As a new crop of students enter university, the sense of hope and promise is tangible. While students are at an exciting developmental stage, as a researcher and practising clinical consultant to university student health services, I know that for some students the associated stress and new pressures will become overwhelming.
Several authoritative reports from Canada and the United Kingdom have drawn attention to increased demand for student mental health care that is straining university resources. Reports also point out that campus mental health services and initiatives are fragmented and inadequate to address the growing breadth and depth of student mental health need.
The tension between need for effective, accessible and engaging student mental care and the status quo in terms of resources has reached a tipping point. Such a state of affairs risks student well-being and academic success and has consequences for the university as evidenced by recent tragedies across different campuses in different countries. A key stumbling block toward change has been a relative lack of systematically collected data to help universities with the development of a coordinated and comprehensive system of student mental health care.
In the face of a seemingly changing university landscape and a relative lack of data, we have launched a new research initiative called “U-Flourish.” In collaboration with colleagues at Queen’s University (Canada) and Oxford University (U.K.), we are launching a longitudinal study to evaluate the scope of mental health need among undergraduate students and understand what factors determine different student mental health and academic outcomes.
As a multidisciplinary group of clinicians, academics and students, experienced in developing and evaluating mental health services and studying the onset of mental disorders, we know the importance of the university taking a lead role in the development of a system of student mental health care.
Time of transition, critical period
One of the most important contributors to healthy individual growth and societal development is higher education. Success depends upon health, including mental health. The transition to university coincides with a critical period of accelerated biological, psychological and social development with the peak period of risk for onset of serious and persistent mental illness. The brain is undergoing accelerated growth and has heightened sensitivity to risk exposures commonly encountered by university students, such as stress, recreational drugs, alcohol and sleep problems.
University students are also exposed to a number of unique stresses related to financing their studies and making new social connections. Research finds that in Canada, younger students (under the age of 22) are driving undergraduate growth. Not only a rising number of international students, but also domestic students are studying away from home and their support network.
Competition has increased in Canadian universities and across the western world, as enrolment and threshold grades for entry to professional and graduate schools have risen.
Evidence suggests that not fitting into the predominant demographic at university and constant social media presence may be important psychosocial risk factors associated with mental health problems. Many students experience distress and their ability to cope is overwhelmed.
Serious and persistent mental illness typically emerges over childhood and adolescence. Research shows that 75 per cent of all mental disorders onset by the mid-twenties, and typically there is is a substantial delay between illness onset and first treatment contact. This delay is associated with progression to more complex disorders, dropping out of school, addiction and self-harm.
Emerging research underscores the substantial unmet need for screening and effective care of students. A large international study using World Health Organization surveys reported that one-fifth of college students met criteria for a 12-month mental disorder. Yet, treatment rates were exceedingly low and mental disorders were associated with higher rates of drop out.
Absence of evidence-based models
There is limited publicly available information about the outcomes of current student mental health services in Canada or the U.K. From what we as a research collective have observed, most campus mental health services do not have validated quality or outcome indicators embedded in routine care. These circumstances make it difficult to assess how effective current services are.
Student mental health services vary significantly across institutions in how they are organized, integrated and resourced. These variances reflect in part the absence of an evidence-based model guiding the development of student mental health care, and a lack of universal benchmarks for informing standards of care.
There is also a lack of consistency around approaches to determine and monitor the mental fitness of students to continue or return to studies after taking medical leave for a mental health reason.
Unique student needs
University mental health services have typically developed from short-term counselling services which are generally not adequately organized or resourced to systematically assess or respond to the full spectrum of university student mental health need. Compared to community-based care, student mental health services need to be more proactive, expeditious and preventive in nature.
University students are particularly disadvantaged in accessing timely and appropriate care as they move between university and home, and are at an age between child and adult services. Students often struggle with impairing and distressing symptoms that fall short of inclusion criteria for specialized community-based services.
It is likely that effective reform will mean not only re-organizing and strengthening existing services, but also developing new campus-based services and partnerships with specialty programs in the community based on clinical need.
Key principles for development
With an intent to help universities move forward, our research collective has set out key principles to guide the development of an integrated system of student mental health care moving forward. We propose that university mental health services should:
Be accessible, evidence-based, culturally competent and developmentally appropriate;
Have an engaging clinical triage at the student’s first point of contact that is linked to a properly resourced service, where intensity of care matches complexity of needs (stepped care);
Have facilitated transitions between campus and community-based services;
Have outcome and quality indicators embedded in routine care;
Develop standards-of-care and fitness-to-study guidelines;
Rely upon integrated research to inform development.
Determining risk factors
The U-Flourish research program aims to evaluate the scope of mental health need and identify what factors contribute to poor mental health and academic outcomes in university students and what might be important targets for early intervention and prevention initiatives on campuses.
Preliminary research found that almost one-third of students starting university at Queen’s screened positive for both clinically significant anxiety and depressive symptoms (45 per cent with functional impairment) and 18 per cent had significant sleep problems. Almost one-third of students had serious thoughts of ending their life and 6 per cent reporting having attempted suicide at least once. Mental illness, including having suicidal thoughts and self-harm, are treatable conditions. People can get help. Yet, in this study only 8.5 per cent of students indicated that they were receiving any form of treatment. Collectively, evidence points to a significant unmet need for mental health assessment and targeted intervention at entry to university.
The transition to university represents a critical opportunity for prevention through effective screening for mental health problems including suicide and self-harm, and to deliver appropriate evidence-based interventions at the right time.
To support positive outcomes for all students, researchers, clinicians and universities must work together and use the available evidence to put in place a co-ordinated system of mental health care that meets the needs of our students.
If you are experiencing suicidal thoughts, you are not alone. If your life or someone else’s is in danger, call 911 for emergency services in Canada or the U.S. (or 999 in the U.K.). Or, in Canada, download The LifeLine App to find one-touch hotline crisis call, text and chat options and prevention and awareness tips; or call Canada Suicide Prevention Service (CSPS) at 1-833-456-4566.