52.81 ± 0.98 to 78.86 ± 1.03 ( p

<0.05). While in the groups on the background of

complex treatment it increased by 42.52% (from

54.3 ± 0.97 to 94.5 ± 1.97) in patients of the first

group, by 13.10% (from 62 .01 ± 1.87 to 71.36 ±

0.61) – in II and 46.28% (from 50.81 ± 1.07 to

94.6 ± 2.01) – in the III, respectively (p1 , p2, p3

<0.05).

Physical Functiong Scale (PF) improved by

17.9% under the influence of the prescribed

treatment (from 59.32 ± 0.97 to 72.3 ± 0, 61) in

patients of the Comparison Group (p <0.05) and

by 30.38% (from 61.12 ± 1.38 to 87.8 ± 2.09) – in

the I Group; 27.47% (from 57.01 ± 2.63 to 79.03 ±

0.97) – in the II Group; 29.17% (from 61.12 ± 0.68

to 86.3 ± 1.16) – in the III Group, respectively (p1,

p2, p3 <0.05).

Role Physical Scale (RP) scores improved by

25.14% (from 58.31 ± 0.91 to 77.9 ± 1.12) in

Comparison Group (p <0.05) and by 33.6 % (from

61.24 ± 1.12 to 92.3 ± 2.07) in patients of the I

Group, by 22.58% (from 53.71 ± 0.76 to 69.38 ±

1.56) - in the II Group, by 40.20% (from 53.20 ±

0.13 to 89.12 ± 0.97) – in the III (p1, p2, p3 <0.05)

Dynamics of data in Body Pain (BP) scale

under the influence of the proposed therapy

improved by 21.84% (from 61.9 ± 0.89 to 79.2 ±

1.33) in patients of the Comparison Group (p

<0.05) and by 37.28% (from 59.2 ± 0.86 to 94.4 ±

1.25) – in the I Group, by 25.46% (from 58.36 ±

1.15 to 78.3 ± 2.13) – in the II Group, by 35.92%

(from 59 , 41 ± 1.08 to 92.73 ± 1.05) – in the III

Group (p1, p2, p3 <0.05).

Dynamics of mental components of quality of

life under the influence of the offered complex

treatment at the examined patients presented in

figure 2.

63

Fig. 2. Dynamics of quality of life indicators (mental component) in the examined patients

Notes: 1. * - (p <0,05) data are reliable in relation to indicators before and after treatment

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Mental Health: Global Challenges Journal

Under the influence of complex therapy, the

values of the Vitality (VT) increased by 17.18%

(from 72.3 ± 1.62 to 87.3 ± 0.97) in patients of

Group I, by 21.93% (from 69.76 ± 1.32 to 89.36 ±

1.36) – in the Group II, in which the basic therapy

was added to the calcium drug; by 37.87% (from

59.86 ± 0.96 to 96.36 ± 2.31) – in the Group III, to

which both drugs were added to the basic therapy

(p1, p2, p3 <0.05). Among patients with GERD

without UCTD, who received basic therapy with

PPIs and alginate-antacid formulation, the influx of

strength and energy felt 9.50% (69.86 ± 0.32 to

77.2 ± 1.08), p <0.05.

Data of Social Functioning Scale (SF) under

the influence of the proposed therapy improved by

8.8% (from 74.36 ± 0.98 to 81.5 ± 1.64) in patients

of the Comparison Group (p <0 , 05) and by

22.7% (from 61.12 ± 0.81 to 79.1 ± 0.62) in

patients in the Group I, by 29.6% (from 59.36 ±

1.65 to 84.3 ± 1.31) – in the Group II, by 29.31%

(from 63.16 ± 0.38 to 89.36 ± 1.13) - in the Group

III (p1, p2, p3 <0.05).

Gorczyca, R., Pardak, P., Pękala, A., & Filip, R..

(2019). Impact of gastroesophageal reflux

disease on the quality of life of Polish patients.

World Journal of Clinical Cases, 7(12), 1421–

1429.

https://doi.org/10.12998/wjcc.v7.i12.1421

Hill, C., Versluijs, Y., Furay, E., Reese-White, D.,

Holan, C., Alexander, J., Doggett, S., Ring, D.,

& Buckley, F. P.. (2020). Psychoemotional

factors and their influence on the quality of life

in patients with GERD. Surgical Endoscopy.

https://doi.org/10.1007/s00464-020-08145-8

Iudici, M., Irace, R., Riccardi, A., Cuomo, G.,

Vettori, S., & Valentini, G.. (2017). Longitudinal

analysis of quality of life in patients with

undifferentiated connective tissue diseases.

Patient Related Outcome Measures, Volume 8,

7–13. https://doi.org/10.2147/prom.s117767

Kulich, K. R., Madisch, A., Pacini, F., Piqué, J. M.,

Regula, J., Van Rensburg, C. J., Újszászy, L.,

Carlsson, J., Halling, K., & Wiklund, I. K..

(2008). Reliability and validity of the

Gastrointestinal Symptom Rating Scale

(GSRS) and Quality of Life in Reflux and

Mental Health Scale (MH) improved by 17.23%

(from 71.26 ± 0.36 to 86.1 ± 1.95) in patients of

the Group I, by 22.41% (from 61.96 ± 0.68 to

79.86 ± 1.07) – in the Group II, 21.96% (from

79.19 ± 1.02 to 97.63 ± 2.03) – in the Group III

(p1, p2, p3 <0.05) and 14.22% (from 68.36 ± 0.35

to 79.7 ± 1.04) - in the Comparison Group (p

<0.05).

Dyspepsia

(QOLRAD)

questionnaire

in

dyspepsia: A six-country study. Health and

Quality of Life Outcomes, 6(1), 12.

https://doi.org/10.1186/1477-7525-6-12

Romash, I., Mishchuk, V. (2019). Improvement of

Magnesium and Calcium Deficiency in Patients

Also in the patients we treated there was a

positive dynamics of the scale Role Emotional

functioning (RE): by 27.37% (from 70.3 ± 1.16 to

96.8 ± 2.07) in patients of the Group I, by 12.36%

(from 73.26 ± 0.64 to 83.6 ± 1.35) – in the Group

II, by 15.7% (from 79.43 ± 0.38 to 94.3 ± 0.92 ) –

in the Group III (p1, p2, p3 <0.05) and 9.05%

(from 69.3 ± 0.31 to 76.2 ± 0.82) - in patients of

the Comparison Group who received basic

therapy (p < 0.05).

with

Gastroesophageal

Reflux

Disease

64

Associated with Undifferentiated Connective

Tissue Disease. Galician Medical Journal,

26(4). https://doi.org/10.21802/gmj.2019.4.3

Romash, I. (2020). Disorders of social functioning

and quality of life in patients with

gastroesophageal

combined with undifferentiated connective

tissue dysplasia. Mental Health: Global

reflux

disease

while

Challenges

Journal,

3(1),

11–16.

https://doi.org/10.32437/mhgcj.v3i1.100

Romash, I.R., Vynnyk, M.I. (2020). Dynamics of

Quality of Life Indices in Case of Metabolic

Conclusions

Thus, the inclusion in the standard therapy of

gastroesophageal reflux disease in patients with

its development on the background of

undifferentiated connective tissue dysplasia of

magnesium lactate dihydrate in combination with

pyridoxine hydrochloride ("Magne -B6 ") and

Syndrome

Schizophrenia on the Background of Atypical

Neuroleptic Agents Application and

in

Patients

with

Paranoid

Improvement of Comorbidity. Ukrains’kyi

visnyk psykhonevrolohii. 27, 4 (101):62-67. doi:

https://doi.org/10.36927/2079-0325-V27-is4-

2019-11

calcium

carbonate

in

combination

with

cholecalciferol

contributed to a significant improvement in their

quality of life.

("Calcium-D3

Nicomed")

Salome Satya Vani P et al., (2018). Assessment

on Patients Health Related Quality of Life

Associated With Gerd. Int J Recent Sci Res.

9(4),

pp.

25840-25845.

DOI:

http://dx.doi.org/10.24327/ijrsr.2018.0904.194)

Conflict of interest

The authors declare that they have no conflict

of interest.

References

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MHGCJ – 2020

Mental Health: Global Challenges Journal

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