Reading of the Week: Psychiatry & Daily Life with Papers on Mood Variation, Loneliness, and the Fear of Miscarriage

From the Editor 

In recent months, we have covered topics such as emerging evidence for a new medication treatment for alcohol use disorder, a new, short therapy for PTSD, and recommendations for managing insomnia. But what about psychiatry and daily life? This week, we make a bit of a pivot and ask: Should we have more morning meetings? How do we understand loneliness? And is the fear of miscarriage in need of its own (Greek-based) medical term? 

How does mood and anxiety vary over the course of the day, the week, and the season? In the first selection, Feifei Bu (of University College London) and her co-authors try answer that question in a new paper for BMJ Mental Health. Drawing on nearly a million observations, they assess time-of-day association with depression, anxiety, well-being, and loneliness. “Generally, things do indeed seem better in the morning.” We consider the paper and its implications – including whether morning meetings are, in fact, ideal.

Early morning, better mood?

Loneliness is increasingly recognized as a societal problem. A few years ago, the UK government created a Cabinet position to focus on the issue; Time magazine applauded “the World’s First Loneliness Minister.” In a new review for Nature Mental Health, Brendan E. Walsh (of the University of South Florida) and his co-authors push past the rhetoric and focus on the concept – or, rather, a couple of them. Walsh et al. then analyze demographics and propose treatments. “This Review is intended to be heuristic and to inspire future inquiry research across disciplines, including public health, psychology, healthcare, and social work/community health.”

And in the third selection, nurse Ruth Oshikanlu and Dr. Babatunde A. Gbolade (of the University of Leeds) discuss the fear of miscarriage. In a British Journal of Psychiatry letter, they argue that pregnant women worry about it, and a formal medical term (and more research) is needed. “We believe that apotychiaphobia, our proposed label for the fear of miscarriage experienced by pregnant women, goes beyond semantics. It entails appreciation for the emotional turmoil that many pregnant women face in silence.”

DG

Selection 1: “Will things feel better in the morning? A time-of-day analysis of mental health and wellbeing from nearly 1 million observations”

Feifei Bu, Jessica K Bone, Daisy Fancourt

BMJ Mental Health, 4 February 2025 Online First

A theoretical rationale for diurnal changes in MHW [mental health and wellness] comes from multiple domains. First, MHW is influenced by physiological processes, including neurotransmitters (eg, dopamine, serotonin), hormones (eg, cortisol) and inflammatory markers. Some of these physiological processes are known to change across the day. For example, cortisol typically peaks shortly after waking and decreases throughout the day, with the lowest levels between 8:00pm and 4:00am. Serotonin 5-HT1A receptor and serotonin transporter 5-HTT have also been shown to vary across the day. Second, MHW is subject to the influences of geographical context and environmental factors (eg, sunlight, temperature, noise, air pollution), some of which may vary with systematic patterns across the day…

Yet, empirical evidence on diurnal changes in MHW is lacking. Much of the existing evidence is on mood, a psychological concept that is closely related to MHW but focused on shorter-term affective states. But even the evidence on diurnal variation in mood is mixed and inconclusive, showing different patterns across the day. Inconsistent findings might be explained by the inclusion of small and biased samples (eg, university students) in studies… Longer term, there is evidence of weekly and seasonal changes in mood. For example, at weekends, people typically report higher positive affect and circadian mood patterns are different compared with weekdays. There are seasonal patterns in signals of anger, anxiety, sadness and fatigue on social media, with anxiety peaking in spring and autumn and sadness peaking in winter. Alongside this, research has explored seasonal MHW variation. It has repeatedly been proposed that mental health is worst in winter and best in summer, with the extreme case being seasonal affective disorder.

So begins a paper by Bu et al.

Here’s what they did:

• They analyzed data from the University College London COVID-19 Social Study which “gathered detailed repeated measurements from the same participants across time over a 2-year period (March 2020–March 2022, 18.5 observation per person).”
• Participants were recruited through existing mailing lists, and also through advertising and social media.
• They did surveys at regular time intervals (weekly then monthly). That said, participants were prompted at different times of the day and the week, and the survey responses were time stamped (allowing for comparisons of timing).
• Participants completed various scales. For depression, they did the PHQ-9; for anxiety, the GAD-7; for well-being, the UK Office for National Statistics personal well-being questions; for loneliness, the three-item UCLA Loneliness Scale.
• Different statistical analyses were done, including linear mixed-effects models.

Here’s what they found:

• There were 49 218 participants. 
• Demographics. With weighing, 50.8% were women; 34.2% of participants had higher education; 14.6% self-identified as being a member of an ethnic minority.
• Time of day. “Although the differences across time were small, outcomes were consistently best early in the day (lowest depressive and anxiety symptoms and loneliness and highest happiness, life satisfaction and worthwhile ratings) and worst late at night.”
• Day of week. “For depressive and anxiety symptoms, Tuesday and Wednesday showed different patterns of change compared with Sunday. On these 2 days, depressive and anxiety symptoms were higher in the morning, and decreased slightly throughout the day, before starting to increase into the night. However, on other days, depressive and anxiety symptoms were at the lowest level in the morning, fluctuated throughout the day, and then peaked at midnight.”
• Season. There was “strong evidence for better mental health and well-being in the summer.”
• Loneliness. “Loneliness was relatively stable across time, and there were no differences in time-of-day patterns across different days of the week.”

A few thoughts:

1. This is an interesting study with an impressive dataset (almost a million observations) and published in a major journal. Nice.

2. The main finding in five words: we are all morning people. 

3. To add some details: people felt better in the mornings; there was greater well-being in the summer months; there was variation across the days of the week.  

4. The authors see implications for service delivery. “Data on calls to Samaritans helplines show similar patterns across time of day for ‘regular callers’ and similar increases across the afternoon into the evening for ‘typical callers’, the two largest categories of callers (although other smaller categories of callers have alternative patterns). Our findings demonstrating the likely fluctuations in people’s MHW patterns could inform training of staff involved in 24-hour services to support their conversations with patients/callers. The findings presented here also have implications for clinical assessments, suggesting that mental health screening could result in different outcomes depending on when that screening occurs.”

5. Like all studies, there are limitations. The authors note that the sample wasn’t random – though it was large.

6. The paper is interesting and fun. Is it persuasive? This paper drew from survey data that sought to capture variations in mood, anxiety and other things at different points in time. But did the scales used truly measure what they intended to? The PHQ-9, for example, is meant to review symptoms over the past fortnight. Conclusion: more data is needed before we start rescheduling all of our meetings to the morning hours.

The full BMJ Ment Health paper can be found here:

https://mentalhealth.bmj.com/content/28/1/e301418

Selection 2: “Why loneliness requires a multidimensional approach: a critical narrative review”

Brendan E. Walsh, Jonathan Rottenberg, Robert C. Schlauch

Nature Mental Health, 30 January 2025

Loneliness has become a growing global concern, with reports of its detriment to overall health and wellbeing increasing worldwide. The World Health Organization recently declared loneliness a ‘pressing health threat’, citing associated elevations in risk of heart disease, stroke, anxiety, susceptibility to illness, premature death, and more. Surkalim et al. reinforce loneliness as a public health priority with data showing that problematic levels of loneliness characterize many countries and territories throughout the world. Despite mobilization by policy-makers, public health authorities, and clinicians, it remains challenging to precisely characterize the subjective experiences of loneliness that contribute to different forms of dysfunction.

So begins a paper by Walsh et al.

On a different model

“Loneliness is typically defined as the subjective state associated with deficits in social connection, characterized by perceived discrepancies between one’s desired and objective social relationships… Our perspective has deep theoretical antecedents. More than four decades ago, Weiss posited that loneliness consists of two dimensions: EL (that is, perceived lack of intimate or deep connections with others) and SL (that is, perceived broader social network deficits). Notably, each dimension can arise even where objective markers of connectedness are present. For example, an individual may feel emotionally lonely within a marriage if the quality of that marriage is low and opportunities for secure attachment are lacking. Alternatively, a person may feel socially lonely in the presence of a social network if they feel that there are not enough people available to talk to or lean on. It is therefore assumed that EL and SL are linked to objective and subjective deficits in distinctive relational needs.”

On support for the model

“Empirically, EL is more strongly related to subjective deficits in emotional support and closeness (for example, feelings of there being no-one to turn to), whereas SL is more strongly related to instrumental support deficits (for example, perceiving lack of people who want to help). Another key distinction between EL and SL relates to differences in ‘social provisions’ (social antecedents). The social provision underlying EL is posited to be ‘attachment’ (that is, a sense of emotional security and wellbeing), while the social provision underlying SL is ‘social integration’ (that is, being a part of a social network). Objective and subjective deficits in such provisions have been shown to differentially predict each loneliness subtype. Prototypical examples of situations that may potentiate SL include major life transitions and social ostracization. By contrast, EL may be precipitated by abrupt changes in intimate ties (for example, death of a loved one, betrayal) or by problems with the integrity of social ties (for example, mistrust of others).”

On demographics

“Female individuals consistently exhibit higher levels of EL than male individuals. Research on gender differences in SL is similarly consistent, with men reporting higher levels of SL than women, but two studies do not show this pattern. Among the interpretations of gender differences in loneliness subtypes is that they may reflect societal gender norms, such that female individuals tend to value/maintain emotionally close relationships and male individuals hold less interdependent values.”

On treatment

“EL is consistently recognized as a more severe form of loneliness that is characterized by deficits in intimate attachment and substantial overlap with negative affective experiences. By this logic, EL might be mitigated by a greater clinical focus on development of deeper social connection. On this point, Ingram et al. applied a group intervention named Groups for Belonging that facilitates feelings of connectedness in a residential substance abuse treatment program. Although efficacy was not tested, mean levels of EL only improved from before to after intervention. These findings parallel evidence that Alcoholics Anonymous is an effective intervention for alcohol-related problems that inherently involves the development of supportive networks. A reasonable speculation that warrants explicit empirical consideration is that fostering meaningful human connection around shared experiences may promote alleviations in EL, which then drive improvements in treatment outcomes for behavioral conditions that are defined by high levels of loneliness. On this point, sustained Alcoholics Anonymous sponsor involvement has been demonstrated to independently predict long-term abstinence outcomes above and beyond meeting attendance, possibly reflecting newfound fulfillment of the attachment provision.”

A few thoughts:

1. This is an interesting paper published in an important journal.

2. Their paper is long and nuanced, and considers different aspects of loneliness and illness, including depression and anxiety. The review here is superficial.

3. The writing on loneliness is timely. That said, as the authors suggest, the concept itself is broad – indeed, too broad.

4. The core idea: that there are two different subtypes of loneliness. That seems to be a step in the right direction – but a small step. Have they replaced one broad concept with two slightly less broad ones?

The full Nat Mental Health paper can be found here:

https://www.nature.com/articles/s44220-024-00382-3

Selection 3: “Apotychiaphobia: should there be a term for fear of miscarriage?”

The British Journal of Psychiatry, 21 October 2024  Online First

Ruth Oshikanlu and Babatunde A. Gbolade

Pregnancy, which is marked by substantial physical and emotional transformations, typically elicits immense joy and anticipation in most women. However, it also involves profound and transformative changes, which can lead to uncertainty, vulnerability and anxiety. Fear of miscarriage, which is the deepest and most persistent fear experienced by expectant mothers, deserves formal recognition within the medical community and lexicon to validate their experiences, facilitate open discussions, stimulate research, and improve healthcare interventions.

The true prevalence of fear of miscarriage is unknown, and no formal medical term has been associated with it.

So begins a letter by Oshikanlu and Gbolade.

They draw on their clinical experience and the literature. “During our extensive clinical practice, we encountered women who faced fear of a primary miscarriage. We searched the literature using the fundamental search terms ‘fear’, ‘dread’, ‘terror’, ‘anxiety’, ‘distress’ and ‘horror’ in conjunction with ‘miscarriage’ in a title search in Medline. However, none of the 36 publications retrieved had a formal term for this fear, and most addressed it in the context of recurrent miscarriage.”

They highlight a study of “17 expectant British mothers with various reproductive histories found a running theme of ‘uncertainty of pregnancy’, emphasising the anxieties and doubts that women typically face during pregnancy and their efforts to exert control over these unpredictable situations.” They note the findings: “the primary concerns and fears of expectant mothers were focused on the potential for miscarriage.”

They observe the burden carried by some. “Fear of miscarriage, a genuine and distressing concern for many expectant mothers, is often hidden discreetly and rarely discussed openly. Fear of miscarriage can have a profound effect on the well-being of women, causing substantial emotional distress, altering their daily functioning and affecting their physical health.”

“We suggest apotychiaphobia as a formal medical term for the intense fear of miscarriage experienced by certain pregnant women. The new term would be restricted to women not experiencing trauma- or stress-related disorders in their current pregnancy.” 

They feel that such a move would spark action. “This would also lead to greater recognition of the existence of the condition, leading to extensive research to develop a clear and acceptable measure of fear of miscarriage and to understand its prevalence, underlying causes and effective treatment.”

A few thoughts:

1. This is an interesting letter.

2. They argue that there is precedence for the creation of a term: “This absence of a formal term is incongruous given that fear of childbirth has a formal medical label: tokophobia (tocophobia), first introduced in the medical literature in 2000.”

3. Are they recognizing an under-researched area? Or are they simply pathologizing a normal process? After all, isn’t it natural for expectant mothers to worry about losing their baby?

4. This week’s Reading has focused on psychiatry and daily life. Is the risk here that we end up pushing the boundaries of our field into the normal human experiences?

The full BJP letter can be found here:

https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/apotychiaphobia-should-there-be-a-term-for-fear-of-miscarriage/E21CBDFA475473051A455DAFCB81D69A

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.