A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Objective: Mental health plays a central role in the well‐being of individuals. Understanding the factors that influence mental wellness is critical in order to develop effective policy that addresses the burden of mental illness in society. The objective of this study is to identify a possible relationship between healthcare access and the presence of mental distress in individuals. Methods: Logistic regression was performed using cross sectional data from a CDC developed nationwide behavioral health surveillance program (BRFSS, 2013‐4). Odds ratios were estimated using frequent mental distress as the outcome of interest while adjusting for confounding variables such as smoking, binge drinking, obesity, etc. Six models were estimated utilizing our hypothesized variables of interest. Results: The calculated adjusted odds ratios (AOR) and confidence intervals (CI) demonstrated a positive correlation between certain variables measuring access to healthcare and the reporting of frequent mental distress, agreeing with the hypothesis. Those variables were financial cost preventing access to medical care (AOR [2], CI [1.9‐2.1]) as well as a span of more than 2 years having elapsed since a routine medical checkup by a healthcare provider (AOR [1.1], CI [1.1‐ 1.2]). The opposite effect was demonstrated in individuals who had no insurance coverage (AOR [.8], CI [.7‐.9]), which was contrary to the hypothesis. Conclusion: After adjusting for confounding variables, a strong relationship exists between individuals who are not able to see a physician due to cost, and the presence of frequent mental distress. Frequent mental distress is also increased in individuals who have not had a routine medical checkup with a physician in the last 2 years.

This thesis is an investigation of social problem-solving skills, psychological distress, and supportive relationships among three distinct samples. The research groups comprise a) 25 depressed inpatients and a matched comparison group; b) 50 hospital admissions following an act of suicidal behaviour; and c) 5 sub-groups of incarcerated young offenders (inmates on Strict Suicidal Supervision, inmates on protection, victims of bullying, identified bullies, comparison group) with 25 inmates in each group. Data was collected by structured interviews, standardised psychometric measures of mood states (e.g. Hospital Anxiety and Depression Scale, Beck Hopelessness Scale), problem-solving ability (e.g. Means-Ends Problem-Solving Procedure) and supportive relationships (e.g. Significant Others Scale). Data were analysed by means of parametric statistical techniques (e.g. analyses of variance and multiple regression analyses). Eight cross-sectional studies are reported. Depressed patients demonstrated problem-solving difficulties, which were related to the level of psychological distress experienced. Clinically depressed patients were also found to differ from a comparison group in their autobiographical memory recall and concentration ability - both of which were related to their impoverished problem-solving ability. Deficits in problem-solving ability in the depressed patients were not an artefact of their verbal IQ. Regression analyses of the data relating to suicidal community inpatients illustrated that social support variables were the prime predictors of suicidal intent, depression and hopelessness. Social problem-solving variables also emerged as significant predictors of psychological distress, albeit to a lesser extent. Social support and problem-solving variables were also important moderator variables in the relationship between stress and suicidality. The studies conducted with young offenders illustrated a hierarchy of problem-solving deficits and psychological distress among the inmate groups. Problem-solving ability was not an artefact of verbal IQ. The value of using problem-solving interventions with vulnerable offenders is discussed. The importance of prison relationships in the experience of stress by inmates was also highlighted. Similarly, parental relationships were related to the levels of distress experienced while incarcerated. The results of each study are discussed in relation to the relevant literature, practical implications for clinical interventions with each group, and suggestions for future research. The findings of the thesis are discussed in relationship to transactional, stress-hopelessness-distress models of psychological illness and distress.

Recent scholarly efforts have sought to examine the cumulative impact of deleterious adverse childhood exposures on various mental health outcomes. Lifetime prevalence rates for depressive disorders are approximately 20% among adolescents. Depression is ranked as the leading cause for disability and fourth leading contributor to the global burden of disease in the world. The purpose of this study was to determine the cumulative impact of adolescent adverse experiences on outcomes of depression, suicide ideation, and overall mental distress in a cohort of 125 adolescent girls receiving public assistance. The adverse exposures studied were personal victimization, household dysfunction, and community violence exposures. Across the three categories of exposures, adolescents reported that community exposures were the highest 92.8%, followed by household dysfunction 89.6 %, and lastly, personal victimization 80%. Over 40% reported experiencing more than seven adverse exposures. There was a doubling in the incidence of depression by the fourth year, and an almost ten percent increase in mental distress by the fourth year. Evidence of a significant direct association was found for those experiencing victimization with depression and suicide ideation. The total Adolescent Adverse Exposures (AAE) score was positively correlated with the CES-D scores in the last three years of the study, however not with suicide ideation. The cumulative impact or 'dose-response' relationship of such exposures on depression, suicide ideation, or change over time was not found. In contradiction with general beliefs and existing literature, a significant negative association was found with depression and having a parent incarcerated or experiencing the divorce of parents. This finding suggests given the homogeneity of this population, experiencing both poverty and high levels of exposure to victimization, that having an incarcerated parent or parental divorce may be potentially protective mitigating the stressful experiences of continued victimization. The results of this study offer evidence of high prevalence rates of adversity occurring in the lives of these already at risk adolescents. A call for efforts to reduce community violence and personal victimization in the context of poverty are needed to prevent the growing rates of depression and suicide ideation for these fragile families and adolescence.

The COVID-19 pandemic is a global traumatic stressor affecting millions of individuals worldwide. Traumatic events often cause significant resource loss and negatively affect mental health and emotional well-being. In the wake of trauma, many people draw on religious or spiritual faith to cope with adversity and suffering. One construct that has received increased attention within the field of religious/spiritual coping is spiritual fortitude (SF). SF refers to the one's ability to consistently draw on spiritual resources to transcend negative emotions in the face of stressors. In this study, I recruited 255 participants who had lived during the COVID-19 pandemic. Participants completed measures of resource loss, religious/spiritual struggles, SF, religious commitment, depression, anxiety, and post-traumatic stress disorder (PTSD) symptoms. The overall results suggested participants utilized a wide range of coping strategies (e.g., religious/spiritual, social, health practice) during the COVID-19 pandemic. Both resource loss and religious/spiritual struggles were positively associated with mental distress. SF buffered the deleterious relationship between resource loss and mental distress. Specifically, for individuals high in SF, the relationship between resource loss and mental distress was weaker than for individuals low in SF.

Background: There are about 23.7 million internally displaced persons worldwide today, still living in the low-income countries. Ethiopia has for the past four decades been ravaged by war and famine. A lengthy civil war resulted in Eritrea, formerly a part of Ethiopia, becoming an independent state in 1991. This war led to displacement of one million people, and currently there are about 55000 internally displaced Ethiopians in Addis Ababa, most of them living in temporary shelters. A minority resettled in a small town Debre Zeit south east of Addis Ababa, dispersed in the community. Objectives: To study the consequences of trauma and extreme stress among these displaced persons. Methods: A random sample of 1200 displaced persons was selected from the Kaliti and Kore shelters of Addis Ababa, aged between 18 and 60 years. They were interviewed by internationally validated instruments which were translated into the Ethiopian official language Amharic. Information thus obtained covered sociodemographics, childhood trauma, traumatic life events, and mental distress as assessed by the SCL-90-R, the four domains of quality of life assessed by WHOQOL-BREF, coping strategies, perceived social support, and basic living conditions. A sample of 120 subjects from the displaced persons living in Debre Zeit was similarly evaluated. A study comparing prevalence rates and risk factors for PTSD in four postconflict, low-income countries (Algeria, Cambodia, Ethiopia, Gaza) was also undertaken. Results: Men, compared to women, reported significantly higher experience of trauma, higher perceived social support, and higher task-oriented coping. Women reported higher emotion-oriented coping. In both genders, emotion-oriented coping was correlated with higher trauma events, and task-oriented coping was correlated with higher perceived social support. Mental distress increased and quality of life decreased with age. Mental distress mediated the effects of most trauma in reducing quality of life, and some trauma reduced quality of life directly. Living conditions were also significantly related to quality of life. Coping strategies and perceived social support influenced mental distress and quality of life directly as well as indirectly by moderation, in part gender specific. Placement in the community setting of Debre Zeit gave a better quality of life compared to placement in the shelters of Addis Ababa. This difference was accounted for by the difference in living conditions, particularly protection from animals (rodents) and insects (mosquitoes), for three domains of quality of life. For domain 3 (social relationships), however, several further factors accounted for the difference, like marital status, ethnic belonging and coping strategy. The comparative study of 4 postconflict countries contributes to the theory that trauma may be the direct cause of the onset of PTSD but that a multiplicity of other adverse events determine the development of this disorder. Conclusions: Using the same assessment methods, a wide range of rates of symptoms of PTSD were found among 4 low-income populations who have experienced war, conflict, or mass violence. In the Ethiopian context we also found gender differences in the trauma background, coping strategies and perceived social support. Mental distress mediated much of the effects of trauma on quality of life. Coping strategies and perceived social support were significant moderators in this process.

It is very important to study the mental health impact of disasters to provide adequate mental health services when there is an increased demand of mental health services and a concurrent deterioration of mental healthcare capacity after disasters. This study examined the mental health impact of 9/11 attacks among the individuals living close to the disaster area and compared them to the individuals living farther from the disaster area. New York (NY) state and Washington DC were selected as the disaster areas and Illinois (IL) was selected to study individuals living farther from the disaster area. The study also assessed the effects of mental health on risky behaviors such as cigarette smoking and alcohol consumption and how they vary based on age, gender and proximity to the disaster. Ten year Behavior Risk Factor Surveillance System (BRFSS) data from 1996-2005 was obtained for NY, DC and IL. Significant increase in mental distress was observed in NY and DC but not in IL. Increased use of alcohol was found among DC and NY residents but the increase in IL was not significant. Logistic regression showed that increase in alcohol consumption was not associated with mental health. An overall decrease in cigarette smoking was observed and there was no impact of disaster on smoking rates. Mental distress was much higher among the female respondents as compared to the male respondents. Mental distress was highest among 35- 49 year old respondents as compared to other age groups. In future longitudinal studies should be conducted in order to establish the causal relationship of mental health and risk behaviors such as smoking and alcohol consumption after disasters. Most of the interventions regarding post-disaster mental health focus on PTSD but other mental disorders should also be addressed.

Aim: The overall aim of this thesis was to study mental distress, health and lifestyle habits, social factors and psychotropic drug use by young people, and how PHNs conceive their roles in relation to this. Methods: Quantitative and qualitative methods were used. Study I included data  from the Norwegian Youth Health Study (NYHS, 11 620 participants, aged 15-16 years) (2000–2003) linked to the Norwegian Prescription Database (NorPD) (2004–2009). Study II included prescription data on psychotropic drugs among 15-16 year olds from the NorPD (2006–2010). Eight young people were interviewed and qualitative content analysis was used to analyse the data (III). Study IV included interviews with 20 Public Health Nurses (PHN), and was analysed using a phenomenographic approach. Main results: Mental distress was reported among 15.5% of the adolescents non-users of psychotropic drugs, 75% of whom were girls. In both genders reporting mental distress, incident psychotropic use was higher one to nine years, up to 27.7% among girls, as compared with the rest of the participants. In addition, health, lifestyle habits and social factors were associated with incident use (I). Psychotropic drug use increased during 2006–2010, hypnotics and melatonin accounted for most of the increase. In total, 16.4% of all incident psychotropic drug users in 2007 were still having prescriptions dispensed in 2010 (II). Young people experience both beneficial and undesired effects from psychotropic drugs. Access to professional support and follow-up was experienced as insufficient. Life with family, friends, school and work was influenced by psychotropic drug use, and they were afraid of being lonely and stigmatized (III). The PHNs conceived their roles in relation to young people as; the discovering PHNs who became aware of psychotropic drug use in the health dialogues and chose either to act or not to act in relation to this. Those PHNs who took action continued to be the cooperating PHNs who cooperated with the young people, their families, schools, and others. If cooperation was established, the supporting PHNs teach and support the young people in relation to psychotropic drug use (IV). Conclusions: Attention must be paid to poor mental health and increasing psychotropic drug use by young people. Advances in knowledge, treatment and follow-up are needed. The prevalence of mental distress among young people, with differences between the genders, as well as between socioeconomic groups, should have consequences for health promotion strategies. PHNs in Norway, working in health centres and schools, have responsibility and opportunity to identify and follow-up young people with mental health problems. / Baksidestext International studies indicate an increase in mental distress and psychotropic drug use among young people. In this thesis mental distress is reported among 15.5 % of the young people. Of those reporting mental distress 75 % were girls. One quarter of the girls reporting mental distress at 15-16 years of age was incident users of psychotropic drugs one to nine years later. Psychotropic drug use, increase among young people, particularly hypnotic drugs. The young people experience beneficial and undesired effects of the psychotropic drugs. They miss out on professional availability and follow-up, and experience negative reactions related to their psychotropic drug use by their significant others. The public health nurse who discovers psychotropic drug use among young people chooses either to act or not to act in relation to this. Those who choose to act continue to cooperate with the young people and others. An established cooperation was followed by a public health nurse who supports and teaches the young people. The prevalence of mental distress, with a high frequency of initiation of psychotropic drug use among young people should have consequences for health promotion in the school health service. Public health nurses, working in health centers and schools, have a responsibility to promote health and prevent health problems. They have the responsibility and opportunity to identify young people struggling with mental health problems and psychotropic drug use as well as teach and support significant others.

Background and Aims Estimates suggest more than three million children and young people (CYP) live with a parent experiencing mental distress (PEMD). It is suggested that CYP are often left to make sense of the uncertain nature of mental distress on their own. Furthermore, the existence of stigma can silence CYP and their families, as they try and hide from the view of others. CYP have voiced their desire for support. However, there are few services available to them in the UK, despite developments in policy highlighting the need for support. As CYP grow up, greater emphasis gets placed on relationships with friends. Therefore, CYP's peer group may provide a valuable source of support. This research aims to explore how CYP living with a PEMD gaining support from their friends. Methodology This research used a qualitative design to explore CYP's lived experiences. A purposive sample of six CYP who were living with a PEMD were recruited. CYP were invited to take part in semi-structured interviews, which were then transcribed. Analysis and Findings The interviews were analysed using Interpretative Phenomenological Analysis (IPA). The analysis revealed three superordinate themes: 'Fitting the puzzle together', 'Finding the experience of talking risky', and 'Coping with the up and down rollercoaster'. The findings support research recognising the importance of understanding mental distress, but CYP's accounts in this study provide further insight into the intricacies of what is meant by understanding. Furthermore, the research brings to light the challenges that CYP face when trying to build trusting relationships, in order to confide in their friends about their parent's experience of mental distress. Clinical implications, including recommendations for possible interventions are discussed and suggestions for future research are made.

This thesis investigates the everyday oppression of people with experiences of trauma and ‘mental illness’ through hegemonic discourses by psy-professionals within mental health care. The research is built around a case study of a narrative of a professional relationship between a social worker and a person experiencing mental distress. Using intersectionality as a theoretical and methodological framework it attempts to show how Madness is constructed as well as to identify how mechanisms of discrimination and oppression are interconnected simultaneously. Madness as a stand-alone category and at the same time an influence to gender, race and class. By applying narrative analysis and intersectionality systems of inequality can be made visible which need to be understood to bring about change and include any potential of meaning making processes by those affected through trauma or mental distress.

Mental health in Sweden is on the decline, with young people reporting the poorest outcomes. Reports show how schools fail in their preventive work when dealing with mental illness and that the burden of responsibility falls mainly on teachers who are forced to take initiative and thus are behind the few efforts that are made. The purpose of the study is to contribute with increased knowledge about how teachers are affected by their students’ struggle with mental health. Using an activity-pedagogical and social-cognitive theoretical approach and with qualitative content analysis, the results of five qualitative interviews with Swedish secondary school teachers are examined. The results of this study find that teachers are reporting a decline in mental health in their students and that they feel the weight of responsibility in dealing with this very complex issue. The results show that teachers tend to seek help and support via their teacher colleagues rather than the mental health professionals in the student health team. The interviews also showed that teachers in a lot of cases can tell early on when their students are experiencing symptoms of mental illness and in doing so take it upon themselves to adapt their planning and teaching to facilitate the student’s learning. Mental illness is however not considered when grading. Teachers are missing the resources to support students in mental illness and the burden of responsibility needs to be shared with professionals who are trained in and equipped with dealing with mental health.