Students for Mental Wellness

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Students for Mental Wellness Phase 1: Literature Review Purpose The purpose of this literature review is to investigate what mental health issues are important to university students and what types of services they feel would be helpful to those dealing with mental health problems. Research on student preferences is relatively sparse and unlikely to be generalizable to other places and populations. Research on prevalence, incidence, and objective statistics were gathered in an attempt to increase the relevance of this report to Canadian students. The findings and analysis of the literature review will inform development of a web-based survey tool. Method A literature search was conducted to collect articles published in the last 10 years in English. Electronic databases searched include Medline, PsycInfo, ERIC and SocIndex. Search terms were university students AND mental health AND issues as well as university students AND mental health AND services. Because this search procedure located few Canadian studies, an additional search of students AND mental health AND Canada was conducted. Related terms from thesaurus searching were included. The initial search collected 1074 article abstracts. The abstracts were screened for direct relevance to the research questions and limited to studies conducted in North America, the United Kingdom and Australia. Reference lists and citations were hand searched for additional articles. A snowball sampling method was used to search for grey literature reports. At the end of the screening and selection process, 46 articles were deemed relevant and included in the findings. Findings Prevalence and incidence of mental health problems in university students There are no national epidemiological data on prevalence and incidence of mental health

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problems in university students in Canada (Adlaf et al, 2001). The largest study using random sampling collects self-report data on student mental health and relies on self-selecting universities (American College Health Association, 2009). Two Canadian universities participated in the Fall 2009 survey. Of all students surveyed, 7.6% had been diagnosed with a mental illness within the past 12 months (American College Health Association, 2010). The most prevalent conditions were anxiety (9.4%), depression (9.2%) and panic attacks (4.6%). Suicide was more common in men than women, while women suffered from higher rates of anxiety and depression. A survey of Canadian students found that 30% reported elevated distress levels in the prior 4 weeks (Adlaf et al., 2001). In comparison, a systematic review of global research found that the most common mental health issues reported by university students include depression, anxiety, eating disorders, self-harm, obsessive-compulsive disorder, and psychotic disorders (Storrie, Ahern & Tuckett, 2010). Mental health problems and alcohol abuse have been considered more significant problems in Canadian post-secondary students in comparison with illicit substance abuse (Adlaf, Gliksman, Demers, & Newton-Taylor, 2003). The prevalence of illicit drug use in Canadian post-secondary students (18.7% in the past month) is on par with other young adults, with cannabis accounting for more than 90% of use (Adlaf et al., 2003). Illicit drug use does become a concern when combined with alcohol abuse, mental health problems, or both (Cook, 2007) and tends to worsen outcomes (Cranford, Eisenberg & Serras, 2009). Approximately half of students with a diagnosis of mental illness are diagnosed while attending university (Storrie, Ahern & Tuckett, 2010). The age of onset for most diagnosable mental disorders is late adolescence to early adulthood although most do not seek treatment for an average of 8 years after the onset of first symptoms (Adlaf, Gliksman, Demers & Newton-Taylor, 2001). Academic and personal consequences of mental health problems are devastating to students on an individual-level, but also affect friends, family, social networks, and the university community. Several negative outcomes have been linked to mental health problems and illnesses in university students, including social

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isolation, financial difficulties, poor grades, poor attendance, academic probation, and drop-out (Kadison & DiGeronimo, 2004; Storrie, Ahern & Tuckett, 2008). University academic reputations are built on a healthy student body, whereas drop-outs and academic probations can impact university rankings and funding. Mental health promotion and prevention of mental health illness are fundamental to the success of students, the university and its community (Kadison & Digeronimo, 2008). In the absence of large-scale longitudinal studies, it is difficult to determine whether incidence of mental health problems has increased in recent years. University counselors and counseling centre administrators have reported the perception that both the number of students with mental health problems and the severity of problems have increased (Gallagher, 2006). Factors thought to influence this perception are reduced funding for counseling centre staff and services in some regions and increased demand for services, due to more diverse student populations with complex mental health needs (Much & Swanson, 2010), increased help-seeking behavior, and improvements in psychiatric medications that make it possible for young adults with significant mental health problems to stay in school (Hunt & Eisenberg, 2010; Mowbray et al., 2006). A recent review of the literature on incidence concluded that it is plausible that incidence and severity have increased in university populations, in light of these contextual factors and the data available in the UK on general and university populations (Hunt & Eisenberg, 2010). Stress and Mental Health University students are exposed to many stressors that can precipitate and contribute to the onset of both chronic and short-term mental health problems. These include financial difficulties, leaving the family home, trouble sleeping, exam and performance anxiety, time management difficulties, social and relationship problems, lack of transportation, peer pressure, concerns about graduation and career opportunities (Clark, 2007; Hinkelman & Luzzo, 2007; Mowbray et al.,2006; Oswalt & Finkelberg, 1995). A study in Ontario found higher prevalence of mental health problems in

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university students compared with the non-student young adult population, suggesting that stresses associated with university life contribute to elevated emotional distress in young adults (Adlaf et al., 2001). Stressors that impact university students can be grouped into three broad categories (Kadison & Digeronimo, 2004): normal developmental issues; pressure and competition; safety and financial worries. Normal development for young adults involves processes of identity development, relationships and sexuality, and interpersonal issues. These development processes occur in the majority of young adults and can be extremely stressful when subject to family and societal pressures. Along with normal developmental stress, university students are faced with intense pressure and competition in academics, athletics and relationships. Some students must find ways to develop and maintain their cultural or racial identities in the face of enormous pressure to fit in. Many students experience financial difficulties and must rely on family members, find part-time work and obtain loans in order to pay for tuition, accommodation, and living expenses. Added to these stressors are concerns about personal safety on campus. Traditionally, women have been particularly affected by worries about personal safety, but the recent spate of high-profile campus shootings in the United States has increased the overall level of student anxiety about safety on campus (Kadison & Digeronimo, 2004). Empirical research on the associations between specific stressors and mental illness in university populations is limited. In the UK, financial difficulties have been demonstrated as a contributing factor to depression (Andrews & Wilding, 2004) and sleeping difficulties, tension, (Cooke, Barkham, Audin, Bradley & Davy, 2004), and relationship difficulties have been linked to anxiety (Andrews & Wilding, 2004). In the absence of scientific data, students are the best source of information on stress and its relationship to mental health problems. As well, students should be involved in deciding what services help to relieve stress, reduce mental health problems, and support those who have developed mental health problems and illnesses.

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What Services Do Students Receive, and What Do They Want? Access to information and supports Students and researchers agree that literacy about mental health problems and campus services should be requisite of campus faculty and staff. Literacy helps to reduce stigma, which is a significant barrier to care (Mowbray et al., 2006; SAMSHA, 2007; Sharp, Hargrove & Johnson, 2006). Self-report data from a large sample of North American university students suggest that there is an unmet need for university-provided information on mental health problems and illnesses (American College Health Association, 2010) such as sleep difficulties and stress. Other areas surveyed include suicide prevention, depression and anxiety, eating disorders, and grief and loss. The percentages of students receiving information and requesting information were approximately the same for these categories, but it cannot be determined if the students with the greatest need received this information. Unmet need is a significant problem for students with co-occuring mental illness and substance abuse (Cranford, Eisenberg & Serras, 2009) which was not assessed in this study. Considering that students with mental health problems tend to rely on friends and family for support (Alipuria, 2008; XXX) it is especially salient that students be equipped to offer support and to know when to call for help for fellow students experiencing distress. In fact, over half of students reported a desire for information about helping other students in distress, which suggests that a number of students have provided or anticipate providing mental health support to other students. Approximately 30% of students reported receiving such information. Help-seeking behavior and barriers A small minority of students reported utilizing campus counseling services in a recent literature review (Raunic & Xenos, 2008). Of students reporting emotional distress, one quarter or less reported utilizing these services (Blanco, 2008; Rosenthal & Wilson, 2008). Barriers to campus mental health services include perceived stigma of mental health treatment (Eisenberg et al., 2009), lack of awareness

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of services (Kadison & DiGeronimo, 2004), the perception that services are ineffective (Eisenberg, Golberstein & Gollust, 2007), and preference for support from family and friends (Alipuria, 2008; Raunic & Xenos, 2008). Utilization of services tends to be lower in males, racial/ethnic minorities, and international students (Yorgasan, Linville & Zitman, 2008). It is theorized that because men are socialized to be ‘strong’ and to deal with problems independently, they are less likely to seek counseling than women. When they do seek counseling, the most common reasons are substance abuse, worries about career choices, relationship issues and mood problems (Robertson, 2001). University men surveyed about desired services requested mental health education classes, a dedicated male callin line, and establishment of a men's centre. For students who access campus counseling services, treatments are often limited to short-term interventions, neglecting to work on long-term coping skills (Getie, 2007; Mowbray et al., 2006). Some centres have minimized mental health problems in the past to make them more amenable to short-term treatment (e.g. PTSD downgraded to situational anxiety). In another study, students who sought professional counseling abandoned this approach after the ‘intake’ session because they found it difficult to seek services and that an intake session delayed treatment (Bean, 2006). The role of student organizations: Student control and choice Student-led mental health organizations are a source of information, advocacy, and support for university students. Students perceive a number of benefits of these organizations, including peer support, helping to achieve recovery, improving awareness and literacy on campus, and working with counseling centre staff to improve their services from a consumer perspective (SAMHSA, 2007). Creating linkages between student-led mental health or peer organizations and campus services has been recommended as part of a broad package of reforms to campus mental health programs (Cooke, 2007; Mowbray et al., 2006), and is especially salient given the rise in students seeking underfunded campus-based mental health services (McKinney, 2009). Active Minds is a prominent example of this

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approach. A national student-led organization in the United States with 267 campus chapters, Active Minds promotes mental health awareness and education through campus-wide events and serves as a liason between students and the mental health community (www.activeminds.org). Campus counseling centre staff participate in most Active Minds events, including social events, mental health screenings, and panel discussions. A recent study of the Active Minds chapter at Colorado State University found a reduction in stigma-related attitudes towards mental health problems, after participation in at least one Active Minds activity (McKinney, 2009). In Canada, a contact-based educational approach has been shown to reduce stigma of mental health problems in university populations (Lillie, Koller & Stuart, n.d.). A symposium that included speakers with mental health problems discussing their experiences with stigma as well as media and journalism experts increased understanding and empathy, holding promise for the effectiveness of educational efforts by student groups to reduce stigma and barriers to seeking care. Research Questions The scientific evidence on university student mental health confirms that a) stress and mental health problems have a substantial impact on students’ academic and social functioning and b) there is a lack of information on what services and supports students find most helpful for dealing with stress and resulting mental health problems. The evidence has been gathered from specific, relatively small samples and may not be representative of the preferences of Canadian students. Student perspectives on the stressors and mental health problems most important to Canadian students, and the services and supports they would like, is necessary to tailor services and supports to the student community. to reduce stigma and improve mental health literacy and help-seeking behavior. The present study will be conducted at four universities in British Columbia to ascertain the student’s perspectives on two broad questions: a) What mental health issues (stress and mental health problems) are most important to students? and b) What student-led services and supports can best address these mental health issues?

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References Adlaf, E. M., Gliksman, L., Demers, A., & Newton-Taylor, B. (2001). The prevalence of elevated psychological distress among Canadian undergraduates: Findings from the 1998 Canadian Campus Survey. Journal of American College Health, 50, 67-72. Adlaf, E. M., Gliksman, L., Demers, A., & Newton-Taylor, B. (2003). Illicit drug use among Canadian university undergraduates. Canadian Journal of Nursing Research, 35, 24-43. Alipuria, A. K. (2008). First-year college student decision making: How freshmen respond to the stress of the college transition. Dissertation Abstracts International Section A: Humanities and Social Sciences. US: ProQuest Information & Learning. Angle, S. P. (2002). Perceptions of college students diagnosed with panic disorder with agoraphobia: Academic, psychosocial, and environmental views of their college experience. Dissertation Abstracts International Section A: Humanities and Social Sciences. US: ProQuest Information & Learning. Bean, M. C. (2006). Choosing not to return: Diverse students' intake experiences at a university counseling center. Dissertation Abstracts International: Section B: The Sciences and Engineering. US: ProQuest Information & Learning. Blanco, C., Okuda, M., Wright, C., Hasin, D. S., Grant, B. F., Liu, S., & Olfson, M. (2008). Mental health of college students and their non-college-attending peers: results from the National Epidemiologic Study on Alcohol and Related Conditions. Archives of general psychiatry, 65, 1429-37. Connell, J., Barkham, M., & Mellor-Clark, J. (2007). CORE-OM mental health norms of students attending university counselling services benchmarked against an age-matched primary care sample. British Journal of Guidance & Counselling, 35, 41-57. Cook, L. J. (2007). Striving to help college students with mental health issues. Journal of Psychosocial

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Nursing and Mental Health Services, 45, 40-44. Cooke, R., Barkham, M., Audin, K., Bradley, M., & Davy, J. (2004). Student debt and its relation to student mental health. Journal of Further and Higher Education, 28, 53-66. Cooke, R., Bewick, B. M., Barkham, M., Bradley, M., & Audin, K. (2006). Measuring, monitoring and managing the psychological well-being of first year university students. British Journal of Guidance & Counselling, 34, 505-517. Cranford, J. A., Eisenberg, D., & Serras, A. M. (2009). Substance use behaviors, mental health problems, and use of mental health services in a probability sample of college students. Addictive Behaviors, 34, 134-145. Davidson, M. M., Yakushka, O. F., & Sanford-Martens, T. C. (2004). Racial and ethnic minority clients' utilization of a university counseling center: An archival study. Journal of Multicultural Counseling and Development, 32, 259 Davies, J., McCrae, B. P., Frank, J., Dochnahl, A., Pickering, T., Harrison, B., et al. (2000). Identifying male college students' perceived health needs, barriers to seeking help, and recommendations to help men adopt healthier lifestyles. Journal of American College Health, 48, 259-267. Dunne, C., & Somerset, M. (2004). Health promotion in university: What do students want? Health Education, 104, 360-370. Eisen, A., Kushner, H., McLeod, M., Queen, E., Gordon, J., Ford, J. L., et al. (2009). An integrated approach to addressing addiction and depression in college students. Journal of the American College Health Association, 57, 455-456. Eisenberg, D., Downs, M. F., Golberstein, E., & Zivin, K. (2009). Stigma and help seeking for mental health among college students. Medical Care Research and Review, 66, 522-541. Eisenberg, D., Golberstein, E., & Gollust, S. E. (2007). Help-seeking and access to mental health care in a university student population. Medical Care, 45, 594-601. Eisenberg, D., Gollust, S. E., Golberstein, E., & Hefner, J. L. (2007). Prevalence and correlates of

Students for Mental Wellness 10 depression, anxiety, and suicidality among university students. American Journal of Orthopsychiatry, 77, 534-542. Field, L. D., Elliott, M. S., Korn, P. R., & Schuh, J. H. (2006). A successful community-based intervention for addressing college student depression. Journal of College Student Development, 47, 105-109. Furr, S. R., Westefeld, J. S., Jenkins, J. M., & Mcconnell, G. N. (2001). Suicide and depression among college students: A decade later. Practice, 32, 97-100. Ghetie, D. (2007). The debate over time-limited treatment in college counseling centers. Journal of College Student Psychotherapy, 22, 41-61. Hai-Jew, S. (2009). The University Life Cafe: Promoting students' emotional health. EDUCAUSE Quarterly, 32(4). Hermon, D. A. (2005). Wellness counseling in colleges and universities. In J. E. Myers, T. J. Sweeney, J. E. Myers, & T. J. Sweeney, Counseling for Wellness: Theory, Research, and Practice. (pp. 245-252). Alexandria, VA US: American Counseling Association. Hinkelman, J. M., & Luzzo, D. A. (2007). Mental health and career development of college students. Journal of Counseling & Development, 85, 143-147. Howard, B. (2003). Use of the Internet as a service delivery alternative for college counseling centers. Dissertation Abstracts International: Section B: The Sciences and Engineering. US: ProQuest Information & Learning. Hoyt, W. D. (2003). Self-harm among college students: An epidemiological and qualitative analysis. Dissertation AbstractsInternational: Section B: The Sciences and Engineering. US: ProQuest Information & Learning. Hoyt, W. D., & Ross, S. D. (2003). Clinical and subclinical eating disorders in counseling center clients: A prevalence study. Journal of College Student Psychotherapy, 17, 39-54. Hunt, J., & Eisenberg, D. (2010). Mental health problems and help-seeking behavior among college

Students for Mental Wellness 11 students. Journal of Adolescent Health, 46, 3-10. Kadison, R., & DiGeronimo, T. F. (2004). College of the Overwhelmed: The Campus Mental Health Crisis and What To Do About It. San Francisco, CA US: Jossey-Bass. McKinney, K. (2009). Initial evaluation of Active Minds: A student organization dedicated to reducing the stigma of mental illness. Journal of College Student Psychotherapy, 23, 281-301. Mowbray, C. T., Megivern, D., Mandiberg, J. M., Strauss, S., Stein, C. H., Collins, K., et al. (2006). Campus mental health services: Recommendations for change. American Journal of Orthopsychiatry, 76, 226-237. Much, K., & Swanson, A. (2010). The debate about increasing college student psychopathology: Are college students really getting “sicker?”. Journal of College Student Psychotherapy, 24, 86-97. Pace, D., & Quinn, L. (2000). Empirical support of the overlap between career and mental health counseling of university students. Journal of College Student Psychotherapy, 14, 41-50. Quinn, N., Wilson, A., Macintyre, G., & Tinklin, T. (2009). "People look at you differently": Students' experience of mental health support within higher education. British Journal of Guidance & Counselling, 37(4), 405-418. Raunic, A., & Xenos, S. (2008). University counselling service utilisation by local and international students and user characteristics: A review. International Journal for the Advancement of Counselling, 30, 262-267. Robertson, J. M. (2001). Counseling men in college settings. In G. R. Brooks, G. E. Good, G. R. Brook, & G. E. Good, The new handbook of psychotherapy and counseling with men: A comprehensive guide to settings, problems, and treatment approaches, Vol. 1 & 2. (pp. 146169). San Francisco, CA US: Jossey-Bass. Rosenthal, B., & Wilson, W. C. (2008). Mental health services: Use and disparity among diverse college students. Journal of American College Health, 57, 61-67. Schwartz, A. J. (2006). Are college students more disturbed today? Stability in the acuity and

Students for Mental Wellness 12 qualitative character of psychopathology of college counseling center clients: 1992-1993 through 2001-2002. Journal of American College Health, 54, 327-337. Serras, A., Saules, K. K., Cranford, J. a., & Eisenberg, D. (2010). Self-injury, substance use, and associated risk factors in a multi-campus probability sample of college students. Psychology of Addictive Behaviors, 24, 119-28. Sharp, W., Hargrove, D. S., Johnson, L., & Deal, W. P. (2006). Mental health education: An evaluation of a classroom based strategy to modify help seeking for mental health problems. Journal of College Student Development, 47, 419-438. Storrie, K., Ahern, K., & Tuckett, A. (2010). A systematic review: Students with mental health problems—A growing problem. International Journal of Nursing Practice, 16, 1-6. Substance Abuse and Mental Health Services Administration. (2007). Building Bridges- Mental Health on Campus. US: Author. Tinklin, T., Riddell, S., & Wilson, A. (2005). Support for students with mental health difficulties in higher education: The students' perspective. British Journal of Guidance & Counselling, 33, 495-512. Westefeld, J. S., Homaifar, B., Spotts, J., Furr, S., Range, L., Werth Jr., J. L., et al. (2005). Perceptions concerning college student suicide: Data from four universities. Suicide and Life-Threatening Behavior, 35, 640-645. Yorgason, J. B., Linville, D., & Zitzman, B. (2008). Mental health among college students: Do those who need services know about and use them? Journal of American College Health, 57, 173181. Zivin, K., Eisenberg, D., Gollust, S. E., & Golberstein, E. (2009). Persistence of mental health problems and needs in a college student population. Journal of Affective Disorders, 117, 180185.

Students for Mental Wellness 13

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