case study on mental disorder

Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

• Theresa Cerulli, MD
• Tina Matthews-Hayes, DNP, FNP, PMHNP

Custom Around the Practice Video Series

Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.

EP: 1 . Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Ep: 2 . clinical significance of bipolar disorder, ep: 3 . clinical impressions from patient case #1, ep: 4 . diagnosis of bipolar disorder, ep: 5 . treatment options for bipolar disorder, ep: 6 . patient case #2: 47-year-old man with treatment resistant depression (trd), ep: 7 . patient case #2 continued: novel second-generation antipsychotics, ep: 8 . role of telemedicine in bipolar disorder.

Michael E. Thase, MD : Hello and welcome to this Psychiatric Times™ Around the Practice , “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.

Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.

Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.

We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.

Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.

On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.

At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.

Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.

So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.

Transcript Edited for Clarity

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

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• Case report
• Open access
• Published: 11 September 2017

A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Med. 2012;9(11):e1001349. https://doi.org/10.1371/journal.pmed.1001349 . Epub 2012 Nov 27

Article   PubMed   PubMed Central   Google Scholar  

Kreppner JM, O'Connor TG, Rutter M, English and Romanian Adoptees Study Team. Can inattention/overactivity be an institutional deprivation syndrome? J Abnorm Child Psychol. 2001;29(6):513–28. PMID: 11761285

Article   CAS   PubMed   Google Scholar  

Dejong M. Some reflections on the use of psychiatric diagnosis in the looked after or “in care” child population. Clin Child Psychol Psychiatry. 2010;15(4):589–99. https://doi.org/10.1177/1359104510377705 .

Article   PubMed   Google Scholar  

Pincus HA, McQueen LE, Elinson L. Subthreshold mental disorders: Nosological and research recommendations. In: Phillips KA, First MB, Pincus HA, editors. Advancing DSM: dilemmas in psychiatric diagnosis. Washington, DC: American Psychiatric Association; 2003. p. 129–44.

Google Scholar  

Shankman SA, Lewinsohn PM, Klein DN, Small JW, Seeley JR, Altman SE. Subthreshold conditions as precursors for full syndrome disorders: a 15-year longitudinal study of multiple diagnostic classes. J Child Psychol Psychiatry. 2009;50:1485–94.

AACAP. Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood. J Am Acad Child Adolesc Psychiatry. 2005;44:1206–18.

Article   Google Scholar  

dosReis S, Zito JM, Safer DJ, Soeken KL. Mental health services for youths in foster care and disabled youths. Am J Public Health. 2001;91(7):1094–9.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Breland-Noble AM, Elbogen EB, Farmer EMZ, Wagner HR, Burns BJ. Use of psychotropic medications by youths in therapeutic foster care and group homes. Psychiatr Serv. 2004;55(6):706–8.

Olfson M, Crystal S, Huang C. Trends in antipsychotic drug use by very young, privately insured children. J Am Acad Child Adolesc Psychiatry. 2010;49:13–23.

PubMed   Google Scholar  

Ercan ES, Basay BK, Basay O. Risperidone in the treatment of conduct disorder in preschool children without intellectual disability. Child Adolesc Psychiatry Ment Health. 2011;5:10.

Memarzia J, Tracy D, Giaroli G. The use of antipsychotics in preschoolers: a veto or a sensible last option? J Psychopharmacol. 2014;28(4):303–19.

Safer DJ. A comparison of risperidone-induced weight gain across the age span. J Clin Psychopharmacol. 2004;24:429–36.

Correll CU, Manu P, Olshanskiy V. Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents. JAMA. 2009;302:1765–73.

Kearns GL, Abdel-Rahman SM, Alander SW. Developmental pharmacology – drug disposition, action, and therapy in infants and children. N Engl J Med. 2003;349:1157–67.

Monk C, Spicer J, Champagne FA. Linking prenatal maternal adversity to developmental outcomes in infants: the role of epigenetic pathways. Dev Psychopathol. 2012;24(4):1361–76. https://doi.org/10.1017/S0954579412000764 . Review. PMID: 23062303

Cecil CA, Viding E, Fearon P, Glaser D, McCrory EJ. Disentangling the mental health impact of childhood abuse and neglect. Child Abuse Negl. 2016;63:106–19. https://doi.org/10.1016/j.chiabu.2016.11.024 . [Epub ahead of print] PMID: 27914236

Nemeroff CB. Paradise lost: the neurobiological and clinical consequences of child abuse and neglect. Neuron. 2016;89(5):892–909. https://doi.org/10.1016/j.neuron.2016.01.019 . Review. PMID: 26938439

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MR, AJM, JVV conceptualized and followed up the patient. MR, AJM, JVV did literature survey and wrote the report and took part in the scientific discussion and in finalizing the manuscript. All the authors read and approved the final document.

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Correspondence to Magdalena Romanowicz .

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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Part 2 Lucy’s Story

2.4 Lucy case study 3: Mental illness diagnosis

Nicole Graham

Introduction to case study

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

Learning Objectives

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

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

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

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

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

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

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

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

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

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

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

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

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

Case study questions

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

 Thinking point

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

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

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

Learning objectives.

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

Resources required

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

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

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

Role 1 – Clinician

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

Role 2 – Lucy who lives with bipolar

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

Post role play debrief

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

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

Additional resources that might be helpful

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

Key information and links to other resources

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

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

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

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

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

Organisations providing information relevant to this case study

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

 Case study 3 summary

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

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

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

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

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

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

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Module 11: Schizophrenia Spectrum and Other Psychotic Disorders

Case studies: schizophrenia spectrum disorders, learning objectives.

• Identify schizophrenia and psychotic disorders in case studies

Case Study: Bryant

Thirty-five-year-old Bryant was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled clinicians to diagnose Bryant with obsessive-compulsive disorder (OCD). Shortly after, psychotic symptoms such as disorganized thoughts and delusion of control were noticeable. He told the doctors he has not been receiving any treatment, was not on any substance or medication, and has been experiencing these symptoms for about two weeks. Throughout the course of his treatment, the doctors noticed that he developed a catatonic stupor and a respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat the psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone (antibiotic) were administered, and these therapies proved to be dramatically effective. [1]

Case Study: Shanta

Shanta, a 28-year-old female with no prior psychiatric hospitalizations, was sent to the local emergency room after her parents called 911; they were concerned that their daughter had become uncharacteristically irritable and paranoid. The family observed that she had stopped interacting with them and had been spending long periods of time alone in her bedroom. For over a month, she had not attended school at the local community college. Her parents finally made the decision to call the police when she started to threaten them with a knife, and the police took her to the local emergency room for a crisis evaluation.

Following the administration of the medication, she tried to escape from the emergency room, contending that the hospital staff was planning to kill her. She eventually slept and when she awoke, she told the crisis worker that she had been diagnosed with attention-deficit/hyperactive disorder (ADHD) a month ago. At the time of this ADHD diagnosis, she was started on 30 mg of a stimulant to be taken every morning in order to help her focus and become less stressed over the possibility of poor school performance.

After two weeks, the provider increased her dosage to 60 mg every morning and also started her on dextroamphetamine sulfate tablets (10 mg) that she took daily in the afternoon in order to improve her concentration and ability to study. Shanta claimed that she might have taken up to three dextroamphetamine sulfate tablets over the past three days because she was worried about falling asleep and being unable to adequately prepare for an examination.

Prior to the ADHD diagnosis, the patient had no known psychiatric or substance abuse history. The urine toxicology screen taken upon admission to the emergency department was positive only for amphetamines. There was no family history of psychotic or mood disorders, and she didn’t exhibit any depressive, manic, or hypomanic symptoms.

The stimulant medications were discontinued by the hospital upon admission to the emergency department and the patient was treated with an atypical antipsychotic. She tolerated the medications well, started psychotherapy sessions, and was released five days later. On the day of discharge, there were no delusions or hallucinations reported. She was referred to the local mental health center for aftercare follow-up with a psychiatrist. [2]

Another powerful case study example is that of Elyn R. Saks, the associate dean and Orrin B. Evans professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California Gould Law School.

Saks began experiencing symptoms of mental illness at eight years old, but she had her first full-blown episode when studying as a Marshall scholar at Oxford University. Another breakdown happened while Saks was a student at Yale Law School, after which she “ended up forcibly restrained and forced to take anti-psychotic medication.” Her scholarly efforts thus include taking a careful look at the destructive impact force and coercion can have on the lives of people with psychiatric illnesses, whether during treatment or perhaps in interactions with police; the Saks Institute, for example, co-hosted a conference examining the urgent problem of how to address excessive use of force in encounters between law enforcement and individuals with mental health challenges.

Saks lives with schizophrenia and has written and spoken about her experiences. She says, “There’s a tremendous need to implode the myths of mental illness, to put a face on it, to show people that a diagnosis does not have to lead to a painful and oblique life.”

In recent years, researchers have begun talking about mental health care in the same way addiction specialists speak of recovery—the lifelong journey of self-treatment and discipline that guides substance abuse programs. The idea remains controversial: managing a severe mental illness is more complicated than simply avoiding certain behaviors. Approaches include “medication (usually), therapy (often), a measure of good luck (always)—and, most of all, the inner strength to manage one’s demons, if not banish them. That strength can come from any number of places…love, forgiveness, faith in God, a lifelong friendship.” Saks says, “We who struggle with these disorders can lead full, happy, productive lives, if we have the right resources.”

You can view the transcript for “A tale of mental illness | Elyn Saks” here (opens in new window) .

• Bai, Y., Yang, X., Zeng, Z., & Yang, H. (2018). A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. BMC psychiatry , 18(1), 67. https://doi.org/10.1186/s12888-018-1655-5 ↵
• Henning A, Kurtom M, Espiridion E D (February 23, 2019) A Case Study of Acute Stimulant-induced Psychosis. Cureus 11(2): e4126. doi:10.7759/cureus.4126 ↵
• Modification, adaptation, and original content. Authored by : Wallis Back for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A tale of mental illness . Authored by : Elyn Saks. Provided by : TED. Located at : https://www.youtube.com/watch?v=f6CILJA110Y . License : Other . License Terms : Standard YouTube License
• A Case Study of Acute Stimulant-induced Psychosis. Authored by : Ashley Henning, Muhannad Kurtom, Eduardo D. Espiridion. Provided by : Cureus. Located at : https://www.cureus.com/articles/17024-a-case-study-of-acute-stimulant-induced-psychosis#article-disclosures-acknowledgements . License : CC BY: Attribution
• Elyn Saks. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Elyn_Saks . License : CC BY-SA: Attribution-ShareAlike
• A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. Authored by : Yuanhan Bai, Xi Yang, Zhiqiang Zeng, and Haichen Yangcorresponding. Located at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851085/ . License : CC BY: Attribution

Mental Health Case Study: Understanding Depression through a Real-life Example

Imagine feeling an unrelenting heaviness weighing down on your chest. Every breath becomes a struggle as a cloud of sadness engulfs your every thought. Your energy levels plummet, leaving you physically and emotionally drained. This is the reality for millions of people worldwide who suffer from depression, a complex and debilitating mental health condition.

Understanding depression is crucial in order to provide effective support and treatment for those affected. While textbooks and research papers provide valuable insights, sometimes the best way to truly comprehend the depths of this condition is through real-life case studies. These stories bring depression to life, shedding light on its impact on individuals and society as a whole.

In this article, we will delve into the world of mental health case studies, using a real-life example to explore the intricacies of depression. We will examine the symptoms, prevalence, and consequences of this all-encompassing condition. Furthermore, we will discuss the significance of case studies in mental health research, including their ability to provide detailed information about individual experiences and contribute to the development of treatment strategies.

Through an in-depth analysis of a selected case study, we will gain insight into the journey of an individual facing depression. We will explore their background, symptoms, and initial diagnosis. Additionally, we will examine the various treatment options available and assess the effectiveness of the chosen approach.

By delving into this real-life example, we will not only gain a better understanding of depression as a mental health condition, but we will also uncover valuable lessons that can aid in the treatment and support of those who are affected. So, let us embark on this enlightening journey, using the power of case studies to bring understanding and empathy to those who need it most.

Understanding Depression

Depression is a complex and multifaceted mental health condition that affects millions of people worldwide. To comprehend the impact of depression, it is essential to explore its defining characteristics, prevalence, and consequences on individuals and society as a whole.

Defining depression and its symptoms

Depression is more than just feeling sad or experiencing a low mood. It is a serious mental health disorder characterized by persistent feelings of sadness, hopelessness, and a loss of interest in activities that were once enjoyable. Individuals with depression often experience a range of symptoms that can significantly impact their daily lives. These symptoms include:

1. Persistent feelings of sadness or emptiness. 2. Fatigue and decreased energy levels. 3. Significant changes in appetite and weight. 4. Difficulty concentrating or making decisions. 5. Insomnia or excessive sleep. 6. feelings of guilt, worthlessness, or hopelessness. 7. Loss of interest or pleasure in activities.

Exploring the prevalence of depression worldwide

Depression knows no boundaries and affects individuals from all walks of life. According to the World Health Organization (WHO), an estimated 264 million people globally suffer from depression. This makes depression one of the most common mental health conditions worldwide. Additionally, the WHO highlights that depression is more prevalent among females than males.

The impact of depression is not limited to individuals alone. It also has significant social and economic consequences. Depression can lead to impaired productivity, increased healthcare costs, and strain on relationships, contributing to a significant burden on families, communities, and society at large.

The impact of depression on individuals and society

Depression can have a profound and debilitating impact on individuals’ lives, affecting their physical, emotional, and social well-being. The persistent sadness and loss of interest can lead to difficulties in maintaining relationships, pursuing education or careers, and engaging in daily activities. Furthermore, depression increases the risk of developing other mental health conditions, such as anxiety disorders or substance abuse.

On a societal level, depression poses numerous challenges. The economic burden of depression is significant, with costs associated with treatment, reduced productivity, and premature death. Moreover, the social stigma surrounding mental health can impede individuals from seeking help and accessing appropriate support systems.

Understanding the prevalence and consequences of depression is crucial for policymakers, healthcare professionals, and individuals alike. By recognizing the significant impact depression has on individuals and society, appropriate resources and interventions can be developed to mitigate its effects and improve the overall well-being of those affected.

The Significance of Case Studies in Mental Health Research

Case studies play a vital role in mental health research, providing valuable insights into individual experiences and contributing to the development of effective treatment strategies. Let us explore why case studies are considered invaluable in understanding and addressing mental health conditions.

Why case studies are valuable in mental health research

Case studies offer a unique opportunity to examine mental health conditions within the real-life context of individuals. Unlike large-scale studies that focus on statistical data, case studies provide a detailed examination of specific cases, allowing researchers to delve into the complexities of a particular condition or treatment approach. This micro-level analysis helps researchers gain a deeper understanding of the nuances and intricacies involved.

The role of case studies in providing detailed information about individual experiences

Through case studies, researchers can capture rich narratives and delve into the lived experiences of individuals facing mental health challenges. These stories help to humanize the condition and provide valuable insights that go beyond a list of symptoms or diagnostic criteria. By understanding the unique experiences, thoughts, and emotions of individuals, researchers can develop a more comprehensive understanding of mental health conditions and tailor interventions accordingly.

How case studies contribute to the development of treatment strategies

Case studies form a vital foundation for the development of effective treatment strategies. By examining a specific case in detail, researchers can identify patterns, factors influencing treatment outcomes, and areas where intervention may be particularly effective. Moreover, case studies foster an iterative approach to treatment development—an ongoing cycle of using data and experience to refine and improve interventions.

By examining multiple case studies, researchers can identify common themes and trends, leading to the development of evidence-based guidelines and best practices. This allows healthcare professionals to provide more targeted and personalized support to individuals facing mental health conditions.

Furthermore, case studies can shed light on potential limitations or challenges in existing treatment approaches. By thoroughly analyzing different cases, researchers can identify gaps in current treatments and focus on areas that require further exploration and innovation.

In summary, case studies are a vital component of mental health research, offering detailed insights into the lived experiences of individuals with mental health conditions. They provide a rich understanding of the complexities of these conditions and contribute to the development of effective treatment strategies. By leveraging the power of case studies, researchers can move closer to improving the lives of individuals facing mental health challenges.

Examining a Real-life Case Study of Depression

In order to gain a deeper understanding of depression, let us now turn our attention to a real-life case study. By exploring the journey of an individual navigating through depression, we can gain valuable insights into the complexities and challenges associated with this mental health condition.

Introduction to the selected case study

In this case study, we will focus on Jane, a 32-year-old woman who has been struggling with depression for the past two years. Jane’s case offers a compelling narrative that highlights the various aspects of depression, including its onset, symptoms, and the treatment journey.

Background information on the individual facing depression

Before the onset of depression, Jane led a fulfilling and successful life. She had a promising career, a supportive network of friends and family, and engaged in hobbies that brought her joy. However, a series of life stressors, including a demanding job, a breakup, and the loss of a loved one, began to take a toll on her mental well-being.

Jane’s background highlights a common phenomenon – depression can affect individuals from all walks of life, irrespective of their socio-economic status, age, or external circumstances. It serves as a reminder that no one is immune to mental health challenges.

Presentation of symptoms and initial diagnosis

Jane began noticing a shift in her mood, characterized by persistent feelings of sadness and a lack of interest in activities she once enjoyed. She experienced disruptions in her sleep patterns, appetite changes, and a general sense of hopelessness. Recognizing the severity of her symptoms, Jane sought help from a mental health professional who diagnosed her with major depressive disorder.

Jane’s case exemplifies the varied and complex symptoms associated with depression. While individuals may exhibit overlapping symptoms, the intensity and manifestation of those symptoms can vary greatly, underscoring the importance of personalized and tailored treatment approaches.

By examining this real-life case study of depression, we can gain an empathetic understanding of the challenges faced by individuals experiencing this mental health condition. Through Jane’s journey, we will uncover the treatment options available for depression and analyze the effectiveness of the chosen approach. The case study will allow us to explore the nuances of depression and provide valuable insights into the treatment landscape for this prevalent mental health condition.

The Treatment Journey

When it comes to treating depression, there are various options available, ranging from therapy to medication. In this section, we will provide an overview of the treatment options for depression and analyze the treatment plan implemented in the real-life case study.

Overview of the treatment options available for depression

Treatment for depression typically involves a combination of approaches tailored to the individual’s needs. The two primary treatment modalities for depression are psychotherapy (talk therapy) and medication. Psychotherapy aims to help individuals explore their thoughts, emotions, and behaviors, while medication can help alleviate symptoms by restoring chemical imbalances in the brain.

Common forms of psychotherapy used in the treatment of depression include cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and psychodynamic therapy. These therapeutic approaches focus on addressing negative thought patterns, improving relationship dynamics, and gaining insight into underlying psychological factors contributing to depression.

In cases where medication is utilized, selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed. These medications help rebalance serotonin levels in the brain, which are often disrupted in individuals with depression. Other classes of antidepressant medications, such as serotonin-norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants (TCAs), may be considered in specific cases.

Exploring the treatment plan implemented in the case study

In Jane’s case, a comprehensive treatment plan was developed with the intention of addressing her specific needs and symptoms. Recognizing the severity of her depression, Jane’s healthcare team recommended a combination of talk therapy and medication.

Jane began attending weekly sessions of cognitive-behavioral therapy (CBT) with a licensed therapist. This form of therapy aimed to help Jane identify and challenge negative thought patterns, develop coping strategies, and cultivate more adaptive behaviors. The therapeutic relationship provided Jane with a safe space to explore and process her emotions, ultimately helping her regain a sense of control over her life.

In conjunction with therapy, Jane’s healthcare provider prescribed an SSRI medication to assist in managing her symptoms. The medication was carefully selected based on Jane’s specific symptoms and medical history, and regular follow-up appointments were scheduled to monitor her response to the medication and adjust the dosage if necessary.

Analyzing the effectiveness of the treatment approach

The effectiveness of treatment for depression varies from person to person, and it often requires a period of trial and adjustment to find the most suitable intervention. In Jane’s case, the combination of cognitive-behavioral therapy and medication proved to be beneficial. Over time, she reported a reduction in her depressive symptoms, an improvement in her overall mood, and increased ability to engage in activities she once enjoyed.

It is important to note that the treatment journey for depression is not always linear, and setbacks and challenges may occur along the way. Each individual responds differently to treatment, and adjustments might be necessary to optimize outcomes. Continuous communication between the individual and their healthcare team is crucial to addressing any concerns, monitoring progress, and adapting the treatment plan as needed.

By analyzing the treatment approach in the real-life case study, we gain insights into the various treatment options available for depression and how they can be tailored to meet individual needs. The combination of psychotherapy and medication offers a holistic approach, addressing both psychological and biological aspects of depression.

The Outcome and Lessons Learned

After undergoing treatment for depression, it is essential to assess the outcome and draw valuable lessons from the case study. In this section, we will discuss the progress made by the individual in the case study, examine the challenges faced during the treatment process, and identify key lessons learned.

Discussing the progress made by the individual in the case study

Throughout the treatment process, Jane experienced significant progress in managing her depression. She reported a reduction in depressive symptoms, improved mood, and a renewed sense of hope and purpose in her life. Jane’s active participation in therapy, combined with the appropriate use of medication, played a crucial role in her progress.

Furthermore, Jane’s support network of family and friends played a significant role in her recovery. Their understanding, empathy, and support provided a solid foundation for her journey towards improved mental well-being. This highlights the importance of social support in the treatment and management of depression.

Examining the challenges faced during the treatment process

Despite the progress made, Jane faced several challenges during her treatment journey. Adhering to the treatment plan consistently proved to be difficult at times, as she encountered setbacks and moments of self-doubt. Additionally, managing the side effects of the medication required careful monitoring and adjustments to find the right balance.

Moreover, the stigma associated with mental health continued to be a challenge for Jane. Overcoming societal misconceptions and seeking help required courage and resilience. The case study underscores the need for increased awareness, education, and advocacy to address the stigma surrounding mental health conditions.

Identifying the key lessons learned from the case study

The case study offers valuable lessons that can inform the treatment and support of individuals with depression:

1. Holistic Approach: The combination of psychotherapy and medication proved to be effective in addressing the psychological and biological aspects of depression. This highlights the need for a holistic and personalized treatment approach.

2. Importance of Support: Having a strong support system can significantly impact an individual’s ability to navigate through depression. Family, friends, and healthcare professionals play a vital role in providing empathy, understanding, and encouragement.

3. Individualized Treatment: Depression manifests differently in each individual, emphasizing the importance of tailoring treatment plans to meet individual needs. Personalized interventions are more likely to lead to positive outcomes.

4. Overcoming Stigma: Addressing the stigma associated with mental health conditions is crucial for individuals to seek timely help and access the support they need. Educating society about mental health is essential to create a more supportive and inclusive environment.

By drawing lessons from this real-life case study, we gain insights that can improve the understanding and treatment of depression. Recognizing the progress made, understanding the challenges faced, and implementing the lessons learned can contribute to more effective interventions and support systems for individuals facing depression.In conclusion, this article has explored the significance of mental health case studies in understanding and addressing depression, focusing on a real-life example. By delving into case studies, we gain a deeper appreciation for the complexities of depression and the profound impact it has on individuals and society.

Through our examination of the selected case study, we have learned valuable lessons about the nature of depression and its treatment. We have seen how the combination of psychotherapy and medication can provide a holistic approach, addressing both psychological and biological factors. Furthermore, the importance of social support and the role of a strong network in an individual’s recovery journey cannot be overstated.

Additionally, we have identified challenges faced during the treatment process, such as adherence to the treatment plan and managing medication side effects. These challenges highlight the need for ongoing monitoring, adjustments, and open communication between individuals and their healthcare providers.

The case study has also emphasized the impact of stigma on individuals seeking help for depression. Addressing societal misconceptions and promoting mental health awareness is essential to create a more supportive environment for those affected by depression and other mental health conditions.

Overall, this article reinforces the significance of case studies in advancing our understanding of mental health conditions and developing effective treatment strategies. Through real-life examples, we gain a more comprehensive and empathetic perspective on depression, enabling us to provide better support and care for individuals facing this mental health challenge.

As we conclude, it is crucial to emphasize the importance of continued research and exploration of mental health case studies. The more we learn from individual experiences, the better equipped we become to address the diverse needs of those affected by mental health conditions. By fostering a culture of understanding, support, and advocacy, we can strive towards a future where individuals with depression receive the care and compassion they deserve.

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Providing Sustainable Mental and Neurological Health Care in Ghana and Kenya: Workshop Summary (2016)

Chapter: 4 case studies, 4 case studies.

Throughout the workshop, case studies were presented of some of the successful mental health projects in Ghana, Kenya, and around the world. Although each case study was multifaceted and addressed many challenges, the workshop participants focused on distilling lessons learned from each project that could be applied to potential mental health demonstration projects.

AFRICA MENTAL HEALTH FOUNDATION 1 : COMMUNITY PARTNERSHIPS

Founded in 2004, AMHF has stated the vision of being “the center of excellence in Africa for research, training, knowledge translation, and advocacy in mental health.” 1 AMHF uses a multidisciplinary, multisectoral approach to improve mental health through programs at all levels, from physician specialist training to community-based stigma reduction, including school-based programs. According to David Ndetei, AMHF’s greatest successes have been in creating community partnerships and joint ownership of programs. One partnership in particular that has been successful is the relationship AMHF has built with traditional and faith healers. AMHF works with them to build awareness of mental health disorders, to develop skills to screen for and refer cases of mental illness, and to deliver evidence-based, mhGAP-adapted psychosocial interventions. Other partnerships critical to the success of their programs, noted

_______________________

1 See http://www.africamentalhealthfoundation.org (accessed July 14, 2015).

Ndetei, include those with county government where health services have been devolved and with the government of Kenya.

BASICNEEDS 2

BasicNeeds was founded in 2000 with the goal of improving the lives of people around the world diagnosed with a mental illness or epilepsy, by ensuring that their basic needs are met and their rights are recognized and respected.

Ghana 3 : Building Capacity of NGOs

BasicNeeds’ Mid-Ghana Project is focused on the Ashanti and Brong Ahafo regions. It is a community-based model that seeks to ensure that people with mental illness or epilepsy can access their human rights. Specifically, BasicNeeds’ activities can be categorized into four main areas: identifying and supporting people who have treatment needs; training community health workers; creating awareness; and supporting service delivery through psychiatric outreach to communities. Since 2000, BasicNeeds Ghana has provided 7,800 women, men, and children with mental illness or epilepsy and caregivers access to mental health and development services through community-based mental health, and it has developed 130 self-help user groups as a mechanism for patients and caregivers to express their needs and claim their rights to inclusion and development. Peter Yaro, executive director of BasicNeeds Ghana, said that a key component of their work is training local partners such as NGOs. BasicNeeds trains and supports key local partners on their Mental Health and Development model to enable the organizations to gain accreditation as a BasicNeeds franchise partner. The components of the model include capacity building, community mental health, sustainable livelihoods (e.g., promoting social reintegration), research, advocacy, policy, and collaboration. The NGOs they work with are not necessarily mental health organizations: for the Mid-Ghana project, for instance, the organizations were focused on child labor, reproductive health care, education, and women’s issues. Yaro said that this type of collaboration among NGOs is a great way to align mental health activities with what

2 See http://www.basicneeds.org (accessed July 14, 2015).

3 See http://www.basicneeds.org/where-we-work/ghana (accessed July 14, 2015).

the NGOs are already doing. He cautioned, however, that even though many NGOs are interested in working in mental health, they “sometimes do not know how.” He said that if given the proper support and training, these NGOs can be valuable partners in improving community mental health. As a result, BasicNeeds Ghana established two regional mental health alliances that bring together more than 45 community-based organizations/NGOs and decentralized government ministries, departments, and agencies to foster these collaborations and implement work in mental health.

Kenya 4 : Patients as Ambassadors

BasicNeeds works at the community level to build the capacity of people with MNS disorders to participate in their own treatment and recovery, as well as to reduce stigma and prepare the rest of the community to help people with MNS disorders. Joyce Kingori reported that the critical partners of BasicNeeds are the adults and children with MNS disorders “who have taken the courage to come and get treatment, to share their stories, to provide their insights.” BasicNeeds uses mental health “ambassadors”: young people who have been treated and now work to create awareness among their peers, and to reach out to provide support to those in need. Kingori noted that in addition to the critical partnership with patients, BasicNeeds also has important partnerships with organizations such as KAWE and AMHF, as well as the MoH and local government and health officials.

DIRECT RELIEF 5 AND BREAST CARE INTERNATIONAL 6 : COLLABORATION

Founded in 1948, Direct Relief provides medical resources to areas affected by poverty or emergency situations. It focuses primarily on maternal and child health, disease prevention and treatment, emergency preparedness and response, and strengthening health systems. 5 In partnership with Breast Care International (BCI), a Ghanaian-based organization dedicated to breast cancer awareness, the two organizations conducted a mental

4 See http://www.basicneeds.org/where-we-work/kenya (accessed July 14, 2015).

5 See http://www.directrelief.org/about (accessed July 14, 2015).

6 See http://www.breastcareghana.com/about (accessed July 14, 2015).

health research project in the Ashanti region of Ghana. They are currently collecting data on the burden of mental health and examining what types of mental health services are available, with the purpose of using the data to recommend measures to address the challenges in the region. Andrew Schroeder, director of research and analytics for Direct Relief, and Samuel Kwasi Agyei, of BCI, stressed the importance of collaboration in their work. Schroeder noted that the collaboration with BCI was critical to the success of the project because they are a community-based organization that is trusted in the area in which they work. In addition, because of BCI’s interest in broad-based health care, the project is working to embed mental health care services in the general health care system, rather than operating as a stand-alone mental health program, thus making improvements that are systematic and sustainable.

EMERGING MENTAL HEALTH SYSTEMS IN LOW- AND MIDDLE-INCOME COUNTRIES (EMERALD) 7 : STRENGTHENING HEALTH SYSTEMS

EMERALD, or Emerging Mental Health Systems in Low- and Middle-Income Countries, is a 5-year program (2012–2017) that works in six countries (Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda) to improve mental health outcomes by improving health system performance, said Jibril Abdulmalik, Co-Investigator of EMERALD at the University of Ibadan in Nigeria. The program consists of six work packages: (1) project management and coordination; (2) capacity building in mental health systems research; (3) adequate, fair, and sustainable resourcing for mental health (health systems inputs); (4) integrated provision of mental health services (mental health system processes); (5) improved coverage and goal attainment in mental health (health system outputs); and (6) dissemination. EMERALD seeks to strengthen the system itself through activities such as holding trainings for policy makers, researchers, and service users; providing scholarships for students seeking advanced degrees in mental health; developing curricula for master’s training in public mental health; helping countries with cost projections; facilitating the integration of mental health into primary care; and improving health information systems. Abdulmalik added that having cultivated

7 See http://www.emerald-project.eu (accessed July 14, 2015).

relationships with policy makers and key stakeholders was useful to understanding health care systems hierarchy, as well as leveraging existing platforms. He acknowledged that some of these individual efforts are “droplets” in a bucket, but he hoped that the EMERALD project, as a whole, would result in a comprehensive template for strengthening mental health systems in low- and middle-income countries.

FIGHT AGAINST EPILEPSY 8 : STAKEHOLDER ENGAGEMENT

WHO and the Ghana MoH, with support from Sanofi Espoir Foundation, have teamed up for a 4-year project (2012–2015) to reduce the epilepsy treatment gap, using a variety of strategies: promoting training of all health care providers, improving community awareness to reduce stigma and increase demand for care, and integrating epilepsy care within the primary health care system. Since the initiation of the project:

• A national/district coordinating committee was established;
• A situation analysis report was developed at the national, regional, and district levels;
• 330 volunteers and 404 primary health care providers were trained in epilepsy management;
• Gradual scale up occurred, with coverage now in 10 districts in 5 regions;
• A monitoring and evaluation strategy was developed; and
• A draft model of epilepsy care was developed.

Cynthia Sottie, national coordinator of the Fight Against Epilepsy project at the Ghana Health Service, said that engaging with stakeholders at all levels, at all stages of the project, has been critical to the project’s success. She noted that they have involved the Minister of Health, representatives from the teaching hospitals, national and international NGOs, the Mental Health Society of Ghana, regional health directors, faith healers, and community members. By involving so many stakeholders from the beginning of the project, “everybody was involved [and] everybody knows what is going on at each time.” Sottie said that everyone’s in-

8 See http://fondation-sanofi-espoir.com/download/2012-10-22_CP_Ghana_EN.pdf (accessed July 14, 2015).

volvement was vital to getting the support and participation necessary to carry out the project.

KENYA ASSOCIATION FOR THE WELFARE OF PEOPLE WITH EPILEPSY 9 : PUBLIC EDUCATION

KAWE was founded in 1982 and seeks to improve the lives of those with epilepsy through a variety of efforts, including the training of primary health workers, awareness creation and stigma reduction through community projects, medical provision and support (e.g., epilepsy clinics, patient groups), and policy advocacy at the MoH in Kenya. Between 2000 and 2014, KAWE trained 1,814 clinical officers and nurses and 3,095 CHWs, and the organization’s awareness programs reached an estimated 254,000 people directly and more than 3 million through mass media, said Osman Miyanji. In addition, more than 25,000 patients have been registered throughout clinics in Nairobi, Kenya, as a result of KAWE’s community programs, and from a training perspective, the organization helped launch national epilepsy guidelines and developed a more comprehensive curriculum for medical training institutions. Miyanji reported that KAWE has demonstrated that they can close the treatment gap, and he noted that in 30 years of experience, public education to address social stigma and reduce ignorance has been a key element of their success.

THE KINTAMPO PROJECT 10 : FOCUS ON COMMUNITY- BASED CARE

The Kintampo Project, a collaboration between Ghana and the United Kingdom, is “training a new generation of mental health workers,” said Joseph B. Asare. The project trains clinical psychiatry officers (CPOs) and community mental health officers (CMHOs). CPOs can diagnose mental illness and prescribe medication, while CMHOs focus on detection of mental illness in the community, education of local people, and reducing stigma and discrimination. CMHOs work in part by developing relationships with local families, schools, prayer camps, and tradi-

9 See http://www.kawe-kenya.org (accessed July 14, 2015).

10 See http://www.thekintampoproject.org (accessed July 14, 2015).

tional healers. The organization’s objective is to have one CPO and two to three CMHOs in each of Ghana’s 216 districts by 2017. Through the Kintampo Project, workers have been trained and deployed all over Ghana, helping thousands of the most needy people. The project is on track to boost the mental health workforce by 60 percent and the number of patients treated per year by 500 percent. By focusing on community-based care, Kintampo is shifting the focus of mental health care away from large hospitals and into the community where it is most needed, Asare said.

PROGRAM FOR IMPROVING MENTAL HEALTH CARE (PRIME) 11 : BUY-IN, BUY-IN, BUY-IN

Tedla Wolde-Giorgis provided an overview of PRIME’s efforts to integrate mental health into the existing health delivery system in five countries (Ethiopia, India, Nepal, South Africa, and Uganda). The purpose of the 6-year study, launched in 2011, is to research the magnitude, impact, and tractability of mental disorders in low- and middle-income countries. Using Ethiopia as an example, Wolde-Giorgis reported that integration was an incredibly complex process (beyond the instructions in the mhGAP intervention guide [IG]) that required buy-in from decision makers at all levels—national, regional, and community—as well as support from health care facilities and NGOs. Wolde-Giorgis said that, regardless of the level of support at the top, a top-down approach will not work; ultimately, the day-to-day work is done in the community and facilities, so it must be led at this level. He also noted that stigma reduction is a critical part of getting buy-in at the community level. For an effort to be sustainable, the buy-in must be continuous—it is not a one-time effort. Leadership must be continuously reminded of the importance of mental health and how it aligns with national priorities because there are so many other competing health concerns and health initiatives (e.g., MDGs).

11 See http://www.prime.uct.ac.za (accessed July 14, 2015).

PROJECT FIVES ALIVE! 12 : SCALING UP

The goal of Project Fives Alive! is to reduce mortality rates among children below age 5. Sodzi Sodzi-Tettey said the project uses a quality improvement approach, which requires forming quality improvement teams, having the teams develop initiatives on how to change mortality rates, implementing these initiatives, and then using data to assess if there was a positive effect. The project started in 9 hospitals but has since been scaled up to 200 hospitals. Sodzi-Tettey said that the initial 9 hospitals were chosen because they were high-burden hospitals with high rates of mortality for children below age 5. By the end of the first 18 months of operation, 6 of the 9 hospitals showed significant improvement in mortality reduction. By learning what worked in these high-burden hospitals, the project created a “change package,” which consisted of data-driven initiatives that had led to improvement related to improving delay in seeking and providing care and to reliable use of protocols. Sodzi-Tettey said that of the 134 hospitals in which the project currently operates, nearly 70 percent have adopted ideas from the change package, while also developing their own initiatives (e.g., targeted health education on early care-seeking using interactive platforms, triage systems for screening and emergency treatment of critically ill children, and training staff on protocols, followed by regular coaching and mentoring) ( Twum-Danso et al., 2012 ). In these 134 hospitals, there has been a 31 percent reduction in facility-based mortality in children younger than age 5. Sodzi-Tettey reported on three lessons learned from the project. First, initiatives should be tested promptly and on a small scale; this creates data that management can use to decide whether or not to implement a change. Second, teams should be empowered to know and use their own data. Sodzi-Tettey said that many workers were used to reporting data to the top but had not been aware of their own performance. Once they had the ability to track their own progress, they became even more invested in improvement. Finally, Sodzi-Tettey said that sustainability is only possible if a project understands and works within the existing health system, rather than with its own schedule and priorities.

12 See http://www.ihi.org/engage/initiatives/ghana/pages/default.aspx (accessed July 14, 2015).

PARTNERS IN HEALTH IN RWANDA 13 : INTEGRATION OF MENTAL HEALTH INTO THE GENERAL CARE SYSTEM THROUGH PUBLIC-SECTOR COLLABORATION AND LEVERAGE OF EXISTING HEALTH PLATFORMS

Partners In Health strives “to bring the benefits of modern medical science to those most in need of them and to serve as an antidote to despair.” 13 The Partners In Health program in Rwanda focused on close collaboration within the public sector to integrate mental health care into the general community-based care system within the district. At each level (hospital, health centers, and community), health workers were trained in mental health care. Partners In Health’s primary mental health endeavor in Rwanda was the integration of mental health care into health centers using existing structure of intensive supported supervision and quality improvement following training. One challenge that the program faced was resistance from the staff to admitting and treating psychiatric patients in the general ward. Smith offered several reasons for the resistance, including stigma and discrimination. She said the most successful strategy for reducing stigma among the health care workers was effective treatment of patients. When staff saw people come in with very acute psychiatric conditions, receive treatment, and get better, the workers’ perspective on mental health was significantly changed. Smith recalled the story of a district hospital manager who unknowingly hired a former patient to work on the grounds of the hospital. When he learned that she had been admitted to his hospital as a psychiatric patient only 2 months earlier, and was now capable of holding a job, he “became a big advocate for the work.” Smith said, “It was the witnessing of people getting better that was the most destigmatizing.” In addition to reducing stigma, Smith said that another key element of successful integration was leveraging the existing system structures and human resources. Rather than restructuring or bringing in new people, they worked within the existing system by mapping skill sets and matching them to the skills needed for mental health care. Smith said that by using what was already available, a much more rapid and efficient integration into primary care was possible.

13 See http://www.pih.org (accessed July 14, 2015).

MENTAL HEALTH CARE IN TURKEY: POLICY DEVELOPMENT

Oğuz Karamustafalioğlu, professor of psychiatry at Üsküdar University, provided an overview of mental health care in Turkey. He noted the high treatment gap for schizophrenia, depression, and substance use problems, and the lack of human and material (i.e., psychiatric beds) resources needed to adequately meet the demands of patients. In 2006, the MoH in Turkey released a National Mental Health Policy (NMHP) 14 aimed at mobilizing resources to ensure that mental health care services are accessible and balanced. Karamustafalioğlu stated that the NMHP encouraged preventative methods to decrease the burden of mental disorders, to increase attainable mental health care and services at both primary and secondary care levels, to encourage the respect of human rights for those with a mental illness, and to support the necessary legislation to protect their rights. Although there have been some successes since the NMHP was released—including an increase in the outpatient mental health care units at the general hospitals, the number of adult and child psychiatrists, and public education and awareness programs about mental health to reduce stigma—he emphasized that there is still more to be done to provide care and treatment to all patients.

WORLD ASSOCIATION FOR SOCIAL PSYCHIATRY AND SANOFI: COUNTRY-SPECIFIC APPROACHES

Sanofi’s Access to Medicines department works in some of the world’s poorest countries, disseminating information about MNS disorders, improving diagnosis, and making treatment affordable and accessible to patients, said Francois Bompart. Programs are specifically tailored to each country in which they work, an approach that is critical to success. For example, Sanofi works in Comoros, a small group of islands off the coast of Mozambique. Bompart said that several issues complicate mental health care in Comoros: transportation is difficult and expensive, and there is only one psychiatrist in the country. In order to work within these confines, Sanofi is working to train primary health care providers to use telemedicine to connect to the one psychiatrist—a tailored ap-

14 See https://www.mindbank.info/item/69 (accessed August 13, 2015).

proach that works for the specific context of Comoros but might be wholly inappropriate elsewhere. Similarly, in Guatemala, Sanofi tailored its approach by choosing to partner with a local NGO instead of the MoH because of instability in the government. With regards to cultural and societal sensitivities, Bompart noted that in some areas in countries such as Morocco, traditional and faith healers were not involved in the awareness programs given the local contexts.

686 PROJECT IN CHINA: FOCUS ON GENERAL PRACTITIONERS

The 686 project was a 2004 initiative that launched mental health reform in China after the severe acute respiratory syndrome (SARS) epidemic. Prior to the reform, mental health institutions (565 hospitals) were worn and outdated, there were no community-based mental health care services, and medical insurance was provided only to employed people. Ma Hong, deputy director of mental health programs at the China MoH, stated that initially, the government granted 6.86 million Yuan (860,000 USD) to train providers in mental health, and as the program continued, it covered free hospital treatment for patients and out-of-pocket medical costs for impoverished patients. Hong noted that it was critical to learn how to express the need for funding and the overall burden of mental health in the language of the government. The project consisted of 60 demonstration projects reaching a population of 42.9 million people, in which providers were trained; hospital services were expanded to communities; and, when universal medical insurance was implemented in China, the project covered out-of-pocket costs for impoverished patients. One significant challenge was that while there was adequate funding for services, the human resources necessary to actually provide care lagged behind. Hong said, “Money does not equal service—human resources development is much slower than simply building a new hospital.” She proposed that too much reliance on specialists in rural areas is misguided, and that when building a mental health program, the focus should be on expanding general practitioners’ knowledge of mental health and building their capacity to diagnose and treat MNS disorders. Hong noted that a hospital–community continuous care system has since been established and 4.29 million patients have been registered in the health information system, including 3.41 million patients who have received community health care, 61.7 percent of whom are farmers.

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Mental, neurological, and substance use (MNS) disorders have a substantial impact on global health and well-being. Disorders such as depression, alcohol abuse, and schizophrenia constitute about 13 percent of the total burden of disease. Worldwide, MNS disorders are the leading cause of disability, and the 10th leading cause of death. Despite this high burden, there is a significant shortage of resources available to prevent, diagnose, and treat MNS disorders. Approximately four out of five people with serious MNS disorders living in low- and middle-income countries do not receive needed health services.

This treatment gap is particularly high in Sub-Saharan Africa (SSA). Challenges to MNS care in SSA countries include a lack of trained mental health professionals, few mental health facilities, and low prioritization for MNS disorders in budget allocations. African countries, on average, have one psychiatrist for every 2 million people, whereas European countries have one psychiatrist per 12,000 people.

Expanding on previous efforts to address the development and improvement of sustainable mental health systems in SSA, the Institute of Medicine convened this 2015 workshop series, bringing together key stakeholders to examine country-specific opportunities to improve the health care infrastructure in order to better prevent, diagnose, and treat MNS disorders. Providing Sustainable Mental and Neurological Health Care in Ghana and Kenya summarizes the presentations and discussions from these workshops.

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Open Access

Peer-reviewed

Research Article

Friendship matters—An interview study with adolescents with attention deficit hyperactivity disorder

Contributed equally to this work with: Anna-Carin Robertz, Viola Nyman

Roles Conceptualization, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Current address: Department Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden

Affiliations Sahlgrenska Academy, Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden, Child and Adolescent Psychiatry Clinic, NU Hospital Group, Trollhättan, Sweden

Roles Methodology, Writing – review & editing

¶ ‡ AKK, SN and CJT also contributed equally to this work.

Affiliation Child and Adolescent Psychiatry Clinic, NU Hospital Group, Trollhättan, Sweden

Affiliations Sahlgrenska Academy, Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden, University of Gothenburg Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, Queen Silvia Children´s Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden

Roles Writing – review & editing

Affiliations Department of Paediatrics, Skaraborg Hospital, Skövde, Sweden, Sahlgrenska Academy, Institution for Clinical Science, University of Gothenburg, Gothenburg, Sweden

Affiliations Sahlgrenska Academy, Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden, Department of Health Sciences, University West, Trollhättan, Sweden, Department of Research and Development NU-Hospital Group, Trollhättan, Sweden

• Anna-Carin Robertz, 
• Anne-Katrin Kantzer, 
• Stefan Nilsson, 
• Carl-Johan Törnhage, 
• Viola Nyman

• Published: June 4, 2024
• https://doi.org/10.1371/journal.pmen.0000023
• Reader Comments

Attention deficit hyperactivity disorder (ADHD) is a condition diagnosed in 5% of children and adolescents. This neurodevelopmental condition causes impaired academic, social, and occupational functioning. Adolescents with ADHD symptoms have lower health-related quality of life and children with ADHD have been described as having difficulties forming positive friendships. Therefore, the aim was to describe how 15–17-year-old adolescents with ADHD experience friendship with peers. A semi-structured interview study was conducted with twelve adolescents about their experiences of friendships. The adolescents were recruited from a Swedish psychiatry clinic. A qualitative content analysis was used. In the results, three main categories were constructed: "Bonding with Friends" underscores the importance of understanding, shared interests, and adaptability. The "One’s own role" category emphasises the dynamic interplay of self-perception and interpersonal behaviours in interaction with friends. The "How Friendship Matters" category describes the complex nature of friendships, involving both support and conflicts. The adolescents’ relationships improved with age, influenced by self-awareness, ADHD medication and support from adults. In conclusion, friendships play a crucial role in the well-being of the participants, providing vital support when navigating ADHD associated challenges. It is essential that the adolescents themselves, but also adults and healthcare providers, recognise and address their impulsivity issues and need for daily planning. We should assist adolescents in developing effective interaction strategies with friends. The study highlights the significance of friendships and peer support for the adolescents’ health and functioning.

Citation: Robertz A-C, Kantzer A-K, Nilsson S, Törnhage C-J, Nyman V (2024) Friendship matters—An interview study with adolescents with attention deficit hyperactivity disorder. PLOS Ment Health 1(1): e0000023. https://doi.org/10.1371/journal.pmen.0000023

Editor: Kizito Omona, Uganda Martyrs University, UGANDA

Received: January 2, 2024; Accepted: March 28, 2024; Published: June 4, 2024

Copyright: © 2024 Robertz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The datasets presented in this article are not readily available because the General Data Protection Regulation (GDPR) applies to the data collected in this study, i.e., any information that refers to an identified or identifiable natural person. The GDPR applies in principle to every kind of operation and activity, regardless of who carries out the processing of this personal data. It thus applies to companies, associations, organizations, authorities, and private individuals. Requests to access the dataset should be directed to [email protected] .

Funding: This work was supported by the Ekhagastiftelsen (2020-16 to ACR), the Majblommans Riksförbund (27 to ACR), the Ebba Danelius Stiftelse (to ACR), and the Fonden för rehabilitering och medicinsk forskning (FRF)-Foundation (to ACR). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Attention deficit hyperactivity disorder (ADHD) is a common condition in children and adolescents, with a prevalence of 5% [ 1 ]. It is a childhood-onset neurodevelopmental disorder characterised by inappropriate and impairing inattention, motor hyperactivity and impulsivity. ADHD causes deficient academic, social, and occupational functioning [ 2 ]. Adolescents diagnosed with ADHD may be restless, tire easily and have difficulty understanding the consequences of their behaviour. The symptoms can also lead to an increase in risky behaviours, accidents, and injuries [ 3 ]. There is a higher risk of other mental health problems and almost half of all adolescents with ADHD develop depression [ 4 ]. ADHD is characterised by its association with an elevated risk of various challenges including low self-esteem, poor educational achievements, involvement in criminality [ 5 ], substance abuse, accidents, speeding and driving while under the influence of drugs or alcohol [ 6 , 7 ].

The following studies outline previous research and existing knowledge concerning the experience of friendship among children and adolescents diagnosed with ADHD. Additionally, we have attempted to uncover contemporary insights on this topic. Children with ADHD often find it difficult to form good friendships [ 8 , 9 ]. A questionnaire disclosed that if the relationship with friends was of poor quality at age 13–14, it often deteriorated further by the age of 17–18 years. The boys in th study more often reported different best friends over time compared to the girls [ 10 ]. In a Lancet series about adolescent health, being popular and experiencing love and passion in others is important [ 11 ]. An observational study on 6-18-year-old adolescents with ADHD reported that they were more often involved in bullying than adolescents without ADHD [ 12 ]. Recent research shows that concomitant motor coordination disorders in adolescents with ADHD impair their ability to form friendships [ 13 , 14 ]. In an observational study of children with ADHD aged 7–11 years, low prosocial behaviour, lack of social insight or inability to accurately report social competence were found to be common [ 8 ]. Children with hyperactivity/impulsivity symptoms combined with impaired executive ability were rated by their friends as more aggressive, while children with inattention symptoms combined with impaired executive ability were perceived by their friends as having low prosocial ability [ 15 ]. However, Maya Beristain and Wiener’s [ 16 ] questionnaires to 107 adolescents with and without ADHD aged between 13 and 18 years revealed no difference in the frequency of contact with friends, the number of friends or the duration of friendships. In the same study, fewer of the girls with ADHD had their best friends in other schools.

Krauss and Shellenberg [ 17 ] studied 907 14-24-year-olds with impairments and behavioural problems in Switzerland, finding that adolescents with ADHD symptoms had lower health-related quality of life, but the study revealed no significant differences in well-being related to friends/peers between those with subclinical and unremarkable ADHD symptoms. The results indicate a potential need for preventive measures in schools to address subclinical ADHD symptoms and improve well-being, particularly among adolescents. Barfield [ 18 ] underscores the value of seeking a person’s subjective view to understand their life situation. In an other study including nine interviews with adolescents aged 16–18 years, the participants experienced chronic peer rejection, loneliness, and conflictual relationships with friends during childhood and early adolescence, which highlights the developmental and contextual factors that shape the friendship experiences of adolescents with ADHD. Despite many expressing a sense of resignation to remaining friendless during adolescence, the transition to secondary school emerged as a period when they found peers with similar interests, thus fostering the development of close friendships [ 19 ]. There is a great deal of research describing the lives of children and adolescents with ADHD diagnosis. However, to our knowledge, there are only a limited number of interview studies about adolescents with ADHD exploring their own experiences of relationships with friends.

To describe how 15-17-year-old adolescents with ADHD experience friendship with peers and explore the dynamics of living with ADHD emphasising the transformative role of friendship due to the influence it has in their lives.

The study was approved by the Swedish Ethics Review Authority (registration number 2020–01414). One month before the interviews, information letters were sent to the potential participants, which included an invitation to participate in the interview. They were then contacted by phone and invited to take part in the TaMa–ADHD study. Oral and written consent was obtained from the adolescents before the interviews started. In Sweden, consent from parents or guardians is not required for adolescents who have reached the age of 15 years. The interviews were recorded and saved in a file on the secure hospital server. All data were handled confidentially, and no individual participant could be identified. The participants were informed that they could withdraw their participation at any time before submission without giving a reason or without any consequences for their care. Adolescents who were interested in the results were informed that they could contact the first author for information.

Study design

The study is part of the Tactile Massage (TaMa)-ADHD research project. Other results from this research will be presented elsewhere. Here we present results from an interview study with semi-structured questions. In qualitative content analysis, the researchers strive to make the participants’ voices heard [ 20 ]. The rationale behind adopting a qualitative study design is to capture variations in experiences within a population, in this case, adolescents with ADHD. The purpose of employing this design was to interpret and comprehend adolescents’ perspectives and how the diagnosis influences their lives. Qualitative content analysis considers a text in its context and the interpretation of participants’ narratives should be done with an awareness of their life conditions, history, and prevailing culture [ 21 ].

Participants

The participants were retrieved from the patient registration system of a child and adolescent psychiatry clinic in Western Sweden, based on diagnosis and medication. To obtain a homogeneous group, the inclusion criteria were: 1) age 15:0–17:11 years; 2) previously diagnosed with ADHD in combined form F90.0B according to the International Classification of Diseases (ICD-10) [ 22 ]; 3) unmedicated or medicated with central stimulants and/or atomoxetine without modifications in the medication for the last six months. Sleep medication such as melatonin or promethazine was allowed; 4) able to speak, write and read Swedish. Exclusion criteria were: 1) ongoing suicidality; 2) ongoing substance abuse; 3) other severe mental disorders, such as autism, severe depression, epilepsy, manic episode or psychosis and intellectual disability; 4) involvement in other ongoing psychological treatment such as psychotherapy, group therapy and parent training. In September 2021 the clinic registration system contained 377 adolescents aged 15–17 years diagnosed with ADHD and comorbid conditions. From these, a homogenous group of 195 with combined type ADHD who did not have any of the excluded diagnoses was chosen. After a review of each patient’s record (from September to October 2021) to check for the inclusion and exclusion criteria, 78 adolescents were selected. An invitation letter was sent to all 78 adolescents containing information about the study and informing them that the first author would contact them from a randomised list or that they could contact the first author themselves. The recruitment ended after 14 adolescents had agreed to participate in the whole TaMa-ADHD study. No additional adolescents volunteered after the inclusion period ended, eliminating the necessity to exclude anyone from participation. In qualitative content analysis, research questions frequently appear to be adequately addressed with 10–15 participants [ 23 ]. This validates the acceptability of the chosen sample size of 14 participants. All 14 participants, five girls and nine boys, were aged from 15.5 to 17.5 years, with a mean age of 16.4 years. Two male participants were unable to attend the interview part of friendships. Thus, a total of 12 adolescents participated.

Data collection

An appointment was arranged for a first visit in December 2021, where their ADHD diagnosis was double-checked with the ADHD section of the MINI-KID. This is a standardised diagnostic interview with children and adolescents under the age of 18 years [ 24 ]. The MINI-KID interview contains 24 diagnostic parts, but only the section related to ADHD (section O) was included in this study. The interviews started with the following questions: O4 Did you have problems with inattention , overactivity , or impulsiveness before you turned 12 ? and O5 Did this cause problems with your friends ? In addition to these two questions from the MINI-KID the interviews were based on an interview guide with the opening question ‘How do you view your peer relationships?’ and other key questions were ‘How do your peer relationships affect your well-being?’ and ‘What is a good peer relationship for you?” The interviews were conducted from the 7 th to the 27 th of December 2021. Two psychiatry master students each performed six one-to-one interviews. Eleven interviews were performed in face-to-face meetings and one over the telephone. The interviews were recorded, each lasting between 15 to 40 minutes; (mean 27.5).

Qualitative content analysis was used [ 25 ]. The approach involved an unbiased analysis of the text, where patterns were sought in the material based on the adolescents´ experiences. The analysis process in qualitative content analysis is not linear but characterised by a de-contextualisation and re-contextualisation [ 21 ]. The text was transcribed verbatim by the master students and they as well as the last author read through the text several times to gain an overview, after which they condensed the text while remaining close to the content. In the next step, they created meaning units. The meaning units were then abstracted and brought together under different codes based on the aim of the study. The codes were labelled with a descriptive code close to the original text and then grouped into sub-categories by the master students. The analysis was then reviewed critically by the first, second and third authors. After this, all authors discussed the analysis together on several occasions and three main categories were constructed.

Three main categories were constructed from the interviews: Bonding with friends , One’s own role and How friendship matters .

Bonding with friends

This category revolves around the multifaceted dynamics and factors influencing the formation and maintenance of friendships among the participants. It encompasses the qualities, shared experiences, activities, and digital interactions that contribute to the formation and maintenance of their friendships, highlighting the importance of understanding, shared interests, and adaptability in the face of external challenges such as the COVID-19 pandemic. The participants stated that a friend should be kind, humble and caring. It was important to be invited to participate in an activity and being with friends who made no demands was appreciated. Having fun together and paying attention to each other when socialising was seen as positive.

“It’s that you… so you’re always kind… and you ask, do you want to hang out? … and … yes caring … like and … always thinking of each other .” Participant 1

It was described as easier to talk about everyday problems with friends of the same age than with adults. In this respect, friends could be seen as a complement to parents, especially when talking about relationship problems, love problems or when adolescents have difficulties at home. Another important factor for friendships was growing up together. Other adolescents with ADHD were also valuable, as they had a better understanding of the situation.

"It’s probably one who has it [ADHD] confirmed , but I think the rest of the guys also have something if I’m completely honest . " Participant 7 "Most people in my group of friends have problems sitting still so … most of them are the same so … it turns out that you fit better together because you … everyone is the same . " Participant 5

Sports and other leisure interests were described as an important basis for friendship. Common leisure activities after school were talking, watching TV, playing games, applying make-up, trying on outfits, or listening to music. Other leisure activities included meeting up at shopping centres, going out to eat or driving A-tractors (low-speed vehicles that can be driven from the age of 15 years) and hanging out in large groups. What mattered was not so much the kind of activity, but that the adolescents socialised and took the day as it came. It also emerged that it could be nice to be alone sometimes, but they more often wanted to meet friends.

Social media was described as the main way of socialising, which could be via text messages, scrolling on different applications or online games. However, some adolescents did not use social media at all. Social media was a way to keep in touch with friends, but also a way to meet new friends. Certain steps in the friendship-building process could be skipped, which made it quicker to get to know each other. Participants stated that when things were difficult it was sometimes easier to open up to their old friends online than in real life. An online friendship could last several years and was valued just as much as physical friendships.

“I think it’s easier, you don´t feel like you are being judged or something … if you were to be judged, it’s nothing more than your friend on Snapchat disappearing. Nothing changes in the group of friends or anything.” Participant 4

When the interviews were conducted, the COVID-19 pandemic had been ongoing for two years. The pandemic and subsequent distance learning were something that affected friendships, especially for those adolescents who had just started secondary school and had not had time to get to know their new classmates. They perceived that the process of making new friends and assimilating into the new social context of secondary school took significantly more time.

"Over the past year, it’s like … when I feel, ’Now I need to talk to someone,’ then there have been fewer and fewer people I could turn to… I haven’t really noticed until it was needed that I don’t have anyone to talk to." Participant 4.

One’s own role

The essence of this category concerns the participants actively managing their roles in friendships and navigating challenges associated with impulsivity, insecurity, and conflicts. The category highlights the active role the participants play in shaping and maintaining friendships. The essence revolves around the dynamic interplay of self-perception, coping mechanisms, and interpersonal skills in the context of friendships. In new friendships, it was important that the socialising continued to be interesting and that friends were active and wanted to do things, otherwise the participants became bored and moved on to new friends. If the friend continued to be interesting, it could become a long-term relationship. The participants often took on the role of the happy one who tried to lighten the mood of the group when someone was feeling bad and attempted to entertain their friends. When the adolescents described themselves in relation to their friends, they talked about themselves as being outgoing and having the ability to make new friends easily.

“I’ve always heard , and I know it myself … that I’m like … very easy to be friends with and make friends . It’s like an interest” Participant 4 "So , I’ve never had any problems making friends because I’m quite social , so …" Participant 5

However, some adolescents described themselves as introverted or shy, which made it harder for them to make new friends. They might prefer a few close friends rather than many acquaintances. Overall, there was a range of attitudes concerning friendship and socializing among the participants.

"I’m not exactly the friend expert …" Participant 13

Being spontaneous or impulsive could be perceived as both positive and negative. It was described that impulsivity could be expressed through, for example, quick comments and by amusing their friends with witty attacks. One difficulty that emerged was controlling their impulses, including in the performance of team sports. One way to deal with this was to carefully plan the intake of ADHD medication so that the effect occurred during the sport period. This could be perceived as limiting and frustrating as it required careful planning, sometimes several days in advance. The fact that their peers did not realise their need to take medication before a team activity could also be annoying for the adolescents.

"Because I don’t have enough impulse control, I think, to manage if something goes against me or if something unplanned happens. Because it will go to hell if I can’t control myself ”. Participant 11

Insecurity in the relationship with friends was described, an example being when friends did not respond immediately to text messages. That created a feeling that the friends did not want to socialise, which could lead to negative thoughts and not having the courage to get in touch again. Another description was that it took a long time to become attached to and trust people, resulting in a sense of not having many real friends but only superficial ones. It could also be difficult to initiate contact with friends from school to do things in their leisure time, even if they had common interests. There was also uncertainty about seeking contact with new people and it could take several terms before a relationship felt secure.

“I didn’t really know how to… what to say… how to be a friend, that’s how it was. And how to be… without saying anything, without someone getting hurt or sad like .” Participant 1

Conflicts could arise due to misunderstandings in communication, which could complicate new friendships. They stated that it could be difficult to interpret situations that had led to conflicts in the past and still did. The tone in different situations with friends could also be difficult to interpret, which, among other things, made it challenging to decide when it was appropriate to be serious and not take jokes too far. It could also be difficult to determine when something was wrong in a friendship.

“What can I say… not drama but things happen all the time. Because I don’t understand that I have…done anything wrong but… Then it became a big misunderstanding and I just…well …” Participant 4

There was a fear of conflict and withdrawal was a way of trying to avoid it. There were also statements about being drawn into conflicts between friends against their will. Participants expressed that they avoided conflicts with friends at school and in their leisure time as much as possible but sometimes took their irritation out at home instead.

“I must always have something to argue about, sort of. I’m not really that addicted to drama, but I kind of always get drawn into drama because I’m kind of in the middle. So, I always get drawn into it anyway .” Participant 2

It could be difficult to withdraw from friends in their leisure time and might be easier to say yes and meet up for a while, even if they did not want to. It was easier to keep in touch with friends by phone or online when they did not have enough energy to meet up. Friends were important even when energy levels were low but there was a fear of using friends as therapists. Being a positive and social person in a friendship could be associated with demands, making it difficult to keep up that facade as it required a great deal of energy on the part of the young person. One way to deal with this was to retreat from their friends during periods when they were unable to cope.

"I’m known as the positive one and so when you’re having a bit of a bad day, you just… yup… Because I kind of can’t stand it if I’m not… happy or how to put it… then I can’t stand being social … because it takes so much energy .” Participant 4

At times it was necessary to prioritise schoolwork, mainly on weekdays but also at weekends. The school took a lot of energy and sometimes the participants had to take a nap in the afternoons. They needed to study while the ADHD medication was active. There was a fear of falling behind in school, especially at the beginning of the last years of secondary school.

"Go home and sleep… . I kind of do, I’m completely exhausted after school, so I can’t take it… it’s so tough at school so … you have to go home and rest." Participant 10

How friendship matters

This category describes the multifaceted impact and diversity of experiences of friendships on the lives of the participants. In essence, it captures the nuanced nature of friendships in the lives of the participants, encompassing both positive and challenging aspects and highlighting the evolution of these relationships over time. The influence of friends varied, but socialising with friends was invigorating and provided relaxation in an otherwise hectic life. Friendships could also negatively affect their behaviours, such as when they felt vulnerable or were provoked by their friends.

"Some people screw up, are annoying and irritating… just because they know that even if you get angry that day, you’re not angry the next day… They always think it’s fun to be annoying to those who get the angriest ." Participant 2.

Some participants described having long-standing friendships and never feeling that they had been left out or had no one to socialise with. Living in a small community with small classes at school contributed positively to friendships. As they had always been social and chatty, it facilitated their ability to make friends. An occasion when it was difficult to make friends was when a sense of alienation occurred and led to conflicts with classmates. This evoked negative feelings of being different or weird, resulting in anger.

"When I was smaller and around the 2nd and 4th class… then I had a very hard time with friends or I was often frozen out and like that, fought a lot with my friends because they shut me out… so that time was tough… but now it’s much easier. I was frozen out… It was harder for me at school, I didn’t finish as quickly, so the others ran out and played ." Participant 10

Relationships with friends often improved as the participants became older, although the opposite also occurred in some cases. Why it became easier over time was due to a greater awareness of their diagnosis, starting ADHD medication, getting help from supportive adults such as parents and teachers and the fact that they themselves and their friends had become older and more mature.

“I was thirteen years old when I was diagnosed with ADHD… Yes, so I was very late. I guess they thought I was a little weird… or I don’t really know. I couldn’t really control myself when I was younger. I didn’t really know how to say or not say and… well, so it was a bit tough at times with my friends when I was younger .” Participant 1

This qualitative study aims to describe twelve adolescents with ADHD and their experiences of friendship. Three main categories were constructed when analysing the interviews: Bonding with friends, One’s own role and How friendship matters. Key findings reveal the importance of meaningful friendships for this group of adolescents. While most of the participants in the study described themselves as finding it easy to make friends, many of them struggled with maintaining friendships and finding a functioning life balance between school and leisure time that they could spend with friends due to ADHD-related difficulties. The participants mostly described themselves as social and that they found it easy to make new friends. In addition, they expressed that they attempted to lighten the mood and entertain their friends. However, they also experienced periods of suffering due to problems with peer relationships. For example, when they were younger not being allowed to go on a break at the same time as the other children had created a feeling of exclusion, which led to frustration, and fighting and could affect their ability to make and keep friends. In their study Hanai et al. [ 26 ] also noted that adolescents derived a sense of security by maintaining stable connections with their friends, classmates, teachers, and family members. Lam et al. [ 27 ] found that friends were important for adolescents in general as friends influenced their behaviour, norms, and values. Additionally, two other studies underscored that adolescents typically spend a significant amount of time with friends and are influenced by both their negative and prosocial behaviours [ 28 , 29 ]. This is in line with this study, where the participants reported experiencing both benefits and challenges within their friendships.

The participants described online games and social media were the main way to socialise with their friends, although they also socialised with their friends in real life. Socialising online could be a way to conserve energy when there was no time to meet in person. Bolic Baric et al. [ 30 ] reported that adolescents with ADHD performed fewer leisure activities such as meeting friends, doing homework, taking part in sports, reading, or performing theatre/dance compared to a reference group. They were more likely to play computer games, and internet activities were an opportunity for adolescents to communicate with friends as a complement to face-to-face meetings. Dawson et al. [ 31 ] found that 92.5% of the adolescents with ADHD were online daily via a smartphone or computer, which was also representative of adolescents of the same age in general. The participants in this study mainly interacted online with friends or family members who they saw in person every day and to a lesser extent with friends they only knew online. Interacting frequently online with friends they met each day was a protective factor against online risk behaviours. However, in their study, Maya Beristain et al. [ 16 ] reported that girls with ADHD had friends whom they had initially met online. Likewise, participants in this study described that interacting online could broaden their network of friends and they believed that it prevented them from engaging in negative behaviours. They considered online friends just as important as physical friends and described the advantages of online friendships. It could be easier to meet new friends online as some formal steps of getting to know each other could be skipped. They also reported that some online friendships lasted for several years.

The participants in this study mentioned that the COVID pandemic and subsequent distance learning was something that affected their friendships, especially for those who had just started secondary school and had not had the chance to get to know their new classmates. The COVID-19 pandemic meant that it could take longer to settle into the community of a new class and make new friends. During the pandemic, depression, anxiety [ 32 , 33 ], slow cognitive tempo, inattention and non-cooperation increased in all adolescents. However, these symptoms increased even more in adolescents with ADHD [ 32 ]. However, these two studies were not conducted in Sweden, whereby the results may differ in terms of how the COVID-19 pandemic affected adolescents. This is because Sweden had contrasting guidelines and restrictions during the pandemic compared to other countries. We only found one Swedish study investigating the impact of COVID-19 on adolescents with ADHD. In that study, adolescents exposed to COVID-19 during most of 2020 showed no differences in longitudinal changes in mental health, relationships with parents and peers and health behaviours compared to those not exposed to COVID-19 [ 34 ]. In the present study, the contact with friends during the pandemic varied for the different participants. There were descriptions of how friendship had been affected in such a way that they did not meet as much as before the pandemic and had more contact via social media, or that meeting places for adolescents were closed, forcing them to meet outdoors more often. However, some adolescents did not feel that they had been much affected by the pandemic and continued to meet their friends as usual.

Research on positive illusory bias (PIB) suggests individuals with ADHD, especially children and adolescents, may underestimate difficulties and overestimate competence. However, caution should be exercised when using the term "positive illusory bias," as girls with ADHD rated themselves more negatively than did their parents, teachers, and peers [ 35 ]. In contrast, it has been found that young people with ADHD aged 14 to 24 years do not differ from young people in general in their ability to form friendships [ 17 ]. McKee [ 36 ] found that adolescents (17–19 years) with ADHD rate themselves as being as good as their peers in terms of initiating social contact. However, Rokeach and Weiner [ 37 ] identified a difference in the perceived quality of friendships among 16–18-year-old adolescents with ADHD compared with adolescents without ADHD. ADHD symptoms were associated with increasing negative friendship quality across secondary school for boys, which may be one mechanism that explains the development of depressive symptoms in adolescent boys with elevated ADHD symptoms [ 10 ]. The participants in this study described emotional support, intimacy, and security as valuable, as well as mutual entertainment. However, Morsink et al. [ 38 ] suggested that adolescents with ADHD might consider mutual entertainment to be the core aspect of friendship in contrast to the group without ADHD, where the active pursuit of shared feelings of affection was expressed as the most important. The participants in this study described how long-lasting friendships mattered in their lives and coming from a small community was seen as a facilitator for making friendships last.

The participants reported that the energy required to be with friends sometimes disappeared and that schoolwork had to be prioritised because otherwise, they would have no energy left. In a systematic review, adolescents with ADHD reported more subjective sleep problems compared to the control groups [ 39 ]. Daytime sleepiness is prevalent in ADHD, affecting over 50% of adolescents with the condition [ 40 ]. The participants needed careful planning to both be able to do their homework and participate in team sports while the ADHD medication was effective. The fact that friends did not understand the importance of planning to ensure that the activity and medication intake coincided and that it was pivotal for their functioning in physical interactions was described as frustrating. Meaux et al. [ 41 ] found that the perception of being able to concentrate was 100% during the period when the medication was effective, but that the level dropped to 20% when the effect decreased and became even less than on days when the adolescents did not take the medication at all. In a review, medication was reported to be crucial for ADHD management but did not address all symptoms or skill-building ability. While it aids organisational skills, daily life skills are also necessary [ 42 ]. However, Blase et al. [ 43 ] observed no difference in the ability to concentrate between college students with ADHD who took medication and those who did not. Adolescents with ADHD often experience comorbid internalising disorders such as anxiety and depression [ 44 ]. It is therefore crucial to address these challenges in adolescents with ADHD and their interactions with peers, as they persist into adulthood, accompanied by issues such as sleep problems and low self-esteem. Multimodal treatment approaches encompassing psychoeducation, pharmacotherapy and disorder-oriented psychotherapy are essential at any age. Non-pharmacological methods, including complementary and alternative medicine, may also be beneficial. Studies highlight elevated risks of poor social outcomes, such as separation and early parenthood for individuals with ADHD [ 42 ], emphasising the importance of a range of interventions. The use of complementary and alternative medicine, such as massage therapy, is promising for improving ADHD symptoms, including anxiety and asocial behaviours [ 45 , 46 ]. There is a need for further investigation of complementary treatments. It is essential to understand that there is no one-size-fits-all solution. Each young person with ADHD is a unique individual with their strengths, challenges, and preferences. Tailoring support systems and interventions to align with their specific needs ensures a more effective and personalised approach.

Strengths and limitations

Rich data were obtained from the sample, which included approximately equal numbers of girls (n = 5) and boys (n = 7), as well as being relatively evenly distributed in terms of age and where the participants served as a good source of information. All participants were recruited from the same hospital in western Sweden. Because the study was conducted during the COVID-19 pandemic, there was a requirement to use face masks. This may have influenced participants’ perception of safety but also the interviewer’s ability to read their facial expressions. However, there was a photo and a brief presentation of the interviewers in the information letter sent to the participants before the interview. The participants came from a limited geographical area, mostly from small towns or medium-sized cities. The results might have been different if the geographical distribution had been larger. To achieve trustworthiness, the COREQ checklist [ 47 ] was consulted throughout the study to optimize the quality.

This study is one of the few in its investigation of the perspectives of young individuals, conveyed through personal narratives shared in interviews. From their reflections, three categories of peer relationships have been discerned: Bonding with friends, One’s own role and How friendship matters. The result indicates that despite perceiving themselves as having good relationships with friends, the participants experienced difficulties understanding and reading situations involving friends. Experiences of conflict were described, where they had been misunderstood and excluded. The adolescents with ADHD were drawn to other adolescents with the same diagnosis or similar energy levels, as they expressed having an increased understanding of each other. Friends of the same age play a central role in the identity formation of adolescents with ADHD. It is crucial to comprehend the challenges these adolescents face in managing their daily lives, such as the necessary planning to function. They struggle with impulsivity, a challenge often misunderstood by others who may not grasp the constant energy waste it causes. Friendships are seen as essential, impacting the participants’ well-being and providing support when navigating the challenges associated with ADHD. For guardians and healthcare providers, support involves considering the adolescents’ entire lifeworld in which relationships are an important aspect, by, for example supporting the adolescents to develop strategies in their interactions with friends and helping them build self-esteem. Healthcare providers can additionally provide psychosocial treatment, contribute to the understanding of ADHD symptoms, and teach strategies to cope with them. Creating an environment that embraces neurodiversity and fosters inclusion is essential. Educators, parents, and peers play a pivotal role in building a supportive community that encourages the development of strengths while providing understanding and accommodation for challenges. By doing so, we empower young people with ADHD to navigate the world confidently, armed with a sense of self-worth and the knowledge that their differences are not limitations but can also be valuable assets.

Acknowledgments

Our gratitude and special thanks go out to all the adolescents who participated in the interviews. We would also like to thank Nathalie Björkman and Nanna Hallberg for conducting the interviews. We also extend appreciation to Monique Federsel for proofreading.

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• Introduction
• Conclusions
• Article Information

Hazard ratios with 95% CIs for the associations between having 1 or more than 1 ninth-grade classmate with any of the examined mental disorder diagnoses ( International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, codes F10-F50 or F90-F98) and later risk of being diagnosed with a mental disorder in 4 follow-up time windows. The Cox proportional hazards models were adjusted for sex, birth year, school class size, school’s ninth grade size, area-level urbanicity, area-level morbidity, area-level educational level, area-level employment rate, parental educational level, parental income, and parental mental health, with a random intercept per school. For the diagnosis-specific results with the 3-level exposure, see Figure 2; eFigure 2 in Supplement 1 .

Hazard ratios with 95% CIs shown for mood ( International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ ICD-10 ], codes F30-F39) (A), anxiety ( ICD-10 codes F40-F48) (B), and internalizing (C) and externalizing (D) disorders in 4 follow-up time windows. The Cox proportional hazards models were adjusted for sex, birth year, school class size, school’s ninth grade size, area-level urbanicity, area-level morbidity, area-level educational level, area-level employment rate, parental educational level, parental income, and parental mental health, with a random intercept per school. For the diagnosis-specific associations for substance misuse, schizophrenia spectrum, eating, and behavioral and emotional disorders, see eFigure 2 in Supplement 1 .

eTable 1. Annual Number of Mental Disorder Diagnoses Together With the Number of Exposed/Unexposed Classes and Cohort Members

eTable 2. Additional Descriptive Statistics of the Study Population

eFigure 1. Schoenfeld Residuals for the Diagnosis Categories

eTable 3. Diagnosis-Specific Associations Between Having Ninth Grade Classmates With a Mental Disorder Diagnosis and Later Risk of Being Diagnosed With a Mental Disorder

eFigure 2. Diagnosis-Specific Associations Between Having Ninth Grade Classmates With a Mental Disorder Diagnosis and Later Risk of Being Diagnosed With a Mental Disorder

eFigure 3. Diagnosis-Specific Associations Between Having Ninth Grade Classmates With a Mental Disorder Diagnosis and Later Risk of Being Diagnosed With a Mental Disorder Using Binary Exposure

eTable 4. Sensitivity Analyses on the Associations Between Having Diagnosed Ninth Grade Classmates and Later Risk of Being Diagnosed With a Mental Disorder

eTable 5. Series of Cox Regression Models Indicating the Respective Confounding Influences of Each Covariate Domain (School-Level, Parental-Level, and Area-Level)

eTable 6. The Associations Between Having Ninth Grade Classmates With a Mental Disorder Diagnosis and Later Risk of Being Diagnosed With a Mental Disorder Stratified Into Three Shorter Time Periods

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Alho J , Gutvilig M , Niemi R, et al. Transmission of Mental Disorders in Adolescent Peer Networks. JAMA Psychiatry. Published online May 22, 2024. doi:10.1001/jamapsychiatry.2024.1126

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Transmission of Mental Disorders in Adolescent Peer Networks

• 1 Department of Psychology, University of Helsinki, Helsinki, Finland
• 2 School of Business and Economics, University of Jyväskylä, Jyväskylä, Finland
• 3 Centre for Mental Health and Safety, Division of Psychology & Mental Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
• 4 National Institute for Health and Care Research Greater Manchester Patient Safety Research Collaboration, Manchester, United Kingdom
• 5 Finnish Institute for Health and Welfare, Helsinki, Finland

Question   Is having peers with a mental disorder in the same social network during adolescence associated with later risk of mental disorder?

Findings   In this cohort study including more than 700 000 individuals in Finland, analysis of nationwide, interlinked registry data found that having classmates diagnosed with a mental disorder in the ninth grade of comprehensive school was associated with increased risk of receiving a mental disorder diagnosis later in life. Increased risk remained after adjusting for an array of parental, school-level, and area-level confounders.

Meaning   The findings of this study suggest that mental disorders might be socially transmitted within adolescent peer networks.

Importance   Previous research indicates that mental disorders may be transmitted from one individual to another within social networks. However, there is a lack of population-based epidemiologic evidence that pertains to the full range of mental disorders.

Objective   To examine whether having classmates with a mental disorder diagnosis in the ninth grade of comprehensive school is associated with later risk of being diagnosed with a mental disorder.

Design, Setting, and Participants   In a population-based registry study, data on all Finnish citizens born between January 1, 1985, and December 31, 1997, whose demographic, health, and school information were linked from nationwide registers were included. Cohort members were followed up from August 1 in the year they completed ninth grade (approximately aged 16 years) until a diagnosis of mental disorder, emigration, death, or December 31, 2019, whichever occurred first. Data analysis was performed from May 15, 2023, to February 8, 2024.

Exposure   The exposure was 1 or more individuals diagnosed with a mental disorder in the same school class in the ninth grade.

Main Outcomes and Measures   Being diagnosed with a mental disorder during follow-up.

Results   Among the 713 809 cohort members (median age at the start of follow-up, 16.1 [IQR, 15.9-16.4] years; 50.4% were males), 47 433 had a mental disorder diagnosis by the ninth grade. Of the remaining 666 376 cohort members, 167 227 persons (25.1%) received a mental disorder diagnosis during follow-up (7.3 million person-years). A dose-response association was found, with no significant increase in later risk of 1 diagnosed classmate (HR, 1.01; 95% CI, 1.00-1.02), but a 5% increase with more than 1 diagnosed classmate (HR, 1.05; 95% CI, 1.04-1.06). The risk was not proportional over time but was highest during the first year of follow-up, showing a 9% increase for 1 diagnosed classmate (HR, 1.09; 95% CI, 1.04-1.14), and an 18% increase for more than 1 diagnosed classmate (HR, 1.18; 95% CI, 1.13-1.24). Of the examined mental disorders, the risk was greatest for mood, anxiety, and eating disorders. Increased risk was observed after adjusting for an array of parental, school-level, and area-level confounders.

Conclusions and Relevance   The findings of this study suggest that mental disorders might be transmitted within adolescent peer networks. More research is required to elucidate the mechanisms underlying the possible transmission of mental disorders.

Mental disorders are major contributors to the global disease burden, having detrimental individual, societal, and economic impacts. 1 - 3 When investigating the impacts of mental disorders, the focus has typically been on the directly affected individual. It is, however, well established that the immediate family members are also adversely affected. 4 Empirical findings suggest that harmful effects extend beyond the immediate family to friends and peers via social networks. 5 - 8 For example, a longitudinal cohort study where a social network of 12 067 adults was followed up over 20 years indicated that depressive symptoms appear to transmit from person to person. 7

Investigating the transmission of mental disorders is especially important in childhood and adolescence. These are key developmental periods when the onset of many mental disorders is most likely to occur 9 and when enduring peer networks and behaviors are established, 10 particularly in the context of peer relationships. 11 , 12 Understanding the role of peer effects in early-life mental health problems would also offer tools for more successful prevention and intervention measures, thus reducing the economic and societal burden of mental disorders. Yet, despite a few survey studies reporting that adolescents may experience increased mental health symptoms when exposed to friends or peers with mental health problems, 6 , 13 large-scale studies on the potential peer influences of mental disorders in youth are lacking.

When analyzing network associations, an additional difficulty arises from people’s tendency to network with others who have similar traits. Such self-selection bias (or homophily) can be mitigated by using institutionally imposed networks, such as school classes, which are not formed endogenously by the pupils choosing similar others as classmates. In Finland, parents also cannot directly choose their children’s comprehensive school; instead, the school is selected based on the proximity to the residential location. Moreover, school class constitutes arguably the most substantial peer network in childhood and adolescence due to the amount of time spent together with classmates. 14 - 16 In the present study, we combined the use of registry data and institutionally imposed peer networks to study the possible transmission of mental disorders among peers. More specifically, we used nationwide, interlinked Finnish registers to examine whether mental disorders are transmitted within peer networks formed by adolescents who were in the same class in the ninth grade of comprehensive school.

The study population comprised all Finnish citizens born between January 1, 1985, and December 31, 1997, whose demographic, health, and school information was linked from several nationwide registers based on unique identification numbers, assigned to all Finnish residents since 1969. Death or emigration before the start of follow-up, move to the municipality of the school later than 3 years before the start of follow-up, and, for those who were born outside Finland, immigration to Finland after school starting age (ie, August 1 in the year they turn 7 years) were used as exclusion criteria. The ethics committee of the Finnish Institute for Health and Welfare approved the study plan (THL/184/6.02.01/2023§933). Data were linked with the permission of Statistics Finland (TK-53-1696-16) and the Finnish Institute for Health and Welfare. According to Finnish law, informed consent is not required from participants in register-based studies. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

The school information was based on the National Joint Application Register. It discloses school class divisions in the final year (ie, ninth grade) of comprehensive school. Individuals with missing or insufficient school class information were excluded. To exclude the smallest classes and omit incorrect registry information (eg, implausibly large classes), individuals in classes with fewer than 10 or more than 40 pupils were excluded. Of the remaining 713 809 individuals, 47 433 had a mental disorder diagnosis ( International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ ICD-10 ] diagnoses F10-F50 or F90-F98) before follow-up commenced and were therefore excluded from follow-up. The remaining 666 376 individuals in 860 schools and 39 992 classes (median, 6 [IQR, 4-7] classes per grade) formed the outcome population and were followed up from August 1 in the year during which they completed ninth grade (approximately aged 16 years) until the first diagnosed mental disorder, death, emigration, or end of follow-up on December 31, 2019, whichever occurred first. The maximum length of follow-up was thus from August 1, 2001, to December 31, 2019. For the annual number of mental disorder diagnoses and proportion of exposed classes and individuals in the outcome population, see eTable 1 in Supplement 1 .

Information on mental disorders was acquired from the Care Register for Health Care of the Finnish Institute for Health and Welfare. It contains information on all inpatient hospital admissions in Finland since 1970, hospital outpatient care since 1998, and primary care since 2011. Mental disorders were diagnosed according to the International Statistical Classification of Diseases Spectrum Health Problems, Eighth Revision , from 1970 to 1986; International Classification of Diseases, Ninth Revision , from 1987 to 1995; and ICD-10 since 1996.

For the study population, we used the following mental disorder diagnosis categories: substance misuse disorders (F10-F19), schizophrenia spectrum disorders (F20-F29), mood disorders (F30-F39), anxiety disorders (F40-F48), eating disorders (F50), and behavioral and emotional disorders (F90-F98). Additionally, categories of internalizing disorders (F30-F39, F40-F48, F93-F94) and externalizing disorders (F10-F19, F90-F92) were constructed.

We included the following demographic, socioeconomic, and intergenerational variables as covariates: sex (0 = male, 1 = female), birth year, degree of urbanicity in residential location (0 = unknown, 1 = urban, 2 = semiurban, 3 = rural) based on the urban-rural classification of the Finnish Environment Institute, morbidity index of the municipality by the Finnish Institute for Health and Welfare in quintiles (0 = 1st quintile, 1 = 2nd quintile, 2 = 3rd quintile, 3 = 4th quintile, 4 = 5th quintile; as data were not available for 2001, data from 2002 were used instead), proportion of people without upper secondary or higher educational levels in the municipality in quintiles (0 = 1st quintile, 1 = 2nd quintile, 2 = 3rd quintile, 3 = 4th quintile, 4 = 5th quintile), proportion of unemployed people in the municipality in quintiles (0 = 1st quintile, 1 = 2nd quintile, 2 = 3rd quintile, 3 = 4th quintile, 4 = 5th quintile), size of school class (number of pupils), size of school’s ninth grade (number of pupils), parental education level at time of child’s ninth grade (0 = comprehensive, 1 = upper secondary, 2 = higher education), parental income level in quintiles relative to study population at time of child’s ninth grade (0 = unknown, 1 = 1st quintile, 2 = 2nd quintile, 3 = 3rd quintile, 4 = 4th quintile, 5 = 5th quintile), and parental mental health history at the time of child’s ninth grade (0 = no mental disorder diagnosis, 1 = any mental disorder diagnosis). The median population of Finnish municipalities in 2001-2013 was 6530 inhabitants. Any mental disorder diagnosis (F00-F99) was used for parental mental health history.

Data analysis was conducted from May 15, 2023, to February 8, 2024. We used mixed-effects Cox proportional hazards regression models with a random intercept per school to estimate the association between having a classmate with a mental disorder diagnosis and later risk of being diagnosed with a mental disorder. Random intercept per school was included to account for the varying predisposition to mental health problems between schools. Results are reported as hazard ratios (HRs). Schoenfeld residuals were calculated to test the proportional hazards assumption of Cox regression models and estimate the time dependence of the HR throughout the entire follow-up period. We also separately estimated the HRs in shorter intervals: first year of follow-up, years 2 and 3, years 4 and 5, and after year 5. In the primary analyses, all models were adjusted for sex, birth year, area-level urbanicity, area-level morbidity, area-level educational level, area-level employment rate, school class size, school’s ninth grade size, parental educational level, parental income, and parental mental health, and included a 3-level exposure variable for diagnosed classmates (0 = none, 1 = 1, 2 = >1).

As a sensitivity analysis, we estimated the Cox proportional hazards regression models separately for all the mental disorder diagnosis categories (with the same category both as exposure and outcome). Since the number of cases where more than 1 diagnosed classmate was low for some diagnosis categories, a binary variable indicating the presence or lack of individuals diagnosed in the class (0 = no, 1 = yes) was used as a secondary exposure. As additional sensitivity analyses, we limited exposure diagnoses to 3 years preceding the start of follow-up, specifically focusing on diagnoses received during lower secondary education (grades 7-9) and, to control for incorrect registry information regarding school class divisions (eg, implausibly large classes), only considered school classes with sizes falling within 5th and 95th percentiles (corresponding to classes with 12-25 pupils). We also assessed the attenuating impact of the covariates and random intercepts by adding a random intercept per school and covariates in 3 domains (parental, school-level, and area-level) separately in a crude model adjusted for sex and birth year. Moreover, to elucidate possible differences in the 2001-2013 study period, we stratified it into 3 shorter time periods: 2001-2004, 2005-2008, and 2009-2013. A 2-tailed P value <.05 was considered to indicate statistical significance. The statistical analyses were done using Stata, version 16.1 (StataCorp LLC) and R Statistical Software, version 4.2.2 (R Foundation for Statistical Computing) survival (version 3.4.0) and coxme (version 2.2.18.1) packages.

Among the 713 809 cohort members, 50.4% were male and 49.6% were female. Median age at the start of follow-up was 16.1 (IQR, 15.9-16.4) years. Descriptive statistics of the exposure and outcome populations are reported in Table 1 (additional descriptive statistics are provided in eTable 2 in Supplement 1 ). During 7.3 million person-years of follow-up time, with a median of 11.4 (IQR, 7.4-14.4) years, 167 227 cohort members (25.1%) were diagnosed with a mental disorder, corresponding to an incidence rate of 2283 per 100 000 person-years at risk. Table 2 reports the incidence rates and HRs for the association between classmates diagnosed with a mental disorder and later risk of being diagnosed with a mental disorder for each diagnosis category. Having more than 1 diagnosed classmate with any of the examined mental disorders was associated with a 5% higher risk of later diagnosis (HR, 1.05; 95% CI, 1.04-1.06). The SD of the random intercepts for schools was 0.12, indicating that pupils in a school that was 1 SD above the mean had (e 0.12  = 1.13) 13% higher risk of being diagnosed with a mental disorder. Diagnosis-specific analyses revealed positive associations for mood, anxiety, and eating disorders, as well as the internalizing disorders category, even with only 1 diagnosed classmate. For behavioral and emotional disorders, as well as the externalizing disorders category, the findings were significant only with more than 1 diagnosed classmate.

Schoenfeld residual-based tests showed that the proportional hazards assumption held only for the schizophrenia spectrum, eating, and behavioral and emotional disorders models. In contrast, models for other diagnosis categories displayed larger coefficient values (or HRs) earlier in follow-up (eFigure 1 in Supplement 1 ). Figure 1 shows the HRs for the association between diagnosed classmates and later risk of being diagnosed with any of the examined mental disorders in 4 shorter follow-up time windows ( Figure 2 ; eFigure 2 and eTable 3 in Supplement 1 provide diagnosis-specific results). During the first year of follow-up, the risk of being diagnosed was 9% higher with 1 diagnosed classmate (HR, 1.09; 95% CI, 1.04-1.14) and 18% higher with more than 1 diagnosed classmate (HR, 1.18; 95% CI, 1.13-1.24). After the first year of follow-up, the risk of being diagnosed was statistically significant during years 4 and 5 with 1 diagnosed classmate with a mental disorder and in all 3 time windows with more than 1 diagnosed classmate with a mental disorder.

eFigure 3 in Supplement 1 shows the HRs for the association using binary exposure (see also eTable 4a in Supplement 1 ). The risk of being diagnosed with any mental disorder was 3% higher during the entire follow-up period (HR, 1.03; 95% CI, 1.02-1.04), 13% higher during the first year of follow-up (HR, 1.13; 95% CI, 1.08-1.18), and significantly increased also in the later time windows. Diagnosis-specific analyses showed that the risk was significantly increased for mood, anxiety, and internalizing disorders in each follow-up time window, with the greatest risks observed during the first year. For example, the risk of being diagnosed with a mood disorder was 21% higher during the first year of follow-up when a pupil was exposed to mood disorder (HR, 1.21; 95% CI, 1.13-1.29).

The results remained similar when considering only more recent exposure (diagnosis received during lower secondary education, ie, grades 7-9) as opposed to all previous childhood diagnoses (eTable 4b in Supplement 1 ), the most noticeable difference being that the association became statistically significant for schizophrenia spectrum disorders (HR, 1.17; 95% CI, 1.02-1.34). When repeating the analysis by limiting school class sizes within the 5th and 95th percentiles (12-25 pupils), the results remained similar, with no notable differences (eTable 4c in Supplement 1 ).

Assessing the impact of the different covariate domains, a crude model adjusted only for sex and birth year without a random intercept per school showed the highest HRs for all diagnosis categories. In contrast, a model including additional covariates describing area-level characteristics showed the largest reduction in HRs (eTable 5 in Supplement 1 ). For example, having classmates with a mood disorder diagnosis was associated with a 32% higher risk of being diagnosed with a mood disorder during the first year of follow-up (HR, 1.32; 95% CI, 1.23-1.41) in a model adjusted for sex and birth year without a random intercept per school. Including a random intercept per school decreased the risk to 24% (HR, 1.24; 95% CI, 1.16-1.32) and including covariates describing area-level characteristics further decreased the risk to 22% (HR, 1.22; 95% CI, 1.14-1.30). We also assessed differences in the 2001-2013 study period by stratifying it into 3 shorter periods (eTable 6 in Supplement 1 ). While the HRs showed a slight increase trend from the earliest to the latest period, the differences between the periods were statistically nonsignificant.

In our analysis of nationwide, interlinked registry data, including more than 700 000 individuals from 860 comprehensive schools in Finland, we found an association between having peers diagnosed with a mental disorder during adolescence and an increased risk of receiving a mental disorder diagnosis later in life. This risk was most pronounced in the first year of follow-up. The association showed a dose-response relationship, with higher risk when multiple diagnosed individuals were in the peer network. Of the mental disorders examined, the risk was greatest for mood, anxiety, and eating disorders. These associations were not explained by differences in area-level general morbidity or socioeconomic characteristics, parental mental disorders or socioeconomic position during childhood, or random differences in predisposition to mental health problems occurring among schools’ student populations.

To our knowledge, the present study is the largest and most comprehensive investigation on this topic to date. Our findings are consistent with previous studies reporting clustering of mood and/or anxiety symptoms in social networks of adolescents 6 , 13 and adults, 5 , 7 , 8 as well as with evidence suggesting similar social transmission of eating disorders. 17 For example, a longitudinal survey study with a school-based design showed that exposure to peers with depressive symptoms in the same school grade was associated with more depressive symptoms in a sample of 8290 adolescents. 6 Although using institutionally imposed peer network (eg, school grade or class) mitigates the self-selection bias often compromising studies on network peer effects, the study by Lee and Lee 6 is not immune to biases related to selection and attrition that are typical in longitudinal survey studies. We sought to minimize these biases by using institutionally imposed peer networks (school classes) in combination with population-wide registry data and found that exposure to a peer with a mental disorder is associated with an increased risk of mental disorder across several different diagnosis categories.

If mental disorders are transmitted socially via peer networks, the phenomenon could be explained by several mechanisms. One plausible mechanism is the normalization of mental disorders through increased awareness and receptivity to diagnosis and treatment when having individuals with diagnosis in the same peer network. 18 Similarly, having individuals with no diagnosis in the peer network might discourage seeking help for any underlying mental health problems. The observed higher risks of being diagnosed during the first year of follow-up after the exposure are consistent with this mechanism. Namely, due to diagnostic delay, the brief latency between exposure and diagnosis challenges the likelihood of harmful contagion occurring without an already existing, undiagnosed disorder. For some diagnosis categories, such as eating disorders, transmission could also occur through processes of peer social influence to which adolescents are particularly susceptible. 19 Another possible mechanism facilitating the transmission of certain mental disorders, such as depression, pertains to direct interpersonal contagion. For instance, it is conceivable that long-term exposure to a depressive individual could lead to gradual development of depressive symptoms through the well-established neural mechanisms of emotional contagion. 20

The primary strengths of the present study are its use of a nationwide study population tracked from adolescence up to age 34 years, inclusion of interlinked primary and secondary health care registry data, and reliance on institutionally imposed peer networks within a comprehensive school setting, mitigating self-selection bias. However, our findings should be interpreted in the context of the study’s limitations. First, while the observed associations were statistically significant, the HRs were relatively small. Therefore, we cannot rule out residual confounding due to unmeasured or inaccurately measured covariates in this cohort study. Second, it is expected that some individuals with underlying mental disorders refrain from seeking help from health care services, which implies that the reported mental disorder diagnoses are likely an underestimate of the true underlying prevalence of these disorders. Third, school class as an indicator for peer network is quite crude and the National Joint Application Register discloses information on school class divisions only for the final year (ie, ninth grade) of comprehensive school. Furthermore, although school classes in Finland are predominantly institutionally imposed without the freedom for pupils to choose their classmates, some schools have classes with special emphasis (eg, music or bilingual teaching) to which pupils are selected based on aptitude tests. 21 That said, classes within comprehensive schools in the Finnish educational system, particularly during lower secondary education (grades 7-9), are generally stable and transitions between classes are infrequent. 22 In addition, since Finland is a relatively small and homogeneous Nordic country with a health care system providing universal access to services for all citizens, replications of this study in other countries are necessary to evaluate the generalizability of our findings.

Based on a nationwide cohort of over 700 000 Finnish individuals, the results of this cohort study suggest a dose-response association between the number of persons with a mental disorder diagnosis in the same peer network during adolescence and later risk of being diagnosed with a mental disorder, even after accounting for a broad set of potential individual and environmental confounders. The association was most clearly present for mood, anxiety, and eating disorders. These findings suggest that mental disorders may be transmitted within adolescent peer networks. Consequently, prevention and intervention measures that consider potential peer influences on early-life mental health could substantially reduce the disease burden of mental disorders in society. Further research is required to clarify the mechanisms that explain these observed associations.

Accepted for Publication: March 15, 2024.

Published Online: May 22, 2024. doi:10.1001/jamapsychiatry.2024.1126

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Alho J et al. JAMA Psychiatry .

Corresponding Author: Jussi Alho, PhD, University of Helsinki, PO Box 21, 00014 Helsinki, Finland ( [email protected] ).

Author Contributions: Drs Alho and Hakulinen had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Alho, Gutvilig, Niemi, Elovainio, Hakulinen.

Acquisition, analysis, or interpretation of data: Alho, Gutvilig, Niemi, Komulainen, Böckerman, Webb, Hakulinen.

Drafting of the manuscript: Alho, Hakulinen.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Alho, Gutvilig, Niemi, Webb.

Obtained funding: Elovainio, Hakulinen.

Administrative, technical, or material support: Hakulinen.

Supervision: Hakulinen.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was funded by the European Union (ERC, MENTALNET, 101040247) and the Academy of Finland (354237 to Dr Hakulinen; 339390 to Dr Elovainio). Dr Webb is funded by the National Institute for Health and Social Care Research (NIHR) Manchester Biomedical Research Centre (NIHR203308) and by the NIHR Greater Manchester Patient Safety Research Collaboration (NIHR204295).

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Views and opinions expressed in this article are those of the authors only and do not necessarily reflect those of the European Union or the European Research Council, or the NIHR or the Department of Health and Social Care.

Data Sharing Statement: See Supplement 2 .

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• v.10(7); 2018 Jul

A Strange Case of Dissociative Identity Disorder: Are There Any Triggers?

Muhammad awais rehan.

1 Department of Pathology, Khawaja Muhammad Safdar Medical College, Sialkot, PAK

Annapurna Kuppa

2 Department of Research, University of Bonn/the Johns Hopkins University, Baltimore, USA

Abhilasha Ahuja

3 Department of Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA

Shazra Khalid

4 Department of Research, California Institute of Behavioral Neurosciences & Psychology, Karachi, PAK

Nishita Patel

5 Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA

Firman Sandiyah Budi Cardi

Viraj v joshi, amna khalid.

6 Internal Medicine, Icahn School of Medicine, Mount Sinai/Queens Hospital Center, New York, USA

Hassaan Tohid

7 Neurology, Center for Mind & Brain, University of California, Davis, Fairfield, USA

We discuss a strange case of dissociative identity disorder, also known as multiple personality disorder. This article describes the case of a 55-year-old Caucasian woman with a history of substance use disorder with seven personalities. The patient describes a couple of triggers for her condition. More research is needed to understand these triggers.

Introduction

Dissociative identity disorder (DID), or dissociative personality disorder, is the presence of at least two varied personalities in one person [ 1 - 2 ]. Thus, it is also referred to as multiple personality disorder [ 3 ]. There are several conditions found to be associated with this disorder, including depression, self-harm, post-traumatic stress disorder (PTSD), substance use disorder, borderline personality disorder or anxiety [ 4 - 5 ], and conversion or somatoform disorder [ 6 ]. DID also includes the unexplained loss of personal information from one's memory [ 1 ]. The estimated DID prevalence around the globe is about 5% among the inpatient psychiatric population, 2%–3% among outpatients, and 1% in the general population [ 7 - 8 ].

In this case study, we present an interesting case of DID with triggers. The association of triggers with DID is not well-studied and understood. We hope that this case study will help unearth the possible association of DID with triggers like stress and substance use disorder.

Case presentation

Here, we present a case of a 55-year-old Caucasian female with a history of substance use disorder and a comorbid bipolar disorder, who presented to the local general hospital with a history of the fragmentation of a single personality into different personalities under emotional stress and under the influence of a drug. Multiple aspects of her personalities were reported, including the following:  a personality of a seven-year-old child, a personality that would behave as a teenager, and another that acted like a male person in addition to her normal 55-year-old personality. She reported that she had been constantly dominated by her alternate personalities and became aware of their existence when people around her informed her, usually after a situation ended. She reported that stressful situations and substance abuse could aggravate the fragmentation of her personality. This was found to be mostly an involuntary phenomenon with seldom memory of the event.

While transitioning between these personalities, she was found to be violent even to people who were close to her. This could range from being suicidal to homicidal for which she was arrested twice in the past. She had to be isolated and restrained by being locked in a room and calling the police. As a result, she was hospitalized in a mental institution for a significant period at least two to three times in the past. Under the influence of stress or substances like marijuana or cocaine, her personality would split into various personalities. These states were very different from one another in terms of age or gender.

One of her alternate personalities behaved as a seven-year-old child and would show the same interests and choices that included becoming moody or a self-arrogant personality. While in these states, she could hurt herself or had weeping spells if her wants were not met.

Another personality acted as a teenager with some sharp choices and dressing. Increase in substance abuse, alcohol use, and smoking would lead to multiple cases of fights or homicidal attacks, with some incidents of self-harming events. Multiple scars were found on the dorsal side of her right hand. Her speech was found to be pressured and she would repeat the same words/ conversations.

The next personality was diagnosed to be a temporary transition to the opposite gender (a male). There was a change in voice and behavior. This included male dressing, language, a perception of male body parts, choices of friends, and attraction towards females, including sexual behavior.

The normal state of a 55-year aged female was the default personality that made her feel most comfortable. She reported that she had anxiety during a personality state transition, as it could occur at any time, and involuntarily, but mostly in stressful situations and during substance abuse. More violent and harmful events were reported when someone tried to meet the patient alone rather than in a group.

The treatment included psychotherapy with cognitive behavioral therapy addressing stress and substance use disorder. The psychotherapeutic treatment lasted for at least six months. The dual treatment of drug therapy was also involved to calm her down. The patient was prescribed escitalopram to reduce her anxiety symptoms. She believed that the anxiety pills were really helpful. After six months, the patient's condition was not drastically different. However, she believed her stress was getting better. The patient was further followed up for the next one year and the treatment continues to date. 

Dissociative identity disorder (DID) is a severe condition characterized by a marked discontinuity in the identity of an individual, with fragmentation into two or more distinct personality states, which alternately take control of the individual. It reflects a loss of the ability to assimilate various aspects of one’s identity, memory, as well as consciousness into a single multidimensional self.

The primary identity is the individual’s original identity that carries their given name and is passive, dependent, and usually guilty and depressed. The alternate personality states, when in control, have a distinct history and identity, with their own pattern of self-perception. These states are referred to as “Alters” and have different characteristics compared with the primary identity. These characteristics could include the name, age, gender, functions, mood, memories, and vocabulary, along with other traits. The emergence of a particular episode generally occurs due to a certain stressor.

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM 5) published in 2013, the symptoms of dissociative identity disorder include:

●       The individual experiences two or more distinct identities or personality states, each with its own pattern of perceiving, relating to, and thinking about the self and the world.

●       The disruption in identity involves a change in sense of self, loss of personal agency, and alterations in effect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor function.

●       Frequent gaps in memories of personal history, including the distant and recent past as well as everyday events. These gaps are not consistent with the expected normal forgetfulness.

●       Significant distress and impairment in the level of functioning because of the symptoms.

●       The disturbance cannot be attributed to the physiological effects of a substance or another medical condition.

More than 70% of people with DID have attempted suicide, and self-injurious behavior is common among this population [ 2 ]. Treatment is crucial to improving quality of life and preventing suicide attempts. Cognitive Behavioral Therapy (CBT) could be used as a mode of treatment for these patients [ 9 ].

The cause of DID is not completely understood. It is believed to be due to severe physical and sexual abuse, particularly during childhood. Among those with DID in the U.S., Canada, and Europe, approximately 90% report a history of abuse in childhood.

Our findings

The case study discussed here describes a strange case of DID where the patient had triggers of the DID episodes. Every time the patient had an episode of a new personality, she had triggers like a migraine patient would have before an episode. She was either under the influence of a drug or she had emotional stress, which led to a personality change. The strength of this case study is that we have an idea that probably stress and drug use can lead to DID symptoms. However, we don't yet know if this change in personality is only due to marijuana and cocaine or can be due to any drug use. We also need more understanding of whether her episodes were triggered when she had either one of these triggers or is it necessary to have both triggers at the same time to develop DID symptoms.

Conclusions

In the described case, the patient had dissociative identity disorder. Her condition was reported to be associated with any emotional stress and substance use disorder. The transition to a different personality was involuntarily and, most of the time, the patient was not aware of the transition or had any memory of the event. Most patients with this condition are informed by nearby observers about the personality state shift. Post-event confusion and guilt is also reported sometimes. Avoidance of triggers like stress and substance abuse may help in unpredicted personality fragmentations into multiple personality states. However, more research is needed to understand these possible triggers better.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained by all participants in this study

Case Study Research Method in Psychology

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

Case studies are in-depth investigations of a person, group, event, or community. Typically, data is gathered from various sources using several methods (e.g., observations & interviews).

The case study research method originated in clinical medicine (the case history, i.e., the patient’s personal history). In psychology, case studies are often confined to the study of a particular individual.

The information is mainly biographical and relates to events in the individual’s past (i.e., retrospective), as well as to significant events that are currently occurring in his or her everyday life.

The case study is not a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies.

Freud (1909a, 1909b) conducted very detailed investigations into the private lives of his patients in an attempt to both understand and help them overcome their illnesses.

This makes it clear that the case study is a method that should only be used by a psychologist, therapist, or psychiatrist, i.e., someone with a professional qualification.

There is an ethical issue of competence. Only someone qualified to diagnose and treat a person can conduct a formal case study relating to atypical (i.e., abnormal) behavior or atypical development.

 Famous Case Studies

• Anna O – One of the most famous case studies, documenting psychoanalyst Josef Breuer’s treatment of “Anna O” (real name Bertha Pappenheim) for hysteria in the late 1800s using early psychoanalytic theory.
• Little Hans – A child psychoanalysis case study published by Sigmund Freud in 1909 analyzing his five-year-old patient Herbert Graf’s house phobia as related to the Oedipus complex.
• Bruce/Brenda – Gender identity case of the boy (Bruce) whose botched circumcision led psychologist John Money to advise gender reassignment and raise him as a girl (Brenda) in the 1960s.
• Genie Wiley – Linguistics/psychological development case of the victim of extreme isolation abuse who was studied in 1970s California for effects of early language deprivation on acquiring speech later in life.
• Phineas Gage – One of the most famous neuropsychology case studies analyzes personality changes in railroad worker Phineas Gage after an 1848 brain injury involving a tamping iron piercing his skull.

Clinical Case Studies

• Studying the effectiveness of psychotherapy approaches with an individual patient
• Assessing and treating mental illnesses like depression, anxiety disorders, PTSD
• Neuropsychological cases investigating brain injuries or disorders

Child Psychology Case Studies

• Studying psychological development from birth through adolescence
• Cases of learning disabilities, autism spectrum disorders, ADHD
• Effects of trauma, abuse, deprivation on development

Types of Case Studies

• Explanatory case studies : Used to explore causation in order to find underlying principles. Helpful for doing qualitative analysis to explain presumed causal links.
• Exploratory case studies : Used to explore situations where an intervention being evaluated has no clear set of outcomes. It helps define questions and hypotheses for future research.
• Descriptive case studies : Describe an intervention or phenomenon and the real-life context in which it occurred. It is helpful for illustrating certain topics within an evaluation.
• Multiple-case studies : Used to explore differences between cases and replicate findings across cases. Helpful for comparing and contrasting specific cases.
• Intrinsic : Used to gain a better understanding of a particular case. Helpful for capturing the complexity of a single case.
• Collective : Used to explore a general phenomenon using multiple case studies. Helpful for jointly studying a group of cases in order to inquire into the phenomenon.

Where Do You Find Data for a Case Study?

There are several places to find data for a case study. The key is to gather data from multiple sources to get a complete picture of the case and corroborate facts or findings through triangulation of evidence. Most of this information is likely qualitative (i.e., verbal description rather than measurement), but the psychologist might also collect numerical data.

1. Primary sources

• Interviews – Interviewing key people related to the case to get their perspectives and insights. The interview is an extremely effective procedure for obtaining information about an individual, and it may be used to collect comments from the person’s friends, parents, employer, workmates, and others who have a good knowledge of the person, as well as to obtain facts from the person him or herself.
• Observations – Observing behaviors, interactions, processes, etc., related to the case as they unfold in real-time.
• Documents & Records – Reviewing private documents, diaries, public records, correspondence, meeting minutes, etc., relevant to the case.

2. Secondary sources

• News/Media – News coverage of events related to the case study.
• Academic articles – Journal articles, dissertations etc. that discuss the case.
• Government reports – Official data and records related to the case context.
• Books/films – Books, documentaries or films discussing the case.

3. Archival records

Searching historical archives, museum collections and databases to find relevant documents, visual/audio records related to the case history and context.

Public archives like newspapers, organizational records, photographic collections could all include potentially relevant pieces of information to shed light on attitudes, cultural perspectives, common practices and historical contexts related to psychology.

4. Organizational records

Organizational records offer the advantage of often having large datasets collected over time that can reveal or confirm psychological insights.

Of course, privacy and ethical concerns regarding confidential data must be navigated carefully.

However, with proper protocols, organizational records can provide invaluable context and empirical depth to qualitative case studies exploring the intersection of psychology and organizations.

• Organizational/industrial psychology research : Organizational records like employee surveys, turnover/retention data, policies, incident reports etc. may provide insight into topics like job satisfaction, workplace culture and dynamics, leadership issues, employee behaviors etc.
• Clinical psychology : Therapists/hospitals may grant access to anonymized medical records to study aspects like assessments, diagnoses, treatment plans etc. This could shed light on clinical practices.
• School psychology : Studies could utilize anonymized student records like test scores, grades, disciplinary issues, and counseling referrals to study child development, learning barriers, effectiveness of support programs, and more.

How do I Write a Case Study in Psychology?

Follow specified case study guidelines provided by a journal or your psychology tutor. General components of clinical case studies include: background, symptoms, assessments, diagnosis, treatment, and outcomes. Interpreting the information means the researcher decides what to include or leave out. A good case study should always clarify which information is the factual description and which is an inference or the researcher’s opinion.

1. Introduction

• Provide background on the case context and why it is of interest, presenting background information like demographics, relevant history, and presenting problem.
• Compare briefly to similar published cases if applicable. Clearly state the focus/importance of the case.

2. Case Presentation

• Describe the presenting problem in detail, including symptoms, duration,and impact on daily life.
• Include client demographics like age and gender, information about social relationships, and mental health history.
• Describe all physical, emotional, and/or sensory symptoms reported by the client.
• Use patient quotes to describe the initial complaint verbatim. Follow with full-sentence summaries of relevant history details gathered, including key components that led to a working diagnosis.
• Summarize clinical exam results, namely orthopedic/neurological tests, imaging, lab tests, etc. Note actual results rather than subjective conclusions. Provide images if clearly reproducible/anonymized.
• Clearly state the working diagnosis or clinical impression before transitioning to management.

3. Management and Outcome

• Indicate the total duration of care and number of treatments given over what timeframe. Use specific names/descriptions for any therapies/interventions applied.
• Present the results of the intervention,including any quantitative or qualitative data collected.
• For outcomes, utilize visual analog scales for pain, medication usage logs, etc., if possible. Include patient self-reports of improvement/worsening of symptoms. Note the reason for discharge/end of care.

4. Discussion

• Analyze the case, exploring contributing factors, limitations of the study, and connections to existing research.
• Analyze the effectiveness of the intervention,considering factors like participant adherence, limitations of the study, and potential alternative explanations for the results.
• Identify any questions raised in the case analysis and relate insights to established theories and current research if applicable. Avoid definitive claims about physiological explanations.
• Offer clinical implications, and suggest future research directions.

5. Additional Items

• Thank specific assistants for writing support only. No patient acknowledgments.
• References should directly support any key claims or quotes included.
• Use tables/figures/images only if substantially informative. Include permissions and legends/explanatory notes.
• Provides detailed (rich qualitative) information.
• Provides insight for further research.
• Permitting investigation of otherwise impractical (or unethical) situations.

Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of ‘averaging’.

Because of their in-depth, multi-sided approach, case studies often shed light on aspects of human thinking and behavior that would be unethical or impractical to study in other ways.

Research that only looks into the measurable aspects of human behavior is not likely to give us insights into the subjective dimension of experience, which is important to psychoanalytic and humanistic psychologists.

Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person’s life are related to each other.

The method is, therefore, important for psychologists who adopt a holistic point of view (i.e., humanistic psychologists ).

Limitations

• Lacking scientific rigor and providing little basis for generalization of results to the wider population.
• Researchers’ own subjective feelings may influence the case study (researcher bias).
• Difficult to replicate.
• Time-consuming and expensive.
• The volume of data, together with the time restrictions in place, impacted the depth of analysis that was possible within the available resources.

Because a case study deals with only one person/event/group, we can never be sure if the case study investigated is representative of the wider body of “similar” instances. This means the conclusions drawn from a particular case may not be transferable to other settings.

Because case studies are based on the analysis of qualitative (i.e., descriptive) data , a lot depends on the psychologist’s interpretation of the information she has acquired.

This means that there is a lot of scope for Anna O , and it could be that the subjective opinions of the psychologist intrude in the assessment of what the data means.

For example, Freud has been criticized for producing case studies in which the information was sometimes distorted to fit particular behavioral theories (e.g., Little Hans ).

This is also true of Money’s interpretation of the Bruce/Brenda case study (Diamond, 1997) when he ignored evidence that went against his theory.

Breuer, J., & Freud, S. (1895).  Studies on hysteria . Standard Edition 2: London.

Curtiss, S. (1981). Genie: The case of a modern wild child .

Diamond, M., & Sigmundson, K. (1997). Sex Reassignment at Birth: Long-term Review and Clinical Implications. Archives of Pediatrics & Adolescent Medicine , 151(3), 298-304

Freud, S. (1909a). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Freud, S. (1909b). Bemerkungen über einen Fall von Zwangsneurose (Der “Rattenmann”). Jb. psychoanal. psychopathol. Forsch ., I, p. 357-421; GW, VII, p. 379-463; Notes upon a case of obsessional neurosis, SE , 10: 151-318.

Harlow J. M. (1848). Passage of an iron rod through the head.  Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868).  Recovery from the Passage of an Iron Bar through the Head .  Publications of the Massachusetts Medical Society. 2  (3), 327-347.

Money, J., & Ehrhardt, A. A. (1972).  Man & Woman, Boy & Girl : The Differentiation and Dimorphism of Gender Identity from Conception to Maturity. Baltimore, Maryland: Johns Hopkins University Press.

Money, J., & Tucker, P. (1975). Sexual signatures: On being a man or a woman.

Further Information

• Case Study Approach
• Case Study Method
• Enhancing the Quality of Case Studies in Health Services Research
• “We do things together” A case study of “couplehood” in dementia
• Using mixed methods for evaluating an integrative approach to cancer care: a case study

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Depression, schizophrenia and bipolar disorder linked with ancient viral DNA in our genome – new research

Research Fellow, King's College London

Professor of Immunology in Medicine, Cornell University

Senior lecturer, King's College London

Disclosure statement

Rodrigo Duarte received funding from the National Institutes of Health, USA.

Douglas Nixon receives funding from the National Institutes of Health, USA.

Timothy Powell receives funding from the National Institute for Health and Care Research, the National Institutes of Health, and the Medical Research Council.

King's College London provides funding as a member of The Conversation UK.

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Around 8% of human DNA is made up of genetic sequences acquired from ancient viruses . These sequences, known as human endogenous retroviruses (or Hervs), date back hundreds of thousands to millions of years – with some even predating the emergence of Homo sapiens .

Our latest research suggests that some ancient viral DNA sequences in the human genome play a role in susceptibility to psychiatric disorders such as schizophrenia, bipolar disorder and major depressive disorder.

Hervs represent the remnants of these infections with ancient retroviruses. Retroviruses are viruses that insert a copy of their genetic material into the DNA of the cells they infect. Retroviruses probably infected us on multiple occasions during our evolutionary past. When these infections occurred in sperm or egg cells that generated offspring, the genetic material from these retroviruses was passed on to subsequent generations , becoming a permanent part of our lineage.

Initially, scientists considered Hervs to be “junk DNA” – parts of our genome with no discernible function. But as our understanding of the human genome has advanced, it’s become evident that this so-called junk DNA is responsible for more functions than originally hypothesised.

First, researchers found that Hervs can regulate the expression of other human genes. A genetic feature is said to be “expressed” if its DNA segment is used to produce RNA (ribonucleic acid) molecules. These RNA molecules can then serve as intermediaries leading to the production of specific proteins , or help to regulate other parts of the genome .

Initial research suggested that Hervs regulate the expression of neighbouring genes with important biological functions. One example of this is a Herv that regulates the expression of a gene involved in modifying connections between brain cells.

Hervs have also been found to produce RNAs and even proteins in blood and brain samples . These molecules have the potential to exert a wide range of functions, as they can travel across cellular compartments to execute different roles.

Scientists have also found evidence suggesting certain human genes are derived from Hervs. This indicates there were instances during evolution where Hervs were co-opted for specialised biological functions. For example, the human genes syncytins 1 and 2, which are derived from Hervs, play pivotal roles in placental development .

HERVs in psychiatric disorders

Considering the abundance of Hervs in the genome and their potentially numerous functions, we wanted to better understand whether genetic susceptibility to certain psychiatric disorders was associated with differences in Herv expression.

In our study , we profiled Herv expression in nearly 800 autopsy brain samples. This helped us identify DNA variations that influenced Herv expression in the brain.

We then cross-referenced this information with findings from large genetic studies which had compared genetic differences between tens of thousands of people – both with and without mental health conditions. These studies identified variations in DNA associated with different psychiatric conditions.

We found that that the expression of four Hervs was linked with genetic susceptibility to major psychiatric disorders. The expression of two of these Hervs was associated with schizophrenia, one Herv with both schizophrenia and bipolar disorder, and one with depression. These results suggest that Hervs may be playing a more important role in the brain than initially thought.

Read more: Discovering how genetic 'dark matter' plays a role in mental illness is just the tip of the iceberg for human health

There are many genes involved in psychiatric disorders – and Hervs are only a part of this puzzle. Although the precise impact of these Hervs on brain cells and on a person’s susceptibility to certain psychiatric disorders requires further research, our study is the first to show that genetic susceptibility for a psychiatric disorder also acts through these ancient viral DNA sequences.

It’s still too early to determine the practical applications of our findings – and whether they might be used to develop new treatments. But we’re optimistic about this line of research. By linking Herv expression in the brain with psychiatric disorders, our research recognises the importance of these mysterious sequences in the human genome, which have been ignored for years.

• Schizophrenia
• Bipolar disorder
• Retroviruses
• Psychiatric disorders

Head of School, School of Arts & Social Sciences, Monash University Malaysia

Chief Operating Officer (COO)

Clinical Teaching Fellow

Data Manager

Director, Social Policy

Hyperhomocysteinemia is associated with the risk of venous thromboembolism in patients with mental illness: a case-control study

Affiliations.

• 1 Division of Pulmonary and Critical Care Medicine, Wenzhou Medical University Affiliated Taizhou Hospital, Linhai, Zhejiang, China.
• 2 Department of Pulmonary and Critical Care Medicine, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
• 3 Department of mental health, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China.
• PMID: 38827445
• PMCID: PMC11140473
• DOI: 10.3389/fpsyt.2024.1340138

Objective: The risk of venous thromboembolism in patients with mental illness has been insufficiently addressed. This study aimed to assess the correlation between hyperhomocysteinemia and venous thromboembolism prevalence among this population.

Methods: Patients with a diagnosis of mental illness and concurrent venous thromboembolism, admitted to Sir Run Run Shaw Hospital at Zhejiang University School of Medicine between January 2014 and December 2021, were included in the venous thromboembolism group. The control group, approximately twice the size, comprised individuals with mental illness but without venous thromboembolism. Basic clinical data were gathered for both cohorts.

Results: In psychiatric patients, elevated D-dimer levels(OR=5.60,95% CI 3.28-10.00), hyperhomocysteinemia (OR=2.37,95% CI 1.10-5.14), and hyperprolactinemia(OR= 2.68,95% CI 1.12-6.42)were significant risk factors for venous thromboembolism. According to further subgroup analyses, hyperhomocysteinemia is a significant risk factor associated with pulmonary embolism, with an OR of 5.08 (95% CI 1.20-21.48). An interaction effect between gender and homocysteine level was found, with a p-interaction of 0.022. A subsequent analysis confirmed the association between hyperhomocysteinemia and venous thromboembolism in female psychiatric patients, with an OR of 3.34 (95% CI 1.68-6.65), indicating that hyperhomocysteinemia is a significant risk factor for venous thromboembolism in women.

Conclusion: Patients with psychiatric disorders were found to have an elevated risk of venous thromboembolism, which was associated with increased levels of D-dimer, hyperprolactinemia, and hyperhomocysteinemia. A strong correlation between hyperhomocysteinemia and pulmonary embolism was identified in patients with mental illnesses. Furthermore, the study revealed that female psychiatric patients with hyperhomocysteinemia constituted a high-risk group for venous thromboembolism. This finding holds significant clinical implications, suggesting that early preventative measures could be implemented for this high-risk population to reduce the incidence of thromboembolic events during hospitalization for psychiatric patients.

Keywords: hyperhomocysteinemia; hyperprolactinemia; mental illness; pulmonary thromboembolism; venous thromboembolism.

Copyright © 2024 Wang, Zhang, Ren, Li and Ying.

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