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Writing Research Papers

  • Writing a Literature Review

When writing a research paper on a specific topic, you will often need to include an overview of any prior research that has been conducted on that topic.  For example, if your research paper is describing an experiment on fear conditioning, then you will probably need to provide an overview of prior research on fear conditioning.  That overview is typically known as a literature review.  

Please note that a full-length literature review article may be suitable for fulfilling the requirements for the Psychology B.S. Degree Research Paper .  For further details, please check with your faculty advisor.

Different Types of Literature Reviews

Literature reviews come in many forms.  They can be part of a research paper, for example as part of the Introduction section.  They can be one chapter of a doctoral dissertation.  Literature reviews can also “stand alone” as separate articles by themselves.  For instance, some journals such as Annual Review of Psychology , Psychological Bulletin , and others typically publish full-length review articles.  Similarly, in courses at UCSD, you may be asked to write a research paper that is itself a literature review (such as, with an instructor’s permission, in fulfillment of the B.S. Degree Research Paper requirement). Alternatively, you may be expected to include a literature review as part of a larger research paper (such as part of an Honors Thesis). 

Literature reviews can be written using a variety of different styles.  These may differ in the way prior research is reviewed as well as the way in which the literature review is organized.  Examples of stylistic variations in literature reviews include: 

  • Summarization of prior work vs. critical evaluation. In some cases, prior research is simply described and summarized; in other cases, the writer compares, contrasts, and may even critique prior research (for example, discusses their strengths and weaknesses).
  • Chronological vs. categorical and other types of organization. In some cases, the literature review begins with the oldest research and advances until it concludes with the latest research.  In other cases, research is discussed by category (such as in groupings of closely related studies) without regard for chronological order.  In yet other cases, research is discussed in terms of opposing views (such as when different research studies or researchers disagree with one another).

Overall, all literature reviews, whether they are written as a part of a larger work or as separate articles unto themselves, have a common feature: they do not present new research; rather, they provide an overview of prior research on a specific topic . 

How to Write a Literature Review

When writing a literature review, it can be helpful to rely on the following steps.  Please note that these procedures are not necessarily only for writing a literature review that becomes part of a larger article; they can also be used for writing a full-length article that is itself a literature review (although such reviews are typically more detailed and exhaustive; for more information please refer to the Further Resources section of this page).

Steps for Writing a Literature Review

1. Identify and define the topic that you will be reviewing.

The topic, which is commonly a research question (or problem) of some kind, needs to be identified and defined as clearly as possible.  You need to have an idea of what you will be reviewing in order to effectively search for references and to write a coherent summary of the research on it.  At this stage it can be helpful to write down a description of the research question, area, or topic that you will be reviewing, as well as to identify any keywords that you will be using to search for relevant research.

2. Conduct a literature search.

Use a range of keywords to search databases such as PsycINFO and any others that may contain relevant articles.  You should focus on peer-reviewed, scholarly articles.  Published books may also be helpful, but keep in mind that peer-reviewed articles are widely considered to be the “gold standard” of scientific research.  Read through titles and abstracts, select and obtain articles (that is, download, copy, or print them out), and save your searches as needed.  For more information about this step, please see the Using Databases and Finding Scholarly References section of this website.

3. Read through the research that you have found and take notes.

Absorb as much information as you can.  Read through the articles and books that you have found, and as you do, take notes.  The notes should include anything that will be helpful in advancing your own thinking about the topic and in helping you write the literature review (such as key points, ideas, or even page numbers that index key information).  Some references may turn out to be more helpful than others; you may notice patterns or striking contrasts between different sources ; and some sources may refer to yet other sources of potential interest.  This is often the most time-consuming part of the review process.  However, it is also where you get to learn about the topic in great detail.  For more details about taking notes, please see the “Reading Sources and Taking Notes” section of the Finding Scholarly References page of this website.

4. Organize your notes and thoughts; create an outline.

At this stage, you are close to writing the review itself.  However, it is often helpful to first reflect on all the reading that you have done.  What patterns stand out?  Do the different sources converge on a consensus?  Or not?  What unresolved questions still remain?  You should look over your notes (it may also be helpful to reorganize them), and as you do, to think about how you will present this research in your literature review.  Are you going to summarize or critically evaluate?  Are you going to use a chronological or other type of organizational structure?  It can also be helpful to create an outline of how your literature review will be structured.

5. Write the literature review itself and edit and revise as needed.

The final stage involves writing.  When writing, keep in mind that literature reviews are generally characterized by a summary style in which prior research is described sufficiently to explain critical findings but does not include a high level of detail (if readers want to learn about all the specific details of a study, then they can look up the references that you cite and read the original articles themselves).  However, the degree of emphasis that is given to individual studies may vary (more or less detail may be warranted depending on how critical or unique a given study was).   After you have written a first draft, you should read it carefully and then edit and revise as needed.  You may need to repeat this process more than once.  It may be helpful to have another person read through your draft(s) and provide feedback.

6. Incorporate the literature review into your research paper draft.

After the literature review is complete, you should incorporate it into your research paper (if you are writing the review as one component of a larger paper).  Depending on the stage at which your paper is at, this may involve merging your literature review into a partially complete Introduction section, writing the rest of the paper around the literature review, or other processes.

Further Tips for Writing a Literature Review

Full-length literature reviews

  • Many full-length literature review articles use a three-part structure: Introduction (where the topic is identified and any trends or major problems in the literature are introduced), Body (where the studies that comprise the literature on that topic are discussed), and Discussion or Conclusion (where major patterns and points are discussed and the general state of what is known about the topic is summarized)

Literature reviews as part of a larger paper

  • An “express method” of writing a literature review for a research paper is as follows: first, write a one paragraph description of each article that you read. Second, choose how you will order all the paragraphs and combine them in one document.  Third, add transitions between the paragraphs, as well as an introductory and concluding paragraph. 1
  • A literature review that is part of a larger research paper typically does not have to be exhaustive. Rather, it should contain most or all of the significant studies about a research topic but not tangential or loosely related ones. 2   Generally, literature reviews should be sufficient for the reader to understand the major issues and key findings about a research topic.  You may however need to confer with your instructor or editor to determine how comprehensive you need to be.

Benefits of Literature Reviews

By summarizing prior research on a topic, literature reviews have multiple benefits.  These include:

  • Literature reviews help readers understand what is known about a topic without having to find and read through multiple sources.
  • Literature reviews help “set the stage” for later reading about new research on a given topic (such as if they are placed in the Introduction of a larger research paper). In other words, they provide helpful background and context.
  • Literature reviews can also help the writer learn about a given topic while in the process of preparing the review itself. In the act of research and writing the literature review, the writer gains expertise on the topic .

Downloadable Resources

  • How to Write APA Style Research Papers (a comprehensive guide) [ PDF ]
  • Tips for Writing APA Style Research Papers (a brief summary) [ PDF ]
  • Example APA Style Research Paper (for B.S. Degree – literature review) [ PDF ]

Further Resources

How-To Videos     

  • Writing Research Paper Videos
  • UCSD Library Psychology Research Guide: Literature Reviews

External Resources

  • Developing and Writing a Literature Review from N Carolina A&T State University
  • Example of a Short Literature Review from York College CUNY
  • How to Write a Review of Literature from UW-Madison
  • Writing a Literature Review from UC Santa Cruz  
  • Pautasso, M. (2013). Ten Simple Rules for Writing a Literature Review. PLoS Computational Biology, 9 (7), e1003149. doi : 1371/journal.pcbi.1003149

1 Ashton, W. Writing a short literature review . [PDF]     

2 carver, l. (2014).  writing the research paper [workshop]. , prepared by s. c. pan for ucsd psychology.

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  • Research Paper Structure
  • Formatting Research Papers
  • Using Databases and Finding References
  • What Types of References Are Appropriate?
  • Evaluating References and Taking Notes
  • Citing References
  • Writing Process and Revising
  • Improving Scientific Writing
  • Academic Integrity and Avoiding Plagiarism
  • Writing Research Papers Videos

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Biological, Psychological, and Social Determinants of Depression: A Review of Recent Literature

Olivia remes.

1 Institute for Manufacturing, University of Cambridge, Cambridge CB3 0FS, UK

João Francisco Mendes

2 NOVA Medical School, Universidade NOVA de Lisboa, 1099-085 Lisbon, Portugal; ku.ca.mac@94cfj

Peter Templeton

3 IfM Engage Limited, Institute for Manufacturing, University of Cambridge, Cambridge CB3 0FS, UK; ku.ca.mac@32twp

4 The William Templeton Foundation for Young People’s Mental Health (YPMH), Cambridge CB2 0AH, UK

Associated Data

Depression is one of the leading causes of disability, and, if left unmanaged, it can increase the risk for suicide. The evidence base on the determinants of depression is fragmented, which makes the interpretation of the results across studies difficult. The objective of this study is to conduct a thorough synthesis of the literature assessing the biological, psychological, and social determinants of depression in order to piece together the puzzle of the key factors that are related to this condition. Titles and abstracts published between 2017 and 2020 were identified in PubMed, as well as Medline, Scopus, and PsycInfo. Key words relating to biological, social, and psychological determinants as well as depression were applied to the databases, and the screening and data charting of the documents took place. We included 470 documents in this literature review. The findings showed that there are a plethora of risk and protective factors (relating to biological, psychological, and social determinants) that are related to depression; these determinants are interlinked and influence depression outcomes through a web of causation. In this paper, we describe and present the vast, fragmented, and complex literature related to this topic. This review may be used to guide practice, public health efforts, policy, and research related to mental health and, specifically, depression.

1. Introduction

Depression is one of the most common mental health issues, with an estimated prevalence of 5% among adults [ 1 , 2 ]. Symptoms may include anhedonia, feelings of worthlessness, concentration and sleep difficulties, and suicidal ideation. According to the World Health Organization, depression is a leading cause of disability; research shows that it is a burdensome condition with a negative impact on educational trajectories, work performance, and other areas of life [ 1 , 3 ]. Depression can start early in the lifecourse and, if it remains unmanaged, may increase the risk for substance abuse, chronic conditions, such as cardiovascular disease, and premature mortality [ 4 , 5 , 6 , 7 , 8 ].

Treatment for depression exists, such as pharmacotherapy, cognitive behavioural therapy, and other modalities. A meta-analysis of randomized, placebo-controlled trials of patients shows that 56–60% of people respond well to active treatment with antidepressants (selective serotonin reuptake inhibitors, tricyclic antidepressants) [ 9 ]. However, pharmacotherapy may be associated with problems, such as side-effects, relapse issues, a potential duration of weeks until the medication starts working, and possible limited efficacy in mild cases [ 10 , 11 , 12 , 13 , 14 ]. Psychotherapy is also available, but access barriers can make it difficult for a number of people to get the necessary help.

Studies on depression have increased significantly over the past few decades. However, the literature remains fragmented and the interpretation of heterogeneous findings across studies and between fields is difficult. The cross-pollination of ideas between disciplines, such as genetics, neurology, immunology, and psychology, is limited. Reviews on the determinants of depression have been conducted, but they either focus exclusively on a particular set of determinants (ex. genetic risk factors [ 15 ]) or population sub-group (ex. children and adolescents [ 16 ]) or focus on characteristics measured predominantly at the individual level (ex. focus on social support, history of depression [ 17 ]) without taking the wider context (ex. area-level variables) into account. An integrated approach paying attention to key determinants from the biological, psychological, and social spheres, as well as key themes, such as the lifecourse perspective, enables clinicians and public health authorities to develop tailored, person-centred approaches.

The primary aim of this literature review: to address the aforementioned challenges, we have synthesized recent research on the biological, psychological, and social determinants of depression and we have reviewed research from fields including genetics, immunology, neurology, psychology, public health, and epidemiology, among others.

The subsidiary aim: we have paid special attention to important themes, including the lifecourse perspective and interactions between determinants, to guide further efforts by public health and medical professionals.

This literature review can be used as an evidence base by those in public health and the clinical setting and can be used to inform targeted interventions.

2. Materials and Methods

We conducted a review of the literature on the biological, psychological, and social determinants of depression in the last 4 years. We decided to focus on these determinants after discussions with academics (from the Manchester Metropolitan University, University of Cardiff, University of Colorado, Boulder, University of Cork, University of Leuven, University of Texas), charity representatives, and people with lived experience at workshops held by the University of Cambridge in 2020. In several aspects, we attempted to conduct this review according to PRISMA guidelines [ 18 ].

The inclusion and exclusion criteria are the following:

  • - We included documents, such as primary studies, literature reviews, systematic reviews, meta-analyses, reports, and commentaries on the determinants of depression. The determinants refer to variables that appear to be linked to the development of depression, such as physiological factors (e.g., the nervous system, genetics), but also factors that are further away or more distal to the condition. Determinants may be risk or protective factors, and individual- or wider-area-level variables.
  • - We focused on major depressive disorder, treatment-resistant depression, dysthymia, depressive symptoms, poststroke depression, perinatal depression, as well as depressive-like behaviour (common in animal studies), among others.
  • - We included papers regardless of the measurement methods of depression.
  • - We included papers that focused on human and/or rodent research.
  • - This review focused on articles written in the English language.
  • - Documents published between 2017–2020 were captured to provide an understanding of the latest research on this topic.
  • - Studies that assessed depression as a comorbidity or secondary to another disorder.
  • - Studies that did not focus on rodent and/or human research.
  • - Studies that focused on the treatment of depression. We made this decision, because this is an in-depth topic that would warrant a separate stand-alone review.
  • Next, we searched PubMed (2017–2020) using keywords related to depression and determinants. Appendix A contains the search strategy used. We also conducted focused searches in Medline, Scopus, and PsycInfo (2017–2020).
  • Once the documents were identified through the databases, the inclusion and exclusion criteria were applied to the titles and abstracts. Screening of documents was conducted by O.R., and a subsample was screened by J.M.; any discrepancies were resolved through a communication process.
  • The full texts of documents were retrieved, and the inclusion and exclusion criteria were again applied. A subsample of documents underwent double screening by two authors (O.R., J.M.); again, any discrepancies were resolved through communication.
  • a. A data charting form was created to capture the data elements of interest, including the authors, titles, determinants (biological, psychological, social), and the type of depression assessed by the research (e.g., major depression, depressive symptoms, depressive behaviour).
  • b. The data charting form was piloted on a subset of documents, and refinements to it were made. The data charting form was created with the data elements described above and tested in 20 studies to determine whether refinements in the wording or language were needed.
  • c. Data charting was conducted on the documents.
  • d. Narrative analysis was conducted on the data charting table to identify key themes. When a particular finding was noted more than once, it was logged as a potential theme, with a review of these notes yielding key themes that appeared on multiple occasions. When key themes were identified, one researcher (O.R.) reviewed each document pertaining to that theme and derived concepts (key determinants and related outcomes). This process (a subsample) was verified by a second author (J.M.), and the two authors resolved any discrepancies through communication. Key themes were also checked as to whether they were of major significance to public mental health and at the forefront of public health discourse according to consultations we held with stakeholders from the Manchester Metropolitan University, University of Cardiff, University of Colorado, Boulder, University of Cork, University of Leuven, University of Texas, charity representatives, and people with lived experience at workshops held by the University of Cambridge in 2020.

We condensed the extensive information gleaned through our review into short summaries (with key points boxes for ease of understanding and interpretation of the data).

Through the searches, 6335 documents, such as primary studies, literature reviews, systematic reviews, meta-analyses, reports, and commentaries, were identified. After applying the inclusion and exclusion criteria, 470 papers were included in this review ( Supplementary Table S1 ). We focused on aspects related to biological, psychological, and social determinants of depression (examples of determinants and related outcomes are provided under each of the following sections.

3.1. Biological Factors

The following aspects will be discussed in this section: physical health conditions; then specific biological factors, including genetics; the microbiome; inflammatory factors; stress and hypothalamic–pituitary–adrenal (HPA) axis dysfunction, and the kynurenine pathway. Finally, aspects related to cognition will also be discussed in the context of depression.

3.1.1. Physical Health Conditions

Studies on physical health conditions—key points:

  • The presence of a physical health condition can increase the risk for depression
  • Psychological evaluation in physically sick populations is needed
  • There is large heterogeneity in study design and measurement; this makes the comparison of findings between and across studies difficult

A number of studies examined the links between the outcome of depression and physical health-related factors, such as bladder outlet obstruction, cerebral atrophy, cataract, stroke, epilepsy, body mass index and obesity, diabetes, urinary tract infection, forms of cancer, inflammatory bowel disorder, glaucoma, acne, urea accumulation, cerebral small vessel disease, traumatic brain injury, and disability in multiple sclerosis [ 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 ]. For example, bladder outlet obstruction has been linked to inflammation and depressive behaviour in rodent research [ 24 ]. The presence of head and neck cancer also seemed to be related to an increased risk for depressive disorder [ 45 ]. Gestational diabetes mellitus has been linked to depressive symptoms in the postpartum period (but no association has been found with depression in the third pregnancy trimester) [ 50 ], and a plethora of other such examples of relationships between depression and physical conditions exist. As such, the assessment of psychopathology and the provision of support are necessary in individuals of ill health [ 45 ]. Despite the large evidence base on physical health-related factors, differences in study methodology and design, the lack of standardization when it comes to the measurement of various physical health conditions and depression, and heterogeneity in the study populations makes it difficult to compare studies [ 50 ].

The next subsections discuss specific biological factors, including genetics; the microbiome; inflammatory factors; stress and hypothalamic–pituitary–adrenal (HPA) axis dysfunction, and the kynurenine pathway; and aspects related to cognition.

3.1.2. Genetics

Studies on genetics—key points:

There were associations between genetic factors and depression; for example:

  • The brain-derived neurotrophic factor (BDNF) plays an important role in depression
  • Links exist between major histocompatibility complex region genes, as well as various gene polymorphisms and depression
  • Single nucleotide polymorphisms (SNPs) of genes involved in the tryptophan catabolites pathway are of interest in relation to depression

A number of genetic-related factors, genomic regions, polymorphisms, and other related aspects have been examined with respect to depression [ 61 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 , 136 , 137 , 138 , 139 , 140 ]. The influence of BDNF in relation to depression has been amply studied [ 117 , 118 , 141 , 142 , 143 ]. Research has shown associations between depression and BDNF (as well as candidate SNPs of the BDNF gene, polymorphisms of the BDNF gene, and the interaction of these polymorphisms with other determinants, such as stress) [ 129 , 144 , 145 ]. Specific findings have been reported: for example, a study reported a link between the BDNF rs6265 allele (A) and major depressive disorder [ 117 ].

Other research focused on major histocompatibility complex region genes, endocannabinoid receptor gene polymorphisms, as well as tissue-specific genes and gene co-expression networks and their links to depression [ 99 , 110 , 112 ]. The SNPs of genes involved in the tryptophan catabolites pathway have also been of interest when studying the pathogenesis of depression.

The results from genetics studies are compelling; however, the findings remain mixed. One study indicated no support for depression candidate gene findings [ 122 ]. Another study found no association between specific polymorphisms and major depressive disorder [ 132 ]. As such, further research using larger samples is needed to corroborate the statistically significant associations reported in the literature.

3.1.3. Microbiome

Studies on the microbiome—key points:

  • The gut bacteria and the brain communicate via both direct and indirect pathways called the gut-microbiota-brain axis (the bidirectional communication networks between the central nervous system and the gastrointestinal tract; this axis plays an important role in maintaining homeostasis).
  • A disordered microbiome can lead to inflammation, which can then lead to depression
  • There are possible links between the gut microbiome, host liver metabolism, brain inflammation, and depression

The common themes of this review have focused on the microbiome/microbiota or gut metabolome [ 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 , 155 , 156 , 157 , 158 , 159 , 160 , 161 ], the microbiota-gut-brain axis, and related factors [ 152 , 162 , 163 , 164 , 165 , 166 , 167 ]. When there is an imbalance in the intestinal bacteria, this can interfere with emotional regulation and contribute to harmful inflammatory processes and mood disorders [ 148 , 151 , 153 , 155 , 157 ]. Rodent research has shown that there may be a bidirectional association between the gut microbiota and depression: a disordered gut microbiota can play a role in the onset of this mental health problem, but, at the same time, the existence of stress and depression may also lead to a lower level of richness and diversity in the microbiome [ 158 ].

Research has also attempted to disentangle the links between the gut microbiome, host liver metabolism, brain inflammation, and depression, as well as the role of the ratio of lactobacillus to clostridium [ 152 ]. The literature has also examined the links between medication, such as antibiotics, and mood and behaviour, with the findings showing that antibiotics may be related to depression [ 159 , 168 ]. The links between the microbiome and depression are complex, and further studies are needed to determine the underpinning causal mechanisms.

3.1.4. Inflammation

Studies on inflammation—key points:

  • Pro-inflammatory cytokines are linked to depression
  • Pro-inflammatory cytokines, such as the tumour necrosis factor (TNF)-alpha, may play an important role
  • Different methods of measurement are used, making the comparison of findings across studies difficult

Inflammation has been a theme in this literature review [ 60 , 161 , 164 , 169 , 170 , 171 , 172 , 173 , 174 , 175 , 176 , 177 , 178 , 179 , 180 , 181 , 182 , 183 , 184 ]. The findings show that raised levels of inflammation (because of factors such as pro-inflammatory cytokines) have been associated with depression [ 60 , 161 , 174 , 175 , 178 ]. For example, pro-inflammatory cytokines, such as tumour necrosis factor (TNF)-alpha, have been linked to depression [ 185 ]. Various determinants, such as early life stress, have also been linked to systemic inflammation, and this can increase the risk for depression [ 186 ].

Nevertheless, not everyone with elevated inflammation develops depression; therefore, this is just one route out of many linked to pathogenesis. Despite the compelling evidence reported with respect to inflammation, it is difficult to compare the findings across studies because of different methods used to assess depression and its risk factors.

3.1.5. Stress and HPA Axis Dysfunction

Studies on stress and HPA axis dysfunction—key points:

  • Stress is linked to the release of proinflammatory factors
  • The dysregulation of the HPA axis is linked to depression
  • Determinants are interlinked in a complex web of causation

Stress was studied in various forms in rodent populations and humans [ 144 , 145 , 155 , 174 , 176 , 180 , 185 , 186 , 187 , 188 , 189 , 190 , 191 , 192 , 193 , 194 , 195 , 196 , 197 , 198 , 199 , 200 , 201 , 202 , 203 , 204 , 205 , 206 , 207 , 208 , 209 , 210 , 211 ].

Although this section has some overlap with others (as is to be expected because all of these determinants and body systems are interlinked), a number of studies have focused on the impact of stress on mental health. Stress has been mentioned in the literature as a risk factor of poor mental health and has emerged as an important determinant of depression. The effects of this variable are wide-ranging, and a short discussion is warranted.

Stress has been linked to the release of inflammatory factors, as well as the development of depression [ 204 ]. When the stress is high or lasts for a long period of time, this may negatively impact the brain. Chronic stress can impact the dendrites and synapses of various neurons, and may be implicated in the pathway leading to major depressive disorder [ 114 ]. As a review by Uchida et al. indicates, stress may be associated with the “dysregulation of neuronal and synaptic plasticity” [ 114 ]. Even in rodent studies, stress has a negative impact: chronic and unpredictable stress (and other forms of tension or stress) have been linked to unusual behaviour and depression symptoms [ 114 ].

The depression process and related brain changes, however, have also been linked to the hyperactivity or dysregulation of the HPA axis [ 127 , 130 , 131 , 182 , 212 ]. One review indicates that a potential underpinning mechanism of depression relates to “HPA axis abnormalities involved in chronic stress” [ 213 ]. There is a complex relationship between the HPA axis, glucocorticoid receptors, epigenetic mechanisms, and psychiatric sequelae [ 130 , 212 ].

In terms of the relationship between the HPA axis and stress and their influence on depression, the diathesis–stress model offers an explanation: it could be that early stress plays a role in the hyperactivation of the HPA axis, thus creating a predisposition “towards a maladaptive reaction to stress”. When this predisposition then meets an acute stressor, depression may ensue; thus, in line with the diathesis–stress model, a pre-existing vulnerability and stressor can create fertile ground for a mood disorder [ 213 ]. An integrated review by Dean and Keshavan [ 213 ] suggests that HPA axis hyperactivity is, in turn, related to other determinants, such as early deprivation and insecure early attachment; this again shows the complex web of causation between the different determinants.

3.1.6. Kynurenine Pathway

Studies on the kynurenine pathway—key points:

  • The kynurenine pathway is linked to depression
  • Indolamine 2,3-dioxegenase (IDO) polymorphisms are linked to postpartum depression

The kynurenine pathway was another theme that emerged in this review [ 120 , 178 , 181 , 184 , 214 , 215 , 216 , 217 , 218 , 219 , 220 , 221 ]. The kynurenine pathway has been implicated not only in general depressed mood (inflammation-induced depression) [ 184 , 214 , 219 ] but also postpartum depression [ 120 ]. When the kynurenine metabolism pathway is activated, this results in metabolites, which are neurotoxic.

A review by Jeon et al. notes a link between the impairment of the kynurenine pathway and inflammation-induced depression (triggered by treatment for various physical diseases, such as malignancy). The authors note that this could represent an important opportunity for immunopharmacology [ 214 ]. Another review by Danzer et al. suggests links between the inflammation-induced activation of indolamine 2,3-dioxegenase (the enzyme that converts tryptophan to kynurenine), the kynurenine metabolism pathway, and depression, and also remarks about the “opportunities for treatment of inflammation-induced depression” [ 184 ].

3.1.7. Cognition

Studies on cognition and the brain—key points:

  • Cognitive decline and cognitive deficits are linked to increased depression risk
  • Cognitive reserve is important in the disability/depression relationship
  • Family history of cognitive impairment is linked to depression

A number of studies have focused on the theme of cognition and the brain. The results show that factors, such as low cognitive ability/function, cognitive vulnerability, cognitive impairment or deficits, subjective cognitive decline, regression of dendritic branching and hippocampal atrophy/death of hippocampal cells, impaired neuroplasticity, and neurogenesis-related aspects, have been linked to depression [ 131 , 212 , 222 , 223 , 224 , 225 , 226 , 227 , 228 , 229 , 230 , 231 , 232 , 233 , 234 , 235 , 236 , 237 , 238 , 239 ]. The cognitive reserve appears to act as a moderator and can magnify the impact of certain determinants on poor mental health. For example, in a study in which participants with multiple sclerosis also had low cognitive reserve, disability was shown to increase the risk for depression [ 63 ]. Cognitive deficits can be both causal and resultant in depression. A study on individuals attending outpatient stroke clinics showed that lower scores in cognition were related to depression; thus, cognitive impairment appears to be associated with depressive symptomatology [ 226 ]. Further, Halahakoon et al. [ 222 ] note a meta-analysis [ 240 ] that shows that a family history of cognitive impairment (in first degree relatives) is also linked to depression.

In addition to cognitive deficits, low-level cognitive ability [ 231 ] and cognitive vulnerability [ 232 ] have also been linked to depression. While cognitive impairment may be implicated in the pathogenesis of depressive symptoms [ 222 ], negative information processing biases are also important; according to the ‘cognitive neuropsychological’ model of depression, negative affective biases play a central part in the development of depression [ 222 , 241 ]. Nevertheless, the evidence on this topic is mixed and further work is needed to determine the underpinning mechanisms between these states.

3.2. Psychological Factors

Studies on psychological factors—key points:

  • There are many affective risk factors linked to depression
  • Determinants of depression include negative self-concept, sensitivity to rejection, neuroticism, rumination, negative emotionality, and others

A number of studies have been undertaken on the psychological factors linked to depression (including mastery, self-esteem, optimism, negative self-image, current or past mental health conditions, and various other aspects, including neuroticism, brooding, conflict, negative thinking, insight, cognitive fusion, emotional clarity, rumination, dysfunctional attitudes, interpretation bias, and attachment style) [ 66 , 128 , 140 , 205 , 210 , 228 , 235 , 242 , 243 , 244 , 245 , 246 , 247 , 248 , 249 , 250 , 251 , 252 , 253 , 254 , 255 , 256 , 257 , 258 , 259 , 260 , 261 , 262 , 263 , 264 , 265 , 266 , 267 , 268 , 269 , 270 , 271 , 272 , 273 , 274 , 275 , 276 , 277 , 278 , 279 , 280 , 281 , 282 , 283 , 284 , 285 , 286 , 287 , 288 , 289 , 290 ]. Determinants related to this condition include low self-esteem and shame, among other factors [ 269 , 270 , 275 , 278 ]. Several emotional states and traits, such as neuroticism [ 235 , 260 , 271 , 278 ], negative self-concept (with self-perceptions of worthlessness and uselessness), and negative interpretation or attention biases have been linked to depression [ 261 , 271 , 282 , 283 , 286 ]. Moreover, low emotional clarity has been associated with depression [ 267 ]. When it comes to the severity of the disorder, it appears that meta-emotions (“emotions that occur in response to other emotions (e.g., guilt about anger)” [ 268 ]) have a role to play in depression [ 268 ].

A determinant that has received much attention in mental health research concerns rumination. Rumination has been presented as a mediator but also as a risk factor for depression [ 57 , 210 , 259 ]. When studied as a risk factor, it appears that the relationship of rumination with depression is mediated by variables that include limited problem-solving ability and insufficient social support [ 259 ]. However, rumination also appears to act as a mediator: for example, this variable (particularly brooding rumination) lies on the causal pathway between poor attention control and depression [ 265 ]. This shows that determinants may present in several forms: as moderators or mediators, risk factors or outcomes, and this is why disentangling the relationships between the various factors linked to depression is a complex task.

The psychological determinants are commonly researched variables in the mental health literature. A wide range of factors have been linked to depression, such as the aforementioned determinants, but also: (low) optimism levels, maladaptive coping (such as avoidance), body image issues, and maladaptive perfectionism, among others [ 269 , 270 , 272 , 273 , 275 , 276 , 279 , 285 , 286 ]. Various mechanisms have been proposed to explain the way these determinants increase the risk for depression. One of the underpinning mechanisms linking the determinants and depression concerns coping. For example, positive fantasy engagement, cognitive biases, or personality dispositions may lead to emotion-focused coping, such as brooding, and subsequently increase the risk for depression [ 272 , 284 , 287 ]. Knowing the causal mechanisms linking the determinants to outcomes provides insight for the development of targeted interventions.

3.3. Social Determinants

Studies on social determinants—key points:

  • Social determinants are the conditions in the environments where people are born, live, learn, work, play, etc.; these influence (mental) health [ 291 ]
  • There are many social determinants linked to depression, such as sociodemographics, social support, adverse childhood experiences
  • Determinants can be at the individual, social network, community, and societal levels

Studies also focused on the social determinants of (mental) health; these are the conditions in which people are born, live, learn, work, play, and age, and have a significant influence on wellbeing [ 291 ]. Factors such as age, social or socioeconomic status, social support, financial strain and deprivation, food insecurity, education, employment status, living arrangements, marital status, race, childhood conflict and bullying, violent crime exposure, abuse, discrimination, (self)-stigma, ethnicity and migrant status, working conditions, adverse or significant life events, illiteracy or health literacy, environmental events, job strain, and the built environment have been linked to depression, among others [ 52 , 133 , 235 , 236 , 239 , 252 , 269 , 280 , 292 , 293 , 294 , 295 , 296 , 297 , 298 , 299 , 300 , 301 , 302 , 303 , 304 , 305 , 306 , 307 , 308 , 309 , 310 , 311 , 312 , 313 , 314 , 315 , 316 , 317 , 318 , 319 , 320 , 321 , 322 , 323 , 324 , 325 , 326 , 327 , 328 , 329 , 330 , 331 , 332 , 333 , 334 , 335 , 336 , 337 , 338 , 339 , 340 , 341 , 342 , 343 , 344 , 345 , 346 , 347 , 348 , 349 , 350 , 351 , 352 , 353 , 354 , 355 , 356 , 357 , 358 , 359 , 360 , 361 , 362 , 363 , 364 , 365 , 366 , 367 , 368 , 369 , 370 , 371 ]. Social support and cohesion, as well as structural social capital, have also been identified as determinants [ 140 , 228 , 239 , 269 , 293 , 372 , 373 , 374 , 375 , 376 , 377 , 378 , 379 ]. In a study, part of the findings showed that low levels of education have been shown to be linked to post-stroke depression (but not severe or clinical depression outcomes) [ 299 ]. A study within a systematic review indicated that having only primary education was associated with a higher risk of depression compared to having secondary or higher education (although another study contrasted this finding) [ 296 ]. Various studies on socioeconomic status-related factors have been undertaken [ 239 , 297 ]; the research has shown that a low level of education is linked to depression [ 297 ]. Low income is also related to depressive disorders [ 312 ]. By contrast, high levels of education and income are protective [ 335 ].

A group of determinants touched upon by several studies included adverse childhood or early life experiences: ex. conflict with parents, early exposure to traumatic life events, bullying and childhood trauma were found to increase the risk of depression (ex. through pathways, such as inflammation, interaction effects, or cognitive biases) [ 161 , 182 , 258 , 358 , 362 , 380 ].

Gender-related factors were also found to play an important role with respect to mental health [ 235 , 381 , 382 , 383 , 384 , 385 ]. Gender inequalities can start early on in the lifecourse, and women were found to be twice as likely to have depression as men. Gender-related factors were linked to cognitive biases, resilience and vulnerabilities [ 362 , 384 ].

Determinants can impact mental health outcomes through underpinning mechanisms. For example, harmful determinants can influence the uptake of risk behaviours. Risk behaviours, such as sedentary behaviour, substance abuse and smoking/nicotine exposure, have been linked to depression [ 226 , 335 , 355 , 385 , 386 , 387 , 388 , 389 , 390 , 391 , 392 , 393 , 394 , 395 , 396 , 397 , 398 , 399 , 400 , 401 ]. Harmful determinants can also have an impact on diet. Indeed, dietary aspects and diet components (ex. vitamin D, folate, selenium intake, iron, vitamin B12, vitamin K, fiber intake, zinc) as well as diet-related inflammatory potential have been linked to depression outcomes [ 161 , 208 , 236 , 312 , 396 , 402 , 403 , 404 , 405 , 406 , 407 , 408 , 409 , 410 , 411 , 412 , 413 , 414 , 415 , 416 , 417 , 418 , 419 , 420 , 421 , 422 , 423 , 424 , 425 , 426 , 427 , 428 ]. A poor diet has been linked to depression through mechanisms such as inflammation [ 428 ].

Again, it is difficult to constrict diet to the ‘social determinants of health’ category as it also relates to inflammation (biological determinants) and could even stand alone as its own category. Nevertheless, all of these factors are interlinked and influence one another in a complex web of causation, as mentioned elsewhere in the paper.

Supplementary Figure S1 contains a representation of key determinants acting at various levels: the individual, social network, community, and societal levels. The determinants have an influence on risk behaviours, and this, in turn, can affect the mood (i.e., depression), body processes (ex. can increase inflammation), and may negatively influence brain structure and function.

3.4. Others

Studies on ‘other’ determinants—key points:

  • A number of factors are related to depression
  • These may not be as easily categorized as the other determinants in this paper

A number of factors arose in this review that were related to depression; it was difficult to place these under a specific heading above, so this ‘other’ category was created. A number of these could be sorted under the ‘social determinants of depression’ category. For example, being exposed to deprivation, hardship, or adversity may increase the risk for air pollution exposure and nighttime shift work, among others, and the latter determinants have been found to increase the risk for depression. Air pollution could also be regarded as an ecologic-level (environmental) determinant of mental health.

Nevertheless, we have decided to leave these factors in a separate category (because their categorization may not be as immediately clear-cut as others), and these factors include: low-level light [ 429 ], weight cycling [ 430 ], water contaminants [ 431 ], trade [ 432 ], air pollution [ 433 , 434 ], program-level variables (ex. feedback and learning experience) [ 435 ], TV viewing [ 436 ], falls [ 437 ], various other biological factors [ 116 , 136 , 141 , 151 , 164 , 182 , 363 , 364 , 438 , 439 , 440 , 441 , 442 , 443 , 444 , 445 , 446 , 447 , 448 , 449 , 450 , 451 , 452 , 453 , 454 , 455 , 456 , 457 , 458 , 459 , 460 , 461 , 462 , 463 , 464 , 465 , 466 , 467 , 468 , 469 ], mobile phone use [ 470 ], ultrasound chronic exposure [ 471 ], nighttime shift work [ 472 ], work accidents [ 473 ], therapy enrollment [ 226 ], and exposure to light at night [ 474 ].

4. Cross-Cutting Themes

4.1. lifecourse perspective.

Studies on the lifecourse perspective—key points:

  • Early life has an importance on mental health
  • Stress has been linked to depression
  • In old age, the decline in social capital is important

Trajectories and life events are important when it comes to the lifecourse perspective. Research has touched on the influence of prenatal or early life stress on an individual’s mental health trajectory [ 164 , 199 , 475 ]. Severe stress that occurs in the form of early-life trauma has also been associated with depressive symptoms [ 362 , 380 ]. It may be that some individuals exposed to trauma develop thoughts of personal failure, which then serve as a catalyst of depression [ 380 ].

At the other end of the life trajectory—old age—specific determinants have been linked to an increased risk for depression. Older people are at a heightened risk of losing their social networks, and structural social capital has been identified as important in relation to depression in old age [ 293 ].

4.2. Gene–Environment Interactions

Studies on gene–environment interactions—key points:

  • The environment and genetics interact to increase the risk of depression
  • The etiology of depression is multifactorial
  • Adolescence is a time of vulnerability

A number of studies have touched on gene–environment interactions [ 72 , 77 , 82 , 119 , 381 , 476 , 477 , 478 , 479 , 480 , 481 ]. The interactions between genetic factors and determinants, such as negative life events (ex. relationship and social difficulties, serious illness, unemployment and financial crises) and stressors (ex. death of spouse, minor violations of law, neighbourhood socioeconomic status) have been studied in relation to depression [ 82 , 135 , 298 , 449 , 481 ]. A study reported an interaction of significant life events with functional variation in the serotonin-transporter-linked polymorphic region (5-HTTLPR) allele type (in the context of multiple sclerosis) and linked this to depression [ 361 ], while another reported an interaction between stress and 5-HTTLPR in relation to depression [ 480 ]. Other research reported that the genetic variation of HPA-axis genes has moderating effects on the relationship between stressors and depression [ 198 ]. Another study showed that early-life stress interacts with gene variants to increase the risk for depression [ 77 ].

Adolescence is a time of vulnerability [ 111 , 480 ]. Perceived parental support has been found to interact with genes (GABRR1, GABRR2), and this appears to be associated with depressive symptoms in adolescence [ 480 ]. It is important to pay special attention to critical periods in the lifecourse so that adequate support is provided to those who are most vulnerable.

The etiology of depression is multifactorial, and it is worthwhile to examine the interaction between multiple factors, such as epigenetic, genetic, and environmental factors, in order to truly understand this mental health condition. Finally, taking into account critical periods of life when assessing gene–environment interactions is important for developing targeted interventions.

5. Discussion

Depression is one of the most common mental health conditions, and, if left untreated, it can increase the risk for substance abuse, anxiety disorders, and suicide. In the past 20 years, a large number of studies on the risk and protective factors of depression have been undertaken in various fields, such as genetics, neurology, immunology, and epidemiology. However, there are limitations associated with the extant evidence base. The previous syntheses on depression are limited in scope and focus exclusively on social or biological factors, population sub-groups, or examine depression as a comorbidity (rather than an independent disorder). The research on the determinants and causal pathways of depression is fragmentated and heterogeneous, and this has not helped to stimulate progress when it comes to the prevention and intervention of this condition—specifically unravelling the complexity of the determinants related to this condition and thus refining the prevention and intervention methods.

The scope of this paper was to bring together the heterogeneous, vast, and fragmented literature on depression and paint a picture of the key factors that contribute to this condition. The findings from this review show that there are important themes when it comes to the determinants of depression, such as: the microbiome, dysregulation of the HPA axis, inflammatory reactions, the kynurenine pathway, as well as psychological and social factors. It may be that physical factors are proximal determinants of depression, which, in turn, are acted on by more distal social factors, such as deprivation, environmental events, and social capital.

The Marmot Report [ 291 ], the World Health Organization [ 482 ], and Compton et al. [ 483 ] highlight that the most disadvantaged segments of society are suffering (the socioeconomic context is important), and this inequality in resources has translated to inequality in mental health outcomes [ 483 ]. To tackle the issue of egalitarianism and restore equality in the health between the groups, the social determinants need to be addressed [ 483 ]. A wide range of determinants of mental health have been identified in the literature: age, gender, ethnicity, family upbringing and early attachment patterns, social support, access to food, water and proper nutrition, and community factors. People spiral downwards because of individual- and societal-level circumstances; therefore, these circumstances along with the interactions between the determinants need to be considered.

Another important theme in the mental health literature is the lifecourse perspective. This shows that the timing of events has significance when it comes to mental health. Early life is a critical period during the lifespan at which cognitive processes develop. Exposure to harmful determinants, such as stress, during this period can place an individual on a trajectory of depression in adulthood or later life. When an individual is exposed to harmful determinants during critical periods and is also genetically predisposed to depression, the risk for the disorder can be compounded. This is why aspects such as the lifecourse perspective and gene–environment interactions need to be taken into account. Insight into this can also help to refine targeted interventions.

A number of interventions for depression have been developed or recommended, addressing, for example, the physical factors described here and lifestyle modifications. Interventions targeting various factors, such as education and socioeconomic status, are needed to help prevent and reduce the burden of depression. Further research on the efficacy of various interventions is needed. Additional studies are also needed on each of the themes described in this paper, for example: the biological factors related to postpartum depression [ 134 ], and further work is needed on depression outcomes, such as chronic, recurrent depression [ 452 ]. Previous literature has shown that chronic stress (associated with depression) is also linked to glucocorticoid receptor resistance, as well as problems with the regulation of the inflammatory response [ 484 ]. Further work is needed on this and the underpinning mechanisms between the determinants and outcomes. This review highlighted the myriad ways of measuring depression and its determinants [ 66 , 85 , 281 , 298 , 451 , 485 ]. Thus, the standardization of the measurements of the outcomes (ex. a gold standard for measuring depression) and determinants is essential; this can facilitate comparisons of findings across studies.

5.1. Strengths

This paper has important strengths. It brings together the wide literature on depression and helps to bridge disciplines in relation to one of the most common mental health problems. We identified, selected, and extracted data from studies, and provided concise summaries.

5.2. Limitations

The limitations of the review include missing potentially important studies; however, this is a weakness that cannot be avoided by literature reviews. Nevertheless, the aim of the review was not to identify each study that has been conducted on the risk and protective factors of depression (which a single review is unable to capture) but rather to gain insight into the breadth of literature on this topic, highlight key biological, psychological, and social determinants, and shed light on important themes, such as the lifecourse perspective and gene–environment interactions.

6. Conclusions

We have reviewed the determinants of depression and recognize that there are a multitude of risk and protective factors at the individual and wider ecologic levels. These determinants are interlinked and influence one another. We have attempted to describe the wide literature on this topic, and we have brought to light major factors that are of public mental health significance. This review may be used as an evidence base by those in public health, clinical practice, and research.

This paper discusses key areas in depression research; however, an exhaustive discussion of all the risk factors and determinants linked to depression and their mechanisms is not possible in one journal article—which, by its very nature, a single paper cannot do. We have brought to light overarching factors linked to depression and a workable conceptual framework that may guide clinical and public health practice; however, we encourage other researchers to continue to expand on this timely and relevant work—particularly as depression is a top priority on the policy agenda now.

Acknowledgments

Thank you to Isla Kuhn for the help with the Medline, Scopus, and PsycInfo database searches.

Supplementary Materials

The following are available online at https://www.mdpi.com/article/10.3390/brainsci11121633/s1 , Figure S1: Conceptual framework: Determinants of depression, Table S1: Data charting—A selection of determinants from the literature.

Appendix A.1. Search Strategy

Search: ((((((((((((((((“Gene-Environment Interaction”[Majr]) OR (“Genetics”[Mesh])) OR (“Genome-Wide Association Study”[Majr])) OR (“Microbiota”[Mesh] OR “Gastrointestinal Microbiome”[Mesh])) OR (“Neurogenic Inflammation”[Mesh])) OR (“genetic determinant”)) OR (“gut-brain-axis”)) OR (“Kynurenine”[Majr])) OR (“Cognition”[Mesh])) OR (“Neuronal Plasticity”[Majr])) OR (“Neurogenesis”[Mesh])) OR (“Genes”[Mesh])) OR (“Neurology”[Majr])) OR (“Social Determinants of Health”[Majr])) OR (“Glucocorticoids”[Mesh])) OR (“Tryptophan”[Mesh])) AND (“Depression”[Mesh] OR “Depressive Disorder”[Mesh]) Filters: from 2017—2020.

Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations, Daily and Versions(R)

  • exp *Depression/
  • exp *Depressive Disorder/
  • exp *”Social Determinants of Health”/
  • exp *Tryptophan/
  • exp *Glucocorticoids/
  • exp *Neurology/
  • exp *Genes/
  • exp *Neurogenesis/
  • exp *Neuronal Plasticity/
  • exp *Kynurenine/
  • exp *Genetics/
  • exp *Neurogenic Inflammation/
  • exp *Gastrointestinal Microbiome/
  • exp *Genome-Wide Association Study/
  • exp *Gene-Environment Interaction/
  • exp *Depression/et [Etiology]
  • exp *Depressive Disorder/et
  • or/4-16   637368
  • limit 22 to yr = “2017–Current”
  • “cause* of depression”.mp.
  • “cause* of depression”.ti.
  • (cause adj3 (depression or depressive)).ti.
  • (caus* adj3 (depression or depressive)).ti.

Appendix A.2. PsycInfo

(TITLE ( depression OR “ Depressive Disorder ”) AND TITLE (“ Social Determinants of Health ” OR tryptophan OR glucocorticoids OR neurology OR genes OR neurogenesis OR “ Neuronal Plasticity ” OR kynurenine OR genetics OR “ Neurogenic Inflammation ” OR “ Gastrointestinal Microbiome ” OR “ Genome-Wide Association Study ” OR “ Gene-Environment Interaction ” OR aetiology OR etiology )) OR TITLE ( cause* W/3 ( depression OR depressive )).

Author Contributions

O.R. was responsible for the design of the study and methodology undertaken. Despite P.T.’s involvement in YPMH, he had no role in the design of the study; P.T. was responsible for the conceptualization of the study. Validation was conducted by O.R. and J.F.M. Formal analysis (data charting) was undertaken by O.R. O.R. and P.T. were involved in the investigation, resource acquisition, and data presentation. The original draft preparation was undertaken by O.R. The writing was conducted by O.R., with review and editing by P.T. and J.F.M. Funding acquisition was undertaken by O.R. and P.T. All authors have read and agreed to the published version of the manuscript.

This research was funded by The William Templeton Foundation for Young People’s Mental Health, Cambridge Philosophical Society, and the Aviva Foundation.

Conflicts of Interest

The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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What is a Literature Review?

If this is your first time having to do a literature review, you might be wondering what a "literature review" actually is. Typically, this entails searching through various databases to find peer-reviewed research within a particular topic of interest and then analyzing what you find in order to situate your own research within the existing works.

Watch the following video to learn more:

Video Transcript

What is Peer Review?

Most of your literature review will involve searching for sources that have gone through the peer-reviewed process. These are typically academic articles that have been published in scholarly journals and have been vetted by other experts with knowledge of the topic at hand.

How Do I Find Psychology Literature?

The following database are a great place to start to find relevant, peer-reviewed literature within the broad research area of psychology:

  • APA PsycInfo This link opens in a new window From the American Psychological Association (APA), PsycINFO contains nearly 2.3 million citations and abstracts of scholarly journal articles, book chapters, books, and dissertations in psychology and related disciplines. It is the largest resource devoted to peer-reviewed literature in behavioral science and mental health.
  • DynaMed This link opens in a new window A clinical reference tool of more than 3000 topics designed for physicians and health care professionals for use primarily at the point-of-care. DynaMed is updated daily and monitors the content of over 500 medical journal and systemic evidence review databases.
  • EMBASE This link opens in a new window EMBASE is a major biomedical and pharmaceutical database indexing over 3,500 international journals in the following fields of health sciences and biomedical research. It is considered as the European version of Medline.
  • MEDLINE with Full Text This link opens in a new window A bibliographic database that contains more than 26 million references to journal articles in life sciences with a concentration on biomedicine. A distinctive feature of MEDLINE is that the records are indexed with NLM Medical Subject Headings (MeSH®).

Full Text

  • PubMed This link opens in a new window PubMed® comprises more than 30 million citations for biomedical literature from MEDLINE, life science journals, and online books.
  • Web of Science This link opens in a new window Web of Science is a comprehensive research database. It contains records of journal articles, patents, and conference proceedings, It also provides a variety of search and analysis tools. Web of Science Core Collection is a painstakingly selected, actively curated database of the journals that researchers themselves have judged to be the most important and useful in their fields
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Literature Review Overview

A literature review involves both the literature searching and the writing. The purpose of the literature search is to:

  • reveal existing knowledge
  • identify areas of consensus and debate
  • identify gaps in knowledge
  • identify approaches to research design and methodology
  • identify other researchers with similar interests
  • clarify your future directions for research

List above from Conducting A Literature Search , Information Research Methods and Systems, Penn State University Libraries

A literature review provides an evaluative review and documentation of what has been published by scholars and researchers on a given topic. In reviewing the published literature, the aim is to explain what ideas and knowledge have been gained and shared to date (i.e., hypotheses tested, scientific methods used, results and conclusions), the weakness and strengths of these previous works, and to identify remaining research questions: A literature review provides the context for your research, making clear why your topic deserves further investigation.

Before You Search

  • Select and understand your research topic and question.
  • Identify the major concepts in your topic and question.
  • Brainstorm potential keywords/terms that correspond to those concepts.
  • Identify alternative keywords/terms (narrower, broader, or related) to use if your first set of keywords do not work.
  • Determine (Boolean*) relationships between terms.
  • Begin your search.
  • Review your search results.
  • Revise & refine your search based on the initial findings.

*Boolean logic provides three ways search terms/phrases can be combined, using the following three operators: AND, OR, and NOT.

Search Process

The type of information you want to find and the practices of your discipline(s) drive the types of sources you seek and where you search.

For most research you will use multiple source types such as: annotated bibliographies; articles from journals, magazines, and newspapers; books; blogs; conference papers; data sets; dissertations; organization, company, or government reports; reference materials; systematic reviews; archival materials; curriculum materials; and more. It can be helpful to develop a comprehensive approach to review different sources and where you will search for each. Below is an example approach.

Utilize Current Awareness Services  Identify and browse current issues of the most relevant journals for your topic; Setup email or RSS Alerts, e.g., Journal Table of Contents, Saved Searches

Consult Experts   Identify and search for the publications of or contact educators, scholars, librarians, employees etc. at schools, organizations, and agencies

  • Annual Reviews and Bibliographies   e.g., Annual Review of Psychology
  • Internet   e.g., Discussion Groups, Listservs, Blogs, social networking sites
  • Grant Databases   e.g., Foundation Directory Online, Grants.gov
  • Conference Proceedings   e.g., International Psychological Applications Conference and Trends (InPACT), The European Conference on Psychology & the Behavioral Sciences via IAFOR Research Archive
  • Newspaper Indexes   e.g., Access World News, Ethnic NewsWatch, New York Times Historical
  • Journal Indexes/Databases and EJournal Packages   e.g., PsycArticles, ScienceDirect
  • Citation Indexes   e.g., PsycINFO, Psychiatry Online
  • Specialized Data   e.g., American College Health Association-National College Health Assessment survey data, Substance Abuse and Mental Health Data Archive
  • Book Catalogs – e.g., local library catalog or discovery search, WorldCat
  • Library Web Scale Discovery Service  e.g., OneSearch
  • Web Search Engines   e.g., Google, Yahoo
  • Digital Collections   e.g., Archives & Special Collections Digital Collections, Archives of the History of American Psychology
  • Associations/Community groups/Institutions/Organizations   e.g., American Psychological Association

Remember there is no one portal for all information!

Database Searching Videos, Guides, and Examples

  • Comprehensive guide to the database
  • Sample Searches
  • Searchable Fields
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ProQuest (platform for ERIC, PsycINFO, and Dissertations & Theses Global databases, among other databases) search videos:

  • Basic Search
  • Advanced Search
  • Search Results
  • Performing Basic Searches
  • Performing Advanced Searches
  • Search Tips

If you are new to research , check out the Searching for Information tutorials and videos for foundational information.

Finding Empirical Studies

In ERIC : Check the box next to “143: Reports - Research” under "Document type" from the Advanced Search page

In PsycINFO : Check the box next to “Empirical Study” under "Methodology" from the Advanced Search page

In OneSearch : There is not a specific way to limit to empirical studies in OneSearch, you can limit your search results to peer-reviewed journals and or dissertations, and then identify studies by reading the source abstract to determine if you’ve found an empirical study or not.

Summarize Studies in a Meaningful Way

The Writing and Public Speaking Center at UM provides not only tutoring but many other resources for writers and presenters. Three with key tips for writing a literature review are:

  • Literature Reviews Defined
  • Tracking, Organizing, and Using Sources
  • Organizing and Integrating Sources

If you are new to research , check out the Presenting Research and Data tutorials and videos for foundational information. You may also want to consult the Purdue OWL Academic Writing resources or APA Style Workshop content.

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Journals Publishing Literature Reviews

While many scholarly journals may publish literature reviews, some psychology journals are exclusively or mainly devoted to publishing review articles.  When researching a topic, a relevant literature review is an excellent entry point for understanding concepts and the current state of research.

  • Annual Review of Psychology
  • Annual Review of Clinical Psychology
  • Annual Review of Neuroscience
  • Clinical Psychology Review
  • Current Directions in Psychological Science
  • Nature Reviews Neuroscience
  • Perspectives on Psychological Science
  • Psychological Bulletin
  • Psychonomic Bulletin and Review
  • Social and Personality Psychology Compass

Writing a Literature Review

Literature reviews analyze and evaluate previously published material on a topic. When they appear in journals, they are referred to as review articles. A systematic review is a kind of review that uses strict methods for identifying and synthesizing previous studies.

The literature review process

The literature review process. From Diana Ridley, The Literature Review: A Step-by-Step Guide for Students (2008), p. 81

For more information about writing a literature review as a senior thesis, see the Bates Psychology Department's Senior Thesis Proposal Guidelines page . Other resources include:

Baumeister, R. F., & Leary, M. R. (1997). Writing narrative literature reviews (PDF) . Review of General Psychology , 1, 311–320.

Bem, D. J. (1995). Writing a review article for Psychological Bulletin . Psychological Bulletin , 118(2), 172. doi:10.1037/0033-2909.118.2.172

University of Washington Psychology Writing Center.  Writing a Psychology Literature Review (PDF) .

literature review psychology journals

Finding Literature Reviews in PsycINFO

PsycINFO is the premier research tool in psychology. One of its handiest features searching for articles by research methodology, including literature review. From the Advanced Search page, scroll down to the Methodology box in the lower right, and select Literature Review and Systematic Review. Then search the keywords related to your topic.

Methodology in Advanced search in PsycINFO

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What is a Literature Review?

A literature review is a survey of research on a given topic. It allows you see what has already been written on a topic so that you can draw on that research in your own study. By seeing what has already been written on a topic you will also know how to distinguish your research and engage in an original area of inquiry.

Why do a Literature Review?

A literature review helps you explore the research that has come before you, to see how your research question has (or has not) already been addressed.

You will identify:

  • core research in the field
  • experts in the subject area
  • methodology you may want to use (or avoid)
  • gaps in knowledge -- or where your research would fit in

Elements of a Successful Literature Review

According to Byrne's  What makes a successful literature review? you should follow these steps:

  • Identify appropriate search terms.
  • Search appropriate databases to identify articles on your topic.
  • Identify key publications in your area.
  • Search the web to identify relevant grey literature. (Grey literature is often found in the public sector and is not traditionally published like academic literature. It is often produced by research organizations.)
  • Scan article abstracts and summaries before reading the piece in full.
  • Read the relevant articles and take notes.
  • Organize by theme.
  • Write your review .

from Byrne, D. (2017). What makes a successful literature review?. Project Planner . 10.4135/9781526408518. (via SAGE Research Methods )

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What is a Literature Review?

Description.

A literature review, also called a review article or review of literature, surveys the existing research on a topic. The term "literature" in this context refers to published research or scholarship in a particular discipline, rather than "fiction" (like American Literature) or an individual work of literature. In general, literature reviews are most common in the sciences and social sciences.

Literature reviews may be written as standalone works, or as part of a scholarly article or research paper. In either case, the purpose of the review is to summarize and synthesize the key scholarly work that has already been done on the topic at hand. The literature review may also include some analysis and interpretation. A literature review is  not  a summary of every piece of scholarly research on a topic.

Why are literature reviews useful?

Literature reviews can be very helpful for newer researchers or those unfamiliar with a field by synthesizing the existing research on a given topic, providing the reader with connections and relationships among previous scholarship. Reviews can also be useful to veteran researchers by identifying potentials gaps in the research or steering future research questions toward unexplored areas. If a literature review is part of a scholarly article, it should include an explanation of how the current article adds to the conversation. (From: https://researchguides.drake.edu/englit/criticism)

How is a literature review different from a research article?

Research articles: "are empirical articles that describe one or several related studies on a specific, quantitative, testable research question....they are typically organized into four text sections: Introduction, Methods, Results, Discussion." Source: https://psych.uw.edu/storage/writing_center/litrev.pdf)

Steps for Writing a Literature Review

1. Identify and define the topic that you will be reviewing.

The topic, which is commonly a research question (or problem) of some kind, needs to be identified and defined as clearly as possible.  You need to have an idea of what you will be reviewing in order to effectively search for references and to write a coherent summary of the research on it.  At this stage it can be helpful to write down a description of the research question, area, or topic that you will be reviewing, as well as to identify any keywords that you will be using to search for relevant research.

2. Conduct a Literature Search

Use a range of keywords to search databases such as PsycINFO and any others that may contain relevant articles.  You should focus on peer-reviewed, scholarly articles . In SuperSearch and most databases, you may find it helpful to select the Advanced Search mode and include "literature review" or "review of the literature" in addition to your other search terms.  Published books may also be helpful, but keep in mind that peer-reviewed articles are widely considered to be the “gold standard” of scientific research.  Read through titles and abstracts, select and obtain articles (that is, download, copy, or print them out), and save your searches as needed. Most of the databases you will need are linked to from the Cowles Library Psychology Research guide .

3. Read through the research that you have found and take notes.

Absorb as much information as you can.  Read through the articles and books that you have found, and as you do, take notes.  The notes should include anything that will be helpful in advancing your own thinking about the topic and in helping you write the literature review (such as key points, ideas, or even page numbers that index key information).  Some references may turn out to be more helpful than others; you may notice patterns or striking contrasts between different sources; and some sources may refer to yet other sources of potential interest.  This is often the most time-consuming part of the review process.  However, it is also where you get to learn about the topic in great detail. You may want to use a Citation Manager to help you keep track of the citations you have found. 

4. Organize your notes and thoughts; create an outline.

At this stage, you are close to writing the review itself.  However, it is often helpful to first reflect on all the reading that you have done.  What patterns stand out?  Do the different sources converge on a consensus?  Or not?  What unresolved questions still remain?  You should look over your notes (it may also be helpful to reorganize them), and as you do, to think about how you will present this research in your literature review.  Are you going to summarize or critically evaluate?  Are you going to use a chronological or other type of organizational structure?  It can also be helpful to create an outline of how your literature review will be structured.

5. Write the literature review itself and edit and revise as needed.

The final stage involves writing.  When writing, keep in mind that literature reviews are generally characterized by a  summary style  in which prior research is described sufficiently to explain critical findings but does not include a high level of detail (if readers want to learn about all the specific details of a study, then they can look up the references that you cite and read the original articles themselves).  However, the degree of emphasis that is given to individual studies may vary (more or less detail may be warranted depending on how critical or unique a given study was).   After you have written a first draft, you should read it carefully and then edit and revise as needed.  You may need to repeat this process more than once.  It may be helpful to have another person read through your draft(s) and provide feedback.

6. Incorporate the literature review into your research paper draft. (note: this step is only if you are using the literature review to write a research paper. Many times the literature review is an end unto itself).

After the literature review is complete, you should incorporate it into your research paper (if you are writing the review as one component of a larger paper).  Depending on the stage at which your paper is at, this may involve merging your literature review into a partially complete Introduction section, writing the rest of the paper around the literature review, or other processes.

These steps were taken from: https://psychology.ucsd.edu/undergraduate-program/undergraduate-resources/academic-writing-resources/writing-research-papers/writing-lit-review.html#6.-Incorporate-the-literature-r

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What is a Literature Review?

The scholarly conversation.

A literature review provides an overview of previous research on a topic that critically evaluates, classifies, and compares what has already been published on a particular topic. It allows the author to synthesize and place into context the research and scholarly literature relevant to the topic. It helps map the different approaches to a given question and reveals patterns. It forms the foundation for the author’s subsequent research and justifies the significance of the new investigation.

A literature review can be a short introductory section of a research article or a report or policy paper that focuses on recent research. Or, in the case of dissertations, theses, and review articles, it can be an extensive review of all relevant research.

  • The format is usually a bibliographic essay; sources are briefly cited within the body of the essay, with full bibliographic citations at the end.
  • The introduction should define the topic and set the context for the literature review. It will include the author's perspective or point of view on the topic, how they have defined the scope of the topic (including what's not included), and how the review will be organized. It can point out overall trends, conflicts in methodology or conclusions, and gaps in the research.
  • In the body of the review, the author should organize the research into major topics and subtopics. These groupings may be by subject, (e.g., globalization of clothing manufacturing), type of research (e.g., case studies), methodology (e.g., qualitative), genre, chronology, or other common characteristics. Within these groups, the author can then discuss the merits of each article and analyze and compare the importance of each article to similar ones.
  • The conclusion will summarize the main findings, make clear how this review of the literature supports (or not) the research to follow, and may point the direction for further research.
  • The list of references will include full citations for all of the items mentioned in the literature review.

Key Questions for a Literature Review

A literature review should try to answer questions such as

  • Who are the key researchers on this topic?
  • What has been the focus of the research efforts so far and what is the current status?
  • How have certain studies built on prior studies? Where are the connections? Are there new interpretations of the research?
  • Have there been any controversies or debate about the research? Is there consensus? Are there any contradictions?
  • Which areas have been identified as needing further research? Have any pathways been suggested?
  • How will your topic uniquely contribute to this body of knowledge?
  • Which methodologies have researchers used and which appear to be the most productive?
  • What sources of information or data were identified that might be useful to you?
  • How does your particular topic fit into the larger context of what has already been done?
  • How has the research that has already been done help frame your current investigation ?

Examples of Literature Reviews

Example of a literature review at the beginning of an article: Forbes, C. C., Blanchard, C. M., Mummery, W. K., & Courneya, K. S. (2015, March). Prevalence and correlates of strength exercise among breast, prostate, and colorectal cancer survivors . Oncology Nursing Forum, 42(2), 118+. Retrieved from http://go.galegroup.com.sonoma.idm.oclc.org/ps/i.do?p=HRCA&sw=w&u=sonomacsu&v=2.1&it=r&id=GALE%7CA422059606&asid=27e45873fddc413ac1bebbc129f7649c Example of a comprehensive review of the literature: Wilson, J. L. (2016). An exploration of bullying behaviours in nursing: a review of the literature.   British Journal Of Nursing ,  25 (6), 303-306. For additional examples, see:

Galvan, J., Galvan, M., & ProQuest. (2017). Writing literature reviews: A guide for students of the social and behavioral sciences (Seventh ed.). [Electronic book]

Pan, M., & Lopez, M. (2008). Preparing literature reviews: Qualitative and quantitative approaches (3rd ed.). Glendale, CA: Pyrczak Pub. [ Q180.55.E9 P36 2008]

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Evidence Matrix for Literature Reviews

The  Evidence Matrix  can help you  organize your research  before writing your lit review.  Use it to  identify patterns  and commonalities in the articles you have found--similar methodologies ?  common  theoretical frameworks ? It helps you make sure that all your major concepts covered. It also helps you see how your research fits into the context  of the overall topic.

  • Evidence Matrix Special thanks to Dr. Cindy Stearns, SSU Sociology Dept, for permission to use this Matrix as an example.
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This is a brief introduction on how to write a literature review. If you need a refresher, or want to tips, use this guide to help you get started. 

If your professor has assigned a literature review, refer to the syllabus to ensure your review meets their requirements. This is simply a general guide designed to help you with the basics.

Literature Reviews

The narrower the topic the easier it will be to limit the number of sources you need to read..

 A Literature Review is a select list of available resources covering the topic in question accompanied by a short description AND a critical comparative evaluation/analysis of the works included http://www.library.arizona.edu/help/tutorials/litreviews/whatis.html  

  • an integral part of the scientific process
  • reveals whether or not a research question has been answered by someone else

Major points to consider

  • Thematic -- defined by a guiding question or concept
  • Descriptive
  • Directly relevant
  • Highly selective, narrowly focused
  • May include all scholarly formats including government documents; book reviews; films; selected websites; scholarly open source journals
  • Usually includes a thesis statement/narrowly focused research question,summary and/or synthesis of the ideas encountered. (synthesis=reorganization of information of what is known, what is yet to be discovered  

Questions for Literature Reviews

Questions to ask, *expect that your work will be traced by readers., definitions:.

Literature :  a collection of materials on your topic.  (does not mean “literature” in the sense of “language and literature” (To Kill a Mockingbird, Jane Eyre, etc.)   —means understanding the difference between primary, secondary and tertiary literature  Primary—peer reviewed, scholarly, original, review articles—secondary

Review :  to look again at what has been written. (does not mean giving your personal opinion or whether or not you liked the sources.) 

Research :  re search –to search again.  

Important Parts of A Literature Review

What is the purpose of a Literature Review?  Why do people develop them?

How is a Literature Review organized?  How do I do a Literature Review?

  What do Librarians have to do with it?  Librarians are available for assistance:              

Video How To Write A Literature Review

How to write a literature reviews.

This video produced by SJSU explains important research and organizational principles that will help you in thinking about your critical approaches papers.

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  • Published: 14 February 2024

Trauma, early life stress, and mindfulness in adulthood

  • Jonathan Gibson 1  

BMC Psychology volume  12 , Article number:  71 ( 2024 ) Cite this article

Metrics details

This article is a review that was inspired by recent studies investigating the effects of childhood trauma or early life stress (ELS) and mindfulness in adulthood. One recent study found that some forms of abuse and neglect led to higher scores in several subscales of a self-report measure of mindfulness. The authors concluded that some forms of ELS can help cultivate certain aspects of mindfulness in adulthood. However, and in contrast to this recent finding, much of the extant literature investigating ELS and trauma are linked to emotional dysregulation, alexithymia, and a host of psychopathologies in adulthood which makes the results of this study surprising. Central to the mindfulness literature is cultivating an open, non-reactive, or non-judgment awareness of inner experiences which are important for emotional regulation. In this paper, I review some of the effects of trauma or ELS on critical neural circuits linked to mindfulness, interoception, attachment, and alexithymia which I hope may clarify some of the conflicting findings from this study and throughout the literature and provide additional context and a framework that may inform research investigating these two constructs going forward.

Peer Review reports

Introduction

A recent study [ 1 ] set out to explore the link between early life stress (ELS) and trait mindfulness in adulthood. Trait mindfulness was defined as: “the awareness that emerges through deliberate attention in the present moment, with intention, without judgment, making the most of the current experience” [1 p. 2]. As the authors point out, there is a gap in the literature exploring these two constructs and little is known whether ELS can affect the latter or vice versa. There is a wealth of literature demonstrating the benefits of mindfulness and how mindfulness can help build resilience, manage stress and emotions, and improve the overall quality of life which might have an indirect effect on childhood trauma [ 2 , 3 , 4 ], but the authors claimed a study exploring the link between the two had yet been done. It is important to note that there is at least one prior study that has explored the link between childhood and lifetime trauma, mindfulness, PTSD, and dissociative symptoms. That study will be reviewed in a subsequent section below. The authors in this recent study [ 1 ] conducted a cross-sectional correlational design from a Brazilian public university and most of the findings corroborate prior research on ELS and mindfulness. That is, those who experienced less ELS tended to score higher in various facets of mindfulness, at least as it was measured by the Five-Facet Mindfulness Questionnaire (FFMQ) and the Childhood Trauma Questionnaire (CTQ).

However, the researchers found some forms of ELS may help cultivate certain aspects of mindfulness in adulthood. Specifically, participants in their study who experienced more emotional abuse, emotional neglect, and physical abuse scored higher in the subscale of “non-reactivity to inner experience” and those who experienced more emotional abuse, emotional neglect, sexual abuse, physical neglect, and physical abuse scored higher in “acting with awareness,” though those correlations were modest [ 1 ]. The non-reactivity facet of this assessment tool is believed to measure one’s ability to notice internal sensations and emotions and mindfully process those and let them pass without overreacting or being overrun by them. The “acting with awareness” is believed to measure engagement and awareness of the present moment rather than being distracted or on autopilot. This type of awareness and non-reaction or non-judgment of inner experiences are central facets to the mindfulness literature and are critical for emotional regulation and psychological well-being [ 1 , 5 , 6 , 7 ]. This novel finding is provocative especially when compared to prior studies investigating ELS or trauma which have been consistently linked to emotional dysregulation and a host of psychopathologies in adulthood. The authors suggest that this specific population may have learned to cultivate emotional regulation even in the presence of childhood trauma [ 1 ].

The purpose of this article is to provide additional context and a framework that may help inform some of the conceptual and methodological baggage that shapes these constructs. This paper is not meant to be comprehensive, but I will review some of the effects of trauma or ELS on critical neural circuits that influence the development of mindfulness, interoception, attachment, and alexithymia and how those capacities appear to be fundamentally shaped by the relational environment, or as the authors described it as ‘bio-social functions’ [ 1 ]. It may be possible the results of the study [ 1 ] may be skewed due to construct conceptualization and methodological limitation. In short, it is hoped that this framework can shed light and help account for some of the inconsistent and even contradictory findings in the contemplative or mindfulness literature and help identify putative neurological target interventions in the clinical literature.

As the authors [ 1 ] highlight, ELS including emotional, physical, sexual abuse, and neglect is linked to a number of physical and psychological disorders [ 4 , 8 , 9 , 10 ]. These negative outcomes are consistent and well documented throughout the literature. Moreover, ELS has been shown to influence the development of neural structures linked to emotion processing and memory, [ 10 , 11 , 12 , 13 , 14 ] attachment and relational patterns, [ 15 , 16 , 17 , 18 ] interoception (awareness of the internal state of the body), [ 5 , 6 , 7 , 19 , 20 , 21 , 22 ] which is believed to be foundational to mindfulness [ 5 , 22 , 23 , 24 , 25 , 26 ], and alexithymia [ 27 ]. It is generally accepted that ELS can lead to maladaptive or unhealthy emotional and behavioral responses and a myriad of psychological disorders in adult life [see 1 for review].

  • Mindfulness

To begin, a close examination of the constructs described in this study is needed. Despite its growing popularity in the scientific community and society generally, mindfulness itself remains broadly defined and loosely conceptualized [ 26 , 28 – 29 ]. Critics [ 28 ] have emphasized that mindfulness has become an umbrella term that characterizes a large number of practices, processes, and characteristics spanning acceptance, awareness, non-judgment and memory. The confusion surrounding mindfulness includes the problems of defining and measuring it. The capacity to be mindful is believed to be multi-faceted [ 28 , 29 , 30 , 17 ]. Some have argued that attention to the present moment may be the single most critical aspect of mindfulness [ 30 ]. Others emphasize a particular attentional style. For example, Kabat-Zinn [ 31 ] argued that mindfulness is not just moment-to-moment awareness, but a specific type of awareness that includes an objective, non-reactive, non-judgmental, and open-heart. These definitions, however, still leave room for interpretation [see 28 for review].

In addition to its broad definition, sometimes researchers refer to mindfulness as a particular meditation – whether it is an open-monitoring meditation, breathing mediation, or body scan [ 28 ]. This is also problematic because each meditation produces different effects and requires different attentional styles [ 26 , 32 ]. It is generally believed in the contemplative literature that attention regulation is the prerequisite for other beneficial outcomes to take place [ 5 , 33 ]. However, each of those meditations have been categorized in different ways. For example, a mindfulness meditation is often referred to as ‘open-monitoring’ (OM) meditation which explicitly prescribes a mindful attentional style to both interoceptive and exteroceptive sensations, thoughts, and emotions [ 34 , 35 ]. Breathing and body scan meditations have been categorized as a focused attention (FA) meditation [ 34 , 35 , 36 ]. Focused attention meditations involve focusing and maintaining attention on a single object such as one’s breath, heartbeat, or a mantra [ 33 ].

The semantic ambiguity in the meaning of mindfulness or mindful meditations has implications. Van Dam and his colleagues [ 28 ] argued that any study using the term mindfulness must be carefully scrutinized to accurately ascertain what type of “mindfulness” was involved. They also urged scientists, practitioners, and the media alike to move away from the broad use of the term mindfulness and more clearly specify exactly what practices and processes are being taught. That is, when formal meditation is used in a study, one ought to consider whether a mindful or open-monitoring meditation or a focused attention meditation was the target intervention. For instance, the mindfulness-based stress reduction (MBSR) program consists of multicomponent treatments and employs both FA meditative techniques (body scan and yoga) and an OM or mindfulness technique (sitting meditation). Yet, all of these interventions require different attentional styles which produce different effects [ 26 , 37 ]. As Holzel et al., [ 33 ] point out, it is unclear what role “mindfulness” may play in the various, documented outcomes. These distinctions are critical because how mindfulness is operationalized will determine what is measured and how and those differences can vary from scale to scale [ 29 ].

Even though mindfulness has its roots in Buddhism, the scientific investigation of mindfulness has been shaped by Western scientific methodologies and assumptions. Grossman [ 29 ] argued that mindfulness, in the Buddhist tradition, is meant to cultivate “truths” about personal, lived experience which is a subjective phenomenon that is difficult to measure using traditional, Western methodologies. This effort is further problematized because the definition and measurement of mindfulness is enmeshed in a ‘complex web of historical, social, economic, political, and technological factors’ [ 29 ]. The mindfulness assessments themselves – even with good psychometric scores of reliability and validity – are often operationalized in different ways and those meanings (including the meaning of mindfulness itself), and can differ from scale to scale [ 38 ]. Furthermore, there are semantic ambiguities in assessment items which have led to questionable outcomes e.g., binge-drinking students score more “mindfully” than healthy controls or long-term mindfulness meditators [see 29 for review]. It has also been shown that various scales don’t often correlate highly with one another [ 38 , 39 ]. All of these challenges measuring and defining mindfulness should cause one to remain cautious in interpreting results. Mindfulness remains a broadly defined and loosely conceptualized construct and the assessment tools may be too imprecise to ideally capture these nuanced abilities.

Mindfulness, the insula, and interoceptive or salience network

Both the FA and OM mediations produce different neurological and functional effects, [ 26 , 33 ] but there are important commonalities. Research has shown that all meditations included in mindfulness practices directly shape the anatomy and function of the insula and interoceptive network (IA) or salience network (SN) [ 23 , 24 , 25 , 26 , 32 , 40 , 41 , 42 , 43 , 44 , 45 ]. The IA/SN network spans various brain regions, which include the insular cortex, anterior cingulate cortex (ACC), the inferior frontal gyrus, and the sensorimotor cortex, but also presents multiple connections to the amygdala, hypothalamus, hippocampus, and brainstem [ 5 , 23 , 24 , 25 , 26 ]. To be clear, a recent meta-analysis has shown that every meditation type including FA, OM, mantra, and loving/kindness meditations have been shown to modulate the insula in some way [ 32 ]. Furthermore, the insula is believed to be the only neural structure that is modified by any and all meditations [ 32 ]. As Fox and Cahn [ 32 ] point out, given that the insula is the hub for interoception, this finding shouldn’t be surprising as the body plays a central role in mindfulness practices [ 5 , 6 , 7 , 23 , 24 , 25 , 26 ].

Studies have consistently shown that dispositional and trait mindfulness is linked with increased activity and cortical thickness in the insula [ 23 , 24 , 25 , 26 , 42 , 43 , 44 , 45 ]. Friedel et al., [ 25 ] found that these neuroplasticity changes are true not only in adults but also in adolescents. The authors argue: “While evidence for anterior insula involvement in adult long-term meditator has been interpreted to indicate an effect of mindfulness meditation on insula structure and function, the current results suggest that structural development of the anterior insula may contribute to the development of dispositional mindfulness” (pp. 67). Indeed, many have argued that increased interoception and the neuroplasticity changes produced within the insula, ACC, and IA/SN network are foundational to developing mindfulness [ 5 , 6 , 7 , 22 , 23 , 24 , 25 , 26 ]. Thus, a close examination of the functions of insula, ACC, and IA/SN circuits will prove useful here.

Emotional awareness, regulation, and interoception

de Morales et al., [ 1 ] rightly point to emotional awareness and emotional regulation as central facets of mindfulness as it is a consistent theme throughout the literature. Emotion regulation is also at the heart of psychological well-being as it enables an individual to develop appropriate, flexible, and adaptable responses in adult life [ 1 ]. Emotion regulation begins with recognizing a stimulus and then establishing a meaning [ 1 ]. Studies have shown that effective emotional regulation appears to be at least partly dependent upon accurate interoception [ 45 , 46 , 47 , 5 ]. Indeed, in Buddhist philosophy, the first pillar to develop mindfulness is to develop a sense of the body, which includes an awareness of momentary sensation while distinguishing sensation from conceptual thought [ 5 , 48 ].

The insula, ACC, and IA/SN network have been shown to be essential circuits not only for emotional awareness, but awareness of the present moment [see 49 for review] – a salient facet in the mindfulness literature. Craig [ 49 , 50 ] connected human awareness to emotional awareness and interoception. In his review, he discussed how all stimuli or sensations that are salient to the individual are ultimately represented by feelings which are crucial neuropsychological constructs that function as the currency of awareness [ 49 ]. The insula, ACC, and IA/SN network translate interoceptive signals into feelings and emotions. This framework isn’t new as early and modern theories of emotion have emphasized the importance of interoceptive feedback in emotional states and cognitive processes [ 21 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 ]. For example, Damasio, [ 51 ] building off the work of William James, [ 52 ] argued that positive or negative emotional feeling states are associated with visceral and other bodily responses to certain situations and awareness of those are essential for affective, cognitive, and interpersonal processes.

Studies have shown that individuals who are more aware of their body – higher levels of interoceptive awareness – report more intense emotional experiences than those who are less aware [ 54 , 55 , 56 ]. This is important because emotional experiences appear be associated with individual differences in one’s ability to both generate and perceive subtle bodily changes [ 56 , 57 , 58 ]. Zaki et al., [ 58 ] demonstrated that the interoceptive network is highly engaged in emotional processing and that “emotional experience is intimately tied to information about internal bodily states” (p. 498). The insula has been shown to be the key region which integrates information from the body via lamina 1 spinothalamic and vagal afferent tracts [ 49 ]. Much of those body sensations projects ultimately into the posterior portion of the insula and somatosensory cortices and is re-represented in the mid and anterior portion of the insula which is then sent to the prefrontal regions bringing subtle, interoceptive sensations into awareness [ 5 , 49 ]. The anterior portion of the insula provides a multilevel integrated meta-representation of the state of the entire body integrating body sensations and top-down processes into a broader context [ 49 , 50 , 51 , 5 ].

There is a growing body of literature indicating that learning to accurately discern bodily signals through meditation and mindfulness can enhance one’s ability to understand one’s emotional state [ 23 , 24 , 25 , 60 , 61 , 62 ]. Contemplative practices, including mindfulness, produce neuroplasticity changes within IA/SN circuits increasing interoception by bringing subtle interoceptive cues into awareness [ 23 , 24 , 25 , 26 , 43 , 44 , 45 , 46 , 47 ]. The observed neuroplasticity changes within those circuits can explain how meditation and mindfulness enhance interoceptive sensations and emotional awareness [see 26 for review]. This increased awareness can then be used to develop adaptive strategies to regulate stress and improve well-being [ 5 , 63 ].

To summarize, emotional awareness and effective emotional regulation appear to be dependent upon accurate interoception [ 45 , 46 , 47 , 55 , 56 , 57 , 58 ]. Interoception is necessary for emotional awareness, and thus, interoception becomes a basis for engaging emotional processing. To be mindfully aware of interoceptive sensations and resultant emotions in a stable, non-reactive awareness in stressful situations is a central feature in the mindfulness literature [ 5 , 6 , 7 , 63 ]. Mehling and his colleagues [ 63 ] point out, being able to mindfully accept body sensations may reduce the emotional impact of unpleasant ones. This capacity may also enable one to “listen” to emotion-related sensations that are central to insight and decision making rather than being “overrun” by them. This raises two important questions: do individuals who have suffered from various forms of ELS mindfully process interoceptive sensations and the emotional effects? And, in addition, can the assessment tools used accurately capture this refined, nuanced ability?

Interoception and mindfulness

Interoceptive awareness and mindfulness are associated but distinct constructs in mind-body interactions [ 26 , 63 ]. Attention regulation is a critical distinction in teasing these two constructs apart [ 26 , 63 ]. For example, in some mindfulness practices there is no distinction between attention directed to interoceptive sensations, exteroceptive stimuli, or conscious thoughts [ 63 ]. This is relevant as several studies highlight different attentional styles (that is, how and where one focuses attention) elicit different neural responses [ 32 , 45 , 62 ]. In the interoception literature, the assessments tools often fail to distinguish between different attention styles [ 63 ]. For instance, some scales do not differentiate from anxiety or hypervigilant attentional style to interoceptive sensations and mindful and open-monitoring styles [ 63 ]. Training individuals to focus solely on interoceptive sensations does not necessarily imbue participants with knowledge on how to alter attentional style or mental habits commonly employed to avoid unpleasant sensations when they emerge [ 5 , 6 , 26 , 63 ].

Dispositional mindfulness may promote more adaptive interoceptive attentional style and enhance or illuminate discriminative capacities related to various bodily sensations [ 5 , 6 , 26 , 63 ]. That is, intentional mindful awareness may provide a safe focal point from which one can view various signals from the body. As Hanley et al., [ 6 ] argue: “awareness of bodily sensations and the evaluative or regulatory tendencies applied to such sensations are important determinants of emotional health” (p. 5). One way to investigate how some can develop the mindful capacity to be aware of and sift through various interoceptive and emotional processes in a non-reactive, non-judgmental manner is to examine the development of the insula, ACC, and IA/SN network through the biosocial functions [ 1 ], specifically the attachment relationship [ 18 ].

Insula and attachment

There is extensive empirical evidence demonstrating that early childhood relationships and experiences, including ELS, directly shape the development of a number of brain circuits, including and especially the insula, ACC, and IA/SN network [ 15 , 16 , 18 ]. Investigating ELS from the attachment relationship should help clarify how ELS directly shapes mindfulness abilities in adulthood. Indeed, a recent study found attachment orientation seems to have a unidirectional and causal effect on mindfulness in adulthood [ 17 ]. That is, those who had insecure attachments in childhood due to neglect or other forms of ELS, were unable to cultivate trait mindfulness in adulthood.

de Morales et al., [ 1 ] aptly point to biosocial functions in their discussion section. Research has clearly demonstrated that early life experiences, including attachment patterns in childhood, have enduring consequences throughout the lifespan on emotional regulation [ 64 , 65 , 66 , 67 ]. Oldroyd et al., [ 18 ] point out that the insula and IA/SN neural circuits that are necessary for interoception and emotional regulation show protracted post-natal development. The architecture and function of these neural circuits are heavily shaped by early experiences and relationships. Some have even argued that normal brain development may be dependent upon a secure attachment [ 15 , 68 ] which is characterized by sensitive, loving, and supportive relationships [ 68 , 69 ].

Children with secure attachments who have formed a secure bond with their primary caregiver manage their anxiety and autonomic arousal with a degree of trust due to the caregiver’s consistent and attentive response to the child’s needs [ 18 , 68 , 69 ]. Those interpersonal experiences shape internal working models and the development of the neural circuits involved not only in relational processes, but also interoception, mindfulness, and emotional regulation. These processes will be further unpacked below. In summary, when a child feels loved, secure, and trust in their relationship with their caregiver, they will use the caregiver as a “secure base” from which to explore the environment and manage their stress response [ 69 ].

Several studies have shown that individual differences in attachment patterns are characterized by different neural responses to stress [see 18 for review]. When a parent avoids responding to or delays meeting the child’s immediate needs (e.g., neglect), or is inconsistent or only conditionally available, then the child may develop an insecure avoidant or anxious attachment pattern [ 18 ]. Insecure attachment orientation is typically conceptualized along two dimensions: anxious and avoidant [ 70 ]. Individuals with insecure avoidant or insecure anxious attachments show not only altered IA/SN networks, but these individuals also suffer from dysregulated hypothalamus-pituitary-adrenal (HPA) axis activity in response to stress across the lifespan [ 71 , 72 ].

Stress regulation and interoception utilize many of the same anatomical pathways between the brain and body [ 49 , 54 , 73 , 74 , 75 ]. Trauma or ELS found in the attachment relationship directly shape the neural circuits that govern interoception and distress, both of which are necessary for emotional regulation. Furthermore, researchers [ 73 , 74 ] identified a direct link from the sympathetic nervous system to the insula, ACC, and IA/SN network with specialized neurons within that network called Von Economo Neurons (VEN’s). These neurons are believed to be a cerebral representation of the autonomic nervous system [ 73 , 74 ]. Interestingly, these neurons are only found in the IA/SN network [ 49 , 73 , 74 ] and the gut or enteric nervous system [ 53 ] and are believed to process and integrate emotion and behavior [ 49 , 73 , 74 ]. Research is reliably showing that ELS affects the development of the HPA axis, the insula, ACC, and IA/SN network, which, in turn, affects interoception, one’s ability to be mindful, and to regulate stress and emotion. Furthermore, trauma and ELS have been shown to affect both the strength of those interoceptive signals and how those signals are perceived [ 18 ]. Friedel et al., [ 25 ] argue that there should be increased emphasis on the insula, and the IA/SN network as these circuits not only play a critical role in maintaining emotion and self-regulation, but also provides a distinct construct with a measurable neurobiological imprint.

Attachment, interoception, and non-reactivity

Attachment related processes have also been linked to insular anatomy and activity. Studies have shown that those with an avoidant or anxious attachment pattern have markedly lower insular volume and smaller surface areas than those with a secure attachment [ 76 , 77 , 78 , 79 ]. Furthermore, those with avoidant attachment patterns have decreased insular electrical activity compared to securely attached controls [ 78 ]. Oldroyd et al., [ 18 ] argue, insensitive, slow, inconsistent caregiving or rejection of the infant’s distress impairs the child’s ability to form accurate bodily representations because the infant must rely on caregivers’ responses to help shape and inform accurate interoceptive states.

The insula also plays a critical role in comparing feelings in the present moment with those of the past and anticipation of the future [ 80 ], which plays an important role in meta-memory processing [ 81 ]. This meta-memory process can explain why interoceptive predictions that are associated with trauma or ELS are often distorted [ 40 ] as the insula becomes unusually overactive in individuals who have experienced abuse or trauma [ 21 , 49 ] or underactive in those who have been neglected [ 17 , 18 , 82 ]. Individuals with an anxious attachment pattern might overemphasize or exaggerate bodily cues leading to emotional distress and dysregulation. In contrast, those with avoidant attachment patterns might minimize or suppress bodily cues [ 17 , 18 ]. “This means that the more avoidant a person’s attachment style, the less attention they paid to their bodily cues and the less they tended to trust those cues” [18 pp. 5].

ELS and mindfulness

The result de Morales et al., [ 1 ] found that various forms of ELS might help cultivate increased awareness of and non-reactive response to inner experience (i.e., interoception) is surprising because a central facet to mindfulness is the ability to pause, increase awareness, and gain greater access to sensations and emotions without being overcome by those feelings [ 5 , 6 , 7 , 63 ]. The hypothesis in the original study [ 1 ] was that those who experienced certain types of ELS, including neglect and several forms of abuse, may be more aware and less judgmental of bodily sensations. However, the authors [ 1 ] highlight those participants continued to react with “greater intensity to their inner experiences” [ p. 9] which they argued revealed a deficit in their coping or emotional regulation strategies [p. 9]. This raises important questions: Are those participants mindfully processing interoceptive sensations and emotions? Or did those who experienced heightened levels of ELS develop patterns similar to an insecure attachment style consistent with the anatomical and functional neural changes characteristic of those patterns?

Avoidant individuals have often been described in the literature as manifesting a disconnect between bodily cues and their physiological responses [ 82 ]. These individuals may present as if they were calm while in a distressing situation (e.g., mindful), when they simply dissociated from or suppressed those sensations in a non-reactive way [ 83 , 84 ]. As Oldroyd and her colleagues [ 18 ] argue, those with avoidant attachment patterns have learned to either minimize or suppress those signals. It is also possible those participants developed alexithymia which is defined as an impaired ability to be aware of, explicitly identify, and describe one’s feelings [ 85 ]. Those participants may be unable to accurately perceive and identify interoceptive signals and use those to inform their emotional state.

A recent study investigated the effects of childhood trauma, attachment, addiction, and alexithymia [ 27 ]. The results of this recent study [ 27 ] corroborated prior studies which found alexithymia is a common result of childhood trauma or ELS. Moreover, alexithymia is now recognized as a key factor responsible for non-adaptive strategies of regulating emotions [ 27 , 86 ]. Characteristics of alexithymia include (1) difficulty identifying feelings and distinguishing between feelings and bodily sensations of emotional arousal, (2) difficulty describing feelings toward other people, (3) externally oriented cognitive style, and (4) low perspective taking, as well as difficulty describing and understanding the emotions of others [ 86 ].

Interestingly, the authors [ 27 ] found that the strongest predictor for developing alexithymia in adulthood were insecure anxious and avoidant attachment patterns from childhood. Specifically, the authors [ 27 ] found that “avoidant attachment style has the strongest negative impact on the development of a strategy for affect regulation and general emotional development” [p. 9]. Conversely, studies have shown that those with a secure attachment have an inverse relation to alexithymia [see 27 for review]. Insecure avoidant attachment styles also demonstrate lower levels of trust in personal relationships, [ 87 ] trust in themselves, [ 88 ] and the insula has been shown to be the neural correlate for evaluating trustworthiness of others [ 49 ]. The insula is also believed to be a critical neural circuit linked to alexithymia [ 49 ]. Thus, an individual who has not developed trust in a loving caregiver has not learned to trust others or themselves, nor can they expect their body to give them reliable signals that inform their emotional state [ 18 , 27 ]. Indeed, there is an extensive body of literature that has linked insecure attachment styles to alexithymia [see 27, 90–91 for review].

There is growing evidence that accurate interoception develops initially in the context of interpersonal relationships [ 18 ]. A child’s attachment relationship characterized by either a warm and responsive connection with the primary caregiver, or a distressing relationship characterized by trauma, neglect, or indifference inevitably shapes those neural circuits related to stress and interoception. “To the extent that a child’s bodily experiences are denied, devalued, ignored, or punished by parents, the child will find ways to avoid feeling them, and develop a distorted sense of interoception” [18 pp. 10].

de Morales et al., [ 1 ] point to the “biosocial” facet of cultivating emotional awareness, emotional regulation, and mindfulness. It appears that ELS and trauma disrupt the attachment system which creates a ripple effect. In concert with a large body of literature, increased awareness and effective emotional regulation appear to be dependent upon accurate interoception. Accurate interoception is shaped by early life experiences, including the attachment relationship. Accurate interoception and proper development of the insula, ACC, and IA/SN network has been shown to be foundational to developing mindfulness and emotional regulation. Trauma or ELS seems to lead to insecure attachments, alexithymia, and host of psychopathologies.

Attachment and mindfulness

Some research has explored why attachment and mindfulness may be linked. Both constructs are linked to the same neural circuitry, and both contribute to a range of positive outcomes including mental health, and self and emotion regulation [ 89 , 90 ]. Ryan et al., [ 89 ] suggested that mindfulness and attachment have a bi-directional relationship. They argued that attachment security fostered enhanced awareness and attentiveness to relational patterns while mindfulness was believed to increase one’s capacity for a secure relationship by cultivating an open, receptive attention to relationship partners. Stevenson et al., [ 17 ] has challenged that assumption as they found that attachment orientation seems to play a unidirectional, causal role in the development of mindfulness. The authors wrote: “the organization of the attachment system and inner working models, resultant of caregiver warmth and availability, not only influence the way in which we view ourselves and others, but also the capacity in which we attend to our experiences” (pp. 21). Their research indicates that attachment orientation comes first and can predict and affect the capacity for mindfulness in adulthood.

Mindfulness, trauma, PTSD, and dissociation

As mentioned in the introduction, there was at least one prior study investigating childhood trauma and mindfulness. Specifically, the authors explored whether mindfulness traits (measured using the FFMQ) would mediate the relationship between childhood and lifetime trauma, PTSD, and dissociative symptoms [ 91 ]. The authors found an inverse relationship between mindfulness, trauma, PTSD, dissociative PTSD, and trauma-related altered states of consciousness (TRASC). That is, those who had increased traumatic experiences and PTSD symptomology had a decreased capacity for trait mindfulness. Unlike de Moralez et al., [ 1 ], this study did not find a relationship between trauma and the mindfulness facets of non-reactivity and acting with awareness. Moreover, the authors argued that a decreased capacity for different facets of mindfulness may be one mechanism by which trauma exposure leads to the development of PTSD or trauma-related distress or dissociation.

Interestingly, however, the authors did find that individual differences in mindfulness traits may partially mediate the association between increased lifetime and childhood trauma exposure and posttraumatic symptoms [ 91 ]. They found the facets of describing, acting with awareness, non-judgment, and non-reactivity revealed a negative relationship with trauma, PTSD, and PTSD symptomology. They did make particular note of the observing facet. They found observing was associated with increased PTSD symptomology and linked to childhood and lifetime trauma and exposure. The authors wrote: “Observing trait may be a risk factor for , rather than a protective factor against , mental health problems” (pp. 678).

This is interesting because some studies have found a link with the observing trait and a history of trauma [ 91 , 92 ], while others have linked the observing trait with measures of good psychological health [ 93 ]. Herein lies a contradiction as some critics [see 28 for review] have pointed out. How can the observing trait be linked to both mindfulness and emotional regulation, while also linked to emotion dysregulation and a host of psychopathologies? Some hypothesize that the observing facet serves as a marker of vividness or depth of experience [ 91 , 92 ]. Boughner et al., [ 91 ] wrote: “in persons exposed to life experiences that are for the most part positive, nurturing, and safe, being more mindfully observant will heighten the influence of such adaptive life experiences in encouraging psychological health. In contrast, if a person is repeatedly exposed to life events that are highly stressful or traumatic in nature, those who are predisposed toward heightened Observing may experience such events with increased intensity, increasing risk for aversive consequences” [pp. 677].

Early childhood experiences whether nurturing, safe, and secure, or traumatic, abusive, or neglectful alter internal working models and neural circuits linked to those functions that appear to have lifelong effects. Therefore, investigating mindfulness from a developmental and relational or attachment model may prove to be a useful framework in interpreting some of the inconsistent findings throughout the mindfulness and contemplative literature and help identify putative target interventions from a clinical perspective. Indeed, a recent study [ 94 ] has identified disruptions in the dorsal mid-insula across a number of psychological disorders, which the authors found were anatomically distinct from other brain regions in affective processing.

I have attempted to lay out a conceptual or theoretical framework from which to interpret the link between trauma, ELS, and mindfulness. It is my hope this article can prove to be a useful reference piece in aiding future research. It may be possible that ELS or trauma can help cultivate certain aspects of mindfulness in adulthood. If this is the case, this finding warrants further, careful investigation. It is also possible that the results of this recent study [ 1 ] may be skewed due to several factors. Among those is the definition and conceptualization of mindfulness. How mindfulness is operationalized changes how it is measured [ 29 ]. Popular scales don’t often highly correlate and the meanings within those scales can differ [ 29 , 38 ]. There are also semantic ambiguities in assessment items which have led to questionable outcomes such as binge-drinking students scoring higher in mindfulness than practiced meditators [ 29 , 38 ]. Boughner et al., [ 91 ] also pointed to construct limitations as a potential confound in the literature. They highlighted that a significant overlap exists between some mindfulness assessments and PTSD diagnostic criteria in the DSM-5. For example, the mindful trait of describing “overlaps considerably with alexithymic symptomology of PTSD associated with the emotional numbing criteria of DSM-5 PTSD” [pp. 677]. They argue further that the non-reactivity trait implies the opposite of emotion dysregulation but may overlap with trauma-related immobilization defenses [ 91 , 95 ], which is in concert with the conceptual framework of avoidant attachment and alexithymia described above.

de Moralez et al., [ 1 ] acknowledged the questionnaire as a limitation in their study and indicated that the questions “proved outdated, especially with those questions that started with the word “non” [p. 9]. The authors had to assist participants in answering the questions as some participants became fatigued during the process raising questions on the accuracy of the results [ 1 ]. Moreover, the authors noted that during data collection, stress levels were elevated for the given population due to a variety of factors. There are also a number of limitations using self-report assessments. For example, the use of questionnaires rather than interviews is believed to exaggerate the clinical significance of trauma-related symptoms in the general population [ 95 ]. Furthermore, trauma questionnaires measure only the occurrence of an event but not the frequency or severity [ 91 ]. Finally, it was reported that less than 20% of the participants in this study had a meditation or mindfulness practice [ 1 ]. This is relevant because a mindfulness meditation practice has shown to reliably produce neuroplasticity changes within the insula, ACC, and IA/SN network which could affect the results [see also 94]. However, mindfulness questionnaires do not always correlate with mindfulness meditation practices [ 96 ]. This variable ought to be explored more closely in the future.

The authors [ 1 ] also focused on emotion regulation. Emotional awareness is the first step to emotional regulation which requires recognition of a stimulus and to assign it meaning [ 1 ]. Key facets of emotional awareness and regulation appear to be dependent upon accurate interoception, [ 46 – 47 , 54 , 55 , 56 , 57 , 58 ] and interoception is believed to be foundational to mindfulness [ 5 , 22 , 23 , 24 , 25 , 26 ] as all three of these abilities utilize much of the same neural circuitry. Furthermore, a growing body of evidence indicates that accurate interoception is shaped by early life experiences. The effects of ELS and trauma on the nervous system is widely discussed in the literature and the results are consistently linked to emotional dysregulation and a host of psychopathologies [ 4 , 8 , 9 , 10 ]. In short, trauma or ELS have been shown to affect a number of brain regions. The focus here has been on the insula, ACC, and the IA/SN circuits as they appear to be critical circuits in attachment, interoception, which appears to be necessary for emotional awareness and regulation, mindfulness, and alexithymia. As Friedel and his colleagues [ 25 ] argue, there should be increased emphasis on these regions because it provides a distinct construct with a measurable neurobiological imprint. Furthermore, novel treatments focused on the insula may aid in more effective interventions from a clinical perspective as a number of psychological disorders have been shown to have disruptive functions within the insula that are showing to be anatomically distinct from other brain regions [ 94 ].

Some have argued that the insula is an ‘underestimated region of the brain’ [ 97 ] while others have argued that it is still poorly understood [ 98 ]. This is interesting because the insula and IA/SN circuits are not only linked to the functions described above, but also implicated in all subjective feelings [49. 50]. That is, these circuits appear to be the cortical structures that not only engender interoception and emotional awareness, but awareness in the present moment [ 50 ].

Emotional awareness and regulation are also associated with individual differences in ability to both generate and perceive subtle bodily changes [ 57 – 58 ]. Those who have experienced ELS often develop insecure attachments with the characteristic anatomical and functional effects on those neural circuits [ 15 , 16 , 17 , 18 , 76 , 77 , 78 , 79 , 82 , 83 , 84 ]. Someone with an insecure anxious attachment style might overreact to internal sensations while an insecure avoidant may suppress or ignore those. Therefore, the result that some forms of ELS might lead to a non-reactive and non-judgment heightened awareness of inner experience is provocative [ 1 ]. Alternatively, and consistent with an extensive body of literature, it seems plausible that those who scored higher in the awareness and non-reactive or non-judgmental aspect of the assessment tool [ 1 ] may be suppressing or minimizing those signals rather than mindfully, non-judgmentally or non-reactively processing them [see also 94]. This pattern is consistent with the avoidant attachment styles [ 18 , 82 , 83 , 84 ] and alexithymia [ 27 , 49 , 86 – 87 , 99 – 100 ] which could account for the results of the study [ 1 ].

As the authors emphasized, [ 1 ] understanding the link between ELS and mindfulness should encourage researchers to explore the two more carefully. Their findings emphasize the importance of emotional regulation as ELS is consistently linked to emotional dysregulation and psychological disorders later in life, but their results suggest there may be some positives. The authors [ 1 ] also suggested that those within that specific population may have developed various strategies to improve emotional regulation and became more mindful of their internal states. Thus, a more careful, precise analysis of these constructs is needed. I applaud the authors for their study as it brings these important constructs into focal view.

Data availability

Not Applicable.

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  • Early life stress
  • Interoception
  • Emotion regulation
  • And alexithymia

BMC Psychology

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literature review psychology journals

Emerging and Future Directions in Test-Enhanced Learning Research

  • Published: 12 February 2024
  • Volume 36 , article number  20 , ( 2024 )

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  • Steven C. Pan   ORCID: orcid.org/0000-0001-9080-5651 1 ,
  • John Dunlosky   ORCID: orcid.org/0000-0002-7367-7958 2 ,
  • Kate M. Xu   ORCID: orcid.org/0000-0002-1863-9676 3 &
  • Kim Ouwehand   ORCID: orcid.org/0000-0002-5434-0188 4  

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Over the past eighteen years, research into test-enhanced learning has expanded significantly and remains vibrant to this day. The fact that many major research questions in the literature have already been addressed, however, raises the question: “What’s next?” That question motivates this special issue. We asked leading researchers in the field to contribute articles highlighting cutting-edge and new directions in test-enhanced learning research. The resulting review papers, empirical articles, and commentaries address many fascinating topics, including: (a) new approaches that are generating insights into test-enhanced learning in relation to other learning techniques (e.g., combining testing with elaborative or generative learning activities); (b) investigations of lesser-known test-based learning strategies that have the potential to enhance educational outcomes (e.g., pretesting and prequestioning , spaced retrieval practice , test-potentiated new learning or forward testing ; and successive relearning ); (c) new research on effective uses of practice testing during self-regulated learning and in other contexts; and (d) how to promote awareness and acceptance of test-enhanced learning among students and practitioners. These articles showcase some of the most promising new directions in test-enhanced learning research, so we anticipate that this special issue will inspire further investigations of practice testing and its educational applications.

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Development of low back pain curriculum content standards for entry-level clinical training

  • Hazel J. Jenkins   ORCID: orcid.org/0000-0002-0535-687X 1 ,
  • Benjamin T. Brown   ORCID: orcid.org/0000-0002-3064-8815 1 ,
  • Mary O’Keeffe 2 ,
  • Niamh Moloney   ORCID: orcid.org/0000-0001-5957-7224 3 ,
  • Chris G. Maher   ORCID: orcid.org/0000-0002-1628-7857 4 &
  • Mark Hancock   ORCID: orcid.org/0000-0002-9277-5377 1  

BMC Medical Education volume  24 , Article number:  136 ( 2024 ) Cite this article

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The management of low back pain (LBP) is highly variable and patients often receive management that is not recommended and/or miss out on recommended care. Clinician knowledge and behaviours are strongly influenced by entry-level clinical training and are commonly cited as barriers to implementing evidence-based management. Currently there are no internationally recognised curriculum standards for the teaching of LBP content to ensure graduating clinicians have the appropriate knowledge and competencies to assess and manage LBP. We formed an international interdisciplinary working group to develop curriculum content standards for the teaching of LBP in entry-level clinical training programs.

The working group included representatives from 11 countries: 18 academics and clinicians from healthcare professions who deal with the management of LBP (medicine, physiotherapy, chiropractic, osteopathy, pharmacology, and psychology), seven professional organisation representatives (medicine, physiotherapy, chiropractic, spine societies), and one healthcare consumer. A literature review was performed, including database and hand searches of guidelines and accreditation, curricula, and other policy documents, to identify gaps in current LBP teaching and recommended entry-level knowledge and competencies. The steering group (authors) drafted the initial LBP Curriculum Content Standards (LBP-CCS), which were discussed and modified through two review rounds with the working group.

Sixty-two documents informed the draft standards. The final LBP-CCS consisted of four broad topics covering the epidemiology, biopsychosocial contributors, assessment, and management of LBP. For each topic, key knowledge and competencies to be achieved by the end of entry-level clinical training were described.

We have developed the LBP-CCS in consultation with an interdisciplinary, international working group. These standards can be used to inform or benchmark the content of curricula related to LBP in new or existing entry-level clinical training programs.

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Low back pain (LBP) is a common condition and the leading cause of years lived with disability worldwide [ 1 ]. While individual episodes of LBP may resolve quickly with minimal intervention, LBP recurrence and the development of persistent pain are also common and contribute to the overall healthcare burden associated with LBP [ 2 , 3 ]. Clinical practice guidelines are available to guide the appropriate management of LBP and improve patient outcomes [ 4 , 5 ]. Despite these recommendations, however, the management of LBP is highly variable [ 6 ]. Many patients receive management that is not recommended in current guidelines (e.g., imaging, opioids) and/or miss out on the care that is recommended (e.g., education, exercise). Both these problems may lead to poorer patient outcomes [ 4 , 6 ].

Strategies to educate clinicians and implement best-evidence and guideline recommendations into clinical practice have been attempted, with little current evidence of success [ 7 ]. Researchers have identified that a clinician’s beliefs, perceptions and level of clinical knowledge may influence the uptake of LBP guideline recommendations into clinical practice [ 8 ]. In particular, the influence of formal entry-level clinical training has been highlighted as a potential barrier to the uptake of clinical practice guidelines for LBP [ 8 , 9 ], and conversely, that changing student beliefs and attitudes about LBP in clinical training programs may facilitate more guideline-adherent practice in future clinicians [ 10 ].

Entry-level clinical training programs refer to undergraduate or postgraduate programs that train clinicians to enter healthcare professions [ 11 ]. Education related to LBP is variable across training programs, both within and between different healthcare professions. The time spent delivering LBP or general pain management content varies considerably across different clinical training programs [ 9 , 12 , 13 , 14 , 15 , 16 ]. Furthermore, gaps have been identified in different clinical training programs with regards to student knowledge and competencies related to LBP [ 10 , 17 , 18 , 19 , 20 , 21 , 22 ], confidence in ability to manage LBP on graduation [ 23 , 24 , 25 ], and alignment with LBP clinical guideline recommendations [ 12 , 26 ].

Appropriate LBP curriculum content within entry-level clinical training programs is needed to ensure that healthcare professionals are graduating with the knowledge and skills needed to deliver high-quality evidence-based care in clinical practice. Curriculum content standards are defined as the curriculum needed to equip clinicians with the knowledge, skills and attitudes necessary at the time of graduation [ 27 ]. Currently, while core competencies for clinical training programs as a whole have been developed [ 28 ], there are no specific content standards to guide teaching for LBP. Therefore, we aimed to develop the first curriculum content standards for the teaching of LBP in entry-level clinical training programs worldwide.

Overview and scope of the development of the low back pain curriculum content standards

An international, interdisciplinary working group, led by a steering group (authors), was formed to develop the Low Back Pain Curriculum Content Standards (LBP-CCS) using an iterative process. An initial literature review was performed by the steering group to identify the range of content to be included in the LBP-CCS. The content and structure of the LBP-CCS was then modified through two rounds of group discussion and feedback from the working group. The final version of the LBP-CCS was approved by all members of the working group. Ethical approval was not required for the development of the LBP-CCS as no participants or participant data were recruited or collected. All members of the working group who contributed to the LBP-CCS are acknowledged in this publication.

The LBP-CCS were developed to include a complete list of content items necessary for comprehensive education on LBP epidemiology, diagnosis, and management. Input into the development was sought from a diverse range of healthcare professions involved in the management of LBP. The working group recognised that different healthcare professions may require different levels of knowledge related to the diagnosis and management of LBP. Therefore, the LBP-CCS were designed to provide guidance that can be implemented to the appropriate level for individual entry-level clinical training programs.

Formation of the working group

The steering group (authors) identified professional organisations, academics, researchers, clinicians, and consumers to invite to participate in the development of the LBP-CCS. International professional organisations with interest in the management of LBP in primary care were invited to be involved in the development of the LBP-CCS. Organisations agreeing to be involved were asked to nominate a representative to be part of the working group. Other potential working group members were purposively invited to achieve a spread of different occupational and clinical backgrounds, sex, and geographic location.

Of 15 organisations approached, seven agreed to participate in the LBP-CCS development and provide representatives to join the working group. Participating organisations included: International Society for the Study of the Lumbar Spine (ISSLS), International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) on behalf of World Physiotherapy (WP), World Federation of Chiropractic (WFC), European Pain Federation (EFIC), Musculoskeletal Association of Chartered Physiotherapists (MACP), and Council of Physiotherapy Deans Australia and New Zealand (CPDANZ). Responses were not received from the remaining organisations approached, which included invitations to medical and osteopathic organisations. A further 22 academics, researchers, clinicians, or healthcare consumers were invited to join the working group, with 19 accepting, leading to a final working group of 32 participants (including the steering group). The spread of occupational backgrounds, sex, and geographic locations represented within the working group is presented in Table  1 .

Literature review to inform development of the low back pain curriculum content standards

The steering group conducted an initial review of the literature to establish a draft list of content to be included in the LBP-CCS. Three search strategies were used to find relevant literature:

Medline (OVID), Embase (OVID), CINAHL, and PsycInfo were searched from inception to March, 2022 to identify current gaps in entry-level clinical education related to LBP. Search terms related to: (i) LBP; (ii) curriculum/knowledge; and (iii) healthcare students. Searches were developed for each database and are available in Additional file 1 . Articles were screened by one member of the steering group (HJ) and were included if the article assessed or discussed LBP or pain education in an entry-level clinical training program. ‘Education’ could relate to any of the following: required competencies, learning outcomes, identified gaps, student preparedness for clinical practice, or alignment with evidenced-based practice or clinical practice guidelines. Articles discussing clinical practice with respect to the required competencies or knowledge needed from entry-level clinical training were also included. Clinical training programs could relate to any healthcare profession that requires training in LBP epidemiology, diagnosis, or management.

Clinical practice guidelines and accreditation documents, identifying required competencies or knowledge for healthcare clinicians related to the management of LBP, were identified by the steering group. To be included, clinical practice guidelines needed to be related to the multidisciplinary management of LBP in primary care, be produced by a national organisation, and be informed by literature review. A published overview of clinical practice guidelines [ 5 ] meeting these criteria was used to identify guidelines for inclusion. A search was performed for updates to the guidelines identified in the overview, with the most recent version included. National and international accreditation documents were included if they related to entry-level clinical training programs in medicine, physiotherapy, or chiropractic, and were written in English. Summary documents, collating information across multiple clinical guidelines or accreditation documents, were used where available.

The working group was asked to recommend documents, including curriculum and policy documents and new or updated guidelines not captured by the above process, that they considered appropriate to inform the development of the LBP-CCS.

From each included article or document, one of the steering group (HJ, BB, MO, MH) extracted the key findings, gaps, or requirements related to LBP education that were identified and categorised as content/knowledge and skills/competencies required.

Iterative development of the low back pain curriculum content standards

The first iteration of the LBP-CCS was developed by the steering group. The extracted data from the literature review were collated by one of the steering group (HJ) under broad topic headings. These topic headings were then discussed with the members of the steering group to determine an initial topic structure. The extracted data were then collated into the topic structure, with consolidation of individual items where there was duplication of data. It was not considered within the scope of the development of the LBP-CCS to evaluate the strength of available evidence and provide specific recommendations on how the content should be taught. Instead, the aim of the LBP-CCS was to provide high-level guidance of the content topics to be included within curriculum for LBP and be taught within an evidenced-based framework.

Two rounds of review, including group discussion and written feedback, were held with the working group to determine any necessary changes to the draft LBP-CCS. For each review round, members of the working group were provided with the latest iteration of the LBP-CCS and a feedback document, including the questions to be reviewed within group discussion and opportunity to provide more specific written feedback on each element of the LBP-CCS. Multiple online discussion groups were held to accommodate time-zone differences and enable all working group members to attend a session. Each discussion group was recorded (with permission of the working group members in attendance) and had at least two of the steering group members in attendance, to moderate the group discussion and record notes. The review questions were discussed within each group. Key discussion points from groups were also presented at subsequent groups within the same round to encourage further discussion. After each of the review rounds, both the feedback from the discussion groups and feedback documents were collated, qualitatively summarised, and a list of potential changes developed and discussed within the steering group. Where feedback was conflicting, potential changes were suggested in alignment with the majority of opinions from the working group and flagged for discussion within the next working group review. For each new iteration of the LBP-CCS, a summary of the changes was provided to the working group and discussed within the following review round. In this way, the working group were able to provide feedback on the changes which were incorporated into the following review round.

Literature review

The database search returned 577 articles, of which 57 were screened for full-text and 34 were included for data extraction. A previously published paper summarising 15 clinical practice guidelines from Africa, Australia, Brazil, Belgium, Canada, Denmark, Finland, Germany, Malaysia, Mexico, the Netherlands, Philippine, Spain, the USA, and the UK was used to extract clinical guideline recommendations [ 5 ]. Updates to two of the 15 guidelines were identified and used to extract guideline recommendations [ 29 , 30 ]. Ten accreditation documents were sourced from international and regional (North America, Australasia, Europe) accrediting bodies for medical, physiotherapy, and chiropractic entry-level clinical training programs. On assessing these accreditation documents, we decided not to source accreditation documents from other healthcare professions, as no criteria or competencies specific to LBP were found within the sourced documents. Seventeen additional documents were identified by the working group including clinical care standards, a musculoskeletal education framework, curriculum documents, and LBP overview papers. No new or updated clinical practice guidelines were identified by the working group. The complete list of documents used to inform the development of the LBP-CCS is available in Additional file 2 .

First iteration

Data from the literature review were collated under 12 topic headings as described in Table  2 . The steering group determined the structure of the first iteration to include: (i) the overarching objectives of the LBP-CCS; and (ii) 10 topic headings outlining the content to be included (Table  2 ). The individual content items were listed under: (i) principles; (ii) knowledge; and (iii) skills. The sub-heading ‘principles’ was intended to capture context to clarify the intent of the required knowledge and skills for each topic. For example, under the topic ‘Investigations’ one of the principles was for clinicians to consider whether investigation findings will substantially alter patient management; whereas, the associated knowledge item required that clinicians know the risks and benefits of the proposed investigations. The related skills item in this example stated that clinicians should be able to order and interpret investigations appropriately.

Second iteration

The first round of review with the working group was used to inform the second iteration of the LBP-CCS. The first review round focused on: (i) the appropriateness of the topic structure; (ii) the level of detail included within the content items and whether more specific recommendations should be made; (iii) the inclusion of content items not specific to LBP education (e.g., communication skills, clinical reasoning); and (iv) specific feedback on the individual content items or suggestions for additional/missing content items. The general structure of the document was agreed to be appropriate; however, a preamble to provide context to the document was thought necessary and suggestions were made to integrate some of the existing topic headings to improve the flow of the document and reduce repetition (Table  2 ). While the separation of ‘Principles’, ‘Knowledge’, and ‘Skills’ under each topic heading was considered important, the working group thought that ‘Principles’ should be replaced with an explanatory statement under each topic heading to explain alignment within the current evidence-base. The working group preferred the term ‘Competency’ to ‘Skills’ to reflect the move of many academic programs to competency-based teaching and assessment.

The working group agreed that the LBP-CCS should provide the general topics of content to be included (e.g., the risks and benefits of management options for LBP) rather than provide the specific evidenced-based recommendations (e.g., opioids should not be used in the management of LBP). This was to ensure that the LBP-CCS would be appropriate to use across different entry-level training programs and that the LBP-CCS would not become out-dated as new evidence becomes available. It was considered important, however, that the preamble clearly outline the need to apply the LBP-CCS within an evidenced-based context as appropriate for the clinical training program and local context/culture. A ‘Suggested resource’ section was also recommended to provide current evidence-based resources that could be used to inform application of the LBP-CCS. Regular review and update of the LBP-CCS (e.g., every five-years) was recommended to ensure that the standards align with emerging research findings. The inclusion of items not specific to LBP education but important in the development of appropriate patient management (e.g., patient communication, clinical reasoning), were considered essential. However, it was suggested that these be integrated within the items specific to LBP rather than included as stand-alone content items (e.g., ‘Synthesise clinical assessment findings and communicate a meaningful explanation of their LBP to the patient’).

Finally, feedback related to the specific content items was incorporated into the second iteration of the LBP-CCS. This included the addition of new content items and the removal/rewording of some content items to limit repetition, increase the consistency of language throughout the document, and increase the focus on some content items.

Third iteration

The second round of review with the working group was used to inform the third, and final, iteration of the LBP-CCS. The second review round focused on: (i) the appropriateness of the new sections of the LBP-CCS (preamble, explanatory statements, suggested resources); (ii) the structure/flow of the topic headings and included content items; and (iii) specific feedback on the individual content items. Overall, there was support for the new sections of the LBP-CCS, with some minor changes or additional resources suggested. Within the discussion groups it was highlighted that there were some differences in the interpretation of terms/words between members of the working group. The addition of a glossary to define common terms within the document was recommended. The topic flow was considered improved from the first iteration; however, to further improve the flow, it was suggested that the ‘Clinical assessment’ and ‘Investigations’ topics be collapsed together, and to integrate the ‘Low back pain diagnosis and classification’ topic across the remaining topics. The final topic structure is presented in Table  2 . The third iteration of the LBP-CCS was approved for dissemination and implementation by all members of the working group. The final LBP-CCS is available in Additional file 3 .

Key findings

We have developed curriculum content standards for LBP education in entry-level clinical training programs. The content items included in the LBP-CCS were informed by current literature, clinical practice guidelines, accreditation requirements, and other policy documents. The structure and content of the LBP-CCS were reviewed through three iterations and approved by an interdisciplinary international working group. The developed LBP-CCS are ready to be implemented in entry-level clinical training programs to inform the development or review of LBP curriculum and ensure that graduates have the knowledge and competencies required to deliver high-quality care to patient with LBP in clinical practice. The LBP-CCS will be reviewed and updated periodically to ensure that it remains current.

Comparison to previous literature

To our knowledge, curriculum content standards for LBP entry-level clinical training have not been previously developed. Current clinical practice guidelines [ 5 ] and clinical care standards for LBP [ 6 ] that exist have been developed to inform clinical practice for qualified clinicians with existing knowledge about LBP. Instead, we developed the LBP-CCS to focus on the curriculum requirements for entry-level clinical students with no prior knowledge of LBP. For example, clinical guidelines tend to focus on the appropriate assessment and management of LBP [ 5 ] and do not provide details of required knowledge related to the epidemiology and course of LBP that underpins clinical reasoning and management decisions. A similar outline of recommended curriculum content in healthcare programs has been developed for pain education as a whole (IASP Interprofessional Pain Curriculum Outline) [ 31 ]; however, this does not include details specific to LBP that are important to highlight within entry-level clinical training. For example, imaging is rarely recommended in the assessment of LBP and inappropriate use has been associated with poorer patient outcomes [ 32 ]; details such as determining the appropriate use of imaging can be highlighted more specifically in the LBP-CCS rather than within curriculum content for general pain [ 31 ], where the concept may not be relevant for all pain presentation types.

Strengths and limitations

A systematic and rigorous approach was used to develop the LBP-CCS. The working group was selected to ensure representation across diverse healthcare professions involved in the management of LBP, geographic locations, and professional backgrounds with academic, clinician, and consumer involvement. Eleven countries across 5 continents were represented within the working group; however, there was an underrepresentation of developing countries (1/11, 9%). Similar concerns related to the implementation of best-practice care for LBP have been identified globally [ 4 ], and, therefore, similar education requirements are likely to be needed. However, curriculum content requirements for developing countries may not have been completely explored. We therefore recommend, in the preamble to the LBP-CCS, that the LBP-CCS be implemented with consideration of the local context and environment. Physiotherapists and chiropractors commonly manage patients with LBP in primary care, which is reflected in more hours on LBP education in entry-level clinical training programs [ 12 ]. Therefore, we included larger proportions of physiotherapists and chiropractors within the working group to ensure that the LBP-CCS reflected the content required by programs with a stronger focus on LBP education. Moving forward, we intend to develop modified versions of the LBP-CCS for healthcare professions that are involved in the management of LBP but have different educational needs, such as medicine, pharmacy, clinical psychology, clinical exercise physiology, occupational therapy, and nursing. The current version can still be used to inform the education of all health professionals who treat people with LBP, but individual programs will need to consider the level of detail required.

The first iteration of the LBP-CCS was informed by a review of the literature and other professional policy documents. The literature search was performed in March, 2022 and new literature or guideline documents may change the content of the LBP-CCS. To minimise this limitation, regular review of the literature is planned by the steering group to ensure that the LBP-CCS remain current. The working group did not identify any new or updated clinical practice guidelines during the development process; however, the World Health Organization have published new guidelines for the management of chronic LBP since the development process concluded (December, 2023) [ 33 ]. The new guidelines have been assessed by the steering committee, and the guideline messages are consistent with the LBP-CCS. A sparsity of literature related to LBP education was identified from healthcare professions other than medicine, physiotherapy, chiropractic, and osteopathy; potentially highlighting gaps in other professions in identifying educational requirements related to LBP. The second and third iterations of the LBP-CCS were informed by review from the working group and all members of the working group approved the final iteration.

The LBP-CCS provides LBP educational content that should be feasible to incorporate into entry-level clinical training. Achieving a balance between providing constructive guidelines without dictating how the content should be taught is challenging. Highly prescriptive content recommendations (e.g., do not prescribe opioids in the management of LBP) might hold benefits of greater consistency of content across clinical training programs without individual interpretation. However, the exact recommendations to be included would be difficult to agree upon, would likely be nuanced depending on healthcare profession or geographic region (as seen in clinical guidelines from different regions [ 5 ]), and would need to be more frequently updated as specific knowledge evolves. The working group agreed that the content included in the LBP-CCS be less prescriptive to maintain flexibility of use. However, the content of the LBP-CCS is, therefore, more open to individual interpretation. Strategies were included to minimise negative effects of individual interpretation, including: (i) explanation of the need to reflect on current evidence; (ii) the use of explanatory statements to provide context to each topic; and (iii) the provision of high-quality suggested resources to inform use of the LBP-CCS.

Implementation of the low back pain curriculum content standards

The LBP-CCS have been designed to be used in entry-level clinical training programs for future healthcare clinicians involved in the assessment or management of patients presenting with LBP. The LBP-CCS can be used to guide the development of content in new programs or revise/benchmark content in existing programs. It must be noted that the time available to teach content related to LBP in different clinical training programs may differ considerably, which will impact the degree of detail to which the LBP-CCS can be implemented. For example, in an Australian study the number of hours related to the teaching of spinal assessment and management ranged from 2 h in pharmacy training to 310 h in chiropractic training [ 12 ]. In addition, the level of detail required for each item within the LBP-CCS may differ between clinical training programs and healthcare professions. For example, pharmacy programs would need to teach more detail related to the use of pharmaceutical management options for LBP, whereas physiotherapy programs would need to teach more detail on exercise and manual therapy options. Therefore, the LBP-CCS has been designed to provide high-level guidance regarding the content that should be covered, while acknowledging that the implementation of the LBP-CCS within individual academic programs may vary depending upon numerous factors. Moving forward, the development of profession-specific versions of the LBP-CCS, informed by professional representatives, could be considered to identify the content of most importance for each profession, while recognising time restraints within training programs.

Wide-spread dissemination of the LBP-CCS is essential to facilitate global uptake and produce change in LBP education standards. The LBP-CCS and associated resources are freely available online [ 34 ] and these will be disseminated to entry-level clinical training programs worldwide. Dissemination will occur through endorsing organisations, including professional organisations with global reach, working group members, and directly to entry-level clinical training programs.

We have developed the LBP-CCS in consultation with an interdisciplinary, international working group. These standards can be used to develop or benchmark the content of curriculum related to LBP in new or existing entry-level clinical training programs. Use of the LBP-CCS will help to increase the consistency and quality of LBP education.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

  • Low back pain

Low Back Pain Curriculum Content Standards

International Society for the Study of the Lumbar Spine

International Federation of Orthopaedic Manipulative Physical Therapists

World Physiotherapy

World Federation of Chiropractic

European Pain Federation

Musculoskeletal Association of Chartered Physiotherapists

Council of Physiotherapy Deans Australia and New Zealand

International Association for the Study of Pain

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Acknowledgements

The authors wish to acknowledge and thank the members of the Low Back Pain Curriculum Content Standards working group for their involvement in the development of the Low Back Pain Curriculum Content Standards: Fiona Blyth (Medicine– general practice, Australia); Dawn Carnes (Osteopathy, England); Chad Cook (Physiotherapy, America); Ben Darlow (Physiotherapy, Primary health care, New Zealand); Renee de Ruijter (IFOMPT representative, Physiotherapy, Switzerland); Julie Fritz (Physiotherapy, America); Brona Fullen (EFIC representative, Physiotherapy, Ireland); Doug Gross (Physiotherapy, Canada); Jill Hayden (Chiropractic, Canada); Jonathan Hill (Physiotherapy, England); Jaro Karppinen (Medicine– physical and rehabilitation medicine, Finland); Greg Kawchuk (Chiropractic, Canada); Alice Kongsted (Chiropractic, Denmark); Deborah Kopansky-Giles (WFC representative, Chiropractic, Canada); Henrik Hein Lauridsen (Chiropractic, Denmark); Michael Lee (CPDANZ representative, Chiropractic, Physiotherapy, Australia); Quinette Louw (Physiotherapy, South Africa); Kerry Mace (Consumer, Australia); James McAuley (Psychology, Australia); Andrew McLachlan (Pharmacy, Australia); Chris Mercer (MACP representative, Physiotherapy, England); Peter O’Sullivan (Physiotherapy, Australia); Sue Reid (Physiotherapy, Australia); Anna Ryan (Medicine, Chiropractic, Australia); Paolo Sanzo (IFOMPT representative, Physiotherapy, Canada); Edward Vresilovic (ISSLS representative, Medicine– orthopaedic surgery, America); Arnold Wong (Physiotherapy, Hong Kong).

No funding was obtained to support the development of the LBP-CCS.

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Hazel J. Jenkins, Benjamin T. Brown & Mark Hancock

Institute for Musculoskeletal Health, The University of Sydney, Sydney Musculoskeletal Health, Sydney, Australia

Mary O’Keeffe

Faculty of Health Sciences, Curtin University, Perth, Australia

Niamh Moloney

Sydney Musculoskeletal Health, The University of Sydney, Sydney, Australia

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Contributions

HJ formed and led the steering group, was involved in the design of the development process, formed the working group, performed the literature review, extracted data, drafted each iteration of the LBP-CCS, led the review of the LBP-CCS by the working group, reviewed all iterations of the LBP-CCS, and approved the final version. MH was a member of the steering group, was involved in the design of the development process, formed the working group, extracted data, reviewed all iterations of the LBP-CCS, and approved the final version. BB was a member of the steering group, was involved in the design of the development process, formed the working group, extracted data, reviewed all iterations of the LBP-CCS, and approved the final version. MO was a member of the steering group, was involved in the design of the development process, formed the working group, extracted data, reviewed all iterations of the LBP-CCS, and approved the final version. CM was a member of the steering group, was involved in the design of the development process, formed the working group, reviewed all iterations of the LBP-CCS, and approved the final version. All authors read and approved the final manuscript.

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Jenkins, H.J., Brown, B.T., O’Keeffe, M. et al. Development of low back pain curriculum content standards for entry-level clinical training. BMC Med Educ 24 , 136 (2024). https://doi.org/10.1186/s12909-024-05086-x

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