library anxiety research paper

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Library anxiety: A decade of empirical research

• Library Review 53(3):177-185
• 53(3):177-185
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Library Review

ISSN : 0024-2535

Article publication date: 1 April 2004

This paper reviews the major publications by Qun G. Jiao and Anthony J. Onwuegbuzie that chronicles the development of empirical research conducted on the construct of library anxiety among college students in the United States during the past decade. It also examines the sizeable contribution that these two researchers have made to the body of knowledge of this emerging field of study in library and information science. The paper concludes by encouraging more researchers to continue the work of Jiao and Onwuegbuzie by examining further this widespread and pervasive phenomenon.

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Cleveland, A. (2004), "Library anxiety: a decade of empirical research", Library Review , Vol. 53 No. 3, pp. 177-185. https://doi.org/10.1108/00242530410526583

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Copyright © 2004, Emerald Group Publishing Limited

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Library Anxiety: Theory, Research, and Applications

• A. Onwuegbuzie , Qun G. Jiao , Sharon L. Bostick
• Published 1 April 2004
• Psychology, Education

90 Citations

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Do You Suffer from Library Anxiety?

What is library anxiety? Librarians and experts discuss how technology is changing students’ attitudes toward libraries and librarians.

Gillian S. Gremmels still remembers the aha moment she had when, as a reference librarian at DePauw University in Indiana, she first read “Library Anxiety: A Grounded Theory and Its Development” by Constance A. Mellon in the March 1986 issue of College & Research Libraries .

“The resonance I felt when I read about library anxiety was powerful,” she wrote in the same journal nearly 30 years later . “[Y]es, I thought; this is what I’m seeing in my students, who seem overwhelmed by the library, in need of librarians’ help, yet reluctant to approach us.”

That term—library anxiety—is hardly a household name among students, but say it to a college librarian, and he or she will know exactly what you’re talking about. It’s the feeling that one’s research skills are inadequate and that those shortcomings should be hidden. In some students it’s manifested as an outright fear of libraries and the librarians who work there. To many librarians it’s a phenomenon as real as it is perplexing.

“Why would anyone think we are intimidating?” writes Michel C. Atlas . “What is intimidating about a master’s-prepared professional earning $35,000 a year?”

Librarians have been discussing the general phenomenon since at least the mid-to-late 1970s, says Ann Campion Riley, president of the Association of College & Research Libraries, but it was Mellon who first gave it a name three decades ago. Her original study was based on analysis of journal entries college students had been required by their instructors to keep during the research process. After reading the student diaries, Mellon concluded, “Seventy-five to 85 percent of students in each class described their initial response to the library in terms of fear or anxiety.”

“Terms like scary, overpowering, lost, helpless, confused, and fear of the unknown appeared over and over again,” Mellon wrote. One student admitted to feeling like a “lost child”; another said she was “lost in there and actually scared to death.”

According to Mellon, three general themes emerged: Students found their own library skills inadequate; they found their perceived shortcomings shameful; they feared seeking out help would only reveal their inadequacy.

The enduring influence of the work is clear. By Gremmels’s published count in 2015, a Web of Science search produced 120 citations, and Google Scholar generated more than 400. Scholars now have insight into how library anxiety affects specific groups of students—first generation, minority, nontraditional age, and LGBT among them—and library anxiety’s impact can even be seen in popular culture, according to Eamon Tewell , who suggests library-based fear is evident in Megan Mullally’s portrayal of the manipulative public librarian Tammy Swanson in the NBC show Parks and Recreation.

So What’s Behind Library Anxiety?

In 1992, Sharon Bostick developed the Library Anxiety Scale, a now copyrighted and statistically validated measurement tool that allows researchers to examine library anxiety and tease out how it affects various demographics. It includes more than 40 statements for students to agree or disagree with, including: I’m embarrassed that I don’t know how to use the library; I am unsure about how to begin my research; I feel like I am bothering the reference librarian if I ask a question.

Bostick, now dean of libraries at the Illinois Institute of Technology in Chicago, says library anxiety is similar to “math anxiety” and “test anxiety” in that all three are state anxieties rather than trait anxieties, meaning the apprehension is situational rather than necessarily linked to a person’s temperament. She says one significant lesson from the research she conducted is understanding the important role played by interactions with people.

“If they were anticipating a positive interaction with a human being, their levels of anxiety statistically were much lower than if they anticipated a bad interaction with a human,” Bostick said in an interview, adding that the same takeaway was true of other elements of the library experience. “Everything else—anything about technology or other components—always had a human component.”

That’s a big part of the reason why librarians have worked hard over the past 30 years to make the experience for students more “ customer-service focused ,” says Riley, the Association of College & Research Libraries president and acting director of University Libraries at the University of Missouri.

She and other librarians say a big part of this is making sure libraries are welcoming spaces. “Inspirational spaces can also be intimidating spaces, so you want to make them as warm and fuzzy as you can,” Riley said in an interview.

“We have a big reading room [at the University of Missouri]; it’s intended to be an inspiring space, as many historical libraries are, but sometimes people associate [that look] with authoritarian environments.”

Bostick, who consulted on a library renovation and expansion project when she worked at the University of Missouri-Kansas City, says reducing fear can come down to something as simple as layout: “One of the big things is, if you walk into a library, you should immediately see a human there to help you. It’s amazing how many library designs do not allow that.”

Reducing Library Anxiety: “Warmth Seminars”

In her 1986 article, Constance A. Mellon envisioned library instruction sessions that functioned as “warmth seminars,” opportunities for librarians to establish themselves as friendly, open, and helpful people. It’s a philosophy that’s central today. In addition to informational sessions for students, library tours, ask-a-librarian tools, and the placement of younger, more approachable graduate students at the reference desk, librarians have also teamed up with instructors to better integrate themselves into courses. It’s an important factor considering research has shown a connection between library use and encouragement from professors .

“I think you partner together,” says Sarah Naomi Campbell, a reference librarian at Johnson & Wales University in Providence, Rhode Island. “I reach out to faculty; we spend time together; I’m sometimes involved in course design.”

Campbell says a personal touch can go a long way in helping students, including ones who may have unique anxieties about being in a library, whether it be a first-generation, black, or LGBT student. Campbell, who identifies as being on the trans spectrum, says transgender and other LGBT students sometimes have apprehensions about even checking out a book on a topic that interests them.

“They may not be out, or there may be reasons why it’s not safe, or they’re not comfortable,” Campbell says. “I definitely have identified with feeling anxious about divulging research topics that I’m working on, or just personal—maybe a fantasy novel with a queer character. Little anxieties can really prevent you from engaging in the process.”

Re-thinking Library Anxiety

It’s hard to deny that American colleges are far different places today than they were 30 years ago, and that probably means something for the way we look at library anxiety.

“Perhaps the situation is complicated in ways that Mellon could not have foreseen in 1986, by a much more diverse student body and a much more complex information universe,” writes Gillian S. Gremmels, citing one academic who “has warned that stereotype threat [being at risk of confirming a negative group stereotype] influences the choices students of color make when considering approaching a librarian; welcoming and friendly behavior from a librarian may not be perceived as intended.”

In addition to more diverse student bodies, librarians need to take into account the prevalence and variety of online research options—reliable and unreliable—in today’s digital age. Digital resources are credited with helping more people receive a college education through distance learning as well as reducing traditional library anxiety. But there is also a concern that the abundance of information available over the Internet has brought with it entirely new challenges.

Somewhat ironically, librarians today have found that some younger college students now overestimate their abilities when it comes to online research. Lauren Consolatore, an instruction librarian at Mitchell College, a small liberal arts school in New London, Connecticut, says this is particularly true of incoming first-year students.

“Part of the problem that this presents for instruction librarians is the reluctance [of] students to participate in library instruction sessions or to come to librarians for help because they feel that they know all of this,” she says.

This affects not only their ability to access information but also to evaluate it. As part of an instructional session on identifying and weeding out illegitimate or biased sources, Consolatore uses an exercise where she asks her students to look at a site dedicated to the civil rights hero Martin Luther King, Jr. What she doesn’t tell them is that a group affiliated with the white supremacist David Duke created it.

“It looks like a professional website,” she says. “And all of the information on there is false, but students tend to take it at face value. They see something that looks good, and so they think that information is good information.”

These days, a new threat to academic research may be students’ lack of understanding about the value of libraries, rather than anxiety about librarians. “[A] new qualitative project has yielded another surprise: Students in this study weren’t intimidated by librarians or reluctant to lose face by approaching them; they simply had no idea why the librarians were there and what they were for,” Gremmels writes. “Are we labeling as library anxiety phenomena that would more accurately be described as library ignorance or library indifference?”

That fact can be particularly concerning when considering the demonstrated benefits of physically stepping into the college library. “We have research that shows [students] do benefit significantly by using the library,” says Riley, citing GPA performance and levels of institutional engagement as indicators. “Plus, we love to just generate that love of learning. So, obviously, I think it’s better if they come to the library.”

So where does this all leave the student who’s still fearful of making that first approach to the reference desk? Librarian Michel C. Atlas has some age-old, conventional wisdom to offer: “[T]he bottom line on library anxiety—just get over it!”

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Current Diagnosis and Treatment of Anxiety Disorders

Anxiety disorders are the most prevalent mental health conditions. Although they are less visible than schizophrenia, depression, and bipolar disorder, they can be just as disabling. The diagnoses of anxiety disorders are being continuously revised. Both dimensional and structural diagnoses have been used in clinical treatment and research, and both methods have been proposed for the new classification in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-5). However, each of these approaches has limitations. More recently, the emphasis in diagnosis has focused on neuroimaging and genetic research. This approach is based partly on the need for a more comprehensive understanding of how biology, stress, and genetics interact to shape the symptoms of anxiety.

Anxiety disorders can be effectively treated with psychopharmacological and cognitive–behavioral interventions. These inter ventions have different symptom targets; thus, logical combinations of these strategies need to be further studied in order to improve future outcomes. New developments are forthcoming in the field of alternative strategies for managing anxiety and for treatment-resistant cases. Additional treatment enhancements should include the development of algorithms that can be easily used in primary care and with greater focus on managing functional impairment in patients with anxiety.

INTRODUCTION

Anxiety disorders are present in up to 13.3% of individuals in the U.S. and constitute the most prevalent subgroup of mental disorders. 1 The extent of their prevalence was first revealed in the Epidemiological Catchments Area study about 26 years ago. 2 Despite their widespread prevalence, these disorders have not received the same recognition as other major syndromes such as mood and psychotic disorders; in addition, the primary care physician is usually the principal assessor and treatment provider. 3 , 4 As a result of this management environment, anxiety disorders can be said to account for decreased productivity, increased morbidity and mortality rates, and the growth of alcohol and drug abuse in a large segment of the population. 5 – 7

Anxiety disorders currently included in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (DSM IV-TR) are listed in Table 1 . 8

Anxiety Disorders

Advances in anxiety research over the previous decade are likely to be reflected in modifications of diagnostic criteria in the upcoming DSM-5 , 9 planned for publication in May 2013. For instance, post-traumatic stress disorder (PTSD) and obsessive–compulsive disorder (OCD) have been reclassified in the separate domains of Trauma and Stressor Related Disorders and Obsessive–Compulsive and Related Disorders, respectively. 10 , 11

In this article, we review the challenges to the diagnosis of anxiety disorders, provide a model that explains how anxiety symptoms occur and change over time, highlight the neurotransmitter systems affected by these disorders, and discuss the roles and relative efficacy of pharmacological and non-pharmacological interventions.

DIAGNOSTIC DILEMMAS

Within the past 10 years or so, epidemiological data have been used in the attempt to refine the boundaries of diagnostic categories of anxiety disorders. The results of this approach have been progressively reflected from DSM III to IIIR to DSM IV-TR (see Table 1 ) and, finally, to DSM-5 . However, this effort has been hampered by the extensive presence of comorbidities in patients with anxiety, as revealed by the National Comorbidity Survey (NCS). 11 For instance, in patients with some disorders such as generalized anxiety disorder (GAD) and social anxiety disorder (SAD), the presence of comorbidities is a rule rather than the exception. 12 In clinical practice and in research, it is not unusual to find the coexistence of two or more diagnosable conditions in the same patient or at least symptomatic overlap with several subsyndromal states. This is particularly true for symptom overlap between different anxiety disorders, depression, and alcohol and drug abuse. 13

A related phenomenon is the emergence of different disorders in the same patient over a lifetime. For example, during an initial evaluation, the original diagnosis could be panic disorder that resolves after treatment, and then presents after a few years with symptoms more suitable to a diagnosis of OCD or GAD. Whether this process reflects a primary diathesis or two distinct entities is uncertain.

Another significant problem with the present classification of anxiety disorders is the absence of known etiological factors and of specific treatments for different diagnostic categories. Studying the genetic underpinnings of anxiety disorders using molecular biological techniques has failed to produce a single gene or a cluster of genes implicated as an etiologic factor for any single anxiety disorder, even though some genetic findings exist for OCD and panic disorder. 14 , 15 Despite a lack of specificity, family and twin studies point to the importance of genetic factors that are possibly shared among various anxiety disorders, depression, and alcohol and drug abuse. 16

Despite these diagnostic ambiguities, the emergence of efficacious serotonergic medications that cut across a variety of categorical disorders (e.g., mood and anxiety) has led many to suggest that a dimensional model might be more applicable in the study and treatment of these conditions. 17 In this view, the disorder is seen as a complex set of coexisting symptom dimensions (e.g., panic, social awkwardness, and obsessiveness). Each of these dimensions can vary, depending on hypothetical, biological, or genetic factors, which may dictate separate biological or psychological treatment approaches. 9 The usefulness of the dimensional versus the categorical approach remains a highly debatable topic in research and in clinical practice and is one of the bases for the introduction of DSM-5 . 18 , 19

Within psychiatry, similarities between distinct disorders has led to the emergence of the term “spectrum” disorders, a concept initially developed for OCD. 20 This conceptualization was helpful in evaluating similar responses to pharmacological and psychological treatments and has been expanded to consider many other spectra such as social anxiety, panic–agoraphobia, and post-traumatic disorders. 21 – 23 This approach, although useful, can be overly inclusive and misleading because it sometimes lumps together disorders that have little in common, such as placing pathological gambling and body dysmorphic disorder (BDD) in the same OCD spectrum. So far, few genetic or neuro-circuitry investigations have validated this concept.

Dimensional and categorical diagnosis in the DSM-IV-TR is usually produced by cross-sectional comparisons of distinct subject samples. However, diagnostic presentations in clinical practice occur in individuals treated sequentially and may therefore be better understood as part of a psychopathological process that unfolds over time. For example, although a patient might meet criteria for OCD purely on the basis of obsessions or compulsions, the latter usually arise later in the disorder as if to counteract the threat and anxiety associated with obsessive thoughts. 24

Analogous viewpoints can be found in medical disease, with symptoms usually representing a combination of a noxious agent and the body’s reaction to its presence. For instance, when the lungs are infected with the harmful organism Mycobacterium tuberculosis , they compensate by forming scars around the tissue. In the short run, this may be effective in walling off the infection (and may even elude clinical detection), but the strategy fails when pushed to the extreme, leading to respiratory compromise in some cases.

In recent years, scientists and clinicians have begun to realize that the processes underlying anxiety and fear might be similar among the various disorders. This has resulted in the implementation of uniform treatment regimens in primary care 25 and in the development of the unified theory of anxiety. 26

THE ‘ABC’ MODEL OF ANXIETY

Understanding how emotional reactivity, core beliefs, and coping strategies interact in time should lead to more precise diagnoses and better management of anxiety disorders. We recently applied a mathematical model using nonlinear dynamics to describe these processes 27 and further developed this model to cover diagnostic presentations and their underlying processes. 28 The model that we, for simplicity, call the “ABC model of anxiety” could be viewed as an interaction in space and time of a larms, b eliefs and c oping strategies ( Figure 1 ).

Schematic detailing the “ABC” model of anxiety. In this model, a variety of triggering events can elicit responses at the levels of A larm sensations, B eliefs, and associated C oping (ABC) strategies, including behaviors. Each of these processes originates in discrete brain circuits that are functionally connected. Over time, this perpetuates a vicious circle, shaping the presentation of a variety of anxiety disorders.

Alarms (A) are emotional sensations or physiological reactions to a trigger situation, sensation, or thought. A well-defined set of brain circuits rapidly processes information about the alarm.

The ensuing decision to act is made on the basis of beliefs (B) that rely heavily on previous experiences, personal and cultural background, and the information that is perceived by the sensory organs. Patients with anxiety disorders appear to process information about a supposedly dangerous situation with more focused attention compared with individuals without the disorder. 29 Accurate decision-making regarding beliefs is obscured by a flood of details, which leads to catastrophic thinking and indecision.

This, in turn, leads to coping strategies (C), for example, specific behaviors or mental activity aimed at reducing anxiety and avoiding the perceived “danger.” Coping strategies can be considered adaptive or maladaptive, based on their efficacy in reducing the target anxiety. These processes evolve over time, forming a complex picture of a particular anxiety disorder.

As a clinical example, panic disorder may start as an initial devastating panic attack driven by activation of the brain’s alarm networks. This event activates circuits that process information about danger and, when coupled with personal beliefs about the event, leads to increased concern about personal health and safety. This in turn leads to a specific attempt to decrease the danger of the situation (e.g., a medical workup that initially calms the fear).

These processes often occur in healthy people who might experience an unpleasant or dangerous situation; in patients with panic disorder, however, a regular medical workup is in-sufficient to calm them because they require a 100% assurance of “no danger.” Because this is impossible to provide, worry and anticipation of another impending attack persist. The patient subsequently increases “safety” coping behaviors such as having repeated medical examinations (seeking reassurance) and having a “safe” person around at all times.

Unfortunately, because no absolute safety is to be found, these behaviors become more extensive and chronic in the attempt to alleviate anxiety. The fact that anxiety persists induces more worry and eventually distress, thus perpetuating the vicious circle of the disorder (recurrent panic attacks). If the pattern is uninterrupted, it eventually leads to even more inappropriate coping behavior, such as avoidance of any potential triggers of panic (agoraphobia), and can result in comorbid despair and depression. Most of the anxiety disorders follow this process even though different stages may predominate in different disorders; that is, ritualistic behavior is more characteristic of OCD, and avoidance predominates in social anxiety disorder.

We have found that patients quickly recognize and interpret their symptom patterns within the ABC model. We effectively incorporate this pattern with medication and behavioral techniques, as described in the previous studies. 30 We have also found that conceptualization of clinical cases using the ABC model is particularly helpful in teaching psychiatric residents. Using this model, residents are able to understand and to begin administering cognitive–behavioral therapy (CBT) within relatively few sessions.

Interplay Between Biological and Psychological Factors

In order to treat an anxiety disorder effectively, clinicians should understand how these conditions emerge and which factors are involved in maintaining them. In recent years, we have gained a better understanding of the interplay between genetic, biological, and stress factors that shape the presentation of the disorder, although it is not clear which factors are inherited.

One possibility is that abnormal cognition could be the inherited factor. Cognitive theory assigns a primary importance to abnormal or “catastrophic” cognition as an underlying mechanism of all anxiety disorders. Most cognitive strategies for treatment and research were developed in earlier years.

The ABC model focuses on the interaction of information processing and emotional and cognitive processes that are controlled by overlapping circuits and compete for the same brain resources. 27

In most anxiety disorders, patients usually process fear-inducing information in excessive detail that overwhelms their ability to appraise it properly. They cope by separating the information into “good” and “bad” with no gray area in between. As a result, they consider the worst-case scenario (i.e., by catastrophizing about the situation) and then act to protect themselves against the perceived danger.

Stress also plays a major role in the pathology of anxiety disorders. For example, PTSD is a condition in which stress is considered the main etiological factor, although there is a high degree of co-occurring stress reported by these patients. In other anxiety disorders such as GAD and OCD, the role of stress is less apparent. Nevertheless, patients with any anxiety disorder often pinpoint the onset of their disorder in relation to a striking stressful event or to a continuous persistent stressor. Whether a cause or a consequence, increased stress reactivity sometimes accounts for relapses in chronic anxiety conditions like GAD. According to some studies, a stressful event or a persistent and chronic disorder can even cause secondary biological changes in specific brain structures. 31 , 32

The current DSM-IV-TR system does not adequately address the role of stressors. Although stressors are separately identified along Axis IV of the multiaxial system, the context for the patient is unclear. Perhaps a better way to address the patient’s anxiety would be to indicate the source and rate the persistence (i.e., immediate, intermittent, or constant) and the degree of the stress (i.e., mild, moderate, severe, or catastrophic). With this approach, we might be better able to capture the landscape and dynamic of the stress. For example, panic disorder resulting from exposure to catastrophic combat may differ clinically from panic disorder that results from a persistent work-related stress or separation from family. Exploration of how stress affects biology and the course of anxiety disorders is clearly needed.

Biological Factors

Biological factors are of primary importance in anxiety disorders. Anxiety disorders can occur in the context of medical illness, 33 and the clinician should consider an intricate relationship between medical illnesses and anxiety disorders. This relationship could be manifold.

First, metabolic or autonomic abnormalities caused by the illness can produce the syndrome of anxiety (i.e., hyperthyroidism sometimes results in panic attacks). The symptom of medical illness can be a trigger for anxiety (i.e., sensations of arrhythmia can serve as a trigger for a panic attack). Sometimes medical illness can mimic the anxiety disorder (i.e., when perseverations in mental retardation are mistaken for OCD).

Finally, medical illness and an anxiety disorder can simply coexist in the same patient. One of the most interesting interactions between medical illness and anxiety disorders is pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS), which has been reported in a subset of OCD patients. 34

Over the previous two decades, the main thrust of biological research in anxiety disorders has shifted from peripheral measures of autonomic and neurochemical parameters to identifying reactivity and neurochemistry of the living brain directly through advances in neuroimaging technology. Anxiety disorders are an appropriate target for neuroimaging research because it is easy to provoke specific symptoms in many cases. Much of the research on neural circuits has focused on models of anxiety and fear proposed earlier by basic scientists, 35 , 36 and a synthesis of current data has been attempted for panic disorder 37 and OCD. 38

There have been some excellent reviews of neuroimaging experiments in anxiety, 39 , 40 but the picture remains incomplete, in part because of a lack of clinical trials addressing the long-term integration of threat responses. As in the dynamical model, every anxiety disorder may be viewed as an interplay of anxious feelings, abnormal processing of information, and inadequate coping strategies. In accordance with this model of anxiety, overlapping neuronal circuits are responsible for alarm reactions, processing of perceived threats, and behavioral coping (see Figure 1 ). This model attempts to simplify complex brain circuitry that needs to be studied over the next several decades before we can truly understand how the brain processes threats over time.

For simplicity we identify Alarm circuits (A), in which the amygdala is the structure of primary importance. These circuits also include periaqueductal gray matter and multiple nuclei in the brainstem. 41 The disturbance of anxiety circuits results in a lower threshold for alarm reactions that leads to spontaneous panic attacks. These circuits are possibly responsible for the quick response to a threat.

Circuits associated with Beliefs (B), responsible for processing information related to “threats,” are probably closely associated with the basal ganglia, cingulum, and corticostriatal connections, which are typically affected in OCD.

Abnormalities in Coping (C) should be governed by distributed cortical networks and are difficult to tease apart. Thus, a convenient mnemonic explaining these circuits could be A (Alarm, amygdala), B (Beliefs, basal ganglia), and C (Coping, cortex).

How Anxiety Affects Neurotransmitters

Neuronal circuits are governed by multiple neurotransmitter systems; the most extensive of these are gamma-aminobutyric acid (GABA) and glutamate. The neural systems of the three major neurotransmitter systems—serotonin, dopamine, and norepinephrine—have been extensively studied in normal and pathological anxiety states. 40 , 42 The significance of these systems in anxiety is apparent from the fact that most effective therapies for these disorders affect one or several of them. However, anxiety disorders are not simply a deficiency of one neurotransmitter or another. The networks governed by these transmitters have extensive interrelationships, multiple feedback mechanisms, and complex receptor structures. 43 This complexity helps to explain the unpredictable and sometimes paradoxical responses to medication.

Research involving other neurotransmitter systems has been fruitful in elucidating their function in anxiety but thus far has failed to produce new treatments. The primary neurotransmitter and receptor systems implicated in the pathogenesis of anxiety disorders are discussed next.

The primary serotonergic pathways originate in the raphe nuclei and project widely to numerous targets throughout the forebrain. 44 These circuits play a fundamental role in regulating brain states, including anxiety, and modulate the dopaminergic and noradrenergic pathways as well. 45 Increased serotonergic tone appears to be correlated with a reduction in anxiety; however, the mechanism underlying this correlation is not known.

There are also numerous serotonin receptor subtypes whose roles may vary, depending on location. For example, the serotonin-1a receptor serves as both a mediator and an inhibitor of serotonergic neurotransmission, depending on whether it is located on the presynaptic or the postsynaptic neuron. 46 Furthermore, not all serotonin receptor subtypes mediate anxiolytic effects; this is demonstrated by the fact that serotonin-2a receptor agonism underlies the psychedelic properties of drugs such as lysergic acid (LSD) and mescaline. 47

Despite this complexity, it is recognized that medications that inhibit the reuptake of serotonin, presumably increasing serotonergic neurotransmission, result in a reduction in symptoms of anxiety for many patients. 48

Gamma-aminobutyric Acid

GABA is the main inhibitory neurotransmitter in the central nervous system (CNS). Increases in GABA neurotransmission mediate the anxiolytic effect of barbiturates and benzodiazepines. 49 Medications in these classes do not bind directly to the GABA receptor; instead, they promote the open configuration of an associated chloride channel. Barbiturates do this by increasing the duration of the channels’ open state, whereas benzodiazepines increase the frequency of opening.

Although modulation of GABA-ergic pathways can reduce anxiety almost immediately, compensatory mechanisms associated with these circuits and the use of barbiturates and benzodiazepines can result in tolerance and potentially fatal withdrawal. 50 Further, these drugs impair memory encoding and thus may undermine the efficacy of concomitantly administered psychotherapy.

Anticonvulsant agents also alter GABA transmission and are used to treat anxiety. 51 This class of medications affects GABA transmission indirectly by blocking calcium channels, resulting in a lower potential for withdrawal and addiction. 52

The principal dopaminergic pathways originate from the midbrain in the ventral tegmental area and substantia nigra, with projections to the cortex, striatum, limbic nuclei, and infundibulum. Dopamine’s role in normal and pathological anxiety states is complex, and dopaminergic pathways may affect anxiety states in several ways. 53 It is well known that dopamine D 2 blockade, the characteristic mechanism of antipsychotic medications, is also anxiolytic. 54

This class of medications has been widely used in the treatment of anxiety. However, as a catecholamine, dopamine is up-regulated with norepinephrine in anxiety states, whereas increases in dopaminergic signaling also appear to mediate feelings of self-efficacy and confidence—which can act to reduce anxiety. 55 , 56 The result of this complexity is a variation in responses to medications that increase dopamine. Some patients with anxiety disorder respond well to pro-dopaminergic drugs such as bupropion (Wellbutrin, GlaxoSmithKline); other patients find that such agents exacerbate their symptoms.

Norepinephrine

Noradrenergic neurons originate primarily in the locus coeruleus in the pons and project widely throughout the CNS. 57 Like dopamine, norepinephrine is a catecholamine that is up-regulated in anxiety states, but it has a complex and potentially bidirectional role in mediating normal and pathological anxiety. Many of the physiological symptoms of anxiety are mediated by norepinephrine, and antagonists of various norepinephrine receptor subtypes are used to combat particular aspects of anxiety.

For example, propranolol, an antagonist of the beta 2 -norepinephrine receptor, is used to reduce the rapid heart rate, hand tremor, and quivering voice that might accompany public speaking or other activities associated with performance anxiety. 58 Although propranolol has been useful in targeting these physiological symptoms of normal anxiety, it has not been particularly effective in reducing the emotional or cognitive aspects of anxiety and is not generally used as a therapy for anxiety disorders.

Similarly, prazosin (Minipress, Pfizer), an antagonist of the alpha 1 -norepinephrine receptor, is used to reduce the intensity and frequency of nightmares associated with PTSD but has not been effective in relieving other symptoms of anxiety disorders. 59 , 60 Serotonin–norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine (Effexor, Wyeth/Pfizer) and duloxetine (Cymbalta, Eli Lilly), have been effective in the treatment of anxiety disorders. 61 These medications also help to reduce neuropathic pain and may target the agonal component of anxiety.

Glutamate is the primary excitatory neurotransmitter in the CNS and is involved in virtually every neuronal pathway, including those underlying normal and pathological anxiety states. 62 , 63 The N -methyl- d -aspartate (NMDA) receptor subtype may be particularly important in anxiety disorders, as it is believed to mediate learning and memory. Activation of the NMDA receptor triggers protein synthesis, which appears to strengthen the connection between neurons when they fire concurrently. Therefore, glutamatergic pathways are probably involved in both conditioning and extinction, the processes associated with the development and treatment of anxiety disorders, respectively. 64

Preliminary evidence suggests that both augmentation and antagonism of NMDA-mediated pathways are effective in the treatment of anxiety disorders, although no glutamatergic medications have received an FDA indication for this use. d -cycloserine enhances glutamatergic neurotransmission and has been effective in augmenting the effects of exposure therapy for anxiety disorders. 65 However, the NMDA receptor antagonists memantine (Namenda, Forest) and riluzole (Rilutek, Sanofi) have evidence supporting their efficacy in the treatment of OCD. 66 Interestingly, memantine appears to be much less effective in the treatment of GAD, suggesting that different pathways may underlie different anxiety disorders. 67

Other Neurotransmitters

Many other neurotransmitter systems participate in the biological mechanisms of fear and anxiety. Neuropeptides, including substances P, N, and Y; corticotropin-releasing factor (CRF); cannabinoids; and others, modulate fear in animal models. 68 – 70 However, none of the experimental agents that utilize these systems have been translated into FDA-approved treatments. 71 Stringent criteria for approval, along with high placebo responses typical in anxiety trials, could be responsible. 72

PHARMACOLOGICAL THERAPY

Numerous neurotransmitters play a role in normal states and in pathological anxiety states. Each of these systems is a potential target for pharmacological intervention, but relatively few classes of medications are used in clinical practice for the treatment of anxiety. These drug classes are briefly discussed next.

Selective Serotonin Reuptake Inhibitors

SSRIs, usually indicated in depression, are considered to be the first line of therapy for anxiety disorders. This drug class includes fluoxetine (Prozac, Eli Lilly), sertraline (Zoloft, Pfizer), citalopram (Celexa, Forest), escitalopram (Lexapro, Forest), fluvoxamine (Luvox, Solvay), paroxetine (Paxil, GlaxoSmithKline), and vilazodone (Viibryd, Forest). 72 The essential characteristic of the medications in this class is that they inhibit the serotonin transporter and appear to cause desensitization of postsynaptic serotonin receptors, thus normalizing the activity of serotonergic pathways.

The mechanism by which this leads to amelioration of anxiety symptoms is not fully understood. Vilazodone, the most recently approved medication in this class (although indicated for major depressive disorder), also acts as a partial agonist at the serotonin-1a receptor, which may contribute to anxiolysis. 73 Buspirone (BuSpar, Bristol-Myers Squibb), which is not a serotonin reuptake inhibitor (SRI), is also a 5-HT 1a agonist and is frequently used as a single agent or as augmentation to SSRI therapy. 74

Serotonin–Norepinephrine Reuptake Inhibitors

SNRIs, which inhibit the serotonin and norepinephrine transporters, include venlafaxine, desvenlafaxine (Pristiq, Pfizer), and duloxetine. 75 Milnacipran (Savella, Cypress/Forest) is rarely, if ever, used to treat anxiety because its only FDA-approved indication is for fibromyalgia. 76 SNRIs are typically used after failure or inadequate response to an SSRI. They are used in place of augmentation to SSRIs because the combination of these two drug classes may result in serotonin syndrome.

Patient responses to SNRIs can vary widely; some patients may experience an exacerbation of the physiological symptoms of anxiety as a result of the increased norepinephrine-mediated signaling caused by inhibition of the norepinephrine transporter. For patients who do not experience this effect, the increased noradrenergic tonus may contribute to the anxiolytic efficacy of these medications.

Benzodiazepines

Although benzodiazepines were widely used in the past to treat anxiety conditions, they are no longer considered to be first-line therapies because of the risks associated with their chronic use. 75 They are very effective in reducing acute anxiety but are associated with problematic adverse effects when used for a long time in high doses, including:

• physiological and psychological dependence.
• potential fatalities upon withdrawal.
• impaired cognition and coordination.
• a potentially lethal overdose when they are mixed with alcohol or opioids.
• inhibition of memory encoding, which can interfere with the efficacy of concomitant psychotherapy.

For these reasons, the use of benzodiazepines is often restricted to the short-term treatment of acute anxiety or as therapy for refractory anxiety after failed trials of several other drugs. Of note, some subgroups of patients do well with low doses of benzodiazepines and are able to safely taper from high doses, especially when cognitive–behavioral therapy (CBT) is added. 77

Antiseizure Medications

Because of the side effects of benzodiazepines, antiepileptic agents have been used more extensively for the treatment of anxiety. Antiseizure drugs were initially used for mood stabilization in mood disorders; however, their anxiolytic properties were quickly noted. Many agents in this drug class are being used in an off-label fashion to treat anxiety, especially gabapentin (Neurontin, Pfizer) and pregabalin (Lyrica, Pfizer). 51 , 78 Less information is available for topiramate (Topamax, Janssen), lamotrigine (Lamictal, GlaxoSmithKline), and valproate (Depacon, Abbott). 79 In higher doses, the antiseizure class can produce adverse effects similar to those of the benzodiazepines. 80

Tricyclic Antidepressants

All tricyclic antidepressants (TCAs) function as norepinephrine reuptake inhibitors, and several mediate serotonin reuptake inhibition as well. Although several medications in this drug class are comparable in efficacy to the SSRIs or SNRIs for anxiety disorders, TCAs carry a greater number of adverse effects and are potentially lethal in an overdose. For this reason, TCAs are rarely used in the treatment of anxiety disorders. A notable exception is clomipramine (Anafranil, Malinckrodt), which may be more efficacious than SSRIs or SNRIs in patients with OCD. 81

Additional Medications

Hydroxyzine (Atarax, Pfizer), mirtazapine (Remeron, Organon), nefazodone (Bristol-Myers Squibb), and atypical neuroleptic agents are commonly used to treat anxiety. 82 Although all of these medications are efficacious for anxiety disorders, especially OCD, they are not considered first-line treatments and are typically used as an adjunct to an SSRI or an SNRI. Hydroxyzine is indicated for anxiety and probably achieves anxiolysis by inhibiting the histamine H 1 receptor and the serotonin-2a receptor. 83

TREATMENT STRATEGIES

Initial treatment algorithms.

During the 1990s, mainstream psychological and pharmacological treatments of anxiety disorders were developed and tested, leading to an initial algorithm that is similar for all major anxiety disorders. 84 , 85 The typical algorithm, adapted from Roy-Byrne et al., 25 is presented in Figure 2 .

Stepped-care treatment algorithm. AD = antidepressant therapy; CBT = cognitive–behavioral therapy; MED = medication; rTMS = repetitive transcranial magnetic stimulation; SSRI = selective serotonin reuptake inhibitor. (Adapted from Roy-Byrne, et al. Arch Gen Psychiatry 2005;62[3]:290–298; 3 and Roy-Byrne et al. JAMA 2010;303[19]:1921–1928. 25 )

In general, clinicians must choose between CBT and an SSRI and then try another SSRI if the first one did not work or was not tolerated. None of the SSRIs has shown superiority to another. The choice of an SSRI is usually based on the side-effect profile, pharmacokinetic and pharmacodynamic properties, and potential interactions with coadministered medications.

Several excellent reviews of SSRI therapies for anxiety disorders have been published. 86 A general principle with SSRIs is to “start low and go slow,” starting with approximately half the dose of that used for depression and slowly titrating the dose upward, with no more than a once-weekly change in the dosage.

Antidepressants with broader mechanisms of action (i.e., venlafaxine and clomipramine) have been tried in nonresponders. The rationale for this practice is that these medications affect more than one neurotransmitter system and have some, albeit weak, meta-analytic data supporting their superiority in depression and OCD. 87 Benzodiazepines are generally avoided except in acute states or treatment-resistant chronic conditions.

Few data have been published about what to do after the few initial steps of treatment, such as how long maintenance therapy should last. Based on clinical experience, we generally recommend continuing treatment until the patient has achieved marked symptom reduction for at least 6 months. More research on this topic is needed.

Further testing of combined treatments at the initial and later steps of the typical algorithm was subsequently performed. 88 , 89 In the later stages of anxiety treatment, GABA-ergic anti-epileptic drugs and atypical antipsychotic agents may be tried. Atypical neuroleptic medications have shown even better evidence of efficacy in anxiety disorders, according to some placebo-controlled trials. 90

Side Effect Profiles

Patients and physicians need to be aware of adverse drug reactions. An extensive review of the side effects of SSRIs has been published by Valuck. 91 In other studies, SSRIs and SNRIs were found to increase the risk of suicidality 92 and atypical neuroleptic agents caused tardive dyskinesia and arrhythmias. 93 All of these drugs can cause weight gain and sexual dysfunction. Because polypharmacy is becoming the rule rather than the exception, especially in complex and treatment-resistant anxiety, practitioners should be cognizant of potential drug–drug interactions. 94

Serotonin syndrome and neuroleptic malignant syndromes, although rare, should be kept in mind. Discontinuation of SSRIs has not been well studied, but a withdrawal syndrome upon abrupt discontinuation of SSRIs (and SNRIs) is common. Symptoms may include paresthesias, nonvertiginous dizziness, nausea, diaphoresis, and rebound anxiety. 95 For this reason, stopping SSRIs and SNRIs should involve a gradual tapering and should take place, if possible, in parallel with CBT.

Cognitive–Behavioral Therapy and Medications

CBT has received the greatest amount of empirical support for the psychological treatment of anxiety disorders. 96 In our treatment algorithm, CBT stands with the SSRIs as a first-line treatment choice (see Figure 2 ). Combining drug therapy and CBT has shown mixed results in favoring one approach over the other, depending on the type of anxiety disorder.

A review and meta-analysis approached the question of combination treatment over monotherapy or CBT in anxiety by hypothesizing that CBT would be more successful compared with medications; however, the medication held an advantage over CBT in depression. 97 Within the anxiety disorders, there was great heterogeneity in their responsiveness to either CBT or medication, with CBT holding an advantage over medication in patients with panic disorder. By contrast, patients with social anxiety disorder were more responsive to medication.

The choice of medication or CBT, alone or in combination, is based on several variables, including the availability of a therapist; the affordability of CBT, which costs more than medication, especially if drugs are prescribed in primary care settings; and patient preference.

Cognitive–Behavior Therapy Alone

It is generally acknowledged that the treatment of anxiety disorders is suboptimal because of a lack of CBT therapists or the availability of affordable sessions. There is a great need to distill the essence of good therapy and to bring it into the primary care setting, with an emphasis on education and staff training. 25 Oxford University Press has published many excellent manuals that include both therapist and patient guides. 98 The proliferation of the Internet-based, self-administered therapies calls for further research into the efficacy of this method of dissemination. 99 Complex anxiety disorders might not be able to be self-treated adequately, whereas a specific phobia might be self-treated alone or with the support of a friend of family member.

Koszycki et al. 100 discussed whether self-administered CBT could stand alone or could be optimized with therapist-directed CBT, self-administered CBT, or medication augmented with self-administered CBT. Their work suggested that even self-administered treatment might be an effective addition to the CBT armamentarium.

Although many treatments are effective for anxiety, not all of them can help everyone and not all of them are effective for all anxiety disorders. A simple phobia is easier to treat than a complicated case of PTSD. The most empirically supported treatments are SSRIs and CBT. Relapse rates for CBT, compared with medication, are an understudied area, although our clinical experience suggests that CBT has a longer treatment effect if the patient continues to use the skills and tools learned in therapy.

CBT shares much in common with other more dynamically based forms of psychotherapy. A patient seeks help from an expert caregiver who treats the patient in a warm and nonjudgmental relationship in an attempt to help the patient function and feel better in a reality-oriented setting. However, CBT is directive and collaborative; the therapist establishes clear and specific goals with the patient and uses evidence-based techniques to elicit the patient’s feelings and bodily sensations (Arousal, or Alarm), dysfunctional and irrational thinking (Beliefs), and subsequent behavior (Coping).

The helping relationship is less emphasized in CBT as a curative factor, but it is considered important in building trust and support, serving as a springboard for patients to consider their erroneous beliefs and behaviors that cause them anxiety and fear. The therapist is explicit about conceptualizing the patient’s disorder, with regard to the genesis, evolution, and maintenance of the disorder over time. The therapist often incorporates manuals or other psychoeducational materials and may propose daily homework to help the patient learn more adaptive ways to manage and reduce the alarm (A), change irrational and dysfunctional beliefs (B), and develop adaptive coping (C) mechanisms, often through exposure exercises. To the most appropriate extent possible, patients are taught the ABC model to help them understand the dynamic and reciprocal relationship among feelings, thoughts, and behaviors.

Patient compliance with therapy is directly proportional to the treatment’s effectiveness. Motivational interviewing, which is used to help patients examine the cost–benefit ratio of their maladaptive thoughts and behavior, often increases compliance and, subsequently, effectiveness. 101 Patients are taught self-monitoring and symptom-reduction techniques to increase their motivation to confront their anxiety. Breathing and relaxation techniques can be explained as mental hygiene to raise one’s threshold for the onset of alarm reactivity and for increasing the patient’s ability to notice whether an alarm reaction is mounting over the course of the day.

The linchpin in the CBT model of anxiety is considered to be the patient’s thoughts. 102 Misguided beliefs must change for both the alarm to down-regulate and for subsequent adaptive coping to replace avoidant and escape-based coping. Although beliefs are the linchpin, exposure to the anxiety-producing thought, image, or situation is often the essential CBT component for jogging the linchpin loose. This too is a dynamic process. Cognitive restructuring techniques aimed at reducing catastrophic thinking help to diminish irrational or exaggerated thoughts, thereby allowing patients to become more willing to test those beliefs through exercises involving exposure.

Exposure is the gradual and systematic presentation of the anxiety-inducing thought, image, or situation for a long enough time for patients to see that their anxious feelings can be decreased without engaging in avoidance or escape. For example, a patient who is afraid of dogs might first be shown a picture of a dog, then stand across the street from a pet shop, and finally hold a dog in his or her arms. The patient would engage in each of these steps repeatedly and in a concentrated but not overwhelming way.

Ideally, the patient would experience a gradual lessening of anxiety at each step before moving on to the next. The patient would experience the alarm being reduced, and the exaggerated belief that all dogs are dangerous could be modified to a more accurate belief that most pet dogs are not threatening. The hoped-for outcome would be that the patient would no longer have a phobic avoidance of all dogs.

Mindfulness (The Third Wave)

A final emerging area in the evolution of CBT is the approach based on mindfulness (acceptance). This is the “third wave” in CBT, the first wave being the strict behavioral approach and the second wave emphasizing the cognitive approach. 103

Mindfulness is a type of meditation that has been adapted from Buddhist psychology. One definition is “awareness of present experience with acceptance.” 103 These therapies owe a debt of gratitude to Jon Kabat-Zinn’s Mindfulness-Based Stress Reduction (MBSR) program, which began at the University of Massachusetts in 1979. 104

Mindfulness-based cognitive therapy (MBCT) is one component of the integration of mindfulness into CBT. 105 MBCT has been applied to the treatment of panic disorder and other anxiety disorders, but more carefully controlled research is needed in this area. 106 MBCT emphasizes the prevention of relapse through a meta-cognitive or mindful awareness that leads patients to realize that their current symptoms do not necessarily mean that they are relapsing.

Acceptance and commitment therapy involves a mindful focus; many exercises are aimed at the meta-cognitive level to help patients perceive their thinking and subsequent anxiety to be separate from, and less identified with, their sense of self. Anxiety-causing thoughts are to be observed and accepted, not to be struggled with and changed, as in more traditional CBT and Western psychological approaches. 107

Shifting Treatment to Primary Care

In today’s managed care environment, the treatment of anxiety usually takes place in the primary care setting. Given the increasing limits on primary care physicians’ time, it is not surprising that anxiety disorders are underrecognized and undertreated. At the same time, SSRIs (antidepressants) are increasingly used in primary care, and physicians in fact are the largest group of prescribers. This is a mixed blessing for several reasons:

• SSRIs are often prescribed quickly in response to emotional distress that might not meet criteria for an anxiety disorder.
• The dose and duration of therapy might be inadequate.
• Adverse effects might not be managed by any means other than by discontinuation of the treatment.

This state of affairs may partly explain why psychiatrists are seeing more patients who are disenchanted with numerous failed attempts at pharmacotherapy.

Another problem in primary care is a lack of understanding of behavioral strategies that result in low referral rates to mental health professionals. There has been a trend toward developing comprehensive treatments for panic disorder to be delivered by primary care physicians.

In one study, an algorithm was tested for the treatment of panic disorder. 108 This study reflected the trend of how psychiatrists became more like consultants to primary care physicians, assisting them with correct initial management plans and taking over the management of more severe and treatment-resistant anxiety.

Management of Treatment-Resistant Anxiety

In managing refractory anxiety, it is important to start with a re-evaluation of the patient, including the diagnosis; comorbidities; and the interplay of cognitive, stress-related, and biological factors. Inadequate coping strategies on the part of patients and their family members should be reviewed. Doses and duration of the initial treatments should be assessed.

Initially, more intensive CBT, combined with an adequate trial of SSRIs, SNRIs, or both, may be needed in refractory anxiety. After that, the treatment may progress to a combination of SSRIs with antiepileptic or atypical neuroleptic agents, especially if bipolar disorder or a psychotic disorder is suspected. 109 , 110 Later, partial hospitalization in specialized centers with more extensive CBT and medication management might be recommended. 111

Although other forms of therapy have not demonstrated efficacy in anxiety disorders, they may be helpful for addressing personality issues in chronically anxious patients.

Experimental and Off-Label Nonpharmacological Treatments

Therapies for anxiety disorders, beyond combining conventional treatments, using off-label antiepileptic and antipsychotic agents, and introducing more intensive CBT programs, are mostly experimental. Promising medications have included intravenous clomipramine, citalopram, and morphine. 109 Many other treatments targeting more specific neurotransmitter systems have failed. 72

A handful of invasive therapies have emerged. These options may be considered after several off-label pharmacotherapy and psychotherapeutic approaches have failed or when significant functional impairment remains. They are typically reserved for the most treatment-resistant cases, typically those involving severe OCD. Invasive treatments often target brain circuits implicated in the processing of fear and anxiety.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) involves the application of brief electrical impulses to the scalp to induce large-scale cortical neuronal discharges, eventually producing generalized seizure activity. Although ECT is effective in treatment-resistant mood disorders, data regarding its efficacy in anxiety disorders are limited. 112 The mechanism and focal targets of ECT have not yet been determined.

Vagal Nerve Stimulation

Initially developed as an antiepileptic treatment, vagal nerve stimulation (VNS) was used in psychiatric patients after sustained mood improvements were noted with this therapy. 113 VNS is thought to stimulate brain networks relevant to anxiety and fear processing (taking place in the amygdala, hippocampus, insula, and orbitofrontal cortex) via the afferent vagal nerve. This modality is not routinely used to treat anxiety, and evidence of its effectiveness in resistant anxiety disorders is limited. 114 To date, no randomized controlled trials have investigated this intervention further.

Repetitive Transcranial Magnetic Stimulation

Focal magnetic stimulation of the scalp is used with the goal of invoking excitation or inhibition of cortical neurons. Repetitive transcranial magnetic stimulation (rTMS) is less invasive than ECT; anesthesia induction is not required, and rTMS does not elicit generalized seizure activity in the brain. It also has the advantage of being able to target brain regions thought to be involved in anxiety disorders.

The main limitations of rTMS include the inability to penetrate deeper brain structures implicated in OCD (the caudate nucleus, thalamus, and anterior capsule fiber tracts) or in panic disorder (the amygdala, hippocampus, and anterior cingulate); there is also a lack of specificity at the site of stimulation.

rTMS has not been approved as a treatment for any anxiety disorder, probably because of the paucity of large-scale studies. There is limited evidence for efficacy in treating OCD, although larger treatment effects have been reported by altering the stimulation site. 115 , 116 rTMS has been reported to improve anxiety symptoms in PTSD and panic disorder, although the approach has not been incorporated into clinical practice. 117

A small study reported significant anxiety reductions in patients with generalized anxiety disorder (GAD) using a symptom-provocation task during functional magnetic resonance imaging (fMRI) to guide individual selection of the rTMS site. 118 No studies have investigated the role of rTMS in social anxiety disorder.

Although psychosurgery has been used for various treatment-resistant anxiety disorders such as GAD, panic disorder, and social phobia, long-term follow-up studies in these patients have revealed adverse cognitive outcomes, including apathy and frontal lobe dysfunction. 119 Consequently, surgical approaches are usually reserved for OCD, given the disproportionate functional deficits that are a hallmark in treatment-refractory cases.

Several surgical approaches have been used, including anterior capsulotomy (which targets the anterior limb of the internal capsule), anterior cingulotomy (which targets the anterior cingulate and cingulum bundle), subcaudate tractotomy (which targets the substantia innominata, just inferior to the caudate nucleus), and limbic leucotomy (which combines anterior cingulotomy with subcaudate tractotomy). 120 , 121

Cingulotomy remains the most commonly used psychosurgical procedure in North America, probably because of its clinical efficacy as well as low morbidity and mortality rates. Postsurgical effects have included transient headache, nausea, or difficulty urinating. Postoperative seizures, the most serious common side effect, have been reported from 1% to 9% of the time.

Patient outcomes cannot be fully assessed until at least 6 months to 2 years after the definitive procedure, suggesting that postoperative neural reorganization plays an important role in recovery. Direct comparisons of each lesion approach within studies are rare.

Overall, the long-term outcomes of these approaches have demonstrated significant therapeutic effects of each procedure. In general, reported response rates vary from 30% to 70% in terms of remission, response, and functional improvements in quality of life.

Deep-Brain Stimulation

Deep-brain stimulation (DBS) involves the insertion of small electrodes under precise stereotactic MRI guidance. The major advantage of DBS over ablative surgery is the ability to adjust and customize neurostimulation. 122 Following implantation, parameters of electrode stimulation (electrode polarity, intensity, frequency, and laterality) can be modified. Parameters can be optimized by a specially trained clinician during long-term follow-up.

Several studies with blinded stimulation have been conducted with moderate-to-fair results. 123 More recently, structures adjacent to the internal capsule have also been targeted. 124 , 125 In all trials, response rates have been consistently reported in the 50% range. 125

Postoperative complications (e.g., infections, lead malfunctions) occur more commonly with DBS because of the prosthetic nature of the procedure. Batteries must also be periodically explanted and replaced. Stimulation-related side effects have been reported, including mood changes (transient sadness, anxiety, euphoria, and hypomania), sensory disturbances (olfactory, gustatory, and motor sensations), and cognitive changes (confusion and forgetfulness). These side effects are typically stimulation-dependent and disappear after the stimulation parameters are altered.

Complementary and Alternative Medicine

During the 1990s, many alternative treatment strategies for anxiety disorders emerged. 126 These included herbal medications (with St. John’s wort the most frequently used), vitamins, nutritional supplements, magnetic and electroencephalographic synchronizing devices, “energy” treatments, and meditation-based therapies (see Mindfulness on page 38).

These treatments may be provided by alternative medicine practitioners within the scope of a health care model, such as acupuncture, homeopathy, Ayurvedic medicine, Reiki, and healing touch. Because of minimal FDA regulation and widespread over-the-counter availability, many of these same treatments are self-selected and used by patients. Herbs are the most commonly used complementary and alternative medicine (CAM) products and are particularly popular with those with psychiatric disorders. Anxiety is one of the strongest predictors of herbal remedy utilization, 127 and patients often use these treatments without the knowledge of their physician. Consequently, clinicians and pharmacists are advised to regularly monitor the full range of treatments used by their patients, including a thorough medication reconciliation of prescription and non-prescription products, herbs, and supplements at each visit.

Results of herbal trials for anxiety disorders have been mixed. The widespread use of Piper methysticum (Kava) for anxiolysis was curtailed by reports of hepatotoxicity, prompting government warnings and withdrawal of the product from the market in many Western countries. 128 , 129 However, a randomized placebo crossover trial using a supposedly benign aqueous formulation reported moderate reductions in anxiety symptoms in a small sample of patients with mixed anxiety disorders. 128 , 130 Both Hypericum perforatum (St. John’s wort) and Silybum marianum (milk thistle) have been used for the treatment of OCD symptoms, although no placebo-controlled trials revealed any significant differences in symptoms or adverse effects between treatment groups. 131 , 132 Lower-quality studies of CAM have reported modest treatment effects for interventions such as mindfulness meditation, yoga, and acupuncture. 133

Despite a lack of data on efficacy, many patients continue to use CAM therapies, prompting a need to monitor use for potential interactions with prescription medications. 134 For instance, St. John’s wort is known to interact with many medications because of the induction of cytochrome P450 (CYP) isoenzymes 3A4 and 2C9. Of relevance in anxiety disorders, CYP3A4 may cause a decrease in serum levels of alprazolam (Xanax, Pfizer) and clonazepam (Klonopin, Roche). Combining St. John’s wort with SSRIs also increases the risk of serotonin syndrome. Milk thistle inhibits CYP3A4 and has the potential to increase levels of other medications metabolized by this pathway. Kava has been linked with inhibition of several CYP isoenzymes, including 1A2, 2D6, 2C9, and 3A4. 135 Further exploration of the efficacy of these alternative strategies for anxiety disorders is needed.

Functional Status

Although many patients with anxiety disorders experience symptom relief with treatment, residual symptoms still have an impact on everyday functions. Even subclinical anxiety can produce disability sometimes exceeding that seen in other severe mental illnesses. 111 , 136 In addition, chronic, persistent anxiety disorders have a significant impact on patients’ lives, often leading to deficits in social and work skills. Yet there are few clear interventions or programs with a focus on rehabilitation and restoration of function in these patients.

Stress is an important factor in the emergence and maintenance of anxiety syndromes. Patients who need to return to the workforce can experience increased stress that in turn may cause re-emergence of the symptoms, again resulting in decreased productivity and even loss of employment. More research is needed to address this problem.

Anxiety disorders are treatable. Effective treatments have been developed, and algorithms have been refined. However, more work needs to be directed toward merging of our knowledge of the biological mechanisms of anxiety with treatment in order to more accurately predict and improve treatment response. Dynamic models of anxiety—such as the ABC model—can be helpful in understanding the interplay between processes responsible for development and maintenance of the symptoms over time and between biological and psychological factors affecting them.

We need to learn how to better administer existing efficacious treatments in real-world health care environments, such as in primary care, and to inform the public via media outlets. We should continue to test alternative therapies for treating and preventing anxiety disorders and to help patients whose anxiety is resistant to conventional treatments.

Finally, we need to consider the patient’s feelings about mental illness and address their responses early in treatment. All of these measures will enhance the care of patients with anxiety.

Disclosure: Dr. Bystritsky reports that he has received honoraria, research grants, and travel reimbursements from AstraZeneca, Takeda, and Brainsway. He has also served as a consultant for UpToDate, John Wiley & Sons, Brainsonix Corp., and Consumer Brands. Dr. Khalsa, Dr. Cameron, and Dr. Schi3man report that they have no financial or commercial relationships in regard to this article. This work was supported in part by a grant from the Saban Family Foundation.

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Dispelling the Myth of Library Anxiety and Embracing Academic Discomfort

By Kelleen Maluski and Symphony Bruce

Countless articles, essays, studies, and conference presentations have been devoted to library anxiety and defining, analyzing, and reviewing behaviors of our users that are seen as “abnormal” or “counterintuitive” to using our services. However, there is not much critique of library anxiety as a concept and it seems that much of the literature accepts library anxiety as not only a completely true “condition.” In this essay, the authors will problematize the concept of library anxiety by dispelling how library anxiety looks at the symptoms rather than the causes and systems that perpetuate a lack of confidence for users within library spaces. The authors will suggest that the way library anxiety is generally framed by the profession is faulty, as it often assumes that libraries are separate from the rest of the academic experience, neutral, and welcoming instead of regular sites of discrimination and stress. Concepts like anti-deficit thinking, vocational awe, and the recognition that libraries are not neutral will be explored while highlighting their connections to white niceness/politeness and systems of white supremacy within and throughout our profession The authors will show why we as a profession need to reconsider our use of this term and instead think holistically when finding solutions to assist our users and take care of ourselves within this service work. 

Introduction 

Since the introduction of the concept of library anxiety by Constance Mellon in 1986, the term has become ubiquitous within our profession. According to Mellon, library anxiety is a phenomena that impacts students once they enter into an academic library space, making it so “when confronted with the need to gather information in the library for their research paper many students become so anxious that they are unable to approach the problem logically or effectively,” and is constantly used to explain why our users are seemingly unable to accomplish specific tasks or ask for assistance (Mellon, 1986, p.163). This term was further solidified in our profession with the creation of a Library Anxiety Scale (LAS) in 1992 by Sharon Lee Bostick in order to allow academic library workers to “determine if library anxiety exists, and if so, which areas of the library are likely to cause anxiety.” Bostick went on to explain that the instrument could be used as a “diagnostic tool” to assist “administrators in determining which services to fund” (1992, p. 5–6).

However, large issues that have yet to be explored include who decides what is “logical” or “effective,” why we have as a profession deemed specific behaviors that seem to be so prevalent within students “abnormal,” and why we feel the need to phenominize, utilizing a structure that is greatly reliant on the dominant narrative of whiteness, ableism, heteronormativity, elitism, and misogyny (Ettarh, 2018; Leung & López-McKnight, 2020). There is an acknowledgement within academia that learning and engaging with new spaces can bring about discomfort for students in any capacity, which is why positions like academic counselors and student success liaisons in academic departments were created. We know that learning new things, no matter what they are, can be anxiety-inducing and that this is not just something that happens within libraries. This anxiety is a perfectly appropriate response to such an overwhelming amount of new information during one’s academic career. This is why we are concerned that the unexamined use of the term library anxiety as a negative condition and subsequent studies to prove its existence further perpetuate a deficit-thinking approach to identifying student needs without questioning the role of the library procedures and library worker beliefs, values, and actions in producing those feelings. 

History and Background of Library Anxiety and Scale

Mellon’s 1986 study utilized the journal entries and end-of-semester essay writings of first year students in an undergraduate writing course, where students were asked to respond to questions about their experiences using the library for their research, how they felt about those experiences, how their feelings changed, and how they felt about using the library upon the conclusion of the course (p.162). Student responses ranged from surprise about the resources and skills they didn’t know existed, to confusion, to what Mellon coded as anxiety or fear. These reflections led Mellon to wonder “Why didn’t students explain their lack of library skills to their professors?”(1986, p.163) – which she believed was illogical and led to ineffective use of library resources. The answer that Mellon gathered, based on analysis of this reflective student writing (though without having any direct conversations/interviews with the students), is that students felt their behavior was not in line with the abilities of other students, and therefore felt shame. The concerns with such a conclusion are that this creates a monolithic concept of students and how they conduct research and utilize our services and revolves around conclusions of a library researcher and not the students themselves. Mellon’s use of “logical and effective” are subjectively based upon a library professional’s interpretation of student behaviors. 

In this analysis, though, there is little reflection or discussion of the ways in which the librarian or the course professor may have contributed to feelings of inadequacy in their students. Additionally, we get no discussion of the students’ behaviors which are deemed ineffective or illogical. Students are described as “lacking,” with very little analysis on what that could actually mean and why that is the case. 

In 1992, Bostick developed the Library Anxiety Scale (LAS) to measure these “inadequacies” in students. In developing this scale, Bostick attempted to learn more about the demographics of the students studied, gathering data on grade levels, age, and sex in addition to developing questions to rate student’s experiences and feelings about using library resources. It is important to note that the scale does not consider possible discrimination as a source of anxiety as it doesn’t ask for identity markers such as race, ethnicity, dis/ability status, sexual orientation, mental health concerns, socioeconomic background, first generation students, or other historically marginalized communities. The omission of these identity markers suggest an inherent belief that library spaces are inclusive by default and validates the existence of library anxiety in students against that faulty inherent belief. 

The five factors impacting library anxiety have evolved through the years, but have been largely based on Bostick’s (1992) analysis. They are:

• barriers with staff: students not feeling comfortable or able to approach library staff
• affective barriers: users’ mental state/feelings impacting their interactions with the library; a lot of this revolves around students feeling they don’t know what the library has
• comfort with the library: users feeling accepted within the spaces and therefore able to move about them with ease
• knowledge of the library: users’ understanding of the library and knowing what resources are available
• mechanical barriers: issues accessing materials due to problems such as internet access, computer availability, broken links, etc. 

According to Bostick, these five factors were decided upon after validation from a group of “experts” working from an original list that was “based on an extensive review of the literature, discussions with university faculty, students, and librarians, and the researcher’s professional experience” (p.47).  Students were then asked to respond to statements based upon these five components (For example, the Staff section included the statement “I don’t like to bother the reference librarian” p. 95). The implication in this study is that library workers know what is the correct behavior or feelings to have in these scenarios and therefore they are able to make judgments about what is creating anxiety in students. What is more, the identification of how the reflections of the students are correlated to concepts of anxiety are also completely subjective. Thus, the very foundation of library anxiety is steeped in perspectives that align with white supremacy, deficit thinking, and dominant narratives within academia as it “translate[s] into common language surrounding library ‘users,’ whose often-assumed homogeneity creates false impressions that individuals interact with and experience libraries in similar ways regardless of their identities” (Floegel & Jackson, 2019, p.413).

In 2004 two more works that expand on the LAS were published, an article by Doris J. Van Kampen and the publication of “Library Anxiety: Theory, Research, and Applications,” edited by Anthony J. Onwuegbuzie, Qun G. Jiao, and Sharon L. Bostick. However, much like the previous works, these texts provide an emphasis on specific “symptoms” users might present rather than with the causes underlying the problems. These works offer “generalizable intervention procedures” (Onwuegbuzie et al., 2004, p.10) – like training library workers to be friendly and kind or library-based instruction – that are counterintuitive to holistic concepts of learning which work to understand that every learner is different. When combined with the 2018 article by Erin L. McAfee, which correlated feelings of shame with the concept of library anxiety, we have to ask, if as a profession we generally believe this shame is “inevitable,” what are we doing to change that? How can we as library workers dismantle the oppressive practices of the spaces that we are embedded within and very much a part of? 

These studies show why we focus more readily on behaviors, symptoms, and our preconceived ideas of what our learners should be doing as opposed to tearing down those walls. Our profession aligns itself with white supremacy (Leung & López-McKnight, 2020), therefore we view the anxiety associated with these constructs as being abnormal.

Deficit Thinking as Central

Much has been written about deficit thinking in both the K-12 education and higher education literature, such as The Evolution of Deficit Thinking (1997), edited by Richard R. Valencia, where he describes how the deficit thinking model “posits that the student who fails in school does so because of internal deficits or deficiencies” (p.2). As Heinback, Mitola, and Rinto (2021) paraphrase, Valencia outlines that deficit thinking is characterized by “blaming the victim, oppression, pseudoscience, temporal changes, educability, and heterodoxy” (p.12). Furthermore, the history of institutionalized deficit thinking – like what is seen in discourse around Black students in Title I K-12 schools – has a basis in racism (Menchaca, 1997). For an excellent mapping of the six characteristics of deficit thinking to academic libraries, see Heinback, Mitola, and Rinto’s (2021) Dismantling Deficit Thinking in Academic Libraries . 

As described above, the very basis of the concept of library anxiety is the idea that students are in some way deficient – in skills, confidence, understanding of procedures – and that this deficiency is something to be treated, fixed, and attended to. This belief that library workers can fix or cure students of their library anxiety by teaching them to use the resources or to see librarians as inherently helpful and good is an example of a deficit thinking model. Using this framework as the basis of instruction, reference, or library services is harmful to students, as it ignores the many skills and life experiences that students bring with them. And as Heinbach, Paloma Fielder, Mitola, & Pattini (2019) concluded in their study of deficit thinking and transfer students, “Rather than encouraging students to inform the nature of the learning environment, educators attempt to fix them to fit a mold defined by a society rife with inequities such as sexism, racism, ableism, and classism.” Library anxiety, when viewed through the deficit thinking lens, assumes that students are unprepared and set up for failure; and quite frankly, it is offensive to the work of students, their life experiences, and the educators they’ve already learned from. 

Gillian Gremmels’ (2015) critique of Constance Mellon’s work helps to illuminate why the deficit thinking model seems so embedded in the library anxiety theory: 

Where most qualitative projects focus on small numbers of respondents, studied in depth, Mellon used several writing samples from each of hundreds of students, creating a dataset whose scope bears more resemblance to a quantitative study. She maintained great distance between herself and her informants: the English instructors assigned and collected the personal writing samples from students over two years. Mellon did not reveal whether she ever met the students or interacted with them in any way. By masking her own experience and interests and minimizing her interaction with the study participants, she showed how entrenched in the positivist paradigm she remained, even while employing qualitative techniques (Gremmels, p.271)

Gremmels’s critique here is one of research method, showing that Mellon worked from a positivist paradigm that believes reality is “single, tangible, and fragmentable” even though she claimed to work from a naturalist view, which understands realities to be “multiple, constructed and holistic” (Lincoln & Guba as cited in Gremmels, p.271). Mellon analyzed the journal entries of students in writing classes but very likely never talked to the students herself, observed their research processes, or inquired about their strengths. She seemed to believe that what students wrote in the moment, as part of an assignment, represented the totality of their feelings, experiences, and skills. This is quite opposite of the method that Heinbach, Paloma Fielder, Mitola, & Pattini (2019) developed to create a strengths-based review of the research skills of transfer students, which, through survey and interviews, inquired about students’ previous life experiences, their information seeking behaviors, and the transferable skills gained from previous work and schooling. Their study showed a group of students who not only had plenty of library and research skills but were also self-aware and self-sufficient. 

When library instruction is situated as a completely new experience for students with no connection to their prior knowledge, we set students up for feelings of anxiety or fear. We signal to students that their previous knowledge and experience are not enough or are invalid. Instead, we have the opportunity to acknowledge that we can build upon the skills, experiences, and talents they already possess. It is not that our students are deficient, but that our beliefs of students don’t account for their skills or acknowledge that they are learners in the process of learning. 

White Niceness/Supremacy 

One of the reasons why library workers cling to the idea of library anxiety, mostly without questioning the concept, is that this conceptualization places the onus of the problems on students instead of library workers. The possibility that students could be too anxious to use the library or work with a library worker means that there could be something wrong with us , challenging the vocational awe of libraries and library workers as irrefutable. Some library workers feel, “There could not possibly be anything wrong with us because we are so helpful , and the library is a good, comfortable, useful place for everyone .” In addition to this, we equate efforts in trying to assist with supposed library anxiety as going above and beyond, feeding into our profession’s white savior narratives by allowing us to point to our goodness and service mentality, instead of simply addressing the barriers and problems that exist in libraries. 

Since Mellon’s coining of library anxiety, library workers have worked to make their spaces appear warm, inviting, and non-threatening. Library instruction sessions provide introductions to library resources and to students in an effort to say look how nice and helpful we are. But even this emotional labor is not consistently expected of all library workers; women and BIPOC library colleagues bear the brunt of needing to appear happy, accommodating, resourceful, and clear because they are often penalized when they don’t. 

Kawana Bright (2018) showed that women library workers of color often perform high levels of emotional and invisible labor during reference desk interactions. Due to the microaggressions library workers of color face when doing their job, Bright’s study participants reported over-performing niceness or politeness and supporting the needs of students of color at higher rates than their white counterparts. And as Emmelhainz, Pappas, and Seale (2017) found in their content analysis of reference guidelines, niceness is baked into expectations for library workers, usually at the cost of their autonomy and with disregard for their skill. Even with all this niceness, many would argue that library anxiety still seems to exist in our students. 

When embedded in teaching sessions, what Mellon might have called “warmth seminars,” this overt niceness can be contrary to what students experience once they are in the library and navigating it alone. For example, in a 2018 study of African Nova Scotian students’ library anxiety levels and experiences with library workers at a predominantly white institution, “students expressed that about half of their experiences were negative. They interacted with supportive librarians that assisted them with their information needs, but they also interacted with unfriendly and condescending library staff that made them avoid future interactions” (Fraser & Bartlett, p.12). For some students, especially those marginalized, they may be less inclined to ask for assistance not because they are anxious about using the library but because they don’t want to replicate a negative experience they’ve had working with our personnel. 

Furthermore, according to Patricia F. Kapotol’s piece on stereotype threat, Black students may be resistant to asking for help not because of the library anxiety per se, but because they don’t want to appear as if they do not belong. In reality, Kapotol suggests, Black students come to the library, use the resources, and navigate other information sources based upon their prior skills – they just simply wish to avoid the possibility of being judged by the library worker, which is a reasonable feeling considering the discrimination experienced in higher education environments (2014, p.2-3).

At some point, we have to ask how much the nice, helpful library worker cosplay is hurting our relationships with students, especially if they end up having negative interactions anyway. Perhaps our students have the right response to an environment that has convoluted policies and procedures and filled with personnel who commit microaggressions or outright discrimination against them. When we create environments that are so centralized around the idea of “niceness” we continue to perpetuate these cycles of harm because we can hide behind our “good intentions” as opposed to analyzing the true nature of these spaces. We can further use our concepts of professionalism to bolster our authority which in turn allows us to believe our ideas of “how to use a library” are correct and that our role is to fix student behaviors. Confronted with this, it makes perfect sense that some students might not feel comfortable approaching us, speaking up, or sharing their experiences and knowledge with us. 

Symptoms vs Systems 

We have outlined a plethora of components that we see as problematic for utilizing the concept of library anxiety and the LAS, such as not accounting for the fact that all students are different and have different intersecting identities, the fact that the concept phenomizes feelings that seem to be so common, a need to silo the library from the rest of the academic institution, and deficit thinking as central to the development of library anxiety. However, one of the key issues with library anxiety is its insistence on diagnosing and addressing “symptoms” instead of focusing on the systems or systemic problems at play. 

The studies and discussions of library anxiety based upon the LAS often use the more broad contributing key factors of staff, resources, technology, reference, and policies and procedures (Onwuegbuzie et al., 2004) which were largely chosen and identified by library “experts.” The LAS sections are categorized by how library workers interact with the library, instead of how library users might label their own use of our resources. While most LAS literature does include focus groups, surveys, and pre- and post-tests of students, these methodologies are used to further diagnose an expected anxiety instead of building mutually beneficial feedback loops that actually address student needs. This approach is problematic for two reasons. First, the emphasis is on assessing students as opposed to asking them what they need and already know means we “neglect the possibility of sharing experience outside of what we seek and expect to find” (Arellano Douglas, 2020, p.56). Secondly, we rarely see students’ input on the categories of the LAS and the very concept itself. 

The language and categorization of services that were offered to students when assessing their expected anxiety matters because they were created by those in the profession and the language of our profession is centered in whiteness. As Anastasia Collins states, “Because white people hold hegemonic power within libraries, the language they use to frame institutional concepts (e.g., professional ethics, classification systems, service standards, performance expectations, etc.) reaffirms the dominance of their racial privilege, and because ‘the dominant cultural groups [are] generating the discourse [it] represent[s] [their dominance] as ‘natural’” (2018, p.43). Accordingly, our profession focuses on creating the concept of library anxiety, detailing how our students feel and why, attaching them to “symptoms” without trusting them to tell us if they actually agree that these feelings are related to their library experiences or why these feelings might exist. 

Further complicating these issues is that when discussing library anxiety, we ignore the larger picture of how our systems have been built with a false narrative of neutrality. We structure these reviews around behaviors and how to “change” or “fix” them without asking why these feelings and possible moments of confusion have become so universal. This issue is of course not specific to library anxiety, but it nonetheless directly impacts the work and concepts of library anxiety. This has been discussed in great detail by many before us, but nina de jesus hits on this issue perfectly: 

Regardless of many people’s feelings about the coherence of individual neutrality, many have taken it as axiomatic that libraries are neutral institutions and that any failure of libraries to be neutral is largely the fault of individuals failing to live up to the ideals or ethics of the profession, rather than understanding the library as institution as fundamentally non-neutral. Libraries as institutions were created not only for a specific ideological purpose but for an ideology that is fundamentally oppressive in nature. As such, the failings of libraries can be re-interpreted not as libraries failing to live up to their ideals and values, but rather as symptoms and evidence of this foundational and oppressive ideology (de jesus, 2014).

We focus attention on deficits within our students and refuse to consider in the equation that these spaces were not made to be comfortable for everyone, indeed for most people, and our students’ reactions to the library are reasonable. Most discussions of library anxiety even discuss how ineffective or incompetent students are repeatedly. For instance, Marisa A. McPherson says of library anxiety, “This fear can prevent students from approaching a research assignment rationally and effectively and can influence a student’s ability to complete assignments and be successful,” but she doesn’t consider who is making the decision about what is “rational,” “effective” or even useful (2015, p.318). 

The systems that have dictated what is appropriate for academic research are not intended for inclusion but rather to continue to uphold power for a select few and further hegemony. It’s as Nicola Andrews says when discussing issues within the profession as a whole, though we can easily see where this translates to our users as well: “When are we going to stop signaling that fear and anxiety is normal within our profession, and instead examine how these narratives are the result of institutions deflecting the need for change” (Andrews, 2020)?

Disrupting the Systems of Oppression

We have shown through many examples in this article why the discussion of library anxiety has become less interested in student success and making our users comfortable with the research process and more interested in blaming the learner for not fitting a prescribed idea of behaviors. The behaviors displayed in library anxiety are described as being “faulty” and our adherence to insisting they are necessary are built on white supremacy and hegemony. In that case, how do we disrupt the narrative of library anxiety to build services that address student needs in a realistic way? We posit that instead of focusing on services and symptoms, we should instead focus on our users holistically. The time spent researching if students feel anxiety about libraries without actually connecting this anxiety to being specific to libraries might be better used to understand the inequities that are fraught throughout academia and how to help make structural change. We need to think holistically about our users, yes, but also about our institutions and our profession. 

We know that “in many circumstances, individuals with marginalized identities experience discrimination during interpersonal encounters in libraries” (Floegel & Jackson, 2019, p. 414). We also know “studies have shown that students who are first-generation college students, nonwhite, or from lower socioeconomic backgrounds make less use of university library resources overall, and students who speak English as a second language are more likely to have higher levels of library anxiety” (as summarized by Blecher-Cohen, 2019, p. 360). What is more, “research shows us that students often face mental health challenges such as anxiety and depression, either as acute episodes or as part of a lifelong mental health journey. We also see increasing evidence that not only do campuses hold a sizeable neurodiverse population, but those individuals are often not provided with the services that best speak to the ways in which we engage with the world” (Skinner & Gross, 2021, p. xvi). We can note in these numbers, which were assessed before the extreme and general trauma that COVID-19 has inflicted on the majority of our learners, how prevalent the damaging practices of hegemony were, so we need to look at the entire picture and not focus on a micro-level revolving solely around library services.

Shifting our thinking from “what we know our students need” to gathering an understanding of what they feel they need and/or want would be a good start to disrupting the status quo that has existed within our profession for so long. One way in which to address this would be to engage with trauma-informed care as a way to understand the individual experiences of our students and the implications of how their different experiences have shaped their engagement with the library (SAMHSA, 2014). As Symphony Bruce pointed out in a previous article, students “should never feel as though their presence or needs are a burden. Students should be able to ask questions and request assistance and still be recognized for the knowledge they possess. In this way, librarians can and should play a vital role in creating a sense of belonging for our students” (2020).

Libraries were not created for everyone. In order to alter our approach to service we must truly understand that libraries were created for a small part of our general population. The concept of library anxiety hinges on the idea of an easily navigable space that was built for every type of user. However, as Fobazi Ettarh tells us, “Libraries were created with the same architectural design as churches in order to elicit religious awe. Awe is not a comforting feeling, but a fearful and overwhelming one….awe is used as a method of eliciting obedience from people in the presence of something bigger than themselves” (2018). 

It is not only the physical spaces themselves that can impact our learners’ use of our services and spaces, it is also the virtual spaces, the ways in which library employees interact with our users, and the policies we enact (or have enacted and not committed to reviewing regularly). The structures in place that allow this behavior to continue, that refuse to acknowledge and own up to the harm caused, and the continuation of racism and other forms of discrimination based around dis/ability status, neurodiversity, sexual orientation, gender identity, and more will only continue to cause anxiety, depression, and unmitigated harm. Too often our institutions are willing to confront issues of discrimination only in the abstract (like mission or values statements), which only furthers our profession’s insistence that any anxiety our users feel is a phenomena we must research. It’s as Charlice Hurst aptly points out: 

We can talk about it [racism] at conferences but not in our organizations’ conference rooms. White colleagues who have never given serious thought to racism believe themselves more fit to identify it; more capable of being “objective” or “reasonable.” They almost seem to pity us for our sensitivity to signals of racism. They believe that what they cannot see must not exist, overlooking the possibility that they do not see racism because it does not happen to them (2021).  

If our profession does not actively work to give up power and break down the structures that we so desperately cling to, then we can only expect our learners’ discomfort to continue to grow as our refusal to accept reality makes us even more distanced from their needs. 

The concept of library anxiety has its roots in deficit thinking and the oppressive, hegemonic values that undergird it. A belief that library anxiety – as a special phenomenon separate from any other sort of academic anxiety – bolsters the belief that libraries are at least neutral and at most consistently helpful, comfortable, and safe. None of this is inherently true. Instead, the academic library functions as part of a larger neoliberal project that situates students and other users in a deficient state benefiting from and fixed by the institution. 

To more fully engage with our learners, “We must not only apply an intersectional theoretical approach to creating community but center these narratives in the decision-making process in order to have a truly student-centric approach” (Moreno & Jackson, 2020, p. 11) We can move away from monolithic ideas of what a student should be and instead focus on how we can best address the actual needs of our student body through holistic measures. Making decisions that are informed by students’ stated needs and gathering this information through focus groups, ethnographic studies, and other methodologies, instead of based on our needs or our perceived ideas of student needs, will shift our institutions to being more inclusive and less discomforting for all our users. We need to be aware that the reality is that academic libraries are, generally, the actual monolith, not our students: our systems and procedures work very similarly across institutions despite the differences in our populations and specific user needs.  Although as library workers we can never truly divorce ourselves from the work of our institutions, we can rethink how we evaluate student needs, understand their strengths, and make a better learning environment for them and work environment for us. 

Acknowledgments

The authors would like to thank the editorial board of In the Library with the Lead Pipe for their dedication in allowing us to share our work and for their assistance through the process. In particular we would like to thank our peer editors, Jesus Espinoza and Lorin Jackson for their time, labor, and thoughtful feedback. We would also like to thank our editors, Ian Beilin and Ikumi Crocoll, for walking us through this process and particularly Ikumi’s considerable and generous commentary. 

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REVIEW article

A bibliometric analysis of anxiety and depression among primary school students.

• 1 Teaching Center of Fundamental Courses, Ocean University of China, Qingdao, Shandong, China
• 2 Institute of Sports Science, Nantong University, Nantong, Jiangsu, China

Background: Rising anxiety and depression in primary school students adversely affect their development and academics, burdening families and schools. This trend necessitates urgent, focused research within this young demographic. This alarming trend calls for a systematic bibliometric analysis to develop effective preventative and remedial strategies

Objectives: This study aims to identify and analyze the prevailing research hotspots and emerging trends concerning anxiety and depression in primary school students, thereby furnishing a foundational reference for future academic endeavors in this area.

Methods: This study uses the Web of Science (WOS) Core Collection database as the data source, focusing on literature published between 2013 and 2023 concerning anxiety and depression in primary school students. An initial search identified 1852 articles, which were then manually screened to exclude duplicates, conferences, announcements, and unrelated literature, resulting in 1791 relevant articles. The analysis, executed on December 31, 2023, employed CiteSpace and Vosviewer tools to assess various bibliometric indicators including authorship, country, institutional affiliations, publication trends, keyword frequency, and citation analysis.

Results: The analysis revealed a corpus of 1,791 English-language articles, with a discernible upward trend in publications over the decade. The USA and China were the leading countries in this field, with 482and 272 papers, respectively. The research predominantly addresses the etiological factors of anxiety and depression, various intervention strategies, and the comorbidities associated with these conditions in the target population. Key research focuses have been identified in areas such as suicidal thoughts, bullying in schools, the impact of COVID-19, mindfulness interventions, and anxiety related to mathematics. Future research is projected to increasingly focus on the effects of mathematics anxiety on the psychological and behavioral outcomes in students.

Conclusion: This study provides a critical visual and analytical overview of the key research areas and trends in the field of anxiety and depression among primary school students. It underscores the necessity of concentrating on the underlying causes and potential interventions. Such focused research is imperative for mitigating the mental health challenges faced by young students and enhancing their educational and developmental outcomes.

1 Introduction

Depression and anxiety are prominent contributors to illness and disability in adolescents ( 1 ). In recent years, the prevalence of anxiety and depression among primary school students has been on the rise due to various factors such as family stress, social pressure and academic burden, which has become a global concern demanding significant attention. Research indicates a concerning upward trend in depression rates, escalating from 18.4% in 2000 to 26.3% in 2016 ( 2 ). A 2023 meta-analysis in China revealed that during the COVID-19 pandemic, both depressive and anxiety symptoms were prevalent at rates of 31% ( 3 ). Depression is expected to become the highest-burden disease worldwide by 2030 ( 4 ). Given that primary school students are undergoing crucial stages of emotional development, addressing psychological issues during this period is paramount, as they can have profound and enduring effects on their lives. The research indicates that the emergence of depression during primary school can lead to a series of irreversible adverse consequences, including social disorders, substance abuse (particularly alcohol abuse, internet addiction, and smoking), as well as severe obesity ( 5 ). However, it is essential to recognize that students’ anxiety and depression issues are not static; they are dynamic processes influenced by various factors over time. For example, during the COVID-19 pandemic, the probability of anxiety and depression in primary school students increased significantly, primarily due to social isolation ( 6 ). Recently, the anxiety and depression of primary school students in China have been attributed to excessive academic burden and insufficient sleep ( 7 ). Additionally, there is heterogeneity among different groups. Studies have shown that anxiety and depression levels are generally higher among rural primary school students compared to their urban counterparts ( 8 ). These differences are closely related to various factors, including family economic status, the availability of educational resources, family support systems, and differences in social environments ( 9 , 10 ). Thus, investigating the problems and interventions related to anxiety and depression in primary school students is vital for promoting their mental health, supporting their healthy development, and contributing to the harmonious progress of society.

There is a need to investigate specific hypotheses regarding the underlying mechanisms of these psychological issues and the efficacy of targeted interventions. Possible hypotheses for this study include: (1) family stress, social pressure, and academic burden significantly contribute to the prevalence of anxiety and depression among primary school students; (2) early intervention and targeted therapeutic approaches can substantially reduce the prevalence and severity of anxiety and depression. Additionally, cultural factors must be considered in the study of anxiety and depression among primary school students. Cultural considerations encompass family expectations, societal norms, and the stigma surrounding mental health. In many Chinese families, a strong emphasis on academic success leads to significant pressure on primary school students ( 11 ). Societal norms often discourage open discussion of mental health issues, resulting in a lack of awareness and support, thereby exacerbating feelings of isolation and helplessness. The stigma surrounding mental health issues can prevent students from seeking help, creating a cultural barrier that must be addressed in any effective intervention strategy. By incorporating these cultural considerations, this study aims to provide a comprehensive understanding of the factors contributing to anxiety and depression among primary school students and to develop interventions that are both effective and culturally sensitive.

VOSviewer and CiteSpace are advanced bibliometric tools that help researchers visualize complex data from scientific publications. VOSviewer uses Visualization of Similarities mapping to identify and display relationships between different scientific entities like countries, organizations, and keywords ( 12 ). Similarly, CiteSpace applies network algorithms to analyze literature trends and co-citation patterns, offering visual maps that highlight key themes and development trajectories in a field ( 13 ). Currently, this field lacks metrological studies. This study utilizes CiteSpace (6.3.R1 advance) and the VOSviewer to conduct a visual analysis of primary school students’ depression and anxiety, aiming to provide a foundational reference for future theoretical and practical research.

2 Materials and methods

2.1 data source and search strategy.

The Web of Science was utilized as the primary data source for this study, with literature being specifically collected from the core collection of the Web of Science database, spanning the period from January 1, 2013, to December 31, 2023. We used the PubMed database and queried subject terms through MeSH terminology, confirming the search terms based on expert knowledge. The search strategy employed was: TS=(“elementary school students” OR “primary school students”) AND TS=(“anxiety” OR “anxious” OR “nervousness” OR “apprehension” OR “hypervigilance” OR “depression”). The initial search yielded 1862 documents. To ensure the quality and reliability of our literature review, we used the filtering functions of the Web of Science to exclude certain document types, retaining only articles and reviews. We manually excluded 61 documents that were duplicates, off-topic, or did not meet the predefined selection criteria through a review of authors, keywords, titles, and abstracts. Ultimately, 1791 articles were included in this study. For further analysis, the selected literature was saved in “full record and cited references” format as txt files for subsequent bibliometric analysis using CiteSpace and VOSviewer. The article screening process is illustrated in Figure 1 . The specific exclusion criteria were: (1) articles not related to anxiety and depression in elementary school students (ages 6-14); (2) document types other than articles and reviews.

Figure 1 Data retrieval flow chart.

2.2 Data extraction

A standardized search strategy was employed by two researchers to extract literature, with synonymous keywords being consolidated; for example, variations of “primary school students” were standardized to “primary school students”, and different forms of “depression” were unified to “depression”. Discrepancies in keywords were resolved through discussions among the researchers and, when necessary, with the consultation of a third party. Literature was screened in batches according to the inclusion criteria to identify eligible studies. Authors were included regardless of their rank, and their contributions were referenced for the number of publications in this study.

2.3 Visualization analysis method and bibliometric analysis

Software tools such as CiteSpace (version 6.3.R1 advance) and VOSviewer were utilized for the bibliometric analysis of literature concerning the mental health of primary school students. Knowledge graphs were generated by these tools, focusing on word frequency, clustering, and citation analysis across modules such as authors, countries, institutions, keywords, and references. Leading authors, countries, and institutions in the field over the past decade were identified by the analysis. Additionally, dominant themes and burgeoning frontiers in the research of primary school students’ mental health were explored, offering insights into prospective research trajectories.

3.1 Overall characteristics of publications

As illustrated in Figure 2 , the publication trend of articles has been segmented into two periods. In the initial phase (from 2013 to 2017), a slow fluctuation in the number of publications was observed, indicating modest scholarly interest in the mental health of primary school students. During this period, research was primarily focused on exploring basic concepts without extensive in-depth investigation. However, in the subsequent phase (from 2017 to 2023), a rapid increase in publications was noted, signifying that anxiety and depression among primary school students have emerged as significant research topics, with related studies entering a phase of rapid development.

Figure 2 Annual number of English articles published on anxiety and depression in primary school students from 2003 to 2023.

Moreover, a consistent rise in the overall volume of literature on anxiety and depression among primary school students from 2013 to 2023 was observed, particularly notable between 2017 and 2023. This trend suggests a likely continuation in the increase of relevant literature in this area, reflecting the growing academic focus in recent years on the study of anxiety and depression among primary school students and underscoring its increasing relevance.

3.2 Analysis of authors and co-cited authors

Putwain, David W. (n=7), and Ginsburg, Golda S. (n=7), are the two most prolific authors. There were two authors who were co-cited more than 150 times: COHEN J. (n = 167) and HU LT. (n = 151) ( Table 1 ). These authors can be considered leaders in the field of anxiety and depression research among primary school students. In the visual knowledge map of co-authors, depicted in Figure 3 , the size of author nodes is shown to be proportional to their publication output, and the connecting lines represent collaborations between authors. Significant collaborative networks among several researchers have been identified. For instance, collaborations between Tim Dalgleish, Mark T. Greenberg, and Darren Dunning, as well as active work between Catherine Crane, Jennifer Harper, Elizabeth Nuthall, and others, indicate robust cooperative relationships within this scholarly community.

Table 1 The author of the study on the anxiety and depression of primary school students with the most frequent publication.

Figure 3 The visualization of authors on research of anxiety and depression among primary school students.

3.3 Analysis of country

As illustrated in Figure 4 , the leading three countries in terms of publication volume have been identified as the USA (482 publications, 26.91%), China (272 publications, 15.19%), and Australia (141 publications, 7.87%). In terms of centrality, the USA (0.37), England (0.18), and Australia (0.09) are ranked as the top three, respectively. The graphical analysis has revealed a global distribution of research literature on anxiety and depression among primary school students, with dense interconnections between countries, indicating a robust international collaboration network and highlighting extensive cooperative relationships in this research area across numerous countries.

Figure 4 The global distribution of anxiety and depression among primary school students.

3.4 Analysis of institution

The top five cited institutions have been identified as the University of California System, University of London, University of Melbourne, Beijing Normal University, and State University System of Florida ( Table 2 ). These institutions are depicted as pivotal nodes within the global cooperation network, engaging in extensive collaborations both among themselves and with other global entities. They are actively involved in research on anxiety and depression among primary school students, yielding significant outcomes. Additionally, in the institution co-occurrence knowledge map ( Figure 5 ) illustrates that institutions both domestic and international have established broad cooperative relationships, highlighting the global recognition and attention garnered by this research.

Table 2 Top 10 countries and organizations on the research of anxiety and depression among primary school students.

Figure 5 The visualization of organizations of anxiety and depression among primary school students.

3.5 Analysis of references

A co-cited reference is one that appears jointly in multiple publications, thereby establishing it as a foundational element within a specific research domain ( 13 ). Among the top ten co-cited references, the most cited article was cited 139 times, the least 61 times, and the average number of citations was 83 times( Table 3 ). As shown in Figure 6 , “hu lt, 1999, struct equ modelling” demonstrated robust co–citation relationships with “hembree r, 1990, j res math educ”, “richardson fc, 1972, j couns psychol”, “ramirez g, 2016, j exp child psychol”.

Table 3 Top 10 co-cited references on the research of anxiety and depression among primary school students.

Figure 6 The visualization of co–cited references of anxiety and depression among primary school students.

The dynamic characteristics of a research topic are manifested by a significant increase in the frequency of citations in the literature. These highly cited documents, referred to as ‘burst literature’, represent the current hotspots in academic research within their respective fields. In CiteSpace software, the display option “Burstness” is configured and initiated by clicking “View” to identify significant citation bursts within the literature on anxiety and depression among primary school students. In the emergence map of cited literature, the red line segment represents the explosive citation time of the corresponding year ( Figure 7 ).

Figure 7 Top 25 references with strong citation bursts of anxiety and depression among primary school students.

3.6 Analysis of keywords

Keywords are the essence and focal points of an article, encapsulating its content and key themes. In a specific field, the prominence of a keyword, as indicated by its co-occurrence frequency and centrality, reflects its significance as a research hotspot.

By analyzing keywords, we can swiftly identify the evolving frontiers and hotspots in the research on anxiety and depression among primary school students. In this domain, notably, ‘mental health’ emerges as the most frequently mentioned term, alongside ‘depression’, ‘children’, ‘adolescents’, and ‘anxiety’, which collectively delineate the principal research directions in this field.

Using VOSViewer and CiteSpace for visual keyword cluster analysis, the results depicted in Figure 8 reveal three distinct clusters representing specific research directions. The keywords in the red cluster focus on interventions for anxiety and depression, the blue cluster addresses the mental and behavioral effects of these conditions, and the green cluster explores their formative factors. These clusters underscore the primary research themes: interventions, mental and behavioral impacts, and causative factors of anxiety and depression in primary school students. As a complement, Figure 9 illustrates the 11 hot keywords in the field of anxiety and depression in primary school children, which were #0 math anxiety, #1mindfulness-based intervention, #2 preventing depression, #3 early elementary school, #4 psychosocial well-being, #5 COVID-19 pandemic, #6 resilient children, #7 student-classroom, #8 medical student, #9 achievement goal orientation, #11 approach, #12 bullying behavior.

Figure 8 The visualization of frequency keywords on research anxiety and depression among primary school students.

Figure 9 Keywords cluster analysis co-occurrence map.

4 Discussion

4.1 general information.

In the first period (2013-2017), 443 articles were published, with an average of 86 per year. In the second period (2018-2023), 1478 articles were published, with an average of 246 per year, which is three times that of the first period. Indicated the research on anxiety and depression of primary school students has become increasingly popular, and anxiety and depression of primary school students has attracted increased attention. This phenomenon may be related to a major report (Global Accelerated Action for the Health of Adolescents: Guidance to support country implementation) published by the World Health Organization in 2023 ( 14 ). Additionally, the significant increase in publications during (2018-2023) may be attributed to the outbreak of the COVID-19 pandemic ( 15 , 16 ). The pandemic has had a profound impact on mental health globally, bringing issues such as anxiety and depression to the forefront of academic and public health discussions.

According to the analysis of authors, Putwain, David W from Liverpool John Moores University and Golda S. Ginsburg from the University of Connecticut, both ranked first with seven publications. Committed to the field of educational psychology, Putwain, David W has recently focused on studying the role of achievement emotions in primary school mathematics, the relationship between test anxiety and emotional disorders in primary school, and methods of protection against test anxiety, offering further guidance for school educators to prevent mental health issues ( 17 – 19 ). Unlike Putwain, David W, Ginsburg, Golda S has conducted research on the role of teachers in student anxiety ( 20 ). Furthermore, Ginsburg, Golda S has conducted research on preventing the onset of anxiety disorders in the offspring of anxious parents over the past decade ( 21 ). Following Putwain, David W and Ginsburg, Golda S, Irene C. Mammarella from the University of Padua was the third most active author with six publications. Recent studies have focused on the differences in visuospatial memory in children with mathematical learning disabilities and on visuospatial processing in students with non-verbal learning disabilities who do not have an intellectual disability ( 22 , 23 ).

The United States (482 publications) and China (272 publications) lead globally in the volume of research outputs, significantly outpacing other countries. Among the top 10 research institutions, half are based in the United States, indicating robust national research capabilities. There is notable international cooperation, especially between the United States and countries like China, Canada, the United Kingdom, and Australia. In addition, there are robust connections among developing countries. Particularly notable is the collaboration between India, Thailand, and South Africa, which indicates that Asian scholars place significant emphasis on mental health issues. Furthermore, research in this field reveals regional connections, characterized by close cooperation between neighboring countries. This is exemplified by the Asian collaboration network led by China and the European and American collaboration network led by the United States.

Prominent research institutions, including the University of Melbourne, University of Oxford, and Harvard University, have established substantial collaborative networks, engaging with over seven institutions each. Our analysis reveals that these collaborations predominantly involve partners from developed countries, with significantly fewer cooperative engagements with institutions in developing nations. Furthermore, the pattern of collaboration among these institutions tends to be relatively static. To dismantle research barriers and foster a more inclusive global research environment, we advocate for the strengthening of trans-regional cooperation among institutions worldwide. This approach is essential to ensure a broader and more diverse contribution to the critical field of anxiety and depression among primary school students.

4.2 Hot spots and trends

Research hotspots are defined as fields that capture significant academic attention during specific periods, particularly due to their relevance to contemporary issues ( 13 ). These areas not only mirror the literature that has engaged scholars but also contribute to a cohesive research network. The clustering of keywords effectively summarizes these hotspots, clearly delineating the prevailing topics within the field of anxiety and depression among primary school students. Each cluster identifies a distinct area of focus, enriching our comprehensive understanding of the domain. Through an analysis of high-frequency keywords and their clustering, we have identified dominant themes such as math anxiety, science anxiety, achievement, mindfulness, physical activity, bullying, intervention, COVID-19, suicidal ideation, and gender differences. These themes currently shape the research trends in anxiety and depression among primary school students, highlighting the field’s dynamic and evolving nature.

4.3 Intervention

Intervention is a frequent high-frequency word and a trend topic from 2013 to 2020. Among the interventions, mindfulness and physical activities are recognized for their efficacy as gentle treatment options. The emergence of depression and anxiety typically during childhood or adolescence underscores the importance of early intervention.

Research into intervention strategies reveals ongoing exploration with diverse approaches and variable efficacy. A 2013 evaluation indicated that the AOPTP program did not alleviate anxiety and depression in primary school students, though it significantly reduced ADHD prevalence ( 24 ). In contrast, a 2015 study demonstrated that school-based cognitive-behavioral therapy (CBT) interventions significantly ameliorated test anxiety, with the most effective strategies being a blend of skills-based and either behavioral or cognitive therapies ( 25 ). The educational setting has been identified as an advantageous venue for implementing mental health interventions. A 2017 study assessed the CALM-Child Anxiety Learning Module, a concise nurse-managed intervention based on cognitive-behavioral strategies, noting substantial reductions in anxiety, somatic symptoms, and attentional disturbances ( 26 ).In more recent developments, mindfulness-based interventions have gained traction. A 2021 meta-analysis affirmed the effectiveness of these interventions in reducing mild-to-moderate depressive symptoms among adolescents aged 10 to 19 years ( 27 ). Further empirical research supports that mindfulness training not only lowers anxiety but also enhances social orientation, positive emotional states, and attentional focus in children ( 28 ).

Furthermore, it is noteworthy that the application of artificial intelligence (AI) for the early identification and intervention of anxiety disorders and depression has gained widespread popularity ( 29 ). AI applications such as chatbots and virtual assistants conduct initial screenings and symptom assessments through personalized interactions, while wearable and mobile sensors collect objective data like sleep duration, activity levels, and heart rate to inform treatment plans ( 30 , 31 ). AI algorithms analyze this data to propose personalized treatment strategies, and remote monitoring and support systems aid in detecting depression and providing continuous support, thereby enhancing treatment adherence and engagement ( 32 ). Additionally, AI-driven digital therapeutic interventions offer cognitive behavioral therapy (CBT), mindfulness practices, and other evidence-based methods for self-managing depression and anxiety ( 33 , 34 ). Despite these advancements, challenges remain, including issues of accountability, the need for standardized ethical and legal frameworks, and concerns over data privacy ( 31 ). Addressing these challenges is crucial for the responsible and effective use of AI in mental health interventions.

4.4 Suicidal ideation

In light of the substantial body of research, it is evident that suicidal ideation (SI) among elementary school students is a critical concern, particularly as it serves as a precursor to suicide attempts and completions. Previous literature identifies SI as a key predictor for such outcomes, emphasizing the need for early and effective intervention ( 35 ). The multifaceted nature of risk factors for suicide includes substance abuse, early childhood trauma, stigma associated with seeking help, barriers to accessing care, and availability of means to commit suicide ( 36 ). A significant independent factor contributing to SI in children is a contentious home environment children from such backgrounds are at a 3.7 times higher risk of developing SI compared to their peers from harmonious homes. This risk increases dramatically to 27 times in depressed children living in discordant homes compared to non-depressed children in harmonious settings ( 37 ). Furthermore, gender-specific analyses reveal that girls typically exhibit higher rates of SI, particularly when exposed to high levels of perceived environmental stress, authoritarian parenting styles, and multiple stressful life events ( 38 ).

The correlation between depression and SI is notably strong, with anxiety and sleep disturbances contributing indirectly through their impact on depression ( 39 ). Additionally, the relationship between academic and social anxiety and SI underscores the importance of supportive educational and familial environments in mitigating these risks. Conversely, factors such as self-esteem, life satisfaction, and academic achievement serve as protective buffers against the development of SI ( 40 ).

Given these insights, it is recommended that schools implement robust support systems to prevent SI in students experiencing high stress or depression. Parents and teachers should vigilantly monitor for any signs of emotional distress and educate children on how to alleviate worries and grievances. Additionally, promoting core self-evaluations in students could serve as a preventive measure against SI, as higher self-esteem and self-worth are associated with lower risks of depression and suicidal thoughts.

4.5 COVID-19

COVID-19 is the hot key word for 2020-2023. COVID-19 triggered a pandemic just months after it was first reported in 2019, with more than 774 million confirmed cases globally by 4 February 2024 ( 41 ). During the COVID-19 pandemic, the prevalence of anxiety and depression among students has increased due to the lockdown policy and panic without specific drugs. According to the research, during the COVID-19 pandemic, 88.4% of students have experienced anxiety, 72.1% have been diagnosed with depression, and 35.7% have experienced moderate to severe stress ( 42 ). These issues were particularly acute among females, older students, and those from larger or low-income families, exacerbated by pandemic-related economic and educational disruptions ( 3 ). The correlation between increased anxiety and depression symptoms and pandemic stressors is clear, while social support has proven to mitigate these effects ( 43 ). The transition to online learning and reduced social interactions further compounded these challenges, affecting students’ mental well-being and their ability to adapt to traditional learning environments ( 44 ). Addressing these issues requires a collaborative approach involving educational institutions, healthcare providers, and policymakers to integrate comprehensive mental health strategies within educational settings. This includes enhancing online learning environments with mental health resources, improving access to psychological counseling, and building robust community support systems to help young learners navigate these unprecedented challenges effectively.

4.6 Bullying

bullying is a serious global issue within the educational sector, affecting not only the academic achievements and social capabilities of victims but also inflicting profound psychological impacts on children ( 45 ). Bullying behavior has been extensively studied and linked to a variety of psychological health issues. Of particular concern is the relationship between bullying and anxiety and depression among primary school students, which has garnered widespread attention in the field of mental health. In 2018, Bayer conducted a survey across numerous primary schools in Australia, revealing that a significant 29% of students frequently faced bullying, with physical bullying affecting 13.8% and verbal bullying 22.7% of students ( 46 ). Subsequent research by Shayo linked bullying to increased instances of suicide, identifying it as a significant predictor, especially among victims exhibiting suicidal ideation and a heightened likelihood of attempting suicide ( 47 ). Complementarily, Diana’s study established a positive correlation between exposure to school bullying and the development of depression, significantly highlighting that bullying escalates the risk of depression in primary school students ( 48 ). Further investigations have shown that bullying victims also suffer from higher levels of anxiety, Internet gaming disorder, and mobile phone addiction ( 49 ). These findings underscore the critical need for comprehensive anti-bullying strategies that involve families, schools, and societal interventions to effectively mitigate the adverse mental health impacts of bullying on children.

4.7 Future research trend

4.7.1 math anxiety.

Math anxiety, a complex state elicited by math-related stimuli, represents a considerable source of distress among elementary students, encompassing cognitive, emotional, behavioral, and physiological aspects ( 50 ). Notably, this anxiety is widespread among primary students, whose neural development is not yet fully mature, making them especially vulnerable to anxiety when grappling with abstract concepts. A study involving 1,327 children from grades 2 to 5 revealing that over 15% reported experiencing math anxiety ( 51 ). The research further indicates that math anxiety emerges from the early stages of schooling, with first-grade students exhibiting mild anxiety that escalates at the beginning of the academic year; while the majority of children experience low levels of math anxiety, a minority report higher levels, often linked to the fear of failure, task difficulty, time pressure, and concerns over poor grades ( 52 ).However, Nathan conducted a global survey across various countries and age groups, uncovering significant disparities in the relationship between math anxiety and mathematics performance, thereby highlighting the crucial role of educational and cultural backgrounds in comprehending the impact of math anxiety on academic achievement ( 53 ). Contextual and linguistic teaching methods have been found to evoke math anxiety less than traditional symbol-based instruction, suggesting that the teaching approach plays a role in the development of this anxiety ( 54 ). An eye-tracking study investigating the inner workings of math anxiety revealed that students with this condition frequently exhibit inadequate attention control when solving math problems ( 55 ). Gender differences in math anxiety have also been documented, with Perez’s research demonstrating that girls generally exhibit higher levels of math anxiety than boys, a gap that increases with age ( 56 ). These findings underscore the multifaceted nature of math anxiety and the necessity for tailored educational strategies to address it effectively.

4.8 Advantages and shortcomings

The bibliometric analysis conducted in this study demonstrates unique strengths. Firstly, there is currently a lack of research employing bibliometric methods to address anxiety and depression issues among elementary school students. This study examines the research landscape surrounding multimodal imaging tools using bibliometric methods. We utilized two different types of bibliometric software for bibliometric and visual analysis, synthesizing relevant publications on anxiety and depression among elementary school students over the past decade. The entire analytical process was conducted rigorously and objectively, resulting in credible findings. Additionally, this systematic analysis provides comprehensive guidance to scholars in this research domain, offering a more objective and comprehensive presentation of research hotspots and trends compared to traditional reviews, along with predictions for future research directions. It is important to note that this study solely relied on the Web of Science Core Collection as its source of literature, which may introduce certain limitations in terms of literature sources. Additionally, the use of bibliographic co-citation analysis inherently poses some challenges, particularly regarding the citation frequency of newly published papers. To address this shortcoming, this paper analyzes and summarizes the hot spots and emerging trends of anxiety and depression among primary school students by using keyword co-occurrence clustering. Future studies, while ensuring the quality of literature data, could expand the scope of data retrieval, innovate in related analytical methods, and strive for a more complete and accurate portrayal of research progress in this field.

5 Conclusion

The escalating number of articles published annually on elementary students’ anxiety underscores the intensifying global focus on this issue. Putwain, David W., is the most prolific author in this field, while COHEN J. is the most cited. The United States and China dominate the publication landscape in this field, yet their collaborations are predominantly with economically and technologically advanced countries. To elevate the caliber of global collaborative research, fostering enhanced cooperation among nations and institutions is crucial.

Present investigations into anxiety and depression among elementary students concentrate on intervention strategies, mental health, and the precipitating factors and intrinsic mechanisms of these conditions. Current research highlights include studies on suicidal ideation, bullying, the effects of COVID-19, and mindfulness interventions. Future research is poised to delve into the impact of mathematical anxiety on the psychological health and behavioral patterns of primary school students. Additionally, our findings indicate that family stress and academic burden are significant contributors to the prevalence of anxiety and depression among primary school students. There is notable heterogeneity across different groups and cultures. Specifically, in Asian populations, academic burden are identified as the primary factors leading to anxiety and depression in primary school students. This study not only furnishes a benchmark for current hot topics and emerging frontiers in the realm of elementary students’ anxiety and depression but also forecasts pivotal research trends, thereby providing valuable guidance for ongoing scholarly inquiry.

Author contributions

JF: Writing – original draft, Software, Investigation, Conceptualization. WY: Writing – review & editing, Supervision, Methodology, Data curation. SL: Writing – review & editing, Supervision, Data curation. WS: Writing – review & editing, Supervision, Methodology, Data curation.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article.

This study was supported by the Qingdao Philosophy and Social Science Planning Project (grant number : QDSKL2201013).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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48. Doumas DM, Midgett A, Peck M. The association between internalizing symptoms and witnessing school bullying and defending behavior: an analysis of gender differences among elementary and middle school students. Children (Basel) . (2023) 10:1199. doi: 10.3390/children10071199

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Keywords: anxiety, depression, primary school students, bibliometrics, CiteSpace, VOSviewer

Citation: Fu JN, Yu WB, Li SQ and Sun WZ (2024) A bibliometric analysis of anxiety and depression among primary school students. Front. Psychiatry 15:1431215. doi: 10.3389/fpsyt.2024.1431215

Received: 11 May 2024; Accepted: 17 July 2024; Published: 02 August 2024.

Reviewed by:

Copyright © 2024 Fu, Yu, Li and Sun. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Wen Ze Sun, [email protected]

†These authors share first authorship

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Penn State University Libraries

Soc 210n: social determinants of health.

• Scholarly Journals

Reports & Working Papers

Government agencies, selected research organizations, evaluating organizational reports & working papers.

• Evaluating Resources
• Statistics & Data
• Policy Commons This link opens in a new window Database for public policy, with more than 3.2 million reports, working papers, policy briefs, data sources, and media drawn from a directory of more than 24,000 IGOs, NGOs, think tanks, and research centers. more... less... Database for public policy, with more than 3.2 million reports, working papers, policy briefs, data sources, and media drawn from a directory of more than 24,000 IGOs, NGOs, think tanks, and research centers.
• Social Science Research Network SSRN is devoted to the dissemination of social science research and is composed of a number of specialized research networks in each of the social sciences.
• NBER Working Papers This link opens in a new window Founded in 1920, the National Bureau of Economic Research is a private, nonprofit, nonpartisan research organization dedicated to promoting a greater understanding of how the economy works. The NBER is committed to undertaking and disseminating unbiased economic research among public policymakers, business professionals, and the academic community. more... less... Founded in 1920, the National Bureau of Economic Research is a private, nonprofit, nonpartisan research organization dedicated to promoting a greater understanding of how the economy works. The NBER is committed to undertaking and disseminating unbiased economic research among public policymakers, business professionals, and the academic community.
• CIAO (Columbia International Affairs Online) This link opens in a new window CIAO (Columbia International Affairs Online) is a comprehensive source for research in international affairs. It includes full text of selected books on international affairs, working papers from university research institutes, occasional papers series from NGOs, foundation-funded research projects, and proceedings from conferences. It also, contains abstracts and some full text of selected journal articles. more... less... CIAO (Columbia International Affairs Online) is a comprehensive source for research in international affairs. It includes full text of selected books on international affairs, working papers from university research institutes, occasional papers series from NGOs, foundation-funded research projects, and proceedings from conferences. It also, contains abstracts and some full text of selected journal articles

United States Government Agencies

• Office of Disease Prevention and Health Promotion Healthy People 2023: Social Determinants of Health
• Agency for Health Care Research & Quality Social Determinants of Health (site)
• Office of Health Equity: US Department of Veterans Affairs
• Office of Behavioral Equity: Substance Abuse and Mental Health (USDH)

International Government Organizations & Agencies

• World Health Organizations Social Determinants of Health (site).
• Pan American Health Organization Social Determinants of Health (site)
• European Union: Health Inequalities Portal
• National Collaborating Centre for Determinants of Health (Canada)
• Institute of Health Equity (England)
• OECD iLibrary This link opens in a new window Full-text book and serial publications from the Organisation for Economic Cooperation and Development. more... less... Full-text book and serial publications from the Organisation for Economic Cooperation and Development. Also includes many of the data sets available from the organization. Open Access as of 7/1/24.
• UN iLibrary This link opens in a new window It provides librarians, information specialists, scholars, students, policy makers, influencers and the general public with a single digital destination for seamlessly accessing publications, journals, data, and series published by the United Nations Secretariat, and its funds and programs more... less... It provides librarians, information specialists, scholars, students, policy makers, influencers and the general public with a single digital destination for seamlessly accessing publications, journals, data, and series published by the United Nations Secretariat, and its funds and programs. United Nations iLibrary offers an extensive list of features that deliver flexibility, speed, and efficiency such as intuitive navigation, integrated search results, granular content, citation tool, DOI identification, and multilingual content. Every year around 500 new titles are planned to be added to United Nations iLibrary.
• Rural Health Information Hub Social Determinants of Health for Rural People
• Robert Wood Johnson Foundation
• Center for American Progress
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• American Medical Association
• For a list of other government and organizations explore ...

When evaluating reports, consider the following criteria:

• Authority: Who is the author/source? What are is her/qualifications? Do they have any expertise in the area?
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• Currency: How up-to-date is the information? When was it created?  Is there more recent information available?
• AACODS Checklist Developed by Flinders University, this is a useful tool for appraising report literature expands the ideas mentioned above.
• SourceWatch Published by the Center for Media and Democracy. A nonprofit advocacy organization that is characterized by some as a liberal organization.
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How to cite ChatGPT

Use discount code STYLEBLOG15 for 15% off APA Style print products with free shipping in the United States.

We, the APA Style team, are not robots. We can all pass a CAPTCHA test , and we know our roles in a Turing test . And, like so many nonrobot human beings this year, we’ve spent a fair amount of time reading, learning, and thinking about issues related to large language models, artificial intelligence (AI), AI-generated text, and specifically ChatGPT . We’ve also been gathering opinions and feedback about the use and citation of ChatGPT. Thank you to everyone who has contributed and shared ideas, opinions, research, and feedback.

In this post, I discuss situations where students and researchers use ChatGPT to create text and to facilitate their research, not to write the full text of their paper or manuscript. We know instructors have differing opinions about how or even whether students should use ChatGPT, and we’ll be continuing to collect feedback about instructor and student questions. As always, defer to instructor guidelines when writing student papers. For more about guidelines and policies about student and author use of ChatGPT, see the last section of this post.

Quoting or reproducing the text created by ChatGPT in your paper

If you’ve used ChatGPT or other AI tools in your research, describe how you used the tool in your Method section or in a comparable section of your paper. For literature reviews or other types of essays or response or reaction papers, you might describe how you used the tool in your introduction. In your text, provide the prompt you used and then any portion of the relevant text that was generated in response.

Unfortunately, the results of a ChatGPT “chat” are not retrievable by other readers, and although nonretrievable data or quotations in APA Style papers are usually cited as personal communications , with ChatGPT-generated text there is no person communicating. Quoting ChatGPT’s text from a chat session is therefore more like sharing an algorithm’s output; thus, credit the author of the algorithm with a reference list entry and the corresponding in-text citation.

When prompted with “Is the left brain right brain divide real or a metaphor?” the ChatGPT-generated text indicated that although the two brain hemispheres are somewhat specialized, “the notation that people can be characterized as ‘left-brained’ or ‘right-brained’ is considered to be an oversimplification and a popular myth” (OpenAI, 2023).

OpenAI. (2023). ChatGPT (Mar 14 version) [Large language model]. https://chat.openai.com/chat

You may also put the full text of long responses from ChatGPT in an appendix of your paper or in online supplemental materials, so readers have access to the exact text that was generated. It is particularly important to document the exact text created because ChatGPT will generate a unique response in each chat session, even if given the same prompt. If you create appendices or supplemental materials, remember that each should be called out at least once in the body of your APA Style paper.

When given a follow-up prompt of “What is a more accurate representation?” the ChatGPT-generated text indicated that “different brain regions work together to support various cognitive processes” and “the functional specialization of different regions can change in response to experience and environmental factors” (OpenAI, 2023; see Appendix A for the full transcript).

Creating a reference to ChatGPT or other AI models and software

The in-text citations and references above are adapted from the reference template for software in Section 10.10 of the Publication Manual (American Psychological Association, 2020, Chapter 10). Although here we focus on ChatGPT, because these guidelines are based on the software template, they can be adapted to note the use of other large language models (e.g., Bard), algorithms, and similar software.

The reference and in-text citations for ChatGPT are formatted as follows:

• Parenthetical citation: (OpenAI, 2023)
• Narrative citation: OpenAI (2023)

Let’s break that reference down and look at the four elements (author, date, title, and source):

Author: The author of the model is OpenAI.

Date: The date is the year of the version you used. Following the template in Section 10.10, you need to include only the year, not the exact date. The version number provides the specific date information a reader might need.

Title: The name of the model is “ChatGPT,” so that serves as the title and is italicized in your reference, as shown in the template. Although OpenAI labels unique iterations (i.e., ChatGPT-3, ChatGPT-4), they are using “ChatGPT” as the general name of the model, with updates identified with version numbers.

The version number is included after the title in parentheses. The format for the version number in ChatGPT references includes the date because that is how OpenAI is labeling the versions. Different large language models or software might use different version numbering; use the version number in the format the author or publisher provides, which may be a numbering system (e.g., Version 2.0) or other methods.

Bracketed text is used in references for additional descriptions when they are needed to help a reader understand what’s being cited. References for a number of common sources, such as journal articles and books, do not include bracketed descriptions, but things outside of the typical peer-reviewed system often do. In the case of a reference for ChatGPT, provide the descriptor “Large language model” in square brackets. OpenAI describes ChatGPT-4 as a “large multimodal model,” so that description may be provided instead if you are using ChatGPT-4. Later versions and software or models from other companies may need different descriptions, based on how the publishers describe the model. The goal of the bracketed text is to briefly describe the kind of model to your reader.

Source: When the publisher name and the author name are the same, do not repeat the publisher name in the source element of the reference, and move directly to the URL. This is the case for ChatGPT. The URL for ChatGPT is https://chat.openai.com/chat . For other models or products for which you may create a reference, use the URL that links as directly as possible to the source (i.e., the page where you can access the model, not the publisher’s homepage).

Other questions about citing ChatGPT

You may have noticed the confidence with which ChatGPT described the ideas of brain lateralization and how the brain operates, without citing any sources. I asked for a list of sources to support those claims and ChatGPT provided five references—four of which I was able to find online. The fifth does not seem to be a real article; the digital object identifier given for that reference belongs to a different article, and I was not able to find any article with the authors, date, title, and source details that ChatGPT provided. Authors using ChatGPT or similar AI tools for research should consider making this scrutiny of the primary sources a standard process. If the sources are real, accurate, and relevant, it may be better to read those original sources to learn from that research and paraphrase or quote from those articles, as applicable, than to use the model’s interpretation of them.

We’ve also received a number of other questions about ChatGPT. Should students be allowed to use it? What guidelines should instructors create for students using AI? Does using AI-generated text constitute plagiarism? Should authors who use ChatGPT credit ChatGPT or OpenAI in their byline? What are the copyright implications ?

On these questions, researchers, editors, instructors, and others are actively debating and creating parameters and guidelines. Many of you have sent us feedback, and we encourage you to continue to do so in the comments below. We will also study the policies and procedures being established by instructors, publishers, and academic institutions, with a goal of creating guidelines that reflect the many real-world applications of AI-generated text.

For questions about manuscript byline credit, plagiarism, and related ChatGPT and AI topics, the APA Style team is seeking the recommendations of APA Journals editors. APA Style guidelines based on those recommendations will be posted on this blog and on the APA Style site later this year.

Update: APA Journals has published policies on the use of generative AI in scholarly materials .

We, the APA Style team humans, appreciate your patience as we navigate these unique challenges and new ways of thinking about how authors, researchers, and students learn, write, and work with new technologies.

American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). https://doi.org/10.1037/0000165-000

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COVID-19: Long-term effects

Some people continue to experience health problems long after having COVID-19. Understand the possible symptoms and risk factors for post-COVID-19 syndrome.

Most people who get coronavirus disease 2019 (COVID-19) recover within a few weeks. But some people — even those who had mild versions of the disease — might have symptoms that last a long time afterward. These ongoing health problems are sometimes called post- COVID-19 syndrome, post- COVID conditions, long COVID-19 , long-haul COVID-19 , and post acute sequelae of SARS COV-2 infection (PASC).

What is post-COVID-19 syndrome and how common is it?

Post- COVID-19 syndrome involves a variety of new, returning or ongoing symptoms that people experience more than four weeks after getting COVID-19 . In some people, post- COVID-19 syndrome lasts months or years or causes disability.

Research suggests that between one month and one year after having COVID-19 , 1 in 5 people ages 18 to 64 has at least one medical condition that might be due to COVID-19 . Among people age 65 and older, 1 in 4 has at least one medical condition that might be due to COVID-19 .

What are the symptoms of post-COVID-19 syndrome?

The most commonly reported symptoms of post- COVID-19 syndrome include:

• Symptoms that get worse after physical or mental effort
• Lung (respiratory) symptoms, including difficulty breathing or shortness of breath and cough

Other possible symptoms include:

• Neurological symptoms or mental health conditions, including difficulty thinking or concentrating, headache, sleep problems, dizziness when you stand, pins-and-needles feeling, loss of smell or taste, and depression or anxiety
• Joint or muscle pain
• Heart symptoms or conditions, including chest pain and fast or pounding heartbeat
• Digestive symptoms, including diarrhea and stomach pain
• Blood clots and blood vessel (vascular) issues, including a blood clot that travels to the lungs from deep veins in the legs and blocks blood flow to the lungs (pulmonary embolism)
• Other symptoms, such as a rash and changes in the menstrual cycle

Keep in mind that it can be hard to tell if you are having symptoms due to COVID-19 or another cause, such as a preexisting medical condition.

It's also not clear if post- COVID-19 syndrome is new and unique to COVID-19 . Some symptoms are similar to those caused by chronic fatigue syndrome and other chronic illnesses that develop after infections. Chronic fatigue syndrome involves extreme fatigue that worsens with physical or mental activity, but doesn't improve with rest.

Why does COVID-19 cause ongoing health problems?

Organ damage could play a role. People who had severe illness with COVID-19 might experience organ damage affecting the heart, kidneys, skin and brain. Inflammation and problems with the immune system can also happen. It isn't clear how long these effects might last. The effects also could lead to the development of new conditions, such as diabetes or a heart or nervous system condition.

The experience of having severe COVID-19 might be another factor. People with severe symptoms of COVID-19 often need to be treated in a hospital intensive care unit. This can result in extreme weakness and post-traumatic stress disorder, a mental health condition triggered by a terrifying event.

What are the risk factors for post-COVID-19 syndrome?

You might be more likely to have post- COVID-19 syndrome if:

• You had severe illness with COVID-19 , especially if you were hospitalized or needed intensive care.
• You had certain medical conditions before getting the COVID-19 virus.
• You had a condition affecting your organs and tissues (multisystem inflammatory syndrome) while sick with COVID-19 or afterward.

Post- COVID-19 syndrome also appears to be more common in adults than in children and teens. However, anyone who gets COVID-19 can have long-term effects, including people with no symptoms or mild illness with COVID-19 .

What should you do if you have post-COVID-19 syndrome symptoms?

If you're having symptoms of post- COVID-19 syndrome, talk to your health care provider. To prepare for your appointment, write down:

• When your symptoms started
• What makes your symptoms worse
• How often you experience symptoms
• How your symptoms affect your activities

Your health care provider might do lab tests, such as a complete blood count or liver function test. You might have other tests or procedures, such as chest X-rays, based on your symptoms. The information you provide and any test results will help your health care provider come up with a treatment plan.

In addition, you might benefit from connecting with others in a support group and sharing resources.

• Long COVID or post-COVID conditions. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects.html. Accessed May 6, 2022.
• Post-COVID conditions: Overview for healthcare providers. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-conditions.html. Accessed May 6, 2022.
• Mikkelsen ME, et al. COVID-19: Evaluation and management of adults following acute viral illness. https://www.uptodate.com/contents/search. Accessed May 6, 2022.
• Saeed S, et al. Coronavirus disease 2019 and cardiovascular complications: Focused clinical review. Journal of Hypertension. 2021; doi:10.1097/HJH.0000000000002819.
• AskMayoExpert. Post-COVID-19 syndrome. Mayo Clinic; 2022.
• Multisystem inflammatory syndrome (MIS). Centers for Disease Control and Prevention. https://www.cdc.gov/mis/index.html. Accessed May 24, 2022.
• Patient tips: Healthcare provider appointments for post-COVID conditions. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/post-covid-appointment/index.html. Accessed May 24, 2022.
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