Uncertainty has become a defining feature of life in recent years. The pandemic, climate-related disasters, economic shocks, and political instability have left millions unsure about work, safety, housing, and the future. Public health agencies often describe these conditions as drivers of fear and distress. Yet the scientific literature on how uncertainty affects mental health is surprisingly thin.
A new scoping review published in the Journal of Mental Health set out to determine what researchers actually know about this relationship. The team, led by Alessandro Massazza of the London School of Hygiene & Tropical Medicine, reviewed more than 3,900 articles and found that the evidence base is narrow and uneven. Most studies focus on illness-related uncertainty in medical settings. Very few examine the structural forces—such as poverty, conflict, occupation, or unstable labor—that shape uncertainty for much of the world.
“Uncertainty is often referred to as a trigger for several negative mental health outcomes, such as stress and anxiety,” the authors write. “Recently, this narrative has been particularly evident in the context of COVID-19.” They continue:
“Never before has the link between uncertainty and mental health been more central in public and academic discourses. Yet, there is little systematic evidence concerning the link between uncertainty and mental health.”
If uncertainty is a core determinant of distress, the researchers argue, then psychology needs tools that reflect the conditions under which most people experience it. The review suggests that current approaches overlook the forms of instability created by political circumstances, economic precarity, and social upheaval. In doing so, the science risks misrepresenting both the nature of uncertainty and the sources of mental suffering.
Conceptualization of emotion or feeling as pathogenic has been criticized in recent years. While fear, worry, and stress are not necessarily pleasant emotions, they aren’t, strictly speaking, abnormal. Researchers Alessandro Massazza and colleagues sought to review the quantitative literature on uncertainty in mental health to begin a conversation about recommendations for research, policy, and practice.
They conducted a review to understand how uncertainty is quantified and to develop a metric applicable to a broad range of lived experiences. The authors specified their review is “part of a larger mixed-methods research project investigating the experience of uncertainty and its link to mental health in the occupied Palestinian territory.” Although uncertainty can also represent room for hope, the researchers emphasized that uncertainty is often seen as a feeling associated with people in need, and that research typically views it as occurring more at the individual and family levels than at the community or societal levels (most of the time). For example, someone who cannot afford healthcare or struggles to put food on the table will experience more uncertainty than someone who perceives their daily life as safe and comfortable.
The authors identified and then screened 3,931 scientific articles. The screening alone filtered 3,642 records from their review, leaving them with 289 eligible articles. More than 200 of the remaining articles were not fit for a review on uncertainty, but by combing through bibliographies, another 46 articles were added back into the pool. One hundred one articles were ultimately included in the final evaluation. Of these records, 92 were primary published studies, and more than half came from the fields of medicine or nursing.
Looking at the data regionally, 61 studies were from the United States. Every other location was responsible for fewer than 10 sources, including seven from Taiwan, four from the United Kingdom, three from Hong Kong, and two or fewer from Lebanon, Switzerland, Japan, Thailand, South Korea, Canada, Norway, Israel-Palestine, Sweden, Greece, Yemen, Germany, the Netherlands, and Italy. Most studies came from high-income countries—the authors cited only Lebanon, Yemen, and Thailand as lower-income source countries.
The review as a whole is painted under the assumption that this is true, and it makes sense that uncertainty is viewed as occurring at the individual or family level, given that the countries reporting data are essentially capitalist and (at least somewhat) wealthy. If data on uncertainty were reported from a greater number of lower-income or politically unstable regions, data could point towards greater feelings of uncertainty at the communal and societal levels.
That said, the data also reflected personal situations in which uncertainty was experienced. Fourteen studies focused only on women, for example, because these studies were looking at gendered medical conditions’ links to uncertainty (e.g., breast cancer). It’s also noteworthy that 52% of all participants were Caucasian, and another 31% of studies did not report demographics, meaning only 17% of participants were certainly* not white. [I mean to say, we can be certain only of this amount of the demographic, but maybe the phrasing sounds strange.]
The review found that the mental health outcomes associated with uncertainty were depression (23% of all studies), anxiety (19%), psychological distress (15%), PTSD (10%), and stress 10%). The measures used to collect data on mental health outcomes were highly heterogeneous; however, many types of mental well-being were studied across the included studies.
According to the review, the main factor generating uncertainty was illness. Ninety-two studies focused on medical settings, with 58 focusing on patients, so it logically follows that this source of uncertainty dominated the data. Uncertainties about treatment, prognosis, symptoms, and the future were prevalent sources of uncertainty for patients. 27 studies focusing on caregivers found that treatment was the most significant source of uncertainty.
Another four studies focused on disaster and conflict settings, where sources of uncertainty were coming from the futures of themselves, friends, and family. The other source was from more macro-level issues, such as “job insecurity, housing, and the future of one’s country’s safety and future.”
Finally, four additional studies examined occupational settings. Workers and students alike reported insecurity about their futures.
In all, 20 measures of uncertainty were used across the review, but nearly half of the studies used the Mishel Uncertainty in Illness Scale (MUIS), and many others used slight variations of it. The MUIS asks people to rate on a 1-5 scale how confident they are in different aspects of their lives (1- Strongly Disagree, 5- Strongly Agree). Here are some examples from the MUIS (Community) form:
I am unsure if my illness is getting better or worse.
The doctors say things to me that could have many meanings.
Because of the unpredictability of my illness, I cannot plan for the future.
The single explanation consistently offered across contexts was that uncertainty interrupts control. Whether due to illness, unstable employment, or disasters, the inability to predict or prepare for events was associated with emotional strain.
The authors argue that conceptual and methodological limitations constrain the current literature. Three themes stand out:
Overreliance on biomedical settings
Most studies measure uncertainty in people already navigating the medical system. This skews the field toward illness-related uncertainty and reinforces a narrow view of instability.
Lack of attention to social determinants
Although the authors situate uncertainty within socioeconomic and political contexts, the studies rarely measure structural factors. Little work examines the uncertainty associated with housing insecurity, poverty, policing, or state violence.
Structural forms of uncertainty are understudied.
Disasters, conflict, displacement, and occupation generate pervasive uncertainty, yet only four studies addressed these contexts. For populations living under chronic or imposed instability—such as those in the occupied Palestinian territory—the quantitative literature offers almost no insight.
All in all, the researchers concluded that “a substantial majority of studies identified a positive relationship between higher levels of uncertainty and worse mental health outcomes (79%).” 15% of studies reported mixed findings, and another 6% reported no correlation between uncertainty and mental health outcomes.
This review highlights, first and foremost, that there is very likely a correlation between uncertainty and mental well-being.
That being true, this review shows that uncertainty is currently studied only in high-income countries and predominantly white populations, and that these populations usually view it through a lens of illness or medicine. There is a gaping hole in the research on uncertainty: the review finds few insights into the Global South’s experiences with uncertainty, despite being disproportionately affected by the global pandemic. While it’s true that most studies highlight a gap in the literature, the present review incisively supports the argument that uncertainty affects mental health and that the field of psychology currently does not know how it affects non-WEIRD populations.
The authors call for future research that expands beyond illness-centered frameworks and includes populations facing chronic political or economic instability. They emphasize that uncertainty can also involve hope, creativity, and openness, but these dimensions rarely appear in quantitative work.
They write that uncertainty should be studied not only as an individual psychological state but also as “a structural and political condition.” This shift would require new methods, new measures, and new ways of interpreting distress.
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Massazza, A., Kienzler, H., Al-Mitwalli, S., Tamimi, N., & Giacaman, R. (2023). The association between uncertainty and mental health: A scoping review of the quantitative literature. Journal of Mental Health, 32(2), 480–491. https://doi.org/10.1080/09638237.2021.2022620 (Link)