# data[].attributes.attachment_link.title
Reforms to the Mental Health Act welcome, but need scrutiny

# data[].attributes.attachment_link.description
Mind responds to the UK Government’s publication of the draft Mental Health Bill, which will overhaul the 1983 Mental Health Act

# data[].attributes.headline
An article exploring the safety and efficacy of psychotropic medication in young people

# data[].attributes.subject
An article exploring the safety and efficacy of psychotropic medication in young people

# data[].attributes.body
An article exploring the safety and efficacy of psychotropic medication in young people

# data[].attributes.attachment_link.readable_text
Marco Solmi, 1 , 2 , 3 Michele Fornaro, 4 Edoardo G. Ostinelli, 5 , 6 Caroline Zangani, 6 Giovanni Croatto, 1 Francesco Monaco, 7 Damir Krinitski, 8 Paolo Fusar‐Poli, 3 , 9 , 10 , 11 and Christoph U. Correll 12 , 13 , 14 , 15

Abstract

Mental disorders frequently begin in childhood or adolescence. Psychotropic medications have various indications for the treatment of mental disorders in this age group and are used not infrequently off‐label. However, the adverse effects of these medications require special attention during developmentally sensitive periods of life. For this meta‐review, we systematically searched network meta‐analyses and meta‐analyses of randomized controlled trials (RCTs), individual RCTs, and cohort studies reporting on 78 a priori selected adverse events across 19 categories of 80 psychotropic medications - including antidepressants, antipsychotics, anti‐attention‐deficit/hyperactivity disorder (ADHD) medications and mood stabilizers - in children and adolescents with mental disorders. We included data from nine network meta‐analyses, 39 meta‐analyses, 90 individual RCTs, and eight cohort studies, including 337,686 children and adolescents. Data on ≥20% of the 78 adverse events were available for six antidepressants (sertraline, escitalopram, paroxetine, fluoxetine, venlafaxine and vilazodone), eight antipsychotics (risperidone, quetiapine, aripiprazole, lurasidone, paliperidone, ziprasidone, olanzapine and asenapine), three anti‐ADHD medications (methylphenidate, atomoxetine and guanfacine), and two mood stabilizers (valproate and lithium). Among these medications with data on ≥20% of the 78 adverse events, a safer profile emerged for escitalopram and fluoxetine among antidepressants, lurasidone for antipsychotics, methylphenidate among anti‐ADHD medications, and lithium among mood stabilizers. The available literature raised most concerns about the safety of venlafaxine, olanzapine, atomoxetine, guanfacine and valproate. Nausea/vomiting and discontinuation due to adverse event were most frequently associated with antidepressants; sedation, extrapyramidal side effects, and weight gain with antipsychotics; anorexia and insomnia with anti‐ADHD medications; sedation and weight gain with mood stabilizers. The results of this comprehensive and updated quantitative systematic meta‐review of top‐tier evidence regarding the safety of antidepressants, antipsychotics, anti‐ADHD medications and mood stabilizers in children and adolescents can inform clinical practice, research and treatment guidelines.

Keywords: Safety, tolerability, children, adolescents, psychopharmacology, antidepressants, antipsychotics, mood stabilizers, psychostimulants, meta‐review

Childhood and adolescence are a crucial time of biopsychosocial development 1 . Many, if not most, severe mental disorders have their onset prior to age 18 2 . Early intervention is a cornerstone of modern psychiatry which has demonstrated superior outcomes, for example, in psychotic disorders and bipolar disorder 3, 4. In addition to psychotherapeutic and psychosocial interventions, psychotropic medications are often necessary to treat severe mental disorders that result in subjective distress and/or significant dysfunction in youth.

Several antidepressants, antipsychotics, anti‐attention‐deficit/hyperactivity disorder (ADHD) medications and mood stabilizers indicated in adults have received regulatory approval for use in children and/or adolescents 5 , and many are used off‐label 6, 7, 8, 9, 10. However, despite evidence for the efficacy of a number of psychotropic medications in youth, the duration of untreated illness in depressive disorder 11 , bipolar disorder 12, 13, schizophrenia 14 , obsessive‐compulsive disorder 15 , anxiety disorders 16 , and other mental disorders 17 is often long 18, 19, which adversely affects long‐term outcomes 14, 20, 21, 22, 23, 24. Such delay can be related to several factors. These certainly include reduced access to care due to stigma and self‐stigma surrounding mental illness 25, 26, 27, but stigma‐derived or data‐based concerns about the safety of psychotropic medications in children and adolescents are also relevant 28, 29, 30, 31, 32, 33, 34.

The poor quality of data on safety of psychotropic medications can potentially induce a delay or refusal of treatment, despite evidence that medications used in psychiatry are generally not less effective than those prescribed in other fields of medicine 35 . For instance, poor reporting of adverse events in available randomized controlled trials (RCTs) may have led to inaccurate estimates of some serious events, such as suicidality with antidepressants 36 . In addition, regulatory agencies may issue boxed warnings for adverse events of medications, such as for antidepressants increasing suicidality in children, adolescents and young adults 37 , which can impact prescribing habits in everyday clinical practice 38 , but whose validity may then be questioned 39, 40. At the same time, evidence‐based safety concerns and warnings are essential to inform treatment guidelines and clinical care and are crucial to protect patients according to the primum non nocere principle.

The evidence on safety of psychotropic agents in children and adolescents with mental disorders has been rapidly growing 41 , but remains fragmented. The available network meta‐analyses (NMAs) and meta‐analyses (MAs) have generally considered efficacy as their primary outcome, while safety is usually not prioritized in the primary RCTs and related evidence syntheses. Moreover, NMAs and MAs only include RCTs, usually concerning one or, rarely, few related mental disorders.

While RCTs minimize the influence of several sources of bias on estimates of medication effects in a specific population, they also apply strict selection criteria, which reduces the generalizability and external validity of their findings. Moreover, RCTs are often relatively small and short in duration, which precludes the adequate identification of rare but serious or long‐term adverse events 42 . Furthermore, NMAs and MAs generally focus on the use of medications in disorders for which they are indicated, excluding evidence about off‐label use. Therefore, a comprehensive summary of the evidence concerning the safety of psychotropic medications for all the mental health conditions for which they are used in children and adolescents, based on RCTs as well as on large cohort studies including more generalizable samples and reflecting real‐world use patterns, is important to inform clinical practice.

To the best of our knowledge, no systematic meta‐review exists to date that has focused on the safety of psychotropic drugs in children and adolescents as its primary outcome, summarizing data from NMAs, MAs, largest individual RCTs, and well‐designed matched cohort studies across all relevant mental disorders. The aim of the present meta‐review was to provide the largest and most comprehensive evidence synthesis on the safety of four major psychotropic medication classes (antidepressants, antipsychotics, anti‐ADHD drugs, mood stabilizers) in children and adolescents with mental disorders, in order to inform clinical decision making and guideline development, and to identify areas needing further research.

METHODS

Search, inclusion and exclusion criteria

This systematic meta‐review followed an a priori protocol (available upon request). We conducted a systematic search in PubMed and PsycINFO, from database inception up to September 7, 2019, using an exhaustive combination of key words for both psychotropic medications and adverse health outcomes (full search string available upon request). Additional manual searches were performed on reference lists of included articles. Pairs of authors conducted title/abstract screening and full‐text assessment, and extracted data into a pre‐defined excel spreadsheet. A third author resolved any conflict.

Inclusion criteria were: a) NMAs, MAs, individual RCTs, and cohort studies controlling for confounding by indication (i.e., medication vs. placebo/no medication in subjects affected by the same disorder); b) data on the association between antidepressants, antipsychotics, anti‐ADHD medications, or mood stabilizers and adverse health outcomes; c) population of children and/or adolescents with any mental disorder.

Exclusion criteria were: a) studies on conditions other than mental disorders for which psychotropic medications are indicated or used (e.g., epilepsy); b) confounding by indication (i.e., comparing patients on medications with healthy controls), even if they adjusted analyses for covariates; c) designs other than those indicated in inclusion criteria; d) no data on the association between the targeted medications and adverse health outcomes.

Included adverse events and psychotropic medications

The 78 a priori selected adverse events were subdivided into the following 19 categories: central nervous system (agitation, anxiety, asthenia, irritability, cognitive impairment, depression, dizziness, headache, mania, psychosis, sedation, insomnia, seizures, suicidal ideas/behaviors/attempts); nutritional and metabolic (anorexia, binge eating/increased appetite, increased cholesterol, increased triglycerides, metabolic syndrome, glucose dysregulation/diabetes, insulin resistance, increased waist circumference, weight gain/increased body mass index, weight loss); cardiovascular (arrhythmias/tachycardia, cardiomyopathy, cerebrovascular disease, coronary heart disease, hypertension, hypotension, myocarditis, QT prolongation, sudden cardiac death); gastrointestinal (abdominal pain, constipation, diarrhea, gastrointestinal symptoms, liver damage, nausea/vomiting); genitourinary (enuresis, kidney disease/failure, menstrual cycle alterations, polycystic ovarian syndrome, sexual dysfunction); movement disorders (akathisia, any extrapyramidal side effect, tremor, dystonia, tardive dyskinesia); impulse dyscontrol and risky behavior (criminal behavior, gambling, substance abuse, non‐suicidal self‐injury behaviors); endocrine (gynecomastia/galactorrhea, hypo/hyperprolactinemia, hypo/hyperthyroidism); hematologic (anemia, leukocytopenia, thrombocytopenia); mouth (dental caries, dry mouth, sialorrhea); respiratory (acute respiratory failure, asthma, nasopharyngitis/upper respiratory tract infection/pneumonia); venous thromboembolism (deep vein thrombosis, pulmonary embolism); bone health (osteopenia/osteoporosis, fractures); accidents (any accident, fall); neuroleptic malignant syndrome (neuroleptic malignant syndrome/fever/creatine phosphokinase elevation); any cancer; discontinuation due to adverse event; serious adverse events; and mortality (all‐cause, due to natural causes, due to suicide).

The 80 psychotropic medications were subdivided into the four categories of antidepressants, antipsychotics, anti‐ADHD medications, and mood stabilizers. The category of antidepressants included nine classes: monoamine oxidase inhibitors (I‐MAOs) (bifemelane, hydracarbazine, isocarboxazid, moclobemide, nialamide, phenelzine, pirlindole, rasagiline, safinamide, selegiline, toloxatane and tranylcypromine); tricyclics (TCAs) and tetracyclics (TeCAs) (amitriptyline, amoxapine, clomipramine, desipramine, doxepine, imipramine, maprotiline, nortriptyline, protriptyline and trimipramine); selective serotonin reuptake inhibitors (SSRIs) (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline); serotonin‐noradrenaline reuptake inhibitors (SNRIs) (desvenlafaxine, duloxetine, levomilnacipran, milnacipran and venlafaxine); serotonin partial agonist and reuptake inhibitors (SPARIs) (nefazodone, trazodone and milazodone); noradrenergic and specific serotoninergic antidepressants (NASSAs) (mianserin and mirtazapine); noradrenaline reuptake inhibitors (NRIs) (reboxetine); noradrenaline and dopamine reuptake inhibitors (NDRIs) (buproprion); others (agomelatine, esketamine, S‐adenosyl‐methionine and vortioxetine). The category of antipsychotics included two classes: first‐generation antipsychotics (FGAs) (chlorpromazine, fluphenazine, haloperidol, loxapine, molindone, perphenazine, promazine and trifluoperazine) and second‐generation antipsychotics (SGAs) (amisulpride, aripiprazole, asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone and ziprasidone). Anti‐ADHD medications included psychostimulants (d‐amphetamine, lisdexamphetamine and methylphenidate) and medications with other mechanisms (atomoxetine, clonidine, guanfacine and modafinil). Mood stabilizers included antiepileptics (carbamazepine, gabapentin, lamotrigine, pregabalin, oxcarbazepine, topiramate and valproate) and lithium.

Primary and secondary outcomes

The primary outcome was the safety/coverage ratio (i.e., the number of adverse events significantly worse than placebo/no treatment over the number of adverse events covered by literature) for those psychotropic medications for which ≥20% of the 78 a priori selected events were covered by the literature. The secondary outcomes were the list of adverse events associated with each medication, their effect size ± 95% CI, and the study quality.

The magnitude of associations of each medication with the main adverse events was classified as small (≤0.5), medium (between >0.5 and <0.8) and large (≥0.8) for continuous outcomes (effect sizes >0) and inverse thresholds for effect sizes <0. For categorical outcomes, the magnitude of associations was classified as small (<3), medium (between ≥3 and <5) and large (≥5) for equivalent odds ratios (eORs) >1, and reciprocal thresholds for eORs <1 43 .

Quality of evidence

The quality of MAs and NMAs was measured with a modified version of the A Measurement Tool for the Assessment of Multiple Systematic Reviews (AMSTAR)‐PLUS 44 , which allows to measure both the quality of the methodology of (N)MAs, and the quality of the studies included in (N)MAs (AMSTAR‐Content). AMSTAR quality was considered low when the final score was <4, medium when it was 4‐7, and high when >7 45 . For AMSTAR‐Content, quality was considered low when the final score was <4, medium when it was 4‐6, and high when >6. The overall quality of (N)MAs was rated choosing the lower score of either AMSTAR or AMSTAR‐Content.

The quality of RCTs was assessed with the Risk of Bias tool 2 46 , assigning high risk, low risk, or some concerns. The quality of cohort studies was measured with the Newcastle‐Ottawa Scale (NOS) 47 , and high quality was assigned when the NOS score was ≥7.

Statistical analysis

We extracted random effects effect sizes ± 95% CIs for the difference in the incidence of specific adverse events between individual medications and placebo (RTCs), or between treated vs. untreated youth with mental disorders (cohort studies). We considered ORs, log ORs or risk ratios (RRs) with respective numbers‐needed‐to‐harm (NNH) for categorical outcomes, and standardized mean differences (SMDs) or mean differences (MDs) for continuous outcomes.

We calculated the overall proportional coverage of the a priori selected adverse events for each of the individual psychotropic medications using descriptive statistics, and divided the covered adverse events into those with and without significantly higher frequencies vs. placebo or matched subjects. Furthermore, we identified medications with the best or worst safety/coverage ratio among those that had results for ≥20% of the adverse events.

RESULTS

Search results

The flow chart of the search process for the three systematic searches is presented in Figure 1 . At title and abstract level, we screened 1,309 hits for NMAs and MAs, 5,716 hits for individual RCTs and 8,518 hits for cohort studies. We assessed full texts of 292 articles for NMAs and MAs, 519 for individual RCTs, and 173 for cohort studies. We ultimately extracted data from nine NMAs, 39 MAs, 90 individual RCTs, and eight cohort studies, including 337,686 children and adolescents (120,637 for antidepressants, 66,764 for antipsychotics, 148,664 for anti‐ADHD medications, and 1,621 for mood stabilizers).

Quality of included evidence

Among nine NMAs, the median AMSTAR score was 10 (interquartile range, IQR=9‐11) and the median AMSTAR‐Content score was 5 (IQR=5‐7). The quality was moderate in two (22.2%) NMAs, and high in the remaining seven NMAs (77.8%). The RCTs included in NMAs had moderate quality in six (66.7%) NMAs, and high quality in three (33.3%). The overall quality of the evidence from included NMAs was moderate in six (66.7%) and high in three (33.3%).

Among 39 MAs, the median AMSTAR score was 9 (IQR=7‐10) and the median AMSTAR‐Content was 5 (IQR=4‐6). The quality was moderate in 11 MAs (28.2%), and high in the remaining 28 (71.8%). The RCTs included in MAs had low quality in nine (23.1%) MAs, moderate quality in 23 (59.0%), and high in seven (17.9%). The overall quality of the evidence from included MAs was low in nine (23.1%), moderate in 25 (64.1%) and high in five (12.8%).

Among 90 individual RCTs, 26 (28.6%) had high risk of bias, 43 (47.3%) raised some concerns, and 22 (24.2%) had low risk of bias.

Among eight cohort studies, six (75%) had a high quality according to the Newcastle‐Ottawa scale, and the median quality score was 7 (IQR=7‐8).

Overall safety of classes of psychotropic medications in children and adolescents with mental disorders

Antidepressants

Out of 44 antidepressants, 18 (40.9%) had adverse event data covered in the literature. The available antidepressant literature covered 0‐24.4% (mean: 5.6%, median: 0%) of the reviewed adverse events. Details on the proportion of the 78 adverse events covered in the literature and of the adverse events that were significantly worse with individual antidepressants vs. placebo/controls are reported in Table 1 and Figure 2 .

Among antidepressants with ≥20% of adverse events covered, the safety/coverage ratio was the best for escitalopram (1/17 adverse events covered significantly worse) and fluoxetine (1/16), progressively decreasing through vilazodone (2/16), paroxetine (3/16), sertraline (4/19), to venlafaxine, which had the worst safety/coverage ratio (7/16).

Five antidepressants were associated with significantly worse nausea/vomiting (duloxetine, nefazodone, paroxetine, sertraline, vilazodone), four with discontinuation due to adverse event (duloxetine, imipramine, venlafaxine, vilazodone), three with any extrapyramidal side effect (clomipramine, imipramine, paroxetine), two each with sedation (imipramine, nefazodone), diarrhea (duloxetine, sertraline), headache (nefazodone, venlafaxine), anorexia (amitriptyline, venlafaxine), and weight gain/increased body mass index (escitalopram, sertraline), and one each with weight loss (fluoxetine), and suicidality (venlafaxine).

Antipsychotics

Out of 21 antipsychotics, 15 (71.4%) had adverse event data covered in literature. The antipsychotic literature covered a range of 0‐56.4% (mean: 16.6%, median: 2.6%) of the reviewed adverse events. Details of the proportion of the 78 adverse events covered in the literature and of adverse events that were significantly worse with individual antipsychotics vs. placebo/controls are reported in Table 2 and Figure 2 .

Among antipsychotics with ≥20% of adverse events covered, lurasidone had the best safety/coverage ratio (1/33 covered adverse events significantly worse), progressively decreasing through asenapine (2/22), quetiapine (5/37), ziprasidone (4/25), paliperidone (5/26), risperidone (12/44), aripiprazole (10/35), to olanzapine, which had the worst safety/coverage ratio (13/25).

Ten antipsychotics were associated with significantly worse sedation (aripiprazole, clozapine, haloperidol, loxapine, molindone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone), nine with any extrapyramidal side effect (amisulpride, aripiprazole, haloperidol, loxapine, molindone, olanzapine, paliperidone, risperidone, ziprasidone), seven with weight gain/increased body mass index (aripiprazole, asenapine, clozapine, olanzapine, paliperidone, quetiapine, risperidone), five with hyperprolactinemia (haloperidol, olanzapine, paliperidone, quetiapine, risperidone), and three each with increased cholesterol (aripiprazole, olanzapine, quetiapine) and glucose increase/diabetes (asenapine, olanzapine, risperidone).

Anti‐ADHD medications

All seven anti‐ADHD medications had adverse event data covered in the literature. The available literature covered 7.7‐32.1% (mean: 19.0%, median: 17.9%) of the reviewed adverse events. Details of the proportion of the 78 adverse events covered in the literature and of adverse events that were significantly worse with individual anti‐ADHD medications vs. placebo/controls are reported in Table 3 and Figure 2 .

Among anti‐ADHD medications with ≥20% of adverse events covered, methylphenidate had the best safety/coverage ratio (5/25 adverse events covered significantly worse), while guanfacine and atomoxetine had the worst safety/coverage ratio (4/16 and 5/20, respectively).

Five anti‐ADHD medications were associated with significantly worse anorexia (atomoxetine, d‐amphetamine, lisdexamphetamine, methylphenidate, modafinil), four with insomnia (d‐amphetamine, lisdexamphetamine, methylphenidate, modafinil), three with weight loss (atomoxetine, methylphenidate, modafinil), two each with abdominal pain (methylphenidate, guanfacine), discontinuation due to adverse event (lisdexamphetamine, guanfacine), hypertension (atomoxetine, lisdexamphetamine), and sedation (clonidine, guanfacine), and one with QT prolongation (guanfacine).

Mood stabilizers

Out of eight mood stabilizers, six (75.0%) had adverse event data covered in the literature. The mood stabilizer literature covered 0‐24.4% (mean: 12.7%, median: 14.1%) of the reviewed adverse events. Details on the proportion of the 78 adverse events covered in the literature and of adverse events that were worse with individual mood stabilizers vs. placebo/controls are reported in Table 4 and Figure 2 .

Among mood stabilizers with ≥20% of adverse events covered, the best safety/coverage ratio emerged for lithium (0/16 adverse events covered significantly worse), while valproate showed the worst safety/coverage ratio (4/19).

Two mood stabilizers were associated with significantly worse sedation (oxcarbazepine, valproate), and weight gain/increased body mass index (oxcarbazepine, valproate), and one each with weight loss or anorexia (topiramate), thrombocytopenia and leucocytopenia (valproate), and nausea/vomiting (oxcarbazepine).

Evidence from studies lasting ≥6 months

For antidepressants, no RCT lasted ≥6 months, while one cohort studies lasted 6 to 12 months 100 , and two ≥12 months (range: 12‐130 months) 98, 99. Significant associations emerged between current mixed antidepressants and fractures (small effect size, ≥12 months), but this association became non‐significant when considering past exposure to antidepressants. Also, while antidepressants had a small association (≥12 months) with increased risk of any cancer in the first version of the analyses from a large cohort study, additional analyses from the same database did not confirm such association when removing mixed medications 99 .

For antipsychotics, no RCT lasted ≥6 months, no cohort study lasted 6‐12 months, while two cohort studies lasted ≥12 months (range: 84‐130 months) 99, 143. A large association was found between mixed SGAs and diabetes (≥12 months).

For anti‐ADHD medications, no RCT lasted ≥6 months, no cohort study 6‐12 months, while five cohort studies lasted ≥12 months (range: 12‐130 months) 99, 174, 175, 176, 177. A large protective association was found between methylphenidate and any cancer (≥12 months), which survived after additional analyses from the same database removing mixed medications 99 .

For mood stabilizers, no RCT lasted ≥6 months and no cohort studies were identified, so there was no long‐term data on adverse events for any mood stabilizer.

DISCUSSION

This meta‐review of 80 psychotropic medications summarized data on 78 preselected adverse events in children and adolescents with mental illness, quantifying data for 18 antidepressants (N=120,637), 15 antipsychotics (N=66,764), seven anti‐ADHD medications (N=148,664) and six mood stabilizers (N=1,621).

Overall, the amount of coverage of the preselected adverse events was 0‐24.4% for antidepressants (no data for 26 antidepressants), 0‐56.4% for antipsychotics (no data for six antipsychotics), 7.7‐32.1% for anti‐ADHD medications (data for all anti‐ADHD medications), and 0‐24.4% for mood stabilizers (no data for two mood stabilizers).

Data were reported on ≥20% of the preselected adverse events for only six antidepressants (sertraline, escitalopram, paroxetine, fluoxetine, venlafaxine, vilazodone), eight antipsychotics (risperidone, quetiapine, aripiprazole, lurasidone, paliperidone, ziprasidone, olanzapine, asenapine), three anti‐ADHD medications (methylphenidate, atomoxetine, guanfacine), and two mood stabilizers (valproic acid, lithium).

Thus, the present meta‐review shows that the evidence on adverse events of psychotropic medications in children and adolescents is modest overall, and that psychostimulants are the drugs which have been most studied up to now.

The main adverse events for antidepressants were (in descending order of number of medications associated with the specific event): nausea/vomiting, discontinuation due to adverse event, extrapyramidal side effects, weight gain, sedation, diarrhea, headache and anorexia. Based on the safety/coverage ratio among agents with ≥20% adverse event coverage, the safest profile emerged for escitalopram and fluoxetine, and the worst for venlafaxine. These data confirm, and put in a more comprehensive framework, the findings of a previous NMA on antidepressants in children and adolescents 40 (focusing, however, on efficacy as its primary outcome), which showed that both fluoxetine and escitalopram were not associated with more drop‐outs than placebo, while venlafaxine was, with a moderate effect size (OR=3.19). In the same NMA, fluoxetine was found to be the only antidepressant significantly superior to placebo with respect to its impact on depressive symptoms (SMD=-0.51). Merging the safety results of the present meta‐review with the available evidence on efficacy from that NMA 40 , fluoxetine probably has the best harm‐benefit ratio among all antidepressants for youth, and might be proposed as the first‐line treatment for depressive disorders in children and adolescents.

The main adverse events for antipsychotics were (in descending order of number of medications associated with the specific event): sedation, extrapyramidal side effects, weight gain, hyperprolactinemia, increased cholesterol, and glucose increase. Based on the safety/coverage ratio among agents with ≥20% adverse event coverage, the safest profile emerged for lurasidone, and the worst for olanzapine. These data confirm in part, and put in a more comprehensive framework, the findings of the largest NMA of antipsychotics in children and adolescents with schizophrenia 101 (which, however, focused on efficacy as primary outcome). In the same NMA, the only antipsychotic superior to all others in terms of efficacy was clozapine, and no further difference emerged among other antipsychotics, except for ziprasidone being inferior to molindone, olanzapine and risperidone, and fluphenazine being inferior to all other antipsychotics.

Merging the safety results of the present meta‐review with available evidence on efficacy 101 , lurasidone might be proposed as the first‐line treatment for schizophrenia spectrum disorders in children and adolescents. Less tolerable yet effective medications can be used as second‐line treatments, tailoring the choice to each individual patient's expectations and safety priorities (e.g., sexually active subjects might prefer agents not increasing prolactin). Importantly, clozapine should be considered only for treatment‐resistant cases, given the lack of evidence regarding its safety in children and adolescents, and its poor safety profile in adults 192 , which can be expected to be similar in children and adolescents, if not worse.

The main adverse events for anti‐ADHD medications were (in descending order of number of medications associated with the specific event): anorexia, insomnia, weight loss, abdominal pain, hypertension, and sedation. Based on safety/coverage ratio among agents with ≥20% adverse event coverage, the safest profile emerged for methylphenidate, and the worst for atomoxetine and guanfacine. Our comprehensive meta‐review provides a finer‐grained insight into the adverse events of anti‐ADHD medications, while the largest NMA to date 144 did not reveal differences among these drugs concerning tolerability. Somewhat surprisingly, methylphenidate was also protective against cancer when long follow‐up was considered, with such protective association surviving additional analyses excluding mixed medications 99 . Further research is warranted on this protective effect.

Our meta‐review shows that both atomoxetine and methylphenidate induce weight loss, consistent with previous findings 144 . Sedation was only observed with the alpha‐2 agonists clonidine and guanfacine. Clinically, this effect can sometimes be exploited to counter insomnia, but residual daytime sedation may impair cognitive performance in subjects with ADHD. In terms of efficacy, in the above‐mentioned NMA 144 , only methylphenidate outperformed placebo (SMD=-0.82) according to teachers' ratings. Moreover, methylphenidate was superior to atomoxetine (SMD=0.22). Considering the available safety and efficacy data, methylphenidate might be considered the first‐line treatment for ADHD in children and adolescents.

The main adverse events for mood stabilizers were (with the same number of medications associated with the specific event) sedation and weight gain. Based on the safety/coverage ratio among agents with ≥20% adverse event coverage, the safest event profile emerged for lithium, and the worst for valproate. While the lack of any association between lithium and thyroid/kidney damage 188 as well as weight gain 190 is likely due to the small sample size of the included RCTs (N=124 and N=31, respectively), and the short duration of one RCT (3 months) 188 , significant lithium‐induced weight gain would have emerged during the six‐month RCT 190 . Considering the well‐established efficacy of lithium, which is the first‐line treatment in adolescent bipolar disorder according to international guidelines 193 , currently available data on the harm‐benefit ratio favor the choice of lithium among mood stabilizers in youth. However, long‐term cohort studies in this age group are clearly warranted. All antipsychotics have more adverse events than lithium according to this meta‐review, except for lurasidone, which seems to have a comparably safe profile and could be preferred to lithium for the treatment of bipolar depression 193, 194.

The results of this meta‐review need to be interpreted considering some limitations. First, data for adverse events are lacking for some, and limited for many of the reviewed psychotropic medications. Absence of evidence for certain adverse events cannot be taken as evidence of their absence. Therefore, a more comprehensive reporting of adverse events is strongly recommended in studies concerning the use of psychotropic medications in children and adolescents.

Second, information on adverse events is mostly based on spontaneous reports. While these will underestimate the frequency of such events, the use of rating scales might increase the level of noise. Interviews and/or self‐report scales would assure a more comprehensive capturing of adverse events, and applying appropriate thresholds for severity and frequency could enhance the signal‐to‐noise ratio.

Third, long‐term and rare adverse events are likely underrepresented in the reviewed data, that are based mostly on short‐ and medium‐term RCTs, with only eight cohort studies of sufficient methodological quality providing longer‐term data. Fourth, we did not differentiate the adverse events based on dose effects due to limited data. Fifth, we took a transdiagnostic approach in order to capture all available information. Although certain adverse events could possibly differ across the various mental disorders, no clear evidence exists for this possibility, and other patient‐ and medication‐related factors that are transdiagnostic (e.g., age, treatment‐naiveté, dose, co‐medications) are likely much more important than diagnosis.

Of course, safety of medications needs to be considered along with their efficacy. This was not a focus of this large‐scale meta‐review, but we discussed our findings in the context of efficacy data from the largest and most recent NMA or MA for the respective medication class for its main indication. Finally, this meta‐review does not include data on strategies to prevent or mitigate adverse events of psychotropic medications in youth. While this is clearly an important area, this topic is beyond the scope of the present review and needs to be considered on the basis of targeted reviews and studies focusing on specific adverse events of individual medications 195, 196, 197, 198, 199, 200, 201.

In summary, the results of this meta‐review have several clinical implications, which can guide the use of psychotropic medications in children and adolescents. First, for some medications, there are no or very insufficient high‐quality adverse event data in this age group, which should caution their use. Second, within each of the four major classes, we provide a hierarchy of medications on the basis of the available safety evidence: the preferred agents are likely to be fluoxetine and escitalopram among antidepressants, lurasidone among antipsychotics, methylphenidate among anti‐ADHD medications, and lithium among mood stabilizers. By contrast, potentially least preferred agents based on safety are likely to be venlafaxine among antidepressants, olanzapine among antipsychotics, atomoxetine and guanfacine among anti‐ADHD medications, and valproate among mood stabilizers.

Together with the efficacy data for these medications, the results of this comprehensive and updated meta‐review of top‐tier evidence regarding the safety of antidepressants, antipsychotics, anti‐ADHD medications and mood stabilizers in children and adolescents can inform clinical practice, research and treatment guidelines.

ACKNOWLEDGEMENTS

E.G. Ostinelli is supported by the National Institute for Health Research (NIHR) Oxford Cognitive Health Clinical Research Facility and the NIHR Oxford Health Biomedical Research Centre (grant BRC‐1215‐20005).

REFERENCES

10. Shekelle P, Maglione M, Bagley S. Efficacy and comparative effectiveness of off‐label use of atypical antipsychotics. Agency Healthc Res Qual 2007;6. [ Google Scholar]

21. Ghio L, Gotelli S, Marcenaro M et al. Duration of untreated illness and outcomes in unipolar depression: a systematic review and meta‐analysis. J Affect Disord 2014;152‐154:45‐51. [ PubMed]

43. Chen H, Cohen P, Chen S. How big is a big odds ratio? Interpreting the magnitudes of odds ratios in epidemiological studies. Commun Stat ‐ Simul Comput 2010;39:860‐4. [ Google Scholar]

45. Shea BJ, Grimshaw JM, Wells GA et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007;7(10). [[ PubMed] PMC free article] [ Google Scholar]

49. Dobson ET, Bloch MH, Strawn JR. Efficacy and tolerability of pharmacotherapy for pediatric anxiety disorders: a network meta‐analysis. J Clin Psychiatry 2019;80:17r12064. [ PubMed]

75. Pfizer . Double‐blind, placebo‐controlled study of venlafaxine ER in children and adolescents with generalized anxiety disorder. EMA Paediatric Web Synopsis, 2011.

95. Herscu P, Handen BL, Arnold LE et al. The SOFIA study: negative multi‐center study of low dose fluoxetine on repetitive behaviors in children and adolescents with autistic disorder. J Autism Dev Disord (in press). [[ PubMed] Google Scholar]

108. Seida JC, Schouten JR, Mousavi SS et al. First‐ and second‐generation antipsychotics for children and young adults. Rockville: Agency for Healthcare Research and Quality, 2012. [ Google Scholar]

112. Fung LK, Mahajan R, Nozzolillo A et al. Pharmacologic treatment of severe irritability and problem behaviors in autism: a systematic review and meta‐analysis. Pediatrics 2016;137 (Suppl. 2):S124‐35. [[ PubMed] Google Scholar]

200. Wigal SB. Efficacy and safety limitations of attention‐deficit hyperactivity disorder pharmacotherapy in children and adults. CNS Drugs 2009;23(Suppl. 1):21‐31. [[ PubMed] Google Scholar]

Articles from World Psychiatry are provided here courtesy of The World Psychiatric Association

# data[].attributes.attachment_link.title
Safety of 80 antidepressants, antipsychotics, anti‐attention‐deficit/hyperactivity medications and mood stabilizers in children and adolescents with psychiatric disorders: a large scale systematic meta‐review of 78 adverse effects

# data[].attributes.attachment_link.description
Marco Solmi, 1 , 2 , 3 Michele Fornaro, 4 Edoardo G. Ostinelli, 5 , 6 Caroline Zangani, 6 Giovanni Croatto, 1 Francesco Monaco, 7 Damir Krinitski, 8 Paolo Fusar‐Poli, 3 , 9 , 10 , 11 and Christoph U. Correll 12 , 13 , 14 , 15 Mental disorders frequently begin in childhood or adolescence.

# data[].attributes.attachment_link.readable_text
ABSTRACT

While becoming inextricable to our daily lives, online social media are blamed for increasing mental health problems in younger people. This systematic review synthesized evidence on the influence of social media use on depression, anxiety and psychological distress in adolescents. A search of PsycINFO, Medline, Embase, CINAHL and SSCI databases reaped 13 eligible studies, of which 12 were cross-sectional. Findings were classified into four domains of social media: time spent, activity, investment and addiction. All domains correlated with depression, anxiety and psychological distress. However, there are considerable caveats due to methodological limitations of cross-sectional design, sampling and measures. Mechanisms of the putative effects of social media on mental health should be explored further through qualitative enquiry and longitudinal cohort studies.

Introduction

Children and adolescent mental health

Reasons for the apparently growing psychological morbidity in young people are not known conclusively. McCrae ( Citation2018) suggests that diagnostic activity has been influenced by educational initiatives to raise mental health awareness. Undeterred by stigma, many young people feel free to discuss their psychological difficulties and seek professional help. Another important factor is the ease of sharing personal experiences in the digital information age (Reid-Chassiakos, Radesky, Christakis, & Moreno, Citation2016). Whereas in the past mental health problems were suffered in isolation, today a struggling younger person can readily find others with similar problems, either through social interaction or support groups. Alongside increasing awareness and help-seeking behaviour, doctors may be more inclined to diagnose and treat mental health problems, possibly with the effect of lowering the diagnostic threshold.

Social media

The term 'social media' refers to the various internet-based networks that enable users to interact with others, verbally and visually (Carr & Hayes, Citation2015). According to the Pew Research Centre ( Citation2015), at least 92% of teenagers are active on social media. Lenhart, Smith, Anderson, Duggan, and Perrin ( Citation2015) identified the 13-17 age group as particularly heavy users of social media users, with 87% having access to a computer, and 58% to a tablet device. Almost three-quarters of adolescents aged 15 to17 use a smartphone, and 68% of those aged 13 to 14 (Pew Research Centre, Citation2015).

Impact on mental health

Understanding the impact of social media on adolescents' well-being has become a priority due to a simultaneous increase in mental health problems (Kim, Citation2017). Problematic behaviours related to internet use are often described in psychiatric terminology, such as 'addiction'. However, some activity in younger people could be misconstrued as abnormal. For example, young people who frequently post images of themselves ('selfies') may appear narcissistic, but such behaviour has emerged as a social norm in younger social networks (McCrae, Citation2018). Nonetheless, warnings have been issued by psychologists and other experts on how younger people are engaging with social media and related impairment to personal and social development (Greenfield, Citation2014; Twenge, Citation2006).

Current study

This systematic review examined evidence for the influence of social media use on depression, anxiety and psychological distress in adolescents. The intention was to inform policy and practice and to indicate further research on this topic.

Method

Protocol and registration

For transparency, the protocol for this review was registered with the International Prospective Register of Systematic Reviews (Prospero; CRD42018102770). This report follows the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Moher, Liberati, Tetzlaff, & Altman, Citation2009a).

Eligibility criteria

For inclusion in this review, studies fulfilled the following eligibility criteria:

Participants: aged 13 to 18

Exposure: measurement of social media use

Outcome: depression, anxiety or psychological distress, assessed by validated instruments

Studies published in peer-reviewed journals with full text available in English

Studies were excluded if they crossed either boundary of the age range. Studies measuring exposure to other internet activities such as video-gaming were not included unless social media use was also measured. Outcomes of substance misuse, eating disorder, well-being, life satisfaction, self-esteem, body image problems, conduct disorders, loneliness or stress were excluded, unless the outcomes of interest were also measured by the researchers.

Search strategy

The databases Medline, Embase, PsychINFO, Cumulative Index to Nursing and Allied Health (CINAHL) and Social Sciences Citation Index (SSCI) were systematically searched in May 2018. A set of search terms was created with truncations, Medical Subject Headings (MESH) and Boolean operators, as shown in Table 1.

Data extraction

All papers from the automated database searches were collated using the Mendeley reference management software. After duplicates were deleted, screening was conducted to ensure that studies fulfilled the eligibility criteria. In a three-stage process, papers were screened on title and on abstract (by BK) and the remaining papers were screened on full text (by BK, NM and AG). Key information relevant to the research question was systematically extracted and tabulated to aid comparison and synthesis of the studies. These data comprised authors, publication date, country of origin, study design and data analysis method, relevant outcome measures, sample size, demographic data and results. The extraction process was conducted by BK and AG and any disagreements resolved through discussion with NM.

Assessment of quality

The quality of eligible studies was assessed using the National Institutes of Health Quality Assessment tool for Observational Cohort and Cross-Sectional Studies (NIH, Citation2014), which covers design, selection bias, data collection, confounders, blinding and attrition. An overall rating of 'good', 'fair' or 'poor' was given for each study. All of the studies were independently rated by BK and AG, and any disagreements were resolved through discussion with NM.

Data analysis

As outcome measures varied across the studies, we were unable to perform meta-analysis. Instead, narrative synthesis was conducted. This enabled consideration of confounding, mediating and moderating variables, which are often not given due attention in meta-analysis (Popay et al., Citation1995). Each study was described, followed by comparative analysis and synthesis.

Results

The literature search yielded 6598 articles from the five databases. After 1818 duplicates were removed, screening on title excluded 4206 of the 4780 unique papers. The remaining 574 articles were screened on abstract, with 475 removed, leaving 99 papers. On reading the full text, 86 papers found to be ineligible, the most common reason being the age range. The PRISMA (Moher, Liberati, Tetzlaff, & Altman; The PRISMA Group, Citation2009b) flowchart ( Figure 1) provides further detail on reasons for exclusion. Ultimately a total of 13 papers were eligible for the review.

Description of studies

The reviewed papers are summarized in Table 2. In design, 12 studies were cross-sectional and only one was longitudinal. The total sample across the studies was 21,231. Three studies were conducted in Australia, three in China, and one each in Serbia, USA, Malaysia, Belgium, Thailand and Canada; one study was conducted in six European counties including Greece, Spain, Poland, the Netherlands, Romania and Iceland. Participant ages ranged from 13 to 18. Nine studies covered exposure to social media in general, while four studies (Banjanin, Banjanin, Dimitrijevic, & Pantic, Citation2015; Dumitrache, Mitrofan, & Petrov, Citation2012; Frison & Eggermont, Citation2016; Hanprathet, Manwong, Khumsri, Yingyeun, & Phanasathit, Citation2015) focused specifically on Facebook use. As well as measuring depression, anxiety or psychological distress, some studies investigated confounding variables (e.g. age and gender) and mediating and moderating factors (e.g. insomnia, rumination and self-esteem). Ten of the studies entailed both correlational and regression analyses; one study (Dumitrache et al., Citation2012) performed correlational analyses and a t-test for gender differences; Vernon, Modecki, and Barber ( Citation2017) used latent growth modelling to test longitudinal mediation.

Quality assessment

The aim was clearly stated for almost all of the studies, but generally, the methodological quality was poor to fair ( Table 3). The cross-sectional design of 12 studies is susceptible to three common sources of bias: selection, information and confounding bias (Yu & Tse, Citation2012). Two studies (Barry et al., Citation2017; Wang et al., Citation2018) recruited by convenience sampling, which raises the risk of selection bias. O'Dea and Campbell ( Citation2011) omitted their sampling procedure. Apart from Hanprathet et al. ( Citation2015), the papers did not state or explain their intended sample size, of which two were small (Barry et al., Citation2017; Dumitrache et al., Citation2012). Five studies did not report the participant response rate. Barry et al. ( Citation2017) had a response rate of 33%, which increases the risk of bias and limits generalizability of the results.

Analysis of results

Key findings of the studies were classified into four common domains of exposure to social media: time spent, activity, investment and addiction. Time spent refers to the amount of time that users spent on social media. Activity can be defined as the quality and quantity of users' engagement and interaction with social media sites and other users. Investment refers to the act of putting effort and time into social media whereas addiction refers to the state of being dependent on social media. For each domain we discuss the relationship with depression, anxiety and psychological distress, with reference to confounding, mediating or moderating variables if measured.

Time spent

The studies produced opposing evidence on the relationship between time spent on social media and mental health problems. With an Australian sample, O'Dea and Campbell ( Citation2011) found an inverse correlation for psychological distress; no relationship between frequency of social media use and depressed mood was reported by Neira and Barber ( Citation2014) in another study in Australia, and Banjanin et al. ( Citation2015) in Serbia. By contrast, Sampasa-Kanyinga and Lewis ( Citation2015) in Canada found that daily social media use of over two hours was associated with psychological distress. A study of 10,930 adolescents from six European countries by Tsitsika et al. ( Citation2014) showed a positive relationship between heavy social media use and both depression and anxiety. Yan et al. ( Citation2017) found that time spent on social media was associated with anxiety in Chinese adolescents.

Activity

Frison and Eggermont ( Citation2016) found that both active and passive use of Facebook, in a sample of Belgian high school pupils, correlated with an increased frequency of depressed mood. In a study of 113 adolescent-parent dyads, Barry et al. ( Citation2017) found that data from parents showed correlation between adolescents' social media activities (i.e. number of accounts, frequency of checking for messages) and both anxiety and depression. However, Banjanin et al. ( Citation2015) did not find any relationship between social media activities (i.e. number of 'selfies') and depression in Serbian high school pupils.

Investment

Dumitrache et al. ( Citation2012) found a significant correlation between the number of identity-related information on Facebook profiles and depressive tendencies in adolescents. The studies by Neira and Barber ( Citation2014) and by Vernon et al. ( Citation2017), both using secondary data from the Youth Activity Participation Study of Western Australia, investigated the relationship between investment in social media and depressed mood. The cross-sectional study by Neira and Barber ( Citation2014) showed that investment in social media sites was associated with an increased depressed mood. Vernon et al. ( Citation2017) conducted a longitudinal investigation and found an association between problematic social media investment and depressed mood, with sleep disruption as a mediating variable.

Addiction

Three studies focused on addictive behaviour. Hanprathet et al. ( Citation2015) found a significant association between Facebook addiction and depression among 972 high school pupils in affluent districts in Thailand. A study of Chinese secondary school students by Li et al. ( Citation2017) showed a mediating influence of insomnia on the statistically significant relationship between social media addiction and depression. In another study in China, Wang et al. ( Citation2018) found that social networking sites addiction was positively associated with depression; rumination mediated the relationship between social networking sites addiction and depression while self-esteem moderated this mediating effect. In other words, low self-esteem compounded the impact of addiction on depression through rumination.

Confounding factors

Four studies measured the effect of gender in the relationship between social media-related variables and mental health outcomes. Neira and Barber ( Citation2014) found that social media might have negative aspects for female youth while being a positive leisure activity for male youth. Frison and Eggermont ( Citation2016) found that girls who passively use Facebook and boys who actively use Facebook in a public setting were more likely to be affected by the negative impacts of Facebook. Banjanin et al. ( Citation2015) did not find any significant effect of gender in the relationship between depression and time spent on social media. Similarly, Barry et al. ( Citation2017) did not find any change in the analysis when controlling for gender in the relationship between social media use and depression as well as between social media use and anxiety.

Two studies measured the effect of age. Tsitsika et al. ( Citation2014) found a significant effect of age in the relationship between heavy social media use and negative internalizing symptoms (anxious/depressed, withdrawn/depressed), with younger heavier social media users being more likely to experience internalizing symptoms compared to older heavier users. Banjanin et al. ( Citation2015) did not find any significant age effect in the relationship between depression and time spent on social media.

Discussion

This systematic review examined the evidence for a putative relationship between social media use and mental health problems in adolescents. In the 13 studies, depression was the most commonly measured outcome. The prominent risk factors for depression, anxiety and psychological distress emerging from this review comprised time spent on social media, activities such as repeated checking for messages, personal investment, and addictive or problematic use.

Although results of the studies were not entirely consistent, this review found a general correlation between social media use and mental health problems. However, most authors noted that the observed relationship is too complex for straightforward statements. Few studies were designed to explore this complexity although some assessed the effect of mediating and moderating factors. Insomnia and other sleep-related factors were most frequently reported as mediators of the relationship between social media use and depressed mood (Li et al., Citation2017; Vernon et al., Citation2017). Perceived social support (Frison & Eggermont, Citation2016) and rumination (Wang et al., Citation2018) were other mediating factors reported in the studies. Researchers suggested further investigation of these factors, and other factors such as personal traits (O'Dea & Campbell, Citation2011), socio-cultural factors that influence the roles of and expectations from adolescents in family and society, environmental factors which may affect development of adolescents and social skills (Tsitsika et al., Citation2014), motivations for social media use (Barry et al., Citation2017; O'Dea & Campbell, Citation2011), social comparison and peer feedback (Neira & Barber, Citation2014), self-esteem (Banjanin et al., Citation2015), contextual factors, lack of physical activity, and cyberbullying (Sampasa-Kanyinga & Lewis, Citation2015).

Other important findings of this review suggest that particular attitudes or behaviours (e.g. social comparison, active or passive use of social media, motives for social media use) may have a greater influence on the symptoms of depression, anxiety and psychological distress than the frequency of social media use or the number of online friends. Although there is evidence of a relationship between time spent on social media and depression as well as social media-related activities and depression, contrary findings have also emerged. For example, Banjanin et al. ( Citation2015) found no relationship between the amount of time spent on social media and depression, or between social media-related activities such as the number of online friends and the number of 'selfies' and depression. Similarly, Neira and Barber ( Citation2014) found that while higher investment in social media (e.g. active social media use) predicted adolescents' depressive symptoms, no relationship was found between the frequency of social media use and depressed mood. Such mixed findings might be explained by confounders, mediators and moderators as discussed above.

This systematic review also sheds light on the influence of age and sex. Although some studies found that these variables had no effect on the relationship between social media use and mental health problems, other studies showed that girls and younger adolescents are more prone to depression and anxiety. Further investigation is needed to assess the effects of age and gender.

Limitations

Although the results of this systematic review contributed to the existing literature in a way of providing considerable evidence for the mental health impact of social media use by focussing on not only the symptoms of depression but also other related outcomes including anxiety and psychological distress among adolescents who are at higher risk of developing anxiety and depression. Several limitations in the evidence emerged from included studies and review process have been identified. First, 12 out of 13 studies did not answer the review question since they were cross-sectional and unable to determine a causal relationship between the variables of interest. Looking evidence emerged from cross-sectional studies, it is not possible to decide whether social media use causes depression, anxiety and psychological distress, or whether those with depression, anxiety and psychological distress are more likely to spend more time on social media; have addictive and problematic social media use behaviour; have negative interaction with social media; and invest on social media. Only one longitudinal study (Vernon et al., Citation2017) investigated the causal relationship between problematic social media use and change in depressed mood, but this study has also limited to show evidence whether social media use causes depressed mood in adolescents. The study did not use a control and a comparison group to differentiate those who exposed to social media sites and those who not. Therefore, it is difficult to determine whether a change in depressed mood was more in those who exposed to social media more compared to those who less or not.

Second, small sample size and the use of convenience sampling in some studies limited the representativeness of and generalizability to a larger adolescent population. Third, all studies included in this review used self-report measures which may not provide reliable outcomes because of some sources of risk of bias. Participants may show positive self-presentation by over- or under-reporting their social media-related behaviours and some mental health-related items, which may directly or indirectly lead to social desirability bias, information bias and reporting bias. Another identified limitation was that some studies made an investigation towards only Facebook use over other social media sites, which also causes a significant bias and limits the generalizability of findings to other social media sites. Finally, despite the fact that the proposed relationship between social media-related variables, depression, anxiety and psychological distress is complex, few studies investigated mediating factors that may contribute or exacerbate this relationship. Further investigations are needed to explain the underlying factors that help determine why social media has negative impact on some adolescents' mental health whereas it has no or positive affect on others' mental health.

Conclusion

The impact of social media use on incidence of depression, anxiety and psychological distress among adolescents, as examined by this review, is likely to be multifactorial. It is important to distinguish between the terms used for the relationship. It is fair to say that there is an 'association' between social media use and mental health problems, on the basis that this means a socially constructed reality. But this is not necessarily scientifically valid. Objective researchers investigate correlations rather than accepting socially assumed truths. Correlation is statistical, not phenomenal. Thirdly, there is causation, which requires directional evidence. The latter has not been adequately investigated in this topic, and we must, therefore, state that the relationship is correlational but not conclusively causative.

Key findings of included studies were classified into four categories of exposure to social media: time spent; activity; investment; and addiction. All these categories were found as correlated with depression, anxiety and psychological distress, with an acknowledgement for the complexity of these relationships. Although there are studies which investigated mediating and moderating factors that may contribute or exacerbate the proposed relationship, there are still several underexplored mediators and moderators, which may explain the direction of this relationship. We also identified gaps in literature in terms of methods, study design and sampling. Causality was unclear due to the cross-sectional study design used in almost all studies and the lack of comparison group in the cohort study. Also, the number of quantitative studies in literature is substantially higher than qualitative studies. Through this systematic review, we hope we contribute to the existing literature in the way of addressing the gaps and highlighting the importance of the phenomenon of the mental health impact of social media use on adolescents.

Acknowledgments

The authors would like to thank Dr Sorina Daniela Dumitrache who supplied us the full-text of their study which was not available online. The authors also declare that there is no conflict of interest regarding the publication of this article.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Notes on contributors

Betul Keles

Niall McCrae

Annmarie Grealish

References

Achenbach, T. M., & Resorta, L. A. (2001). Manual for ASEBA school-age forms and profiles (pp. 99-107). Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families. doi:10.1080/713932693

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Hanprathet, N., Manwong, M., Khumsri, J., Yingyeun, R., & Phanasathit, M. (2015). Facebook addiction and its relationship with mental health among Thai high school students. Journal of the Medical Association of Thailand, 98, S81-S90.

Morgan, C., Webb, R. T., Carr, M. J., Kontopantelis, E., Green, J., Chew-Graham, C. A., ... Ashcroft, D. M. (2017). Incidence, clinical management, and mortality risk following self harm among children and adolescents: Cohort study in primary care. BMJ (Online), 359. doi:10.1136/bmj.j4351

Primack, B. A., & Escobar-Viera, C. G. (2017). Social media as it interfaces with psychosocial development and mental illness in transitional age youth. Child and Adolescent Psychiatric Clinics of North America, 26(2), 217-233. doi:10.1016/j.chc.2016.12.007

Rosen, L. D. (2011). Social networking's good and bad impacts on kids. Washington, DC: American Psychological Association. Retrieved from http://www.apa.org/news/press/releases/2011/08/social-kids.aspx(open in a new window)

Vandervoort, D. (1999). Quality of social support in mental and physical health. Current Psychology, 18(2), 205. Retrieved from: https://link.springer.com/content/pdf/10.1007%2Fs12144-999-1029-8.pdf(open in a new window)

# data[].attributes.attachment_link.title
A systematic review: the influence of social media on depression, anxiety and psychological distress in adolescents

# data[].attributes.attachment_link.description
While becoming inextricable to our daily lives, online social media are blamed for increasing mental health problems in younger people. This systematic review synthesized evidence on the influence ...

# data[].attributes.attachment_link.readable_text
Keywords: youth, adolescence, young adulthood, mental health

Introduction

Globally, Muslim adolescent and emerging adults are constantly facing scrutiny from their environments. However, very little is known regarding how they perceive themselves and experience the world around them, what their mental health needs are, and how to promote healthy development. The last decade (2005-2015) was characterized by rapid growth and expansion of research on global populations of Muslim adolescents and emerging adults. This paper aims to identify major advances in research, highlight trends, and suggest directions for future research. We begin with the major research trends in global youth research before contextualizing the research on Muslim youth. The paper then explores the major research contributions in identity and development, mental illness, and wellbeing.

General Trends in Adolescent and Emerging Adulthood Research

The last decade has resulted in numerous advances in the field of adolescent and emerging adult psychological research, ranging from research methodology and cross-cultural research, to decoupling of factors impacting youth development, and an increased influence of positive psychology. Advances in research methodology, designs, and innovations in technology have enabled creative approaches to explore the complicated process of youth development, resulting in greater interdisciplinary research (e.g., Syed, Azmitia, & Cooper, 2011), an increase in mixed-methods approach (e.g., Azmitia, Syed, & Radmacher, 2013; Rao et al., 2013), and greater collaboration with "end user", through approaches such as Community-Based Participatory Research (CBPR) (e.g., Jacquez, Vaughn, & Wagner, 2013), which have resulted in valuable insight. As a result, mental health theories have been extended to global populations to test their applicability. In some cases, current theories have been further confirmed (e.g., Lai et al., 2014; Gupta et al., 2013), whereas in other cases they have revealed cross-cultural differences, resulting in the need to reformulate current theories (e.g., Neese, Pittman, & Hunemorder, 2013; Seiffge-Krenke et al., 2013). This has contributed to the maturation of developmental theories -- such that the individual-context fit, and the bidirectional nature development are now being investigated (e.g., Lerner, 1995; Abo-Zena & Ahmed, 2014; Hafen, Spilker, Chango, Marston, & Allen, 2014). Researchers are studying variations in social contexts (i.e., family, peers, socioeconomic environments, and cultural conditions), conflated factors within these contexts, the influence of changing social processes, and increasingly global cultural context resulting in a more nuanced understanding of adolescent development globally (e.g., Lund & Dearing, 2013; Dhariwal & Connolly, 2013; Rao et al., 2013).

The increasingly multifaceted perspective on development has resulted in researchers utilizing a more nuanced approach when studying risk, protective, and moderating factors in adolescence and emerging adulthood. While the awareness of the dynamic interaction of individual risk and social contexts (e.g., Kretschmer, Vitaro, & Barker, 2014; Boeninger, Masyn, & Conger, 2013), intergenerational transmission of risk (Hipwell et al., 2014), and increased evidence for the clustering of risk behaviors (e.g., Ohene, Ireland, & Blum, 2005) have been undertaken, the identification of modern risks (such as digital settings) are beginning to be explored. For example, although social media and digital contexts have highlighted the negative impact of risk messaging by digital peers, increased cyberbullying, and sexual solicitation, digital contexts have also created buffers that increase communication, build relationships, enhance friendship quality and ability to increase self-esteem, and promote sexual self-exploration (MacLean, Geier, Henry, & Wilson, 2014; Valkenburg & Peter, 2011).

The interest in positive mental health and protective factors highlight the profound impact of positive psychology on adolescent and emerging adulthood research. This has resulted in a paradigm shift from a deficit model to a strength-based model and growth of positive youth development. Researchers are exploring developmental assets among young people (e.g., Tolan, 2014; Hope & Jagers, 2014), as well as ethnic and racial adaptations of positive youth development approaches (e.g., Travis & Leech, 2014). In addition, research on varying forms of intervention, such as activity-based mentoring (Deane & Harré, 2014) and developmental-stage-specific intervention (Vuolo, Mortimer, & Staff, 2014) are charting pathways to more effectively implement research findings with young people. However, there is a great need for more outcome research to determine the effectiveness of prevention/intervention programs for youth from diverse backgrounds (Guerra & Williamson, 2014).

While advances in psychological research have taken place in the last decade, it has had little influence on social policy or programming (Jenson & Fraser, 2015). The impacts of social policy in the lives of young people have been limited, with the exception of a few studies (e.g., Snell et al., 2013; Andersen et al., 2014; Lambert et al., 2014). A developmentally contextualized approach is needed to addresses the multitudes of factors leading to youth risk behavior as well as to promote resiliency in youth through the building of developmental assets, which must be integrated across agencies and systems of care (Jenson & Fraser, 2015). Additionally, in order for research to truly benefit the lives of young people, policymakers must integrate emerging research into current programming, evaluate impact, and adapt to the needs of diverse audience.

Trends in Muslim Adolescent and Emerging Adulthood Research

As the field of research on adolescent and emerging adulthood expanded during the last decade, interest in Muslim populations grew concurrently. Global research on Muslim adolescents and emerging adults has grown exponentially, and in many areas reflect the trends mentioned in the preceding section. This review will limit itself to topics directly related to Muslim youth mental health. In so doing, the review will cover global Muslim youth research specific to identity and development, mental illness, interventions, and wellbeing.

Identity & Development

How a young person identifies themselves (e.g., Muslim or not), the many social identities they carry (i.e., gender, ethnic/racial, socioeconomic status, etc.), and how their environment responds to them impacts their development, mental health and well-being. The vast majority of research on identity and development among Muslim adolescents and emerging adults has focused on regions where Muslim youth are religious minorities. This may be due to the saliency of their identities within a majority culture. Researchers highlight the need to understand the varying factors impacting identity development, the existence of multiple social identities, as well as the impact on values and behaviors.

Research on identity development of Muslim adolescents and emerging adults highlights the need to consider development from a relational, contextual, global, and fluid perspective, as well as one that considers past spaces and places not currently occupied by young people (Ahmed, Patel, & Hashem, 2015; Fine et al., 2012; Kumar, Seay, & Karabenick, 2015). For example, numerous studies highlighted the impact of sociopolitical contexts as an important factor in strengthening both religious and ethnic identity development across global populations and forms of conflict (e.g., Pinson, 2008; Basit, 2009; Abu-Rayya & Abu-Rayya, 2009; Khandelwal, Dhillon, Akalamkam, & Papneja, 2014). In their study on the religious and ethnic in-group identification of Israeli Arab Muslim youth, Abu-Rayya & Abu-Rayya (2009) noted that more positive outcomes for in-groups identification were observed than identification with the majority group (i.e. Israeli). These finding seem contrary to conclusions Berry's (1997) theory of acculturation, and encourages mental health providers to acknowledge socio-political and cultural context in models of development. Similarly, the influence of educational context on identity development of Muslim youth populations has highlighted potential institutional roles in racializing Muslim students, experiences of social exclusion, and the impact these experiences have on religious identity (e.g., Keaton, 2005; Mac an Ghaill & Haywood, 2014; Moulin, 2015; Basford, 2008). Basford (2008) described how African-origin Muslims in the U.S. reported perceived academic, religious, and cultural hostility, often feeling hidden and unwelcome in their schools. In this study, parents eventually responded and formed culture-specific charter schools to better accommodate their children's needs. Additional forms of environmental influence examined the role of media influence (Khan, 2009), socioeconomic factors (Ghaffar-Kucher, 2008), cultural community influence (Kumar, Seay, & Karabenick, 2015), and family context (Britto & Amer, 2007; Dimitrova, Chasiotis, Bender, & van de Vijver, 2014). While preliminary efforts to understand contextual influences impacting development has begun, more contexts need to be investigated in order to provide a thorough understanding of Muslim youth development. In particular, investigations of peer, extended family, religious institutional, and digital contexts are recommended, as these are believed to have immense influence in the lives of young people.

Developmental experiences may impact the prominence of a young person's religious identity. While some researchers report religious identity to be the most salient aspect of a young Muslim's identity and helps them navigate and negotiate their environment (e.g., Ghaffar-Kucher, 2008; Kashyap & Lewis, 2013; Walseth, 2006a), for other young people, the importance of religious identity was mitigated by other social identities and factors in their context (e.g., Maliepaard, Lubbers, & Gijsberts, 2010; Clark, 2007). As a result, the last decade noted an increase in researchers exploring the multiple dimensions of young Muslim's social identities that are often conflated with religious identity. Some of the social identities include ethnic (e.g., Abu-Rayya & Abu-Rayya, 2009), gender (e,g., Kassissieh, 2005), sports (e.g., Walseth, 2006b), nationalism (e.g., Saroglou & Mathijsen, 2007; Hussain & Bagguley, 2005; Sirin & Fine, 2007), refugee status (Valentine & Sporton, 2009), disability (Hussain, 2005), familial (Dimitrova, Chasiotis, Bender, & van de Vijver, 2014), and language (Jaspal & Coyle, 2010). The intersectionality of these social identities has highlighted the complexity of young person's identities, internalized values, and subsequent behaviors. In a study on religious identities of young Muslim British women hijab (head covering), often considered a publicly displayed religious marker, was actively embraced and served to further facilitate religious identity development and practice (Hopkins & Greenwood, 2013). However, for young Muslims that report a decrease in religious and ethnic identity, evidence for an increase in acceptance of national values and practices was observed (Verkuyten & Martinovic, 2012). Interestingly, among young Muslims in Belgium, perceived discrimination was observed to translate into increased youth participation in both ethno-religious and mainstream organizations (Fleischmann, Phalet, & Swyngedouw, 2013). The most prominent social identity may also be situational or issue-specific. For example, in separate studies of young British and French Arab women, cultural identities appeared to have a greater impact on maintaining sexual virginity than religious identity, as it served as a symbolic cultural identity marker (Amer, Howarth, & Sen, 2015; Skandrani, Taïeb, & Moro, 2012). The intersection of religious, gender, and communal identity on youth behavior was also noted in data on Muslim youth choices, whether or not they abstain from alcohol and drug use, and the expected response from their community (Bradby & Williams, 2006). The conflation of multiple social identities and its impact on a young person's subsequent behavior is important to further explore and understand. Various researchers have attempted to conceptualize the interconnectedness of the multiple social identities (e.g., Mishra, 2005; Dimitrova, Chasiotis, Bender, & van de Vijver, 2014; Zaal, Salah, & Fine, 2007), but more research is needed to support their findings as well as better explain when and how a particular identity is most prominent and how it impacts behavioral outcomes.

What is most striking about the research on Muslim youth identity and development is that the vast majority of research has focused on Muslim minority populations. Research is also needed to understand Muslim adolescent and emerging adult development in Muslim-majority nations. While youth in non-Muslim-majority countries may grapple with their multiple social identities, it is unclear if the saliency of religious identity would be as prominent in Muslim-majority nations.

Mental illness

Accurate information on mental illness within global populations of Muslim adolescents and emerging adults is currently difficult to obtain due to a multitude of factors, including mental health illiteracy, stigma, accessibility of facilities, and a lack of funding and documentation. However, the last decade has helped build the foundation for what is needed to reduce the gap in our knowledge. Preliminary research on help-seeking behaviors, mental illness, risk factors, and intervention with young Muslims have been undertaken in both Muslim-majority and -minority countries and is presented below.

Help seeking

Research continues to show low levels of mental health literacy among Muslim adolescents and emerging adults, which impacts their ability to recognize mental health problems, and often results in misattribution of symptoms (Essau, Olaya, Pasha, O'Callaghan, & Bray, 2012; Raja, 2004). In communities experiencing historical, constant intimidation and violence, such as in the case of Palestinian Muslims, young people reported they did not seek help because they minimized the trauma experienced, did not believe obtaining help would change their situation, and desire to maintain their independence w greater (Guterman, Haj-Yahia, Vorhies, Ismayilova, & Leshem, 2010). One compounding factor is the remote dispersal of mental health services across large regions of many Muslim majority countries, increasing access difficulties. For adolescents in countries with accessible care, such as in the U.K., underutilization was attributed to not wanting to share their problems with "strangers" (Randhawa & Stein, 2007). These factors, combined with mental health stigma, often result in young people's unwillingness to seek professional treatment (Raja, 2004). Instead, young Muslims relied on primarily friends, family, and spiritual healers to help cope with mental health issues (e.g., Al-Krenawi & Graham, 2011; Haroun et al., 2011).

However, research in the U.S. has highlighted the potential role of religion, parental support, and physicians in young patient's acceptance of mental health diagnosis and willingness to obtain treatment (Haroun et al., 2011; Herzig, Roysircar, Kosyluk, & Corrigan, 2013, Herzig, 2011). These findings suggest that while underutilization of services continues, public health efforts to increase mental health literacy, more government funding to expand accessibility in Muslim-majority countries, and creative approaches to reduce mental health stigma are all needed. Potential methods to influence young Muslims' mental health beliefs and attitudes may include the use of social media (Din, Ahmed, & Killawi, 2016) as well as collaboration with individuals (e.g., religious leaders, community organizers) and institutions valued by young people.

Research on the prevalence of DSM-5/ICD-10 categorization of mental illnesses on adolescent and emerging adult Muslim populations is limited. Despite preliminary studies on the prevalence of specific disorder, it is believed that mental illness is grossly underreported and therefore is not presented in this review. Instead issues and trends on specific mental illnesses that have received research attention will be highlighted in order to provide direction in the coming years. Specifically, anxiety-related disorders, depression symptomatology, and eating disorders are addressed below.

While anxiety is globally documented, surprisingly few studies have explored anxiety disorders among Muslim adolescents and young adults (e.g., Essau, Olaya, Pasha, O'Callaghan, & Bray, 2012; Ahmadi et al., 2014). In a study on anxiety levels in populations of Muslim-majority countries, significant gender differences were noted in some countries (i.e., Egypt, Iraq, Morocco, Kuwait, Oman, Qatar, Lebanon, Pakistan, Algeria Yemen, and Syria), while in other countries (i.e., Saudi Arabia, Jordan, Sudan, the United Arab Emirates, and Palestine), no differences were observed (Alansari, 2006). These findings highlight the potential role of sociocultural contextual differences, warranting further investigation. In a study on Saudi patient perceptions of OCD symptom presentation, when symptomology was expressed within ritualistic aspects of worship (prayers), they were considered more upsetting than symptomology present in other areas of daily functioning (Al-Solaim & Loewenthal, 2011). This study emphasizes the need to consider the contextual meaning and impact of symptom presentation in the lives of young people. In addition, risk factors associated with anxiety disorders among adolescents need to be studied in order for preventative efforts to be undertaken (Ahmadi et al., 2014; Shams, Foroughi, Esmaili, Amini, & Ebrahimkhani, 2011). Studies on anxiety have examined comorbid conditions, such as depression and body dysmorphic disorder (Barahmand & Shahbazi, 2015; Shams, Foroughi, Esmaili, Amini, & Ebrahimkhani, 2011), which will be important for assessment and intervention purposes. In addition, examples of how institutional policy can contribute to anxiety symptoms were investigated in a Turkish study, which found the inability to wear hijab due to the headscarf ban in Turkish universities, resulted in partial-hijab-wearing young women experiencing symptoms of guilt, fear, and anxiety (Seggie & Austin, 2012). Potential evidence for digital contribution to symptoms of anxiety was found in an Iranian study (Ahmadi et al., 2014). At present, there is insufficient research on anxiety symptoms, etiology, and risk and protective factors, while intervention and prevention are needed.

Ethnic cleansing, political and civil wars, and natural disasters during the last decade have resulted in large concentrations of Muslim youth experiencing considerable loss and trauma. When studying tsunami child survivors, researchers noted that Muslim children often incorporated religious attributions in order to cope with traumatic events, resulting in the need to re-conceptualize current explanatory models of trauma (Dawson et al., 2014). The type of trauma, whether natural disaster or war-related, has been shown to impact the course and presentation of PTSD. In a study on child survivors of the Indonesian tsunami, the level of PTSD symptoms did not differ between those who had single exposure to trauma compared to those who had multiple experiences of trauma (Agustini, Asniar, & Matsuo, 2011). In this study, factors that increased the severity level of PTSD symptoms included being female, somatic response to trauma, loss of parents, and low support levels (Agustini, Asniar, & Matsuo, 2011). However, for war-related trauma, researchers found that direct exposure, brutality of trauma, and number of traumas experienced were all related to the severity of PTSD, depression, and social dysfunction (e.g., Ellis, MacDonald, Lincoln, & Cabral, 2008; Fazel, Reed, Panter-Brick, & Stein, 2012; Hasanović, Sinanović, & Pavlović, 2011). For example, Hasanović, Sinanović, and Pavlović (2011) found that young Srebrenica survivors had the greatest severity and prevalence of PTSD among Bosnian refugee adolescents studied, and attributed the intensity of horror experienced as one possible reason for the higher levels of PTSD compared to survivors from other regions. The extent of resettlement stress for refugees from war-torn areas served as a greater predictor of psychological problems than the initial traumatic experiences itself (Fazel, Reed, Panter-Brick, & Stein, 2012). These stressors include: acculturative stress, perceived discrimination, depressed living conditions, school-related anxiety, family discord, and daily stressors (Ellis, MacDonald, Lincoln, & Cabral, 2008; Fazel, Reed, Panter-Brick, & Stein, 2012; Fernando, Miller, & Berger, 2010; Jones & Kafetsios, 2005). Among U.S. Iraqi refugee adolescents that have experienced multiple types of trauma, researchers found that those experiencing discrimination and backlash had the poorest mental health outcomes, after controlling for life trauma (Kira, Lewandowski, Chiodo, & Ibrahim, 2014). While some risk factors for PTSD have been identified, more research is needed. Limited research on protective factors of displaced individuals or those living in oppressed communities (e.g., Palestinians) found that young people with strong ethnic identification, abilities to obtain social support, and those who relied upon religious coping had better mental health outcomes, with some gender differences noted (Ellis, MacDonald, Lincoln, & Cabral, 2008; Kira, Alawneh, Aboumediene, Lewandowski, & Laddis, 2014). As researchers continue to explore the impact of trauma on young refugees, it is important to understand the long-term impact of trauma, to engage in greater research on protective factors buffering the impact of trauma, and to highlight environmental factors and government policies that may better support the adaptations of young refugees. In addition, research addressing other forms of trauma and stress is desperately needed. In Western countries where Muslim adolescents and young adults are increasingly facing discrimination and hate crimes, how do young people internalize these experiences? Are these experiences more pronounced for some ethnic/racial groups than others? What are the long-term mental health impact of sustained, diffuse, societal intimidation and discrimination? What are protective factors that can serve to buffer young people in these environments? These and other questions need to be addressed in future trauma studies.

The study of depression within Muslim adolescent and emerging populations varies across prevalence reports (e.g., Sajjadi et al., 2013; Alansari, 2006; Rahman et al., 2009). Similar to anxiety disorders, gender differences have been noted. In some Muslim-majority countries (i.e., Iraq, Syria, Egypt, Pakistan, Algeria, Oman, Qatar, Morocco, and Kuwait), female participants reported higher levels of depressive symptoms, In Saudi Arabia, however, young male participants reported greater levels of depression (Alansari, 2006). In other Arab countries (i.e., Lebanon, Tunisia, Palestine, United Arab Emirates, Yemen, Jordan, and Sudan), there was no significant gender difference in reported depression levels, highlighting the potential role of social-cultural context in contributing to presentation (Alansari, 2006). Research reflects increased risk factors associated with depression include poor academic performance (Sajjadi et al., 2013); ineffective parenting style, poor relationships between parents and parent-child, lower parent education (Sajjadi et al., 2013), family acculturation context fit (Asvat & Malcarne, 2008); socioeconomic status (Sajjadi et al., 2013); majority/minority status (Iqbal, Ahmad, & Ayub, 2013); extent of urbanization (Rahman et al., 2009); immigration status (van Geel & Vedder, 2010); and perceived discrimination (Tummala-Narra & Claudius, 2013).

Suicidal behaviors -- including ideation, attempts, and completions -- are often associated with severe depression. While studies investigating prevalence have been undertaken, researchers warn that gross underreporting is likely, given prohibition of and stigma associated with suicide in Islam (Gal et al., 2012). The prevalence of suicide attempts have been investigated in countries such as Pakistan, Iran, and Malaysia (Khokher & Khan, 2005; Groohi, Rossignol, Barrero, & Alaghehbandan, 2006; Chen, Lee, Wong, & Kaur, 2005). While some researchers noted gender differences (Groohi, Rossignol, Barrero, & Alaghehbandan, 2006; Chen, Lee, Wong, & Kaur, 2005; Syed & Khan, 2008), others did not (Khokher & Khan, 2005). The level of risk facing Muslim adolescent suicidal attempts also appears to differ. For example, in a study conducted in Malaysia, Muslim Malay adolescents reported the lowest risk for suicidal attempts compared to Malaysians of other religious backgrounds (Chen, Lee, Wong, & Kaur, 2005); in other countries, such as Netherlands, Turkish youth have higher risk for suicide attempts than non-Turkish youth (Burger, van Hemert, Schudel, & Middelkoop, 2009). It is unclear if the differences noted are related to differences in majority/minority status, ethnic affiliation, socioeconomic conditions, level of stress or discrimination, or some other unknown factors. Studies have suggested that suicidal risk factors may include being female, single, in the presence of family conflict, lower socioeconomic status, mental health issues, marriage problems, and greater reports of stress (Khokher & Khan, 2005; Groohi, Rossignol, Barrero, & Alaghehbandan, 2006; Rezaeian, 2010; Ineichen, 2008). While risks have been identified, cross-cultural comparisons between Muslim adolescents/young adults across countries as well between Muslim and non-Muslims peers are needed to better understand suicide in Muslim populations. How Muslim adolescents and young adults choose to attempt suicide may also vary cross-culturally. Preliminary studies noted young people attempting suicide in Pakistan predominantly overdosed using benzodiazepine (Syed & Khan, 2008); in Iran, young people attemping suicide often engaged in self-immolation (Groohi, Rossignol, Barrero, & Alaghehbandan, 2006); whereas, a U. K. study noted that self-immolation within its states was on the decline during the last decade (Ineichen, 2008). In addition to further studies on suicide, risk and protective factors, and the effectiveness of current prevention programs, qualitative studies on how individuals and their families cope with suicidal attempts and completions, given religious prohibition, are recommended.

Finally, eating disorders are increasing within Muslim populations. Researchers are reporting high prevalence of problematic eating attitudes among Muslim populations (e.g., Latzer, Azaiza, & Tzischinsky, 2009; Thomas, Khan, & Abdulrahman, 2010; Mousa, Al-Domi, Mashal, & Jibril, 2010; Abraham & Birmingham, 2008). Interestingly, significant gender differences were not noted in Arab countries (Schulte & Thomas, 2013; Latzer, Azaiza, & Tzischinsky, 2009) but noted in Pakistan (Memon et al., 2012). Given the limited number of studies, it is difficult to draw any conclusive statements and therefore warrants replication. Triggers and risks associated with eating disorders are currently being explored. One study in Turkey reported an increased report of eating disorders coinciding with the Ramadan, the month of fasting for Muslims (Akgül, Derman, & Kanbur, 2014). This has raised questions whether drastic changes in meal habits may contribute to triggering eating disorder among adolescents that are predisposed or current unreported cases (Akgül, Derman, & Kanbur, 2014); more research is needed before a conclusion can be made. Cultural values specific to socioeconomic class may also contribute to unhealthy eating attitudes. In a within-group study comparing eating attitudes of Pakistani females attending English (middle socioeconomic status) and Urdu (lower socioeconomic status) medium schools, researchers found that English-medium students expressed more negative eating attitudes (Mahmud & Crittenden, 2007). While research on eating disorders is ongoing, much more is needed to parse out the varying factors that may contribute to the increasing prevalence. Some questions to consider include family and social risk factors, as well as the digital impact of body images given increasing social media use by Muslim adolescents and emerging adults.

A review of the global research on mental illness highlights the foundations that have been built during the last decade. However, analysis of current research draws attention to the many gaps that exist within our knowledge. Accurate prevalence rates among Muslim adolescents and emerging adult populations of most mental illnesses are unknown. Similarly, differences in prevalence rates by ethnicities need to be further explored. For example, why are some researchers noting higher rates of Pervasive Developmental Disorders among Somali children in Sweden (Barnevik-Olsson, Gillberg, & Fernell, 2008; Barnevik-Olsson, Gillberg, & Fernell, 2010)? Are there other disorders that have a higher prevalence by ethnicity, minority status, or geographical location? In addition, cross-cultural comparisons between young Muslims in Muslim-majority versus -minority countries are needed in order to better understand socio-cultural influences on mental illness.

Interventions

Among Muslim adolescents and emerging adults, minimal research has been conducted on mental health interventions, clinical, psycho-education or otherwise. Publications have primarily covered cultural consideration for specific ethnic groups (e.g., Yilmaz, Dalkilic, Al-Mateen, Sood, & Pumariega, 2013; Whittaker, Hardy, Lewis, & Buchan, 2005), presented individual case studies (e.g., Bragazzi, & del Puente, 2012; Kennedy, Godlas, Gale, & Parker, 2010), or highlighted considerations based on clinical experience (e.g., Ahmed, 2012). Recommendations for working with Muslim youth in individual psychotherapy have included the suggestion for clinicians to engage in critical consciousness, use of an ecological approach in assessment and treatment, and integrating religious consultants when needed (Ahmed, 2012; Kennedy, Godlas, Gale, & Parker, 2010; Bragazzi & del Puente, 2012; Suárez, Newman, & Reed, 2008). While little is known globally about Muslim youth psychotherapeutic preferences, studies with U.S. emerging adults reveal a preference for individual therapy compared to psychotherapeutic options (Raja, 2004). In a separate study on U.S. emerging adults, young Muslims favored therapists with cultural competency training and knowledge on emerging adulthood needs (Herzig, 2011). However, it is unknown if these findings are generalizable to emerging adults in Muslim-majority countries, which have collectivist social values. There have been no known large-scale clinical trials to identify the most effective individual psychotherapy approach for the treatment of mental disorders within Muslim adolescent and emerging adult populations. Smaller studies have evaluated the effectiveness of cognitive behavioral and psychodynamic intervention using individual psychotherapy for young Muslims suffering from depression; both interventions reported treatment gains in post-treatment follow up (e.g., Hamdan-Mansour, Puskar, & Bandak, 2009; Heidari, Lewis, Allahyari, Azadfallah, & Bertino, 2013).

Group-based interventions with Muslim youth populations have also received attention from researchers. The vast majority of research on group-based intervention efforts have been in school settings. The primary target of school interventions has been to reduce symptoms of trauma. Some studies evaluated the effectiveness of group counseling interventions that address grief and forgiveness in traumatized populations and noted treatment gains (e.g., Cox et al., 2007; Shechtman, Wade, & Khoury, 2009). Other studies have investigated the effectiveness of both content and systems interventions. For example, a study aimed at supporting Bosnian adolescents' post-war recovery integrated a multi-tiered intervention into schools (Layne et al., 2008). In the study, surviving children were provided psycho-education and coping skills (tier 1); those who previously experienced severe trauma and loss were provided specialized trauma- and grief-focused intervention (tier 2); and young people with acute symptoms were referred to community-based mental health services (tier 3). This multi-tiered, school-based intervention was found to be significant in reducing grief reactions and may serve as a model for future interventions with child refugees from war-torn areas (Layne et al., 2008). Preliminary evidence for the effectiveness of group interventions have also been observed for health education and skills-based intervention in both Muslim-majority and -minority countries. A study in Iran implemented a skill-based intervention program that reduced substance use among Iranian high school students, with treatment gains maintained one year after intervention (Allahverdipour, Bazargan, Farhadinasab, Hidarnia, & Bashirian, 2009). Other studies have explored the impact of health- and religious-education-based interventions to reduce smoking among Indonesian Muslim youth, and found positive effect for use of both (Tahlil, Woodman, Coveney, & Ward, 2013). Similarly, evidence for the positive impact of group intervention on developing resilience, positive self-concept, and strengthening religious identity was observed in Muslim Malay female orphans (Kamsani, 2014).

While family and humanistic therapy are purported to be the most effective forms of therapy with Muslim populations, no empirical research has been conducted to assess their effectiveness. Similarly, culturally based therapeutic interventions have also been described without empirical evidence (Dwairy, 2009). Future research on the effectiveness of interventions with Muslim adolescents and emerging adults is imperative. Researchers must focus not only on providing empirical evidence for the type of intervention, but also to identify the therapeutic factors and practices that enhance treatment for Muslim adolescents and emerging adults.

Similar to the overall field of psychology, positive mental health and wellbeing has sparked interest among researchers studying global Muslim youth populations. The positive impact of religiosity has been extensively studied by researchers primarily from the Middle East. These studies have noted that increased religiosity served as a buffer against depression and anxiety and had a positive relationship to happiness and wellbeing (e.g., Yapici & Bilican, 2014; Abdel-Khalek, 2007; Abdel-Khalek & Naceur, 2007; Vasegh & Mohammadi, 2007). Similarly, a study in the U.K. found that Muslims minorities had the lowest levels of psychological distress when compared to other faith groups (Dabbagh, Johnson, King, & Blizard, 2012). Lower levels of distress were attributed in part to being part of a religious minority community that had strong sense of social cohesion (Dabbagh, Johnson, King, & Blizard, 2012). It would be important to see if these findings would be replicated in other countries with both Muslim- and non-Muslim- majority youth populations. It is possible that other factors may contribute to the findings and should also be investigated. For example, religious and ethnic identification in minority group settings was shown to support a young person's self-concept and positively impact their sense of wellbeing (Abu-Rayya & Abu-Rayya, 2009). There may be other social identities or factors that could contribute to the subjective wellbeing of Muslim adolescents and emerging adults and should be considered.

Positive psychology research has been advanced in numerous countries with large Muslim populations. In Iran, research has primarily focused on the validation of positive psychology research measures and concepts related to resilience and mindfulness (e.g., Jowkar, Friborg, & Hjemdal, 2010; Ghorbani, Watson, & Weathington, 2009; Ghorbani & Watson, 2009). Researchers have explored correlates of happiness (Abdel-Khalek & Lester, 2010), as well as differentiating between different types of gratitude (dispositional versus religious) and its predictive impact of mental health and subjective wellbeing (Aghababaei & Tabik, 2013). Research on factors related to positive youth development has also begun; for example, the relationship between religiosity and the development of character strengths was explored with U.S. Muslim college students (Ahmed, 2009). In the study, religious minority status and socio-political cultural context were identified as potential factors resulting in higher levels of religiosity among U.S. Muslim college students when compared to their non-Muslim peers (Ahmed, 2009). In addition, preliminary research among Muslim minority youth identified that strong family structure, positive parent-child relationship and home environment, positive school environment, and academic success promoted youth development (e.g., Aroian, Templin, Hough, Ramaswamy, & Katz, 2011; Azam & Shaikh, 2011; Dabbagh, Johnson, King, & Blizard, 2012). In Muslim-majority countries, to the knowledge of the authors, only two known studies on youth promotion exist. The first, conducted in Malaysia, noted that among Muslim Malay youth, religiosity was the most important variable to promote pro-social behaviors; positive parenting practices served as the most significant protective factor against risk behaviors; and community support was the most vital element to help young Muslims thrive (Krauss et al., 2012). In a study on Pakistani adolescent youth development, personal growth initiative was noted to have a positive relationship with wellbeing and a negative relationship with levels of distress (Ayub & Iqbal, 2012).

While research on positive psychology and youth development exists, much more is needed. For example, while religiosity has been found to be a protective factor, the mediating factors and pathways of function are unclear. How Muslim adolescents and emerging adults compare to youth of other faith groups expressing similar levels of religiosity should also be investigated. Similarly, while Muslim youth development research has begun, these findings must be incorporated into programming, with evaluations of their effectiveness in Muslim youth populations across socio-contextual environments.

Recommendations for the Next 10 Years

The global increase in research on Muslim youth is a welcome development; however, the field is still in its infancy stage and major gaps in the research continue to exist. Minimal research has been conducted on important topics that impact Muslim adolescent and emerging adult development and mental health. For example, peer relationships are known to influence young people's developmental trajectory yet minimal research on peer relationships appears to exist. Similarly, Muslim youth are developing within a global context, actively engaging and connecting through social media, and in some cases sharing global popular culture through music, art, and social justice causes. However, minimal research has been undertaken to investigate the impact these influences have had on global Muslim youth populations. While Muslim adolescents and emerging adults may share similar values and beliefs, they also have additional social identities which may result in unique issues specific to their socio-/political/cultural histories, as is the case of African American Muslim youth.

Increased research on reducing mental health stigma, effective programming for mental health literacy, and greater funding to establish baseline measures for the global prevalence of mental illness by country and cultural groups is needed. Research to identify cultural manifestations of mental illness, as well as treatment interventions that are best suited by populations and disorders will help clarify mental illness presentations. In addition, sustained attention is needed to examine the long-term impact of global unrest on the mental health of displaced Muslim youth.

Additional gaps in research include limited information about Muslim youth in African countries as well as Muslim-minority populations in South and Central America. It is possible that research may exist on many of the topics highlighted in this review, however language barriers between researchers may interfere with access. Thus, efforts are needed to ensure greater collaboration and exchange of knowledge across languages. In addition, country-specific longitudinal studies are needed to begin exploring developmental changes and trends over multiple generations. Identifying within-country differences as well as cross-cultural studies of Muslim youth are also needed to understand the nature of varying factors that influence Muslim adolescent and emerging adulthood outcomes. In addition, much of the available research has not been incorporated into social policy and programming and cannot be evaluated for its greater social impact.

Despite the need for additional research, the immense contribution and expansion of knowledge on the global mental health of Muslim adolescents and emerging adults should not go unnoticed. The foundations for research have been established and expectations for the next decade run high.

References

Ahmadi, J., Amiri, A., Ghanizadeh, A., Khademalhosseini, M., Khademalhosseini, Z., Gholami, Z., et al. (2014). Prevalence of addiction to the internet, computer games, DVD, and video and its relationship to anxiety and depression in a sample of Iranian high school students. Iranian Journal of Psychiatry and Behavioral Sciences, 8(2), 75-80.

Ahmed, S. (2012). Adolescents and emerging adults. In S. Ahmed & M. M. Amer (Eds.), Counseling Muslims: Handbook of mental health issues and interventions (pp. 251-280). New York, NY: Routledge.

Ahmed, S., Patel, S., & Hashem, H. (2015). State of American Muslim youth: Research & recommendations. Canton, MI: Institute for Social Policy and Understanding and The Family & Youth Institute.

Ayub, N., & Iqbal, S. (2012). The relationship of personal growth initiative, psychological well-being, and psychological distress among adolescents. Journal of Teaching and Education, 1(6), 101-107.

Azam, A., & Shaikh, F. (2011). Resilience among adolescent boys: Role of home and school environment. Indian Journal of Community Psychology, 7(2), 306-315.

Basford, L. E. (2008). From mainstream to East African charter: East African Muslim students' experiences in US schools. (Unpublished doctoral dissertation). University of Minnesota, Minneapolis, MN.

Clark, E. H. (2007). 'I'm a product of everything I've been through': A narrative study of the cultural identity construction of Bosnian Muslim female refugee students. (Unpublished doctoral dissertation). Florida State University, Tallahassee, FL.

Din, H., Ahmed, S., & Killawi, A. (2016). Pathways to wellness: Muslim mental health promotion in the digital age. Presented at the Muslim Mental Health Conference on March 18, 2016, Dearborn, MI.

Ghaffar-Kucher, A. (2008). The (mis)education of Pakistani immigrant youth. (Unpublished doctoral dissertation). Teachers College, Columbia University, New York, NY.

Hasanović, M., Sinanović, O., & Pavlović, S. (2011). Acculturation and psychological characteristics of Bosnian internally displaced and refugee adolescents from Srebrenica region after the war 1992-1995 in Bosnia and Herzegovina. In T. Johnson (Ed.), Acculturation: Implications for Individuals, Families and Societies (pp. 197-233). New York: Nova Publishers.

Herzig, B. A. (2011). An examination of American-born Muslim college students' attitudes toward mental health. (Unpublished doctoral dissertation). Antioch University, Keene, NH.

Ineichen, B. (2008). Suicide and attempted suicide among South Asians in England: Who is at risk? Mental Health in Family Medicine, 5(3), 135-138.

Jenson, J. M., & Fraser, M. W. (Eds.). (2015). Social policy for children and families: A risk and resilience perspective (3rd ed.). Thousand Oaks, CA: Sage.

Kamsani, S. R. (2014). Religious identity, self-concept, and resilience among female orphan adolescents in Malaysia: An evidence-based group intervention. (Unpublished doctoral dissertation). Southern Illinois University, Carbondale, IL.

Kassissieh, N. N. (2005). "And say to the believing women...": The multiple meanings of the hijab as a window into Muslim-American women's identity. (Unpublished doctoral dissertation). Massachusets School of Professional Psychology. Boston, MA.

Khan, T. (2009). Emerging Muslim identity in India's globalized and mediated society: An ethnographic investigation of the halting modernities of the Muslim youth of Jamia enclave, New Delhi. (Unpublished doctoral dissertation). Ohio University, Athens, OH.

Mishra, S. (2005). Religious identity and ego strengths: A study of Hindu and Muslim boys and girls. Psychological Studies, 50, 127-133.

Neese, A. L., Pittman, L. D., & Hunemorder, R. (2013). Depressive symptoms and somatic complaints among Zambian adolescents: Associations with stress and coping. Journal of Research on Adolescence, 23, 118-127. doi:10.1111/j.1532-7795.2012.00834.x

Raja, R. A. (2004). Attitude of Pakistani American Muslim men towards seeking psychotherapy. (Unpublished doctoral dissertation). Chicago School of Professional Psychology, Chicago, IL.

Shams, G., Foroughi, E., Esmaili, Y., Amini, H., & Ebrahimkhani, N. (2011). Prevalence rates of obsessive-compulsive symptoms and psychiatric comorbidity among adolescents in Iran. Acta Medica Iranica, 49(10), 680-687.

# data[].attributes.attachment_link.title
A Decade of Muslim Youth: Global Trends in Research

# data[].attributes.attachment_link.description
Keywords: youth, adolescence, young adulthood, mental health Globally, Muslim adolescent and emerging adults are constantly facing scrutiny from their environments. However, very little is known regarding how they perceive themselves and experience the world around them, what their mental health needs are, and how to promote healthy development.

# data[].attributes.attachment_link.readable_text
Socially withdrawn children and adolescents may be showing signs of depression.﻿﻿ While it is normal for a child to begin to pull away from their parents and identify more with peers as they reach adolescence, social withdrawal from friends and peers may be a sign of something more serious.

Learn to spot the telltale signs that indicate a child or teen is depressed and what you can do to help.

Why Depressed Children May Withdraw

Children who are depressed may feel misunderstood, irritable, worthless, or hopeless.﻿﻿ They may feel like no one can understand or help them-so why should they bother keeping or making friends?

Having friends to talk to and confide in is thought to be very helpful emotionally, especially for those who suffer from depression.

Without social relationships, some children and teens may begin to feel lonely and isolated, two factors often associated with increased suicide risk.

Additionally, depressed children may lack the ability to experience pleasure in social activities, such as school, group activities, or social outings.﻿﻿ So, they might avoid these situations.

Social Withdrawal and Other Disorders

Social withdrawal is not limited to depression and is thought to also be associated with other disorders, such as anxiety, schizophrenia, and certain personality disorders.

In addition, social withdrawal was found to be a good indicator of major depressive disorder (MDD) in children with co-existing attention-deficit/hyperactivity disorder ( ADHD), according to a study that tried to distinguish which symptoms best discriminate cases of MDD in children with attention disorders.﻿﻿

What to Do If Your Child Seems to Be Withdrawing

As children navigate childhood and adolescence, they are likely to hit some bumps in the road, and parents and caregivers are often left wondering what is normal and when they should intervene.

First, talk to your child. Perhaps they had an argument with a friend or is grieving the loss of a relationship by keeping to themselves for a few days. This may be a temporary and normal reaction to an unpleasant event.

Perhaps they're experiencing another conflict at school such as being bullied. They may have been ousted from the social group that they previously belonged to. Situations like these may explain why your child appears to be socially withdrawn.

Contact a health care provider sooner if their symptoms escalate or they are experiencing:

Additional symptoms of depression

Recurring thoughts or actions of self-harm or suicide

Inability to engage in normal daily functions or activities

A Word From Verywell

If your child is depressed, an effective treatment plan can help put them on the road to enjoying their childhood and those around them.﻿﻿ Don't delay getting treatment. Give your child the help they need to maintain good mental health.

# data[].attributes.attachment_link.title
How Parents Should React When Children Seem to Be Socially Withdrawn

# data[].attributes.attachment_link.description
Socially withdrawn children and adolescents may be showing signs of depression.﻿﻿ While it is normal for a child to begin to pull away from their parents and identify more with peers as they reach adolescence, social withdrawal from friends and peers may be a sign of something more serious.

# data[].attributes.body
A really interesting article around the plight of individuals with a range of learning disabilities during this 'Covid-19' situation - may give some context to the importance of this weeks material

# data[].attributes.body
After watching the risk assessment video Laurence posted i went on a hunt for others. Unfortunately there aren't many and they are all very old. but thought this one was interesting giving the two angles of the same assessment, although both not great.. even just where they sat.

Erin, Adult Nursing

# data[].attributes.attachment_link.title
Assessing someone who is potentially psychotic and dangerous in the community

# data[].attributes.attachment_link.title
Children and young people -addaction-briefing

# data[].attributes.attachment_link.title
TWENGE screen time and lower psychological well-being

# data[].attributes.body
Vital link to the importance of of listening to families and carers of children with autism and lessons can be learned from Oliver McGowan case

# data[].attributes.attachment_link.description
This is the home page for the Oliver Mcgowan campaign. Since the untimely death of Oliver in 2016, his parent's Paula & Tom Mcgowan have been campaigning for mandatory autism training for all health care professionals.

# data[].attributes.attachment_link.title
Improving the physical health of people with severe mental illness

# data[].attributes.attachment_link.title
integrating mental and physical healthcare0

# data[].attributes.body
I have been looking at alternative therapies for children/young people.  Art therapy can help children to externalise their emotions which they may find difficult to express verbally.  Painting, drawing and the use of puppets  can often uncover issues children may be having at home or school etc.

The charity MIND, which have various locations across the UK, offer lots of alternative therapies such as meditation, yoga and massage.  Although not all therapies are available on the NHS , many people appear to find them helpful and can often allow individuals to gain some level of control over negative thinking/thought processes.  They are non-invasive and do not carry the side-effects experienced by many medications.  These alternative therapies feature in the Fountain Centre short film and seem to be making a huge difference to patients both pyhsical and mentally.

YOUNGMINDS are a UK  charity which offers  support for young people and parents.  They have  helplines, toolkits, drop-in centres and online chat discussions/forums for young people who may feel isolated and alone.  There are short films available on the website which encourage people to seek help and share their experiences with others.

Mental health is such a vast and complex area of healthcare and one that seems to be so neglected. I have had limited exposure to mental health issues, during my placements but I am aware that this is a growing problem both locally and nationally.  I hope I can always provide patients with helpful and genuine support, throughout their time of need.

Jo, child nursing student

# data[].attributes.body
Elyn Saks, a women who kept her diagnosis of schizophrenia a secret from her colleagues and studied to become a specialist in schizophrenia before telling her story about the problems she experienced due to the perception of 'normals' towards people with symptoms of schizophrenia.

Quite insightful, especially in humanising sufferers instead of animalising them.

# data[].attributes.headline
Safety of service users with severe mental illnessreceiving inpatient care on medical and surgicalwards: A systematic review

# data[].attributes.subject
Safety of service users with severe mental illnessreceiving inpatient care on medical and surgicalwards: A systematic review

# data[].attributes.body
A really interesting, contemporary article about patients with Serious Mental Illness receiving care in general hospitals - lots of issues highlighted that we have/will discuss within this module - thoughts?

# data[].attributes.attachment_link.title
Safety of service users with severe mental illness

# data[].attributes.body
Current mental health service provision for children and young people in Surrey.

# data[].attributes.headline
Improving the Physical Health of People with Mental Health Problems

# data[].attributes.subject
Improving the Physical Health of People with Mental Health Problems

# data[].attributes.body
This

# data[].attributes.attachment_link.title
10 priorities for integrating physical and mental health

# data[].attributes.attachment_link.description
10 areas where there is scope to improve integration between physical and mental health, from public health to acute hospital care.

# data[].attributes.headline
Recognising and Assessing Medical Problems in a Psychiatric Setting (RAMPPS)

# data[].attributes.subject
Recognising and Assessing Medical Problems in a Psychiatric Setting (RAMPPS)

# data[].attributes.attachment_link.authors[].name
Health Education England working across Yorkshire and the Humber

# data[].attributes.attachment_link.description
A short video to explain what RAMPPS (Recognising and Assessing Medical Problems in a Psychiatric Setting) is.

# data[].attributes.body
Unprofessional conduct and poor communication skills, this video ties in really well with last Friday's lecture. Hope you enjoy.

# data[].attributes.attachment_link.title
Holly and Chris case study: Unprofessional conduct

# data[].attributes.attachment_link.description
This case study illustrates how a worker places themselves at risk and commits a number of professional mistakes.

# data[].attributes.body
Written By Surrey PhD Student Scott Munro

# data[].attributes.attachment_link.readable_text
I love my job. I'm certainly proud of it and I love it when people ask me what I do for a living. But there is one question I get asked that I struggle with.

The conversation normally goes along the lines of this:

Joe Bloggs: So, what do you do for a living?
Me: I'm a paramedic
JB: Oh, that's pretty cool! You must really enjoy it?
Me: Yeah I love it!
JB: Cool. So, what's the WORST thing you've EVER seen???!!!!

Me: ...

I get it, and I'd probably ask the same thing before I was a paramedic! Paramedics do a job that people find curious. It seems exciting and all paramedics will have some fantastic stories up their sleeves that are great at dinner parties (well, actually, maybe not at dinner parties, or generally when people are eating). But I've been asked this question a lot of times, and the way I hear it in my head is like this:

"Please re-live the most traumatic and harrowing event you've encountered in your life".

I still haven't come up with a good answer.

I know people don't mean it like that, and its probably more of a case of a poorly worded question than a sadistic request.

The day to day job of a paramedic is a lot more mundane than people might expect. We deal with more and more urgent and non-emergency cases. But, it's still a bloody hard job. The job of a paramedic is one of unpredictability. Though only a small percentage of the incidents we attend, we are still exposed to events such as the death of a child, the abuse of children, the elderly and other vulnerable groups, murders, suicides, terrorist attacks and natural disasters¹. In Regehr's study², all 86 paramedics involved had been involved in an "emotionally traumatic event", which the authors defined as the death of a patient, line-of-duty death, violence against self or others, near-death experience, death of a child, and multiple casualties. And, throughout all of this, paramedics are expected to keep a level head, act professionally and provide the highest clinical care we can.

Added to this, paramedics, like all jobs, have work related and occupational stress. It's no secret that the NHS is under immense strain from every possible direction. This goes for the ambulance service too.

Targets. The much maligned 8-minute target to respond to emergency calls is like a constant internal stop-watch that's impossible to beat every time. Hospital turn-around times, mobilisation times, response times, compliance of paperwork and care bundles, patient clinical outcomes, Key performance indicators. Targets.

Although shift work was something that lured me to the profession and is still an aspect of the job I enjoy (ask me in 10 years), it takes its toll physically and emotionally. 12 hour shifts, working nights and a lack of routine all mess with your circadian rhythm, your eating habits (try sticking to your diet through your 3rd night shift in a row) and the amount of time spent with your family. Then there is always the dread of an email coming through to say you have received a complaint, or an incident you were involved in is being investigated (even if it's not your part in it that's being questioned!).

Lets not even start on trying to do a PhD on top of all of it.

So then, it is no surprise that staff and volunteers working for the emergency services are at greater risk of experiencing a mental health problem, but are less likely to receive support ( Mind charity). Levels of stress, anxiety and depression do vary across the literature, but have been found to be as high as 20% for PTSD, 10% for depression and 22% for anxiety³.

And, while the ambulance service attend a lot of jobs to help people having mental health issues, historically the mental well-being of staff has been overlooked. Fortunately, the mental health of emergency service staff has been getting more attention recently. The mental health charity Mind have been given funding to set up the Blue Light Programme, to provide mental health support for emergency services staff and volunteers, from police, fire, ambulance and search and rescue services across England. The Ambulance service I'm employed by provide counselling and listening services, a chaplaincy team and have also recently introduced Trauma Risk Management ( TRiM) (developed by the armed forces) to support staff that may be suffering with PTSD. There are also a range of 'Healthy Living' apps available to staff.

I've been a paramedic for a relatively short amount of time, and despite all of the stresses mentioned above, I still couldn't imagine doing and enjoying any other job as much as this at this moment of my life. I try to be mindful of my own mental well-being and I've noticed a few times in my career where I've felt like I need to take a proactive stance before things get worse. What that involves will be different for everyone. For me, it involves clearing my calendar of any outside work commitments I have and just taking time to do things I enjoy (finding a nice seat in a coffee shop and reading). I'm quite fortunate in that my brother is a doctor, so we can share our experiences with each other and understand where the other is coming from. Then, there is always the therapeutic natter with a well-trusted crew mate.

The stigma of mental-health problems is also a recognised barrier to those wanting to seek help. The perception that ambulance service staff are immune to difficult circumstances, that we come equipped with some sort of emotional force field, is a false mentality that is detrimental to those that need support. I remember as a student paramedic, starting my training with the thought that you shouldn't be affected by things you see on the road, because to be a paramedic you need to be 'tough enough' to deal with them, and if you're not then you are in the wrong job. I am grateful to the paramedic who showed me that this wasn't the case, after a nasty traumatic cardiac arrest. He took us off road and made sure I was ok, explained the different means of support available and took the time to talk things through. I hope that I get this important message across when I work with students now.

So next time you're speaking to a paramedic, emergency service staff or volunteer, do ask them about their job, because most of them absolutely LOVE to talk about their jobs and share all of the bizarre and crazy things we get up to (ahem, whilst remaining confidential and respectful), just maybe don't ask them "What's the WORST thing you've EVER seen?".

You can check out the Blue Light Programme by clicking on the link below, following them on twitter @mindbluelight and using the hashtag #mybluelight.
http://www.mind.org.uk/news-campaigns/campaigns/bluelight/ Here is a link to another blog by a paramedic talking about mental health, featured in the metro.
Reference list (Thanks to Emma Vyvyan (@mrsevyvyan) for pointing me in the right direction to find the literature)

Bentley, M. MacCrawford, J. Wilkins, J. Fernandez, A. & Studnek, J. (2013). An assessment of Depression, Anxiety and Stress among Nationally Certified EMS professionals. Prehospital Emergency Care, (17), 330-338.

Regehr, C. Goldberg, G. & Hughes, J. (2002). Exposure to Human Tragedy, Empathy, and Trauma in Ambulance Paramedics American Journal of Orthopsychiatry. Educational Publishing Foundation 72(4), 505-513.

Bennett, P. Williams, Y. Page, N. & Woollard, M. (2004). Levels of mental health problems among UK emergency ambulance workers. Emergency Medical Journal, (21), 235-236.

Bennett, P. Williams, Y. Page, N. Hood, K. & Woollard, M. Vetter, N. (2005). Associations between organizational and incident factors and emotional distress in emergency personnel. British Journal of Clinical Psychology, (44), 215-226.

Donnelly, E. (2011). Work-related stress and posttraumatic stress in emergency medical services. Prehospital Emergency Care, 16(1), 76-85.

# data[].attributes.attachment_link.title
"What's the WORST thing you've EVER seen"

# data[].attributes.attachment_link.description
I love my job. I'm certainly proud of it and I love it when people ask me what I do for a living. But there is one question I get asked that I struggle with. The conversation normally goes al...

# data[].attributes.attachment_link.readable_text
PM: "I want us to employ the power of government as a force for good to transform the way we deal with mental health problems right across society"

comprehensive package of reforms to improve mental health support at every stage of a person's life - with an emphasis on early intervention for children and young people

leading mental health figures to undertake independent expert report on companies' work to support mental health

Delivering the annual Charity Commission lecture today, Prime Minister Theresa May will announce a comprehensive package of measures to transform mental health support in our schools, workplaces and communities.

The Prime Minister will say that true parity for mental and physical health can only be achieved if every institution recognises the vital role it can play in delivering this objective.

Prime Minister Theresa May is expected to say:

For too long mental illness has been something of a hidden injustice in our country, shrouded in a completely unacceptable stigma and dangerously disregarded as a secondary issue to physical health. Yet left unaddressed, it destroys lives, it separates people from each other and deepens the divisions within our society. Changing this goes right to the heart of our humanity; to the heart of the kind of country we are, the values we share, the attitudes we hold and our determination to come together and support each other.

I want us to employ the power of government as a force for good to transform the way we deal with mental health problems right across society, and at every stage of life.

What I am announcing are the first steps in our plan to transform the way we deal with mental illness in this country at every stage of a person's life: not in our hospitals, but in our classrooms, at work and in our communities.

This starts with ensuring that children and young people get the help and support they need and deserve - because we know that mental illness too often starts in childhood and that when left untreated, can blight lives, and become entrenched.

This is a historic opportunity to right a wrong, and give people deserving of compassion and support the attention and treatment they deserve. And for all of us to change the way we view mental illness so that striving to improve mental wellbeing is seen as just as natural, positive and good as striving to improve our physical wellbeing.

The plans to tackle the burning injustice of mental illness form part of the government's wider commitment to wholesale social reform - and its mission to create a country that works for everyone, not just the privileged few.

The Prime Minister's speech this morning follows her words on the steps of Downing Street, where she vowed to create a country where if you struggle to get by, the government will do what it can to help; and a government which stands up to vested interests and tackles the everyday injustices that have been ignored for too long.

The speech will set out her determination to build a shared society based on the values of citizenship, responsibility and fairness, backed by a government which takes an active role in helping those who feel they have been ignored for too long.

The plans aim to make mental health an everyday concern for every bit of the system, helping ensure that no one affected by mental ill-health goes unattended. It includes:

new support for schools with every secondary school in the country to be offered mental health first aid training and new trials to look at how to strengthen the links between schools and local NHS mental health staff. There will also be a major thematic review of children and adolescent mental health services across the country, led by the Care Quality Commission, to identify what is working and what is not and a new green paper on children and young people's mental health to set out plans to transform services in schools, universities and for families

a new partnership with employers to improve mental health support in the workplace. The Prime Minister has appointed Lord Dennis Stevenson, the long-time campaigner for greater understanding and treatment of mental illness, and Paul Farmer CBE, CEO of Mind and Chair of the NHS Mental Health Taskforce, to drive work with business and the public sector to support mental health in the workplace. These experts will lead a review on how best to ensure employees with mental health problems are enabled to thrive in the workplace and perform at their best. This will involve practical help including promoting best practice and learning from trailblazer employers, as well as offering tools to organisations, whatever size they are, to assist with employee well-being and mental health. It will review recommendations around discrimination in the workplace on the grounds of mental health

further alternatives to hospital to support people in the community. Recognising that seeing a GP or going to A&E is not or does not feel like the right intervention for many people with mental ill-health, the government will build on its £15 million investment to provide and promote new models of community - based care such as crisis cafes and community clinics. The initial £15 million investment led to 88 new places of safety being created and the government now plans to spend up to a further £15 million to build on this success

plans to rapidly expand treatment by investing in and expanding digital mental health services. Digitally assisted therapy has already proved successful in other countries and the government will speed up the delivery of a £67.7 million digital mental health package so that those worried about stress, anxiety or more serious issues can go online, check their symptoms and if needed, access digital therapy immediately rather than waiting weeks for a face-to-face appointment - with further follow up face-to-face sessions offered as necessary

new ways to right the injustices people with mental health problems face. Despite known links between debt and mental health, currently hundreds of mental health patients are charged up to £300 by their GP for a form to prove they have mental health issues. To end this unfair practice the Department for Health will undertake a formal review of the mental health debt form, working with Money and Mental Health. The government will also support NHS England's commitment to eliminate inappropriate placements to inpatient beds for children and young people by 2021 - a practice which currently sees hundreds of children being sent halfway across the country to access mental health services

One in 4 people has a common mental disorder at any one time and the economic and social cost of mental illness is £105 billion - similar to the entire annual NHS budget.

Figures show mental illness also disproportionately affects young people and those on lower and middle incomes with over half of mental health problems starting by the age of 14 and 75% by 18.

In 2014 mental health conditions affected almost 1 in 5 of all working-age people and around 1 in 7 of people in full-time employment. In the workplace 18 million days were lost to sickness absence caused by mental health conditions in 2015 at a cost of around £9 billion a year to employers.

Today's announcements build on improvements to mental health support since 2010. The government is currently investing more in mental health than ever before - spending an estimated £11.7 billion a year and has already legislated to give mental and physical health equal priority in law.

The first ever access and waiting standards have also been introduced for both talking therapies and early intervention in psychosis and the government is investing £1.4 billion over the course of this Parliament into mental health support for children and young people.

Paul Farmer, Chief Executive of Mind, the mental health charity, said:

It's important to see the Prime Minister talking about mental health and shows how far we have come in bringing the experiences of people with mental health problems up the political agenda. Mental health should be at the heart of government, and at the heart of society and communities - it's been on the periphery for far too long.

We welcome the announcements around a focus on prevention in schools and workplaces and support for people in crisis. The proof will be in the difference it makes to the day-to-day experience of the 1 in 4 who will experience a mental health problem this year. Mental health is everyone's business and we need to see sustained leadership to make sure services and support improve for all of us with mental health problems. Having been neglected for decades, we need to see it made a priority for decades to come to make sure everyone with mental health problems can live the life they want to lead.

In a statement issued today, Sir Ian Cheshire, Chairman of the Heads Together campaign, said:

The Prime Minister's announcements today are extremely important and very welcome, as they show both a willingness to tackle the broad challenge of mental health support and a practical grasp of how to start making a real difference.

As the chair of Heads Together, an alliance of charity and corporate partners committed to changing the national conversation on mental health, I would urge all involved in the sector to collaborate and build on these initiatives.

Background

Mental health training for teachers and staff will be rolled out to a third of secondary schools this year (around 1,200 schools), with the remaining two-thirds of secondary schools offered this training in the following 2 years. The training will be run by Mental Health First Aid UK working with the government.

The government will also consult employers, charities and legal experts to gather evidence about current discrimination protections for workers with mental ill-health.

Existing laws already protect people when mental illness is classed as a disability - when the illness persists for a year or more - but for many common disorders, such as depression, average length of illness can be much shorter and there is anecdotal evidence of people facing issues in employment in these situations.

# data[].attributes.attachment_link.title
Prime Minister unveils plans to transform mental health support

# data[].attributes.attachment_link.description
PM: "I want us to employ the power of government as a force for good to transform the way we deal with mental health problems right across society" comprehensive package of reforms to improve mental health support at every stage of a person's life - with an emphasis on early

# data[].attributes.headline
Back pain may 'increase' risk of mental health issues

# data[].attributes.subject
Back pain may 'increase' risk of mental health issues

# data[].attributes.body
An interesting viewpoint - feel free to add comments as to what you think.....

# data[].attributes.attachment_link.readable_text
A study, involving almost 200,000 participants, finds that individuals who have back pain are more likely to also experience a range of mental health issues. Knowing about these links could form a more successful treatment plan for both sets of conditions.

According to recent findings, back pain and mental health are deeply linked.

Back pain is a leading cause of disability across the globe. In fact, it causes more global disability than any other condition.

According to the Global Burden of Disease study, lower back pain affects almost 1 in 10 people.

There is also a wealth of evidence that back pain negatively impacts quality of life and heightens the risk of other physical health problems. Additionally, it comes with substantial healthcare cost.

One earlier study of note used data from the World Mental Health Survey and found that chronic back or neck pain was associated with increased risk for mood disorders, alcohol abuse, and anxiety disorders.

Despite its high prevalence, little work has been done to investigate back pain's links with mental health outcomes in low- and middle-income countries (LMICs).

The largest back pain-mental health study to date

The latest and largest study to investigate the connections between back pain and psychological illness in LMICs was published this week in the journal General Hospital Psychiatry.

The research team - headed up by Prof. Patricia Schofield and Dr. Brendon Stubbs from Anglia Ruskin University in the United Kingdom - took data from 190,595 individuals aged 18 or older across 43 countries, making it the largest study of its type. Of the 43 countries, 19 were low-income and 24 were middle-income.

The team used data from the World Health Survey 2002-2004, a project set up by the World Health Organization (WHO) to "generate information on the health of adult populations and health systems."

Overall, in LMICs, back pain affected 35.1 percent of the population, and 6.9 percent reported chronic back pain. Of the countries investigated, China's levels of back pain were lowest, at 13.7 percent.

In some countries, more than half of respondents reported back pain; Nepal was highest with 57.1 percent. Similarly, 53.1 percent of Bangladeshis reported back pain, as well as 52 percent of people from Brazil.

Back pain and mental health

The analysis of the questionnaire data showed that, when compared with people without back pain, those who did experience back pain were more than twice as likely to experience one of five mental health conditions - anxiety, depression, psychosis, stress, and sleep deprivation.

People with chronic back pain were also three times more likely to experience a depressive episode and 2.6 times more likely to experience psychosis.

Interestingly, the results were relatively similar across all 43 LMICs, regardless of their standing on the socioeconomic ladder.

"Our data shows that both back pain and chronic back pain are associated with an increased likelihood of depression, psychosis, anxiety, stress, and sleep disturbances.

This suggests that back pain has important mental health implications which may make recovery from back pain more challenging. The exact reasons for this are yet to be established."

Dr. Stubbs

Because the study used such a large group of people across a section of populations, the findings can be considered highly reliable. As back pain is so prevalent in LMICs (and the world at large), any connection to mental health needs to be thoroughly understood.

As Dr. Stubbs says:

"Further research is required to find out more about the links between these problems and to ensure effective treatments can be developed. It is also important that healthcare professionals are made aware of this link to refer patients to other services if necessary."

Learn how motor control exercise may help lower back pain.

# data[].attributes.attachment_link.title
Back pain may raise risk of mental health problems

# data[].attributes.attachment_link.description
A study, involving almost 200,000 participants, finds that individuals who have back pain are more likely to also experience a range of mental health issues. Knowing about these links could form a more successful treatment plan for both sets of conditions. According to recent findings, back pain and mental health are deeply linked.

# data[].attributes.body
Quite a 'wordy' document (100 pages!) from 2014 that may have some relevance to current challenges - it has a very concise contents page that allows you to 'jump' to a section!

# data[].attributes.headline
Bringing together physical and mental health: A new frontier for integrated care

# data[].attributes.subject
Bringing together physical and mental health: A new frontier for integrated care

# data[].attributes.body
A fantastic article demonstrating the challenge for Health Professionals in Managing Physical and Mental Health Challenges