Exploring the Psychological Impacts of Participating in Sports

Tackling Mental Health 

Participating in competitive and high-performance sports is a multifaceted experience that can influence mental health in positive and negative ways. While sports offer numerous psychological benefits, they can also expose individuals to unique challenges that affect their well-being. 

The mental health impacts of participating in sports are extensive. From bolstering self-esteem and regulating emotions to fostering social connections and building resilience, the benefits of sports on mental well-being are undeniable. Individuals’ participation in sports not only strengthens their bodies but also nurtures their minds. 

While sports offers these many benefits, it's crucial to recognize that they can also have negative consequences for mental health. The pressures, injuries, social expectations, burnout and body image issues can all contribute to adverse psychological outcomes among athletes.

POSITIVE MENTAL HEALTH IMPACTS OF SPORTS

Participation in sports extends beyond physical fitness and competition. Engaging in sports has a profound impact on mental health, offering a range of psychological benefits that contribute to overall well-being. From boosting self-esteem to reducing stress, the effects of sports on mental health are becoming increasingly evident in research and everyday life. 

Enhanced Self-Esteem & Confidence

One of the most notable psychological benefits of engaging in sports is the significant boost in self-esteem and self-confidence, since participating in sports allows individuals to set and achieve personal goals, fostering a profound sense of accomplishment. Notably, Smith et al. (2019) found that athletes often exhibit higher self-esteem and a more positive self-image compared to non-athletes, and that consistent success in sports can translate into greater self-assurance in other areas of life, as well.[1] Additionally, Warburton et al. (2006) found that feeling physically fit and healthy can significantly boost an individual's self-esteem and self-confidence.[2]

Stress Reduction & Emotional Regulation

The Cleveland Clinic (2022) notes that regular physical activity releases endorphins which help relieve pain, reduce stress and improve mood.[3] Notably, Craft & Perna (2004) found that exercise through sports can lead to reduced stress, alleviation of symptoms related to anxiety and depression and improved emotional well-being.[4]

Social Interaction & Connection

Team sports, in particular, offer a unique opportunity for social interaction and the establishment of strong connections. The social connection formed through shared victories and defeats can lead to strong and lasting relationships. Jones et al. (2018) found that these social bonds among teammates can serve as a protective factor against mental health issues such as loneliness and depression.[5] Especially for individuals susceptible to feelings of isolation or loneliness, the sports environment can offer a supportive network that positively contributes to mental health.[6]

Lauren Becker Rubin, a former collegiate athlete at Brown University and current advisor to Haverford College’s varsity teams, spoke in depth about this topic in The Seattle Psychiatrist Interview Series. She explains that social connection is one of the biggest benefits of sports participation.[7] Particularly in being part of a team, individuals can find meaning in a sense of purpose while working together towards a common goal. She notes that there is a shared humanity in the wins, but more importantly also in the losses, as team members act as a support system for one another. Within the sports and team community there is group connection, fun, shared experience and striving for something bigger than oneself.[8]  

Improved Body Image & Self-Perception

Sports promote physical activity and fitness, which can contribute to improvements in physique and overall health. Thus, engaging in regular exercise can lead to a more positive body image and self-perception. Adams et al. (2020) note that as individuals see the positive changes in their bodies through training and participation, they often develop a greater appreciation for their physical selves, leading to increased self-acceptance and reduced body dissatisfaction.[9]

Goal-Setting Motivation

Goal setting is a common aspect of sports participation, whether it's achieving a personal best, improving a skill or winning a championship. The process of establishing, working towards and attaining these goals can significantly boost motivation, resilience and provide individuals with a sense of purpose. Emmons & McCullough (2003) highlighted the positive correlation between goal achievement and psychological well-being and found that engaging in goal-setting activates the brain's reward systems, releasing dopamine and reinforcing feelings of accomplishment.[10] 

Strengthened Mental Resilience

Participating in sports often involves facing challenges, setbacks, and even failures. These experiences help build mental resilience by teaching individuals how to adapt, learn from mistakes and persist. The skills learned in sports participation are transferable to other aspects of life, helping individuals manage stressors and overcome hardship with greater ease. Notably, Johnson et al. (2021) found sports participation enhances mental toughness and the ability to bounce back from life’s adversities.[11] 

Lauren Becker Rubin also discussed resilience in her interview, explaining that athletics builds resilience simply through the unpredictable nature of sports.[12] Never knowing if you’re going to win or lose makes us more adaptable and encourages us to learn how to manage emotions around unpredictable outcomes. Rubin notes that the resilience in sports is correlated to life: “There's ups and downs, there's good things, there's bad things. You have to learn to be able to manage your emotions around that and athletics really helps you do that.”[13] 

NEGATIVE MENTAL HEALTH IMPACTS OF SPORTS

While sports are celebrated for their many physical and psychological benefits, it's also important to acknowledge that sports participation isn't always a source of positive mental health. For some individuals, the pressures, expectations and experiences associated with sports can lead to negative psychological outcomes. 

Performance Anxiety & Stress

The competitive nature of sports can lead to high levels of performance anxiety and stress. In the Journal of Sport & Exercise Psychology, Stress et al. (2018) note that athletes are susceptible to performance-related anxiety, which can have adverse effects on mental health.[14] Athletes may experience overwhelming pressure to perform consistently at their best, which can result in debilitating stress and anxiety. 

Rubin speaks to performance anxiety in her interview and explains how the public stage athletes are on opens the door to stress, anxiety, pressure, worry and fear. Athletes’ fear is multifaceted, as she describes there is “fear of losing, fear of winning, fear of embarrassment, fear of getting injured, fear of losing social status, fear of losing your position - so there's a lot of fear, worry, stress and anxiety about performing.”[15] These stressors affect athletes both on and off the field as these fears do not always subside once someone is away from the competition.

Injury-Related Mental Health Issues & Identity Crisis

Injuries are a common part of sports, and they can have serious impacts on an athlete's mental health. Whether an athlete suffers a season-ending injury, one that sidelines them for a handful of games or one that only limits their performance, Timpka et al. (2017) explain how the physical pain and the fear of lost opportunities can lead to symptoms of depression, anxiety and even post-traumatic stress disorder (PTSD).[16]

In her interview, Rubin acknowledges injury-related mental health issues, particularly concerning a loss of identity. When an athlete or individual suffers an injury it can affect their sense of self, especially if participation in sports is a part of one's daily life.[17] Often, athletes have been athletes for much of their lives, so when a time comes where they cannot play or their role has changed, an identity issue can arise. Even retirement from a sports career can be mentally and emotionally challenging, as athletes often face an identity crisis when their sporting journey ends. In particular, Lavallee et al. (2012) note that the transition to a life outside of sports can lead to feelings of loss, depression, and anxiety.[18] 

Social Pressure & Isolation

Despite the comradery, sports can be isolating for some individuals, particularly those who struggle to meet the expectations of their peers, coaches or parents. Smith et al. (2020) notes athletes’ fear of judgment or rejection can lead to social anxiety and feelings of isolation.[19] Failing to meet the expectations of others, self-shame and the pressure to succeed can have adverse effects on one’s mental health.

Rubin speaks to the pressure all athletes face while performing on a public stage, but notes that it is increasingly challenging the more competitive the participation becomes. She describes how social media, fans, money, and contracts are just a few aspects of the pressure elite athletes face on a daily basis. While recreational sports have their own unique set of stressors as well, Rubin describes that the “pressure, stress, anxiety, worry, isolation, just really ramps up the higher you get” in competition.[20] 

Burnout & Overtraining

Raedeke et al. (2002) stress the links between burnout and negative mental health outcomes in athletes.[21] The drive for success in sports can often lead to overtraining and burnout, which can result in physical and mental exhaustion. Additionally, athletes may lose their passion for the sport, experience symptoms of depression and face difficulties in other aspects of life (e.g., relationships, school or work). Overtraining and burnout are especially problematic among competitive athletes, who often spend most of their free time training, with few days off from training per year,

Eating Disorders & Body Image Issues

Sports that emphasize weight and appearance (e.g., gymnastics, wrestling) can contribute to the rise of eating disorders and body image issues. Joy et al. (2016) found there is a high prevalence of eating disorders among athletes due to the physical demands of sports as well as unhealthy expectations of physique, diet and exercise.[22] Athletes may develop unhealthy relationships with food and their bodies, which can have lasting psychological effects. 

It's essential to provide support and resources for athletes throughout their careers to address these mental health challenges and create a more balanced, nurturing sports environment. Regardless of age and level, this support includes promoting mental health awareness, reducing stigma for those who are suffering, providing access to mental health professionals and fostering a culture that values athletes' well-being over their performance or success.

If someone or someone you know is struggling with the stressors of competing in sports, reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support. 

Contributed by: Jordan Denaver

Editor: Jennifer (Ghahari) Smith, Ph.D.

REFERENCES

1 Smith, J., et al. (2019). Psychological correlates of university athletes and nonathletes: An exploration of the mental health hypothesis. Journal of Sport and Exercise Psychology, 41(2), 97-103.

2 Warburton, D. E., Nicol, C. W., & Bredin, S. S. (2006). Health benefits of physical activity: The evidence. CMAJ: Canadian Medical Association Journal, 174(6), 801-809.

3 Cleveland Clinic. (2022, May 19). Endorphins: What they are and how to boost them. https://my.clevelandclinic.org/health/body/23040-endorphins

4 Craft, L. L., & Perna, F. M. (2004). The Benefits of Exercise for the Clinically Depressed. Primary Care Companion to the Journal of Clinical Psychiatry, 6(3), 104-111.

5 Jones, A., et al. (2018). The Impact of Team Sports on Mental Health in Adolescents: A Systematic Review. Journal of Sport and Social Issues, 42(1), 3-22.

6 Ibid.

7 Denaver, J. E., & Rubin, L. B. (2023). Certified Mental Performance Coach Lauren Becker Rubin on the Mental Health of Athletes. Seattle Anxiety Specialists, PLLC. https://seattleanxiety.com/psychology-psychiatry-interview-series/2023/7/14/certified-mental-performance-coach-lauren-becker-rubin-on-the-mental-health-of-athletes

8 Ibid.

9 Adams, K., et al. (2020). Sports involvement and body image: The mediating role of physical activity and body composition. Journal of Eating Disorders, 8(1), 1-12.

10 Emmons, R. A., & McCullough, M. E. (2003). Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being in daily life. Journal of Personality and Social Psychology, 84(2), 377-389.

11 Johnson, R., et al. (2021). The relationship between sports participation, resilience, and mental health in college athletes. Journal of Sport and Exercise Psychology, 43(3), 195-203.

12 Denaver & Rubin (2023)

13 Ibid.

14 Stress, A. B., et al. (2018). Performance Anxiety and Coping in Athletes. Journal of Sport & Exercise Psychology, 40(6), 292-301.

15 Denaver & Rubin (2023)

16 Timpka, T., et al. (2017). The Psychological Health of Injured Athletes. Journal of Athletic Training, 52(3), 231-238.

17 Denaver & Rubin (2023)

18 Lavallee, D., et al. (2012). Retirement from Sport and the Loss of Athletic Identity. Journal of Applied Sport Psychology, 24(4), 362-379.

19 Smith, R. E., et al. (2020). Interpersonal Stressors and Resources as Predictors of Athlete Burnout. Journal of Sport & Exercise Psychology, 42(1), 65-75.

20 Denaver & Rubin (2023)

21 Raedeke, T. D., Lunney, K., & Venables, K. (2002). Understanding athletes burnout: Coach perspectives. Journal of Sport Behavior, 25(2), 181.

22 Joy, E., et al. (2016). Prevalence of Eating Disorders and Pathogenic Weight Control Behaviors Among NCAA Division I Female Collegiate Gymnasts and Swimmers. Journal of Eating Disorders, 4(1), 19.

Developments in Art Therapy for Mental Health

What Words Can’t Express 

The process of making art, like literature, has long been shown to have mental and emotional health benefits. The APA describes art therapy as a type of psychotherapy that helps provide a way to express emotions and experiences not easily expressed in words.[1] The artist Georgia O’Keeffe said, “I found I could say things with color and shapes that I couldn’t say any other way – things I had no words for.” 

The American Art Therapy Association explains that art therapy includes active art-making, the creative process, and applied psychological theory - within a psychotherapeutic relationship - to enrich the lives of individuals, families, and communities.[2] Furthermore, art therapy is used to foster self-esteem and self-awareness, cultivate emotional resilience, promote insight, enhance social skills and reduce conflicts and distress. Although art therapy has been used to treat a range of mental health disorders including anxiety and depression, this type of therapy is particularly applicable to survivors of trauma because the nonverbal and experiential character of art therapy appears to be an appropriate approach to the often “wordless and visual nature of traumatic memories.”[3]

MechanismS of Art Therapy  

Art therapy engages the mind, body, and spirit in ways that are distinct from verbal communication. In an article published in the Journal of the American Art Therapy Association, Lusebrink 2010 differentiates art therapy from verbal therapies by the use of art media as a means of expression and communication, the multileveled meaning present in visual expressions, and the therapeutic effects of the creative process.[4] In a schematic framework known as the Expressive Therapies Continuum (ETC), three distinct levels (kinesthetic/sensory, perceptual/affective, and cognitive/symbolic) reflect different functions and structures in the brain that process visual and affective information.[5]  

This is particularly useful because the art therapist can first assess the client’s cognitive and emotional functioning through these different ETC levels in order to better address their strengths, challenges, and progress in art therapy. For example, Hendler et al. (2001) found that in individuals with post-traumatic stress disorder (PTSD), affectively-charged visual stimuli activate limbic regions and sensory areas of the cerebral cortex but not the prefrontal area. This is significant, as visual processing within non-PTSD individuals does include the prefrontal cortex which is critically involved in the emergence of conscious visual perception. On the other hand, client areas of strength would constitute a lack of difficulty in processing visual information on particular levels of the ETC. This framework is useful for helping art therapists determine where the “missing links'' are in terms of the sequence of visual information processing. 

These assessments can act as guidelines for starting points, pathways, and goals in art therapy.[6] The range of kinesthetic, sensory, perceptual, and symbolic opportunities also allow clients to practice and create alternative modes of expressive communication, which can help circumvent the limitations of language.[7] 

Art Therapy Sessions 

Though one can always choose to pursue the arts on their own time to calm and relax the mind, formal art therapy sessions are typically carried out by licensed clinicians, master's-level or higher degree holders trained in art and therapy work. Art therapists work with diverse populations in a variety of settings including hospitals, schools, veterans’ clinics, private practice and psychiatric and rehabilitation facilities.[8] One may choose to engage in a private art therapy session or a group setting with other individuals. 

Before beginning, it is important for the therapist to emphasize that the client does not need to be artistically or creatively inclined to benefit from this process. During a typical session, clients will engage in both art-making and meaningful conversation with the therapist.[9] The therapist's main goal is to describe the goal of art therapy, help the client choose an appropriate medium for expression (e.g., collage, painting, sculpture, drawing), and prompt the client with questions which will shape and guide the art making session. At the conclusion of the session, the therapist and client will debrief. To make sense of the process, they may collaboratively discuss any emotions and feelings that arose during the art making process, the work of art itself and its potential meanings, as well as plans for future sessions.[10] 

Applications for Addressing Trauma 

Art therapy has historically been used to address and treat trauma for a variety of reasons. Art is an effective means of expressing past trauma from a safe environment; it provides emotional distance from the actual event and provides an alternative outlet to confront unresolved trauma memories through the use of symbols and visual media. Additionally, PTSD UK notes how new research has found that art therapy fosters a mind-body connectedness and allows the brain to use mental and visual imagery.[11]

In 2016, Campbell et al. (2016) conducted research to examine the impact of art therapy on those with combat-related PTSD. They administered a series of art therapy sessions in which participants engaged in creating a visual trauma narrative, mapping representations of their emotions, making images of the self before and after the trauma and creating final reflective art pieces. Results from a depression scale score showed that although not statistically significantly different, a trend toward greater reduction in depression symptoms for the test group compared to the control was noted.[12] Although these quantitative measures did not show statistical significance, a more recent study by Berberian et al. (2019) examined the qualitative outcomes of art therapy, or more specifically, montage painting, for active-duty military service members with traumatic brain injuries or PTSD. They found that group art therapy elicited improvement in interpersonal relatedness, as well as the expression of hopefulness and gratification. Art therapy allowed the individuals to work toward creating an individual trauma narrative which is a key component for recovery and healing.[13]

Aside from veterans and active-duty military service members, PTSD within children and early relational trauma has also been addressed through art therapy. Individuals who have experienced trauma at a young age show increased levels of suicide, alcohol addiction, and/or drug addiction later in life, thus art therapy is especially valuable as an early intervention for children who have been exposed to trauma in a variety of contexts and in different forms (e.g., witnessed or experienced gang violence, bullying, loss and grief, domestic abuse, suicide, homelessness, and drug abuse).[14] A study conducted by Woollett et al. (2020) invited school-aged children and their mothers in domestic violence shelters to participate in a pilot study aiming to integrate trauma-informed art and play therapy with traditional cognitive behavioral therapy (CBT). From baseline levels, children's depressive symptoms showed significant reduction and improvement in PTSD symptoms.[15] 

Another specific context which art therapy has been applied to is early relational trauma. This type of trauma is distinct from post-traumatic stress disorder in its emphasis on childhood abuse, various forms of neglect, and other neurological effects that occur during a specific time period when the developing brain was exposed to prolonged trauma.[16] Art therapy can be particularly helpful for early relational trauma clients who exhibit anger and frustration as they struggle to confront and articulate their emotions. The art they make is a non-verbal activity that reflects, mirrors and amplifies expression of the client's internal state of affects. A study by Chong (2015) presented a collection of clinical vignettes in which she notes that school-aged children with early relational trauma showed improvement in dimensions such as confidence, attention span, and the formation of positive relationships in school settings.[17]

Within communities of all ages and backgrounds, art therapy is a flexible, effective and low-intensity intervention for individuals dealing with trauma which can cultivate a greater sense of creativity, empowerment, and independence while fostering a healthy psychosocial relationship with themselves and others.[18] 

If you or someone you know would like to learn more about art therapy and how to incorporate it into your own life, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support.  

Contributed by: Kaylin Ong

Editor: Jennifer (Ghahari) Smith, Ph.D.

References 

1 (2020, January 30). Healing Through Art - APA Blogs - Patients and Families. American Psychiatric Association. https://www.psychiatry.org/news-room/apa-blogs/healing-through-art#:~:text=Art%20therapy%2C%20a%20type%20of,the%20process%20of%20making%20art 

2 American Art Therapy Association. (2014). American Art Therapy Association. https://arttherapy.org/ 

3 Schouten, K. A., van Hooren, S., Knipscheer, J. W., Kleber, R. J., & Hutschemaekers, G. J. M. (2018). Trauma-Focused Art Therapy in the Treatment of Posttraumatic Stress Disorder: A Pilot Study. Journal of Trauma & Dissociation, 20(1), 114–130. https://doi.org/10.1080/15299732.2018.1502712 

4 Lusebrink, V. B. (2010). Assessment and Therapeutic Application of the Expressive Therapies Continuum: Implications for Brain Structures and Functions. Art Therapy, 27(4), 168–177. https://doi.org/10.1080/07421656.2010.10129380

5 Expressive Therapies Continuum: Three-Part Healing Harmony | Psychology Today. (December 30, 2018). Www.psychologytoday.com. https://www.psychologytoday.com/us/blog/arts-and-health/201812/expressive-therapies-continuum-three-part-healing-harmony 

6 Lusebrink (2010) 

7 American Art Therapy Association 

8 Ibid. 

9 Homepage - The British Association Of Art Therapists. (2022, September 26). The British Association of Art Therapists; BAAT. https://baat.org/ 

10 What Is Art Therapy? | Psychology.org. (2022, February 15). Www.psychology.org. https://www.psychology.org/resources/what-is-art-therapy/#:~:text=During%20a%20session%2C%20an%20art 

11 How art therapy has helped those with PTSD – PTSD UK. (n.d.). https://www.ptsduk.org/how-art-therapy-has-helped-those-with-ptsd/ 

12 Campbell, M., Decker, K. P., Kruk, K., & Deaver, S. P. (2016). Art Therapy and Cognitive Processing Therapy for Combat-Related PTSD: A Randomized Controlled Trial. Art Therapy, 33(4), 169–177. https://doi.org/10.1080/07421656.2016.1226643 

13 Berberian, M., Walker, M. S., & Kaimal, G. (2018). “Master My Demons”: art therapy montage paintings by active-duty military service members with traumatic brain injury and post-traumatic stress. Medical Humanities, 45(4), 353–360. https://doi.org/10.1136/medhum-2018-011493 

14 Helping Kids Cope with Trauma. (October 20, 2017). Cedars-Sinai. https://www.cedars-sinai.org/blog/art-therapy-helps-children-cope-with-trauma.html#:~:text=Art%20therapy%20teaches%20kids%20how 

15 Woollett, N., Bandeira, M., & Hatcher, A. (2020). Trauma-informed art and play therapy: Pilot study outcomes for children and mothers in domestic violence shelters in the United States and South Africa. Child Abuse & Neglect, 107(1), 104564. https://doi.org/10.1016/j.chiabu.2020.104564 

16 Terradas, M. M., Poulin-Latulippe, D., Paradis, D., & Didier, O. (2020). Impact of early relational trauma on children’s mentalizing capacity and play: A clinical illustration. European Journal of Trauma & Dissociation, 100160. https://doi.org/10.1016/j.ejtd.2020.100160 

17 Chong, C. Y. J. (2015). Why art psychotherapy? Through the lens of interpersonal neurobiology: The distinctive role of art psychotherapy intervention for clients with early relational trauma. International Journal of Art Therapy, 20(3), 118–126. https://doi.org/10.1080/17454832.2015.1079727 

18 Boyadjis, A. (2019). Healing the Child Through Expressive Arts Therapy. https://minds.wisconsin.edu/bitstream/handle/1793/79197/Boyadjis%2C%20Andrea%20Thesis%202019%20compiled.pdf?sequence=1&isAllowed=y 

Addressing Mental Health Amongst First Responders: Sometimes Superheroes Need Saving, Too

Hidden Anguish

First responders play a vital and commendable role in society as they display exceptional bravery to save the lives of others, often at the risk of their own. Many first responders encounter unimaginable tragedy and horror on a daily basis, and then are expected to go home and attend to their loved ones. However, separating work from personal life may not be so easy for these individuals as the impact that traumatic events can have on one’s mental health is often left unacknowledged. Frequent exposure to death and tragedy undoubtedly affects one’s psychological state of well-being, including post-traumatic stress disorder (PTSD), substance abuse, depression and especially suicidal ideations. However, along with the societal expectation of first responders to be brave and strong, comes the suppression of such mental health problems and lack of proper psychiatric treatment.[1] 

Risk factors & Causes 

In comparison to the general population, first responders such as law enforcement officers (LEO), emergency medical technicians (EMT), and firefighters are at a greater risk of suicide ideation and suicide. Stanley et. al. (2016) conducted a systematic review of 63 quantitative studies examining the suicidal thoughts, behaviors, and fatalities of first responders, and found them to be at a significantly higher risk than general population samples.[2] Bond & Anestis (2021) conducted a study which showed that 23-25% of LEOs and 46.8% of firefighters experience suicidal ideations, and 10.4% of EMTs report severe lifetime suicidal ideation.[3] Frequent and severe traumatic experiences also lead to a higher risk of PTSD. Approximately 32% of LEOs, 22% of EMTs and 32% of firefighters experience PTSD. In comparison to the general civilian population, out of whom only 7-12% experience PTSD, these rates are concerningly high. There are also various risk factors amongst first responders that can contribute to their increased risk of developing PTSD, including:[4]

• Family history of psychiatric disorders

• Childhood trauma (abuse/adversity)

• Intelligence level

• Education

• Early conduct problems

Proper sleep hygiene (due to long and demanding shift schedules) also plays a role in the increased rates of disorders such as PTSD, depression, and anxiety. A longitudinal study conducted by Feldman et al. (2021) included 135 emergency medical service providers and recorded changes in symptoms of various psychological disorders over the course of 3 months. Their findings revealed that the increase in symptoms of PTSD, depression, and anxiety were all correlated with a poor sleep pattern and lower social support.[5] Erratic sleep patterns are especially problematic given that they compromise inflammatory and physiological stress responses.[6]

Acute stress disorder (ASD) is another common psychiatric disorder among first responders who experience frequent and high-impact stressors. A few pertinent symptoms of this disorder include:[7]

• Hyperarousal

• Negative mood

• Anger/irritability

• Dissociation

• Avoidance

• Numbing

• Nightmares

• Intrusive thoughts

ASD is developed once an acute stress response leads to more serious impairments after exposure to a traumatic stress with documented biological or psychological sequelae. Within 3 days of the traumatic event, multiple symptoms within five diagnostic categories will appear. ASD is signified by persistent symptoms well beyond the time frame of an acute stress reaction, which is more common and normal for anyone who experiences a traumatic event. While first responders who are acutely impacted by a trauma may develop ASD, developing ASD puts them at a greater risk for subsequently developing PTSD.[8]

The Three-Step Theory 

Not only do first responders experience greater rates of suicidal ideations, but they are also more likely to actually perform suicidal attempts.[9] Ideation-to-action is outlined by the Three-Step Theory (3ST), which states that there are three subcategories of capability that can shift an individual from suicidal thoughts to actual suicidal actions. These subcategories include:[10]

1. Practical - Broader knowledge of lethal weapons/drugs, and potentially even better access to them. The means of suicidal means are more readily obtainable. 

2. Dispositional - Innate tolerance to death and pain. 

3. Acquired - Learned desensitization and tolerance to death and pain. Having encountered numerous tragic events has built a sense of fearlessness in many first responders.

Suffering in Silence

Since a large majority of first responder suicides go unreported by mainstream media, there is an ongoing lack of knowledge/awareness of the general public to the degree that it occurs.  In addition, barriers exist that prevent first responders from accessing the proper psychiatric care they need when experiencing depression or suicidal ideations. Such barriers include shame and stigma surrounding mental health issues within their professions, as the concept of bravery and courage is heavily instilled upon them during training and work. Moreover, first responders and their families often fail to have open discussions about mental health, which unfortunately fuels the lack of awareness on the issue of first responder suicide.[11] 

Even when a first responder recognizes they are in crisis, several factors often prevent them from seeking adequate help: lack of knowledge on where/how to seek help, fear of confidentiality breach, belief that they cannot show weakness, lack of access and availability to therapy, family burden, pride and denial.[12] Destigmatizing mental health issues and spreading awareness is the first crucial step to ensuring that first responders are able to comfortably and willingly ask for help.[13] First responders should also be informed about mental health disorders and how to facilitate help-seeking.[14]

First responders are often expected to prevent their traumatic experiences from interfering with their professional and personal lives. The culture of first responders may prevent them from seeking actual mental health interventions, due to stigma and self-image. However, doing so often leads to unhealthy coping mechanisms such as substance abuse and high-risk behavior as an outlet for their stressors. Some also practice avoidance, leading to absenteeism in work and home, causing tension with their personal relationships. Conflict may even arise between colleagues, as high-stress environments and internal stressors combine together to create overall tension in the workplace. Therefore, psychoeducation to reduce stigma and subcultural barriers could help encourage first responders to seek treatment. This would eventually remediate their own psychological health and mend other impacted professional and personal relationships in their lives.[15] 

Building Resilience 

High resilience has been shown to be associated with lower symptomology of PTSD, depression, and alcohol abuse in active first responders. Therefore, resilience screening can help to protect the long-term mental health of first responders. High resilience indicates the ability to better tolerate problems, illness, failure, pressure, and feelings of pain.

These adaptive qualities of resilience can be developed in first responders via targeted interventions, including cognitive behavioral therapy (CBT) and mindfulness training programs. These two methods have been proven effective in increasing adaptive resilience amongst health professionals, factory workers, civil servants, and even breast-cancer patients. Employing resilience screening as a first responder begins work, one can identify which workers can most benefit from these targeted interventions to increase resilience, thus decreasing their chances of developing debilitating psychological disorders.[16] 

Thompson and Drew (2020) developed a 21-day program to enhance first responder resilience and tested the program with promising results. Every day over the course of 21 days, participants received a keyword which encouraged them to follow certain practices for the day, such as grit, calm, empathy, and gratitude. They also did 5 minutes of controlled breathing exercises, short readings on the keywords, reflections for the day, and an evening gratitude practice. Gratitude was incorporated into the program to increase sleep quality, life satisfaction, and decrease risk of depressive symptoms. In total, the practice work took only 15 minutes a day, accounting for the busy schedules of typical first responders. The participants responded to the 21 day course well, and a majority indicated that they would continue to use the practices they learned during the course of the program.[17]

Programs such as this one, and other resilience programs, would be beneficial for all first responders to incorporate into their lifestyles to increase resilience against developing mental health issues, promote the necessity of managing one’s mental health and reduce stigma in those suffering with PTSD, depression, anxiety and other work-related mental health disorders. 

If one has been suffering from any mental health disorder due to traumatic stress, such as PTSD or ASD, or is experiencing feelings of heightened anxiety or suicidal ideations, it is crucial to contact a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ananya Udyaver

Editor: Jennifer (Ghahari) Smith, Ph.D.

References 

1 Heyman, M., Dill, J., & Douglas, R. (2018, April). The ruderman white paper on mental health and suicide of first ... https://firefightermentalhealth.org/system/files/First%20Responder%20White%20Paper_Final.pdf 

2 Stanley, I., Hom, M., & Joiner, T. (2015, December 12). A systematic review of suicidal thoughts and behaviors among police officers, firefighters, emts, and Paramedics. Clinical Psychology Review. https://www.sciencedirect.com/science/article/abs/pii/S0272735815300684?via%3Dihub 

3 Bond, A., & Anestis, M. (2021, October 26). Understanding capability and suicidal ideation among first responders. https://www.tandfonline.com/doi/full/10.1080/13811118.2021.1993397 

4 Lewis-Schroeder, N. F., Kieran, K., Murphy, B. L., Wolff, J. D., Robinson, M. A., & Kaufman, M. L. (2018). Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues. Harvard review of psychiatry, 26(4), 216–227. https://doi.org/10.1097/HRP.0000000000000176 

5 Feldman, T. R., Carlson, C. L., Rice, L. K., Kruse, M. I., Beevers, C. G., Telch, M. J., & Josephs, R. A. (2021). Factors predicting the development of psychopathology among first responders: A prospective, longitudinal study. Psychological Trauma: Theory, Research, Practice, and Policy, 13(1), 75–83. https://doi.org/10.1037/tra0000957 

6 Lewis-Schroeder, N. F., Kieran, K., Murphy, B. L., Wolff, J. D., Robinson, M. A., & Kaufman, M. L. (2018). 

7 Ibid.

8 Ibid.

9 Bond, A., & Anestis, M. (2021, October 26). 

10 Heyman, M., Dill, J., & Douglas, R. (2018, April).

11 Stanley, I., Hom, M., & Joiner, T. (2015, December 12).

12 Jones S, Agud K, McSweeney J. (2020) Barriers and Facilitators to Seeking Mental Health Care Among First Responders: “Removing the Darkness.” Journal of the American Psychiatric Nurses Association. 26(1):43-54. doi:10.1177/1078390319871997

13 Heyman, M., Dill, J., & Douglas, R. (2018, April).

14 Jones S, Agud K, McSweeney J. (2020)

15 Lewis-Schroeder, N. F., Kieran, K., Murphy, B. L., Wolff, J. D., Robinson, M. A., & Kaufman, M. L. (2018). 

16 Joyce, S., Tan, L., Shand, F., Bryant, R., & Harvey, S. (2019). Can resilience be measured and used to predict mental... : Journal of Occupational and Environmental Medicine. LWW. https://journals.lww.com/joem/abstract/2019/04000/can_resilience_be_measured_and_used_to_predict.4.aspx 

17 Thompson, J., & Drew, J. M. (2020, July 27). Warr;OR21: A 21-day program to enhance first responder resilience and mental health. Frontiers. https://www.frontiersin.org/articles/10.3389/fpsyg.2020.02078/full 

The Unseen Wounds of Dating Violence on Mental Health

Silent Scars

Dating violence is a pervasive issue that inflicts profound wounds on victims, both visible and hidden. The National Coalition Against Domestic Violence reports that 1 in 3 women and 1 in 4 men have experienced intimate partner physical violence such as slapping, injury and sexual abuse.[1] These issues can be difficult to notice from the outside of a relationship, allowing abuse to continue while mental scars shape victims' psychological and physical well-being. The connections between dating violence, abuse, and mental health shed light on the silent struggles endured by survivors.

The Spectrum of Abuse

Abuse in dating relationships takes on various forms - from physical violence to emotional manipulation, coercion, and even digital harassment. The dynamic that leads to violence in a relationship is a power imbalance when one person gains power and control over the other.[2] This may take the forms of threats, intimidation, financial abuse, stalking and isolation[3] and this multifaceted spectrum of dating violence can leave victims feeling trapped in a cycle of abuse. Dating violence shatters victims' sense of security, trust, and self-worth, planting the seeds for lasting mental health challenges. 

Examples of the warning signs of abusive behaviors include:[4]

• Using force or coercion to initiate sexual activity

• Attempting to isolate one from their family or friends

• Using threats

• Breaking objects, creating noise or yelling to establish intimidation 

• Having a history of abuse in past relationships 

• Expressing control financially (refusing for a partner to work)

• Expressing control over where a partner goes, what they wear, who they speak to...

• Frequent mood swings and shifts when in public compared to in private

• Constant jealousy 

Erosion of Emotional Well-being

The emotional toll inflicted by dating violence relates to poor mental health outcomes. Adolescent dating violence is particularly prevalent (i.e., 1 in 3 adolescents have experienced an abusive or unhealthy relationship) and is a predictor of partner violence as an adult.[5,6] Pérez-Marco et al. (2020) note that adolescents characterized dating violence as psychological, sexist, and verbal types of violence.[7] For example, blackmailing or damaging a partner’s dignity are examples of psychological violence.[8] Further, Piolanti et al. (2023) note that adolescent dating violence contributes to increased risk-taking behaviors such as marijuana and alcohol use, and negative mental health such as victimization, a common result of physical or emotional abuse.[9] These poor outcomes were more common among females when compared to males. Additionally, among 116 married women experiencing domestic abuse, Malik et al. (2021) found that abuse was associated positively with depression, anxiety and stress.[10] Domestic abuse was also related to a decreased quality of life.[11] The constant undercurrent of fear, anxiety, and uncertainty from degradation and physical attacks can erode victims' emotional well-being and even skew the perception of their relationship as being “normal” amidst high psychological distress.

Emotional abuse is related to:[12]

• Social anxiety

• Depression 

• Eating disorders

• Post Traumatic Stress Disorder (PTSD)

• Chronic pain

• Shame

• Self-doubt

• Low self-esteem

• Codependency 

Complex Trauma & Misconceptions of Dating Violence

Exposure to dating violence often inflicts complex trauma, or unique forms of psychological injury that can lead to enduring emotional and mental turmoil. The patterns of abuse – the relentless cycle of tension, explosion, and reconciliation – carve a pattern of fear in victims' minds. Complex trauma can manifest as post-traumatic stress disorder (PTSD), anxiety disorders and depression.[13] From an external perspective, relationship violence is commonly misunderstood as bystanders may question why a victim stays in their violent relationship if they are being abused. It is so easy to ask, “Why don’t they just leave?”[14] However, there is a deep manipulative aspect to dating violence that maintains a harmful cycle.

De Sousa et al. (2023) found that among participants ages 15-22 in relationships, control tactics were predominantly isolation, domination, and emotional manipulation.[15] These controlling dynamics establish heavy power imbalances that lead to both a bystander's and a victim's blindness to the harm of a relationship. For example, an abusive partner may conceal their violent tendencies when in public or around peers, but when in private with their partner, inflict abuse. The victim may even develop learned helplessness, in which they have repeatedly experienced violence and eventually stop resisting or trying to change the uncontrollable circumstance. Additionally, it is common for victims to find comfort in their abusive relationship, as they are manipulated to believe that they abuse because their partner “loves them,” as Shawn Guy writes for Genesis Women’s Shelter in an article about teen dating violence.[16] This occurrence is sometimes referred to as Stockholm syndrome, or the psychological response of a positive connection to an abuser.[17]

The Path to Recovery: Empowerment and Support

Victims of dating violence find it challenging to escape their abusers. Feelings of shame, guilt, and societal stigma can create barriers to seeking help. Additionally, financial dependence and isolation enforced by abusers can make it difficult for victims to end relationships.

Professional help through therapy can help survivors regain a sense of agency and control over their lives to minimize the long-term effects of abuse and trauma. For example, Karakurt et al. (2022) found that cognitive-behavioral therapy (CBT), mindfulness, motivational interviewing and expressive writing have led to successful results in increasing empowerment among women who had experienced intimate partner violence.[18] These modalities lowered stress and depressive symptoms, as well.[19]

Empowerment becomes a sign of hope as victims rebuild their self-worth as Pérez-Marco et al. found that empowerment skills were an effective resource to combat negative outcomes of abuse.[20] Treatment for perpetrators of domestic violence is less researched, but also integral to preventing relationship violence and subsequent mental health challenges. Taking into consideration social, societal and developmental contexts may be involved in methods to address high levels of violence exhibited by abusers as well as equitable access to treatment.[21,22]

Dating violence and abuse result in devastating impacts on victims' mental health, inflicting trauma that may never fully fade without proper intervention. By amplifying awareness, education, and access to mental health resources, society can stand against the silent scars left by dating violence and empower survivors on their journey toward recovery.

If one is experiencing any form of abuse or mental health challenges due to a relationship, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Phoebe Elliott

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 National Coalition Against Domestic Violence. National Statistics. https://ncadv.org/STATISTICS#:~:text=NATIONAL%20STATISTICS&text=On%20average%2C%20nearly%2020%20people,10%20million%20women%20and%20men.

2 Washington University in St. Louis. (2023). What is Relationship and Dating Violence? https://students.wustl.edu/relationship-dating-violence/

3 Ibid.

4 Ibid.

5 Liz Claiborne Inc and The Family Fund. Teen Dating Abuse 2009 Key Topline Findings. http://nomore.org/wp-content/uploads/2014/12/teen_dating_abuse_2009_key_topline_findings-1.pdf 

6 Piolanti, A., Waller, F., Schmid, I. E., & Foran, H. M. (2023). Long-term Adverse Outcomes Associated With Teen Dating Violence: A Systematic Review. Pediatrics, 151(6), e2022059654. https://doi.org/10.1542/peds.2022-059654 

7 Pérez-Marco, A., Soares, P., Davó-Blanes, M. C., & Vives-Cases, C. (2020). Identifying Types of Dating Violence and Protective Factors among Adolescents in Spain: A Qualitative Analysis of Lights4Violence Materials. International journal of environmental research and public health, 17(7), 2443. https://doi.org/10.3390/ijerph17072443

8 Ibid.

9 Polanti et al. (2023)

10 Malik, M., Munir, N., Ghani, M. U., & Ahmad, N. (2021). Domestic violence and its relationship with depression, anxiety and quality of life: A hidden dilemma of Pakistani women. Pakistan journal of medical sciences, 37(1), 191–194. https://doi.org/10.12669/pjms.37.1.2893

11 Ibid.

12 Telloian, C. (2023, March 23). What Are the Effects of Emotional Abuse? https://psychcentral.com/health/effects-of-emotional-abuse#relationship-impacts 

13 PTSDuk. (2023). Causes of PTSD: Domestic Abuse. https://www.ptsduk.org/what-is-ptsd/causes-of-ptsd/domestic-abuse/

14 Ibid.

15 De Sousa, D., Paradis, A., Fernet, M., Couture, S., & Fortin, A. (2023). "I felt imprisoned": A qualitative exploration of controlling behaviors in adolescent and emerging adult dating relationships. Journal of adolescence, 95(5), 907–921. https://doi.org/10.1002/jad.12163

16 Guy, S. (2020, October 19). When Love is Blind: What Teens Don’t See in an Abusive Relationship. https://www.genesisshelter.org/when-love-is-blind-what-teens-dont-see-in-an-abusive-relationship/

17 Cleveland Clinic. (2022, February 14). Stockholm Syndrome. https://my.clevelandclinic.org/health/diseases/22387-stockholm-syndrome

18 Karakurt, G., Koç, E., Katta, P., Jones, N., & Bolen, S. D. (2022). Treatments for Female Victims of Intimate Partner Violence: Systematic Review and Meta-Analysis. Frontiers in psychology, 13, 793021. https://doi.org/10.3389/fpsyg.2022.793021

19 Ibid.

20 Pérez-Marco, et al. (2020)

21 Oğuztüzün, Ç., Koyutürk, M., & Karakurt, G. (2023). Characterizing Disparities in the Treatment of Intimate Partner Violence. AMIA Joint Summits on Translational Science proceedings. AMIA Joint Summits on Translational Science, 2023, 408–417. 

22 Wexler D. B. (1999). The broken mirror. A self psychological treatment perspective for relationship violence. The Journal of psychotherapy practice and research, 8(2), 129–141. 

The Bystander Effect - Inaction During an Emergency

The Kitty Genovese Tragedy

On March 13, 1964, 28-year-old Kitty Genovese was raped and stabbed outside of her apartment building in Queens, New York.[1] Thirty eight people saw the event and yet none of them called the police.[2] Residents of her apartment building turned their lights on after hearing her screams, yet it was after three separate attacks on her that someone finally called for help. At that point, it was too late and Kitty had brutally died. When some residents were asked why they did not call, they said that they “did not know”, were “tired”, thought that the altercation was a lover's quarrel and that they were “afraid”.  But was there something more that led to the missed opportunities of saving Kitty’s life?[3]

In times of danger, Raihani & Bshary (2015) note the existence of the innate human instinct to help those in need - even strangers.[4] However, the infamous Kitty Genovese story exposed a social phenomenon known as the bystander effect, demonstrating that people in a group are less likely to help someone in trouble than when they are alone.[5] Understanding the mechanisms of prosocial and helping behavior, being “good”, and the social and emotional triggers of helping others expand the explanations behind why people may help in some situations but not in others. 

Mechanisms of the Bystander Effect

Diffusion of Responsibility 

Despite being in a crowded neighborhood, Kitty's pleas for help went unanswered, leaving many questioning why 38 bystanders failed to intervene. Hortensius & Gelder (2018) note that the increased presence of other bystanders can create a diffusion of responsibility, leading individuals to assume someone else will take action.[6] As a result, the responsibility to help is shared among the group, leaving people less likely to individually act.

Pluralistic Ignorance 

Once assumed that another bystander will likely take action, the event is then interpreted socially. When bystanders rely on others to identify a social norm, the norm of inaction can often get established due to the diffused responsibility. For example, if no one else is doing anything about a potentially dangerous situation, it is likely that another bystander will interpret that norm and not do anything as well (e.g., when people ignore a fire alarm in a crowded, public place). This occurrence, or pluralistic ignorance, establishes an understanding of the emergency, and if it is socially perceived as an emergency or not.[7]

Understanding Altruistic Impulse

These bystander mechanisms are evidence-based ways to explain how people may act in emergency situations. However, several other factors contribute to why people do or do not help each other. Emotional models suggest that empathy plays a large role in why we help people, as Fultz et al. (1986) found that the more we empathize with someone, the more reason we find to help them.[8] This is because empathy allows people to experience the distress of others, leading to altruism. Additionally, Fultz et al. found that feelings of similarity to someone drive prosocial behavior (i.e., the actions by someone that are intended to be beneficial to someone else).[9]

However, where empathy may fail to result in helping lies the empathy gap, or the tendency for people to underestimate others’ experiences of social rejection or physical pain.[10] Further, Hotensius & Gelder point out that the disposition of the bystander may contribute to apathy.[11] It is important to note that personal values and moral principles significantly influence the decision to help others or to remain passive. For example, causal attribution towards someone in danger may affect perceptions of the person’s need for help and their level of effort, ultimately deciding if the bystander will help. Additionally, the Social Exchange Theory (introduced by George Homans in 1958) notes that people are more likely to help when there is no threat related to them helping and that people tend to avoid negative outcomes to themselves.[12] 

While the bystander effect highlights human passivity in some situations, it does not overshadow our innate altruistic impulse. Harnessing empathy can actually help to overcome issues involved in the bystander effect to reduce harmful emergency situations reliant on bystanders. For example, reminding oneself to take the perspective of the person in need may close the empathy gap and lead to prosocial actions. 

Social Influence: The Power of Norms

Social and situational factors can largely emphasize individual pursuits in a group by establishing norms. These established norms can then override other group members’ helping desires. In stories where the passive social norms won (such as the Kitty Genovese incident), it was socially agreed that a situation was safe based on others’ inaction, leading to more inaction by the group. Easily accepting inactive (passive) norms, even when situations are dangerous can be due to fears of negative social consequences. Collins (2017) notes that these concerns impact if someone helps in situations that involve sexual violence.[13] 

Overcoming the influence of normalcy may occur naturally. Collins adds that behavior perceived as more deviant from social norms receives more attention from bystanders, leading to more of a perception of emergency and an increased feeling of a responsibility to intervene.[14] However, in situations where norms limit the safety of the individual in danger by concealing the problem, bystander intervention becomes vital. For example, in a crowded party, bystanders may feel awkward intervening in a situation between two people even when they believe the situation to be unsafe. Strategies such as creating commotion and artificially making the situation socially deviant can attract attention to the issue.

Bystander Intervention 

The bystander effect can be employed to promote prosocial behavior rather than passive behavior. When individuals become leaders and understand typical signs of danger (e.g. sexual violence, stalking, coercion and heavy intoxication), this may be achieved.[15] A decisive figure who takes action can inspire others to follow suit, breaking the spell of diffusion of responsibility and pluralistic ignorance. Coker et al. (2019) also found that bystander interventions have reduced acceptance of sexual violence in relationships among 73,044 high school students, emphasizing collective responsibility for the well-being of others and the importance of taking individual action in group settings, even if it is awkward.[16] These types of interventions effectively reduce the negative impacts of the bystander effect and may also be implemented into therapy approaches to increase bystander confidence, agency, awareness, and willingness to intervene.

The Kitty Genovese story serves as a stark reminder of the bystander effect's potential consequences and the importance of understanding human behavior in emergencies. While the bystander effect may momentarily overshadow our altruistic nature, it cannot extinguish the innate compassion and empathy that people are capable of. Accessing this capacity is necessary to reduce the moments in which people did not help others when they could have. 

Contributed by: Phoebe Elliott

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 The New York Times. (1964, March 7). 37 Who Saw Murder Didn’t Call the Police; Apathy at Stabbing of Queens Women Shocks Inspector. https://www.nytimes.com/1964/03/27/archives/37-who-saw-murder-didnt-call-the-police-apathy-at-stabbing-of.html 

2 Ibid.

3 Ibid.

4 Raihani, N. J., & Bshary, R. (2015). Why humans might help strangers. Frontiers in behavioral neuroscience, 9, 39. https://doi.org/10.3389/fnbeh.2015.00039

5  Benderly, B. L. (2012) Psychology's Tall Tales: Who Tried to Help Kitty Genovese? https://www.apa.org/gradpsych/2012/09/tall-tales#:~:text=No%20one%20doubts%20that%20Kitty,hours%20of%20March%2013%2C%201964 

6 Hortensius, R., & de Gelder, B. (2018). From Empathy to Apathy: The Bystander Effect Revisited. Current directions in psychological science, 27(4), 249–256. https://doi.org/10.1177/0963721417749653

7 Ibid. 

8 Fultz, J., Batson, C. D., Fortenbach, V. A., McCarthy, P. M., & Varney, L. L. (1986). Social evaluation and the empathy-altruism hypothesis. Journal of personality and social psychology, 50(4), 761–769. https://doi.org/10.1037//0022-3514.50.4.761

9 Ibid.

10 Nordgren, L. F., Banas, K., & MacDonald, G. (2011). Empathy gaps for social pain: why people underestimate the pain of social suffering. Journal of personality and social psychology, 100(1), 120–128. https://doi.org/10.1037/a0020938

11 Hortensius, R., & de Gelder, B. (2018)

12 Online MSW Programs. (February 2022). Introduction to Social Exchange Theory in Social Work. https://www.onlinemswprograms.com/social-work/theories/social-exchange-theory/#:~:text=Social%20exchange%20theory%20was%20developed,seen%20as%20a%20social%20system.

13 Collins, K. (2017). The Impact of Social Norms on Bystander Behaviors to Prevent Campus Sexual Violence. https://via.library.depaul.edu/cgi/viewcontent.cgi?article=1244&context=csh_etd 

14 Ibid.

15 Ibid.

16 Coker, A. L., Bush, H. M., Brancato, C. J., Clear, E. R., & Recktenwald, E. A. (2019). Bystander Program Effectiveness to Reduce Violence Acceptance: RCT in High Schools. Journal of family violence, 34(3), 153–164. https://doi.org/10.1007/s10896-018-9961-8 

Managing ADHD: Medication, Psychotherapy, and the Potential of Music Therapy

The ABCs of ADHD

ADHD is a prevalent neurodevelopmental disorder that primarily manifests in childhood and often continues into adulthood and is characterized by difficulties in maintaining attention, controlling impulsive behaviors (acting without considering the consequences), and excessive levels of activity.[1] It impacts approximately 11 percent of children attending school; in over 75 percent of cases, symptoms persist into adulthood. Although individuals with ADHD have the potential for success, it is crucial to identify and treat the condition appropriately and in a timely manner. Without proper intervention, ADHD can lead to significant consequences, including academic difficulties, strained family relationships, emotional distress, challenges in forming and maintaining social connections, substance misuse, involvement in delinquent behaviors, accidental injuries and difficulties in employment. Early identification and timely treatment play a vital role in mitigating these potential effects.[2] There are a number of intervention methods for people who experience symptoms of ADHD.

Common Treatments

Two common treatments for ADHD include medication and psychotherapy. 

Medication

ADHD medication is used to address the symptoms such as hyperactivity and impulsiveness.[3] 

Types of ADHD Medication Include:[4]

• Stimulants

• Non-stimulants

• Antidepressants 

Stimulants, such as medications containing methylphenidate or amphetamine, are the usual primary prescriptions for ADHD. These stimulants seem to enhance and stabilize the levels of neurotransmitters, which are brain chemicals responsible for various functions.[5] However, stimulants are classified as controlled substances, implying that they possess the risk of being misused or leading to substance use disorders.

Additional medications utilized in ADHD treatment consist of non-stimulant options (e.g., atomoxetine) and certain antidepressants (e.g., bupropion).[6] While non-stimulants are prescription medications, unlike stimulants, they are not classified as controlled substances. As a result, the risk of improper use or dependency is lower with non-stimulant medications. These medications function by elevating the levels of norepinephrine in the brain. Healthcare providers may prescribe non-stimulant medications either on their own or in conjunction with a stimulant for managing ADHD. 

Antidepressants are also used to treat symptoms of ADHD. The antidepressants commonly prescribed for ADHD primarily target the levels of dopamine and norepinephrine in the brain.[7] While atomoxetine and antidepressants have a slower onset of action compared to stimulants, they can still be viable choices when stimulants are not suitable due to health issues or when the side effects of stimulants are too severe for someone.[8] 

Psychotherapy

Psychotherapy is frequently utilized alongside medication to address mental health conditions. Depending on the situation, medication might be the more appropriate choice in some cases, while psychotherapy may be the preferred option in others.[9] 

Psychotherapy can assist people with ADHD in various ways:[10]

• Enhancing time management and organizational abilities 

• Teaching techniques to minimize impulsive behavior 

• Fostering improved problem-solving skills 

• Dealing with past academic, work, or social challenges 

• Boosting self-esteem

• Learning methods to strengthen relationships with family, co-workers, and friends

• Developing strategies to manage anger effectively

The typical forms of psychotherapy for ADHD treatment include cognitive behavioral therapy (CBT), marital counseling and family therapy. CBT involves a structured approach to teach skills for behavior management and transforming negative thought patterns into positive ones. It aids in handling life challenges like school, work, or relationship issues and also addresses other mental health conditions such as depression or substance misuse.[11] Marital counseling and family therapy aim to assist family members in coping with the challenges of living with someone who has ADHD. They provide tools and techniques to improve communication and problem-solving skills within the family dynamic.[12] 

Music Therapy

There is another form of psychotherapy that can be utilized for treatment of the symptoms of ADHD known as music therapy. Music therapy is a form of psychotherapy that follows a systematic process of intervention. The therapist employs musical experiences and the relationships that evolve from them as dynamic catalysts for promoting health in the client.[13]

During a music therapy session, a patient may:[14]

• Create music

• Sing music

• Listen to music

• Move to music

• Discuss lyrics

• Play an instrument

Music plays an inherent role in the human experience, eliciting responses related to pulse, rhythm, breathing, movement and a wide array of emotions. These deep connections with music can persist even in the face of disabilities and illnesses. As a result, music therapists and counselors can effectively use music to assist individuals, both children and adults, who have diverse needs arising from various causes such as learning disabilities, mental and physical illnesses, physical and sexual abuse, stress and terminal illnesses. Through interactive musical experiences, emotional, cognitive and developmental needs can be addressed.[15] The ADHD brain exhibits reduced levels of dopamine, a neurotransmitter that plays a crucial role in motivation, attention, working memory, and focus. Music has the unique ability to activate both hemispheres of the brain, facilitating comprehensive brain engagement, allowing the activated components to collaborate more effectively and potentially strengthen over time. Consequently, this process enhances motivation and improves the capacity to concentrate.[16]

A number of studies have highlighted the positive effects of music therapy on people with ADHD. One study conducted by Zhang et al. (2017) aimed to assess the effectiveness of music therapy in improving attention, behavior, and social skills in children and adolescents with ADHD. Music therapy was associated with a significant reduction in hyperactivity and impulsivity, and improvements in attention, social skills, and academic performance.[17] Another study by Park et al. (2023) investigated the effects of music therapy as an alternative treatment on depression in children and adolescents with ADHD by activating serotonin and improving stress coping ability. The results showed that both music therapy and pharmacotherapy were effective in reducing depression symptoms.[18]

If you are interested in finding out if Music Therapy can benefit you, you can access the American Music Therapy Association’s provider link here. 

If you or someone you know has or suspects that they have ADHD, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ananya Kumar

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Centers for Disease Control and Prevention. (2022). What is ADHD?. CDC.

https://www.cdc.gov/ncbddd/adhd/facts.html#:~:text=ADHD%20is%20one%20of%20the,)%2C%20or%20be%20overly%20active

2 Children and Adults with Attention-Deficit/Hyperactivity Disorder. (2023). About ADHD - Overview. CHADD. https://chadd.org/about-adhd/overview/ 

3 Mayo Clinic. (2023). Adult attention-deficit/hyperactivity disorder (ADHD). https://www.mayoclinic.org/diseases-conditions/adult-adhd/diagnosis-treatment/drc-20350883#:~:text=and%20certain%20medications-,Treatment,they%20don%27t%20cure%20it

4 Cleveland Clinic. (2022). ADHD Medication. https://my.clevelandclinic.org/health/treatments/11766-adhd-medication

5 Mayo Clinic

6 Ibid.

7 Cleveland Clinic

8 Mayo Clinic

9 Bhatia, Richa. (2023). What is Psychotherapy?. American Psychiatric Association. https://www.psychiatry.org/patients-families/psychotherapy

10 Mayo Clinic

11 Ibid.

12 Ibid.

13 Zhang F, Liu K, An P, You C, Teng L, Liu Q. Music therapy for attention deficit hyperactivity disorder (ADHD) in children and adolescents. Cochrane Database Syst Rev. 2017 May 2;2017(5):CD010032. doi: 10.1002/14651858.CD010032.pub2. PMCID: PMC6481398.

14 Music Therapy. (2020). Cleveland Clinic. https://my.clevelandclinic.org/health/treatments/8817-music-therapy

15 Zhang (2017)

16 Attention Deficit Disorder Association. (2022). Can Music Therapy Help with ADHD?. ADDA. https://add.org/can-music-therapy-help-with-adhd/

17 Zhang (2017)

18 Park, J. I., Lee, I. H., Lee, S. J., Kwon, R. W., Choo, E. A., Nam, H. W., & Lee, J. B. (2023). Effects of music therapy as an alternative treatment on depression in children and adolescents with ADHD by activating serotonin and improving stress coping ability. BMC complementary medicine and therapies, 23(1), 73.

Understanding Electroconvulsive Therapy for Treatment-Resistant Depression

ECT in A New Light 

Electroconvulsive therapy (ECT) is a non-invasive method of inducing brief seizures using an electrical current to relieve symptoms of psychiatric conditions.[1] First administered in 1938 by Italian scientists Ugo Cerletti and Lucio Bini to alleviate symptoms of schizophrenia, ECT has now evolved into a strong treatment option for people suffering from major depressive disorder (MDD).[2,3] However, while ECT has been shown to have greater efficacy than pharmacotherapy in the treatment of MDD, the misconceptions and lack of knowledge about this treatment have led it to become underutilized,[4] with Kellner et al. (2020) noting that less than 1% of depressed individuals are treated with ECT.[5] 

Applications for Depression 

Major depressive disorder has been on the rise over the past decade and now affects over 300 million people worldwide.[6] Those suffering from MDD will experience symptoms such as depressive mood, poor energy, thoughts of guilt or worthlessness, change in weight or appetite, or thoughts about suicide or death for over two weeks. These depressive episodes are quite common - as the National Institute of Mental Health (NIMH) reported 21 million Americans suffered from an episode of MDD in 2020.[7] Additionally, 30% of those suffering from MDD, are categorized as having treatment-resistant depression (TRD) - meaning they have failed to respond to at least two adequate trials of antidepressant medication. This is especially problematic, as Salani et al. (2023) caution that 30% of individuals with TRD have been found to attempt suicide at least once in their life.[8]

In a meta-analysis conducted by Park et. al. (2021), ECT was reported to have a response rate of 50-60% of individuals with TRD while those using antidepressants had a response rate of only 17%.[9] ECT’s effectiveness is most effective in the short term, with a response rate estimated between 80-90%; however, the relapse rate does increase once ECT is suspended. Therefore, given the high response rate of this treatment, it is best used for populations at greatest risk (i.e., those with suicidal ideation, suicide attempts, postpartum depression, and psychotic depression.).[10] 

A study conducted by Husain et al. (2004) utilized over 250 participants and found over 50% improved their depression score by their third treatment session and 75% achieved remission by their tenth treatment.[11] Additionally, a 2021 meta-analysis from Park et al. (2021) reported that when ECT was administered over the course of one year, the relapse rate reached 50% while the placebo group reached a relapse rate of 84%.[12] Subramanian et al. (2022) explain that the goal is to continue acute ECT treatment until the patient has reached remission or until an improvement plateau is achieved.[13] Therefore, continued maintenance ECT allows the patient to continue the positive benefits of treatment with little to no major side effects. 

The most effective treatment for MDD and TRD is actually a combination of ECT and pharmacotherapy.[14] A meta-analysis conducted by Plugims et al. (2021) found that across nine randomized trials and studies, the overall effects of antidepressants paired with ECT were greater than those compared to ECT combined with a placebo.[15] Another study by Brådvik & Berglund (2006) found similar results when investigating ECT in comparison with pharmacotherapy in patients with unipolar or bipolar disorder. They noted suicide attempts reached as low as 2% after ECT plus pharmacotherapy, 8% from ECT alone, and 20% from pharmacotherapy alone.[16] These developments in ECT in combination with pharmacotherapy give individuals suffering from MDD and TRD a new path of treatment and can allow them relief quicker than traditional therapies. 

Procedure 

Before a patient can be approved for ECT, they must receive a pretreatment psychiatric assessment, a medical history and physical examination, an electrocardiogram, a general anesthetic evaluation, and a laboratory evaluation of metabolic panel and urine chemistries.[17] These procedures will assist medical professionals in determining if any special attention needs to be given or if certain medical conditions will contradict the ECT. In addition, written informed consent must be acquired from the patient or court-approved legal guardian before treatment.[18] 

During the treatment: 

• Dosage (of charges) is determined based on the type of ECT treatment and seizure threshold of the individual.

• Oxygen is administered and an anesthetic and muscle relaxant are given through an IV.

• Electrodes are placed on specific locations on the head. 

• A mental healthcare provider ensures the administered muscle relaxant is effective and that all vitals are stable.

• An electrical current is sent through the electrodes into the brain causing a grand-mal seizure lasting under a minute.

• The patient is then taken off anesthesia and is monitored until they can breathe unassisted. Patients wake up within five to ten minutes after the procedure.[19,20] 

Depending on the patient and the severity of their depression, treatment can range from multiple sessions a week to every few months. Typically, patients will need six to twelve treatments in conjunction with the use of antidepressants or mood-stabilizing medication.[21] 

Possible side effects of ECT include: 

• Headaches 

• Muscle aches 

• Upset stomach 

• Disorientation or confusion immediately following the procedure

• Impaired speech fluency 

• Anterograde amnesia for recent information 

• Retrograde amnesia for long-term autobiographical information 

Most side effects will subside within minutes to hours, but others, like memory loss, can last days to weeks following the procedure. However, memory loss issues are more common with bilateral ECT; therefore, unilateral ECT has become the preferred treatment as it has been shown to have less effect on one’s memory.[22]

How it Works 

To date, there is no definite theory as to why ECT produces such therapeutic effects on patients. The lack of consensus can be due to the complexity of the central nervous system and the challenges faced when identifying the neurological components that are involved with ECT.[23] Nevertheless, it is increasingly important to try to make sense of this therapy's effect on the brain to lessen any misconceptions regarding this form of treatment. In particular, expanding the knowledge on the neurological components of ECT will allow the public and medical professionals to form a better understanding of ECT and why it can be so useful and effective for those suffering from mental health issues. 

While there are many hypotheses that have been made to try to explain the benefits of ECT, the most notable ones include: changes in cerebral blood flow and regional metabolism, alterations in neuroplasticity, changes in the expression of brain-derived neurotrophic factors (BDNF), and alterations in the process of neurotransmitters like serotonin, dopamine, acetylcholine, and norepinephrine.[24,25]

ECT for Special Patient Groups 

ECT has also been proven to be effective for patients who may not be able to take traditional medications (e.g., pregnant women, the elderly, and adolescents).[26]

Depression is one of the most common mental disorders during pregnancy, with approximately 9% of pregnant women and 50% of postpartum women experiencing MDD and ECT has been reported as generally safe to use during the entirety of pregnancy.[27] In 37 cases of pregnant women with MDD or depression, 83% reached at least partial remission. Additionally, in a study by Rundgren et al. (2018) evaluating 185 subjects, the postpartum group responded to ECT 87% more than the matched non-postpartum depression comparison group. Thus, ECT can provide a safe and effective treatment for pregnant and postpartum mothers who may not have any alternatives to their MDD.[28]

Geriatric depression has also been shown to greatly benefit from ECT. A study by Dols et al. (2017) compared those with late onset (>55 yrs. old) late-life depression were more responsive to ECT at 86.9% than those with early onset (<55 yrs. old) late-life depression at 67.3%.[29] Elderly patients who received ECT typically reached remission in approximately 3.1 weeks.[30]  

ECT has also been approved for people 13 years or older, thus giving a strong treatment option for adolescents facing high risk of suicide, those suffering from primary mood disorders, catatonia, schizophrenia, or those who are resistant to other treatment methods.[31,32] 

Expanding Access to ECT 

While ECT has been proven to be a strong treatment for MDD, many barriers still stand in the way of expanding treatment. A nationwide survey by Wilkinson et al. (2021) found 192 ECT providers noted significant barriers to providing ECT services to patients. These barriers included: a lack of training for medical staff, transportation issues, lack of space for providing such services, concern about side effects, and stigma about ECT. The survey also found there were only 2.97 providers per 1 million individuals in each state, and states such as Alaska and Idaho had no providers at all.[33]

Stigma is a major concern for expanding ECT treatment as many misconceptions have been drawn from TV and film which portray this therapy as inhumane and harmful to individuals.[34] This misinformation can stop individuals from seeking treatment and may even cause bias in healthcare professionals. Since ECT training is traditionally not included in nursing programs, Salani et al. (2023) discusses the potential for harm to occur if a nurse unknowingly impacts the patient’s understanding of the benefits and procedure based on personal bias and attitudes toward this type of treatment.[35] By expanding training programs for nurses and mental health care providers, it will allow them to address any misconceptions they, their patients or families may hold so they can be fully informed when choosing what treatment option is right for them.[36]

If you or someone you know is struggling with depression, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ryann Thomson

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Brain stimulation therapies. (n.d.). National Institute of Mental Health (NIMH). https://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies 

2 Gazdag, G., & Ungvari, G. S. (2019). Electroconvulsive therapy: 80 years old and still going strong. World Journal of Psychiatry, 9(1), 1–6. https://doi.org/10.5498/wjp.v9.i1.1 

3 Salani, D., Goldin, D., Valdes, B., & De Santis, J. P. (2023). Electroconvulsive Therapy for Treatment-Resistant Depression: Dispelling the stigma. Journal of Psychosocial Nursing and Mental Health Services, 61(6), 11–17. https://doi.org/10.3928/02793695-20230222-02 

4 Park, M. J., Kim, H., Kim, Y. H., Yook, V., Chung, I. W., Lee, S. M., & Jeon, H. J. (2021). Recent Updates on Electro-Convulsive Therapy in Patients with Depression. Psychiatry Investigation, 18(1), 1–10. https://doi.org/10.30773/pi.2020.0350

5 Salani et al., (2023) 

6 Subramanian, S., Lopez, R., Zorumski, C. F., & Cristancho, P. (2022). Electroconvulsive therapy in treatment resistant depression. Journal of the Neurological Sciences, 434, 120095. https://doi.org/10.1016/j.jns.2021.120095 

7 Major Depression. (n.d.). National Institute of Mental Health (NIMH). https://www.nimh.nih.gov/health/statistics/major-depression

8 Salani et al., (2023) 

9 Park, M. J., Kim, H., Kim, Y. H., Yook, V., Chung, I. W., Lee, S. M., & Jeon, H. J. (2021). Recent Updates on Electro-Convulsive Therapy in Patients with Depression. Psychiatry Investigation, 18(1), 1–10. https://doi.org/10.30773/pi.2020.0350

10 Park et al., (2021) 

11 Subramanian et al., (2022) 

12 Park et al., (2021) 

13 Subramanian et al., (2022) 

14 Payne, N., & Prudic, J. (2009). Electroconvulsive Therapy: Part I. A Perspective on the Evolution and Current Practice of ECT. Journal of Psychiatric Practice, 15(5), 346–368. https://doi.org/10.1097/01.pra.0000361277.65468.ef

15 Subramanian et al., (2022)

16 Park et al., (2021) 

17 Salani et al., (2023) 

18 Ibid. 

19 Brain Stimulation Therapies (n.d.) 

20 Salani et al., (2023) 

21 Brain Stimulation Therapies (n.d.) 

22 Salani et al., (2023) 

23 Payne & Prudic (2009) 

24 Ibid. 

25 Singh, A., & Kar, S. K. (2017). How electroconvulsive therapy works?: Understanding the neurobiological mechanisms. Clinical Psychopharmacology and Neuroscience : The Official Scientific Journal of the Korean College of Neuropsychopharmacology, 15(3), 210–221. https://doi.org/10.9758/cpn.2017.15.3.210

26 Salani et al., (2023) 

27 Ibid. 

28 Park et al., (2021) 

29 Ibid. 

30 Salani et al., (2023) 

31 Brain Stimulation Therapies (n.d.) 

32 Salani et al., (2023) 

33 Ibid.

34 Payne & Prudic (2009) 

35 Salani et al., (2023) 

36 Ibid. 

Traumatic Brain Injuries: Why Survivors Face an Increased Risk of Developing Depression and Anxiety

Alleviating the Aftermath of a TBI

Each year, approximately 2.5 million individuals suffer from a traumatic brain injury (TBI) in the United States.[1] As a result of suffering a TBI, individuals can experience a multitude of physical effects, including: mood changes, memory or concentration problems, difficulty sleeping, headaches and fatigue.[2] In addition, individuals who experience a TBI are also more susceptible to developing a mental health disorder. A study conducted by Fann and colleagues in 2004 found that 49% of individuals who suffered a moderate to severe TBI and 36% of those with mild TBI also received a psychiatric diagnosis within a year following their injury. The prevalent comorbidity of traumatic brain injuries and mental health disorders is one that must not be overlooked by physicians and mental health care providers.[3] 

Depression after a TBI: a distinct disease

Depression is one of the most common mental health disorders that TBI survivors face. The heightened risk for depression is largely due to the stress that occurs on the brain following a traumatic injury, such as a TBI. The brain’s neural pathways can become altered with a TBI, causing formally strong and functional pathways within the brain to no longer work properly.[4] How this relates to depression is we rely heavily on these pathways to understand and communicate our own emotions. With damage to these pathways, it becomes difficult to carry out these crucial functions, subsequently leading to an inability to process emotions.[5]

Common symptoms of depression that an individual may face following a traumatic brain injury include:[6]

• Feelings of sadness, emptiness, or hopelessness

• Angry outbursts, irritability or frustration 

• Sleep disturbances

• Tiredness and lack of energy, with small tasks taking extra effort

• Feelings of worthlessness or guilt

• Trouble thinking, concentrating, or decision-making

Anxiety after a TBI

In addition to depression, anxiety is a common problem individuals face after experiencing a traumatic brain injury. Due to the changes that can occur to an individual following their accident, they may feel overwhelmed more easily in situations that previously did not bother them. This can be due to the fact that individuals may struggle to focus, think fast, or process information quickly - so in situations where these tools must be used, they can become easily anxious.[7] It's also important to note that individuals who suffered from anxiety prior to their TBI may find their symptoms have worsened following their accident and more difficult to manage.[8] Common symptoms of anxiety that an individual may experience after a TBI include:[9]

• Feeling nervous, restless, or tense

• Having a sense of impending danger or doom

• Having an increased heart rate

• Breathing rapidly 

• Having trouble sleeping

• Having difficulty controlling worry

Targeted treatments

In order to effectively help treat the depression and anxiety that can occur following a TBI, combination therapy should be used. However, these therapies must be targeted directly to an individual’s TBI. The first treatment course that is often considered when attempting to alleviate the symptoms of depression and anxiety are SSRIs. This class of antidepressants are often used in the treatment of anxiety and depression, and work to increase the amount of serotonin in the brain.[10] The reason why they work so well in the treatment of depression and anxiety after a traumatic brain injury is their dopaminergic effects can help improve cognition in individuals who have suffered a TBI, while also improving their mental state.[11]

In addition to pharmacological interventions, cognitive behavioral therapy (CBT) is extremely effective at helping depression and anxiety in TBI survivors. Cognitive behavioral therapy may be tailored to utilize two things: cognitive restructuring and behavioral activation. Cognitive restructuring helps survivors address and redirect irrational thoughts following their accident, which allows an individual to shift to a more positive mental space.[12] Behavioral activation is a tool used when treating TBI survivors to encourage them to plan activities to improve their mood. This could be as simple as planning a daily walk or as extravagant as a trip away; using this technique allows survivors to look forward to their life again.[13]

Another extremely important treatment in addressing depression and anxiety following a TBI is positive psychology. Positive psychology helps to rewire a survivor's brain and encourage them to use forward, optimistic thinking. This could include simply writing in a journal a gratitude list for the day, or expressing positive thoughts out loud to another individual, daily. This practice has been extremely helpful with survivors' neuroplasticity - the ability of the brain to reform and strengthen neural pathways in the brain. Following a TBI, these pathways can be lost, which is why rewiring these pathways with positive thinking can help alleviate feelings of anxiety and depression.

Overall, it is essential that TBI survivors understand the risk factors for and key signs of anxiety and depression. If you or someone you know would like to learn more about how to seek help alleviating the symptoms of anxiety and depression following a TBI, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support. 

Contributed by: Daphne Lasher

Editor: Jennifer (Ghahari) Smith, Ph.D.

references

1 Brain Trauma Foundation. (n.d.). Frequently asked questions (FAQ). Brain Trauma Foundation. https://braintrauma.org/info/faq#:~:text=Each%20year%20about%202.5%20million,Falls%20(28%25)

2 The Mayo Clinic. (2021, February 4). Traumatic brain injury. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/symptoms-causes/syc-20378557

3 Fann, J. R., Burington, B., Leonetti, A., Jaffe, K., Katon, W. J., & Thompson, R. S. (2004). Psychiatric illness following traumatic brain injury in an adult HealthMaintenance organization population. Archives of General Psychiatry, 61(1), 53. https://doi.org/10.1001/archpsyc.61.1.53

4 Cooney, E. (2023, July 6). Why depression after traumatic brain injury is distinct - and less likely to respond to standard treatment. STAT. https://www.statnews.com/2023/07/06/depression-after-traumatic-brain-injury/

5 Ibid. 

6 The Mayo Clinic. (2022, October 14). Depression (major depressive disorder). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007

7 Model System Knowledge Translation Center

8 Ibid.

9 The Mayo Clinic. (2018, May 4). Anxiety disorders. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/anxiety/symptoms-causes/syc-20350961

10 The Mayo Clinic. (2019, September 17). The most commonly prescribed type of antidepressant. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/depression/in-depth/ssris/art-20044825

11 Fann, J. R., Hart, T., & Schomer, K. G. (2009). Treatment for depression after Traumatic Brain Injury: A systematic review. Journal of Neurotrauma, 26(12), 2383–2402. https://doi.org/10.1089/neu.2009.1091

12 Flint Rehab. (2023, January 6). Brain injury and depression: Causes, symptoms, & treatments. Flint Rehab. https://www.flintrehab.com/brain-injury-and-depression/ 

13 Ibid.