case study related to mental health

150 Case Studies: Real Stories Of People Overcoming Struggles of Mental Health

At Tracking Happiness, we’re dedicated to helping others around the world overcome struggles of mental health.

In 2022, we published a survey of 5,521 respondents and found:

• 88% of our respondents experienced mental health issues in the past year.
• 25% of people don’t feel comfortable sharing their struggles with anyone, not even their closest friends.

In order to break the stigma that surrounds mental health struggles, we’re looking to share your stories.

Overcoming struggles

They say that everyone you meet is engaged in a great struggle. No matter how well someone manages to hide it, there’s always something to overcome, a struggle to deal with, an obstacle to climb.

And when someone is engaged in a struggle, that person is looking for others to join him. Because we, as human beings, don’t thrive when we feel alone in facing a struggle.

Let’s throw rocks together

Overcoming your struggles is like defeating an angry giant. You try to throw rocks at it, but how much damage is one little rock gonna do?

Tracking Happiness can become your partner in facing this giant. We are on a mission to share all your stories of overcoming mental health struggles. By doing so, we want to help inspire you to overcome the things that you’re struggling with, while also breaking the stigma of mental health.

Which explains the phrase: “Let’s throw rocks together”.

Let’s throw rocks together, and become better at overcoming our struggles collectively. If you’re interested in becoming a part of this and sharing your story, click this link!

Case studies

May 7, 2024

My Journey From Hitting Rock Bottom to Overcoming Abuse, Addiction, and Eating Disorder

“Then something happened. On about day 3 or 4, the group spoke and I realized that their way of thinking around food, their rituals, and their tendencies, were all the same as the things I would do. It was wild because I thought I had made these things up myself and here I was with a room full of people who did the same things.”

Struggled with: Abuse Bullying Depression Divorce Eating disorder PTSD

Helped by: Self-Care Social support Therapy Treatment

May 2, 2024

How Yoga Became My Lifeline in Navigating Depression and Building Self-Love

“My relationship with myself was pretty broken and I had no self-belief, I had low self-esteem and I resented my family. It was through yoga that I found the truest feeling of comfort, self-compassion, and courage to move forward, grow as a person, and fall back in love with myself and life again.”

Struggled with: Depression Insomnia Stress Suicidal

Helped by: Exercise Meditation Mindfulness Self-Care

April 30, 2024

Finding Clarity After an ADHD Diagnosis and Bettering Myself With CBT and Medication

“Now as I was getting older, I felt I couldn’t trust my own thoughts in the same way as before, and self-doubt would creep in. I would constantly ask myself whether my emotions and thoughts were accurate or not when reacting to social situations. As you can imagine this was a huge challenge and draining emotionally.”

Struggled with: ADHD Autism

Helped by: Medication Social support Therapy

April 25, 2024

How I’m Seeking Moments of Happiness Despite Struggling With Depression

“The diagnosis I longed for finally arrived, but it didn’t bring the expected empowerment. While it sheds light on my struggles, it also serves as a reminder that this is a part of me that won’t simply vanish. Though mental health can be managed, I know it will always leave its mark. The most challenging part is not always pinpointing why I feel the way I do.”

Struggled with: Depression Negative body image

Helped by: Medication Therapy

April 24, 2024

How Boxing and Therapy Help Me Recover My Identity After Extreme Weight Loss

“When my body changed so drastically and rapidly, it broke my sense of self-identity. About a year into my weight loss, I began to experience early dissociation, depersonalization, and dissociative amnesia. I broke into two people. Me of now and her of before.”

Struggled with: Depression Dissociative amnesia

Helped by: Exercise Self-improvement Therapy

April 18, 2024

How Therapy, Medication and Baking Help Me Navigate Depression and OCD

“I was hospitalized for my eating disorder and my depression several times throughout my college career struggling with the will to live… I was desperate to be “normal” but my brain really got in the way of that.”

Struggled with: Anxiety Depression Eating disorder OCD Suicidal

Helped by: Medication Self-improvement Therapy Treatment

April 16, 2024

How I Found My Self-Worth After Battling Chronic Pain, Anxiety and Panic Attacks

“I remember being floored with a horrible throat infection, and I was just crying. I was done suffering, I couldn’t do it anymore, I was really broken down. That was about 2 years ago now, and it shifted something in my brain. Instead of going down the drain – and keeping that negativity going – it suddenly hit me that I’m the only one responsible for how I feel.”

Struggled with: Anxiety Chronic pain Panic attacks Stress

Helped by: Medication Self-Care Self-improvement Therapy

April 11, 2024

How a Mindset Change Helped Me Break Free From Childhood Trauma and Toxicity

“My mother said she wanted to end it in bloodshed and she waited for him to come home from his late-night meeting. She thought better of it when he was late arriving home. She was overwhelmed with thoughts of her in prison and me in foster care. To say that she made the right decision in achieving the goal of a good life is an answer I struggled to answer for many years.”

Struggled with: Abuse Anxiety Childhood CPTSD Depression

Helped by: Mindfulness Reinventing yourself Self-improvement Therapy

April 9, 2024

Healing From Postpartum Depression With Therapy, Friends & Exercise

“I wasn’t sure how to feel better for a while. People talk about ‘getting help’ but that’s a blanket term and unfortunately it’s not a band-aid you can just put on and suddenly be yourself again. It takes time to find the right therapist, medication if that’s what you decide to do, to find a new rhythm with family, and in my case, I really needed friends locally.”

Struggled with: Postpartum depression

Helped by: Exercise Social support Therapy

April 4, 2024

My Journey from Loneliness and Isolation to Creating an Online Haven for Seniors

“When one is home alone, all day, with nothing to do, nobody to speak with, stuck with their thoughts both good and bad, it’s easy to slip back into a depressive state. Feeling unneeded, unwanted, no happiness, no joy, no reason to get out of bed – just suffering with “the blahs”.”

Struggled with: Depression Loneliness

Helped by: Self-improvement Social support

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It’s a New Era for Mental Health at Work

• Kelly Greenwood

Research on how the past 18 months have affected U.S. employees — and how companies should respond.

In 2019, employers were just starting to grasp the prevalence of mental health challenges at work, the need to address stigma, and the emerging link to diversity, equity, and inclusion (DEI). One silver lining amid all the disruption and trauma over the last two years is the normalization of these challenges. In a follow-up study of their 2019 Mental Health at Work Report, Mind Share Partners’ 2021 Mental Health at Work Report, the authors offer a rare comparison of the state of mental health, stigma, and work culture in U.S. workplaces before and during the pandemic. They also present a summary of what they learned and their recommendations for what employers need to do to support their employees’ mental health.

When we published our research on workplace mental health in October 2019, we never could have predicted how much our lives would soon be upended by the Covid-19 pandemic. Then the murders of George Floyd and other Black Americans by the police; the rise in violence against Asian Americans and Pacific Islanders (AAPIs); wildfires; political unrest; and other major stressors unfolded in quick succession, compounding the damage to our collective mental health.

• Kelly Greenwood is the Founder and CEO of Mind Share Partners , a national nonprofit changing the culture of workplace mental health so both employees and organizations can thrive. Through movement building , custom training, and strategic advising, it normalizes mental health challenges and promotes sustainable ways of working to create a mentally healthy workforce. Follow her on LinkedIn and subscribe to her monthly newsletter.
• Julia Anas is the chief people officer at Qualtrics, the world’s #1 Experience Management (XM) provider and creator of the XM category. At Qualtrics, she is responsible for building a talented and diverse organization and driving employee development as well as organizational design, talent, and succession planning.

Partner Center

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

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

Custom Around the Practice Video Series

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Transcript Edited for Clarity

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

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

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

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

The 2024 APA Annual Meeting: Sunday, May 5

Blue Light, Depression, and Bipolar Disorder

The Week in Review: April 1-5

Four Myths About Lamotrigine

An Update on Bipolar I Disorder

Bipolar Disorder Research Roundup: March 29, 2024

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What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

• Children's mental health case studies
• Food, health and nutrition
• Mental wellbeing
• Mental health

Explore the experiences of children and families with these interdisciplinary case studies. Designed to help professionals and students explore the strengths and needs of children and their families, each case presents a detailed situation, related research, problem-solving questions and feedback for the user. Use these cases on your own or in classes and training events

Each case study:

• Explores the experiences of a child and family over time.
• Introduces theories, research and practice ideas about children's mental health.
• Shows the needs of a child at specific stages of development.
• Invites users to “try on the hat” of different specific professionals.

By completing a case study participants will:

• Examine the needs of children from an interdisciplinary perspective.
• Recognize the importance of prevention/early intervention in children’s mental health.
• Apply ecological and developmental perspectives to children’s mental health.
• Predict probable outcomes for children based on services they receive.

Case studies prompt users to practice making decisions that are:

• Research-based.
• Practice-based.
• Best to meet a child and family's needs in that moment.

Children’s mental health service delivery systems often face significant challenges.

• Services can be disconnected and hard to access.
• Stigma can prevent people from seeking help.
• Parents, teachers and other direct providers can become overwhelmed with piecing together a system of care that meets the needs of an individual child.
• Professionals can be unaware of the theories and perspectives under which others serving the same family work
• Professionals may face challenges doing interdisciplinary work.
• Limited funding promotes competition between organizations trying to serve families.

These case studies help explore life-like mental health situations and decision-making. Case studies introduce characters with history, relationships and real-life problems. They offer users the opportunity to:

• Examine all these details, as well as pertinent research.
• Make informed decisions about intervention based on the available information.

The case study also allows users to see how preventive decisions can change outcomes later on. At every step, the case content and learning format encourages users to review the research to inform their decisions.

Each case study emphasizes the need to consider a growing child within ecological, developmental, and interdisciplinary frameworks.

• Ecological approaches consider all the levels of influence on a child.
• Developmental approaches recognize that children are constantly growing and developing. They may learn some things before other things.
• Interdisciplinary perspectives recognize that the needs of children will not be met within the perspectives and theories of a single discipline.

There are currently two different case students available. Each case study reflects a set of themes that the child and family experience.

The About Steven case study addresses:

• Adolescent depression.
• School mental health.
• Rural mental health services.
• Social/emotional development.

The Brianna and Tanya case study reflects themes of:

• Infant and early childhood mental health.
• Educational disparities.
• Trauma and toxic stress.
• Financial insecurity.
• Intergenerational issues.

The case studies are designed with many audiences in mind:

Practitioners from a variety of fields. This includes social work, education, nursing, public health, mental health, and others.

Professionals in training, including those attending graduate or undergraduate classes.

The broader community.

Each case is based on the research, theories, practices and perspectives of people in all these areas. The case studies emphasize the importance of considering an interdisciplinary framework. Children’s needs cannot be met within the perspective of a single discipline.

The complex problems children face need solutions that integrate many and diverse ways of knowing. The case studies also help everyone better understand the mental health needs of children. We all have a role to play.

These case has been piloted within:

Graduate and undergraduate courses.

Discipline-specific and interdisciplinary settings.

Professional organizations.

Currently, the case studies are being offered to instructors and their staff and students in graduate and undergraduate level courses. They are designed to supplement existing course curricula.

Instructors have used the case study effectively by:

• Assigning the entire case at one time as homework. This is followed by in-class discussion or a reflective writing assignment relevant to a course.
• Assigning sections of the case throughout the course. Instructors then require students to prepare for in-class discussion pertinent to that section.
• Creating writing, research or presentation assignments based on specific sections of course content.
• Focusing on a specific theme present in the case that is pertinent to the course. Instructors use this as a launching point for deeper study.
• Constructing other in-class creative experiences with the case.
• Collaborating with other instructors to hold interdisciplinary discussions about the case.

To get started with a particular case, visit the related web page and follow the instructions to register. Once you register as an instructor, you will receive information for your co-instructors, teaching assistants and students. Get more information on the following web pages.

• Brianna and Tanya: A case study about infant and early childhood mental health
• About Steven: A children’s mental health case study about depression

Cari Michaels, Extension educator

Reviewed in 2023

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• Research Resources

The National Institute of Mental Health (NIMH), part of the National Institutes of Health (NIH), is the lead federal agency for research on mental disorders, supporting research that aims to transform the understanding and treatment of mental illnesses through basic and clinical research. Learn more about NIMH-funded research areas, policies, resources, initiatives, and research conducted by NIMH.

  Notify the NIMH Press Team about NIMH-funded research that has been submitted to a journal for publication, and we may be able to promote the findings.

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The NIMH Strategic Plan for Research outlines the Institute's research goals and priorities over the next five years. Learn more about the Strategic Plan.

NIMH supports research at universities, medical centers, and other institutions via grants, contracts, and cooperative agreements. Learn more about NIMH research areas, policies, resources, and initiatives:

• Research Domain Criteria (RDoC)
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• Inside NIMH - Funding and Research News

The Division of Intramural Research Programs (IRP) is the internal research division of the NIMH. Over 40 research groups conduct basic neuroscience research and clinical investigations of mental illnesses, brain function, and behavior at the NIH campus in Bethesda, Maryland. Learn more about research conducted at NIMH:

• Intramural Investigators
• Intramural Research Groups
• Fellowships and Training
• Office of the Scientific Director
• Collaborations and Partnerships
• Join a Study
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• Research Areas
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Resources for Researchers

• Psychosocial Research at NIMH: A Primer
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NIMH Women Leading Mental Health Research

Diversity in the scientific workforce enhances excellence, creativity, and innovation. NIMH and the National Institutes of Health (NIH) are committed to increasing diversity in the scientific workforce. Learn more about early-career women scientists whose NIMH-funded research is playing a role in advancing our mission of transforming the understanding and treatment of mental illnesses.

Schizophrenic Case Study: Examining Symptom Management And Long-Term Outcomes

Life with schizophrenia can have both clear and confusing moments. There may be times of stability and times when things seem overwhelming. Finding effective ways to manage symptoms can empower people with schizophrenia to overcome challenges, build resilience, and create a future filled with purpose and possibility. Often, a combination of psychosocial interventions, therapy, and medication can help those with schizophrenia manage symptoms and live fulfilling lives.

Understanding schizophrenia symptoms

Schizophrenia can impact how a person experiences the world. Imagine if your thoughts, feelings, and understanding of reality became unreliable. This distortion is something someone with schizophrenia might experience. To better grasp this psychotic disorder, let's explore its three broad categories of symptoms:

• Positive symptoms: These are usually the most recognizable symptoms. They often include visual and auditory hallucinations (perceiving things that aren't there) and delusions (fixed, false beliefs).
• Negative symptoms: Less obvious but often equally disruptive, these might manifest as diminished emotional expression, a loss of motivation, or difficulty finding joy in ordinary activities.
• Cognitive symptoms: These usually center around a person's thought processes, making it hard to focus, retain information, and make decisions.

Schizophrenia can be an unpredictable and severe mental illness. What one person with schizophrenia goes through may not perfectly align with someone else's experience. Symptoms, their intensity, and how they change throughout someone's journey can be unique.

Schizophrenia onset and the significance of early diagnosis

According to information from the National Institute of Mental Health, schizophrenia typically presents between the late teens and early thirties . Sometimes, though much less common, schizophrenia may appear earlier. Some examples include the following:

• Childhood-onset schizophrenia (COS): Also known as very early-onset schizophrenia (VEOS), this extremely rare form is usually marked by symptoms appearing before a child turns 13.
• Early-onset schizophrenia (EOS): EOS generally encompasses those whose symptoms begin between ages 13 and 18.

Early diagnosis of schizophrenia spectrum disorders can unlock a more promising trajectory for an individual's future well-being. Recognizing potential signs and seeking a timely evaluation from mental health professionals may allow for a more proactive approach to managing this complex disorder.

The diagnostic process

While self-diagnosis, especially for serious conditions like psychotic disorders, tends to be unreliable, being aware of early indicators can be empowering. It may enable you to take a proactive step toward seeking professional support. 

If you have concerns about yourself or a loved one, consulting a mental health professional can provide answers. A medical professional can conduct a thorough assessment considering your personal history, current experiences, and other relevant factors.

Mental health professionals typically utilize the Diagnostic and Statistical Manual (DSM-V) to diagnose psychotic disorders, thanks to its standardized approach and detailed criteria. This tool usually helps them apply a precise and consistent approach, potentially ensuring an accurate diagnosis of schizophrenia and ruling out other disorders that could present overlapping symptoms.

While there is currently no cure for schizophrenia, effective treatment can lead to an improved quality of life for many individuals. Treatment typically involves a multi-faceted strategy.

• Medication: Antipsychotic medications often serve as a foundational component of managing schizophrenia. Pharmacological treatment can balance brain chemistry, reducing the severity and frequency of psychotic experiences. Always consult your doctor or psychiatrist before starting, stopping, or changing the way you take medication.
• Therapy: Various types of therapy can offer essential support for the positive and negative symptoms associated with schizophrenia. Cognitive behavioral therapy (CBT) generally helps individuals recognize and change thought patterns that may worsen symptoms. Meanwhile, psychosocial therapies can provide tools to tackle challenges like social interaction, stress, and everyday responsibilities. Family therapy can offer guidance and support to loved ones, promoting understanding and healthy communication.

Discovering the best combination of therapies and medications is often a collaborative, ongoing process. Open communication between the individual, their healthcare team, and their support network can enhance clinical outcomes.

Addressing challenges and optimizing treatment

Living with schizophrenia is usually a long-term journey with unique hurdles at different stages. Some common challenges can include those listed below:

• Medication side effects: While they can be vital for managing symptoms, antipsychotic medications sometimes cause unwanted side effects. Open dialogue with a psychiatrist can help you manage these or explore alternative medications as needed.
• Treatment adherence: Staying on track with medication and therapy appointments can lead to more optimal outcomes. Actively participating in one's treatment plan can foster a sense of agency and boost adherence.
• Relapse prevention: Even with excellent care, some individuals may experience a return of significant symptoms. Identifying personal triggers and developing relapse prevention plans can be beneficial.

Developing resilience and support 

Managing schizophrenia can be emotionally and physically taxing. A strong support network is usually helpful for flourishing with this disorder. This network might include the following:

• Family and friends: Loved ones can offer a lifeline of emotional support, encouragement, and a sense of belonging.
• Support groups: Connecting with those who face similar lived experiences may provide a safe space to share challenges, glean coping strategies, and build a community of understanding.
• Mental health professionals: Consistent appointments with a psychiatrist and therapist can create a collaborative partnership and ensure ongoing monitoring of treatment effectiveness.
• Primary care physicians: Coordinating mental health care with regular physical health checkups can support overall well-being.

The journey with schizophrenia can be difficult, but building a strong team around you can make it easier. By choosing trusted allies, you can advocate for your needs, take charge of your treatment, and find the best path forward.

The long-term outlook

Living with schizophrenia usually involves long-term management, but that doesn't necessarily mean giving up on the possibility of a happy life. Research indicates that with the right combination of early treatment and support, many individuals achieve an improved quality of life , often involving the following elements:

• Improved symptom management and lessening of disruptive episodes
• Enhanced ability to cope with stress and the demands of everyday life
• Increased connection with others and capacity to build meaningful relationships
• Greater independence, allowing for the pursuit of personal goals, such as education, employment, or living alone

Navigating schizophrenia may bring challenges, but with consistent effort and a commitment to your well-being, progress is possible. Working closely with your healthcare team and actively building your resilience may lay the groundwork for that progress. With continued research prompting possible new treatments and a greater understanding of this complex disorder, the future seems increasingly hopeful for those managing schizophrenia.

Humanizing the individual schizophrenia experience

Labels like schizophrenia can be powerful, sometimes with the side effect of reducing a person to their diagnosis. However, behind the clinical term lies an individual with aspirations, talents, and a longing for a meaningful life, just like anyone else. While this condition can present unique challenges, understanding those challenges often means going beyond the clinical jargon and digging into how it affects someone's lived experience.

Imagine navigating the hurdles of adolescence or young adulthood—friendships, romantic relationships, academics, employment, and carving out your sense of self. Now, add the layer of questioning whether your own thoughts and perceptions can be trusted.

The experience of psychotic symptoms characteristic of disorders like schizophrenia can be scary and confusing. Hearing voices that no one else can or struggling with beliefs that don't match reality can be understandably unsettling experiences. While medication often lessens these symptoms, developing coping mechanisms for managing these moments can make a difference in daily life.

Emerging research may hold the potential to improve our understanding of schizophrenia. Scientists are meticulously examining the interplay of genetics, the delicate biological processes of our bodies, and how our environment may influence our health. Their dedication can fuel the hope of not only revolutionizing treatment but potentially finding ways to prevent its onset for generations to come.

Thanks to organizations committed to research and enhanced care, our understanding of schizophrenia may continue to deepen. These efforts can lay the groundwork for continuous improvement in health and clinical excellence related to schizophrenia. While antipsychotic medications currently remain a primary treatment approach, scientists are also investigating innovative combination therapies offering the possibility of enhanced effectiveness when used in conjunction with traditional methods.

Additional support options

Some days, living with schizophrenia might seem like an endless series of setbacks. Even in the hardest moments, progress can still be possible. Finding the right treatment, surrounding yourself with support, and learning ways to navigate challenges can transform your journey.

Consistent therapy is often a fundamental part of managing schizophrenia. Online therapy can offer the flexibility to meet with a therapist at times that work for you from the safety of your own environment. The convenience and affordability of online sessions can make it easier to prioritize your mental health and foster a strong therapeutic relationship.

Research suggests that online therapy can positively impact those with schizophrenia. Studies show it can be a valuable tool for managing symptoms and gaining coping strategies , offering comparable benefits to in-person therapy, although it’s generally not appropriate for crisis situations. The accessibility of online therapy can remove some common barriers to care, potentially making it a viable option for those seeking support.

Managing schizophrenia spectrum disorders tends to be an ongoing process. The right treatment plan and support system, usually involving doctor-prescribed medication, therapy, and psychosocial interventions, can lay the foundation for growth and resilience. Online therapy may expand treatment options, offering personalized support to treat this severe mental health disorder characterized by psychotic symptoms and cognitive impairment.

• Schizophrenia Vs. Dementia: Distinguishing Symptoms, Causes, And Treatment Strategies Medically reviewed by April Justice , LICSW
• Understanding Schizophrenia Speech Patterns Medically reviewed by Julie Dodson , MA
• Schizophrenia
• Relationships and Relations

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Peer-reviewed

Research Article

A Multiple Case Study of Mental Health Interventions in Middle Income Countries: Considering the Science of Delivery

Contributed equally to this work with: Sean A. Kidd, Athena Madan, Susmitha Rallabandi, Kwame McKenzie

* E-mail: [email protected]

Affiliations Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada, Toronto Centre for Addiction and Mental Health Toronto, Ontario, Canada

Affiliation Toronto Centre for Addiction and Mental Health Toronto, Ontario, Canada

¶ ‡ These authors also contributed equally to this work.

Affiliation Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada

Affiliation Ashoka Canada,Toronto, Ontario, Canada

Affiliation BasicNeeds,Bangalore, India

Affiliation Ashoka, Washington D. C., United States of America

• Sean A. Kidd, 
• Athena Madan, 
• Susmitha Rallabandi, 
• Donald C. Cole, 
• Elisha Muskat, 
• Shoba Raja, 
• David Wiljer, 
• David Aylward, 
• Kwame McKenzie

• Published: March 24, 2016
• https://doi.org/10.1371/journal.pone.0152083
• Reader Comments

In the debate in global mental health about the most effective models for developing and scaling interventions, there have been calls for the development of a more robust literature regarding the "non-specific", science of delivery aspects of interventions that are locally, contextually, and culturally relevant. This study describes a rigorous, exploratory, qualitative examination of the key, non-specific intervention strategies of a diverse group of five internationally-recognized organizations addressing mental illness in middle income countries (MICs). A triangulated approach to inquiry was used with semi-structured interviews conducted with service recipients, service providers and leaders, and key community partners (N = 159). The interview focus was upon processes of implementation and operation. A grounded theory-informed analysis revealed cross cutting themes of: a holistic conceptualization of mental health problems, an intensive application of principles of leverage and creating the social, cultural, and policy “space” within which interventions could be applied and resourced. These findings aligned with key aspects of systems dynamic theory suggesting that it might be a helpful framework in future studies of mental health service implementation in MICs.

Citation: Kidd SA, Madan A, Rallabandi S, Cole DC, Muskat E, Raja S, et al. (2016) A Multiple Case Study of Mental Health Interventions in Middle Income Countries: Considering the Science of Delivery. PLoS ONE 11(3): e0152083. https://doi.org/10.1371/journal.pone.0152083

Editor: Chun-Hsi Huang, University of Connecticut, UNITED STATES

Received: November 19, 2015; Accepted: March 7, 2016; Published: March 24, 2016

Copyright: © 2016 Kidd et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: This work was supported by Grand Challenges Canada under grant #0326-04. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: Elisha Muskat and David Aylward were both employees of Ashoka at the time of the study and Shoba Raja was an employee of BasicNeeds at the time of the study. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.

Introduction

In a concerted effort to address the large and growing burden of mental illness in low and middle income settings (LMICs), the field of global mental health (GMH) is increasingly focussed upon the application and scaling up of evidence based interventions, with an emphasis upon task shifting [ 1 ]. Considerable controversy attends this emphasis upon standardization and scaling, with randomized trials as the gold standard of evidence [ 2 ]. There is a concern that Western, biomedical conceptualizations of mental illness and treatment can pathologize the individual and that the focus should be on the social determinants of illness. The critique goes further to note that this emphasis does not address non-technical/specific aspects of intervention and important local, contextual and cultural factors. The dialectic in this debate suggests that the greatest impact and ethical rigour in GMH requires a balanced consideration of the benefits of scaled, evidence-based approaches, particularly for severe mental illness while at the same time carefully attending to importance social determinant, cultural and contextual processes [ 2 ].

This debate may partly grow out of an imbalance in the base of evidence. Specifically, a considerable amount of evidence is available regarding assessment tools and protocols for an array of brief interventions for mental illnesses in LMICs [ 3 ]. Such approaches readily lend themselves to conventional clinical research designs. Far less information is available regarding what are variably referred to as the non-technical or non-specific intervention and service process-oriented factors that many would argue are essential to generating substantive impact [ 4 ]. In the broader healthcare arena this has been referred to as the "science of delivery"[ 5 ]. The problem that arises is that the more circumscribed, trial-amenable interventions cannot succeed without attention to the quality of the service processes and contexts in which they are implemented [ 6 ].

Social entrepreneurship is one lens that is available for understanding what will henceforth be referred to as "non-specific" factors such as models of leadership, partnership, and context-relevant conceptualizations of mental illness and intervention [ 7 , 8 ]. Social entrepreneurs have been characterized as change agents who utilize highly flexible approaches to solving social problems that allow them to effectively bridge gaps between multiple sectors and systems [ 9 – 11 ].

Cultivated to a large extent by organizations such as Ashoka [ 12 ] and the Skoll Foundation [ 13 ], social entrepreneurship has emerged as a prominent way of thinking about how complex problems, social and otherwise, are addressed. Health has been regularly connected with social entrepreneurship, with a recent review of 366 case studies finding that health was the primary target in 18% of the cases [ 14 ]. Social entrepreneurship in mental health specifically has had less attention despite its relevance in addressing the complexity of mental illness in under-resourced contexts [ 7 ].

This paper describes a rigorous examination of the key, non-specific or delivery system intervention strategies of a group of internationally recognized organizations addressing mental illness in middle income countries (MICs)—all of which have been identified as leading examples of social entrepreneurship. It is intended to inform the conversation about balance in considering how interventions are best developed and scaled in under-resourced contexts. It is among the first to apply a rigorous research design in this less well-defined domain of service delivery—studying the organization and service delivery models through which interventions are optimally deployed.

Case Identification

This study employed an instrumental, multiple case study design, one in which case study findings are used to inform the understanding of a specific broader issue [ 15 ]. The organizations that were studied were founded by Ashoka Fellows. Ashoka is the organization that is arguably the most prominent, internationally, in employing a social entrepreneurship lens to identify some of the most promising individuals and organizations that address social problems [ 12 ]. While Ashoka’s network by no means represents all social entrepreneurs, it is known for its accuracy in identifying highly effective social entrepreneurial approaches. It uses an intensive Delphi method [ 16 ] to identify potential Fellows and applies a rigorous selection process with a panel review that attends to key domains of social entrepreneurship, impact, and scale or potential for scaling. The Ashoka website at the time of inquiry described the work of 2,663 Fellows and their organizations from over 70 countries. The Fellows working in mental health were identified through (i) a keyword search of the online Ashoka directory using the terms: “mental health”, “mental illness”, “psychiatric”, “addiction”, and “developmental”; and (ii) cross-referencing the list with Ashoka staff familiar with the Fellows working in health to determine if any had been missed. This two-part process revealed 42 Fellows. Detailed descriptions of all 42 Fellows were reviewed by (Cole, Kidd, McKenzie, and Wiljer) at the level of their Ashoka profiles with further inquiry through websites, publications, and with Ashoka staff (e.g., to ensure the organization is still active). A maximum variation sampling strategy was used to identify 5 Fellows and their organizations with which to engage in intensive case studies. Target problem (type of mental health concern), intervention type/approach (service model; scale and reach), target population (by age, rural/urban, socioeconomic status), and geographic location (sociopolitical context past and current; culture) were key dimensions considered in achieving adequate variation, which was an important consideration given the intent to identify broadly applicable themes.

Given the depth of inquiry it was anticipated that 5 case studies would prove adequate to inform the service implementation and process questions that are the focus of this study and to reach saturation in the analysis [ 17 ]. The study was reviewed and approved by the Toronto Centre for Addiction and Mental Health Research Ethics Board. The protocol was also reviewed and approved by the executive leadership and research leads (individuals responsible for research within the organization, ethics review and approval) of each of the participating organizations. None of the organizations approached refused participation and the five that participated were the five originally selected.

Data Collection

Contextual information regarding organization operations and settings were collected through documentation review including websites and annual reports. This review also assisted with tailoring the plan of inquiry for the specific organizations. The primary source of data was semi-structured interviewing with past and present service/organization leadership anddirect service staff with service recipients and key partners (often less aware of implementation and process details) acting as secondary, triangulating sources of information. Key partners included policy makers who had been regular contacts and practitioners associated with partner organizations as identified by case study organization leadership. Service recipients were approached upon the recommendation of staff who assisted with addressing questions of capacity and minimizing intrusiveness in service settings. Leaders and staff had been informed of the intent to connect with stakeholders ranging in degree of supportiveness of their work. Nonetheless, it is possible that some bias might have attended this method of recruitment. The study also included ethnographic observation of activities of the organization (e.g., non-clinical meetings of staff and clients (e.g., in community activities, common spaces), presentations to the public, advocacy activities, etc.) with observations recorded in field notes. The ethnographic component occurred primarily during tours of organization activities by staff as well as interviewers spending time in common spaces. Interviewers were introduced as researchers attempting to develop an understanding about how a given organization worked. Multiple interviews were undertaken with service leaders and their staff, providing opportunities to ask follow up questions as the inquiry and data analysis progressed. Interviews with other stakeholders took place on a single occasion. Interviews were audio-recorded and transcribed verbatim, with translation services used on an as-needed basis, and took place between May, 2014 and March, 2015. Written consent was obtained for interviews with service leaders, staff, and key partners. Verbal consent was obtained from service recipients due to literacy difficulties in the study contexts, and was documented by noting the name, date, and location in which consent was secured. No service recipient was included for whom there was any question of capacity or any other consideration that might affect their understanding of their involvement. Interviews with service recipients were designed to be minimally intrusive, focusing on perceptions about what had been helpful or less helpful in their service experience over time. This verbal consent procedure was approved by the Research Ethics Board. Interviews were conducted by postdoctoral fellows (Madan and Rallabandi) who had no prior relationships or conflicting interests with the organizations of focus.

Specific areas of inquiry included a detailed history tracking the trajectories and turning points in services offered, service structures/models, goals and values, implementation, leveraging support, and relationships with stakeholders and supporters (See S1 Appendix for interview protocols). We undertook an examination of the specific aims and activities of the people involved in the service. Implicit to this line of investigation was a close study of the “theories of action” of the participants–their understanding of how their activities lead to the outcomes that they are seeking to attain. Also examined were their relationships within relevant systems (service, corporate, government, cultural norms)–how they are positioned, how initiatives are achieved or blocked, and the flow of information, people, and resources into and out of the organization from these systems. This attention to the ‘circumstances’, structures, processes, and contexts of the interventions has been previously highlighted as essential in such case studies [ 18 ].

Data Analysis

Following Stake’s model for multiple case study analysis [ 19 ], we analyzed transcripts and field notes using a thematic analysis informed by grounded theory (i.e., employing constant comparison, exploring connections between themes to inform a more theoretical formulation) [ 20 ]. The analysis moved from line-by-line open coding, to the refinement of codes and the development of an overarching thematic framework. Data collection and analysis proceeded simultaneously, allowing for opportunities to refine structure of the findings through increasingly targeted inquiry.

Several steps were taken to maximize rigor in the analysis and to establish the credibility and trustworthiness of the findings. First, there was a very rich set of data in multiple forms that allows for triangulation by source (staff, leaders, partners, observation) and type (field notes, verbal description). Second, participants were engaged in discussion about the emerging categories to support trustworthiness in the analysis. Third, a method of employing multiple coders was undertaken to develop the thematic framework with multiple rounds of review (by Kidd, Madan, and Rallabandi), negotiation of different perspectives, and revision.

Results and Discussion

Participating organizations and individuals.

The five organizations selected for study were BasicNeeds and its sites in Vietnam, and Ghana [ 21 ], the Acid Survivor's Foundation in Bangladesh [ 22 ], the Banyan in Chennai, India [ 23 ], ADVANCE in Egypt [ 24 ], and the Fundacion Colectivo Aqui y Ahora in Colombia [ 25 ] Table 1 . All of these organizations have mental health as a focus (though have a holistic approach that considers physical health, social and cultural domains) and operate where such supports had previously been extremely limited or completely lacking. BasicNeeds is among the largest and most extensively scaled comprehensive interventions to address mental illness globally—with 12 sites and over 600,000 beneficiaries to date. In Ghana and Vietnam, BasicNeeds operates out of several sites, both rural and urban, targeting impoverished people with mental illness. The Acid Survivors Foundation, which is based in Dhaka but has a national reach, provides a diverse set of services from plastic surgery to psychosocial rehabilitation for Bangladeshi people who have survived acid violence. The Banyan provides an intensive array of services for homeless individuals with severe mental illness with the core services studied located in Chennai. ADVANCE in Egypt provides specialized services for children and adolescents with autism spectrum disorders to support improved social integration. ADVANCE operates a stand along education and support centre and provides a range of outreach supports in close connection with schools and parent groups. The Fundacion Colectivo Aqui y Ahora in Colombia addresses youth addictions through a methodology focused upon personal meaning with engagement at family, school, workplace, and public levels. It has a standalone clinic and has outreach activities taking place at a national level in the range of settings noted above. Further details regarding the operations of each of these organizations and the Ashoka Fellows associated with them can be found at the referenced websites or at www.ashoka.org .

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https://doi.org/10.1371/journal.pone.0152083.t001

The total number of individual participants interviewed was 159 with a mean of 31.8 interviews per organization across the 5 case studies. Broken down by type, this included 93 service/organization staff and leadership, 46 community collaborators and members with a range of connections with the organization, 22 individual service recipients and 7 self-help groups with memberships of up to 30 people (for interview details see Table 2 ). These distinctions are somewhat artificial, as in these organizations there are many examples of service recipients becoming staff. Variability in interview and participant times were accounted for by a number of factors including opportunity with respect to time and travel, availability of participants, and sensitivity with respect to some groups of potential participants (e.g., children with autism). Interviews ranged in length from 15 minutes in a single contact (typically community members and recipients) to over 6 hours over multiple contacts (typically with service leaders and staff). Overall, the interview content was rich though in some instances it appeared that histories of conflict and other sociopolitical factors may have influenced the depth of inquiry (e.g., fears of discussing or criticizing systemic barriers in contexts where such talk in the past or present could lead to severe reprisal).

https://doi.org/10.1371/journal.pone.0152083.t002

Overview: Leverage and Space in Which to Work

Despite the considerable diversity across the specific operations and contexts of these organizations, a saturated and coherent theme structure readily emerged in the data analysis. The two cross-cutting thematic elements were leverage and the generation of resources (e.g., social capital) to support the development, capacity, and scaling of the interventions. Here, leverage could be considered the effort to maximize the outputs of every available resource, while applying pressure to aspects of the given complex problem in a manner that results in the maximum amount of change. Concurrently, these organizations ambitiously and persistently created space in which to work—with space being considered the cultivating of public, political, social and cultural resources around the problem. This provided social and fiscal capital and systems in which bureaucracy and policy enabled rather than hindered efforts. These core themes and their subthemes are described in detail below along with full quotes and excerpts that are representative of the data from which they were derived.

Understanding people , treating people equally , being non-judgmental , being down to earth , open minded , balanced between the rational and emotional , a strategic thinker , a good communicator , trustworthy , setting examples by doing things , team building , team spirit , mobilizing people and resources . (Past Executive Director)

This quote concisely encompasses most of the elements that participants considered important in the leadership of these organizations. They were described as individuals with a specific set of skills and values. They are intimately familiar with and intensely, personally invested in the cultures and contexts in which they work.

"Initially , though they were the founders , they didn’t mind doing anything . They have cleaned the bathrooms , they mopped the floors , and they used to cook in the kitchen , they used to clean and wash the clients , they themselves went for rescues , they themselves used to serve food . They have done the maximum from the beginning . They have done so many things from the ground level and that made them to grow higher and earn so much of manpower through the services that they have rendered to the clients ." Direct service staff person

Whether directly affected by mental illness in their families or through a very intensive study of the issues involved through "sitting with, living with" and "supping with" clients, families and communities, this empathetic approach had numerous implications. It was described as leading to an extremely deep understanding of the problem that needs to be addressed, the contexts and dynamics associated with it, and an intense engagement with and knowledge about the relevant stakeholders. This base of knowledge fed into, without exception, an understanding that effective interventions need to be individualized, staged, and multifaceted to address the many interacting needs of clients, families and communities. Furthermore, in the complex systems that surround the mental health problem that they sought to address, such a depth of knowledge and engagement allowed them to better recognize opportunities, resources, and points of leverage.

“So , as parents we got together and we had parents support meeting and we decided that what our children need is beyond what a center can do , we need a total NGO , we need life span services , we need awareness , we need advocacy , we need a lot of other things that’s not there . We also need to train personnel , because the personnel who existed knew maybe about disability but were not specific in their knowledge about autism and sensory issues and so on .” Executive Director and Founder

This depth of understanding was complemented by skill as educators and communicators who "cultivate trust" and "respect" in aligning diverse stakeholders around a clear vision of the problem and its solution–whether person with mental illness, rural villager, senior policy maker or influential public figure. This knowledge and skill in engaging and aligning had clear implications for the core theme of creating space in which to work as access and support across sectors requires this type of alignment.

Leverage, in the form of maximizing everyone’s potential contribution, was evident in their ability to "diagnose the efficiency and hidden talent" of clients, volunteers, and staff. All described working in low-hierarchy environments where everyone was encouraged to explore and extend the limits of their capabilities. In commentary about process over time, while the launch of these endeavours were typically framed as a "passionate outburst" in addressing a human rights issue, over time strategy became much more of an emphasis. For example, one core strategy was to innovate and expand through experimentation ("low cost, low risk experiments") while skillfully advancing large and complex organizations, carefully assessing points of leverage, timing, and maintaining fidelity to the intervention and its values.

Livelihoods

Attention to livelihoods was a pivotal part of this understanding of client needs across interventions. It was discussed as a leveraged part of the mental illness problem for two reasons—one is that mental health interventions are much less effective without attention to livelihoods. Treating mental illness is "secondary to survival", and people fear the costs, financial and otherwise, of engaging in treatment.

“I was 22 years old and had mental illness and nobody understood what was wrong with me and it shamed my parents , I was unmarriageable and a burden to their house .” Service Recipient

Conversely, attending to livelihoods had many advantages—ranging from the direct benefits of being more active to addressing stigma. Working unlocks sources of support from family and communities and through contact with community reduces isolation and social stigma—demonstrating that people with mental illness can contribute and creating opportunities to improve impacts and expand.

“We saw her progress . And that she could do this [broommaking] . It was satisfying seeing her return to find a useful purpose . So she is not forgotten in society . She makes brooms and with that , has money and earnings so that she can buy what she needs to eat . She can go out and participate in community , at pagoda . She is participating in meetings with her brooms—this helps relieve stress and deal with thoughts and be part of community life . The illness is managed/decreased and gradually her health is better .” Family Member

Empowerment

These interventions were described as fundamentally empowering—this is true for staff and volunteers as described above but emphasized to an even greater extent with respect to service recipients. As with the themes above this had clear implications for leverage in interventions and enhancing reach. The use of the term empowerment by the participants in these case studies was very well aligned with the definition of prominent consumer-survivor advocate Dr. Pat Deegan who described a taking back of power "to become sovereign over our own lives and bodies, to reclaim our right to make choices and have access to resources to improve the quality of our lives."([ 26 ], p.11) Grounded in empathetic and rights-oriented approaches, these organizations described very actively seeking out and cultivating the "inner strength" of clients.

"These survivors at the beginning were completely hopeless and helpless … they were not even thinking about surviving . They were thinking about committing suicide . So when the survivors found that someone is understanding them , treating them as real human being , respecting them , respecting their values and their thoughts and helping them to express themselves … that actually helped them more and more . So , when [acid violence survivor] started to talk with other survivors who were receiving treatment in Dhaka medical college hospital , in that way , drop by drop they were also growing ." Service Staff Member

Many benefits of an empowering approach were described. These included the exposure of communities to empowered people with mental illness, which reduced stigma and increased expectations for what they might accomplish in life. This empowering approach also benefited an array of advocacy and fundraising activities—not in the form of narratives of people being "used" to raise funds, but of organizations creating spaces where people could realize their full potential and make a difference.

“ This aspect of their work , the empowerment piece , was described by our participants as one of the most rewarding . It energized , inspired , and is "the heart of the work ." Direct Service Staff Member

Another thread involved the quality and availability of services. Peer support, developed in these contexts of empowerment, was very actively utilized as a leveraged strategy. It was clear in the narratives of peers, those receiving peer support, and staff, that the employment of peers further cultivated messages of hope and empowerment. Peers worked in ways fundamentally grounded in lived experience knowledge about mental illness, along with a deep knowledge of relevant community resources and local cultures. Peers were described as essential to expanding the reach and impact of these organizations.

… ‘We feel this work is better done by us because it is we who are sick and should therefore support each other… Village mobilisers are more familiar with the participants in their community , have a vested interest in the project , have experience of treatment and are aware of the benefits of the project to participants’ lives .” Peer Provider

Directly Engaging and Involving Key Stakeholders

Along with the more obvious financial capital necessary to operate, the participants spent a considerable amount of time discussing how the problem needs to become seen as important and social capital needs to grow around it.

“We formed different advisory groups , the legal advisory group , the prevention advisory group and these people , the experts were helping us in developing strategies and mobilizing resources not just financial but also other resources and in that way , gradually we are making a public opinion against acid violence . I should say that one event which was a kicking point is like in 2002 on International women’s day , we organized men’s rally . That was organized in collaboration with BRAC and the daily newspaper . In the year 2000 they established a forum to help acid survivors . They were also mobilizing resources . In this Men’s March , over 5000 men participated and hundreds of female survivors were leading that March and media , national and international has publicized that issue . So , that created a huge movement in the country .” Organization Senior Staff

These organizations had cultivated relationships with a range of media outlets and created compelling stories about their work and the problems that they were addressing. Along with creating attention and interest among the general public, most were active in the engagement of key stakeholders whether through a media lens (e.g., supportive celebrity advocates) or with others who have influence. This extended as well into the realm of formal education—offering for free highly regarded trainings to government ministries, lawyers, police, and judiciaries on relevant issues and offering helpful practical advice and assistance. This work was further leveraged, through partnerships with and the involvement of lawyers, with the effort to strike down policies that posed barriers and enact helpful policy. Indeed, this active engagement of government was described by some leaders as essential to sustainability and scaling—even a prerequisite to partnership despite the time it can take to develop and the problem of policies being developed but not implemented in practice.

Branding was another key part of these conversations about creating space in which to work. The brand of the organization was established in several ways. They described cultivating an ethos, a set of values, and a distinctly innovative approach that operates in contexts where there would otherwise be little or no service. Respect was garnered through this way of working, as well as through the generation of impacts for large numbers of people who previously might have been considered hopeless by policy makers and the public.

“We’re a very prominent part of the global mental health community . And we have a place there . It’s not a cakewalk—sometimes I get ignored around the table but we are starting to turn that around . People see us as a competent , collaborative presence that is considered an attractive partner to collaborate with .” Organization Senior Staff

Branding was also enhanced through connections from local to global levels with other prominent organizations, and by becoming well-known for their provision of high quality education opportunities to a range of sectors (e.g., government, other service providers, police). The benefits of cultivating such a brand had many advantages, including its feeding into more effective advocacy through access to public and policy forums, improved fundraising ability, and attracting and retaining skilled staff.

Participants also described facing the challenge that, unless they are able to successfully educate, raise awareness, and engage communities and families at a 'grass roots' level, interventions would not be accessed. As one community partner put the problem: "When I go to people's houses, they will let me come in, but I always hear ‘Come in for tea, okay. but don't do that stupid screening, we are fine." It was clear that "knowledge of the population" was crucial to turning this problem around—understanding how to engage diverse communities who may be facing poverty and have low educational backgrounds. This required persistence, but also an understanding of what is important to people—such as the enhancement of the livelihoods. Similar to the ways of engaging clients, the key theme of collaboration and respect were important here as well.

"Strangely , we have faced the least challenges at the community level , particularly the rural communities have been very receptive and I think they are intelligent people … They are receptive because they are intelligent and they know the difference between somebody who is attempting to work with them and genuinely make a difference versus somebody who is exploiting them , somebody who is talking down or condescending . We learn a lot based on what the community tells us , we develop our services . So , some expertise we have , some expertise the community has . So , it is collaborative in that sense and I think they recognize that ." Organization leader

Building collaborations with communities and families was not always described as reaching out—learning from and engaging communities and supporting clients in community based activities and advocacy. A big part of this effort involved inviting people in . This took place in a range of ways.

"We cover five arrays in youth club . It is education , sports , culture , dance and vocation [programming available to the local community who join clients in these activities] . So , in education , we have free tuition classes , spoken English classes and then , in sports we cover indoor and outdoor . Outdoor is cricket , soccer , tennis , volley ball and things like that and indoor carom , chess , running and catching . It’s all simple . This is open for all . So , in indoor games , a lot of boys from youth club come and play with our own men [clients] . They play chess , they play carom and volley ball within our complex . They [local boys] also take our men to the beach and play soccer casually . They wouldn’t have a match but they would just play so that they get to interact also . [Through this approach] we are simultaneously [decreasing] stigma and we are also getting the men [clients] to engage with the community and also community developing in its own way . Staff Member

This inviting of communities in was another leveraged strategy. It was described as reducing stigma, educating the community about the work of the organization and opening doors in a way that helps staff better understand what the community needs, and raises awareness—and by proxy assists with fundraising and volunteerism. This is essential even at the most basic levels–communities came to understand that mental illness is something that the organization can help within a culturally and context relevant way. This was highlighted in the frame of prevention with some noting that too often "people will not come" into treatment or engage supports when prevention might still be possible.

"Here we make four events—art expression , sports day , a conference and a round table seminar … we invite other societies to share in this , to exhibit art , to join us in our events ." Direct Service Staff Member

Finally, there was a strong commitment to volunteers and volunteer development in these organizations. This was highlighted as essential in contexts where financial support was very limited. The purposeful blurring of boundaries between community and the organization was enhanced by volunteers—people who often had histories of helping communities and who by association enhanced the credibility of the organization.

"If the government will not be able to provide these services in the future , we need to provide for our own community to help with problems at a community level . We were invested in improving our communities before this role [with current organization] . We always have been ." Volunteer

Furthermore, volunteers were engaged in the organization culture—the culture of respect "equal say" and growth for everyone involved—again maximizing people's potential contributions.

"I came here to volunteer actually . It wasn’t a decision to study and start work in a very structured way . So , I decided to work like as in art therapy before working with children which was logical as I studied art , so , I can teach them art with children with disability . That’s how it began but as I started work , I found out that I am kind of talented in this field . I know how to deal with them . I love them and all now , the supervisors told me that you can work in this field and you can start to study and just let it be your career . That’s how I started . So , I started to read and to have courses and of course to have training in the organization and now , I have just finished my Master’s in the field . That’s brief of how I started to work in this field ." Direct Service Staff Member and Former Volunteer

Partnership and Scaling

Two other subthemes, framed largely in interviews as being both a part of the process and as outcomes of leveraged ways of working were partnerships and scaling. Partnerships (developed after careful assessment to ensure the proper alignment of values and complementary activities) were emphasized as necessary to the provision of comprehensive services (e.g., plastic surgery for acid violence survivors), leveraging capacity (e.g., mindfulness meditation in Buddhist temples as an acceptable and accessible intervention), and in maintaining identity and focus (e.g., referring people with intellectual disabilities to a partner organization in that specific sector). Close partnership was essential to the scaling activities of all of these organizations—identifying collaborators who had the capacity to successfully implement and sustain the given intervention with fidelity.

More directly, the topic of scaling was very much on the minds of the leaders of these organizations though there was a considerable amount of variability as to the extent to which it had been undertaken.

“Our strategy in scaling up is we set models , we study them , we fine tune them , we develop protocols , then we impact policy and through policy and advocacy , projects are scaled up . So , much of our models or aspects of our models have been incorporated into the mental health policy and urban health mission . That’s one part of scaling up .” Founder

In the context of scaling, the leveraged intervention was described as one that had been intensively examined and tested to identify the basic model—one that might be considered that of a set of " minimum specifications " or core approaches that are effective yet can be adapted to other settings.

“Why do you think the model is so successful ? It’s completely integrated , and flexible according to the local needs . There is no need for rigidity—it suits customs , culture , and universally applicable . It’s been proved in so many different countries . It aids with treatment , sustains livelihoods , and builds capacity . Sustainability is at the core of all its actions .” Senior Staff Person

Leverage and creating space or capacity were further evident in discussions about how scaling is best accomplished and, most critically, the infrastructure needed to effectively support it. As mentioned previously, some of this had to do with the selection of optimal partners and contexts for scaling. Other prominent topics here included a careful assessment of the resources needed to keep the expanded intervention connected and continuously assess fidelity and impact. As this work progressed the focus increasingly was upon "stabilizing" the resulting "alliance of organizations" through a network that supports continued growth, ensuring quality, and keeping people connected.

“We think , the upcoming year we will also form almost 10–15 new groups for survivors . Within a year we will try to organize district level survivor conference where they show their problems , where they interact with government bodies and local authorities . We will give them a platform . That is a two day activity . That will create a district level network and we are trying to train them on basic leadership and fundamental leadership . When they get it , we will form formal network structure at district level and by 2 or 3 years , we have a plan to organize national level conference with all survivors groups , with district committees , with national committees , with the Public Prosecutor and Police . There , they will discuss their problems at national level and all that meetings will be facilitated by survivors .” Staff Member

Points of Divergence and Limited Coverage

As noted previously, there was a great deal of similarity across the case study narratives with a focus upon non-specific aspects of developing and delivering interventions. The differences that did emerge across case studies were primarily ones of emphasis. For example, participants from some organizations spent more time discussing scaling strategies than others. There was some diversity in emphasis with respect to the role of government. While all discussed the importance of engaging government there were differences with respect to what was needed. This ranged from a need for a general approval of operations through to collaboration on policy changes that were key to the effectiveness of the intervention. Further, there were some differences in what was being leveraged from existing community resources. This again ranged from a reduction in barriers such as stigma to points of synergy in intervention (e.g., mindfulness meditation in monasteries). Finally, while inquired about, more detailed and nuanced information about the use of formal research and technology did not emerge beyond a general commentary about utility.

This multiple case study has focussed upon examining the non-specific aspects of internationally-recognized interventions addressing mental illness in MICs through a social entrepreneurship lens. In the past 30 years social entrepreneurship has become an important concept in understanding how to identify and support individuals and organizations that are effective in addressing social problems [ 9 – 11 ]. It grew to a large extent from the need to identify and cultivate sustainable, contextually established and relevant interventions/approaches that have large impacts [ 10 ]. While less commonly employed in the global mental health literature [ 7 ], it is relevant in that it is a framework that focusses on the consideration of how successful approaches to mental health-related problems are developed and applied (i.e., non-specific components).

Herein lies an opportunity to bring the focus to the science of delivery [ 5 ]—the structures (people, resources, and organizations) within which specific, evidence based interventions might best be applied. These structures are complex and are well-addressed through qualitative methods, particularly in this early stage of knowledge generation. Accordingly, this study employed one of the most rigorous research inquiries in this area to date [ 7 ] and focussed upon organizations and people recognized as socially entrepreneurial through Ashoka’s intensive selection and award process [ 10 ].

A coherent model emerged in this study that included interventions underway in multiple MICs. Cutting across a number of themes describing ways of working in mental health were the two themes of leverage and creating space in which to work. It is understandable that these two particular themes arose in this study as the most prominent. Mental illness in most MICs is characterized by severe resource and infrastructure limitations and intense stigma from individual to structural levels. In such settings, and considering the complex nature of mental illness, leverage is necessary to maximize the impact of limited resources—through both obtaining a maximal output of resources and applying them to points in the complex system of mental illness where the least pressure supplies the greatest change. A leveraged approach, however, must be matched by systems and settings that can accommodate it. Effectiveness cannot be achieved if the problem is not seen as important, the service offered is not seen as relevant, and stigmatizing beliefs and policies limit actions and opportunities.

Underlying these themes of leverage and creating space to work were several subthemes. These included leaders who have developed a very deep and nuanced understanding of the mental health problem that they are addressing and the systems within which it occurs. They also are extremely capable in engaging and aligning diverse stakeholders and assessing and maximizing the potential contributions of strategic collaborations, staff, volunteers, community, and service recipients. Key points of leverage in this context included attention to livelihoods through approaches such as social enterprise and the many benefits that attend the empowerment of recipients in a manner that reflects key aspects of recovery-oriented care [ 27 ]. Complementing leverage, creating space in which to work was an effort that involved establishing and marketing a “brand” that is their organization, values, and way of working. This aligned with the key aspects of successful brands highlighted in marketing literatures. Namely that successful brands are distinct (applied in a way and place where other options are not available), are relevant and important, are esteemed by customers and fulfills their promise, is understood and familiar, and is innovative and dynamic to suit changing needs and conditions [ 28 ]. Branding, in these case studies, was greatly enhanced through connections from local to global levels with other prominent organizations and being recognized for the provision of high quality education to a range of sectors (e.g., government, legal system). In synergy with brand development was an intensive effort to generate social capital through strategic partnerships, engagement of the media and influential public figures, engagement of government, and embeddedness in communities.

All of these activities created systems in which a common language for the problem was cultivated, its importance agreed upon, and their organization positioned as having the solution. This was closely attended by efforts to reduce stigma and create policy-enabling environments. This set of subthemes attended both local and scaled initiatives, though the latter involved greater attention to the careful assessment of sites that could successfully support scaling and the infrastructure necessary to develop and sustain scaled operations [ 1 ]. Contributing to the evidence behind social entrepreneurship as a coherent framework, these themes overlap with those of another multiple case study of seven leading organizations operating in impoverished and marginalized contexts, none of which had mental health as a focus [ 29 ]. The areas of overlap included local capacity building that mobilizes existing resources, with an emphasis upon their being “systemic learning” organizations in which continuous cycles of education and contribution by staff and clients is central, and extending impact through alliances.

While helpful in some respects, the lens of social entrepreneurship is problematic due to its breadth and lack of specificity [ 30 ]. Similar to the problems that attend defining “recovery-oriented care”, it encompasses many domains and activities and applies to both individual and group endeavours and characteristics. Perhaps a better way to capture the work of the social entrepreneurs studied here, and the non-specific aspects of their work that are crucial to effectiveness and scaling up, is through a systems dynamic framework. This is highly relevant to the wicked problem nature of mental illness in low resource settings, in which the problem is typically poorly identified, changing, has no definitive solution nor a clear set of possible solutions, is a cause of other problems and a symptom of other problems, and can be explained in numerous ways [ 31 ].

Systems dynamics theory is largely present other fields (e.g., economics) though is increasingly being applied in areas such as public health and sustainable development [ 32 ]. It is premised upon the need to consider wicked or otherwise complex and dynamic problems in holistic, non-linear ways [ 33 ]. It is highly relevant to GMH in that the debate about specific versus non-specific aspects of intervention [ 2 ] is at least to some extent a debate about perceptions of a linear “project” approach being applied rather than a sustained system behaviour framework. Similar to the findings of the present study, system dynamic approaches emphasize the importance of finding leverage points in complex systems where small shifts can produce large amounts of change [ 33 – 35 ]. The participants in this study, whether systematically and/or intuitively, had located important points of leverage and were pushing them in the right direction. Less well-recognized is the premise that leverage in complex systems must often be matched by an “essential complementary activity” just as subsidized low income housing needs to be matched with job creation to achieve the desired impacts [ 33 , 36 ]. In the present study, this was the observation that leveraged approaches were matched by a range of complementary activities designed to create space to operate and build social capital that enables the intervention. This proposition supports the conclusion of Kirmayer and Pederson [ 2 ] that a balanced approach to inquiry and practice of this type will likely have the greatest overall impact in the lives of those suffering from mental illness in low and middle income countries. This work would involve an improved articulation and means of measuring non-specific aspects of intervention within which the more circumscribed and trialed interventions are optimized. Indeed, this is a line of inquiry already in development as models for effective community engagement and social inclusion are being examined as core non-specific aspects of scaled mental health initiatives [ 37 , 38 ]. The findings of the present study contribute to this emerging area of inquiry and implementation science that attends it, albeit with a somewhat broader frame (e.g., consideration of leadership characteristics, engagement with, and conceptualization of the problems faced; facets of social capital generation such as branding).

This study had a number of limitations. These included questions of representativeness beyond the organizations studied, a limited ability to comment upon how certain activities were directly causal of observed benefit, and a lack of an ability to compare these exceptionally successful interventions with those less successful. Considerations of component impact might be complex and require further study. For example, while some approaches to address livelihoods such as social enterprise have been associated with improve mental health and quality of life [ 39 ] and BasicNeeds and its livelihoods emphasis has demonstrated benefit [ 40 ], other models such as microfinance might negatively impact mental health [ 41 ]. Another limitation of the present study was that selection bias in participant recruitment might have been a factor as it is not possible to assess the degree to which past staff, key partner, and service recipient groups were fully representative. Future work, allowing for more fulsome comparison of more and less successful organizations aided through a random recruitment strategy would help to address these shortcomings, though the voluntary consent required by organizations to open themselves up to research scrutiny may always results in some volunteer bias. Also informative would be the examination of how these approaches might best be propagated through sharing information and mentorship—with propagation considering formal scaling, local growth, and sustainability through successorship as founders retire. Lastly, the scope of the interviews limited the ability to examine how specific interventions (e.g., supplying psychotropic medications) might interact with the non-specific elements highlighted in the study.

Conclusions

In sum, this paper suggests the benefit of using social entrepreneurship as a framework for identifying successful efforts and the possible benefit of applying a systems dynamic lens to problems in GMH. It further suggests the potential benefit of matching the evidence base of circumscribed, specific interventions [ 3 ] with an equally rigorous inquiry into the non-specific factors without which those specific interventions cannot be successfully implemented nor sustained. Such work would assist in a stronger ability to identify and support promising organizations and leaders in the field and allow for the testing of methods for enhancing non-specific resources and strategies. This could lead to fewer failed endeavours and improved effectiveness and scaling of interventions. Indeed, as difficult to define as it is, social entrepreneurship in such a program of work provides a framework for considering how these very similar efforts at social capital generation might become better aligned to generate collective impact [ 42 ]. For additional quotes underlying the themes described in this paper please see S2 Appendix .

Supporting Information

S1 appendix. interview protocols..

https://doi.org/10.1371/journal.pone.0152083.s001

S2 Appendix. Thematic Data from which Study Quotes were Selected.

https://doi.org/10.1371/journal.pone.0152083.s002

Acknowledgments

This work was supported by Grand Challenges Canada under grant #0326–04. There are no competing interests related to this work for any of the authors. Appreciation is extended to Ashoka Global and Ashoka Canada.

Author Contributions

Conceived and designed the experiments: SK DC EM SR DW DA KM. Performed the experiments: SK AM SR EM. Analyzed the data: SK AM SR DC EM SR DW KM. Wrote the paper: SK AM SR DC SR DW KM.

• View Article
• PubMed/NCBI
• Google Scholar
• 3. World Health Organization. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings.[Online].2010. Available: http://www.thehealthwell.info/node/69810 . Accessed 27 August 2015.
• 6. Wampold B. (2010). The research evidence for the common factors models: A historically situated perspective. In Duncan B, Miller S. Wampold B, Hubble M,(eds) The heart and soul of change: Delivering what works in therapy (2nd ed.). Washington, DC: American Psychological Association.
• 10. Bornstein D. How to change the world: Social entrepreneurs and the power of new ideas. New York: Oxford University Press, 2007.
• 12. Available: www.ashoka.org .
• 13. Available: www.skollfoundation.org .
• 15. Stake R. The Art of Case Study Research. Thousand Oaks: Sage, 1995.
• 17. Ritchie J, Lewis J, Elam G. Designing and selecting samples. In: Ritchie J, Lewis J (eds.), Qualitative research practice. A guide for social science students and researchers. Thousand Oaks, CA: Sage, 2003.
• 18. Pawson R. Evidence-Based Policy. Los Angeles, CA: Sage, 2006.
• 19. Stake RE. Multiple case study analysis. New York: Guilford, 2013.
• 20. Charmaz K. Constructing grounded theory. Thousand Oaks, CA: Sage, 2014.
• 21. Available: www.basicneeds.org .
• 22. Available: www.acidsurvivors.org .
• 23. Available: www.thebanyan.org .
• 24. Available: www.advance-society.org .
• 25. Available: www.colectivoaquiyahora.org/ .
• 27. Slade M. 100 ways to support recovery: a guide for mental health professionals. London: Rethink, 2009.
• 36. Forrester J. Urban Dynamics. Portland, OR: Productivity Press, 1969.

10 Realities for Those Living With Serious Mental Illness

These often-overlooked truths are important to recognize, especially in may..

Posted April 30, 2024 | Reviewed by Abigail Fagan

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May is Mental Health Awareness Month, an important opportunity to recognize the needs of those with mental health issues and the ways in which those who struggle with them, both affected individuals and loved ones, can access help. Unfortunately, the mental health-related information and advice that circulates in May is often overwhelmingly focused on short-term mental health conditions like anxiety and depression , issues that today are highly treatable and far less stigmatized than they were even a few years ago.

However, there is a small subset of those experiencing mental health issues that are often overlooked, even during Mental Health Awareness Month. This includes the 10 million adults in the US living with serious mental illness, meaning a mental, behavioral or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities. Serious mental health diagnoses include schizophrenia, bipolar disorder , major depression, acute anxiety and related illnesses.

As a mental health attorney who counsels families of loved ones with serious mental health issues, I always seek to advocate for these individuals, whose needs and realities too often go unseen and/or are misunderstood. With that in mind, and in honor of Mental Health Awareness Month, I’m sharing the following 10 often-overlooked realities of those struggling with serious mental illness.

These include:

• They often lack insight into their condition, which can make it challenging for them to accept they have a mental illness and need treatment. This reality is a major factor in the debate regarding involuntary treatment versus personal autonomy. Among those creating and reforming policies affecting those with serious mental illness, insight must always be top of mind.
• They are statistically more likely to be the victims of crime than perpetrators. Such a tragic reality is well worth reiterating given the enormous spotlight on occasions in which those suffering from mental illness have been involved in incidents of violence, often provoking feelings of fear and prejudice .
• They are overrepresented among our nation’s homeless population and among those incarcerated. Since the large-scale closing of state-run mental health facilities, a vast number of mentally ill individuals have found themselves living on the streets or in jail, where they lack needed medication and other forms of treatment, and the stability often required to make clinical progress. But serious mental illness does not equal homelessness.
• They are entitled to mental health care under the federal Mental Health Parity and Addiction Equity Act , which requires insurance coverage for mental health and substance use disorder treatment to be “no more restrictive” than coverage for physical health conditions. Yet despite these laws, our healthcare system is rife with persistent bias against mental health, adding challenges to individuals and families coping with diagnoses.
• They are further entitled to Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) to help cover the costs of their basic needs. To qualify, a person’s mental illness must be severe enough to prevent them from performing substantial gainful activity (SGA) for at least 12 months or result in death.
• They are too often left out of today’s discourse concerning mental health and mental wellness. Not just during Mental Health Awareness Month but all year long, those struggling with serious mental illness simply aren’t part of the ongoing dialogue that routinely emphasizes help like self-care.
• They will likely require lifelong care. While there is often hope and progress for those experiencing serious mental illness, no cure exists, meaning they and their loved ones live with diagnoses all their lives.
• They often have family members who urgently need respite to take care of their own needs and those of other loved ones. Our country’s dire lack of mental health treatment and supportive housing has put family members on the front lines, all but forcing them to make enormous sacrifices in order to protect the health and wellness of their loved ones.
• They are represented across all demographics. Like all mental health issues, serious mental health illness does not discriminate, but generally first surfaces in young people ages 18-22 across racial identities, socioeconomics, geographies, etc.
• They, along with their families, often require legal advocacy to best ensure someone with their best interests at heart is involved in their treatment plan. The mental health legal system is notoriously complex, frequently necessitating the involvement of attorneys with real expertise in how to navigate it.

While the complexities inherent in serious mental health illnesses—and the fear often surrounding them—make the conditions incredibly challenging to discuss, silence does a tremendous disservice to those who are contending with these conditions day in and day out. This May, let’s make sure our conversations include those with these hard-to-discuss, challenging issues so that they, and their families, know they aren’t alone.

Carolyn Reinach Wolf is a mental health attorney guiding families through the complex landscape of legal issues that impact individuals with serious mental illness and/or substance abuse.

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Five research topics exploring the science of mental health.

Mental wellbeing is increasingly recognized as an essential aspect of our overall health. It supports our ability to handle challenges, build strong relationships, and live more fulfilling lives. The World Health Organization (WHO) emphasizes the importance of mental health by acknowledging it as a fundamental human right.

This Mental Health Awareness Week, we highlight the remarkable work of scientists driving open research that helps everyone achieve better mental health.

Here are five Research Topics that study themes including how we adapt to a changing world, the impact of loneliness on our wellbeing, and the connection between our diet and mental health.

All articles are openly available to view and download.

1 | Community Series in Mental Health Promotion and Protection, volume II

40.300 views | 16 articles

There is no health without mental health. Thus, this Research Topic collects ideas and research related to strategies that promote mental health across all disciplines. The goal is to raise awareness about mental health promotion and protection to ensure its incorporation in national mental health policies.

This topic is of relevance given the mental health crisis being experienced across the world right now. A reality that has prompted the WHO to declare that health is a state of complete physical, mental, and social wellbeing.

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2 | Dietary and Metabolic Approaches for Mental Health Conditions

176.800 views | 11 articles

There is increased recognition that mental health disorders are, at least in part, a form of diet-related disease. For this reason, we focus attention on a Research Topic that examines the mechanistic interplay between dietary patterns and mental health conditions.

There is a clear consensus that the quality, quantity, and even timing of our human feeding patterns directly impact how brains function. But despite the epidemiological and mechanistic links between mental health and diet-related diseases, these two are often perceived as separate medical issues.

Even more urgent, public health messaging and clinical treatments for mental health conditions place relatively little emphasis on formulating nutrition to ease the underlying drivers of mental health conditions.

3 | Comparing Mental Health Cross-Culturally

94.000 views | 15 articles

Although mental health has been widely discussed in later years, how mental health is perceived across different cultures remains to be examined. This Research Topic addresses this gap and deepens our knowledge of mental health by comparing positive and negative psychological constructs cross-culturally.

The definition and understanding of mental health remain to be refined, partially because of a lack of cross-cultural perspectives on mental health. Also, due to the rapid internationalization taking place in the world today, a culturally aware understanding of, and interventions for mental health problems are essential.

4 | Adaption to Change and Coping Strategies: New Resources for Mental Health

85.000 views | 29 articles

In this Research Topic, scientists study a wider range of variables involved in change and adaptation. They examine changes of any type or magnitude whenever the lack of adaptive response diminishes our development and well-being.

Today’s society is characterized by change, and sometimes, the constant changes are difficult to assimilate. This may be why feelings of frustration and defenselessness appear in the face of the impossibility of responding adequately to the requirements of a changing society.

Therefore, society must develop an updated notion of the processes inherent to changing developmental environments, personal skills, resources, and strategies. This know-how is crucial for achieving and maintaining balanced mental health.

5 | Mental Health Equity

29.900 views | 10 articles

The goal of this Research Topic is to move beyond a synthesis of what is already known about mental health in the context of health equity. Rather, the focus here is on transformative solutions, recommendations, and applied research that have real world implications on policy, practice, and future scholarship.

Attention in the field to upstream factors and the role of social and structural determinants of health in influencing health outcomes, combined with an influx of innovation –particularly the digitalization of healthcare—presents a unique opportunity to solve pressing issues in mental health through a health equity lens.

The topic is opportune because factors such as structural racism and climate change have disproportionately negatively impacted marginalized communities across the world, including Black, Indigenous, People of Color (BIPOC), LGBTQ+, people with disabilities, and transition-age youth and young adults. As a result, existing disparities in mental health have exacerbated.

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• Open access
• Published: 15 January 2024

Gender differences in long term sickness absence

• Sheila Timp 1 ,
• Nicky van Foreest 2 &
• Corné Roelen 1  

BMC Public Health volume  24 , Article number:  178 ( 2024 ) Cite this article

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Sickness absence is a major public health problem, given its high cost and negative impact on employee well-being. Understanding sickness absence duration and recovery rates among different groups is useful to develop effective strategies for enhancing recovery and reducing costs related to sickness absence.

Our study analyzed data from a large occupational health service, including over 5 million sick-listed employees from 2010 to 2020, out of which almost 600,000 cases were diagnosed by an occupational health physician. We classified each case according to diagnosis and gender, and performed descriptive statistical analysis for each category. In addition, we used survival analysis to determine recovery rates for each group.

Mean sickness duration and recovery rate both differ significantly among groups. Mental and musculoskeletal disorders had the longest absence duration. Recovery rates differed especially during the first months of sickness absence. For men the recovery rate was nearly constant during the first 1.5 year, for women the recovery rate was relatively low in the first three months, and then stayed nearly constant for 1.5 year.

Across almost all diagnostic classes, it was consistently observed that women had longer average sickness absence durations than to men. Considering mental disorders and diseases of the musculoskeletal system, women had relatively lower recovery rates during the initial months compared to men. As time progressed, the recovery rates of both genders converged and became more similar.

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Introduction

The average sickness absence rates vary between 3% and 6% across European countries. Especially long term sickness absence (LTSA) has high costs amounting up to 2.5% of a country’s gross domestic product [ 1 ]. In the Netherlands, most costs are carried by employers, as they not only lose the productivity of the sick-listed employee but also have to continue to pay the salary of sick employees for two years [ 2 ]. Reducing sickness absence is important for society, the employer, and in particular for employees, as being in employment is often associated with better quality of life, health and physical functioning [ 3 ].

Sickness absence is related to various factors, including the cause of the sickness absence, the age and gender of the employee, and the work environment. The most common causes of LTSA are diseases of the circulatory system, mental disorders and diseases of the musculoskeletal system [ 4 , 5 ]. In the Netherlands, the sickness absence percentage increases with age until 65 years of age. Interestingly, employees between the ages of 65 and 75 exhibit a lower sickness absence percentage than those aged 55 to 64 years, suggesting a “healthy worker” effect. This phenomenon implies that healthier individuals tend to remain in the workforce longer, while those with health issues exit the labor process at an earlier stage [ 4 ].

Extensive research has been done to investigate gender differences in sickness absence. The predominant finding of these studies is that, on average, female employees report sick more frequently and experience longer periods of sickness absence in comparison to male employees [ 6 , 7 , 8 , 9 , 10 , 11 ]. Leijon et al. (1998) investigated gender trends in sickness absence for various causes, and found that women had both a higher sickness absence frequency and longer sickness absence duration compared to men [ 8 ]. Similarly, Arcas et al. (2016) found that among employees with diseases of the musculoskeletal, women had a longer sickness absence duration than men [ 9 ]. However, in some older age groups, they observed a longer absence duration for men. Labriola et al (2011) focused on long term sickness absence and found that the frequency was nearly 40% higher for men compared to women [ 10 ].

Bekker et al. (2009) conducted a literature review on the relationship between gender and sickness absence, finding that women are generally absent more frequently, especially when it comes to short-term absences [ 12 ]. They also found that gender differences in sickness absence are influenced by various factors such as country of residence, age, and professional group. Different other studies focus on factors explaining the so called gender-duration-gap, such as parenthood, type of work, and social roles [ 13 , 14 , 15 , 16 , 17 ]. Nilsen et al. (2017) reviewed eight longitudinal studies and found that although women report higher work-family conflict than men, but this did not explain the gender difference in sickness absence [ 17 ]. Angelov et al. (2013) investigated the effect of parenthood on sickness absence and found that entering parenthood increased women’s absence rate compared to the corresponding rate for men. They also found that this effect was long-lasting and remained at least until 16 years after the birth of first child [ 13 ]. On the other hand, Mastekaasa (2013) analyzed data from 23 EU countries plus Norway and found that dependent children are associated with lower sickness absence among married/cohabiting women [ 16 ]. Casini et al. (2013) also studied factors that could explain gender differences in absence duration. They found that especially job strain is linked to a longer absence duration for women compared to men [ 14 ]. Similarly, Lidwall et al. (2009) found that women have a higher risk on long-term absence when working in high-strain jobs compared with men, especially in the private sector [ 7 ].

Contrarily, some other studies have found limited evidence of a correlation between sickness duration and gender. For example, Cornelius et al. (2010) conducted a systematic review and found only limited evidence to support an association between sickness absence duration and gender [ 18 ]. A study by Spierdijk et al. (2009) on self-employed individuals failed to identify any significant gender differences in sickness absence duration [ 19 ].

While most studies have primarily focused on statistical measures such as average duration of sickness absence or sickness absence frequency, our study takes a more comprehensive approach. In addition to determining descriptive statistical measures, we investigate gender differences by analyzing recovery rates across various diagnoses. This thorough analysis provides us with a more detailed understanding of how gender influences sickness absence and the trajectory of recovery across various diagnoses over time.

Study population and design

In The Netherlands, it is a requirement for all employers to ensure that their employees have access to occupational health care, which is typically provided by an occupational health service (OHS). An OHS is responsible for registering sickness absences, and for providing guidance to sick-listed employees by medical consultations and advice for returning to work (RTW). When an employee reports sick, the OHS registers this in the sickness absence register. Sickness absence can be due to any (i.e., work-related and non-work-related) physical or mental illness or injury. In The Netherlands, the employer financially compensates sickness absence for a period of 104 weeks. Most employers cover 100% of the worker’s salary in the first year of sickness absence and 70% in the second year. The OHS follows employees during 104 weeks of sickness absence, after which the employee may apply for a disability pension provided by the Employee Insurance Agency (UWV) and the employer may end the job contract.

For our study we retrieved data from a sickness absence register of a large Dutch national OHS, registering sickness absence data of approximately 1.24 million Dutch employees from about 11.6 thousand companies of various economic sectors throughout the country. The dataset included all reported employee sickness cases from January 2010 to December 2020. When an employee experienced multiple periods of sickness absence, we included each separate period in the dataset as a single case. For each case, we calculated the duration of sickness, defined as the interval from the first to the last registered day of sickness absence. For our study we included cases aged between 16 and 70 with a sickness duration between 1 day and 104 weeks. We excluded cases diagnosed as pregnancy and pregnancy-related diseases.

Most of the sickness absence cases we observed were short-term, typically lasting less than two weeks. These short-term absences were commonly due to medical conditions like upper respiratory infections or gastrointestinal disturbances. For longer sickness absence periods, employees consult an occupational health physician (OHP) for return-to-work (RTW) advice. In the Netherlands, it is mandatory for employees on sick leave to consult an OHP within 42 days of their absence. The OHP then documents the diagnosis in the Occupational Health Service (OHS) register. To classify the employees’ diagnoses, the OHS uses the Dutch classification system for Occupational and Social insurance physicians (CAS) [ 20 ]. This system is based on the ‘International Statistical Classification of Diseases and Related Health Problems’ (ICD-10) and contains similar main categories. An important distinction between the CAS system and the ICD10 is the classification of neoplasms. In the CAS system, neoplasms are categorized under the relevant organ system, whereas in the ICD10, they are considered a distinct class [ 21 ].

For our detailed analysis, we utilized cases that had been OHP diagnosed, excluding cases with unknown diagnoses.

Statistical analyses were done using the lifelines library for survival analysis and Python 3.10 [ 22 ]. Employees were right-censored when the job contract ended during the sickness absence. Data about sickness duration were analyzed descriptively using the mean, median, and standard deviation.

Descriptive statistics were computed for each diagnostic category and gender. For each diagnostic category, the difference in means between genders was calculated. We focused on differences in means including confidence intervals instead of applying tests of significance. This is because the latter are heavily influenced by sample size and will almost always demonstrate a significant difference, even for small differences that may not have practical significance [ 23 ].

We have analyzed the most important causes for sickness absence, in terms of both frequency and duration, in more detail. For these diagnostic categories, hazard rates have been determined using the Nelson-Aalen estimator [ 24 ]. The estimated hazard function gives the recovery rate at each point in time t , and is defined as the probability that an employee will recover in the next moment \(t + 1\) , conditional on the fact that the employee was still sick at time t . For instance, if 100 employees are absent at the start of a day, and 2 have recovered by the start of the next day, the daily recovery rate is 0.02.

Considering that the onset and recovery of sickness absence are not evenly distributed across weekdays, with a higher percentage of employees reporting recovery on Mondays, we used a one-week moving average filter to smooth hazard the rate \(h_t\) at each point in time t .

Ethical approval Ethical approval was not necessary as the Medical Research involving Human Subjects Act does not apply to studies of anonymized register data. The Medical Ethics Committee of the University Groningen confirmed that ethical clearance was not necessary for this study.

Descriptive results

In the period between January 2010 and December 2020 there were 4,998,455 sickness cases that fulfilled our inclusion criteria, cf., Fig. 1 . Of these cases 52% were male, and 48% were female. This closely reflects the male/female ratio of the Dutch working population during the same period (about 53% male and 47% female) [ 25 ]. The mean absence duration was 23 ± 42 days. Among these approximately 5 million cases, approximately 11% ( n = 562,395) were consulted and diagnosed by an occupational health physician (OHP). For further analysis, we excluded cases where employees were diagnosed with an unknown code ( n = 6).

Flowchart of the inclusion and exclusion of cases used for the analysis

Tables 1 and 2 present descriptive statistics regarding sickness absence duration for men and women across various diagnostic categories. The most prevalent causes of sickness absence were diseases of the musculoskeletal system, mental disorders, diseases of the respiratory system, and diseases of the digestive system. For women, the most prevalent diagnoses were mental disorders, whereas for men diseases of the musculoskeletal system were most prevalent. Across all OHP diagnosed cases, the mean sickness absence duration was 158 days for women and 117 days for men, with an average gender difference of 41 days (95% confidence interval: 40.3-42.0). Among the most prevalent causes, mental disorders had the longest sickness absence duration (186 ± 162 days).

Except for diagnoses of diseases of the blood and blood forming organs, women had a longer average sickness absence duration than men. For each specific diagnosis, the 95% confidence interval indicates that the results are not only statistically significant but also practically relevant. The largest gender differences in sickness absence duration were found for cases diagnosed with diseases of the musculoskeletal system and cases diagnosed with diseases of the genitourinary system.

Analytical results

The most important causes for sickness absence, in terms of both frequency and duration, were diseases of the musculoskeletal system, mental disorders, diseases of the nervous system and diseases of the circulatory system. We have explored these diagnostic categories in more detail.

Plots of hazard (recovery) rate as a function of time (in days) for the most common causes of long term sickness absence. In particular in the first few months of absence, the hazard rates for women are lower than those for men. This difference is the most pronounced for mental disorders and diseases of the musculoskeletal system. For diseases of the circulatory system hazard rates are similar for men and women

Figure 2 displays the recovery rates for these diagnostic categories. For male employees with mental disorders, the recovery rate remains rather constant during the initial 1.5 years. This suggests that the conditional probability of recovery does not change during this period and is independent of the actual sickness absence duration. In contrast, for female employees with mental disorders, we observe considerably lower recovery rates in the first few months. This indicates that a smaller proportion of women recover during this early period relative to men.

For diseases of the musculoskeletal system, the gender difference in recovery rate is even more pronounced, particularly in the initial few months, where the percentage of women reporting recovery is relatively low. However, after approximately three months, the recovery rates become comparable between women and men. For diseases of the nervous system we observe a small difference in recovery rate during in the initial stage of sickness absence. The recovery rates for diseases of the circulatory system are similar for men and women.

Table 3 shows the proportion of cases with either mental or musculoskeletal disorders that have recovered at three different points in time (13, 26, and 52 weeks). We see that the proportion of recovered cases differs most among genders within the first three months. For instance, after 3 months, 67% of men with musculoskeletal disorders have recovered, versus 51% of women. For mental disorders, the proportions are 44% for men and 37% for women.

Besides gender differences the recovery curves show another interesting pattern around one year of sickness absence. Around that period, we observe a sudden increase in recovery rate for both men and women. This might be an effect of a decrease in salary in the second year of sickness absence, as most employers decrease the salary to 70% after the first year of sickness absence. We will investigate this topic in more detail in a future paper.

We studied sickness absence patterns among men and women for different diagnostic categories. The results show that for almost all categories the average sickness absence duration was remarkably longer for women than for men. The largest gender differences in sickness absence duration were found for cases with musculoskeletal disorders and diseases of the genitourinary system. The large difference in absence duration for diseases of the genito-urinary system can be explained as this category includes diseases of the breasts, such as mamma carcinoma, which are more prevalent among women and in general are associated with a long sickness absence duration.

The most common causes for sickness absence were diseases of the musculoskeletal system, mental disorders, diseases of the nervous system and diseases of the circulatory system. For these categories gender differences were analyzed in more detail by determining the recovery rate over time.

In what follows, we will compare our current results with prior studies. To the best of our knowledge, there are only some Dutch studies exploring recovery rates in depth, which might be due to the fact that Dutch regulations for LTSA are rather generous as compared to other countries. However, given that gender differences exist in many Western countries, the observed differences in recovery rates during the initial months might be observed in other countries as well.

The general opinion is that the probability of recovery decreases with increasing sickness duration, or in other words, a negative duration dependency [ 6 , 26 ], although some studies report a positive duration dependence [ 27 ]. Koopmans et al. (2009) studied long-term sickness absence between 1998 and 2001 and found declining recovery rates over time [ 26 ]. In contrast, our study found relatively stable recovery rates during the entire duration of sickness absence, except for the initial months. One important difference between our study and Koopmans et all’s is that we conducted subgroup analyses by gender and type of disease. Nonetheless, given that recovery rates were relatively stable across all diagnoses and genders, we anticipate a similarly stable combined recovery rate. Another key difference is that sickness policies in the Netherlands have changed over time. Before 2004, employers were financially responsible for sick employees for only one year, after which individuals could apply for a disability pension. Under the current regulation employers are financially responsible during the first two years of sickness absence. This extended period of financially responsibility could potentially motivate employers to more actively support employee recovery and thus possibly influence recovery rates. Conversely, the prospect of a disability pension under the previous policy might theoretically also have had a stimulating effect on the recovery rate.

Joling et al. (2006) examined the duration dependence during sickness absence and found that the recovery rate increased over time [ 27 ]. Their study analyzed both short-term and long-term sickness absence for employees who reported sick in 1990. In contrast, our study only focused on long-term sickness absence and included more recent cases. Roelen et al. (2012) investigated the recovery rates for employees that had been sick-listed between 2006 and 2008 with mental disorders and also found that women resumed their work later than men [ 6 ]. This finding is consistent with our results for mental disorders.

By examining recovery rates for different diagnostic groups over the entire duration of sickness absence, our study additionally found that not only the average sickness duration differs between men and women, but that there are also remarkable differences in the recovery rates. In particular during the first months of sickness absence, women have a lower recovery rate than men, indicating women have a certain “delay” in recovery. In the next paragraph, we will explore possible reasons for these observed differences, and discuss their consequences in a practical context.

Gender-related factors

Various gender-related factors may contribute to differences observed in absence duration and recovery rate, including medical, biological, personal, family and work-related factors [ 12 ]. We will investigate some of these factors and explore how these could account for the observed delay in recovery for women compared to men.

Person-related factors Person-related factors, such as coping style and work attitude, can also play a role in sickness absence. Tamres et al. (2002) conducted a meta-analysis of 50 studies on gender differences in coping and identified 17 coping strategies which they classified as problem-focused or emotion-focused behaviors [ 28 ]. Problem-focused coping strategies include active behaviors (such as changing the situation, removing the stressor), planning (review possible solutions), seeking instrumental social support that is directed towards solving problems, and general problem-focused behavior. Emotion-focused behaviors aim to alter the response to the stressor and include seeking emotional support, avoidance, denial, positive reappraisal, isolation, venting, rumination, wishful thinking, self-blame, positive self-talk, and exercise. According to the study, women tend to make more use of coping strategies compared to men, particularly more emotion-focused strategies. Van Rhenen et al. (2008) investigated the role of different coping styles on both the duration and frequency of sickness absence [ 29 ]. They found that both the use of an active problem-solving coping style and seeking emotional support decreased the mean sickness absence duration, with a stronger effect of the problem-solving coping style. Other emotion-based strategies had either no effect (expression of emotions) or a negative effect (avoidance) on sickness absence duration. Conversely, Loset et al. (2018) conducted a survey study to explore differences in attitudes and norms regarding sickness absence and found no significant differences between genders [ 30 ].

Further research is necessary to investigate variations in coping styles throughout the entire period of sickness absence, with particular emphasis on potential differences in coping styles during the initial stage of sickness absence and on changes in coping styles after these initial period.

Daily life characteristics Several differences in daily life and occupational characteristics may also influence sickness absence frequency and duration [ 13 , 15 , 16 , 17 ]. Women generally tend to spend more time to household tasks and childcare compared to men. The double burden hypothesis proposes that the combination of different roles, such as being an employee and a parent, can increase stress and consequently increase the risk for sickness absence. The strain associated with having multiple roles can be reflected by perceived work-family conflicts, where the demands of one’s professional role interfere with their family role, or vice versa. In a systematic review by Nilsen et al. (2017), they found moderate evidence for a positive correlation between work-family conflict and subsequent sickness absence, indicating that the strain from balancing work and family roles can indeed lead to higher levels of sickness absence [ 17 ]. However, the evidence was insufficient to draw conclusions about the role of gender in the prospective association between work-family conflict and subsequent sickness absence.

In our study we found that gender differences in particular influence the recovery rate during the first months of sickness absence. The work-family conflict provides a possible explanation for this observed differential recovery. The strain associated with managing different roles may affect the recovery process differently for men and women. For instance, during the initial recovery phase, women might prioritize resuming their family and social roles, while men may focus more on returning to their professional roles. This potential variance in prioritization could account for the lower recovery rates among women during the early stages of sickness absence. Further research is necessary to investigate the relationship between work-family conflict and recovery rates during the complete sickness absence period.

Occupational characteristics In addition to daily life characteristics, sector-specific gender representation patterns may also play a role. Women are predominantly employed in the healthcare, social services, and education sectors, whereas men are more commonly found in industries such as construction, manufacturing, information technology, and transportation [ 31 ]. Some studies suggest that higher rates of sickness absence are associated with occupations dominated by women [ 32 , 33 ]. The emotionally demanding nature of jobs in healthcare and social services often entails working directly with patients or clients. Such roles may require a more complete recovery from mental disorders before work can be resumed. In contrast, physically demanding work might offer a distraction from mental health issues, which could partly explain why men might return to work sooner.

However, studies about the association between job occupation and sickness absence are not conclusive. In a recent study Østby et al. (2018) found no evidence that the type of occupation is related to gender differences in sickness absence [ 15 ]. Mastekaasa (2014) even found an increase in gender differences when adjusting for the type of occupation [ 11 ].

Convergence of recovery rates Interestingly, recovery rates for men and women become more similar after the initial three months of sickness absence. This could be due to the natural course of the disease, a change in coping techniques or a re-evaluation of work. More research is needed to investigate the reasons behind this change in recovery rates, which could have significant implications for sickness absence management strategies.

Strengths and Weaknesses of the Study The strength of our study is that we could analyze a very large sample of sickness cases over a period of 10 years. Furthermore, we have used the occupational health physician’s (OP) diagnosis, enabling us to investigate sickness absences across various diagnostic categories. A limitation of our study is that we did not examine the impact of other factors that could potentially influence sickness duration and recovery rates. These factors include variations in job type, age, socio-economic status, specific diagnoses, overall health status, and the severity of the disorder. To improve understanding of gender differences in sickness absence, further research is needed to investigate the effect of these factors in particular during the first months of sickness absence.

Conclusions

Our study found marked gender differences in both sickness absence duration and recovery rates, with a longer sickness absence duration for women compared to men across almost all sickness causes. Interestingly, we found that recovery rates for women were considerably lower in the first months, indicating that most women start later with recovery than men. This indicates that there is a kind of delay in the recovery process for women. However, after the initial months, recovery rates for both genders tend to converge.

In the initial months of sickness duration, a considerable number of employees are affected, so even small differences during this period can greatly influence the total sickness duration and the corresponding costs. Consequently, it is very important to comprehend the factors leading to the noticeable delay in recovery for women. There is a need to further explore known factors that may affect the duration of sickness absence, such as coping mechanisms and conflicts between work and family life. Future research might be directed towards understanding how these factors change during the early stages of sickness absence, as well as the differences among genders in these factors during the beginning phase of sickness absence. This understanding can help to develop effective prevention and intervention strategies to minimize recovery delays and reduce the overall period of sickness absence. Ideally, implementing these strategies during the initial stage of sickness absence seems to be most beneficial.

Availability of data and materials

The data that support the findings of this study are available from the authors upon reasonable request. The contact person for requests is Sheila Timp and can be contacted by email [email protected].

Greasley P, Greasley K. Absence from work. Technical report, Eurofound. https://www.eurofound.europa.eu/publications/report/2010/absence-from-work .

Wolvetang S, van Dongen JM, Speklé E, Coenen P, Schaafsma F. Sick Leave Due to Stress, What are the Costs for Dutch Employers? J Occup Rehabil. 2022. https://doi.org/10.1007/s10926-022-10042-x .

Ross CE, Mirowsky J. Does Employment Affect Health? J Health Soc Behav. 1995;36:230–43. https://doi.org/10.2307/2137340 .

Article   PubMed   CAS   Google Scholar  

Venema A, Hooftman W, Fijan D, Swart C, Jansse E. Arbobalans 2020: Kwaliteit van de arbeid, effecten en maatregelen in Nederland. TNO: Technical report; 2020.

Roelen CAM, Koopmans PC, Anema JR, Beek AJVD. Recurrence of medically certified sickness absence according to diagnosis: a sickness absence register study. J Occup Rehabil. 20:113–21. https://doi.org/10.1007/s10926-009-9226-8 .

Roelen CAM, Norder G, Koopmans PC, Rhenen WV, Klink JJLVD, Bültmann U. Employees sick-listed with mental disorders: who returns to work and when? J Occup Rehabil. 2012;22:409–17. https://doi.org/10.1007/s10926-012-9363-3 .

Lidwall U, Bergendorff S, Voss M, Marklund S. Long-Term Sickness Absence: Changes in Risk Factors and the Population at Risk. Int J Occup Med Environ Health. 22:157–68. https://doi.org/10.2478/v10001-009-0018-3 .

Leijon M, Hensing G, Alexanderson K. Gender trends in sick-listing with musculoskeletal symptoms in a Swedish county during a period of rapid increase in sickness absence. Scand J Soc Med. 1998;26:204–13.

Arcas MM, Delclos GL, Torá-Rocamora I. Gender differences in the duration of non-work-related sickness absence episodes due to musculoskeletal disorders. J Epidemiol Community Health. 70:1065–73. https://doi.org/10.1136/jech .

Labriola M, Holte KA, Christensen KB, Feveile H, Alexanderson K, Lund T. The attribution of work environment in explaining gender differences in long-term sickness absence: results from the prospective DREAM study. Occup Environ Med. 2011 3;68(9):703–5. https://doi.org/10.1136/oem.2010.060632 .

Mastekaasa A. The gender gap in sickness absence: long-term trends in eight European countries. Eur J Public Health. 2014 6;24(4):656–62. https://doi.org/10.1093/eurpub/cku075 .

Bekker MHJ, Rutte CG, Rijswijk KV. Sickness absence: a gender-focused review. Psychol Health Med. 14:405–18. https://doi.org/10.1080/13548500903012830 .

Angelov N, Johansson P, Lindahl E. Gender Differences in Sickness Absence and the Gender Division of Family Responsibilities. SSRN Electron J. 2013. https://doi.org/10.2139/ssrn.2263655 .

Casini A, Godin I, Clays E, Kittel F. Gender difference in sickness absence from work: a multiple mediation analysis of psychosocial factors. Eur J Pub Health. 2013. https://doi.org/10.1093/eurpub/cks183 .

Østby KA, Mykletun A, Nilsen W. Explaining the gender gap in sickness absence. Occup Med. 2018. https://doi.org/10.1093/occmed/kqy062 .

Mastekaasa A. Dependent Children and Women’s Sickness Absence in the EU Countries and Norway. Eur Soc. 2013. https://doi.org/10.1080/14616696.2012.721892 .

Nilsen W, Skipstein A, Østby KA, Mykletun A. Examination of the double burden hypothesis–a systematic review of work-family conflict and sickness absence. Eur J Public Health. 2017;27(3):465–71. https://doi.org/10.1093/eurpub/ckx054 .

Article   PubMed   PubMed Central   Google Scholar  

Cornelius LR, van der Klink JJL, Groothoff JW, Brouwer S. Prognostic Factors of Long Term Disability Due to Mental Disorders: A Systematic Review. J Occup Rehabil. 21(2):259–74. https://doi.org/10.1007/s10926-010-9261-5 .

Spierdijk L, van Lomwel G, Peppelman W. The determinants of sick leave durations of Dutch self-employed. J Health Econ. 2009;28(6):1185–96. https://doi.org/10.1016/j.jhealeco.2009.07.003 .

Article   PubMed   Google Scholar  

UWV. CAS, Classificaties voor Arbo en SV (CAS, Classification for Occupational Health and Social Security). 2002. https://www.steungroep.nl/images/her_keuring_WIA_of_WAO/Wetten_en_regels_bij_her_keuring/CAS_Classificaties_voor_Arbo_en_SV_UWV_2002.pdf . Accessed 25 May 2023.

World Health Organization. International Classification of Diseases, 10th Revision; ICD-10. 2004. Technical report. https://icd.who.int/browse10/2019/en .

Davidson-Pilon C. lifelines: survival analysis in Python. J Open Source Softw. 2019;4:1317. https://doi.org/10.21105/joss.01317 .

Sullivan GM, Feinn R. Using Effect Size-or Why the P Value Is Not Enough. J Grad Med Educ. 4(3):279–82. https://doi.org/10.4300/jgme-d-12-00156.1 .

Collett D. Modelling Survival Data in Medical Research. Bristol: Taylor & Francis Group, LLC; 2015.

Book   Google Scholar  

CBS. Open CBS Data: Labour Participation. 2023. https://opendata.cbs.nl/#/CBS/nl/dataset/85264NED/table?searchKeywords=beroepsbevolking . Accessed 25 May 2023.

Koopmans PC, Roelen CAM, Groothoff JW. Parametric hazard rate models for long-term sickness absence. Int Arch Occup Environ Health. 2009;82:575–82. https://doi.org/10.1007/s00420-008-0369-2 .

Joling C, Groot W, Janssen PPM. Duration dependence in sickness absence: How can we optimize disability management intervention strategies? J Occup Environ Med. 2006;48:803–14. https://doi.org/10.1097/01.jom.0000222583.70927.3e .

Tamres LK, Janicki D, Helgeson VS. Sex Differences in Coping Behavior: A Meta-Analytic Review and an Examination of Relative Coping. Personal Soc Psychol Rev. 2002;6:2–30.

van Rhenen W, Schaufeli WB, van Dijk FJH, Blonk RWB. Coping and sickness absence. Int Arch Occup Environ Health. 81:461–472. https://doi.org/10.1007/s00420-007-0238-4 .

Løset GK, Dale-Olsen H, Hellevik T, Mastekaasa A, von Soest T, Østbakken KM. Gender equality in sickness absence tolerance: attitudes and norms of sickness absence are not different for men and women. PLoS ONE. 2018. https://doi.org/10.1371/journal.pone.0200788 .

OECD. Part-time and Partly Equal: Gender and Work in the Netherlands. OECD. https://doi.org/10.1787/204235cf-en . https://www.oecd-ilibrary.org/social-issues-migration-health/part-time-and-partly-equal-gender-and-work-in-the-netherlands_204235cf-en .

Lidwall U. Gender composition in occupations and branches and medically certified sick leave: a prospective population study. Int Arch Occup Environ Health. 2021. https://doi.org/10.1007/s00420-021-01672-4 .

Laaksonen M, Mastekaasa A, Martikainen P, Rahkonen O, Piha K, Lahelma E. Gender differences in sickness absence - the contribution of occupation and workplace. Scand J Work Environ Health. 2010. https://doi.org/10.5271/sjweh.2909 .

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ST, as the primary author of the manuscript, took charge of the intellectual concepts, planned the project, handled the statistical analyses, and wrote the manuscript. ND took on the task of mathematically verifying the analyses. CR played a significant role in crafting the manuscript. All authors have reviewed and given their approval to the final version of the manuscript.

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Timp, S., van Foreest, N. & Roelen, C. Gender differences in long term sickness absence. BMC Public Health 24 , 178 (2024). https://doi.org/10.1186/s12889-024-17679-8

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Received : 11 August 2023

Accepted : 04 January 2024

Published : 15 January 2024

DOI : https://doi.org/10.1186/s12889-024-17679-8

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