review of related studies research example

Review of Related Literature: Format, Example, & How to Make RRL

A review of related literature is a separate paper or a part of an article that collects and synthesizes discussion on a topic. Its purpose is to show the current state of research on the issue and highlight gaps in existing knowledge. A literature review can be included in a research paper or scholarly article, typically following the introduction and before the research methods section.

This article will clarify the definition, significance, and structure of a review of related literature. You’ll also learn how to organize your literature review and discover ideas for an RRL in different subjects.

🔤 What Is RRL?

• ❗ Significance of Literature Review
• 🔎 How to Search for Literature
• 🧩 Literature Review Structure
• 📋 Format of RRL — APA, MLA, & Others
• ✍️ How to Write an RRL
• 📚 Examples of RRL

🔗 References

A review of related literature (RRL) is a part of the research report that examines significant studies, theories, and concepts published in scholarly sources on a particular topic. An RRL includes 3 main components:

• A short overview and critique of the previous research.
• Similarities and differences between past studies and the current one.
• An explanation of the theoretical frameworks underpinning the research.

❗ Significance of Review of Related Literature

Although the goal of a review of related literature differs depending on the discipline and its intended use, its significance cannot be overstated. Here are some examples of how a review might be beneficial:

• It helps determine knowledge gaps .
• It saves from duplicating research that has already been conducted.
• It provides an overview of various research areas within the discipline.
• It demonstrates the researcher’s familiarity with the topic.

🔎 How to Perform a Literature Search

Including a description of your search strategy in the literature review section can significantly increase your grade. You can search sources with the following steps:

🧩 Literature Review Structure Example

The majority of literature reviews follow a standard introduction-body-conclusion structure. Let’s look at the RRL structure in detail.

Introduction of Review of Related Literature: Sample

An introduction should clarify the study topic and the depth of the information to be delivered. It should also explain the types of sources used. If your lit. review is part of a larger research proposal or project, you can combine its introductory paragraph with the introduction of your paper.

Here is a sample introduction to an RRL about cyberbullying:

Bullying has troubled people since the beginning of time. However, with modern technological advancements, especially social media, bullying has evolved into cyberbullying. As a result, nowadays, teenagers and adults cannot flee their bullies, which makes them feel lonely and helpless. This literature review will examine recent studies on cyberbullying.

Sample Review of Related Literature Thesis

A thesis statement should include the central idea of your literature review and the primary supporting elements you discovered in the literature. Thesis statements are typically put at the end of the introductory paragraph.

Look at a sample thesis of a review of related literature:

This literature review shows that scholars have recently covered the issues of bullies’ motivation, the impact of bullying on victims and aggressors, common cyberbullying techniques, and victims’ coping strategies. However, there is still no agreement on the best practices to address cyberbullying.

Literature Review Body Paragraph Example

The main body of a literature review should provide an overview of the existing research on the issue. Body paragraphs should not just summarize each source but analyze them. You can organize your paragraphs with these 3 elements:

• Claim . Start with a topic sentence linked to your literature review purpose.
• Evidence . Cite relevant information from your chosen sources.
• Discussion . Explain how the cited data supports your claim.

Here’s a literature review body paragraph example:

Scholars have examined the link between the aggressor and the victim. Beran et al. (2007) state that students bullied online often become cyberbullies themselves. Faucher et al. (2014) confirm this with their findings: they discovered that male and female students began engaging in cyberbullying after being subject to bullying. Hence, one can conclude that being a victim of bullying increases one’s likelihood of becoming a cyberbully.

Review of Related Literature: Conclusion

A conclusion presents a general consensus on the topic. Depending on your literature review purpose, it might include the following:

• Introduction to further research . If you write a literature review as part of a larger research project, you can present your research question in your conclusion .
• Overview of theories . You can summarize critical theories and concepts to help your reader understand the topic better.
• Discussion of the gap . If you identified a research gap in the reviewed literature, your conclusion could explain why that gap is significant.

Check out a conclusion example that discusses a research gap:

There is extensive research into bullies’ motivation, the consequences of bullying for victims and aggressors, strategies for bullying, and coping with it. Yet, scholars still have not reached a consensus on what to consider the best practices to combat cyberbullying. This question is of great importance because of the significant adverse effects of cyberbullying on victims and bullies.

📋 Format of RRL — APA, MLA, & Others

In this section, we will discuss how to format an RRL according to the most common citation styles: APA, Chicago, MLA, and Harvard.

Writing a literature review using the APA7 style requires the following text formatting:

• When using APA in-text citations , include the author’s last name and the year of publication in parentheses.
• For direct quotations , you must also add the page number. If you use sources without page numbers, such as websites or e-books, include a paragraph number instead.
• When referring to the author’s name in a sentence , you do not need to repeat it at the end of the sentence. Instead, include the year of publication inside the parentheses after their name.
• The reference list should be included at the end of your literature review. It is always alphabetized by the last name of the author (from A to Z), and the lines are indented one-half inch from the left margin of your paper. Do not forget to invert authors’ names (the last name should come first) and include the full titles of journals instead of their abbreviations. If you use an online source, add its URL.

The RRL format in the Chicago style is as follows:

• Author-date . You place your citations in brackets within the text, indicating the name of the author and the year of publication.
• Notes and bibliography . You place your citations in numbered footnotes or endnotes to connect the citation back to the source in the bibliography.
• The reference list, or bibliography , in Chicago style, is at the end of a literature review. The sources are arranged alphabetically and single-spaced. Each bibliography entry begins with the author’s name and the source’s title, followed by publication information, such as the city of publication, the publisher, and the year of publication.

Writing a literature review using the MLA style requires the following text formatting:

• In the MLA format, you can cite a source in the text by indicating the author’s last name and the page number in parentheses at the end of the citation. If the cited information takes several pages, you need to include all the page numbers.
• The reference list in MLA style is titled “ Works Cited .” In this section, all sources used in the paper should be listed in alphabetical order. Each entry should contain the author, title of the source, title of the journal or a larger volume, other contributors, version, number, publisher, and publication date.

The Harvard style requires you to use the following text formatting for your RRL:

• In-text citations in the Harvard style include the author’s last name and the year of publication. If you are using a direct quote in your literature review, you need to add the page number as well.
• Arrange your list of references alphabetically. Each entry should contain the author’s last name, their initials, the year of publication, the title of the source, and other publication information, like the journal title and issue number or the publisher.

✍️ How to Write Review of Related Literature – Sample

Literature reviews can be organized in many ways depending on what you want to achieve with them. In this section, we will look at 3 examples of how you can write your RRL.

Thematic Literature Review

A thematic literature review is arranged around central themes or issues discussed in the sources. If you have identified some recurring themes in the literature, you can divide your RRL into sections that address various aspects of the topic. For example, if you examine studies on e-learning, you can distinguish such themes as the cost-effectiveness of online learning, the technologies used, and its effectiveness compared to traditional education.

Chronological Literature Review

A chronological literature review is a way to track the development of the topic over time. If you use this method, avoid merely listing and summarizing sources in chronological order. Instead, try to analyze the trends, turning moments, and critical debates that have shaped the field’s path. Also, you can give your interpretation of how and why specific advances occurred.

Methodological Literature Review

A methodological literature review differs from the preceding ones in that it usually doesn’t focus on the sources’ content. Instead, it is concerned with the research methods . So, if your references come from several disciplines or fields employing various research techniques, you can compare the findings and conclusions of different methodologies, for instance:

• empirical vs. theoretical studies;
• qualitative vs. quantitative research.

📚 Examples of Review of Related Literature and Studies

We have prepared a short example of RRL on climate change for you to see how everything works in practice!

Climate change is one of the most important issues nowadays. Based on a variety of facts, it is now clearer than ever that humans are altering the Earth's climate. The atmosphere and oceans have warmed, causing sea level rise, a significant loss of Arctic ice, and other climate-related changes. This literature review provides a thorough summary of research on climate change, focusing on climate change fingerprints and evidence of human influence on the Earth's climate system.

Physical Mechanisms and Evidence of Human Influence

Scientists are convinced that climate change is directly influenced by the emission of greenhouse gases. They have carefully analyzed various climate data and evidence, concluding that the majority of the observed global warming over the past 50 years cannot be explained by natural factors alone. Instead, there is compelling evidence pointing to a significant contribution of human activities, primarily the emission of greenhouse gases (Walker, 2014). For example, based on simple physics calculations, doubled carbon dioxide concentration in the atmosphere can lead to a global temperature increase of approximately 1 degree Celsius. (Elderfield, 2022). In order to determine the human influence on climate, scientists still have to analyze a lot of natural changes that affect temperature, precipitation, and other components of climate on timeframes ranging from days to decades and beyond.

Fingerprinting Climate Change

Fingerprinting climate change is a useful tool to identify the causes of global warming because different factors leave unique marks on climate records. This is evident when scientists look beyond overall temperature changes and examine how warming is distributed geographically and over time (Watson, 2022). By investigating these climate patterns, scientists can obtain a more complex understanding of the connections between natural climate variability and climate variability caused by human activity.

Modeling Climate Change and Feedback

To accurately predict the consequences of feedback mechanisms, the rate of warming, and regional climate change, scientists can employ sophisticated mathematical models of the atmosphere, ocean, land, and ice (the cryosphere). These models are grounded in well-established physical laws and incorporate the latest scientific understanding of climate-related processes (Shuckburgh, 2013). Although different climate models produce slightly varying projections for future warming, they all will agree that feedback mechanisms play a significant role in amplifying the initial warming caused by greenhouse gas emissions. (Meehl, 2019).

In conclusion, the literature on global warming indicates that there are well-understood physical processes that link variations in greenhouse gas concentrations to climate change. In addition, it covers the scientific proof that the rates of these gases in the atmosphere have increased and continue to rise fast. According to the sources, the majority of this recent change is almost definitely caused by greenhouse gas emissions produced by human activities. Citizens and governments can alter their energy production methods and consumption patterns to reduce greenhouse gas emissions and, thus, the magnitude of climate change. By acting now, society can prevent the worst consequences of climate change and build a more resilient and sustainable future for generations to come.

Have you ever struggled with finding the topic for an RRL in different subjects? Read the following paragraphs to get some ideas!

Nursing Literature Review Example

Many topics in the nursing field require research. For example, you can write a review of literature related to dengue fever . Give a general overview of dengue virus infections, including its clinical symptoms, diagnosis, prevention, and therapy.

Another good idea is to review related literature and studies about teenage pregnancy . This review can describe the effectiveness of specific programs for adolescent mothers and their children and summarize recommendations for preventing early pregnancy.

📝 Check out some more valuable examples below:

• Hospital Readmissions: Literature Review .
• Literature Review: Lower Sepsis Mortality Rates .
• Breast Cancer: Literature Review .
• Sexually Transmitted Diseases: Literature Review .
• PICO for Pressure Ulcers: Literature Review .
• COVID-19 Spread Prevention: Literature Review .
• Chronic Obstructive Pulmonary Disease: Literature Review .
• Hypertension Treatment Adherence: Literature Review .
• Neonatal Sepsis Prevention: Literature Review .
• Healthcare-Associated Infections: Literature Review .
• Understaffing in Nursing: Literature Review .

Psychology Literature Review Example

If you look for an RRL topic in psychology , you can write a review of related literature about stress . Summarize scientific evidence about stress stages, side effects, types, or reduction strategies. Or you can write a review of related literature about computer game addiction . In this case, you may concentrate on the neural mechanisms underlying the internet gaming disorder, compare it to other addictions, or evaluate treatment strategies.

A review of related literature about cyberbullying is another interesting option. You can highlight the impact of cyberbullying on undergraduate students’ academic, social, and emotional development.

📝 Look at the examples that we have prepared for you to come up with some more ideas:

• Mindfulness in Counseling: A Literature Review .
• Team-Building Across Cultures: Literature Review .
• Anxiety and Decision Making: Literature Review .
• Literature Review on Depression .
• Literature Review on Narcissism .
• Effects of Depression Among Adolescents .
• Causes and Effects of Anxiety in Children .

Literature Review — Sociology Example

Sociological research poses critical questions about social structures and phenomena. For example, you can write a review of related literature about child labor , exploring cultural beliefs and social norms that normalize the exploitation of children. Or you can create a review of related literature about social media . It can investigate the impact of social media on relationships between adolescents or the role of social networks on immigrants’ acculturation .

📝 You can find some more ideas below!

• Single Mothers’ Experiences of Relationships with Their Adolescent Sons .
• Teachers and Students’ Gender-Based Interactions .
• Gender Identity: Biological Perspective and Social Cognitive Theory .
• Gender: Culturally-Prescribed Role or Biological Sex .
• The Influence of Opioid Misuse on Academic Achievement of Veteran Students .
• The Importance of Ethics in Research .
• The Role of Family and Social Network Support in Mental Health .

Education Literature Review Example

For your education studies , you can write a review of related literature about academic performance to determine factors that affect student achievement and highlight research gaps. One more idea is to create a review of related literature on study habits , considering their role in the student’s life and academic outcomes.

You can also evaluate a computerized grading system in a review of related literature to single out its advantages and barriers to implementation. Or you can complete a review of related literature on instructional materials to identify their most common types and effects on student achievement.

📝 Find some inspiration in the examples below:

• Literature Review on Online Learning Challenges From COVID-19 .
• Education, Leadership, and Management: Literature Review .
• Literature Review: Standardized Testing Bias .
• Bullying of Disabled Children in School .
• Interventions and Letter & Sound Recognition: A Literature Review .
• Social-Emotional Skills Program for Preschoolers .
• Effectiveness of Educational Leadership Management Skills .

Business Research Literature Review

If you’re a business student, you can focus on customer satisfaction in your review of related literature. Discuss specific customer satisfaction features and how it is affected by service quality and prices. You can also create a theoretical literature review about consumer buying behavior to evaluate theories that have significantly contributed to understanding how consumers make purchasing decisions.

📝 Look at the examples to get more exciting ideas:

• Leadership and Communication: Literature Review .
• Human Resource Development: Literature Review .
• Project Management. Literature Review .
• Strategic HRM: A Literature Review .
• Customer Relationship Management: Literature Review .
• Literature Review on International Financial Reporting Standards .
• Cultures of Management: Literature Review .

To conclude, a review of related literature is a significant genre of scholarly works that can be applied in various disciplines and for multiple goals. The sources examined in an RRL provide theoretical frameworks for future studies and help create original research questions and hypotheses.

When you finish your outstanding literature review, don’t forget to check whether it sounds logical and coherent. Our text-to-speech tool can help you with that!

• Literature Reviews | University of North Carolina at Chapel Hill
• Writing a Literature Review | Purdue Online Writing Lab
• Learn How to Write a Review of Literature | University of Wisconsin-Madison
• The Literature Review: A Few Tips on Conducting It | University of Toronto
• Writing a Literature Review | UC San Diego
• Conduct a Literature Review | The University of Arizona
• Methods for Literature Reviews | National Library of Medicine
• Literature Reviews: 5. Write the Review | Georgia State University

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What is a Literature Review? How to Write It (with Examples)

A literature review is a critical analysis and synthesis of existing research on a particular topic. It provides an overview of the current state of knowledge, identifies gaps, and highlights key findings in the literature. 1 The purpose of a literature review is to situate your own research within the context of existing scholarship, demonstrating your understanding of the topic and showing how your work contributes to the ongoing conversation in the field. Learning how to write a literature review is a critical tool for successful research. Your ability to summarize and synthesize prior research pertaining to a certain topic demonstrates your grasp on the topic of study, and assists in the learning process. 

Table of Contents

• What is the purpose of literature review? 
• a. Habitat Loss and Species Extinction: 
• b. Range Shifts and Phenological Changes: 
• c. Ocean Acidification and Coral Reefs: 
• d. Adaptive Strategies and Conservation Efforts: 
• How to write a good literature review 
• Choose a Topic and Define the Research Question: 
• Decide on the Scope of Your Review: 
• Select Databases for Searches: 
• Conduct Searches and Keep Track: 
• Review the Literature: 
• Organize and Write Your Literature Review: 
• Frequently asked questions 

What is a literature review?

A well-conducted literature review demonstrates the researcher’s familiarity with the existing literature, establishes the context for their own research, and contributes to scholarly conversations on the topic. One of the purposes of a literature review is also to help researchers avoid duplicating previous work and ensure that their research is informed by and builds upon the existing body of knowledge.

What is the purpose of literature review?

A literature review serves several important purposes within academic and research contexts. Here are some key objectives and functions of a literature review: 2  

• Contextualizing the Research Problem: The literature review provides a background and context for the research problem under investigation. It helps to situate the study within the existing body of knowledge. 
• Identifying Gaps in Knowledge: By identifying gaps, contradictions, or areas requiring further research, the researcher can shape the research question and justify the significance of the study. This is crucial for ensuring that the new research contributes something novel to the field. 
• Understanding Theoretical and Conceptual Frameworks: Literature reviews help researchers gain an understanding of the theoretical and conceptual frameworks used in previous studies. This aids in the development of a theoretical framework for the current research. 
• Providing Methodological Insights: Another purpose of literature reviews is that it allows researchers to learn about the methodologies employed in previous studies. This can help in choosing appropriate research methods for the current study and avoiding pitfalls that others may have encountered. 
• Establishing Credibility: A well-conducted literature review demonstrates the researcher’s familiarity with existing scholarship, establishing their credibility and expertise in the field. It also helps in building a solid foundation for the new research. 
• Informing Hypotheses or Research Questions: The literature review guides the formulation of hypotheses or research questions by highlighting relevant findings and areas of uncertainty in existing literature. 

Literature review example

Let’s delve deeper with a literature review example: Let’s say your literature review is about the impact of climate change on biodiversity. You might format your literature review into sections such as the effects of climate change on habitat loss and species extinction, phenological changes, and marine biodiversity. Each section would then summarize and analyze relevant studies in those areas, highlighting key findings and identifying gaps in the research. The review would conclude by emphasizing the need for further research on specific aspects of the relationship between climate change and biodiversity. The following literature review template provides a glimpse into the recommended literature review structure and content, demonstrating how research findings are organized around specific themes within a broader topic. 

Literature Review on Climate Change Impacts on Biodiversity:

Climate change is a global phenomenon with far-reaching consequences, including significant impacts on biodiversity. This literature review synthesizes key findings from various studies: 

a. Habitat Loss and Species Extinction:

Climate change-induced alterations in temperature and precipitation patterns contribute to habitat loss, affecting numerous species (Thomas et al., 2004). The review discusses how these changes increase the risk of extinction, particularly for species with specific habitat requirements. 

b. Range Shifts and Phenological Changes:

Observations of range shifts and changes in the timing of biological events (phenology) are documented in response to changing climatic conditions (Parmesan & Yohe, 2003). These shifts affect ecosystems and may lead to mismatches between species and their resources. 

c. Ocean Acidification and Coral Reefs:

The review explores the impact of climate change on marine biodiversity, emphasizing ocean acidification’s threat to coral reefs (Hoegh-Guldberg et al., 2007). Changes in pH levels negatively affect coral calcification, disrupting the delicate balance of marine ecosystems. 

d. Adaptive Strategies and Conservation Efforts:

Recognizing the urgency of the situation, the literature review discusses various adaptive strategies adopted by species and conservation efforts aimed at mitigating the impacts of climate change on biodiversity (Hannah et al., 2007). It emphasizes the importance of interdisciplinary approaches for effective conservation planning. 

How to write a good literature review

Writing a literature review involves summarizing and synthesizing existing research on a particular topic. A good literature review format should include the following elements. 

Introduction: The introduction sets the stage for your literature review, providing context and introducing the main focus of your review. 

• Opening Statement: Begin with a general statement about the broader topic and its significance in the field. 
• Scope and Purpose: Clearly define the scope of your literature review. Explain the specific research question or objective you aim to address. 
• Organizational Framework: Briefly outline the structure of your literature review, indicating how you will categorize and discuss the existing research. 
• Significance of the Study: Highlight why your literature review is important and how it contributes to the understanding of the chosen topic. 
• Thesis Statement: Conclude the introduction with a concise thesis statement that outlines the main argument or perspective you will develop in the body of the literature review. 

Body: The body of the literature review is where you provide a comprehensive analysis of existing literature, grouping studies based on themes, methodologies, or other relevant criteria. 

• Organize by Theme or Concept: Group studies that share common themes, concepts, or methodologies. Discuss each theme or concept in detail, summarizing key findings and identifying gaps or areas of disagreement. 
• Critical Analysis: Evaluate the strengths and weaknesses of each study. Discuss the methodologies used, the quality of evidence, and the overall contribution of each work to the understanding of the topic. 
• Synthesis of Findings: Synthesize the information from different studies to highlight trends, patterns, or areas of consensus in the literature. 
• Identification of Gaps: Discuss any gaps or limitations in the existing research and explain how your review contributes to filling these gaps. 
• Transition between Sections: Provide smooth transitions between different themes or concepts to maintain the flow of your literature review. 

Conclusion: The conclusion of your literature review should summarize the main findings, highlight the contributions of the review, and suggest avenues for future research. 

• Summary of Key Findings: Recap the main findings from the literature and restate how they contribute to your research question or objective. 
• Contributions to the Field: Discuss the overall contribution of your literature review to the existing knowledge in the field. 
• Implications and Applications: Explore the practical implications of the findings and suggest how they might impact future research or practice. 
• Recommendations for Future Research: Identify areas that require further investigation and propose potential directions for future research in the field. 
• Final Thoughts: Conclude with a final reflection on the importance of your literature review and its relevance to the broader academic community. 

Conducting a literature review

Conducting a literature review is an essential step in research that involves reviewing and analyzing existing literature on a specific topic. It’s important to know how to do a literature review effectively, so here are the steps to follow: 1  

Choose a Topic and Define the Research Question:

• Select a topic that is relevant to your field of study. 
• Clearly define your research question or objective. Determine what specific aspect of the topic do you want to explore? 

Decide on the Scope of Your Review:

• Determine the timeframe for your literature review. Are you focusing on recent developments, or do you want a historical overview? 
• Consider the geographical scope. Is your review global, or are you focusing on a specific region? 
• Define the inclusion and exclusion criteria. What types of sources will you include? Are there specific types of studies or publications you will exclude? 

Select Databases for Searches:

• Identify relevant databases for your field. Examples include PubMed, IEEE Xplore, Scopus, Web of Science, and Google Scholar. 
• Consider searching in library catalogs, institutional repositories, and specialized databases related to your topic. 

Conduct Searches and Keep Track:

• Develop a systematic search strategy using keywords, Boolean operators (AND, OR, NOT), and other search techniques. 
• Record and document your search strategy for transparency and replicability. 
• Keep track of the articles, including publication details, abstracts, and links. Use citation management tools like EndNote, Zotero, or Mendeley to organize your references. 

Review the Literature:

• Evaluate the relevance and quality of each source. Consider the methodology, sample size, and results of studies. 
• Organize the literature by themes or key concepts. Identify patterns, trends, and gaps in the existing research. 
• Summarize key findings and arguments from each source. Compare and contrast different perspectives. 
• Identify areas where there is a consensus in the literature and where there are conflicting opinions. 
• Provide critical analysis and synthesis of the literature. What are the strengths and weaknesses of existing research? 

Organize and Write Your Literature Review:

• Literature review outline should be based on themes, chronological order, or methodological approaches. 
• Write a clear and coherent narrative that synthesizes the information gathered. 
• Use proper citations for each source and ensure consistency in your citation style (APA, MLA, Chicago, etc.). 
• Conclude your literature review by summarizing key findings, identifying gaps, and suggesting areas for future research. 

The literature review sample and detailed advice on writing and conducting a review will help you produce a well-structured report. But remember that a literature review is an ongoing process, and it may be necessary to revisit and update it as your research progresses. 

Frequently asked questions

A literature review is a critical and comprehensive analysis of existing literature (published and unpublished works) on a specific topic or research question and provides a synthesis of the current state of knowledge in a particular field. A well-conducted literature review is crucial for researchers to build upon existing knowledge, avoid duplication of efforts, and contribute to the advancement of their field. It also helps researchers situate their work within a broader context and facilitates the development of a sound theoretical and conceptual framework for their studies.

Literature review is a crucial component of research writing, providing a solid background for a research paper’s investigation. The aim is to keep professionals up to date by providing an understanding of ongoing developments within a specific field, including research methods, and experimental techniques used in that field, and present that knowledge in the form of a written report. Also, the depth and breadth of the literature review emphasizes the credibility of the scholar in his or her field.  

Before writing a literature review, it’s essential to undertake several preparatory steps to ensure that your review is well-researched, organized, and focused. This includes choosing a topic of general interest to you and doing exploratory research on that topic, writing an annotated bibliography, and noting major points, especially those that relate to the position you have taken on the topic. 

Literature reviews and academic research papers are essential components of scholarly work but serve different purposes within the academic realm. 3 A literature review aims to provide a foundation for understanding the current state of research on a particular topic, identify gaps or controversies, and lay the groundwork for future research. Therefore, it draws heavily from existing academic sources, including books, journal articles, and other scholarly publications. In contrast, an academic research paper aims to present new knowledge, contribute to the academic discourse, and advance the understanding of a specific research question. Therefore, it involves a mix of existing literature (in the introduction and literature review sections) and original data or findings obtained through research methods. 

Literature reviews are essential components of academic and research papers, and various strategies can be employed to conduct them effectively. If you want to know how to write a literature review for a research paper, here are four common approaches that are often used by researchers.  Chronological Review: This strategy involves organizing the literature based on the chronological order of publication. It helps to trace the development of a topic over time, showing how ideas, theories, and research have evolved.  Thematic Review: Thematic reviews focus on identifying and analyzing themes or topics that cut across different studies. Instead of organizing the literature chronologically, it is grouped by key themes or concepts, allowing for a comprehensive exploration of various aspects of the topic.  Methodological Review: This strategy involves organizing the literature based on the research methods employed in different studies. It helps to highlight the strengths and weaknesses of various methodologies and allows the reader to evaluate the reliability and validity of the research findings.  Theoretical Review: A theoretical review examines the literature based on the theoretical frameworks used in different studies. This approach helps to identify the key theories that have been applied to the topic and assess their contributions to the understanding of the subject.  It’s important to note that these strategies are not mutually exclusive, and a literature review may combine elements of more than one approach. The choice of strategy depends on the research question, the nature of the literature available, and the goals of the review. Additionally, other strategies, such as integrative reviews or systematic reviews, may be employed depending on the specific requirements of the research.

The literature review format can vary depending on the specific publication guidelines. However, there are some common elements and structures that are often followed. Here is a general guideline for the format of a literature review:  Introduction:   Provide an overview of the topic.  Define the scope and purpose of the literature review.  State the research question or objective.  Body:   Organize the literature by themes, concepts, or chronology.  Critically analyze and evaluate each source.  Discuss the strengths and weaknesses of the studies.  Highlight any methodological limitations or biases.  Identify patterns, connections, or contradictions in the existing research.  Conclusion:   Summarize the key points discussed in the literature review.  Highlight the research gap.  Address the research question or objective stated in the introduction.  Highlight the contributions of the review and suggest directions for future research.

Both annotated bibliographies and literature reviews involve the examination of scholarly sources. While annotated bibliographies focus on individual sources with brief annotations, literature reviews provide a more in-depth, integrated, and comprehensive analysis of existing literature on a specific topic. The key differences are as follows: 

References 

• Denney, A. S., & Tewksbury, R. (2013). How to write a literature review.  Journal of criminal justice education ,  24 (2), 218-234. 
• Pan, M. L. (2016).  Preparing literature reviews: Qualitative and quantitative approaches . Taylor & Francis. 
• Cantero, C. (2019). How to write a literature review.  San José State University Writing Center . 

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How to Make a Literature Review in Research (RRL Example)

What is an RRL in a research paper?

A relevant review of the literature (RRL) is an objective, concise, critical summary of published research literature relevant to a topic being researched in an article. In an RRL, you discuss knowledge and findings from existing literature relevant to your study topic. If there are conflicts or gaps in existing literature, you can also discuss these in your review, as well as how you will confront these missing elements or resolve these issues in your study.

To complete an RRL, you first need to collect relevant literature; this can include online and offline sources. Save all of your applicable resources as you will need to include them in your paper. When looking through these sources, take notes and identify concepts of each source to describe in the review of the literature.

A good RRL does NOT:

A literature review does not simply reference and list all of the material you have cited in your paper.

• Presenting material that is not directly relevant to your study will distract and frustrate the reader and make them lose sight of the purpose of your study.
• Starting a literature review with “A number of scholars have studied the relationship between X and Y” and simply listing who has studied the topic and what each scholar concluded is not going to strengthen your paper.

A good RRL DOES:

• Present a brief typology that orders articles and books into groups to help readers focus on unresolved debates, inconsistencies, tensions, and new questions about a research topic.
• Summarize the most relevant and important aspects of the scientific literature related to your area of research
• Synthesize what has been done in this area of research and by whom, highlight what previous research indicates about a topic, and identify potential gaps and areas of disagreement in the field
• Give the reader an understanding of the background of the field and show which studies are important—and highlight errors in previous studies

How long is a review of the literature for a research paper?

The length of a review of the literature depends on its purpose and target readership and can vary significantly in scope and depth. In a dissertation, thesis, or standalone review of literature, it is usually a full chapter of the text (at least 20 pages). Whereas, a standard research article or school assignment literature review section could only be a few paragraphs in the Introduction section .

Building Your Literature Review Bookshelf

One way to conceive of a literature review is to think about writing it as you would build a bookshelf. You don’t need to cut each piece by yourself from scratch. Rather, you can take the pieces that other researchers have cut out and put them together to build a framework on which to hang your own “books”—that is, your own study methods, results, and conclusions.

What Makes a Good Literature Review?

The contents of a literature review (RRL) are determined by many factors, including its precise purpose in the article, the degree of consensus with a given theory or tension between competing theories, the length of the article, the number of previous studies existing in the given field, etc. The following are some of the most important elements that a literature review provides.

Historical background for your research

Analyze what has been written about your field of research to highlight what is new and significant in your study—or how the analysis itself contributes to the understanding of this field, even in a small way. Providing a historical background also demonstrates to other researchers and journal editors your competency in discussing theoretical concepts. You should also make sure to understand how to paraphrase scientific literature to avoid plagiarism in your work.

The current context of your research

Discuss central (or peripheral) questions, issues, and debates in the field. Because a field is constantly being updated by new work, you can show where your research fits into this context and explain developments and trends in research.

A discussion of relevant theories and concepts

Theories and concepts should provide the foundation for your research. For example, if you are researching the relationship between ecological environments and human populations, provide models and theories that focus on specific aspects of this connection to contextualize your study. If your study asks a question concerning sustainability, mention a theory or model that underpins this concept. If it concerns invasive species, choose material that is focused in this direction.

Definitions of relevant terminology

In the natural sciences, the meaning of terms is relatively straightforward and consistent. But if you present a term that is obscure or context-specific, you should define the meaning of the term in the Introduction section (if you are introducing a study) or in the summary of the literature being reviewed.

Description of related relevant research

Include a description of related research that shows how your work expands or challenges earlier studies or fills in gaps in previous work. You can use your literature review as evidence of what works, what doesn’t, and what is missing in the field.

Supporting evidence for a practical problem or issue your research is addressing that demonstrates its importance: Referencing related research establishes your area of research as reputable and shows you are building upon previous work that other researchers have deemed significant.

Types of Literature Reviews

Literature reviews can differ in structure, length, amount, and breadth of content included. They can range from selective (a very narrow area of research or only a single work) to comprehensive (a larger amount or range of works). They can also be part of a larger work or stand on their own.

• A course assignment is an example of a selective, stand-alone work. It focuses on a small segment of the literature on a topic and makes up an entire work on its own.
• The literature review in a dissertation or thesis is both comprehensive and helps make up a larger work.
• A majority of journal articles start with a selective literature review to provide context for the research reported in the study; such a literature review is usually included in the Introduction section (but it can also follow the presentation of the results in the Discussion section ).
• Some literature reviews are both comprehensive and stand as a separate work—in this case, the entire article analyzes the literature on a given topic.

Literature Reviews Found in Academic Journals

The two types of literature reviews commonly found in journals are those introducing research articles (studies and surveys) and stand-alone literature analyses. They can differ in their scope, length, and specific purpose.

Literature reviews introducing research articles

The literature review found at the beginning of a journal article is used to introduce research related to the specific study and is found in the Introduction section, usually near the end. It is shorter than a stand-alone review because it must be limited to very specific studies and theories that are directly relevant to the current study. Its purpose is to set research precedence and provide support for the study’s theory, methods, results, and/or conclusions. Not all research articles contain an explicit review of the literature, but most do, whether it is a discrete section or indistinguishable from the rest of the Introduction.

How to structure a literature review for an article

When writing a literature review as part of an introduction to a study, simply follow the structure of the Introduction and move from the general to the specific—presenting the broadest background information about a topic first and then moving to specific studies that support your rationale , finally leading to your hypothesis statement. Such a literature review is often indistinguishable from the Introduction itself—the literature is INTRODUCING the background and defining the gaps your study aims to fill.

The stand-alone literature review

The literature review published as a stand-alone article presents and analyzes as many of the important publications in an area of study as possible to provide background information and context for a current area of research or a study. Stand-alone reviews are an excellent resource for researchers when they are first searching for the most relevant information on an area of study.

Such literature reviews are generally a bit broader in scope and can extend further back in time. This means that sometimes a scientific literature review can be highly theoretical, in addition to focusing on specific methods and outcomes of previous studies. In addition, all sections of such a “review article” refer to existing literature rather than describing the results of the authors’ own study.

In addition, this type of literature review is usually much longer than the literature review introducing a study. At the end of the review follows a conclusion that once again explicitly ties all of the cited works together to show how this analysis is itself a contribution to the literature. While not absolutely necessary, such articles often include the terms “Literature Review” or “Review of the Literature” in the title. Whether or not that is necessary or appropriate can also depend on the specific author instructions of the target journal. Have a look at this article for more input on how to compile a stand-alone review article that is insightful and helpful for other researchers in your field.

How to Write a Literature Review in 6 Steps

So how do authors turn a network of articles into a coherent review of relevant literature?

Writing a literature review is not usually a linear process—authors often go back and check the literature while reformulating their ideas or making adjustments to their study. Sometimes new findings are published before a study is completed and need to be incorporated into the current work. This also means you will not be writing the literature review at any one time, but constantly working on it before, during, and after your study is complete.

Here are some steps that will help you begin and follow through on your literature review.

Step 1: Choose a topic to write about—focus on and explore this topic.

Choose a topic that you are familiar with and highly interested in analyzing; a topic your intended readers and researchers will find interesting and useful; and a topic that is current, well-established in the field, and about which there has been sufficient research conducted for a review. This will help you find the “sweet spot” for what to focus on.

Step 2: Research and collect all the scholarly information on the topic that might be pertinent to your study.

This includes scholarly articles, books, conventions, conferences, dissertations, and theses—these and any other academic work related to your area of study is called “the literature.”

Step 3: Analyze the network of information that extends or responds to the major works in your area; select the material that is most useful.

Use thought maps and charts to identify intersections in the research and to outline important categories; select the material that will be most useful to your review.

Step 4: Describe and summarize each article—provide the essential information of the article that pertains to your study.

Determine 2-3 important concepts (depending on the length of your article) that are discussed in the literature; take notes about all of the important aspects of this study relevant to the topic being reviewed.

For example, in a given study, perhaps some of the main concepts are X, Y, and Z. Note these concepts and then write a brief summary about how the article incorporates them. In reviews that introduce a study, these can be relatively short. In stand-alone reviews, there may be significantly more texts and more concepts.

Step 5: Demonstrate how these concepts in the literature relate to what you discovered in your study or how the literature connects the concepts or topics being discussed.

In a literature review intro for an article, this information might include a summary of the results or methods of previous studies that correspond to and/or confirm those sections in your own study. For a stand-alone literature review, this may mean highlighting the concepts in each article and showing how they strengthen a hypothesis or show a pattern.

Discuss unaddressed issues in previous studies. These studies that are missing something you address are important to include in your literature review. In addition, those works whose theories and conclusions directly support your findings will be valuable to review here.

Step 6: Identify relationships in the literature and develop and connect your own ideas to them.

This is essentially the same as step 5 but focused on the connections between the literature and the current study or guiding concepts or arguments of the paper, not only on the connections between the works themselves.

Your hypothesis, argument, or guiding concept is the “golden thread” that will ultimately tie the works together and provide readers with specific insights they didn’t have before reading your literature review. Make sure you know where to put the research question , hypothesis, or statement of the problem in your research paper so that you guide your readers logically and naturally from your introduction of earlier work and evidence to the conclusions you want them to draw from the bigger picture.

Your literature review will not only cover publications on your topics but will include your own ideas and contributions. By following these steps you will be telling the specific story that sets the background and shows the significance of your research and you can turn a network of related works into a focused review of the literature.

Literature Review (RRL) Examples

Because creating sample literature reviews would take too long and not properly capture the nuances and detailed information needed for a good review, we have included some links to different types of literature reviews below. You can find links to more literature reviews in these categories by visiting the TUS Library’s website . Sample literature reviews as part of an article, dissertation, or thesis:

• Critical Thinking and Transferability: A Review of the Literature (Gwendolyn Reece)
• Building Customer Loyalty: A Customer Experience Based Approach in a Tourism Context (Martina Donnelly)

Sample stand-alone literature reviews

• Literature Review on Attitudes towards Disability (National Disability Authority)
• The Effects of Communication Styles on Marital Satisfaction (Hannah Yager)

Additional Literature Review Format Guidelines

In addition to the content guidelines above, authors also need to check which style guidelines to use ( APA , Chicago, MLA, etc.) and what specific rules the target journal might have for how to structure such articles or how many studies to include—such information can usually be found on the journals’ “Guide for Authors” pages. Additionally, use one of the four Wordvice citation generators below, choosing the citation style needed for your paper:

Wordvice Writing and Academic Editing Resources

Finally, after you have finished drafting your literature review, be sure to receive professional proofreading services , including paper editing for your academic work. A competent proofreader who understands academic writing conventions and the specific style guides used by academic journals will ensure that your paper is ready for publication in your target journal.

See our academic resources for further advice on references in your paper , how to write an abstract , how to write a research paper title, how to impress the editor of your target journal with a perfect cover letter , and dozens of other research writing and publication topics.

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Organizing Your Social Sciences Research Paper

• 5. The Literature Review
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A literature review surveys prior research published in books, scholarly articles, and any other sources relevant to a particular issue, area of research, or theory, and by so doing, provides a description, summary, and critical evaluation of these works in relation to the research problem being investigated. Literature reviews are designed to provide an overview of sources you have used in researching a particular topic and to demonstrate to your readers how your research fits within existing scholarship about the topic.

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . Fourth edition. Thousand Oaks, CA: SAGE, 2014.

Importance of a Good Literature Review

A literature review may consist of simply a summary of key sources, but in the social sciences, a literature review usually has an organizational pattern and combines both summary and synthesis, often within specific conceptual categories . A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information in a way that informs how you are planning to investigate a research problem. The analytical features of a literature review might:

• Give a new interpretation of old material or combine new with old interpretations,
• Trace the intellectual progression of the field, including major debates,
• Depending on the situation, evaluate the sources and advise the reader on the most pertinent or relevant research, or
• Usually in the conclusion of a literature review, identify where gaps exist in how a problem has been researched to date.

Given this, the purpose of a literature review is to:

• Place each work in the context of its contribution to understanding the research problem being studied.
• Describe the relationship of each work to the others under consideration.
• Identify new ways to interpret prior research.
• Reveal any gaps that exist in the literature.
• Resolve conflicts amongst seemingly contradictory previous studies.
• Identify areas of prior scholarship to prevent duplication of effort.
• Point the way in fulfilling a need for additional research.
• Locate your own research within the context of existing literature [very important].

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper. 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . Los Angeles, CA: SAGE, 2011; Knopf, Jeffrey W. "Doing a Literature Review." PS: Political Science and Politics 39 (January 2006): 127-132; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012.

Types of Literature Reviews

It is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the primary studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally among scholars that become part of the body of epistemological traditions within the field.

In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews. Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are a number of approaches you could adopt depending upon the type of analysis underpinning your study.

Argumentative Review This form examines literature selectively in order to support or refute an argument, deeply embedded assumption, or philosophical problem already established in the literature. The purpose is to develop a body of literature that establishes a contrarian viewpoint. Given the value-laden nature of some social science research [e.g., educational reform; immigration control], argumentative approaches to analyzing the literature can be a legitimate and important form of discourse. However, note that they can also introduce problems of bias when they are used to make summary claims of the sort found in systematic reviews [see below].

Integrative Review Considered a form of research that reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated. The body of literature includes all studies that address related or identical hypotheses or research problems. A well-done integrative review meets the same standards as primary research in regard to clarity, rigor, and replication. This is the most common form of review in the social sciences.

Historical Review Few things rest in isolation from historical precedent. Historical literature reviews focus on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.

Methodological Review A review does not always focus on what someone said [findings], but how they came about saying what they say [method of analysis]. Reviewing methods of analysis provides a framework of understanding at different levels [i.e. those of theory, substantive fields, research approaches, and data collection and analysis techniques], how researchers draw upon a wide variety of knowledge ranging from the conceptual level to practical documents for use in fieldwork in the areas of ontological and epistemological consideration, quantitative and qualitative integration, sampling, interviewing, data collection, and data analysis. This approach helps highlight ethical issues which you should be aware of and consider as you go through your own study.

Systematic Review This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report, and analyze data from the studies that are included in the review. The goal is to deliberately document, critically evaluate, and summarize scientifically all of the research about a clearly defined research problem . Typically it focuses on a very specific empirical question, often posed in a cause-and-effect form, such as "To what extent does A contribute to B?" This type of literature review is primarily applied to examining prior research studies in clinical medicine and allied health fields, but it is increasingly being used in the social sciences.

Theoretical Review The purpose of this form is to examine the corpus of theory that has accumulated in regard to an issue, concept, theory, phenomena. The theoretical literature review helps to establish what theories already exist, the relationships between them, to what degree the existing theories have been investigated, and to develop new hypotheses to be tested. Often this form is used to help establish a lack of appropriate theories or reveal that current theories are inadequate for explaining new or emerging research problems. The unit of analysis can focus on a theoretical concept or a whole theory or framework.

NOTE : Most often the literature review will incorporate some combination of types. For example, a review that examines literature supporting or refuting an argument, assumption, or philosophical problem related to the research problem will also need to include writing supported by sources that establish the history of these arguments in the literature.

Baumeister, Roy F. and Mark R. Leary. "Writing Narrative Literature Reviews."  Review of General Psychology 1 (September 1997): 311-320; Mark R. Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Kennedy, Mary M. "Defining a Literature." Educational Researcher 36 (April 2007): 139-147; Petticrew, Mark and Helen Roberts. Systematic Reviews in the Social Sciences: A Practical Guide . Malden, MA: Blackwell Publishers, 2006; Torracro, Richard. "Writing Integrative Literature Reviews: Guidelines and Examples." Human Resource Development Review 4 (September 2005): 356-367; Rocco, Tonette S. and Maria S. Plakhotnik. "Literature Reviews, Conceptual Frameworks, and Theoretical Frameworks: Terms, Functions, and Distinctions." Human Ressource Development Review 8 (March 2008): 120-130; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

Structure and Writing Style

I.  Thinking About Your Literature Review

The structure of a literature review should include the following in support of understanding the research problem :

• An overview of the subject, issue, or theory under consideration, along with the objectives of the literature review,
• Division of works under review into themes or categories [e.g. works that support a particular position, those against, and those offering alternative approaches entirely],
• An explanation of how each work is similar to and how it varies from the others,
• Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research.

The critical evaluation of each work should consider :

• Provenance -- what are the author's credentials? Are the author's arguments supported by evidence [e.g. primary historical material, case studies, narratives, statistics, recent scientific findings]?
• Methodology -- were the techniques used to identify, gather, and analyze the data appropriate to addressing the research problem? Was the sample size appropriate? Were the results effectively interpreted and reported?
• Objectivity -- is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
• Persuasiveness -- which of the author's theses are most convincing or least convincing?
• Validity -- are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

II.  Development of the Literature Review

Four Basic Stages of Writing 1.  Problem formulation -- which topic or field is being examined and what are its component issues? 2.  Literature search -- finding materials relevant to the subject being explored. 3.  Data evaluation -- determining which literature makes a significant contribution to the understanding of the topic. 4.  Analysis and interpretation -- discussing the findings and conclusions of pertinent literature.

Consider the following issues before writing the literature review: Clarify If your assignment is not specific about what form your literature review should take, seek clarification from your professor by asking these questions: 1.  Roughly how many sources would be appropriate to include? 2.  What types of sources should I review (books, journal articles, websites; scholarly versus popular sources)? 3.  Should I summarize, synthesize, or critique sources by discussing a common theme or issue? 4.  Should I evaluate the sources in any way beyond evaluating how they relate to understanding the research problem? 5.  Should I provide subheadings and other background information, such as definitions and/or a history? Find Models Use the exercise of reviewing the literature to examine how authors in your discipline or area of interest have composed their literature review sections. Read them to get a sense of the types of themes you might want to look for in your own research or to identify ways to organize your final review. The bibliography or reference section of sources you've already read, such as required readings in the course syllabus, are also excellent entry points into your own research. Narrow the Topic The narrower your topic, the easier it will be to limit the number of sources you need to read in order to obtain a good survey of relevant resources. Your professor will probably not expect you to read everything that's available about the topic, but you'll make the act of reviewing easier if you first limit scope of the research problem. A good strategy is to begin by searching the USC Libraries Catalog for recent books about the topic and review the table of contents for chapters that focuses on specific issues. You can also review the indexes of books to find references to specific issues that can serve as the focus of your research. For example, a book surveying the history of the Israeli-Palestinian conflict may include a chapter on the role Egypt has played in mediating the conflict, or look in the index for the pages where Egypt is mentioned in the text. Consider Whether Your Sources are Current Some disciplines require that you use information that is as current as possible. This is particularly true in disciplines in medicine and the sciences where research conducted becomes obsolete very quickly as new discoveries are made. However, when writing a review in the social sciences, a survey of the history of the literature may be required. In other words, a complete understanding the research problem requires you to deliberately examine how knowledge and perspectives have changed over time. Sort through other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to explore what is considered by scholars to be a "hot topic" and what is not.

III.  Ways to Organize Your Literature Review

Chronology of Events If your review follows the chronological method, you could write about the materials according to when they were published. This approach should only be followed if a clear path of research building on previous research can be identified and that these trends follow a clear chronological order of development. For example, a literature review that focuses on continuing research about the emergence of German economic power after the fall of the Soviet Union. By Publication Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on environmental studies of brown fields if the progression revealed, for example, a change in the soil collection practices of the researchers who wrote and/or conducted the studies. Thematic [“conceptual categories”] A thematic literature review is the most common approach to summarizing prior research in the social and behavioral sciences. Thematic reviews are organized around a topic or issue, rather than the progression of time, although the progression of time may still be incorporated into a thematic review. For example, a review of the Internet’s impact on American presidential politics could focus on the development of online political satire. While the study focuses on one topic, the Internet’s impact on American presidential politics, it would still be organized chronologically reflecting technological developments in media. The difference in this example between a "chronological" and a "thematic" approach is what is emphasized the most: themes related to the role of the Internet in presidential politics. Note that more authentic thematic reviews tend to break away from chronological order. A review organized in this manner would shift between time periods within each section according to the point being made. Methodological A methodological approach focuses on the methods utilized by the researcher. For the Internet in American presidential politics project, one methodological approach would be to look at cultural differences between the portrayal of American presidents on American, British, and French websites. Or the review might focus on the fundraising impact of the Internet on a particular political party. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Other Sections of Your Literature Review Once you've decided on the organizational method for your literature review, the sections you need to include in the paper should be easy to figure out because they arise from your organizational strategy. In other words, a chronological review would have subsections for each vital time period; a thematic review would have subtopics based upon factors that relate to the theme or issue. However, sometimes you may need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. However, only include what is necessary for the reader to locate your study within the larger scholarship about the research problem.

Here are examples of other sections, usually in the form of a single paragraph, you may need to include depending on the type of review you write:

• Current Situation : Information necessary to understand the current topic or focus of the literature review.
• Sources Used : Describes the methods and resources [e.g., databases] you used to identify the literature you reviewed.
• History : The chronological progression of the field, the research literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Selection Methods : Criteria you used to select (and perhaps exclude) sources in your literature review. For instance, you might explain that your review includes only peer-reviewed [i.e., scholarly] sources.
• Standards : Description of the way in which you present your information.
• Questions for Further Research : What questions about the field has the review sparked? How will you further your research as a result of the review?

IV.  Writing Your Literature Review

Once you've settled on how to organize your literature review, you're ready to write each section. When writing your review, keep in mind these issues.

Use Evidence A literature review section is, in this sense, just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence [citations] that demonstrates that what you are saying is valid. Be Selective Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the research problem, whether it is thematic, methodological, or chronological. Related items that provide additional information, but that are not key to understanding the research problem, can be included in a list of further readings . Use Quotes Sparingly Some short quotes are appropriate if you want to emphasize a point, or if what an author stated cannot be easily paraphrased. Sometimes you may need to quote certain terminology that was coined by the author, is not common knowledge, or taken directly from the study. Do not use extensive quotes as a substitute for using your own words in reviewing the literature. Summarize and Synthesize Remember to summarize and synthesize your sources within each thematic paragraph as well as throughout the review. Recapitulate important features of a research study, but then synthesize it by rephrasing the study's significance and relating it to your own work and the work of others. Keep Your Own Voice While the literature review presents others' ideas, your voice [the writer's] should remain front and center. For example, weave references to other sources into what you are writing but maintain your own voice by starting and ending the paragraph with your own ideas and wording. Use Caution When Paraphrasing When paraphrasing a source that is not your own, be sure to represent the author's information or opinions accurately and in your own words. Even when paraphrasing an author’s work, you still must provide a citation to that work.

V.  Common Mistakes to Avoid

These are the most common mistakes made in reviewing social science research literature.

• Sources in your literature review do not clearly relate to the research problem;
• You do not take sufficient time to define and identify the most relevant sources to use in the literature review related to the research problem;
• Relies exclusively on secondary analytical sources rather than including relevant primary research studies or data;
• Uncritically accepts another researcher's findings and interpretations as valid, rather than examining critically all aspects of the research design and analysis;
• Does not describe the search procedures that were used in identifying the literature to review;
• Reports isolated statistical results rather than synthesizing them in chi-squared or meta-analytic methods; and,
• Only includes research that validates assumptions and does not consider contrary findings and alternative interpretations found in the literature.

Cook, Kathleen E. and Elise Murowchick. “Do Literature Review Skills Transfer from One Course to Another?” Psychology Learning and Teaching 13 (March 2014): 3-11; Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . London: SAGE, 2011; Literature Review Handout. Online Writing Center. Liberty University; Literature Reviews. The Writing Center. University of North Carolina; Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: SAGE, 2016; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012; Randolph, Justus J. “A Guide to Writing the Dissertation Literature Review." Practical Assessment, Research, and Evaluation. vol. 14, June 2009; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016; Taylor, Dena. The Literature Review: A Few Tips On Conducting It. University College Writing Centre. University of Toronto; Writing a Literature Review. Academic Skills Centre. University of Canberra.

Writing Tip

Break Out of Your Disciplinary Box!

Thinking interdisciplinarily about a research problem can be a rewarding exercise in applying new ideas, theories, or concepts to an old problem. For example, what might cultural anthropologists say about the continuing conflict in the Middle East? In what ways might geographers view the need for better distribution of social service agencies in large cities than how social workers might study the issue? You don’t want to substitute a thorough review of core research literature in your discipline for studies conducted in other fields of study. However, particularly in the social sciences, thinking about research problems from multiple vectors is a key strategy for finding new solutions to a problem or gaining a new perspective. Consult with a librarian about identifying research databases in other disciplines; almost every field of study has at least one comprehensive database devoted to indexing its research literature.

Frodeman, Robert. The Oxford Handbook of Interdisciplinarity . New York: Oxford University Press, 2010.

Another Writing Tip

Don't Just Review for Content!

While conducting a review of the literature, maximize the time you devote to writing this part of your paper by thinking broadly about what you should be looking for and evaluating. Review not just what scholars are saying, but how are they saying it. Some questions to ask:

• How are they organizing their ideas?
• What methods have they used to study the problem?
• What theories have been used to explain, predict, or understand their research problem?
• What sources have they cited to support their conclusions?
• How have they used non-textual elements [e.g., charts, graphs, figures, etc.] to illustrate key points?

When you begin to write your literature review section, you'll be glad you dug deeper into how the research was designed and constructed because it establishes a means for developing more substantial analysis and interpretation of the research problem.

Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1 998.

Yet Another Writing Tip

When Do I Know I Can Stop Looking and Move On?

Here are several strategies you can utilize to assess whether you've thoroughly reviewed the literature:

• Look for repeating patterns in the research findings . If the same thing is being said, just by different people, then this likely demonstrates that the research problem has hit a conceptual dead end. At this point consider: Does your study extend current research?  Does it forge a new path? Or, does is merely add more of the same thing being said?
• Look at sources the authors cite to in their work . If you begin to see the same researchers cited again and again, then this is often an indication that no new ideas have been generated to address the research problem.
• Search Google Scholar to identify who has subsequently cited leading scholars already identified in your literature review [see next sub-tab]. This is called citation tracking and there are a number of sources that can help you identify who has cited whom, particularly scholars from outside of your discipline. Here again, if the same authors are being cited again and again, this may indicate no new literature has been written on the topic.

Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: Sage, 2016; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

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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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Literature Review: Conducting & Writing

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Sample Lit Reviews from Communication Arts

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What is a literature review?

A literature review is an integrated analysis -- not just a summary-- of scholarly writings and other relevant evidence related directly to your research question.  That is, it represents a synthesis of the evidence that provides background information on your topic and shows a association between the evidence and your research question.

A literature review may be a stand alone work or the introduction to a larger research paper, depending on the assignment.  Rely heavily on the guidelines your instructor has given you.

Why is it important?

A literature review is important because it:

• Explains the background of research on a topic.
• Demonstrates why a topic is significant to a subject area.
• Discovers relationships between research studies/ideas.
• Identifies major themes, concepts, and researchers on a topic.
• Identifies critical gaps and points of disagreement.
• Discusses further research questions that logically come out of the previous studies.

APA7 Style resources

APA Style Blog - for those harder to find answers

1. Choose a topic. Define your research question.

Your literature review should be guided by your central research question.  The literature represents background and research developments related to a specific research question, interpreted and analyzed by you in a synthesized way.

• Make sure your research question is not too broad or too narrow.  Is it manageable?
• Begin writing down terms that are related to your question. These will be useful for searches later.
• If you have the opportunity, discuss your topic with your professor and your class mates.

2. Decide on the scope of your review

How many studies do you need to look at? How comprehensive should it be? How many years should it cover? 

• This may depend on your assignment.  How many sources does the assignment require?

3. Select the databases you will use to conduct your searches.

Make a list of the databases you will search. 

Where to find databases:

• use the tabs on this guide
• Find other databases in the Nursing Information Resources web page
• More on the Medical Library web page
• ... and more on the Yale University Library web page

4. Conduct your searches to find the evidence. Keep track of your searches.

• Use the key words in your question, as well as synonyms for those words, as terms in your search. Use the database tutorials for help.
• Save the searches in the databases. This saves time when you want to redo, or modify, the searches. It is also helpful to use as a guide is the searches are not finding any useful results.
• Review the abstracts of research studies carefully. This will save you time.
• Use the bibliographies and references of research studies you find to locate others.
• Check with your professor, or a subject expert in the field, if you are missing any key works in the field.
• Ask your librarian for help at any time.
• Use a citation manager, such as EndNote as the repository for your citations. See the EndNote tutorials for help.

Review the literature

Some questions to help you analyze the research:

• What was the research question of the study you are reviewing? What were the authors trying to discover?
• Was the research funded by a source that could influence the findings?
• What were the research methodologies? Analyze its literature review, the samples and variables used, the results, and the conclusions.
• Does the research seem to be complete? Could it have been conducted more soundly? What further questions does it raise?
• If there are conflicting studies, why do you think that is?
• How are the authors viewed in the field? Has this study been cited? If so, how has it been analyzed?

Tips: 

• Review the abstracts carefully.  
• Keep careful notes so that you may track your thought processes during the research process.
• Create a matrix of the studies for easy analysis, and synthesis, across all of the studies.
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CHAPTER 2 REVIEW OF RELATED LITERATURE AND STUDIES

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How to Write a Literature Review

• 6. Synthesize
• Literature Reviews: A Recap
• Reading Journal Articles
• Does it Describe a Literature Review?
• 1. Identify the Question
• 2. Review Discipline Styles
• Searching Article Databases
• Finding Full-Text of an Article
• Citation Chaining
• When to Stop Searching
• 4. Manage Your References
• 5. Critically Analyze and Evaluate

Synthesis Visualization

Synthesis matrix example.

• 7. Write a Literature Review

• Synthesis Worksheet

About Synthesis

Approaches to synthesis.

You can sort the literature in various ways, for example:

How to Begin?

Read your sources carefully and find the main idea(s) of each source

Look for similarities in your sources – which sources are talking about the same main ideas? (for example, sources that discuss the historical background on your topic)

Use the worksheet (above) or synthesis matrix (below) to get organized

This work can be messy. Don't worry if you have to go through a few iterations of the worksheet or matrix as you work on your lit review!

Four Examples of Student Writing

In the four examples below, only ONE shows a good example of synthesis: the fourth column, or  Student D . For a web accessible version, click the link below the image.

Long description of "Four Examples of Student Writing" for web accessibility

• Download a copy of the "Four Examples of Student Writing" chart

Click on the example to view the pdf.

From Jennifer Lim

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Hospital performance evaluation indicators: a scoping review

• Shirin Alsadat Hadian   ORCID: orcid.org/0000-0002-1443-1990 1 ,
• Reza Rezayatmand   ORCID: orcid.org/0000-0002-9907-3597 2 ,
• Nasrin Shaarbafchizadeh   ORCID: orcid.org/0000-0001-7104-2214 3 ,
• Saeedeh Ketabi   ORCID: orcid.org/0000-0002-6778-5645 4 &
• Ahmad Reza Pourghaderi   ORCID: orcid.org/0000-0003-2682-2160 5  

BMC Health Services Research volume  24 , Article number:  561 ( 2024 ) Cite this article

238 Accesses

Metrics details

Hospitals are the biggest consumers of health system budgets and hence measuring hospital performance by quantitative or qualitative accessible and reliable indicators is crucial. This review aimed to categorize and present a set of indicators for evaluating overall hospital performance.

We conducted a literature search across three databases, i.e., PubMed, Scopus, and Web of Science, using possible keyword combinations. We included studies that explored hospital performance evaluation indicators from different dimensions.

We included 91 English language studies published in the past 10 years. In total, 1161 indicators were extracted from the included studies. We classified the extracted indicators into 3 categories, 14 subcategories, 21 performance dimensions, and 110 main indicators. Finally, we presented a comprehensive set of indicators with regard to different performance dimensions and classified them based on what they indicate in the production process, i.e., input, process, output, outcome and impact.

The findings provide a comprehensive set of indicators at different levels that can be used for hospital performance evaluation. Future studies can be conducted to validate and apply these indicators in different contexts. It seems that, depending on the specific conditions of each country, an appropriate set of indicators can be selected from this comprehensive list of indicators for use in the performance evaluation of hospitals in different settings.

Peer Review reports

Healthcare is complex [ 1 ] and a key sector [ 2 ] that is now globally faced with problems of rising costs, lack of service efficiency, competition, and equity as well as responsiveness to users [ 3 ]. One estimate by the WHO has shown a yearly waste of approximately 20–40% of total healthcare resources because of inefficiency [ 4 ]. European countries have spent on average 9.6% of their gross domestic product (GDP) on healthcare in 2017 and 9.92% in 2019. Germany, France, and Sweden reported the highest healthcare expenditures in Europe in 2018 (between 10.9% and 11.5% of GDP) [ 5 ]. In the U.S., healthcare spending consumes 18% of the GDP, which is likely to eclipse $6 trillion by 2027 [ 6 ].

Hospitals, as the biggest consumers of health system budgets [ 7 ], are the major part of the health system [ 8 ]. In many countries 50–80% of the health sector budget is dedicated to hospitals [ 8 , 9 ]. As a result, hospital performance analysis is becoming a routine task for every hospital manager. On the one hand, hospital managers worldwide are faced with difficult decisions regarding cost reduction, increasing service efficiency, and equity [ 10 ]. On the other hand, measuring hospital efficiency is an issue of interest among researchers because patients demand high-quality care at lower expenses [ 11 ].

To address the above mentioned need to measure hospital performance, implementing an appropriate hospital performance evaluation system is crucial in any hospital. In doing so, hospital administrators use various tools to analyse and monitor hospital activities [ 1 ], which need well-defined objectives, standards and quantitative indicators [ 12 ]. The latter are used to evaluate care provided to patients both quantitatively and qualitatively and are often related to input, output, processes, and outcomes. These indicators can be used for continuous quality improvement by monitoring, benchmarking, and prioritizing activities [ 13 ]. These parameters are developed to improve health outcomes and to provide comparative information for monitoring and managing and formulating policy objectives within and across health services [ 12 ]. Studies thus far have used their own set of indicators while evaluating hospital performance, which could be context dependent. In addition, those studies have mostly used a limited set of indicators that focus on few dimensions (2–6 dimensions) of hospital performance [ 14 , 15 , 16 , 17 , 18 ].

Therefore, comprehensive knowledge of potential indicators that can be used for hospital performance evaluation is necessary. It would help choose appropriate indicators when evaluating hospital performance in different contexts. It would also help researchers extend the range of analysis to evaluate performance from a wider perspective by considering more dimensions of performance. Although performance is a very commonly used term, it has several definitions [ 19 , 20 ], yet, it is often misunderstood [ 21 ]. Therefore, some researchers have expressed confusion about the related terms and considered them interchangeable. These terms are effectiveness, efficiency, productivity, quality, flexibility, creativity, sustainability, evaluation, and piloting [ 21 , 22 , 23 ]. Thus, this scoping review aimed to categorize and present a comprehensive set of indicators that can be used as a suitable set for hospital performance evaluation at any needed level of analysis, i.e., clinical, para-clinical, logistical, or departmental, and relate those indicators to the appropriate performance dimensions. The uniqueness of this paper is that it provides its readers with a comprehensive collection of indicators that have been used in different performance analysis studies.

Materials and methods

We conducted a scoping review of a body of literature. The scoping review can be of particular use when the topic has not yet been extensively reviewed or has a complex or heterogeneous nature. This type of review is commonly undertaken to examine the extent, range, and nature of research activity in a topic area; determine the value and potential scope and cost of undertaking a full systematic review; summarize and disseminate research findings; and identify research gaps in the existing literature. As a scoping review provides a rigorous and transparent method for mapping areas of research, it can be used as a standalone project or as a preliminary step to a systematic review [ 24 ]. While a systematic review (qualitative or quantitative) usually addresses a narrow topic/scope and is a method for integrating or comparing findings from previous studies [ 25 ].

In our study, we used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist following the methods outlined by Arksey and O’Malley [ 26 ] and Tricco [ 27 ]. A systematic search for published and English-language literature on hospital performance evaluation models was conducted, using three databases, i.e., PubMed, Scopus, and Web of Science, from 2013 to January 2023. Initially, the identified keywords were refined and validated by a team of experts. Then, a combination of vocabularies was identified by the authors through a brainstorming process. The search strategy was formulated using Boolean operators. The title and abstract of the formulas were searched in the online databases. The search query for each database is presented in Table  1 .

In the screening process, relevant references related to hospital performance evaluation were screened and abstracted into researcher-developed Microsoft® Excel forms by dual independent reviewers and conflicting information was provided by other reviewers.

The inclusion criteria were as follows: focused only on the hospital setting, available full text and written in English. We excluded studies that focused on health organization indicators, not specifically on hospital indicators; articles without appropriate data (only focused on models and not indicators; or qualitative checklist questionnaires); and articles that focused only on clinical or disease-related indicators, not hospital performance dimensions, and provided very general items as indicators, not the domains of the indicators themselves. Then, a PRISMA-ScR Checklist was used to improve transparency in our review [ 28 ].

To extract the data, researcher-developed Microsoft® Excel forms (data tables) were designed. The following data were subsequently extracted into Microsoft®Excel for synthesis and evaluation: title, author, article year, country, indicator category, study environment (number of hospitals studied), study time frame, indicator name, number of indicators, indicator level (hospital level, department level), evaluation perspective (performance, productivity, efficiency, effectiveness, quality, cost, safety, satisfaction, etc. ) , study type (quantitative or qualitative), indicator subtype (input (structure), process, output (result), outcome and impact), and other explanations. To create a descriptive summary of the results that address the objectives of this scoping review, numerical summarization was also used.

The purpose of creating the main category and the evaluation perspective section was to develop them and create new categories, which focused on the type of indicators related to the performance term. For example, in the “Category” section, the names of the departments or wards of the hospital (such as hospital laboratories, pharmacies, clinical departments, and warehouses) and in the “Evaluation perspective” section, various terms related to the evaluation of hospital performance were extracted. These two types were used after extracting their information under the title “performance dimension”.

The indicators’ levels were collected to determine the level of performance evaluation with the relevant index. Some indicators were used to evaluate the performance of the entire hospital, some were used to evaluate the performance of hospital departments, and some were used to evaluate the performance at the level of a specific project. For example, several indicators (such as bed occupancy ratio, length of stay, and waiting time) were used to evaluate the performance of the entire hospital, and other indicators (such as laboratory department indicators, energy consumption indicators, and neonatal department indicators) were used only to measure the performance of specific departments. This sections were used under the title “category”. The “category” and “indicator’s name” sections were defined according to the results of the “subcategory” section.

The subtypes of indicators (input (structure), process, output(result), outcome and impact) were defined based on the chain model, and each of the selected indicators was linked to it (Appendix 1 ). As a result of the chain model, inputs were used to carry out activities, activities led to the delivery of services or products (outputs). The outputs started to bring about change (outcomes), and eventually, this (hopefully) contributed to the impact [ 29 ]. The classification of the set of input, process, output, outcome and impact indicators was such that readers could access these categories if necessary according to their chosen evaluation models. The term was used under the title “Indicators by types”.

The type of study was considered quantitative or qualitative for determining whether an indicator was able to perform calculations. In this way, readers can choose articles that use quantitative or qualitative indicators to evaluate hospital performance.

We included 91 full-text studies (out of 7475) in English published between 2013 and January 2023 (Fig.  1 ), approximately 40% of which were published between 2020 and 2023. More than 20% of the retrieved studies were conducted in Iran and USA.

Study selection and data abstraction

Study characteristic

As shown in Table  2 , in 85% of the reviewed studies, a number of hospitals (1 to 3828 hospitals, 13,221 hospitals in total) were evaluated. More than 90% of the studies used a quantitative approach. In more than 70% of the studies, hospital evaluation occurred at the department level, which can also be divided into three levels: administrative, clinical ward, and paramedical department. In addition, the administrative departments consist of 13 departments, including financial management [ 48 , 55 , 61 , 67 , 68 , 80 , 83 , 109 , 113 ], supply chain management and warehouse [ 15 , 43 , 84 ], value-based purchasing [ 33 , 85 ], human resource management [ 97 , 101 ], medical equipment [ 32 , 87 ], health information management department [ 90 ], information systems [ 106 ], nutritional assessment [ 93 ], energy management [ 30 , 45 , 92 ], facility management [ 52 , 53 ], building sustainability and resilience [ 35 ], research activities [ 44 ], and education [ 107 ].

The clinical wards consisted of 8 wards, namely, emergency departments (EDs) [ 16 , 39 , 56 , 57 , 69 , 70 , 89 ], surgery departments [ 58 , 62 , 63 , 91 , 102 ], intensive care units (ICUs) [ 47 , 64 , 65 ], operating rooms (ORs) [ 38 , 88 , 108 ], surgical intensive care units (SICUs) [ 111 ], obstetrics and gynecology department [ 59 ], neonatal intensive care units (NICUs) [ 74 , 103 ] and quality of care [ 18 , 31 , 40 , 50 , 72 , 92 , 95 , 112 ] indicators. The paramedical departments consisted of 3 departments, pharmacy [ 60 , 76 , 98 ], laboratory and blood bank [ 37 , 42 , 43 , 49 ], and outpatient assessment [ 86 ] indicators.

With regard to data categorization, firstly, a total of 1204 indicators in 91 studies were extracted and after detailed examination, 43 indices (such as hospital ownership, level of care, admission process, and personal discipline) were removed due to their generality and impossibility of calculation in the hospital environment. Then, 1161 performance indicators were entered in this research and were categorized based on the performance criteria (more details about the indicators can be found in Appendix 1 ). Secondly, 145 functional dimensions, including divisions based on different departments and units of the hospital, were defined according to several focus group discussions with 5 health experts. Then, re-categorization and functional summarization were performed, after which 21 performance dimensions were finalized.

As shown in Table  4 , the 21 performance dimensions were divided into three parts: category, subcategory, and related indicators. Additionally, according to the hospital levels, there were three categories: ‘organizational management’, ‘clinical management’, and ‘administrative management’. Then, according to the type of indicators, fifteen subcategories were defined for the 110 selected main indicators.

Performance dimensions

The ‘productivity’ dimension focuses on indicators reflecting the macro-performance of the hospital, considering that this index is more effective and efficient. The ‘efficiency’ dimension focuses on general performance indicators for the optimal use of resources to create optimal output in the hospital. The ‘effectiveness’ dimension is a general performance indicator with an outcome view. The ‘speed’ dimension focuses on the indicators that show attention to the service delivery time and the speed of the procedures. The ‘development’ dimension focuses on matters related to employees’ and students’ training and related training courses. In terms of ‘safety’ dimension, there were issues related to patient safety, unwanted and harmful events, and hospital infections.

The “quality of work life” dimension emphasizes matters related to personnel volume and work conditions. The ‘quality’ dimension is related to the quality of service provided in different parts of the hospital and possible complications in improving the quality of services. The ‘satisfaction’ dimension focuses on the satisfaction of patients, employees, and their complaints. The ‘innovation’ dimension relates to the research process and its output. The ‘appropriateness’ dimension involves proper service from clinical departments, pharmaceutical services, and patient treatment. The ‘evaluation’ dimension focuses on the indicators related to the assessment scores of the para-clinical departments of the hospital.

The ‘profitability’ dimension focuses on the overall output indicators for income and profitability. The ‘cost’ dimension focuses on indicators related to general expenditures and the average cost per bed and patient and budgeting. The ‘economy’ dimension is related to financial rates and their indicators. The ‘coherence’ dimension emphasizes the indicators related to the continuity of the service delivery process. The ‘patient-centeredness’ dimension focuses on the indicators related to the patient’s experience of the facility, environment, treatment processes, communications, and relevant support for the patient. The ‘equity’ dimension studies indicators related to social and financial justice and life expectancy. The ‘relationship’ dimension evaluates the process of consultations and discussions required during the patients’ care provided by the treatment team. The ‘sustainability’ dimension focuses on indicators related to energy standards. The ‘flexibility’ dimension focuses on the hospital’s response to the crisis.

According to Table  4 , most studies focused on ‘efficiency’, ‘productivity’, ‘safety’ and ‘effectiveness’ as performance dimensions in 54, 53, 38 and 37 studies, respectively (40–70% of studies). In the ‘efficiency’ subcategory, resource management, supportive unit assessment, and human resource management indicators were the first to third most common indicators used in 26, 23 and 22 studies, respectively (approximately 25% of the studies).

In addition, for the ‘efficiency’ dimension, ‘medical staff numbers’, ‘emergency department bed numbers’, and ‘nonmedical staff numbers’ were reported in 16, 13, and 11 studies, respectively (between 20 and 30% of the studies). For the ‘productivity’ subcategory, ‘bed utilization rate’ and ‘service delivery and treatment’ were reported in 50% and 20% of the studies, respectively (46 and 19 out of 91).

Additionally, for the ‘productivity’ dimension, the ‘length of stay’ indicator was used more than others and reported in approximately 80% of the studies (43 out of 53), followed by the ‘bed occupancy rate’ in approximately 40% of the studies (21 out of 53). The ‘bed turnover ratio’ and ‘hospitalization rate’ were also reported in 12 studies. Furthermore, for ‘safety’ dimensions, all indicators were in the ‘patient safety’ subcategory, which has been reported in 38 studies, and ‘complications’, ‘accidents or adverse events’, and ‘incidents or errors rates’ were the most concentrated indicators by researchers in 13, 12, and 11 studies, respectively. The performance dimension of ‘effectiveness’ was presented in 37 studies (40%), with only two indicators, ‘mortality rate’ in 29 studies and ‘readmission rate’ in 23 studies.

Performance categories

Considering the three categories shown in Table  4 , ‘organizational management’ indicators were more commonly used among the other two categories (‘clinical’ and ‘administrative’) and were present in more than 85% of the studies (78 out of 91). Two categories, ‘clinical management’ and ‘administrative management’, were reported in 62 and 51 studies, respectively.

Performance subcategories

Considering the 14 subcategories shown in Table  4 , both the ‘bed utilization rate’ and ‘patient safety’ indicators were mentioned in 46 studies and were more common among the other subcategories. The second most common indicator of the ‘financial management’ subcategory was reported in 38 studies. At the third level, both the ‘human resource management’ and ‘time management’ indicators were presented in 31 studies. The ‘paramedical’ subcategory indicators were presented in less than 10% of the studies [ 60 , 96 , 97 , 98 , 106 , 113 ].

Performance indicators

According to the indicator columns in Table  3 , the most used indicators in reviewed studies were the length of stay, mortality rate, and readmission rate in 47%, 32%, and 25% of studies, respectively. Bed occupancy rate and non-personnel costs were reported in 23% of studies. Additionally, among the 110 indicators, 16 indicators, namely, the lab cancellation rate, exam-physician ratios, number of coded diagnoses, number of medical records, laboratory sample/report intervals, medical information request time, safety standards in the archives, nutritional risk screening, imaging quality control failures, errors in medical reports, average impact factor, nutritional measures, laboratory scoring, imaging inspection, discharge process and emergency response rate, were reported in less than 1% of the studies.

The classification of the indicators in Table  4 was performed based on the chain model, which included the input, process, output, outcome and impact. The assignment of the indicators to each category was performed according to the experts’ opinions. For instance, the number of publications by academic member of an academic hospital and the average impact factor of those publications were considered outcome indicators. As depicted in the Table  4 , most studies (80%) focused more on output indicators. Additionally, fifteen studies focused on introducing and extracting some of the input, process, output, outcome and impact indicators; among those, only one study [ 96 ] has examined the input, process, output and impact indicators simultaneously.

Additionally, in approximately 42% (36 out of 91) of the studies, the indicators’ definitions, formulas, or descriptions have been illustrated, while less than 10% of the studies have defined measuring units, standard or benchmark units for all studied indicators [ 15 , 43 , 45 , 51 , 52 , 57 , 67 ].

Overall, nine studies related to hospital performance evaluation were conducted using systematic review methodologies (five systematic reviews [ 16 , 29 , 30 , 56 , 113 ], two literature reviews [ 79 , 80 ], one narrative review [ 98 ] and one brief review [ 92 ]). Most of these studies focused on extracting performance indicators from one or more hospital departments (e.g., the emergency department) [ 16 , 56 ], hospital laboratory and radiology information systems [ 106 ], supply chain performance [ 29 ], resources and financial results and activity [ 113 ], hospital water consumption [ 30 ], and the pharmaceutical sector [ 98 ]. Other reviews included a three-step process to review, evaluate and rank these hospital indicators in a systematic approach [ 16 ], or to evaluate performance indicator models to create an interactive network and visualize the causal relationships between performance indicators [ 79 ]; moreover, some have focused on the importance of indicators to ensure adequate coverage of the relevant areas of health care services to be evaluated [ 92 ].

Only one scoping review aimed to identify current assessments of hospital performance and compared quality measures from each method in the context of the six qualitative domains of STEEEP (safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness) of the Institute of Medicine (IOM) in accordance with Donabedian’s framework and formulating policy recommendations [ 115 ].

In addition, 21 studies divided performance indicators into 2 to 6 dimensions of performance. Also, the reviewed studies included 2–40 indicators in zero [ 29 , 30 , 98 ] to 6 domains [ 34 ]. Moreover, none of the studies have tried to comprehensively summarize and categorize the performance indicators in several categories, focusing on all the indicators reflecting the performance of the entire hospital organization, or the indicators of administrative units or clinical departments.

In this scoping review, a unique set of hospital performance evaluation indicators related to the various performance dimensions was categorized from 91 studies over the past ten years.

Similarly, in a study, 19 performance dimensions, 32 sub-dimensions, and 138 indicators were extracted from only six studies. Those dimensions were described by all studies included in the review, but only three studies specified the relevant indicators, and the list provided for all possible indicators was not comprehensive. Also, despite current review, there was no classification of indicators based on the hospital levels: managerial, clinical, or organizational levels [ 116 ]. Another study has similarly investigated the performance evaluation indicators of the hospital in such a way that among 42 studies, 111 indicators were presented in the four categories: input, output, outcome, and impact. But, there was no classification of indicators based on performance dimensions and hospital levels [ 117 ].

In this study, the importance of categorized indicators, for the first time to our knowledge, was determined based on their frequency of use in the published literature (Appendix 2 ). The ‘Organizational management’ indicators were the most common compared with the other two categories (‘clinical’ and ‘administrative’). It could be because of the fact that the indicators such as ‘bed occupancy rate’, ‘average length of stay’, ‘mortality rate’, ‘hospital infection rate’, and ‘patient safety’ are easier to be registered in hospital software compared to other indicators, and also they better reflect the overall performance of hospital. Thus, researchers are more interested in using these indicators.

Considering 14 subcategories, indicators related to three subcategories i.e. bed utilization, patient safety and financial management are the most frequent used indicators for hospital performance evaluation. It reflects the need of hospital managers to increase the profitability of hospital in one hand, and to control cost on the other hand. As a results, researchers have paid special attention to ‘cost income’, ‘profitability’, ‘economic’, etc., as indicators for evaluating hospital performance.

When considering indicators by type, more studies have focused on output indicators, while input indicators were the least common used. This might be because of the fact that at hospital level, it is difficult for managers to change those inputs such as ‘beds’, ‘human resources’, ‘equipment and facilities’. In addition, due to the complexity of interdepartmental relationships in hospitals, process indicators seemed to provide more variety for analysis than input indicators, so they were more often used. As mentioned above, output indicators were the most used indicators for hospital performance evaluation due to their ease of calculation and interpretation.

The main purpose of this paper was to identify a comprehensive set of indicators that can be used to evaluate hospital performance in various hospital settings by being distilled into a smaller and more related set of indicators for every hospital or department setting. future studies could be designed to validate each set of indicators in any specific context. In addition, they could investigate the relationship between the indicators and their outcomes of interest and the performance dimension each could address. This will enable hospital managers to build their own set of indicators for performance evaluation both at organization or at department level. Also it should be mentioned that.

Although some previous studies have provided definitions for each indicator and determined the standard criteria for them, this was not done in this study because the focus of this study was to provide a collection of all the indicators used in hospital performance evaluation, which resulted in the identification of more than a thousand indicators without limiting to specific country or context. So while preparing a smaller set of indicators, specific conditions of each country, such as the type of health system and its policy, the type of financing system, and the structure of services, should be taken into account to select appropriate indicators.

In addition, although it is important to examine the scope of each article to compare the list of indicators and the relationships between the dimensions of the hospital in terms of size and type and between the number and type of selected indicators, this was considered beyond the scope of this review due to the high number of indicators, which made the abovementioned investigations impossible. Future studies could do that while working with a smaller set of indicators.

This review aimed to categorize and present a comprehensive set of indicators for evaluating overall hospital performance in a systematic way. 1161 hospital performance indicators were drawn from 91 studies over the past ten years. They then were summarized into 110 main indicators, and categorized into three categories: 14 subcategories, and 21 performance dimensions This scoping review also highlighted the most frequent used indicators in performance evaluation studies which could reflect their importance for that purpose. The results of this review help hospital managers to build their own set of indicators for performance evaluation both at organization or at department level with regard to various performance dimensions.

As the results of this review was not limited to any specific country or context, specific conditions of each country, such as the type of health system and its policy, the type of financing system, and the structure of services, should be taken into account while selecting appropriate indicators as a smaller set of indicators for hospital performance evaluation in specific context.

Availability of data and materials

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

Abbreviations

Gross domestic product

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews

Emergency departments

Intensive care unit

Operating room

Surgical intensive care unit

Neonatal intensive care unit

Readmission rate

Quality Control

Medication use evaluation

safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness

Institute of Medicine

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Acknowledgements

The authors are grateful for the support of the Vice Chancellor for Research of Isfahan University of Medical Sciences.

The present article is part of the result of a doctoral thesis approved by Isfahan University of Medical Sciences with code 55657 (IR.MUI.NUREMA.REC.1401.005), without financial source.

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Shirin Alsadat Hadian and Reza Rezayatmans and Saeedeh Ketabi: Study conceptualization and design. Acquisition of data: Shirin Alsadat Hadian, Reza Rezayatmand. Analysis and interpretation of data: Shirin Alsadat Hadian, Reza Rezayatmand, Nasrin Shaarbafchizadeh, Saeedeh Ketabi. Drafting of the manuscript: Shirin Alsadat Hadian, Reza Rezayatmand. Critical revision of the manuscript for important intellectual content: Reza Rezayatmand, Nasrin Shaarbafchizadeh, Saeedeh Ketabi, Ahmad Reza Pourghaderi.

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Hadian, S.A., Rezayatmand, R., Shaarbafchizadeh, N. et al. Hospital performance evaluation indicators: a scoping review. BMC Health Serv Res 24 , 561 (2024). https://doi.org/10.1186/s12913-024-10940-1

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Efficacy of psilocybin for treating symptoms of depression: systematic review and meta-analysis

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Psilocybin for depression

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• EXPRESSION OF CONCERN: Efficacy of psilocybin for treating symptoms of depression: systematic review and meta-analysis - May 04, 2024
• Athina-Marina Metaxa , masters graduate researcher 1 ,
• Mike Clarke , professor 2
• 1 Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
• 2 Northern Ireland Methodology Hub, Centre for Public Health, ICS-A Royal Hospitals, Belfast, Ireland, UK
• Correspondence to: A-M Metaxa athina.metaxa{at}hmc.ox.ac.uk (or @Athina_Metaxa12 on X)
• Accepted 6 March 2024

Objective To determine the efficacy of psilocybin as an antidepressant compared with placebo or non-psychoactive drugs.

Design Systematic review and meta-analysis.

Data sources Five electronic databases of published literature (Cochrane Central Register of Controlled Trials, Medline, Embase, Science Citation Index and Conference Proceedings Citation Index, and PsycInfo) and four databases of unpublished and international literature (ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, ProQuest Dissertations and Theses Global, and PsycEXTRA), and handsearching of reference lists, conference proceedings, and abstracts.

Data synthesis and study quality Information on potential treatment effect moderators was extracted, including depression type (primary or secondary), previous use of psychedelics, psilocybin dosage, type of outcome measure (clinician rated or self-reported), and personal characteristics (eg, age, sex). Data were synthesised using a random effects meta-analysis model, and observed heterogeneity and the effect of covariates were investigated with subgroup analyses and metaregression. Hedges’ g was used as a measure of treatment effect size, to account for small sample effects and substantial differences between the included studies’ sample sizes. Study quality was appraised using Cochrane’s Risk of Bias 2 tool, and the quality of the aggregated evidence was evaluated using GRADE guidelines.

Eligibility criteria Randomised trials in which psilocybin was administered as a standalone treatment for adults with clinically significant symptoms of depression and change in symptoms was measured using a validated clinician rated or self-report scale. Studies with directive psychotherapy were included if the psychotherapeutic component was present in both experimental and control conditions. Participants with depression regardless of comorbidities (eg, cancer) were eligible.

Results Meta-analysis on 436 participants (228 female participants), average age 36-60 years, from seven of the nine included studies showed a significant benefit of psilocybin (Hedges’ g=1.64, 95% confidence interval (CI) 0.55 to 2.73, P<0.001) on change in depression scores compared with comparator treatment. Subgroup analyses and metaregressions indicated that having secondary depression (Hedges’ g=3.25, 95% CI 0.97 to 5.53), being assessed with self-report depression scales such as the Beck depression inventory (3.25, 0.97 to 5.53), and older age and previous use of psychedelics (metaregression coefficient 0.16, 95% CI 0.08 to 0.24 and 4.2, 1.5 to 6.9, respectively) were correlated with greater improvements in symptoms. All studies had a low risk of bias, but the change from baseline metric was associated with high heterogeneity and a statistically significant risk of small study bias, resulting in a low certainty of evidence rating.

Conclusion Treatment effects of psilocybin were significantly larger among patients with secondary depression, when self-report scales were used to measure symptoms of depression, and when participants had previously used psychedelics. Further research is thus required to delineate the influence of expectancy effects, moderating factors, and treatment delivery on the efficacy of psilocybin as an antidepressant.

Systematic review registration PROSPERO CRD42023388065.

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Introduction

Depression affects an estimated 300 million people around the world, an increase of nearly 20% over the past decade. 1 Worldwide, depression is also the leading cause of disability. 2

Drugs for depression are widely available but these seem to have limited efficacy, can have serious adverse effects, and are associated with low patient adherence. 3 4 Importantly, the treatment effects of antidepressant drugs do not appear until 4-7 weeks after the start of treatment, and remission of symptoms can take months. 4 5 Additionally, the likelihood of relapse is high, with 40-60% of people with depression experiencing a further depressive episode, and the chance of relapse increasing with each subsequent episode. 6 7

Since the early 2000s, the naturally occurring serotonergic hallucinogen psilocybin, found in several species of mushrooms, has been widely discussed as a potential treatment for depression. 8 9 Psilocybin’s mechanism of action differs from that of classic selective serotonin reuptake inhibitors (SSRIs) and might improve the treatment response rate, decrease time to improvement of symptoms, and prevent relapse post-remission. Moreover, more recent assessments of harm have consistently reported that psilocybin generally has low addictive potential and toxicity and that it can be administered safely under clinical supervision. 10

The renewed interest in psilocybin’s antidepressive effects led to several clinical trials on treatment resistant depression, 11 12 major depressive disorder, 13 and depression related to physical illness. 14 15 16 17 These trials mostly reported positive efficacy findings, showing reductions in symptoms of depression within a few hours to a few days after one dose or two doses of psilocybin. 11 12 13 16 17 18 These studies reported only minimal adverse effects, however, and drug harm assessments in healthy volunteers indicated that psilocybin does not induce physiological toxicity, is not addictive, and does not lead to withdrawal. 19 20 Nevertheless, these findings should be interpreted with caution owing to the small sample sizes and open label design of some of these studies. 11 21

Several systematic reviews and meta-analyses since the early 2000s have investigated the use of psilocybin to treat symptoms of depression. Most found encouraging results, but as well as people with depression some included healthy volunteers, 22 and most combined data from studies of multiple serotonergic psychedelics, 23 24 25 even though each compound has unique neurobiological effects and mechanisms of action. 26 27 28 Furthermore, many systematic reviews included non-randomised studies and studies in which psilocybin was tested in conjunction with psychotherapeutic interventions, 25 29 30 31 32 which made it difficult to distinguish psilocybin’s treatment effects. Most systematic reviews and meta-analyses did not consider the impact of factors that could act as moderators to psilocybin’s effects, such as type of depression (primary or secondary), previous use of psychedelics, psilocybin dosage, type of outcome measure (clinician rated or self-reported), and personal characteristics (eg, age, sex). 25 26 29 30 31 32 Lastly, systematic reviews did not consider grey literature, 33 34 which might have led to a substantial overestimation of psilocybin’s efficacy as a treatment for depression. In this review we focused on randomised trials that contained an unconfounded evaluation of psilocybin in adults with symptoms of depression, regardless of country and language of publication.

In this systematic review and meta-analysis of indexed and non-indexed randomised trials we investigated the efficacy of psilocybin to treat symptoms of depression compared with placebo or non-psychoactive drugs. The protocol was registered in the International Prospective Register of Systematic Reviews (see supplementary Appendix A). The study overall did not deviate from the pre-registered protocol; one clarification was made to highlight that any non-psychedelic comparator was eligible for inclusion, including placebo, niacin, micro doses of psychedelics, and drugs that are considered the standard of care in depression (eg, SSRIs).

Inclusion and exclusion criteria

Double blind and open label randomised trials with a crossover or parallel design were eligible for inclusion. We considered only studies in humans and with a control condition, which could include any type of non -active comparator, such as placebo, niacin, or micro doses of psychedelics.

Eligible studies were those that included adults (≥18 years) with clinically significant symptoms of depression, evaluated using a clinically validated tool for depression and mood disorder outcomes. Such tools included the Beck depression inventory, Hamilton depression rating scale, Montgomery-Åsberg depression rating scale, profile of mood states, and quick inventory of depressive symptomatology. Studies of participants with symptoms of depression and comorbidities (eg, cancer) were also eligible. We excluded studies of healthy participants (without depressive symptomatology).

Eligible studies investigated the effect of psilocybin as a standalone treatment on symptoms of depression. Studies with an active psilocybin condition that involved micro dosing (ie, psilocybin <100 μg/kg, according to the commonly accepted convention 22 35 ) were excluded. We included studies with directive psychotherapy if the psychotherapeutic component was present in both the experimental and the control conditions, so that the effects of psilocybin could be distinguished from those of psychotherapy. Studies involving group therapy were also excluded. Any non-psychedelic comparator was eligible for inclusion, including placebo, niacin, and micro doses of psychedelics.

Changes in symptoms, measured by validated clinician rated or self-report scales, such as the Beck depression inventory, Hamilton depression rating scale, Montgomery-Åsberg depression rating scale, profile of mood states, and quick inventory of depressive symptomatology were considered. We excluded outcomes that were measured less than three hours after psilocybin had been administered because any reported changes could be attributed to the transient cognitive and affective effects of the substance being administered. Aside from this, outcomes were included irrespective of the time point at which measurements were taken.

Search strategy

We searched major electronic databases and trial registries of psychological and medical research, with no limits on the publication date. Databases were the Cochrane Central Register of Controlled Trials via the Cochrane Library, Embase via Ovid, Medline via Ovid, Science Citation Index and Conference Proceedings Citation Index-Science via Web of Science, and PsycInfo via Ovid. A search through multiple databases was necessary because each database includes unique journals. Supplementary Appendix B shows the search syntax used for the Cochrane Central Register of Controlled Trials, which was slightly modified to comply with the syntactic rules of the other databases.

Unpublished and grey literature were sought through registries of past and ongoing trials, databases of conference proceedings, government reports, theses, dissertations, and grant registries (eg, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, ProQuest Dissertations and Theses Global, and PsycEXTRA). The references and bibliographies of eligible studies were checked for relevant publications. The original search was done in January 2023 and updated search was performed on 10 August 2023.

Data collection, extraction, and management

The results of the literature search were imported to the Endnote X9 reference management software, and the references were imported to the Covidence platform after removal of duplicates. Two reviewers (AM and DT) independently screened the title and abstract of each reference and then screened the full text of potentially eligible references. Any disagreements about eligibility were resolved through discussion. If information was insufficient to determine eligibility, the study’s authors were contacted. The reviewers were not blinded to the studies’ authors, institutions, or journal of publication.

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram shows the study selection process and reasons for excluding studies that were considered eligible for full text screening. 36

Critical appraisal of individual studies and of aggregated evidence

The methodological quality of eligible studies was assessed using the Cochrane Risk of Bias 2 tool (RoB 2) for assessing risk of bias in randomised trials. 37 In addition to the criteria specified by RoB 2, we considered the potential impact of industry funding and conflicts of interest. The overall methodological quality of the aggregated evidence was evaluated using GRADE (Grading of Recommendations, Assessment, Development and Evaluation). 38

If we found evidence of heterogeneity among the trials, then small study biases, such as publication bias, were assessed using a funnel plot and asymmetry tests (eg, Egger’s test). 39

We used a template for data extraction (see supplementary Appendix C) and summarised the extracted data in tabular form, outlining personal characteristics (age, sex, previous use of psychedelics), methodology (study design, dosage), and outcome related characteristics (mean change from baseline score on a depression questionnaire, response rates, and remission rates) of the included studies. Response conventionally refers to a 50% decrease in symptom severity based on scores on a depression rating scale, whereas remission scores are specific to a questionnaire (eg, score of ≤5 on the quick inventory of depressive symptomatology, score of ≤10 on the Montgomery-Åsberg depression rating scale, 50% or greater reduction in symptoms, score of ≤7 on the Hamilton depression rating scale, or score of ≤12 on the Beck depression inventory). Across depression scales, higher scores signify more severe symptoms of depression.

Continuous data synthesis

From each study we extracted the baseline and post-intervention means and standard deviations (SDs) of the scores between comparison groups for the depression questionnaires and calculated the mean differences and SDs of change. If means and SDs were not available for the included studies, we extracted the values from available graphs and charts using the Web Plot Digitizer application ( https://automeris.io/WebPlotDigitizer/ ). If it was not possible to calculate SDs from the graphs or charts, we generated values by converting standard errors (SEs) or confidence intervals (CIs), depending on availability, using formulas in the Cochrane Handbook (section 7.7.3.2). 40

Standardised mean differences were calculated for each study. We chose these rather than weighted mean differences because, although all the studies measured depression as the primary outcome, they did so with different questionnaires that score depression based on slightly different items. 41 If we had used weighted mean differences, any variability among studies would be assumed to reflect actual methodological or population differences and not differences in how the outcome was measured, which could be misleading. 40

The Hedges’ g effect size estimate was used because it tends to produce less biased results for studies with smaller samples (<20 participants) and when sample sizes differ substantially between studies, in contrast with Cohen’s d. 42 According to the Cochrane Handbook, the Hedges’ g effect size measure is synonymous with the standardised mean difference, 40 and the terms may be used interchangeably. Thus, a Hedges’ g of 0.2, 0.5, 0.8, or 1.2 corresponds to a small, medium, large, or very large effect, respectively. 40

Owing to variation in the participants’ personal characteristics, psilocybin dosage, type of depression investigated (primary or secondary), and type of comparators, we used a random effects model with a Hartung-Knapp-Sidik-Jonkman modification. 43 This model also allowed for heterogeneity and within study variability to be incorporated into the weighting of the results of the included studies. 44 Lastly, this model could help to generalise the findings beyond the studies and patient populations included, making the meta-analysis more clinically useful. 45 We chose the Hartung-Knapp-Sidik-Jonkman adjustment in favour of more widely used random effects models (eg, DerSimonian and Laird) because it allows for better control of type 1 errors, especially for studies with smaller samples, and provides a better estimation of between study variance by accounting for small sample sizes. 46 47

For studies in which multiple treatment groups were compared with a single placebo group, we split the placebo group to avoid multiplicity. 48 Similarly, if studies included multiple primary outcomes (eg, change in depression at three weeks and at six weeks), we split the treatment groups to account for overlapping participants. 40

Prediction intervals (PIs) were calculated and reported to show the expected effect range of a similar future study, in a different setting. In a random effects model, within study measures of variability, such as CIs, can only show the range in which the average effect size could lie, but they are not informative about the range of potential treatment effects given the heterogeneity between studies. 49 Thus, we used PIs as an indication of variation between studies.

Heterogeneity and sensitivity analysis

Statistical heterogeneity was tested using the χ 2 test (significance level P<0.1) and I 2 statistic, and heterogeneity among included studies was evaluated visually and displayed graphically using a forest plot. If substantial or considerable heterogeneity was found (I 2 ≥50% or P<0.1), 50 we considered the study design and characteristics of the included studies. Sources of heterogeneity were explored by subgroup analysis, and the potential effects on the results are discussed.

Planned sensitivity analyses to assess the effect of unpublished studies and studies at high risk of bias were not done because all included studies had been published and none were assessed as high risk of bias. Exclusion sensitivity plots were used to display graphically the impact of individual studies and to determine which studies had a particularly large influence on the results of the meta-analysis. All sensitivity analyses were carried out with Stata 16 software.

Subgroup analysis

To reduce the risk of errors caused by multiplicity and to avoid data fishing, we planned subgroup analyses a priori and limited to: (1) patient characteristics, including age and sex; (2) comorbidities, such as a serious physical condition (previous research indicates that the effects of psilocybin may be less strong for such participants, compared with participants with no comorbidities) 33 ; (3) number of doses and amount of psilocybin administered, because some previous meta-analyses found that a higher number of doses and a higher dose of psilocybin both predicted a greater reduction in symptoms of depression, 34 whereas others reported the opposite 33 ; (4) psilocybin administered alongside psychotherapeutic guidance or as a standalone treatment; (5) severity of depressive symptoms (clinical v subclinical symptomatology); (6) clinician versus patient rated scales; and (7) high versus low quality studies, as determined by RoB 2 assessment scores.

Metaregression

Given that enough studies were identified (≥10 distinct observations according to the Cochrane Handbook’s suggestion 40 ), we performed metaregression to investigate whether covariates, or potential effect modifiers, explained any of the statistical heterogeneity. The metaregression analysis was carried out using Stata 16 software.

Random effects metaregression analyses were used to determine whether continuous variables such as participants’ age, percentage of female participants, and percentage of participants who had previously used psychedelics modified the effect estimate, all of which have been implicated in differentially affecting the efficacy of psychedelics in modifying mood. 51 We chose this approach in favour of converting these continuous variables into categorical variables and conducting subgroup analyses for two primary reasons; firstly, the loss of any data and subsequent loss of statistical power would increase the risk of spurious significant associations, 51 and, secondly, no cut-offs have been agreed for these factors in literature on psychedelic interventions for mood disorders, 52 making any such divisions arbitrary and difficult to reconcile with the findings of other studies. The analyses were based on within study averages, in the absence of individual data points for each participant, with the potential for the results to be affected by aggregate bias, compromising their validity and generalisability. 53 Furthermore, a group level analysis may not be able to detect distinct interactions between the effect modifiers and participant subgroups, resulting in ecological bias. 54 As a result, this analysis should be considered exploratory.

Sensitivity analysis

A sensitivity analysis was performed to determine if choice of analysis method affected the primary findings of meta-analysis. Specifically, we reanalysed the data on change in depression score using a random effects Dersimonian and Laird model without the Hartung-Knapp-Sidik-Jonkman modification and compared the results with those of the originally used model. This comparison is particularly important in the presence of substantial heterogeneity and the potential of small study effects to influence the intervention effect estimate. 55

Patient and public involvement

Research on novel depression treatments is of great interest to both patients and the public. Although patients and members of the public were not directly involved in the planning or writing of this manuscript owing to a lack of available funding for recruitment and researcher training, patients and members of the public read the manuscript after submission.

Figure 1 presents the flow of studies through the systematic review and meta-analysis. 56 A total of 4884 titles were retrieved from the five databases of published literature, and a further 368 titles were identified from the databases of unpublished and international literature in February 2023. After the removal of duplicate records, we screened the abstracts and titles of 875 reports. A further 12 studies were added after handsearching of reference lists and conference proceedings and abstracts. Overall, nine studies totalling 436 participants were eligible. The average age of the participants ranged from 36-60 years. During an updated search on 10 August 2023, no further studies were identified.

Flow of studies in systematic review and meta-analysis

After screening of the title and abstract, 61 titles remained for full text review. Native speakers helped to translate papers in languages other than English. The most common reasons for exclusion were the inclusion of healthy volunteers, absence of control groups, and use of a survey based design rather than an experimental design. After full text screening, nine studies were eligible for inclusion, and 15 clinical trials prospectively registered or underway as of August 2023 were noted for potential future inclusion in an update of this review (see supplementary Appendix D).

We sent requests for further information to the authors of studies by Griffiths et al, 57 Barrett, 58 and Benville et al, 59 because these studies appeared to meet the inclusion criteria but were only provided as summary abstracts online. A potentially eligible poster presentation from the 58th annual meeting of the American College of Neuropsychopharmacology was identified but the lead author (Griffiths) clarified that all information from the presentation was included in the studies by Davis et al 13 and Gukasyan et al 60 ; both of which we had already deemed ineligible.

Barrett 58 reported the effects of psilocybin on the cognitive flexibility and verbal reasoning of a subset of patients with major depressive disorder from Griffith et al’s trial, 61 compared with a waitlist group, but when contacted, Barrett explained that the results were published in the study by Doss et al, 62 which we had already screened and judged ineligible (see supplementary Appendix E). Benville et al’s study 59 presented a follow-up of Ross et al’s study 17 on a subset of patients with cancer and high suicidal ideation and desire for hastened death at baseline. Measures of antidepressant effects of psilocybin treatment compared with niacin were taken before and after treatment crossover, but detailed results are not reported. Table 1 describes the characteristics of the included studies and table 2 lists the main findings of the studies.

Characteristics of included studies

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Main findings of included studies

Side effects and adverse events

Side effects reported in the included studies were minor and transient (eg, short term increases in blood pressure, headache, and anxiety), and none were coded as serious. Cahart-Harris et al noted one instance of abnormal dreams and insomnia. 63 This side effect profile is consistent with findings from other meta-analyses. 30 68 Owing to the different scales and methods used to catalogue side effects and adverse events across trials, it was not possible to combine these data quantitatively (see supplementary Appendix F).

Risk of bias

The Cochrane RoB 2 tools were used to evaluate the included studies ( table 3 ). RoB 2 for randomised trials was used for the five reports of parallel randomised trials (Carhart-Harris et al 63 and its secondary analysis Barba et al, 64 Goodwin et al 18 and its secondary analysis Goodwin et al, 65 and von Rotz et al 66 ) and RoB 2 for crossover trials was used for the four reports of crossover randomised trials (Griffiths et al, 14 Grob et al, 15 and Ross et al 17 and its follow-up Ross et al 67 ). Supplementary Appendix G provides a detailed explanation of the assessment of the included studies.

Summary risk of bias assessment of included studies, based on domains in Cochrane Risk of Bias 2 tool

Quality of included studies

Confidence in the quality of the evidence for the meta-analysis was assessed using GRADE, 38 through the GRADEpro GDT software program. Figure 2 shows the results of this assessment, along with our summary of findings.

GRADE assessment outputs for outcomes investigated in meta-analysis (change in depression scores and response and remission rates). The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). BDI=Beck depression inventory; CI=confidence interval; GRADE=Grading of Recommendations, Assessment, Development and Evaluation; HADS-D=hospital anxiety and depression scale; HAM-D=Hamilton depression rating scale; MADRS=Montgomery-Åsberg depression rating scale; QIDS=quick inventory of depressive symptomatology; RCT=randomised controlled trial; SD=standard deviation

Meta-analyses

Continuous data, change in depression scores —Using a Hartung-Knapp-Sidik-Jonkman modified random effects meta-analysis, change in depression scores was significantly greater after treatment with psilocybin compared with active placebo. The overall Hedges’ g (1.64, 95% CI 0.55 to 2.73) indicated a large effect size favouring psilocybin ( fig 3 ). PIs were, however, wide and crossed the line of no difference (95% CI −1.72 to 5.03), indicating that there could be settings or populations in which psilocybin intervention would be less efficacious.

Forest plot for overall change in depression scores from before to after treatment. CI=confidence interval; DL=DerSimonian and Laird; HKSJ=Hartung-Knapp-Sidik-Jonkman

Exploring publication bias in continuous data —We used Egger’s test and a funnel plot to examine the possibility of small study biases, such as publication bias. Statistical significance of Egger’s test for small study effects, along with the asymmetry in the funnel plot ( fig 4 ), indicates the presence of bias against smaller studies with non-significant results, suggesting that the pooled intervention effect estimate is likely to be overestimated. 69 An alternative explanation, however, is that smaller studies conducted at the early stages of a new psychotherapeutic intervention tend to include more high risk or responsive participants, and psychotherapeutic interventions tend to be delivered more effectively in smaller trials; both of these factors can exaggerate treatment effects, resulting in funnel plot asymmetry. 70 Also, because of the relatively small number of included studies and the considerable heterogeneity observed, test power may be insufficient to distinguish real asymmetry from chance. 71 Thus, this analysis should be considered exploratory.

Funnel plot assessing publication bias among studies measuring change in depression scores from before to after treatment. CI=confidence interval; θ IV =estimated effect size under inverse variance random effects model

Dichotomous data

We extracted response and remission rates for each group when reported directly, or imputed information when presented graphically. Two studies did not measure response or remission and thus did not contribute data for this part of the analysis. 15 18 The random effects model with a Hartung-Knapp-Sidik-Jonkman modification was used to allow for heterogeneity to be incorporated into the weighting of the included studies’ results, and to provide a better estimation of between study variance accounting for small sample sizes.

Response rate —Overall, the likelihood of psilocybin intervention leading to treatment response was about two times greater (risk ratio 2.02, 95% CI 1.33 to 3.07) than with placebo. Despite the use of different scales to measure response, the heterogeneity between studies was not significant (I 2 =25.7%, P=0.23). PIs were, however, wide and crossed the line of no difference (−0.94 to 3.88), indicating that there could be settings or populations in which psilocybin intervention would be less efficacious.

Remission rate —Overall, the likelihood of psilocybin intervention leading to remission of depression was nearly three times greater than with placebo (risk ratio 2.71, 95% CI 1.75 to 4.20). Despite the use of different scales to measure response, no statistical heterogeneity was found between studies (I 2 =0.0%, P=0.53). PIs were, however, wide and crossed the line of no difference (0.87 to 2.32), indicating that there could be settings or populations in which psilocybin intervention would be less efficacious.

Exploring publication bias in response and remission rates data —We used Egger’s test and a funnel plot to examine whether response and remission estimates were affected by small study biases. The result for Egger’s test was non-significant (P>0.05) for both response and remission estimates, and no substantial asymmetry was observed in the funnel plots, providing no indication for the presence of bias against smaller studies with non-significant results.

Heterogeneity: subgroup analyses and metaregression

Heterogeneity was considerable across studies exploring changes in depression scores (I 2 =89.7%, P<0.005), triggering subgroup analyses to explore contributory factors. Table 4 and table 5 present the results of the heterogeneity analyses (subgroup analyses and metaregression, respectively). Also see supplementary Appendix H for a more detailed description and graphical representation of these results.

Subgroup analyses to explore potential causes of heterogeneity among included studies

Metaregression analyses to explore potential causes of heterogeneity among included studies

Cumulative meta-analyses

We used cumulative meta-analyses to investigate how the overall estimates of the outcomes of interest changed as each study was added in chronological order 72 ; change in depression scores and likelihood of treatment response both increased as the percentage of participants with past use of psychedelics increased across studies, as expected based on the metaregression analysis (see supplementary Appendix I). No other significant time related patterns were found.

We reanalysed the data for change in depression scores using a random effects Dersimonian and Laird model without the Hartung-Knapp-Sidik-Jonkman modification and compared the results with those of the original model. All comparisons found to be significant using the Dersimonian and Laird model with the Hartung-Knapp-Sidik-Jonkman adjustment were also significant without the Hartung-Knapp-Sidik-Jonkman adjustment, and confidence intervals were only slightly narrower. Thus, small study effects do not appear to have played a major role in the treatment effect estimate.

Additionally, to estimate the accuracy and robustness of the estimated treatment effect, we excluded studies from the meta-analysis one by one; no important differences in the treatment effect, significance, and heterogeneity levels were observed after the exclusion of any study (see supplementary Appendix J).

In our meta-analysis we found that psilocybin use showed a significant benefit on change in depression scores compared with placebo. This is consistent with other recent meta-analyses and trials of psilocybin as a standalone treatment for depression 73 74 or in combination with psychological support. 24 25 29 30 31 32 68 75 This review adds to those finding by exploring the considerable heterogeneity across the studies, with subsequent subgroup analyses showing that the type of depression (primary or secondary) and the depression scale used (Montgomery-Åsberg depression rating scale, quick inventory of depressive symptomatology, or Beck depression inventory) had a significant differential effect on the outcome. High between study heterogeneity has been identified by some other meta-analyses of psilocybin (eg, Goldberg et al 29 ), with a higher treatment effect in studies with patients with comorbid life threatening conditions compared with patients with primary depression. 22 Although possible explanations, including personal factors (eg, patients with life threatening conditions being older) or depression related factors (eg, secondary depression being more severe than primary depression) could be considered, these hypotheses are not supported by baseline data (ie, patients with secondary depression do not differ substantially in age or symptom severity from patients with primary depression). The differential effects from assessment scales used have not been examined in other meta-analyses of psilocybin, but this review’s finding that studies using the Beck depression inventory showed a higher treatment effect than those using the Montgomery-Åsberg depression rating scale and quick inventory of depressive symptomatology is consistent with studies in the psychological literature that have shown larger treatment effects when self-report scales are used (eg, Beck depression inventory). 76 77 This finding may be because clinicians tend to overestimate the severity of depression symptoms at baseline assessments, leading to less pronounced differences between before and after treatment identified in clinician assessed scales (eg, Montgomery-Åsberg depression rating scale, quick inventory of depressive symptomatology). 78

Metaregression analyses further showed that a higher average age and a higher percentage of participants with past use of psychedelics both correlated with a greater improvement in depression scores with psilocybin use and explained a substantial amount of between study variability. However, the cumulative meta-analysis showed that the effects of age might be largely an artefact of the inclusion of one specific study, and alternative explanations are worth considering. For instance, Studerus et al 79 identified participants’ age as the only personal variable significantly associated with psilocybin response, with older participants reporting a higher “blissful state” experience. This might be because of older people’s increased experience in managing negative emotions and the decrease in 5-hydroxytryptamine type 2A receptor density associated with older age. 80 Furthermore, Rootman et al 81 reported that the cognitive performance of older participants (>55 years) improved significantly more than that of younger participants after micro dosing with psilocybin. Therefore, the higher decrease in depressive symptoms associated with older age could be attributed to a decrease in cognitive difficulties experienced by older participants.

Interestingly, a clear pattern emerged for past use of psychedelics—the higher the proportion of study participants who had used psychedelics in the past, the higher the post-psilocybin treatment effect observed. Past use of psychedelics has been proposed to create an expectancy bias among participants and amplify the positive effects of psilocybin 82 83 84 ; however, this important finding has not been examined in other meta-analyses and may highlight the role of expectancy in psilocybin research.

Limitations of this study

Generalisability of the findings of this meta-analysis was limited by the lack of racial and ethnic diversity in the included studies—more than 90% of participants were white across all included trials, resulting in a homogeneous sample that is not representative of the general population. Moreover, it was not possible to distinguish between subgroups of participants who had never used psilocybin and those who had taken psilocybin more than a year before the start of the trial, as these data were not provided in the included studies. Such a distinction would be important, as the effects of psilocybin on mood may wane within a year after being administered. 21 85 Also, how psychological support was conceptualised was inconsistent within studies of psilocybin interventions; many studies failed to clearly describe the type of psychological support participants received, and others used methods ranging from directive guidance throughout the treatment session to passive encouragement or reassurance (eg, Griffiths et al, 14 Carhart-Harris et al 63 ). The included studies also did not gather evidence on participants’ previous experiences with treatment approaches, which could influence their response to the trials’ intervention. Thus, differences between participant subgroups related to past use of psilocybin or psychotherapy may be substantial and could help interpret this study’s findings more accurately. Lastly, the use of graphical extraction software to estimate the findings of studies where exact numerical data were not available (eg, Goodwin et al, 18 Grob et al 15 ), may have affected the robustness of the analyses.

A common limitation in studies of psilocybin is the likelihood of expectancy effects augmenting the treatment effect observed. Although some studies used low dose psychedelics as comparators to deal with this problem (eg, Carhart-Harris et al, 63 Goodwin et al, 18 Griffiths et al 14 ) or used a niacin placebo that can induce effects similar to those of psilocybin (eg, Grob et al, 15 Ross et al 17 ), the extent to which these methods were effective in blinding participants is not known. Other studies have, however, reported that participants can accurately identify the study groups to which they had been assigned 70-85% of the time, 84 86 indicating a high likelihood of insufficient blinding. This is especially likely for studies in which a high proportion of participants had previously used psilocybin and other hallucinogens, making the identification of the drug’s acute effects easier (eg, Griffiths et al, 14 Grob et al, 15 Ross et al 17 ). Patients also have expectations related to the outcome of their treatment, expecting psilocybin to improve their symptoms of depression, and these positive expectancies are strong predictors of actual treatment effects. 87 88 Importantly, the effect of outcome expectations on treatment effect is particularly strong when patient reported measures are used as primary outcomes, 89 which was the case in several of the included studies (eg, Griffiths et al, 14 Grob et al, 15 Ross et al 17 ). Unfortunately, none of the included studies recorded expectations before treatment, so it is not possible to determine the extent to which this factor affected the findings.

Implications for clinical practice

Although this review’s findings are encouraging for psilocybin’s potential as an effective antidepressant, a few areas about its applicability in clinical practice remain unexplored. Firstly, it is unclear whether the protocols for psilocybin interventions in clinical trials can be reliably and safely implemented in clinical practice. In clinical trials, patients receive psilocybin in a non-traditional medical setting, such as a specially designed living room, while they may be listening to curated calming music and are isolated from most external stimuli by wearing eyeshades and external noise-cancelling earphones. A trained therapist closely supervises these sessions, and the patient usually receives one or more preparatory sessions before the treatment commences. Standardising an intervention setting with so many variables is unlikely to be achievable in routine practice, and consensus is considerably lacking on the psychotherapeutic training and accreditations needed for a therapist to deliver such treatment. 90 The combination of these elements makes this a relatively complex and expensive intervention, which could make it challenging to gain approval from regulatory agencies and to gain reimbursement from insurance companies and others. Within publicly funded healthcare systems, the high cost of treatment may make psilocybin treatment inaccessible. The high cost associated with the intervention also increases the risk that unregulated clinics may attempt to cut costs by making alterations to the protocol and the therapeutic process, 91 92 which could have detrimental effects for patients. 92 93 94 Thus, avoiding the conflation of medical and commercial interests is a primary concern that needs to be dealt with before psilocybin enters mainstream practice.

Implications for future research

More large scale randomised trials with long follow-up are needed to fully understand psilocybin’s treatment potential, and future studies should aim to recruit a more diverse population. Another factor that would make clinical trials more representative of routine practice would be to recruit patients who are currently using or have used commonly prescribed serotonergic antidepressants. Clinical trials tend to exclude such participants because many antidepressants that act on the serotonin system modulate the 5-hydroxytryptamine type 2A receptor that psilocybin primarily acts upon, with prolonged use of tricyclic antidepressants associated with more intense psychedelic experiences and use of monoamine oxidase inhibitors or SSRIs inducing weaker responses to psychedelics. 95 96 97 Investigating psilocybin in such patients would, however, provide valuable insight on how psilocybin interacts with commonly prescribed drugs for depression and would help inform clinical practice.

Minimising the influence of expectancy effects is another core problem for future studies. One strategy would be to include expectancy measures and explore the level of expectancy as a covariate in statistical analysis. Researchers should also test the effectiveness of condition masking. Another proposed solution would be to adopt a 2×2 balanced placebo design, where both the drug (psilocybin or placebo) and the instructions given to participants (told they have received psilocybin or told they have received placebo) are crossed. 98 Alternatively, clinical trials could adopt a three arm design that includes both an inactive placebo (eg, saline) and active placebo (eg, niacin, lower psylocibin dose), 98 allowing for the effects of psilocybin to be separated from those of the placebo.

Overall, future studies should explore psilocybin’s exact mechanism of treatment effectiveness and outline how its physiological effects, mystical experiences, dosage, treatment setting, psychological support, and relationship with the therapist all interact to produce a synergistic antidepressant effect. Although this may be difficult to achieve using an explanatory randomised trial design, pragmatic clinical trial designs may be better suited to psilocybin research, as their primary objective is to achieve high external validity and generalisability. Such studies may include multiple alternative treatments rather than simply an active and placebo treatment comparison (eg, psilocybin v SSRI v serotonin-noradrenaline reuptake inhibitor), and participants would be recruited from broader clinical populations. 99 100 Although such studies are usually conducted after a drug’s launch, 100 earlier use of such designs could help assess the clinical effectiveness of psilocybin more robustly and broaden patient access to a novel type of antidepressant treatment.

Conclusions

This review’s findings on psilocybin’s efficacy in reducing symptoms of depression are encouraging for its use in clinical practice as a drug intervention for patients with primary or secondary depression, particularly when combined with psychological support and administered in a supervised clinical environment. However, the highly standardised treatment setting, high cost, and lack of regulatory guidelines and legal safeguards associated with psilocybin treatment need to be dealt with before it can be established in clinical practice.

What is already known on this topic

Recent research on treatments for depression has focused on psychedelic agents that could have strong antidepressant effects without the drawbacks of classic antidepressants; psilocybin being one such substance

Over the past decade, several clinical trials, meta-analyses, and systematic reviews have investigated the use of psilocybin for symptoms of depression, and most have found that psilocybin can have antidepressant effects

Studies published to date have not investigated factors that may moderate psilocybin’s effects, including type of depression, past use of psychedelics, dosage, outcome measures, and publication biases

What this study adds

This review showed a significantly greater efficacy of psilocybin among patients with secondary depression, patients with past use of psychedelics, older patients, and studies using self-report measures for symptoms of depression

Efficacy did not appear to be homogeneous across patient types—for example, those with depression and a life threatening illness appeared to benefit more from treatment

Further research is needed to clarify the factors that maximise psilocybin’s treatment potential for symptoms of depression

Ethics statements

Ethical approval.

This study was approved by the ethics committee of the University of Oxford Nuffield Department of Medicine, which waived the need for ethical approval and the need to obtain consent for the collection, analysis, and publication of the retrospectively obtained anonymised data for this non-interventional study.

Data availability statement

The relevant aggregated data and statistical code will be made available on reasonable request to the corresponding author.

Acknowledgments

We thank DT who acted as an independent secondary reviewer during the study selection and data review process.

Contributors: AMM contributed to the design and implementation of the research, analysis of the results, and writing of the manuscript. MC was involved in planning and supervising the work and contributed to the writing of the manuscript. AMM and MC are the guarantors. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Funding: None received.

Competing interests: All authors have completed the ICMJE uniform disclosure form at https://www.icmje.org/disclosure-of-interest/ and declare: no support from any organisation for the submitted work; AMM is employed by IDEA Pharma, which does consultancy work for pharmaceutical companies developing drugs for physical and mental health conditions; MC was the supervisor for AMM’s University of Oxford MSc dissertation, which forms the basis for this paper; no other relationships or activities that could appear to have influenced the submitted work.

Transparency: The corresponding author (AMM) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as registered have been explained.

Dissemination to participants and related patient and public communities: To disseminate our findings and increase the impact of our research, we plan on writing several social media posts and blog posts outlining the main conclusions of our paper. These will include blog posts on the websites of the University of Oxford’s Department of Primary Care Health Sciences and Department for Continuing Education, as well as print publications, which are likely to reach a wider audience. Furthermore, we plan to present our findings and discuss them with the public in local mental health related events and conferences, which are routinely attended by patient groups and advocacy organisations.

Provenance and peer review: Not commissioned; externally peer reviewed.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

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• Open access
• Published: 05 May 2024

The quality of life of men experiencing infertility: a systematic review

• Zahra Kiani   ORCID: orcid.org/0000-0002-4548-7305 1 ,
• Masoumeh Simbar   ORCID: orcid.org/0000-0003-2843-3150 2 ,
• Farzaneh Rashidi   ORCID: orcid.org/0000-0001-7497-4180 3 ,
• Farid Zayeri   ORCID: orcid.org/0000-0002-7791-8122 4 &
• Homayoon Banaderakhsh   ORCID: orcid.org/0000-0001-8982-9381 5  

BMC Public Health volume  24 , Article number:  1236 ( 2024 ) Cite this article

234 Accesses

Metrics details

Men experiencing infertility encounter numerous problems at the individual, family, and social levels as well as quality of life (QOL). This study was designed to investigate the QOL of men experiencing infertility through a systematic review.

Materials and methods

This systematic review was conducted without any time limitation (Retrieval date: July 1, 2023) in international databases such as Scopus, Web of Science, PubMed, and Google Scholar. The search was performed by two reviewers separately using keywords such as QOL, infertility, and men. Studies were selected based on inclusion and exclusion criteria. The quality of the articles were evaluated based on the Newcastle-Ottawa Scale. In the initial search, 308 studies were reviewed, and after removing duplicates and checking the title and abstract, the full text of 87 studies were evaluated.

Finally, 24 studies were included in the final review based on the research objectives. Based on the results, men’s QOL scores in different studies varied from 55.15 ± 13.52 to 91.45 ± 13.66%. Of the total reviewed articles, the lowest and highest scores were related to mental health problems and physical dimensions, respectively.

The reported findings vary across various studies conducted in different countries. Analysis of the factors affecting these differences is necessary, and it is recommended to design a standard tool for assessing the quality of life of infertile men. Given the importance of the QOL in men experiencing infertility, it is crucial to consider it in the health system. Moreover, a plan should be designed, implemented and evaluated according to each country’s contex to improve the quality of life of infertile men.

Peer Review reports

Introduction

Defined as the absence of pregnancy after one or two years of unprotected sexual intercourse (without the use of contraceptive methods) [ 1 ], infertility is recognized as both a medical and social issue [ 2 ]. Based on the latest Word Health Organization (WHO) report in 2023, the pooled lifetime and period prevalence of infrtility are reported as 17.5% and 12.6%, respectively [ 3 ]. In this regard, male factors play a role in 50% of infertilities [ 4 ].

Complicated treatment protocol, difficult treatment process, semen analysis, multiple ultrasounds, invasive treatments, long waiting lists, and high financial costs for the clients who seek assisted reproductive techniques have been described as psychological stresses for infertile couples [ 5 , 6 ]. Moreover, the diagnosis and treatment of infertility can have negative impact on the frequency of sexual intercourse, self-esteem, and body image [ 5 ]. However, these men usually tend to suppress or deny their problems which may diminish their quality of life (QOL) over time [ 7 ]. This decreased QOL, in turn, can have a detrimental effect on their response to treatment [ 8 ].

The function of infertile people is under the influence of society, family, and the society culture. In many societies, infertility is primarily viewed as a medical problem, often neglecting its individual and social dimensions [ 9 ]. In other words, despite having the right attitude toward infertility, infertile people sometimes cannot adapt to the problem. Thus, non-compliance during the behavioral process may lead to additional problems and impair one’s QOL [ 10 ].

The WHO describes the QOL as people’s perspective of their life circumstances in terms of the cultural systems and standards of their environment, and how these perspectives are associated with their objectives, prospects, ideals, and apprehensions [ 11 ]. Recently, the QOL of men experiencing infertility as a main subject has been carefully considered by health investigators. Furthermore, because of men’s essential role in future phases of life, their QOL can significantly affect their health at both individual and societal levels [ 12 ].

Given the significance of QOL, its precise measurement is substantially important. In this regard, various tools have been designed and used in studies to examine this concept. A systematic study used the World Health Organization Quality Of Life )WHOQOL), 36-Item Short Form Survey (SF-36 ), and general QOL questionnaires. Based on the results, the QOL of men experiencing infertility was reported to be low in two studies that had used the SF-36 questionnaire. By contrast, the QOL of these men was high in a study that used the WHOQOL questionnaire. It was noted in this systematic review that although infertility has a negative effect on the mental health and sexual relationships of couples, there is no consensus regarding its effect on the QOL of infertile couples [ 13 ].

In Almutawa et al.‘s systematic review and meta-analysis 2023, it has been shown that the psychological disturbances in infertile women are higher than in men, and this difference in couples needs further investigation [ 14 ]. Chachavomich et al. 2010 showed that women’s quality of life is more affected by infertility than men study, which was a systematic review [ 12 ], . This study was conducted 14 years ago and due to the increase in the number of articles in this field, it needs to be re-examined.Given that no systematic review had been conducted to address the QOL of men experiencing infertility and considering the significance of this issue in therapeutic responses, this study examined the QOL of men experiencing infertility in the form of a systematic review.

Search strategy

To search and review the studies, reputable international databases and sites such as Scopus, Web of Science, PubMed, and Google Scholar were used. The search was performed using keywords such as QOL, infertility, and men (Table  1 ), without time limitation (Retrieval date: July 1, 2023), and using AND and OR operators, and specific search strategies were used for each database.

The search strategy of PubMed, Web of Science, and Scopus databases is as follows:

Pubmed (retrieval date: July 1, 2023)

Male [tiab] OR Males [tiab] OR Men [tiab] OR Man [tiab] OR Boy [tiab] OR Boys [tiab] AND Quality of Life [tiab] OR Health-Related Quality of Life [tiab] AND Infertility [tiab] OR Sterility OR Reproductive [tiab] OR Reproductive Sterility [tiab] OR Subfertility [tiab] Sub-Fertility [tiab].

Web of science (retrieval date: July 1, 2023)

((TI=(male OR males OR man OR men OR boy OR boys)) AND TI=(Quality of Life OR Health-Related Quality of Life OR Health-Related Quality of Life)) AND TI=(Infertility OR Sterility OR Reproductive OR Reproductive Sterility).

Scopus (retrieval date: July 1, 2023)

TITLE ( male OR males OR men OR man OR boy OR boys ) AND TITLE (quality AND of AND life OR health-related AND quality AND of AND life ) AND TITLE ( infertility OR sterility OR reproductive).

The method of presenting the article, describing the problem, data collection, data analysis, discussion, and conclusion of the findings were based on preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 [ 15 ]. The reviews were conducted separately by two reviewers, and the third reviewer was also used in case of disagreement between them.

Inclusion and exclusion criteria

Those studies with the following criteria were included in the review: (1) Observational studies; (2) Cross-sectional data from longitudinal studies; (3) Using valid tools for measuring the QOL; (4) Studies conducted on men of infertile couples (by men experiencing infertility we mean those men whose unprotected sexual intercourse during the past year did not lead to any pregnancy); (5) Minimum sample size of 30 subjects; (6) Subjects with no chronic disease, and (7) those men of infertile couples who were within the diagnostic process for infertility and before starting infertility treatment. The search and review process for this study were conducted in English, and there were no restrictions imposed on the inclusion of open-access studies.

Exclusion criteria included: (1) Case report studies; (2) Review studies; (3) Animal studies; (4) Studies on mental syndromes; (5) Studies not written in English; (6) Lack of access to the full text of the article, and (7) Unrelated reports.

The patient, intervention, comparison, outcome, and study design (PICOS)

PICOS model was used to help break down the searchable elements of the research question into (P) participants: men experiencing infertility (primary or secondary infertility) (I) intervention/exposure: not applicable; (C) control group: not applicable; (O) outcomes: evaluate infertile men’s QOL, which was measured using standard tools such as general or specific QOL questionnaire and (S) study type: Observational studies and Cross-sectional data from longitudinal studies.

Data extraction

The two reviewers independently reviewed the titles and abstracts of the articles following the inclusion criteria, and the studies which did not have the required criteria were excluded. Then, the full text of the articles with inclusion criteria was reviewed and if appropriate, they were included in the study.

Required information, including authors’ names, year of publication, research location, sample size, QOL score, type of tool, type of infertility, mean age of men, and duration of infertility, were extracted from the studies.

Outcome measurement

The main outcome of this study was to evaluate QOL of men experiencing infertility, which was measured using standard tools such as a general or specific QOL questionnaire.

Quality evaluation

The Newcastle-Ottawa Scale checklist was used to assess the quality of nonrandomized studies in meta-analyses [ 16 ]. This checklist consists of 5 parts that are representativeness of the sample, sample size, non-respondents, ascertainment of anxiety, and quality of descriptive statistics reporting. Each part gets a score of zero and one. Given the fact that the checklist has 5 items, the minimum, and maximum scores are 0 and 5, respectively. Then, studies were divided into high- and low-risk groups if their scores were ≤ 3 and more than 3 [ 16 ]. The quality assessment in this study was performed by two reviewers independently, and in case of disagreement between them, the third reviewer was asked to help. The coefficient of agreement of 0.7 and more among the reviewers was acceptable.

Ethical consideration

Ethics approval was obtained from the Ethics Committee, Faculty of Pharmacy and Nursing.

Midwifery, Shahid Beheshti University (Ethical code: IR.SBMU.PHARMACY.REC.1400.214). All methods were carried out in accordance with relevant guidelines and regulations.

After reviewing the title, abstract, and text of the articles in different stages (Fig.  1 ), finally, 24 articles were reviewed based on the inclusion criteria and research objectives and the coefficient of agreement among the reviewers was K = 0.81 (Table  2 ).

Flowchart for selection of studies

The smallest and largest sample size were 30 [ 19 ] and 1,000 [ 40 ], respectively. Seven studies were conducted in low- and middle-income countries, two studies in upper-middle-income, and 15 studies in high-income countries. High-income countries had a higher quality of life score compared to low- and middle-income countries countries. In all studies, QOL scores were calculated based on 100, and the highest score (91.45 ± 13.66%) obtained from the Fertility quality of life (FertiQoL) questionnaire in South Korea as a high-income country [ 25 ]. Most of the studies showed that education, family income and proper marital relations improved the quality of life of infertile men. Out of 24 reviewed articles, 12 articles used the FertiQoL questionnaire, 7 articles SF-36, and 6 articles WHOQOL-BREF. One study [ 36 ] used SF-36 and WHOQOL-BREF questionnaires simultaneously.

Out of the total articles reviewed, the lowest scores were attributed to different domains. Accordingly, the lowest score in 11 articles was related to mental health problems, in 8 articles it was related to social problems, and 3 articles to communication problems.Some articles did not report the scores based on the dimensions. Based on the results, men’s QOL scores in different studies varied from 55.15 ± 13.52 to 91.45 ± 13.66%. In the total reviewed articles, the lowest and highest scores were related to mental health problems and physical dimensions, respectively.

In most of the studies using the FertiQoL questionnaire, it was observed that the lowest scores belonged to the social and communication dimensions. The FertiQoL questionnaire was developed and psychometrically evaluated in a survey study conducted in the United States. FertiQoL is a 36-item scale with Six dimension: (1) Emotional; (2) Mind-body; (3) Relational; (4) Social; (5) Environment; and (6) Treatment tolerability. A 5-point Likert scale (0–4) was used in the questionnaire, and the total score was between 0 and 100, where the higher the score, the better was the QOL [ 41 ]. This questionnaire has been translated into different languages in the world and has obtained the required validity (content, face, and construct) and reliability (with Cronbach’s alpha of 0.7–0.9) in different populations [ 42 , 43 , 44 , 45 ].

In the studies where the SF-36 and WHOQOL-BREF questionnaires had been used, the lowest scores belonged to the dimensions of limitations in usual role activities because of emotional problems and social relationships. On the other hand, the highest scores in the questionnaires were related to physical dimensions. The SF-36 questionnaire has been considered for clinical investigation, health policy assessments, and surveys. The 8 dimensions of this questionnaire are as follows: Restrictions in physical activities; Restrictions in social activities; Restrictions in standard role activities; Physical pain; General mental health; Restrictions in standard role activities; Vitality; and Common health perceptions. The final scores of the questionnaire are standardized based on 100 [ 46 ]. This questionnaire has been translated into different languages in the world and has obtained validity (content and face) and reliability (Cronbach’s alpha of 0.8–0.95) in different populations [ 47 , 48 , 49 , 50 , 51 , 52 ]. The 26-item version of WHOQOL-BREF was developed in the following four dimensions: physical health, mental health, social connections, and environmental health, and two items associated with common QOL and general health [ 53 ]. The questionnaire has been translated into different languages of the world and has obtained validity (content and face) and reliability (Cronbach’s alpha of 0.74–0.88) in different populations [ 54 , 55 , 56 , 57 ].

This systematic review study investigated the quality of life of infertile men. Based on the results, men’s quality of life scores in different studies varied from 55.15 ± 13.52 to 91.45 ± 13.66%. However, men’s quality of life scores was reported to be between 70 and 80% in the majority of the studies. As one of the health indicators with a combination of each person’s knowledge in different aspects of life and performance in human, work and social relations, quality of life is essentially important for the continuation of an optimal life and well-being of the individuals. Moreover, quality of life is strongly influenced by demographic, social, economic, and cultural variables, as well as the variables related to health and disease, and its measurement is, thus, substantially important [ 58 ]. Quality of life is a reflection of the desires, hopes, and expectations of individuals regarding their current and future life situation, and is influenced by factors such as age, personal and family characteristics, socio-economic status, and time [ 59 ].

In this systematic review, the lowest scores of men’s quality of life belonged to the psychological and emotional dimensions and then to the social and communication dimensions. Although the reviewed studies had used different tools, these tools were essentially similar in these dimensions, indicating the problems of men in these areas. Fertility is highly valued in most cultures and the desire for having a child is one of the human stimuli in the continuation of life. If efforts for fertility do not lead to success, they can have adverse effects on mental health as well as family and social relationships [ 60 ].

The reviewed studies indicated that education has a significantly positive effect on the quality of life of infertile men. Higher levels of education are associated with increased awareness and better decision-making abilities [ 25 ], and improved coping strategies for dealing with infertility-related challenges [ 38 ]. Infertile men with higher education are also more likely to seek treatment, and remain hopeful that treatment will improve their quality of life [ 28 ].

The results of most studies showed the positive and significant relationship between family income and quality of life.The costs of infertility treatment and the potential need for repeated treatment can lead to concerns and anxieties among men and reduce their quality of life [ 61 ]. If men have fewer concerns about the cost of treatment, they are more inclined to pursue infertility treatment. In the International Conference on Population and Development held in Cairo in 1994, addressing the issue of infertility was emphasized as an important health priority. However, it is unfortunate that infertility problems have been overlooked not only in developing countries but also at various levels of international health management [ 62 ].

The results of the study regarding the countries’ income showed that the quality of life score of men in infertile couples residing in low-income countries was lower compared to those in high-income countries. Current infertility policies in the treatment and distribution sector are uncoordinated, which has led to improper distribution of public and private centers in low- and middle-income countery [ 63 ]. This point of view is a kind of simplistic calculation of the problem of infertility that justifies the lack of public centers, inadwquate finantial sources, specialists and affordable treatment options [ 64 ], requireing serious attention and careful planning, especially in low- and middle-income countries.

The results of the studies showed that marital relationships have a positive and significant impact on the quality of life of infertile men. Sometimes, infertile men may experience a lack of sexual attraction, and due to irrational thoughts, they might abstain from having sexual relations with their partners or try to suppress their sexual desires. Sexual desire is a significant aspect of life that can affect the quality of life [ 65 ]. Some studies have indicated that the quality of marital relations is higher among infertile couples than the fertile ones, and infertility can bring couples closer together and encourage more open communication about their concerns and plans for the future [ 33 , 66 ]. Further research is recommended to gain a deeper understanding in this area.

Infertility presents people with a new and challenging world [ 28 ]. In this regard, infertility is characterized as a long-term process that involves time-consuming treatments, fluctuations between hope and disappointment, loss of control over reproductive outcomes, inability to plan for future, and significant shifts in personal identity and worldview [ 28 , 32 , 63 ]. Long working hours, work-caused exhaustion, along with infertility, can exacerbate men’s problems. These problems affect their quality of life, though they may deny the problems [ 67 ].

Given the significance of quality of life, its accurate measurement is essentially important. In this regard, various tools have been designed to investigate this concept and have been used in several studies. The noteworthy point in this systematic review was the use of different measurement tools in various studies. In the majority of the studies, Boivin’s FertiQoL [ 41 ] was used as a specific tool for measuring the quality of life of infertile couples. Covering emotional, physical, communicational, social, environmental, and acceptability dimensions, this questionnaire has been designed for infertile couples and does not specifically assess the quality of life of infertile men. Other studies have used a general quality-of-life questionnaire (SF-36 and WHOQOL-BREF). WHOQOL questionnaire has been designed in 4 dimensions of physical health, psychological health, social relationships, and environmental health [ 53 ]. SF-36 questionnaire also has 8 dimensions of Limitations in physical activities because of health problems; 2) Limitations in social activities because of physical or emotional problems; 3) Limitations in usual role activities because of physical health problems; 4) Bodily pain; 5) General mental health (psychological distress and well-being); 6) Limitations in usual role activities because of emotional problems; 7) Vitality (energy and fatigue); and 8) General health perceptions [ 46 ]. The main drawback of these tools is that they ignore significant dimensions such as sexual and socio-economic dimensions which are important for certain groups including infertile men. Additionally, the other dimensions of the questionnaire are not sensitive enough to measure changes in the quality of life of people with various diseases [ 68 ].

Health researchers have recently paid much attention to the examination of the quality of life and the design of a questionnaire to measure this concept. This measurement can improve clinical decision-making, estimate healthcare in a particular population, perceive different health causes and consequences, and, finally, promote health policy. All of these objectives will be achieved in light of a specific tool in this regard. However, according to the review, no questionnaire has hitherto been designed to measure the quality of life in infertile men. Specific questionnaires for infertile couples or general quality of life questionnaires have been used in different studies. Given the concept of quality of life and its changes over time as well as the expansion of tool-making knowledge, there is a need to design specific tools to measure the quality of life of infertile men by using mixed methods. We hope that more attention will be given to this significant issue in future. Polit and Beck argue that one of the main applications of exploratory mixed methods is in instrument making. They maintain that when a new tool is developed to explain a health-related concept, the complexity of this concept must be carefully explained [ 69 ].

Furthermore, it seems that the concept of men’s quality of life needs more investigation and also this concept may change over time and impact on their life. Besides, the studies demonstrated specific concerns among infertile men such as decreased self-esteem, Fertility- related stress, masculinity identity, hiding the infertility problem, resistance to the treatment, and cost of treatment [ 70 , 71 ]. These concerns could be the specific items for the infertile men-related quality of life questionnaire.

Research limitations

The impossibility of meta-analysis was because of several limitations in the study: (1) Variety of tools and small sample size in each subgroup; (2) Inaccurate report of information; and (3) -heterogeneity of the studies. Other limitation in this systematic review was that the reviewed papers were confined to English literature; thus, it is possible that some relevant non-English language studies were missed.

The systematic review strategies and solutions

The quality of life of men is one of the basic issues in their life. Assessing the quality of life of men should be done during the initial evaluation of infertility, and if necessary, interventions should be made to improve their quality of life. It is recommended that researchers, using qualitative-quantitative methods, first explain the concept of the QOL of men with infertility and then design and psychometrically evaluate the QOL tool for men experiencing infertility. Based on its context, each country should design a suitable program to improve the quality of life of men.

Data availability

All data related to this review is included in the result section of the manuscript. If any further data is needed it can be accessible via the corresponding author on request.

Abbreviations

World Health Organization

The Newcastle-Ottawa Scale

Preferred reporting items for systematic reviews and meta-analyses

Not reported

The Health Survey Short Form

World Health Organization Quality of Life Instruments

The Fertility Quality of Life tool

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The authors would like to express their gratitude and thank to the cooperation and assistance of the officials of faculty, library and computer ward at Shahid Beheshti University of Medical Sciences.

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Kiani, Z., Simbar, M., Rashidi, F. et al. The quality of life of men experiencing infertility: a systematic review. BMC Public Health 24 , 1236 (2024). https://doi.org/10.1186/s12889-024-18758-6

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Cat Ownership and Schizophrenia-Related Disorders and Psychotic-Like Experiences: A Systematic Review and Meta-Analysis

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John J McGrath, Carmen C W Lim, Sukanta Saha, Cat Ownership and Schizophrenia-Related Disorders and Psychotic-Like Experiences: A Systematic Review and Meta-Analysis, Schizophrenia Bulletin , Volume 50, Issue 3, May 2024, Pages 489–495, https://doi.org/10.1093/schbul/sbad168

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It has been proposed that cat ownership may be a risk-modifying factor for schizophrenia-related disorders and psychotic-like experiences (PLE). This study aimed to systematically review and meta-analyze publications that reported the relationship between cat ownership and schizophrenia-related outcomes.

We searched Medline, Embase, CINAHL, Web of Science, and gray literature for publications between January 1, 1980, and May 30, 2023, regardless of geographical location and language. Backward citation search methods were used to locate additional articles. We included studies that reported original data on cat ownership and schizophrenia-related outcomes. We meta-analyzed estimates based on broad definitions (cat ownership, cat bites, and cat contact) with estimates with or without covariate adjustments. We pooled comparable estimates using random-effects models and assessed the risk of bias, heterogeneity, and study quality.

We identified 1915 studies, of which 106 were chosen for full-text review, ultimately resulting in the inclusion of 17 studies. We found an association between broadly defined cat ownership and increased odds of developing schizophrenia-related disorders. For the studies reporting unadjusted odds ratios (OR; n = 10), the pooled OR was 2.14 (95% CI: 1.29–3.55). Exclusion of one outlier study resulted in a pooled OR ( n = 9) of 1.56 (95% CI: 1.27–1.92). For the studies reporting adjusted estimates ( n = 5), the pooled OR was 2.44 (95% CI: 1.59–3.73). After excluding one study with suboptimal exposure/design features, the pooled adjusted OR ( n = 4) was 2.40 (95% CI: 1.50–3.86). We were unable to aggregate the estimates for the PLE outcomes because of the broad range of measures.

Our findings provide support for the hypothesis that cat exposure is associated with an increased risk of broadly defined schizophrenia-related disorders; however, the findings related to PLE as an outcome are mixed. There is a need for more high-quality studies in this field.

PROSPERO 2023 CRD42023426974. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023426974

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A Peek Inside the Brains of ‘Super-Agers’

New research explores why some octogenarians have exceptional memories.

By Dana G. Smith

When it comes to aging, we tend to assume that cognition gets worse as we get older. Our thoughts may slow down or become confused, or we may start to forget things, like the name of our high school English teacher or what we meant to buy at the grocery store.

But that’s not the case for everyone.

For a little over a decade, scientists have been studying a subset of people they call “super-agers.” These individuals are age 80 and up, but they have the memory ability of a person 20 to 30 years younger.

Most research on aging and memory focuses on the other side of the equation — people who develop dementia in their later years. But, “if we’re constantly talking about what’s going wrong in aging, it’s not capturing the full spectrum of what’s happening in the older adult population,” said Emily Rogalski, a professor of neurology at the University of Chicago, who published one of the first studies on super-agers in 2012.

A paper published Monday in the Journal of Neuroscience helps shed light on what’s so special about the brains of super-agers. The biggest takeaway, in combination with a companion study that came out last year on the same group of individuals, is that their brains have less atrophy than their peers’ do.

The research was conducted on 119 octogenarians from Spain: 64 super-agers and 55 older adults with normal memory abilities for their age. The participants completed multiple tests assessing their memory, motor and verbal skills; underwent brain scans and blood draws; and answered questions about their lifestyle and behaviors.

The scientists found that the super-agers had more volume in areas of the brain important for memory, most notably the hippocampus and entorhinal cortex. They also had better preserved connectivity between regions in the front of the brain that are involved in cognition. Both the super-agers and the control group showed minimal signs of Alzheimer’s disease in their brains.

“By having two groups that have low levels of Alzheimer’s markers, but striking cognitive differences and striking differences in their brain, then we’re really speaking to a resistance to age-related decline,” said Dr. Bryan Strange, a professor of clinical neuroscience at the Polytechnic University of Madrid, who led the studies.

These findings are backed up by Dr. Rogalski’s research , initially conducted when she was at Northwestern University, which showed that super-agers’ brains looked more like 50- or 60-year-olds’ brains than their 80-year-old peers. When followed over several years, the super-agers’ brains atrophied at a slower rate than average.

No precise numbers exist on how many super-agers there are among us, but Dr. Rogalski said they’re “relatively rare,” noting that “far less than 10 percent” of the people she sees end up meeting the criteria.

But when you meet a super-ager, you know it, Dr. Strange said. “They are really quite energetic people, you can see. Motivated, on the ball, elderly individuals.”

Experts don’t know how someone becomes a super-ager, though there were a few differences in health and lifestyle behaviors between the two groups in the Spanish study. Most notably, the super-agers had slightly better physical health, both in terms of blood pressure and glucose metabolism, and they performed better on a test of mobility . The super-agers didn’t report doing more exercise at their current age than the typical older adults, but they were more active in middle age. They also reported better mental health .

But overall, Dr. Strange said, there were a lot of similarities between the super-agers and the regular agers. “There are a lot of things that are not particularly striking about them,” he said. And, he added, “we see some surprising omissions, things that you would expect to be associated with super-agers that weren’t really there.” For example, there were no differences between the groups in terms of their diets, the amount of sleep they got, their professional backgrounds or their alcohol and tobacco use.

The behaviors of some of the Chicago super-agers were similarly a surprise. Some exercised regularly, but some never had; some stuck to a Mediterranean diet, others subsisted off TV dinners; and a few of them still smoked cigarettes. However, one consistency among the group was that they tended to have strong social relationships , Dr. Rogalski said.

“In an ideal world, you’d find out that, like, all the super-agers, you know, ate six tomatoes every day and that was the key,” said Tessa Harrison, an assistant project scientist at the University of California, Berkeley, who collaborated with Dr. Rogalski on the first Chicago super-ager study.

Instead, Dr. Harrison continued, super-agers probably have “some sort of lucky predisposition or some resistance mechanism in the brain that’s on the molecular level that we don’t understand yet,” possibly related to their genes.

While there isn’t a recipe for becoming a super-ager, scientists do know that, in general , eating healthily, staying physically active, getting enough sleep and maintaining social connections are important for healthy brain aging.

Dana G. Smith is a Times reporter covering personal health, particularly aging and brain health. More about Dana G. Smith

A Guide to Aging Well

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