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Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood. -MentalHealth.gov

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Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood. -MentalHealth.gov

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https://www.mentalhealth.org.uk/your-mental-health

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Your mental health | Mental Health Foundation

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Our 'your mental health' section includes practical advice for looking after your mental health, along with statistics, information about what mental health is, podcasts, videos and your stories.

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Mental Health ng mga estudyante ngayong pandemic

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Mental Health: Strengthening Our Response (WHO)

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Mental Health: Strengthening Our Response (WHO)

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https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response

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WHO fact sheet on mental health covering risks and protective factors, promotion and prevention, care and treatment, and WHO’s work in this area.

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Graduate School of Education, Nazarbayev University, Nur-Sultan, Kazakhstan

Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan

Psychological Counseling Center, Nazarbayev University, Nur-Sultan, Kazakhstan

The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975-2020. More specifically, this study uses bibliometric procedures to describe and visually represent the available literature on mental health and well-being in university students in terms of the growth trajectory, productivity, social structure, intellectual structure, and conceptual structure of the field over 45 years. Key findings of the study are that research on mental health and well-being in university students: (a) has experienced a steady growth over the last decades, especially since 2010; (b) is disseminated in a wide range of journals, mainly in the fields of psychology, psychiatry, and education research; (c) is published by scholars with diverse geographical background, although more than half of the publications are produced in the United States; (d) lies on a fragmented research community composed by multiple research groups with little interactions between them; (e) is relatively interdisciplinary and emerges from the convergence of research conducted in the behavioral and biomedical sciences; (f) tends to emphasize pathogenic approaches to mental health (i.e., mental illness); and (g) has mainly addressed seven research topics over the last 45 years: positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement. The findings are discussed, and the implications for the future development of the field are highlighted.

Introduction

The entrance to the university marks a period of transition for young people. Through this transition, students face new challenges, such as making independent decisions about their lives and studies, adjusting to the academic demands of an ill-structured learning environment, and interacting with a diverse range of new people. In addition, many students must, often for the first time, leave their homes and distance themselves from their support networks ( Cleary et al., 2011). These challenges can affect the mental health and well-being of higher education students. Indeed, there is evidence that a strain on mental health is placed on students once they start at the university, and although it decreases throughout their studies ( Macaskill, 2013; Mey and Yin, 2015), it does not return to pre-university levels ( Cooke et al., 2006; Bewick et al., 2010). Also, the probabilities of experiencing common psychological problems, such as depression, anxiety, and stress, increase throughout adolescence and reach a peak in early adulthood around age 25 ( Kessler et al., 2007) which makes university students a particularly vulnerable population.

The interest in mental health and well-being in university students has grown exponentially in the last decades. This is likely due to three interrelated challenges. First, although university students report levels of mental health similar to their non-university counterparts ( Blanco et al., 2008), recent studies suggest an increase and severity of mental problems and help-seeking behaviors in university students around the world in the last decade ( Wong et al., 2006; Hunt and Eisenberg, 2010; Verger et al., 2010; Auerbach et al., 2018; Lipson et al., 2019). Some researchers refer to these trends as an emerging "mental health crisis" in higher education ( Kadison and DiGeronimo, 2004; Evans et al., 2018). Second, psychological distress in early adulthood is associated with adverse short-term outcomes, such as poor college attendance, performance, engagement, and completion (e.g., King et al., 2006; Antaramian, 2015), and others in the long term, such as dysfunctional relationship ( Kerr and Capaldi, 2011), recurrent mental health problems, university dropout, lower rates of employment, and reduced personal income ( Fergusson et al., 2007). Third, there is a widespread agreement that higher education institutions offer unique opportunities to promote the mental health and well-being of young adults as they provide a single integrated setting that encompasses academic, professional, and social activities, along with health services and other support services ( Eisenberg et al., 2009; Hunt and Eisenberg, 2010). However, the majority of university students experiencing mental health problems and low levels of well-being are not receiving treatment ( Blanco et al., 2008; Eisenberg et al., 2011; Lipson et al., 2019) and, while universities continue to expand, there is a growing concern that the services available to provide support to students are not developing at an equivalent rate ( Davy et al., 2012).

In response to the increasing volume of research on the mental health and well-being of university students, there have been several attempts to synthesize the accumulating knowledge in the field and to provide an illustration of the theoretical core and structure of the field using traditional content analysis of the literature (e.g., Kessler et al., 2007; Gulliver et al., 2010; Hunt and Eisenberg, 2010; Sharp and Theiler, 2018). This study aims to extend the understanding of mental health in university students by providing a bird's eye view of the research conducted in this field in recent decades using a bibliometric approach. Bibliometric overviews provide an objective and systematic approach to discover knowledge flows and patterns in the structure of a field ( Van Raan, 2014) reveal its scientific roots, identify emerging thematic areas and gaps in the literature ( Skute et al., 2019) and, ultimately, contribute to moving the field forward. Accordingly, this study employs several bibliometric indicators to explore the evolution of the field based on publication and citation trends, key actors and venues contributing to the advancement of research on mental health and well-being of university students, and the structure of the field in terms of patterns of scientific collaborations, disciplines underlying the foundations of the field, and recurrent research themes explored in the literature. This is important because, despite significant advances in the field, research on mental health and well-being remains a diverse and fragmented body of knowledge ( Pellmar and Eisenberg, 2000; Bailey, 2012; Wittchen et al., 2014a). Indeed, mental health and well-being are nebulous concepts and their history and development are quite intricate, with a multitude of perspectives and contributions emerging from various disciplines and contexts (see section "Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview"). Therefore, mapping research on mental health and well-being in university students is essential to identify contributions and challenges to the development of the field, to help guide policy, research, and practice toward areas, domains, populations, and contexts that should be further explored, and to provide better care of students at higher education institutions ( Naveed et al., 2017).

Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview

This section provides an overview of the different perspectives adopted in the literature to conceptualize mental health, well-being, and other relevant constructs in order to identify the glossary of key terms that will be used in the search strategy to create a comprehensive corpus of documents on mental health and well-being in university students for this bibliometric review.

Perspectives on Mental Health and Mental Illness

There is no general agreement on the definition of mental health. For a long time, the term mental health has been used as a euphemism for mental illness ( Manwell et al., 2015). However, mental health and mental illness are regarded as distinct constructs nowadays and two main perspectives differentiating between mental health and illness are available in the literature. The continuum approach considers that mental health and mental illness are the two opposite poles of a continuum. Thus, there are various degrees of health and illness between these poles, with most of us falling somewhere in between. The categorical approach, on the other hand, represents mental health and illness as a dichotomy. People who manifest mental illness symptoms would belong to that category and labeled correspondingly, while those absent of these symptoms can be considered as mentally healthy ( Scheid and Brown, 2010).

Disciplinary Approaches to the Conceptualization of Mental Health/Illness

Conceptualizations of mental health/illness are largely dependent on the theoretical and paradigmatic foundations of the disciplines from which they emerge. In this context, the field has progressively evolved through the accumulation of knowledge generated in a diverse range of disciplines in the biomedical, behavioral, and social sciences. Biomedical disciplines are grounded in the medical paradigm focused on disease and (ab)normality and often emphasize dichotomous conceptions of mental health/illness ( Scheid and Brown, 2010). Research on mental health and well-being in this domain has been traditionally conducted from a psychiatric perspective, which aims to understand the dysfunctionality in the brain that leads to psychiatric symptoms and to also offer a pharmacological treatment to correct neuronal dysfunctions. Consequently, psychiatrists have historically considered mental health as a disease of the brain (e.g., depression), similar to any other physical disease, caused by genetic, biological, or neurological factors ( Schwartz and Corcoran, 2010). While the prevalence of psychiatric approaches to mental health is currently incontestable, the development of other biomedical disciplines has tremendously contributed to the progression of the field in recent decades. For example, Insel and Wang (2010) argue that insights gained from genetics and neuroscience contribute to the reconceptualization of "the disorders of the mind as disorders of the brain and thereby transform the practice of psychiatry." (1979). In addition to that, other disciplines such as behavioral medicine have made important contributions to the field, although it has recently argued that mental health and behavioral medicine should be as two separate fields ( Dekker et al., 2017).

Within the behavioral sciences, the study of mental health focuses on the distinct psychological processes and mechanisms that prompt thoughts, feelings, and behaviors ( Peterson, 2010). Clinical psychology has the longest tradition in the psychological study of mental health and tends to focus on the assessment and treatment of mental illness and disorders that can alleviate psychological distress or promote positive states of being ( Haslam and Lusher, 2011). However, significant contributions to the field have also emerged from other branches of psychology less focused on psychopathology, including personality and social psychology, psychoanalysis, humanistic psychology, and cognitive psychology ( Peterson, 2010). Despite the diversity of theories, principles, and methodological approaches to understanding mental health within the behavioral sciences, these disciplines acknowledge that mental health have a biological basis and reside in the social context, and tend to prioritize continuum approaches to mental health ( Scheid and Brown, 2010).

Perspectives from the social sciences complement the biomedical and behavioral approaches by considering the influence of social and cultural environments in mental health/illness ( Horwitz, 2010). For example, sociologists are interested in how social circumstances (e.g., level of support available) affect levels of mental health/illness and how social structures shape the understanding and response to mental health issues [see Compton and Shim (2015) for an overview of the social determinants of mental health]. Similarly, medical anthropologists attend to the mental health beliefs and practices that form the cultural repertory within and across populations ( Foster, 1975). Beyond sociology and anthropology, social researchers in the fields of business and economics, family and ethnic studies, and educational research have also played a key role in advancing research on mental health in different directions.

The Importance of the Context in Mental Health

Certainly, most notions of mental health/illness in the literature derive from prevailing psychiatric and psychological traditions developed in Western countries ( Gopalkrishnan, 2018). However, cultural values and traditions do shape how mental health and mental illness are conceptualized across contexts ( Vaillant, 2012). In this regard, Eshun and Gurung (2009) pointed out that "culture influences how individuals manifest symptoms, communicate their symptoms, cope with psychological challenges, and their willingness to seek treatment." (4). Fernando (2019) argued that issues related to the 'mind' developed and are often interpreted very differently in non-Western and Low- and Middle-Income Countries (LMICs). For example, cultures explain the manifestation of certain feelings and behaviors based on a range of motives including biological, psychological, social, religious, spiritual, supernatural, and cosmic. Failure to acknowledge alternative non-Western approaches to mental health and mental illness has resulted in imbalances of knowledge exchange and the permeation of dominating Western narratives into LMICs (i.e., so-called medical imperialism) ( Timimi, 2010; Summerfield, 2013). To address this issue, scholars have advocated for a greater willingness to embrace pluralism in the conceptualization of mental health and illness, which might help people to engage with particular forms of support that they deem to be appropriate for them, and to explore how knowledge and practices developed in LMICs can benefit those living in higher-income countries (i.e., knowledge "counterflow") (see White et al., 2014).

Prioritizing Positive Mental Health: The Science of Well-Being

Despite the diversity of disciplinary and contextual approaches to mental health, current definitions of mental health have two things in common. First, mental health is considered from a biopsychosocial point of view that incorporates biological, psychological, and social factors. Second, mental health implies something beyond the absence of mental illness (e.g., Bhugra et al., 2013; Galderisi et al., 2015). An example is the definition by the World Health Organization which refers to mental health as "a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community" ( World Health Organization, 2004). This definition contributed to substantial progress in research and practice in the field as it expanded the notion of mental health beyond the absence of mental illness and integrated the presence of positive features ( Galderisi et al., 2015).

Research on positive mental health is relatively new but has grown rapidly in the last decades fueled by advocates of positive medicine and psychology, who have argued for a change of paradigm from medical and psychopathological-oriented models of mental health that focus on disorders and illness toward more strength-based approaches, which pay more attention to what is right about people and positive attributes and assets ( Kobau et al., 2011). In this regard, the term mental well-being has been progressively incorporated into the study of mental health to account for the positive aspects of mental health beyond the absence of negative factors. While there is not a universally accepted definition of well-being, two perspectives have dominated the discourses on well-being in the literature: subjective well-being (SBW) and psychological well-being (PWB). SWB is based on hedonic perspectives of pleasure and represents "people's beliefs and feelings that they are living a desirable and rewarding life" ( Diener, 2012). SBW is strongly linked with the idea of happiness and is typically understood as the personal experience of high levels of positive affect, low levels of negative affect, and high satisfaction with one's life ( Deci and Ryan, 2008). PWB is grounded in Aristotelian ideas about eudaimonia, i.e., self-realization, with the ultimate aim in life being to strive to realize one's true potential ( Ryff and Singer, 2008). PWB has been broadly defined as a state of positive psychological functioning and encompasses six dimensions: purpose in life (i.e., the extent to which respondents felt their lives had meaning, purpose, and direction); autonomy (i.e., whether they viewed themselves as living in accord with their own convictions); personal growth (i.e., the extent to which they were making use of their personal talents and potential); environmental mastery (i.e., how well they were managing their life situations); positive relationships (i.e., the depth of connection they had in ties with significant others); and self-acceptance (i.e., the knowledge and acceptance they had of themselves, including awareness of personal limitations) ( Ryff, 1989).

Integrating Mental Health, Mental Illness, and Well-Being

The contribution of positive mental health frameworks to the advancement of the field has been undeniable. However, definitions that overemphasize positive emotions and productive functioning as key indicators of mental health have been recently challenged because of the potential they have to discriminate against individuals and groups that, for example, might not be able to work productively or function within the environment because of individual physical characteristics or contextual constraints ( Galderisi et al., 2015). To address these issues, Keyes has successfully integrated the notions of mental illness, mental health, well-being, and other related terms in the literature into a conceptual framework that allows for a more comprehensive understanding of mental health ( Keyes, 2005, 2007; Keyes and Michalec, 2010). The model argues that neither pathogenic approaches focusing on the negative (e.g., mental illness) nor salutogenic approaches focusing on the positive (e.g., well-being) can alone accurately describe the mental health of a person ( Keyes and Michalec, 2010). Instead, the model proposes that mental illness and well-being represent two correlated but differentiated latent continua in defining mental health. More specifically, mental illness and well-being lie on two separate spectra, the first going from absent to present mental illness and the second running from low to high well-being ( Slade, 2010). The absence of mental illness, therefore, does not necessarily imply high levels of well-being. Correspondingly, low levels of well-being do not always indicate the presence of mental illness. Further, in this model, mental health is defined as not only the absence of mental illness, not the mere presence of high well-being. Complete mental health (i.e., flourishing) is a result of experiencing low mental illness and high levels of well-being. Incomplete mental health (i.e., languishing), on the other hand, refers to the absence of mental illness symptoms and low reported levels of well-being. Two other conditions are possible within this framework. Incomplete mental illness (i.e., struggling) refers to high levels of well-being accompanied by high mental illness symptoms. Lastly, complete mental illness (i.e., floundering) accounts for low levels of well-being and high mental illness symptoms ( Keyes and Lopez, 2002).

The Present Study

In light of the complexity of the constructs of mental health and well-being and the multiple theoretical, disciplinary, and contextual approaches to their conceptualization, this study seeks to map out the terrain of international research and scholarship on mental health and university students for the period 1975-2020. More specifically, this study aims to provide new insights into the development and current state of mental health research in university students by mapping and visually representing the literature on mental health and well-being of university students over the last 45 years in terms of the growth trajectory, productivity, and social, intellectual, and conceptual structure of the field. First, the study describes the development of research mental health and well-being in university students examining the trends in publication and citation data between 1975 and 2020 (i.e., growth trajectory). Second, the study identifies the core journals and the research areas contributing most to the development of the field, as well as the key authors and countries leading the generation and dissemination of research on mental health and well-being in university populations (i.e., productivity). Third, the study outlines the networks of scientific collaboration between authors, and countries (i.e., social structure). Fourth, the scientific disciplines underlying the intellectual foundations of research on mental health and well-being in university settings (i.e., intellectual structure) are uncovered. Fifth, the study elucidates the topical foci (i.e., conceptual structure) of the research on the mental health and well-being of university students over the last 45 years.

Materials and Methods

A bibliometric approach was used in this study to map the literature on mental health and well-being in university students over the last 45 years using metadata extracted from four indexes of the Web of Science (WoS): The Science Citation Index-Expanded (SCI-Expanded); the Social Sciences Citation Index (SSCI); the Arts & Humanities Citation Index (A&HCI); and the Emerging Sources Citation Index (ESCI). Several reasons justified the selection of the WoS database in this study. First, the WoS remains as the standard and most widely used for bibliometric analysis ( Meho and Yang, 2007). Second, the WoS is a multidisciplinary database and includes publications on mental health and well-being emerging from distinctive research areas and disciplines published in more than 20,000 journals ( McVeigh, 2009). Using specialized databases such as PubMed would introduce biases into the search strategy favoring biomedical research disciplines. Still, it is important to note that interdisciplinary databases such as WoS and Scopus discriminate against publications in the Social Sciences and Humanities and publications in languages other than the English language ( Mongeon and Paul-Hus, 2016), so the picture provided by WoS is still imperfect. Third, while other databases might provide wider coverage, WoS includes publication and citation information from 1900. For example, Scopus has complete citation information only from 1996 ( Li et al., 2010). Moreover, Google Scholar provides results of inconsistent accuracy in terms of citations, and citation analyses in PubMed are not available ( Falagas et al., 2008). Fourth, WoS has demonstrated better accuracy in its journal classification system compared to Scopus database ( Wang and Waltman, 2016).

The methodological approach used in this study is presented in Figure 1 and further elaborated in the following paragraphs.

Search Strategy

To create a comprehensive corpus of documents on the mental health and well-being of university students, three parallel searches were performed, which accounted for the multiple approaches and perspectives that have been used in the field, as identified in the Section "Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview." All the searches were conducted in the last week of January 2020. The first search aimed at capturing research on mental health broadly and included one single keyword in the topic field: ["mental health"]. The second search was implemented to capture research focusing on pathogenic approaches to mental health. Key terms used in the literature to refer to the negative side of mental health, as well as the most frequent mental health problems experienced by university students, were introduced in this search in the title field: ["mental illness," "mental disorder ∗," "mental distress," "psychological distress," "psychopathology," "depression," "anxiety," "stress," "suicide," "eating disorder ∗," "substance use"]. In the third search, keywords reflecting salutogenic approaches to mental health were input. These included terms related to mental health from a positive mental health perspective (i.e., well-being). These key terms were added in the title field and included the following: ["well-being," "wellbeing," "wellness," "life satisfaction," "happiness," "positive affect," "purpose in life," "personal growth," "self-determination"].

To retrieve research relevant only to higher education students, another set of keywords was imputed in all three searches in the title field. These included: ["university," "college," "higher education," "tertiary education," "post-secondary education," "postsecondary education," "undergrad ∗ student," "grad ∗ student," "master's student," "doctoral student," "Ph.D. student"]. The Boolean operator OR was used between keywords in all the three searches to secure a higher number of relevant hits. Also, asterisks were used as wildcards to account for multiple variations in several keywords (e.g., disorder and disorder-s). All searches were limited to journal articles published between 1975 and 2020 (both inclusive). No restrictions on language were implemented in the search.

The search strategy retrieved a total of 6,356 hits ( n search 1 = 2782; n search 2 = 2814, n search 3 = 760). After the removal of duplicates, 5,561 research articles were finally selected and retained for the study. For each of the documents obtained in the search, the authors extracted metadata about the title of the paper, the year of publication, the journal, the number of citations, and the authors' name, organization, and country. Also, the title, the abstract, the author's keywords, and cited references were retrieved.

Data Analysis Procedures

The corpus of the literature was then analyzed using descriptive and bibliometric approaches to provide an overall picture of the evolution and current state of the research on mental health and wellbeing in university settings. Frequency counts of the number of publications and citations per year were obtained to describe the growth trajectory of research on the mental health and well-being of university students. Rank ordered tables were produced to describe the productivity of the field in terms of core journals and research areas, as well as leading scholars and countries contributing to the development of the field.

Bibliometric analyses in VOSViewer software were implemented to examine and visually represent the social, intellectual, and conceptual structure of the field. VOSViewer is a freely available computer software for viewing and constructing bibliometric maps. In VOSViewer, the units of analysis are journals, publications, citations, authors, or countries, depending on the focus of the analysis. The units of analysis are represented in the maps as circular nodes. The size of the node accounts for volume (e.g., number of publications in the dataset by an author) and the position represents the similarity with other nodes in the map. Closer nodes are more alike than nodes far apart from each other. The lines connecting nodes represent the relationship between nodes and their thickness indicates the strength of that relationship. Finally, the color of the node denotes the cluster to which each node has been allocated. Nodes are clustered together based on relatedness ( Van Eck et al., 2010). The software uses a distance-based approach to constructing the bibliometric maps in three steps ( Van Eck and Waltman, 2014). In the first step, the software normalizes the differences between nodes. In the second step, the software builds a two-dimensional map where the distance between the nodes reflects the similarity between these nodes. In the third step, VOSViewer groups closely related nodes into clusters ( Van Eck and Waltman, 2014).

A series of co-authorship analyses were performed to examine the social structure of research on mental health and well-being in university students. In these analyses, the units of analysis were authors and countries/territories. Each node in the map represents an author or a country/territory and the lines connecting them reflect the relationship between nodes. Clusters represent networks of scientific collaboration, which might be interpreted as groups of authors or countries frequently publishing together (e.g., research groups in the case of authors).

Co-citation analysis of journals was implemented to explore the intellectual structure of the field. Here, the units of analysis were journals in the dataset and the map reflects co-citation relationships between journals. Two journals are co-cited if there is a third journal citing these two. The more times a pair of journals are cited by other journals, the stronger their co-citation relationship will be. Frequently co-cited journals are assumed to share theoretical and semantical grounds. Therefore, in our study, clusters of frequently co-cited journals can be interpreted as disciplines underlying the foundations of research on mental health and well-being in university students.

Finally, a co-occurrence analysis of keywords was used to uncover the conceptual structure of the field. The units of analysis, in this case, were the authors' keywords. The more often two keywords appear in the same record, the stronger their co-occurrence relationship. Clusters of co-occurring keywords represent in this study the topical foci (i.e., knowledge base) that have been addressed in the literature in mental health and well-being in university students in the last 45 years.

Findings and Discussion

Growth Trajectory: Evolution of Publications and Citations in the Field

The developmental patterns of a particular field can be well demonstrated by trends in publications and citations. The 5,561 publications in the dataset have been cited 87,096 times, with an average of 15.6 citations per item. Figure 2 shows the growth trajectory of publication data of research on mental health and well-being in university students from 1975 to January 2020. Overall, the trends demonstrate a gradual increase in the scholarly interest in the mental health of university students over the last 45 years that can be organized in three stages: an emergence stage, in which publications rose slowly (1975-2000); a fermentation stage, with a notable increase in publications in the field (2000-2010); and a take-off stage, during which the number of records published per year in the field has almost risen 10 times (2010-2020). The steady increase of publications in the last 15 years coincides with the first calls for attention on the increase and severity of mental problems and help-seeking behaviors of college students ( Kadison and DiGeronimo, 2004; Evans et al., 2018), potentially indicating a growing interest in exploring the epidemiology of mental disorders and the role of universities in promoting the mental health and well-being of students. A similar pattern has also been observed in a recent bibliometric study examining global research on mental health both in absolute terms and as a proportion of all papers published in medicine and across disciplines, which certainly reflects an increase in the general interest in the field ( Larivière et al., 2013).

Productivity I: Core Journals and Research Areas

In total, 1,560 journals published the 5,561 records included in the dataset. Table 1 presents the ten core journals in the field. The Journal of American College stands out as the main publication venue in the field, accumulating around 5% of the publications in the dataset ( n = 270). Psychological Reports and Journal of College Student Development also stand out, publishing 119 and 102 studies, respectively. The Journal of Counseling Psychology ranks fourth in the list with 83 records. Despite being an interdisciplinary and relatively young journal, Plos One appears in the top five journal publishing research on mental health and well-being in university students.

The top research areas contributing to the publication of research on the mental health and well-being of university students are presented in Table 2. Nearly half of the records in the dataset are published in psychology journals. Another influential research area in the field is psychiatry, which captures almost 20% of the publications. Journals on education and educational research also accumulate a considerable number of publications in the field (15%). Other relevant research areas in the field are connected with health and medicine, including public environmental occupational health, substance abuse, general internal medicine, neurosciences neurology, health care sciences services, and nursing. Finally, the field is also grounded, although to a lower extent, in the publications emerging from journals in the social sciences, family studies, and social work research.

All in all, the productivity analysis for journals and research areas showed that most research on mental health and well-being in university students is disseminated in journals in the "psy disciplines"' (i.e., psychology and psychiatry) ( McAvoy, 2014), which is consistent with previous research on mental health in general populations (e.g., Haslam and Lusher, 2011). However, our findings demonstrated that the volume of research in psychology doubles that of research emerging from psychiatric journals. This contrasts with the findings by Haslam and Lusher (2011), who demonstrated that psychiatry journals had a greater influence on mental health research compared to clinical psychology journals and that psychiatry journals accumulate a higher volume of research and citations on mental health research. This is probably because our study includes publications emerging from all branches of psychology, unlike the study by Haslam and Lusher, which included only journals in the field of clinical psychology. Additionally, mental health services in higher education are typically provided by counseling centers led and staffed by non-medical professionals (e.g., psychologists, social workers, counselors, and family therapists) who tend to adopt developmental models of practice grounded in the behavioral sciences and focused on adjustment issues, vocational training, employment, and other personal needs rather than diagnosis and symptom reduction, more common in the biomedical sciences (i.e., psychiatry) ( LeViness et al., 2018; Mitchell et al., 2019).

Productivity II: Leading Authors and Countries/Territories

The 5,561 publications in the dataset were published by a total of 16,161 authors from 119 countries worldwide. Table 3 shows the researchers with the highest number of publications in the field. D. Eisenberg appears as the most productive researcher, followed by K. Peltzer and S. Pengpid. Authors on the list come from diverse geographical backgrounds. Five of the authors work at three different American universities (University of Michigan, Harvard Medical School, and Boston University), two researchers work at KU Leuven University (Belgium), and two other authors are affiliated to the same two universities in Thailand and South Africa. Other prolific researchers are affiliated with higher education institutions in the Netherlands, Egypt, and Germany.

Countries and territories leading research on mental health and well-being of university students are presented in Table 4. The United States is the indisputable leader in this field, publishing more than half of the records in the dataset. This is nearly 10 times the number of publications produced in China, which occupies the second position in the ranking and accounts for nearly 6% of the volume of research in the dataset. Three predominantly English speaking countries/territories complete the top five of the ranking: Canada (265 records), Australia (254), and England (243). The rest of the countries in the list are situated in Europe (Spain, Germany, Turkey), Western Asia (Iran), Africa (South Africa), and East Asia (Japan), which demonstrates that research on college students' mental health and well-being is a matter of concern in different regions of the world, at least to some extent.

Overall, the productivity analysis for authors and countries indicated that the research of mental health and well-being of university students occurs in a variety of locations around the world, especially in developed countries, and in a very prominent way, in the United States. This is not surprising since it is in those countries where better infrastructures and more abundant resources for research are available ( Wong et al., 2006), and a more lasting tradition in the study of mental health, in general, exists ( Gopalkrishnan, 2018). However, Larivière et al. (2013) found that the productivity of the United States on mental health research has dropped significantly and remained stable in other two English speaking countries (the United Kingdom and Canada) since 1980. On the contrary, the number of publications from European countries and the five major emerging national economies (Brazil, Russia, India, China, and South Africa), has experienced remarkable growth, and collectively account nearly for half of the publications in the field. Still, the predominance of knowledge generated in the developed world today, which tends to be grounded on psychiatric and psychological perspectives, might be eclipsing non-traditional views on mental health and well-being that are popular in other regions of the world and, therefore, limiting the development of effective initiatives that align better with local norms, values, and needs in LMICs ( Timimi, 2010; Summerfield, 2013).

Social Structure: Networks of Scientific Collaboration

Research collaboration is regarded as an indicator of quality research and a means to improve research productivity and academic impact (i.e., citations) ( Kim, 2006; Abramo et al., 2009). In particular, international research collaboration is considered a key contributor to the social construction of science and the evolution of scientific disciplines ( Coccia and Wang, 2016). There is recent evidence that national and international research collaborations have been accelerating in recent years ( Gazni et al., 2012; Wagner et al., 2015), especially in applied fields such as medical and psychological disciplines ( Coccia and Bozeman, 2016). In this study, co-authorship analyses were performed to find out patterns in the scientific collaboration between researchers and countries/territories on the mental health and well-being of university students.

Figure 3 demonstrates collaborative ties among authors who published at least 5 articles in the dataset ( n = 179). The map shows the existence of multiple productive collaborative networks of five or more researchers contributing to the development of the field. The largest collaboration network (red cluster) represents an international research group composed of 15 scholars affiliated to universities in the United States, Belgium, and Netherlands. This cluster groups some of the leading scholars in the field, including R. P. Auerbach, R. Brauffaerts, R. C. Kressler, and P. Cuijpers. Moreover, researchers in this cluster lead The WHO World Mental Health International College Student (WMH-ICS) Initiative, a large scale international project aimed at promoting the mental health and well-being of college students around the world through generating epidemiological data of mental health issues in university students worldwide, designing web-based interventions for the prevention and promotion of mental health, and disseminating evidence-based interventions ( Cuijpers et al., 2019). The second biggest cluster (green) represents an intra-national research network that includes 10 researchers from eight different higher education institutions in the United States. The dark blue cluster represents an institutional collaborative network, including nine researchers from the School of Public Health, Puerto Rico. Other prominent clusters in the map represent collaborative research networks between eight (olive color) and seven researchers (turquoise, violet, orange, and mellow mauve). This contrasts, however, with the limited collaboration that exists between clusters. Only four of the clusters on the map demonstrate some kind of scientific collaboration in the field (light blue, pink, brown, and yellow).

Cross-country collaboration networks in mental health and well-being of university students study are presented in Figure 4. Research collaborations between countries with 20 or more publications were considered in this analysis ( n = 45). The United States occupies the central position of the map and shares collaborative ties with all other countries/territories, forming a cluster together with China, South Korea, and Taiwan. Overall, the results suggest that international collaborations in the field are framed to a large extent by cultural, linguistic, and geographical proximity. For instance, the largest cluster (red) is formed by two European countries (Spain and Portugal) and other South American countries with whom they share historical and cultural backgrounds. Other European countries form the purple cluster. Similarly, the blue cluster clearly brings together predominantly English-speaking countries and territories, while the green cluster agglomerates a range of Asian countries.

Collectively, the results of our study suggest that research collaboration in the field of mental health and well-being in university students remains relatively scarce and localized to date. The social structure of the field at the author level could be described as an archipelago formed by a large number of islands (research groups) of different composition and size but with few bridges connecting them, which suggests a relatively fragmented research community. Moreover, while the existence of international collaborative networks was evident in the analysis, they seem to be formed within national borders, between researchers in neighboring countries/territories, or between countries that share cultural, linguistic, and historical heritages. This may be due to the important role that cultural and traditional values play in the conceptualization of mental health and well-being across contexts ( Eshun and Gurung, 2009; Vaillant, 2012; Fernando, 2019). Also, language differences, divergent cross-national institutional and organizational traditions, and increased costs of extramural collaboration, have been found to complicate the formation and continuity of research partnerships in health research ( Hooper et al., 2005; Freshwater et al., 2006). Nevertheless, limited within- and between-country research collaboration arguably poses challenges to the development of a field in terms of lost opportunities to challenge assumptions taken for granted and move toward fresh perspectives, push boundaries in methods and techniques, meet diverse groups of people from differing cultures and get immersed in those cultures, share information, resources, and skills, and address common mental health problems through the pooling of resources ( Rolfe et al., 2004; Freshwater et al., 2006).

Intellectual Structure: Disciplines Underlying the Foundations of the Field

Interdisciplinarity is considered as a valuable approach to address the complex and multidimensional nature of health and well-being ( Mabry et al., 2008). Buckton (2015) argues that the integration of medical, psychological, and social sciences have contributed to generate "new insights into theory, practice, and research in mental health and development." (3). To examine the disciplines underlying research on the mental health and well-being of university students, a journal co-citation analysis was performed. In this analysis, only journals with at least 50 citations were considered ( n = 593). The nodes on the map represent journals and their size reflects the number of co-citation relationships with other journals. Colors account for journal clusters, which agglutinate journals with higher co-citation relationships and stronger semantic connectedness. Clusters were interpreted and labeled accounting for the WoS categorization of the journals with the highest co-citation links within each cluster. For example, if the Journal of Personality and Social Psychology, the Journal of Counseling Psychology, and Personality and Individual Differences clustered together, this group was interpreted as the personality, social, and counseling psychology cluster.

In general, the findings of this study suggest that research on mental health and well-being in university students is interdisciplinary, to a certain extent, and mainly emerges from the convergence of research conducted in the behavioral and biomedical sciences, as it has been suggested elsewhere ( Schumann et al., 2014; Wittchen et al., 2014b). More specifically, the map shows that the research in the mental health and well-being of university students is constructed through the integration of knowledge generated in five interconnected disciplines (see Figure 5). To the left of the map, the red cluster integrates journals on personal, social, and counseling psychology. To the right, the blue cluster represents the contribution of psychiatric journals to research to the formation and development of the field. At the top, the yellow cluster groups journals on substance abuse and issues related to alcohol consumption, addiction, and interpersonal violence. At the bottom of the map, journals covering topics on eating behaviors, sleep, and other issues related to physical health converge on the green cluster. At the center of the map is the purple cluster, which includes journals in the area of clinical psychology and behavioral therapy.

More broadly, the findings suggest that biomedical sciences contribute to a large extent to the composition of the field. Psychiatric research emerged in our study as an obvious building block in the study of university students' mental health and well-being, which is not surprising considering the historical contributions of biomedical disciplines to mental health research ( Schwartz and Corcoran, 2010). Within the behavioral sciences, personality and social psychology, which explores processes and mechanisms through which social phenomena influence mental health and well-being ( Sánchez Moreno and Barrón López de Roda, 2003), appears as a key discipline underlying the foundations of the field. Surprisingly, clinical psychology journals occupy a central position in the map and demonstrate co-citation relationships with journals from all other clusters but make up the most dispersed network and account for a considerably lower volume of co-citation relationships in the field. This suggests that clinical psychology journals are more subordinate to journals in other disciplines in terms of citations flows, and ultimately, play a less unique role in research on the mental health and well-being of university students, as suggested by Haslam and Lusher (2011). Interestingly, research arising from the social sciences (e.g., sociology and anthropology) does not seem to make a distinctive contribution to the intellectual structure of the field, which suggests that the influence of social contexts and cultures on university students' mental health and well-being (e.g., inequality, social norms, public policies, cultural beliefs, and values) is an underexplored research area. Still, the density of co-citation network relationships within and between clusters is particularly noteworthy, considering the lack of common language between disciplines, the absence of a shared philosophy of practice on mental health, and the tensions between medical, psychological, and social explanations of mental distress ( Bailey, 2012).

Conceptual Structure: Topical Foci Addressed in the Literature Over the Last 45 Years

The topical foci of research on the mental health and well-being of university students during the 1975-January 2020 period are presented in Figure 6. The map offers a visual representation of the co-occurrence analysis of author keywords of all the publications included in the dataset. Only the most frequently occurring keywords (25+ occurrences) were considered in the analysis ( n = 84). Items that were not related to others and do not belong to the existing clusters were excluded. The size of the nodes indicates the occurrence of author keywords in the dataset and the thickness of edges represents the co-occurrence strength between pairs of keywords.

The most frequent keywords in the dataset, excluding students' descriptors (e.g., college students and university students), refer to common mental health challenges experienced by university students such as depression ( n = 612), anxiety ( n = 353), and stress ( n = 341). Salutogenic-related keywords such as well-being and life satisfaction occurred less often ( n = 138, n = 113, respectively), suggesting that pathogenic approaches to the exploration of mental health issues in higher education are more widespread. More broadly, seven general themes seem to summarize the topical foci of interest in the field of mental health and well-being of university students over the last 45 years. First, there has been a general interest in positive mental health, as denoted by frequently co-occurring key terms such as well-being, self-esteem, life satisfaction, social support, emotional intelligence, and happiness (red cluster). Second, mental disorders stand as another theme widely addressed in the literature, with a special emphasis on depression, anxiety, and to a lesser extent, suicide and suicidal ideation (green cluster). A third topical area in this field has been substance abuse, most predominantly alcohol consumption (blue cluster). The fourth theme reflects college counseling for mental health, including interventions and protective factors such as mindfulness, stress management, spirituality, and help-seeking (yellow cluster). Other topics reflected in the map are mental illness stigma (purple), stress (e.g., psychological distress and coping) (light blue), and mental health measurement (orange).

Conclusion

This study provides a comprehensive overview of the research on university students' mental health and well-being in the last 45 years using bibliometric indicators. In general, the results reveal interesting trends in the evolution of the field over the last four decades and promising scientific patterns toward a better understanding of the mental health and well-being of university students internationally. First, the interest in the mental health and well-being of university students has grown in the last decades and in a very significant way during the last 10 years, indicating that this area has not still reached its maturity period and will continue developing in the future. Second, research in the field is relatively interdisciplinary and emerges from the convergence of research conducted in several disciplines within the behavioral and biomedical sciences. Third, research in this field is produced by a community of productive researchers coming from several regions around the world, most notably in the United States, which secures a generation of scholars that will continue shaping the field in the years to come. Fourth, over the last 45 years, researchers have been able to address a multitude of research topics in the field, including positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement.

However, this study also identified some issues that could be hindering the development of the study of the mental health and well-being of university students. For example, the research available overrepresents theoretical and disciplinary approaches from the developed world. Additional studies on the field from developing economies and LMICs are needed to provide a more comprehensive picture and ensure a fair representation of the multiple perspectives available in the field. Such studies would inform administrators and practitioners on how to broaden and enrich available programs and initiatives to promote mental health and well-being in higher education contexts in order to offer alternative forms of support that university students find appropriate for their social and cultural values. Moreover, the research community contributing to the development of the field is relatively fragmented. There are multiple research groups but little research collaborations between them and, at the international level, these connections tend to be limited by geographic, cultural, and language proximity. In this context, more actions like the WMH-ICS Initiative could provide a partial solution to this problem by strengthening national and international research partnerships and facilitating knowledge exchange across regions. Also, special issues in the core journals in the field inviting cross-cultural studies on the topic could contribute to promoting research collaboration across regions and research in less represented countries. The field would also benefit from a greater volume of research from the social sciences and humanities exploring the influence of social, cultural, economic, and educational factors on the conceptualization, manifestation, and experience of mental health and well-being. Moreover, more studies emerging from disciplines such as sociology, anthropology, business, and education, would likely increase the permeability of positive mental health concepts into the field and contribute to the promotion of salutogenic approaches to the study of mental health and well-being of university students.

This study has several limitations. First, publications were retrieved only from the WoS database, which limits the generalizability of the findings. Second, WoS provides stronger coverage of Life Sciences, Biomedical Sciences, and Engineering, and includes a disproportionate number of publications in the English language ( Mongeon and Paul-Hus, 2016). This could partially explain the low number of publications emerging from the Social Sciences, the Arts, and the Humanities, and research conducted in non-English speaking countries in the present study. Third, only journal articles were retrieved for analysis, excluding other relevant publications in the field such as reviews, book chapters, and conference proceedings. Future studies could replicate the findings of this study using alternative databases (e.g., Scopus and PubMed) or a combination of them, as well as different filters in the search strategy, to provide an alternative coverage of research conducted in the field. Nevertheless, we believe that the bibliometric approach used in this study offers novel insights about the development and current status of the field and some of the challenges that undermine its progression.

Data Availability Statement

The datasets generated for this study are available on request to the corresponding author.

Author Contributions

DH-T and LI contributed to conception and design of the study, organized the database, and performed the statistical analysis. DH-T, LI, and JS wrote the first draft of the manuscript. NL, AC, AA, YN, and AM wrote the sections of the manuscript.

Funding

This research was funded by the Nazarbayev University Faculty-Development Competitive Research Grants Program (Reference Number 240919FD3902).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Footnotes

References

LeViness, P., Bershad, C., Gorman, K., Braun, L., and Murray, T. (2018). The Association for University and College Counseling Center Directors Annual Survey. Available online at: https://www.aucccd.org/assets/documents/Survey/2018%20AUCCCD%20Survey-Public-June%2012-FINAL.pdf (accessed February 24, 2020).
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Mental Health and Well-Being of University Students: A Bibliometric Mapping of the Literature

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The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975-2020.

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Mental Health and Well-Being During Pandemic

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Mental Health and Well-Being During Pandemic

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https://www.hsph.harvard.edu/india-center/health-and-well-being-during-covid-19/

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It is difficult to maintain a healthy lifestyle when we are in the middle of a crisis like this. The uncertainty, and worries related to finances, childcare, elderly parents, and job security disrupt our routines, our lifestyles and mental health. The uncertainty about the future, the ceaseless news coverage and constant social media driven flood of messages can increase our sense of anxiety. Stress is a normal response to these types of situations. Stress disturbs our sleeping and eating patterns, leads to irritability or emotional outbursts, low motivation, and changes in use of alcohol or other drugs. Please do not hesitate to seek help if you are experiencing anything like this.* It is also important to maintain a healthy lifestyle and get back into a routine.
Here are some tips to manage stress and promote your mental, physical and social well-being.
* India: A psycho-social toll-free helpline number 08046110007 has been started by the National Institute of Mental Health and Neurosciences (NIMHANS) with the Ministry of Health and Family Welfare.

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It is difficult to maintain a healthy lifestyle when we are in the middle of a crisis like this. The uncertainty, and worries related to finances, childcare, elderly parents, and job security disrupt our routines, our lifestyles and mental health.

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https://namica.org/blog/impact-on-the-mental-health-of-students-during-covid-19/

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School During the Pandemic: Mental Health Impacts on Students

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School During the Pandemic: Mental Health Impacts on Students

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https://www.frontiersin.org/articles/10.3389/fpsyg.2020.01226/full

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Graduate School of Education, Nazarbayev University, Nur-Sultan, Kazakhstan

Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan

Psychological Counseling Center, Nazarbayev University, Nur-Sultan, Kazakhstan

The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975-2020. More specifically, this study uses bibliometric procedures to describe and visually represent the available literature on mental health and well-being in university students in terms of the growth trajectory, productivity, social structure, intellectual structure, and conceptual structure of the field over 45 years. Key findings of the study are that research on mental health and well-being in university students: (a) has experienced a steady growth over the last decades, especially since 2010; (b) is disseminated in a wide range of journals, mainly in the fields of psychology, psychiatry, and education research; (c) is published by scholars with diverse geographical background, although more than half of the publications are produced in the United States; (d) lies on a fragmented research community composed by multiple research groups with little interactions between them; (e) is relatively interdisciplinary and emerges from the convergence of research conducted in the behavioral and biomedical sciences; (f) tends to emphasize pathogenic approaches to mental health (i.e., mental illness); and (g) has mainly addressed seven research topics over the last 45 years: positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement. The findings are discussed, and the implications for the future development of the field are highlighted.

Introduction

The entrance to the university marks a period of transition for young people. Through this transition, students face new challenges, such as making independent decisions about their lives and studies, adjusting to the academic demands of an ill-structured learning environment, and interacting with a diverse range of new people. In addition, many students must, often for the first time, leave their homes and distance themselves from their support networks ( Cleary et al., 2011). These challenges can affect the mental health and well-being of higher education students. Indeed, there is evidence that a strain on mental health is placed on students once they start at the university, and although it decreases throughout their studies ( Macaskill, 2013; Mey and Yin, 2015), it does not return to pre-university levels ( Cooke et al., 2006; Bewick et al., 2010). Also, the probabilities of experiencing common psychological problems, such as depression, anxiety, and stress, increase throughout adolescence and reach a peak in early adulthood around age 25 ( Kessler et al., 2007) which makes university students a particularly vulnerable population.

The interest in mental health and well-being in university students has grown exponentially in the last decades. This is likely due to three interrelated challenges. First, although university students report levels of mental health similar to their non-university counterparts ( Blanco et al., 2008), recent studies suggest an increase and severity of mental problems and help-seeking behaviors in university students around the world in the last decade ( Wong et al., 2006; Hunt and Eisenberg, 2010; Verger et al., 2010; Auerbach et al., 2018; Lipson et al., 2019). Some researchers refer to these trends as an emerging "mental health crisis" in higher education ( Kadison and DiGeronimo, 2004; Evans et al., 2018). Second, psychological distress in early adulthood is associated with adverse short-term outcomes, such as poor college attendance, performance, engagement, and completion (e.g., King et al., 2006; Antaramian, 2015), and others in the long term, such as dysfunctional relationship ( Kerr and Capaldi, 2011), recurrent mental health problems, university dropout, lower rates of employment, and reduced personal income ( Fergusson et al., 2007). Third, there is a widespread agreement that higher education institutions offer unique opportunities to promote the mental health and well-being of young adults as they provide a single integrated setting that encompasses academic, professional, and social activities, along with health services and other support services ( Eisenberg et al., 2009; Hunt and Eisenberg, 2010). However, the majority of university students experiencing mental health problems and low levels of well-being are not receiving treatment ( Blanco et al., 2008; Eisenberg et al., 2011; Lipson et al., 2019) and, while universities continue to expand, there is a growing concern that the services available to provide support to students are not developing at an equivalent rate ( Davy et al., 2012).

In response to the increasing volume of research on the mental health and well-being of university students, there have been several attempts to synthesize the accumulating knowledge in the field and to provide an illustration of the theoretical core and structure of the field using traditional content analysis of the literature (e.g., Kessler et al., 2007; Gulliver et al., 2010; Hunt and Eisenberg, 2010; Sharp and Theiler, 2018). This study aims to extend the understanding of mental health in university students by providing a bird's eye view of the research conducted in this field in recent decades using a bibliometric approach. Bibliometric overviews provide an objective and systematic approach to discover knowledge flows and patterns in the structure of a field ( Van Raan, 2014) reveal its scientific roots, identify emerging thematic areas and gaps in the literature ( Skute et al., 2019) and, ultimately, contribute to moving the field forward. Accordingly, this study employs several bibliometric indicators to explore the evolution of the field based on publication and citation trends, key actors and venues contributing to the advancement of research on mental health and well-being of university students, and the structure of the field in terms of patterns of scientific collaborations, disciplines underlying the foundations of the field, and recurrent research themes explored in the literature. This is important because, despite significant advances in the field, research on mental health and well-being remains a diverse and fragmented body of knowledge ( Pellmar and Eisenberg, 2000; Bailey, 2012; Wittchen et al., 2014a). Indeed, mental health and well-being are nebulous concepts and their history and development are quite intricate, with a multitude of perspectives and contributions emerging from various disciplines and contexts (see section "Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview"). Therefore, mapping research on mental health and well-being in university students is essential to identify contributions and challenges to the development of the field, to help guide policy, research, and practice toward areas, domains, populations, and contexts that should be further explored, and to provide better care of students at higher education institutions ( Naveed et al., 2017).

Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview

This section provides an overview of the different perspectives adopted in the literature to conceptualize mental health, well-being, and other relevant constructs in order to identify the glossary of key terms that will be used in the search strategy to create a comprehensive corpus of documents on mental health and well-being in university students for this bibliometric review.

Perspectives on Mental Health and Mental Illness

There is no general agreement on the definition of mental health. For a long time, the term mental health has been used as a euphemism for mental illness ( Manwell et al., 2015). However, mental health and mental illness are regarded as distinct constructs nowadays and two main perspectives differentiating between mental health and illness are available in the literature. The continuum approach considers that mental health and mental illness are the two opposite poles of a continuum. Thus, there are various degrees of health and illness between these poles, with most of us falling somewhere in between. The categorical approach, on the other hand, represents mental health and illness as a dichotomy. People who manifest mental illness symptoms would belong to that category and labeled correspondingly, while those absent of these symptoms can be considered as mentally healthy ( Scheid and Brown, 2010).

Disciplinary Approaches to the Conceptualization of Mental Health/Illness

Conceptualizations of mental health/illness are largely dependent on the theoretical and paradigmatic foundations of the disciplines from which they emerge. In this context, the field has progressively evolved through the accumulation of knowledge generated in a diverse range of disciplines in the biomedical, behavioral, and social sciences. Biomedical disciplines are grounded in the medical paradigm focused on disease and (ab)normality and often emphasize dichotomous conceptions of mental health/illness ( Scheid and Brown, 2010). Research on mental health and well-being in this domain has been traditionally conducted from a psychiatric perspective, which aims to understand the dysfunctionality in the brain that leads to psychiatric symptoms and to also offer a pharmacological treatment to correct neuronal dysfunctions. Consequently, psychiatrists have historically considered mental health as a disease of the brain (e.g., depression), similar to any other physical disease, caused by genetic, biological, or neurological factors ( Schwartz and Corcoran, 2010). While the prevalence of psychiatric approaches to mental health is currently incontestable, the development of other biomedical disciplines has tremendously contributed to the progression of the field in recent decades. For example, Insel and Wang (2010) argue that insights gained from genetics and neuroscience contribute to the reconceptualization of "the disorders of the mind as disorders of the brain and thereby transform the practice of psychiatry." (1979). In addition to that, other disciplines such as behavioral medicine have made important contributions to the field, although it has recently argued that mental health and behavioral medicine should be as two separate fields ( Dekker et al., 2017).

Within the behavioral sciences, the study of mental health focuses on the distinct psychological processes and mechanisms that prompt thoughts, feelings, and behaviors ( Peterson, 2010). Clinical psychology has the longest tradition in the psychological study of mental health and tends to focus on the assessment and treatment of mental illness and disorders that can alleviate psychological distress or promote positive states of being ( Haslam and Lusher, 2011). However, significant contributions to the field have also emerged from other branches of psychology less focused on psychopathology, including personality and social psychology, psychoanalysis, humanistic psychology, and cognitive psychology ( Peterson, 2010). Despite the diversity of theories, principles, and methodological approaches to understanding mental health within the behavioral sciences, these disciplines acknowledge that mental health have a biological basis and reside in the social context, and tend to prioritize continuum approaches to mental health ( Scheid and Brown, 2010).

Perspectives from the social sciences complement the biomedical and behavioral approaches by considering the influence of social and cultural environments in mental health/illness ( Horwitz, 2010). For example, sociologists are interested in how social circumstances (e.g., level of support available) affect levels of mental health/illness and how social structures shape the understanding and response to mental health issues [see Compton and Shim (2015) for an overview of the social determinants of mental health]. Similarly, medical anthropologists attend to the mental health beliefs and practices that form the cultural repertory within and across populations ( Foster, 1975). Beyond sociology and anthropology, social researchers in the fields of business and economics, family and ethnic studies, and educational research have also played a key role in advancing research on mental health in different directions.

The Importance of the Context in Mental Health

Certainly, most notions of mental health/illness in the literature derive from prevailing psychiatric and psychological traditions developed in Western countries ( Gopalkrishnan, 2018). However, cultural values and traditions do shape how mental health and mental illness are conceptualized across contexts ( Vaillant, 2012). In this regard, Eshun and Gurung (2009) pointed out that "culture influences how individuals manifest symptoms, communicate their symptoms, cope with psychological challenges, and their willingness to seek treatment." (4). Fernando (2019) argued that issues related to the 'mind' developed and are often interpreted very differently in non-Western and Low- and Middle-Income Countries (LMICs). For example, cultures explain the manifestation of certain feelings and behaviors based on a range of motives including biological, psychological, social, religious, spiritual, supernatural, and cosmic. Failure to acknowledge alternative non-Western approaches to mental health and mental illness has resulted in imbalances of knowledge exchange and the permeation of dominating Western narratives into LMICs (i.e., so-called medical imperialism) ( Timimi, 2010; Summerfield, 2013). To address this issue, scholars have advocated for a greater willingness to embrace pluralism in the conceptualization of mental health and illness, which might help people to engage with particular forms of support that they deem to be appropriate for them, and to explore how knowledge and practices developed in LMICs can benefit those living in higher-income countries (i.e., knowledge "counterflow") (see White et al., 2014).

Prioritizing Positive Mental Health: The Science of Well-Being

Despite the diversity of disciplinary and contextual approaches to mental health, current definitions of mental health have two things in common. First, mental health is considered from a biopsychosocial point of view that incorporates biological, psychological, and social factors. Second, mental health implies something beyond the absence of mental illness (e.g., Bhugra et al., 2013; Galderisi et al., 2015). An example is the definition by the World Health Organization which refers to mental health as "a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community" ( World Health Organization, 2004). This definition contributed to substantial progress in research and practice in the field as it expanded the notion of mental health beyond the absence of mental illness and integrated the presence of positive features ( Galderisi et al., 2015).

Research on positive mental health is relatively new but has grown rapidly in the last decades fueled by advocates of positive medicine and psychology, who have argued for a change of paradigm from medical and psychopathological-oriented models of mental health that focus on disorders and illness toward more strength-based approaches, which pay more attention to what is right about people and positive attributes and assets ( Kobau et al., 2011). In this regard, the term mental well-being has been progressively incorporated into the study of mental health to account for the positive aspects of mental health beyond the absence of negative factors. While there is not a universally accepted definition of well-being, two perspectives have dominated the discourses on well-being in the literature: subjective well-being (SBW) and psychological well-being (PWB). SWB is based on hedonic perspectives of pleasure and represents "people's beliefs and feelings that they are living a desirable and rewarding life" ( Diener, 2012). SBW is strongly linked with the idea of happiness and is typically understood as the personal experience of high levels of positive affect, low levels of negative affect, and high satisfaction with one's life ( Deci and Ryan, 2008). PWB is grounded in Aristotelian ideas about eudaimonia, i.e., self-realization, with the ultimate aim in life being to strive to realize one's true potential ( Ryff and Singer, 2008). PWB has been broadly defined as a state of positive psychological functioning and encompasses six dimensions: purpose in life (i.e., the extent to which respondents felt their lives had meaning, purpose, and direction); autonomy (i.e., whether they viewed themselves as living in accord with their own convictions); personal growth (i.e., the extent to which they were making use of their personal talents and potential); environmental mastery (i.e., how well they were managing their life situations); positive relationships (i.e., the depth of connection they had in ties with significant others); and self-acceptance (i.e., the knowledge and acceptance they had of themselves, including awareness of personal limitations) ( Ryff, 1989).

Integrating Mental Health, Mental Illness, and Well-Being

The contribution of positive mental health frameworks to the advancement of the field has been undeniable. However, definitions that overemphasize positive emotions and productive functioning as key indicators of mental health have been recently challenged because of the potential they have to discriminate against individuals and groups that, for example, might not be able to work productively or function within the environment because of individual physical characteristics or contextual constraints ( Galderisi et al., 2015). To address these issues, Keyes has successfully integrated the notions of mental illness, mental health, well-being, and other related terms in the literature into a conceptual framework that allows for a more comprehensive understanding of mental health ( Keyes, 2005, 2007; Keyes and Michalec, 2010). The model argues that neither pathogenic approaches focusing on the negative (e.g., mental illness) nor salutogenic approaches focusing on the positive (e.g., well-being) can alone accurately describe the mental health of a person ( Keyes and Michalec, 2010). Instead, the model proposes that mental illness and well-being represent two correlated but differentiated latent continua in defining mental health. More specifically, mental illness and well-being lie on two separate spectra, the first going from absent to present mental illness and the second running from low to high well-being ( Slade, 2010). The absence of mental illness, therefore, does not necessarily imply high levels of well-being. Correspondingly, low levels of well-being do not always indicate the presence of mental illness. Further, in this model, mental health is defined as not only the absence of mental illness, not the mere presence of high well-being. Complete mental health (i.e., flourishing) is a result of experiencing low mental illness and high levels of well-being. Incomplete mental health (i.e., languishing), on the other hand, refers to the absence of mental illness symptoms and low reported levels of well-being. Two other conditions are possible within this framework. Incomplete mental illness (i.e., struggling) refers to high levels of well-being accompanied by high mental illness symptoms. Lastly, complete mental illness (i.e., floundering) accounts for low levels of well-being and high mental illness symptoms ( Keyes and Lopez, 2002).

The Present Study

In light of the complexity of the constructs of mental health and well-being and the multiple theoretical, disciplinary, and contextual approaches to their conceptualization, this study seeks to map out the terrain of international research and scholarship on mental health and university students for the period 1975-2020. More specifically, this study aims to provide new insights into the development and current state of mental health research in university students by mapping and visually representing the literature on mental health and well-being of university students over the last 45 years in terms of the growth trajectory, productivity, and social, intellectual, and conceptual structure of the field. First, the study describes the development of research mental health and well-being in university students examining the trends in publication and citation data between 1975 and 2020 (i.e., growth trajectory). Second, the study identifies the core journals and the research areas contributing most to the development of the field, as well as the key authors and countries leading the generation and dissemination of research on mental health and well-being in university populations (i.e., productivity). Third, the study outlines the networks of scientific collaboration between authors, and countries (i.e., social structure). Fourth, the scientific disciplines underlying the intellectual foundations of research on mental health and well-being in university settings (i.e., intellectual structure) are uncovered. Fifth, the study elucidates the topical foci (i.e., conceptual structure) of the research on the mental health and well-being of university students over the last 45 years.

Materials and Methods

A bibliometric approach was used in this study to map the literature on mental health and well-being in university students over the last 45 years using metadata extracted from four indexes of the Web of Science (WoS): The Science Citation Index-Expanded (SCI-Expanded); the Social Sciences Citation Index (SSCI); the Arts & Humanities Citation Index (A&HCI); and the Emerging Sources Citation Index (ESCI). Several reasons justified the selection of the WoS database in this study. First, the WoS remains as the standard and most widely used for bibliometric analysis ( Meho and Yang, 2007). Second, the WoS is a multidisciplinary database and includes publications on mental health and well-being emerging from distinctive research areas and disciplines published in more than 20,000 journals ( McVeigh, 2009). Using specialized databases such as PubMed would introduce biases into the search strategy favoring biomedical research disciplines. Still, it is important to note that interdisciplinary databases such as WoS and Scopus discriminate against publications in the Social Sciences and Humanities and publications in languages other than the English language ( Mongeon and Paul-Hus, 2016), so the picture provided by WoS is still imperfect. Third, while other databases might provide wider coverage, WoS includes publication and citation information from 1900. For example, Scopus has complete citation information only from 1996 ( Li et al., 2010). Moreover, Google Scholar provides results of inconsistent accuracy in terms of citations, and citation analyses in PubMed are not available ( Falagas et al., 2008). Fourth, WoS has demonstrated better accuracy in its journal classification system compared to Scopus database ( Wang and Waltman, 2016).

The methodological approach used in this study is presented in Figure 1 and further elaborated in the following paragraphs.

Search Strategy

To create a comprehensive corpus of documents on the mental health and well-being of university students, three parallel searches were performed, which accounted for the multiple approaches and perspectives that have been used in the field, as identified in the Section "Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview." All the searches were conducted in the last week of January 2020. The first search aimed at capturing research on mental health broadly and included one single keyword in the topic field: ["mental health"]. The second search was implemented to capture research focusing on pathogenic approaches to mental health. Key terms used in the literature to refer to the negative side of mental health, as well as the most frequent mental health problems experienced by university students, were introduced in this search in the title field: ["mental illness," "mental disorder ∗," "mental distress," "psychological distress," "psychopathology," "depression," "anxiety," "stress," "suicide," "eating disorder ∗," "substance use"]. In the third search, keywords reflecting salutogenic approaches to mental health were input. These included terms related to mental health from a positive mental health perspective (i.e., well-being). These key terms were added in the title field and included the following: ["well-being," "wellbeing," "wellness," "life satisfaction," "happiness," "positive affect," "purpose in life," "personal growth," "self-determination"].

To retrieve research relevant only to higher education students, another set of keywords was imputed in all three searches in the title field. These included: ["university," "college," "higher education," "tertiary education," "post-secondary education," "postsecondary education," "undergrad ∗ student," "grad ∗ student," "master's student," "doctoral student," "Ph.D. student"]. The Boolean operator OR was used between keywords in all the three searches to secure a higher number of relevant hits. Also, asterisks were used as wildcards to account for multiple variations in several keywords (e.g., disorder and disorder-s). All searches were limited to journal articles published between 1975 and 2020 (both inclusive). No restrictions on language were implemented in the search.

The search strategy retrieved a total of 6,356 hits ( n search 1 = 2782; n search 2 = 2814, n search 3 = 760). After the removal of duplicates, 5,561 research articles were finally selected and retained for the study. For each of the documents obtained in the search, the authors extracted metadata about the title of the paper, the year of publication, the journal, the number of citations, and the authors' name, organization, and country. Also, the title, the abstract, the author's keywords, and cited references were retrieved.

Data Analysis Procedures

The corpus of the literature was then analyzed using descriptive and bibliometric approaches to provide an overall picture of the evolution and current state of the research on mental health and wellbeing in university settings. Frequency counts of the number of publications and citations per year were obtained to describe the growth trajectory of research on the mental health and well-being of university students. Rank ordered tables were produced to describe the productivity of the field in terms of core journals and research areas, as well as leading scholars and countries contributing to the development of the field.

Bibliometric analyses in VOSViewer software were implemented to examine and visually represent the social, intellectual, and conceptual structure of the field. VOSViewer is a freely available computer software for viewing and constructing bibliometric maps. In VOSViewer, the units of analysis are journals, publications, citations, authors, or countries, depending on the focus of the analysis. The units of analysis are represented in the maps as circular nodes. The size of the node accounts for volume (e.g., number of publications in the dataset by an author) and the position represents the similarity with other nodes in the map. Closer nodes are more alike than nodes far apart from each other. The lines connecting nodes represent the relationship between nodes and their thickness indicates the strength of that relationship. Finally, the color of the node denotes the cluster to which each node has been allocated. Nodes are clustered together based on relatedness ( Van Eck et al., 2010). The software uses a distance-based approach to constructing the bibliometric maps in three steps ( Van Eck and Waltman, 2014). In the first step, the software normalizes the differences between nodes. In the second step, the software builds a two-dimensional map where the distance between the nodes reflects the similarity between these nodes. In the third step, VOSViewer groups closely related nodes into clusters ( Van Eck and Waltman, 2014).

A series of co-authorship analyses were performed to examine the social structure of research on mental health and well-being in university students. In these analyses, the units of analysis were authors and countries/territories. Each node in the map represents an author or a country/territory and the lines connecting them reflect the relationship between nodes. Clusters represent networks of scientific collaboration, which might be interpreted as groups of authors or countries frequently publishing together (e.g., research groups in the case of authors).

Co-citation analysis of journals was implemented to explore the intellectual structure of the field. Here, the units of analysis were journals in the dataset and the map reflects co-citation relationships between journals. Two journals are co-cited if there is a third journal citing these two. The more times a pair of journals are cited by other journals, the stronger their co-citation relationship will be. Frequently co-cited journals are assumed to share theoretical and semantical grounds. Therefore, in our study, clusters of frequently co-cited journals can be interpreted as disciplines underlying the foundations of research on mental health and well-being in university students.

Finally, a co-occurrence analysis of keywords was used to uncover the conceptual structure of the field. The units of analysis, in this case, were the authors' keywords. The more often two keywords appear in the same record, the stronger their co-occurrence relationship. Clusters of co-occurring keywords represent in this study the topical foci (i.e., knowledge base) that have been addressed in the literature in mental health and well-being in university students in the last 45 years.

Findings and Discussion

Growth Trajectory: Evolution of Publications and Citations in the Field

The developmental patterns of a particular field can be well demonstrated by trends in publications and citations. The 5,561 publications in the dataset have been cited 87,096 times, with an average of 15.6 citations per item. Figure 2 shows the growth trajectory of publication data of research on mental health and well-being in university students from 1975 to January 2020. Overall, the trends demonstrate a gradual increase in the scholarly interest in the mental health of university students over the last 45 years that can be organized in three stages: an emergence stage, in which publications rose slowly (1975-2000); a fermentation stage, with a notable increase in publications in the field (2000-2010); and a take-off stage, during which the number of records published per year in the field has almost risen 10 times (2010-2020). The steady increase of publications in the last 15 years coincides with the first calls for attention on the increase and severity of mental problems and help-seeking behaviors of college students ( Kadison and DiGeronimo, 2004; Evans et al., 2018), potentially indicating a growing interest in exploring the epidemiology of mental disorders and the role of universities in promoting the mental health and well-being of students. A similar pattern has also been observed in a recent bibliometric study examining global research on mental health both in absolute terms and as a proportion of all papers published in medicine and across disciplines, which certainly reflects an increase in the general interest in the field ( Larivière et al., 2013).

Productivity I: Core Journals and Research Areas

In total, 1,560 journals published the 5,561 records included in the dataset. Table 1 presents the ten core journals in the field. The Journal of American College stands out as the main publication venue in the field, accumulating around 5% of the publications in the dataset ( n = 270). Psychological Reports and Journal of College Student Development also stand out, publishing 119 and 102 studies, respectively. The Journal of Counseling Psychology ranks fourth in the list with 83 records. Despite being an interdisciplinary and relatively young journal, Plos One appears in the top five journal publishing research on mental health and well-being in university students.

The top research areas contributing to the publication of research on the mental health and well-being of university students are presented in Table 2. Nearly half of the records in the dataset are published in psychology journals. Another influential research area in the field is psychiatry, which captures almost 20% of the publications. Journals on education and educational research also accumulate a considerable number of publications in the field (15%). Other relevant research areas in the field are connected with health and medicine, including public environmental occupational health, substance abuse, general internal medicine, neurosciences neurology, health care sciences services, and nursing. Finally, the field is also grounded, although to a lower extent, in the publications emerging from journals in the social sciences, family studies, and social work research.

All in all, the productivity analysis for journals and research areas showed that most research on mental health and well-being in university students is disseminated in journals in the "psy disciplines"' (i.e., psychology and psychiatry) ( McAvoy, 2014), which is consistent with previous research on mental health in general populations (e.g., Haslam and Lusher, 2011). However, our findings demonstrated that the volume of research in psychology doubles that of research emerging from psychiatric journals. This contrasts with the findings by Haslam and Lusher (2011), who demonstrated that psychiatry journals had a greater influence on mental health research compared to clinical psychology journals and that psychiatry journals accumulate a higher volume of research and citations on mental health research. This is probably because our study includes publications emerging from all branches of psychology, unlike the study by Haslam and Lusher, which included only journals in the field of clinical psychology. Additionally, mental health services in higher education are typically provided by counseling centers led and staffed by non-medical professionals (e.g., psychologists, social workers, counselors, and family therapists) who tend to adopt developmental models of practice grounded in the behavioral sciences and focused on adjustment issues, vocational training, employment, and other personal needs rather than diagnosis and symptom reduction, more common in the biomedical sciences (i.e., psychiatry) ( LeViness et al., 2018; Mitchell et al., 2019).

Productivity II: Leading Authors and Countries/Territories

The 5,561 publications in the dataset were published by a total of 16,161 authors from 119 countries worldwide. Table 3 shows the researchers with the highest number of publications in the field. D. Eisenberg appears as the most productive researcher, followed by K. Peltzer and S. Pengpid. Authors on the list come from diverse geographical backgrounds. Five of the authors work at three different American universities (University of Michigan, Harvard Medical School, and Boston University), two researchers work at KU Leuven University (Belgium), and two other authors are affiliated to the same two universities in Thailand and South Africa. Other prolific researchers are affiliated with higher education institutions in the Netherlands, Egypt, and Germany.

Countries and territories leading research on mental health and well-being of university students are presented in Table 4. The United States is the indisputable leader in this field, publishing more than half of the records in the dataset. This is nearly 10 times the number of publications produced in China, which occupies the second position in the ranking and accounts for nearly 6% of the volume of research in the dataset. Three predominantly English speaking countries/territories complete the top five of the ranking: Canada (265 records), Australia (254), and England (243). The rest of the countries in the list are situated in Europe (Spain, Germany, Turkey), Western Asia (Iran), Africa (South Africa), and East Asia (Japan), which demonstrates that research on college students' mental health and well-being is a matter of concern in different regions of the world, at least to some extent.

Overall, the productivity analysis for authors and countries indicated that the research of mental health and well-being of university students occurs in a variety of locations around the world, especially in developed countries, and in a very prominent way, in the United States. This is not surprising since it is in those countries where better infrastructures and more abundant resources for research are available ( Wong et al., 2006), and a more lasting tradition in the study of mental health, in general, exists ( Gopalkrishnan, 2018). However, Larivière et al. (2013) found that the productivity of the United States on mental health research has dropped significantly and remained stable in other two English speaking countries (the United Kingdom and Canada) since 1980. On the contrary, the number of publications from European countries and the five major emerging national economies (Brazil, Russia, India, China, and South Africa), has experienced remarkable growth, and collectively account nearly for half of the publications in the field. Still, the predominance of knowledge generated in the developed world today, which tends to be grounded on psychiatric and psychological perspectives, might be eclipsing non-traditional views on mental health and well-being that are popular in other regions of the world and, therefore, limiting the development of effective initiatives that align better with local norms, values, and needs in LMICs ( Timimi, 2010; Summerfield, 2013).

Social Structure: Networks of Scientific Collaboration

Research collaboration is regarded as an indicator of quality research and a means to improve research productivity and academic impact (i.e., citations) ( Kim, 2006; Abramo et al., 2009). In particular, international research collaboration is considered a key contributor to the social construction of science and the evolution of scientific disciplines ( Coccia and Wang, 2016). There is recent evidence that national and international research collaborations have been accelerating in recent years ( Gazni et al., 2012; Wagner et al., 2015), especially in applied fields such as medical and psychological disciplines ( Coccia and Bozeman, 2016). In this study, co-authorship analyses were performed to find out patterns in the scientific collaboration between researchers and countries/territories on the mental health and well-being of university students.

Figure 3 demonstrates collaborative ties among authors who published at least 5 articles in the dataset ( n = 179). The map shows the existence of multiple productive collaborative networks of five or more researchers contributing to the development of the field. The largest collaboration network (red cluster) represents an international research group composed of 15 scholars affiliated to universities in the United States, Belgium, and Netherlands. This cluster groups some of the leading scholars in the field, including R. P. Auerbach, R. Brauffaerts, R. C. Kressler, and P. Cuijpers. Moreover, researchers in this cluster lead The WHO World Mental Health International College Student (WMH-ICS) Initiative, a large scale international project aimed at promoting the mental health and well-being of college students around the world through generating epidemiological data of mental health issues in university students worldwide, designing web-based interventions for the prevention and promotion of mental health, and disseminating evidence-based interventions ( Cuijpers et al., 2019). The second biggest cluster (green) represents an intra-national research network that includes 10 researchers from eight different higher education institutions in the United States. The dark blue cluster represents an institutional collaborative network, including nine researchers from the School of Public Health, Puerto Rico. Other prominent clusters in the map represent collaborative research networks between eight (olive color) and seven researchers (turquoise, violet, orange, and mellow mauve). This contrasts, however, with the limited collaboration that exists between clusters. Only four of the clusters on the map demonstrate some kind of scientific collaboration in the field (light blue, pink, brown, and yellow).

Cross-country collaboration networks in mental health and well-being of university students study are presented in Figure 4. Research collaborations between countries with 20 or more publications were considered in this analysis ( n = 45). The United States occupies the central position of the map and shares collaborative ties with all other countries/territories, forming a cluster together with China, South Korea, and Taiwan. Overall, the results suggest that international collaborations in the field are framed to a large extent by cultural, linguistic, and geographical proximity. For instance, the largest cluster (red) is formed by two European countries (Spain and Portugal) and other South American countries with whom they share historical and cultural backgrounds. Other European countries form the purple cluster. Similarly, the blue cluster clearly brings together predominantly English-speaking countries and territories, while the green cluster agglomerates a range of Asian countries.

Collectively, the results of our study suggest that research collaboration in the field of mental health and well-being in university students remains relatively scarce and localized to date. The social structure of the field at the author level could be described as an archipelago formed by a large number of islands (research groups) of different composition and size but with few bridges connecting them, which suggests a relatively fragmented research community. Moreover, while the existence of international collaborative networks was evident in the analysis, they seem to be formed within national borders, between researchers in neighboring countries/territories, or between countries that share cultural, linguistic, and historical heritages. This may be due to the important role that cultural and traditional values play in the conceptualization of mental health and well-being across contexts ( Eshun and Gurung, 2009; Vaillant, 2012; Fernando, 2019). Also, language differences, divergent cross-national institutional and organizational traditions, and increased costs of extramural collaboration, have been found to complicate the formation and continuity of research partnerships in health research ( Hooper et al., 2005; Freshwater et al., 2006). Nevertheless, limited within- and between-country research collaboration arguably poses challenges to the development of a field in terms of lost opportunities to challenge assumptions taken for granted and move toward fresh perspectives, push boundaries in methods and techniques, meet diverse groups of people from differing cultures and get immersed in those cultures, share information, resources, and skills, and address common mental health problems through the pooling of resources ( Rolfe et al., 2004; Freshwater et al., 2006).

Intellectual Structure: Disciplines Underlying the Foundations of the Field

Interdisciplinarity is considered as a valuable approach to address the complex and multidimensional nature of health and well-being ( Mabry et al., 2008). Buckton (2015) argues that the integration of medical, psychological, and social sciences have contributed to generate "new insights into theory, practice, and research in mental health and development." (3). To examine the disciplines underlying research on the mental health and well-being of university students, a journal co-citation analysis was performed. In this analysis, only journals with at least 50 citations were considered ( n = 593). The nodes on the map represent journals and their size reflects the number of co-citation relationships with other journals. Colors account for journal clusters, which agglutinate journals with higher co-citation relationships and stronger semantic connectedness. Clusters were interpreted and labeled accounting for the WoS categorization of the journals with the highest co-citation links within each cluster. For example, if the Journal of Personality and Social Psychology, the Journal of Counseling Psychology, and Personality and Individual Differences clustered together, this group was interpreted as the personality, social, and counseling psychology cluster.

In general, the findings of this study suggest that research on mental health and well-being in university students is interdisciplinary, to a certain extent, and mainly emerges from the convergence of research conducted in the behavioral and biomedical sciences, as it has been suggested elsewhere ( Schumann et al., 2014; Wittchen et al., 2014b). More specifically, the map shows that the research in the mental health and well-being of university students is constructed through the integration of knowledge generated in five interconnected disciplines (see Figure 5). To the left of the map, the red cluster integrates journals on personal, social, and counseling psychology. To the right, the blue cluster represents the contribution of psychiatric journals to research to the formation and development of the field. At the top, the yellow cluster groups journals on substance abuse and issues related to alcohol consumption, addiction, and interpersonal violence. At the bottom of the map, journals covering topics on eating behaviors, sleep, and other issues related to physical health converge on the green cluster. At the center of the map is the purple cluster, which includes journals in the area of clinical psychology and behavioral therapy.

More broadly, the findings suggest that biomedical sciences contribute to a large extent to the composition of the field. Psychiatric research emerged in our study as an obvious building block in the study of university students' mental health and well-being, which is not surprising considering the historical contributions of biomedical disciplines to mental health research ( Schwartz and Corcoran, 2010). Within the behavioral sciences, personality and social psychology, which explores processes and mechanisms through which social phenomena influence mental health and well-being ( Sánchez Moreno and Barrón López de Roda, 2003), appears as a key discipline underlying the foundations of the field. Surprisingly, clinical psychology journals occupy a central position in the map and demonstrate co-citation relationships with journals from all other clusters but make up the most dispersed network and account for a considerably lower volume of co-citation relationships in the field. This suggests that clinical psychology journals are more subordinate to journals in other disciplines in terms of citations flows, and ultimately, play a less unique role in research on the mental health and well-being of university students, as suggested by Haslam and Lusher (2011). Interestingly, research arising from the social sciences (e.g., sociology and anthropology) does not seem to make a distinctive contribution to the intellectual structure of the field, which suggests that the influence of social contexts and cultures on university students' mental health and well-being (e.g., inequality, social norms, public policies, cultural beliefs, and values) is an underexplored research area. Still, the density of co-citation network relationships within and between clusters is particularly noteworthy, considering the lack of common language between disciplines, the absence of a shared philosophy of practice on mental health, and the tensions between medical, psychological, and social explanations of mental distress ( Bailey, 2012).

Conceptual Structure: Topical Foci Addressed in the Literature Over the Last 45 Years

The topical foci of research on the mental health and well-being of university students during the 1975-January 2020 period are presented in Figure 6. The map offers a visual representation of the co-occurrence analysis of author keywords of all the publications included in the dataset. Only the most frequently occurring keywords (25+ occurrences) were considered in the analysis ( n = 84). Items that were not related to others and do not belong to the existing clusters were excluded. The size of the nodes indicates the occurrence of author keywords in the dataset and the thickness of edges represents the co-occurrence strength between pairs of keywords.

The most frequent keywords in the dataset, excluding students' descriptors (e.g., college students and university students), refer to common mental health challenges experienced by university students such as depression ( n = 612), anxiety ( n = 353), and stress ( n = 341). Salutogenic-related keywords such as well-being and life satisfaction occurred less often ( n = 138, n = 113, respectively), suggesting that pathogenic approaches to the exploration of mental health issues in higher education are more widespread. More broadly, seven general themes seem to summarize the topical foci of interest in the field of mental health and well-being of university students over the last 45 years. First, there has been a general interest in positive mental health, as denoted by frequently co-occurring key terms such as well-being, self-esteem, life satisfaction, social support, emotional intelligence, and happiness (red cluster). Second, mental disorders stand as another theme widely addressed in the literature, with a special emphasis on depression, anxiety, and to a lesser extent, suicide and suicidal ideation (green cluster). A third topical area in this field has been substance abuse, most predominantly alcohol consumption (blue cluster). The fourth theme reflects college counseling for mental health, including interventions and protective factors such as mindfulness, stress management, spirituality, and help-seeking (yellow cluster). Other topics reflected in the map are mental illness stigma (purple), stress (e.g., psychological distress and coping) (light blue), and mental health measurement (orange).

Conclusion

This study provides a comprehensive overview of the research on university students' mental health and well-being in the last 45 years using bibliometric indicators. In general, the results reveal interesting trends in the evolution of the field over the last four decades and promising scientific patterns toward a better understanding of the mental health and well-being of university students internationally. First, the interest in the mental health and well-being of university students has grown in the last decades and in a very significant way during the last 10 years, indicating that this area has not still reached its maturity period and will continue developing in the future. Second, research in the field is relatively interdisciplinary and emerges from the convergence of research conducted in several disciplines within the behavioral and biomedical sciences. Third, research in this field is produced by a community of productive researchers coming from several regions around the world, most notably in the United States, which secures a generation of scholars that will continue shaping the field in the years to come. Fourth, over the last 45 years, researchers have been able to address a multitude of research topics in the field, including positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement.

However, this study also identified some issues that could be hindering the development of the study of the mental health and well-being of university students. For example, the research available overrepresents theoretical and disciplinary approaches from the developed world. Additional studies on the field from developing economies and LMICs are needed to provide a more comprehensive picture and ensure a fair representation of the multiple perspectives available in the field. Such studies would inform administrators and practitioners on how to broaden and enrich available programs and initiatives to promote mental health and well-being in higher education contexts in order to offer alternative forms of support that university students find appropriate for their social and cultural values. Moreover, the research community contributing to the development of the field is relatively fragmented. There are multiple research groups but little research collaborations between them and, at the international level, these connections tend to be limited by geographic, cultural, and language proximity. In this context, more actions like the WMH-ICS Initiative could provide a partial solution to this problem by strengthening national and international research partnerships and facilitating knowledge exchange across regions. Also, special issues in the core journals in the field inviting cross-cultural studies on the topic could contribute to promoting research collaboration across regions and research in less represented countries. The field would also benefit from a greater volume of research from the social sciences and humanities exploring the influence of social, cultural, economic, and educational factors on the conceptualization, manifestation, and experience of mental health and well-being. Moreover, more studies emerging from disciplines such as sociology, anthropology, business, and education, would likely increase the permeability of positive mental health concepts into the field and contribute to the promotion of salutogenic approaches to the study of mental health and well-being of university students.

This study has several limitations. First, publications were retrieved only from the WoS database, which limits the generalizability of the findings. Second, WoS provides stronger coverage of Life Sciences, Biomedical Sciences, and Engineering, and includes a disproportionate number of publications in the English language ( Mongeon and Paul-Hus, 2016). This could partially explain the low number of publications emerging from the Social Sciences, the Arts, and the Humanities, and research conducted in non-English speaking countries in the present study. Third, only journal articles were retrieved for analysis, excluding other relevant publications in the field such as reviews, book chapters, and conference proceedings. Future studies could replicate the findings of this study using alternative databases (e.g., Scopus and PubMed) or a combination of them, as well as different filters in the search strategy, to provide an alternative coverage of research conducted in the field. Nevertheless, we believe that the bibliometric approach used in this study offers novel insights about the development and current status of the field and some of the challenges that undermine its progression.

Data Availability Statement

The datasets generated for this study are available on request to the corresponding author.

Author Contributions

DH-T and LI contributed to conception and design of the study, organized the database, and performed the statistical analysis. DH-T, LI, and JS wrote the first draft of the manuscript. NL, AC, AA, YN, and AM wrote the sections of the manuscript.

Funding

This research was funded by the Nazarbayev University Faculty-Development Competitive Research Grants Program (Reference Number 240919FD3902).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Footnotes

References

LeViness, P., Bershad, C., Gorman, K., Braun, L., and Murray, T. (2018). The Association for University and College Counseling Center Directors Annual Survey. Available online at: https://www.aucccd.org/assets/documents/Survey/2018%20AUCCCD%20Survey-Public-June%2012-FINAL.pdf (accessed February 24, 2020).
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# data[].attributes.attachment_link.title
Mental Health and Well-Being of University Students: A Bibliometric Mapping of the Literature

# data[].attributes.attachment_link.description
The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975-2020.

# data[].attributes.attachment_link.readable_text
Ayesha S. Al Dhaheri,

Mo'ath F. Bataineh,

Maysm N. Mohamad,

Abir Ajab,

Amina Al Marzouqi,

Amjad H. Jarrar,

Carla Habib-Mourad,

Dima O. Abu Jamous,

Habiba I. Ali,

Haleama Al Sabbah

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Abstract

The COVID-19 pandemic is a major health crisis that has changed the life of millions globally. The purpose of this study was to assess the effect of the pandemic on mental health and quality of life among the general population in the Middle East and North Africa (MENA) region. A total of 6142 adults from eighteen countries within the MENA region completed an online questionnaire between May and June 2020. Psychological impact was assessed using the Impact of Event Scale-Revised (IES-R) and the social and family support impact was assessed with questions from the Perceived Support Scale (PSS). The IES-R mean score was 29.3 (SD = 14.8), corresponding to mild stressful impact with 30.9% reporting severe psychological impact. Most participants (45%-62%) felt horrified, apprehensive, or helpless due to COVID-19. Furthermore, over 40% reported increased stress from work and financial matters. Higher IES-R scores were found among females, participants aged 26-35 years, those with lower educational level, and participants residing in the North Africa region ( p<0.005). About 42% reported receiving increased support from family members, 40.5% were paying more attention to their mental health, and over 40% reported spending more time resting since the pandemic started. The COVID-19 pandemic was associated with mild psychological impact while it also encouraged some positive impact on family support and mental health awareness among adults in the MENA region. Clinical interventions targeted towards vulnerable groups such as females and younger adults are needed.

Citation: Al Dhaheri AS, Bataineh MF, Mohamad MN, Ajab A, Al Marzouqi A, Jarrar AH, et al. (2021) Impact of COVID-19 on mental health and quality of life: Is there any effect? A cross-sectional study of the MENA region. PLoS ONE 16(3): e0249107. https://doi.org/10.1371/journal.pone.0249107

Editor: Bidhubhusan Mahapatra, Population Council, INDIA

Received: December 28, 2020; Accepted: March 12, 2021; Published: March 25, 2021

Copyright: © 2021 Al Dhaheri et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The novel coronavirus, later designated as COVID-19, is an infectious disease that can spread among humans. It emerged initially in the city of Wuhan in China in late December 2019, when cases of pneumonia of unknown etiology were reported [ 1]. Following its emergence, it manifested as an outbreak that led to serious public health concerns by the World Health Organization (WHO), and by mid-March 2020, the WHO declared a global pandemic due to the substantial global-wide spread of the disease affecting many countries [ 2]. By 14 February 2021, over 108 million cases were confirmed worldwide, of which 5.99 million cases were reported in the Eastern Mediterranean region [ 3].

In response to this global health crisis, quarantine and lock down measures were implemented by international and government health organizations to contain the rapid spread of the virus. Further measures included suspension of flights, avoidance of large gatherings, mandatory use of face mask in many countries, social distancing, teleworking, home-schooling of children and health orders to stay at home [ 4]. While the WHO and worldwide health authorities are actively working on containing the outbreak, such a period of health crisis has significant repercussions on human health and welling, accompanied by psychological distress and related symptoms such as stress, panic and anxiety in the general population [ 5]. Moreover, psychological impact is considered to be more profound in comparison to the Severe Acute Respiratory Syndrome (SARS) epidemic in 2003, due to the extensive social media exposure and increased global connectivity [ 6, 7]. SARS-related psychological problems have been reported to be prevalent mainly among healthcare workers and SARS survivors [ 8, 9]. In 2012, the Middle East respiratory syndrome coronavirus (MERS-CoV) was first identified in Saudi Arabia [ 10]. The spread of MERS-CoV across the Middle East was linked to the transmission of the pathogen from Dromedary camels to humans [ 11]. The MERS-CoV outbreak was associated with tremendous public anxiety in the affected countries, and it resulted in thousands of mortality cases, fear, anxiety, and psychosocial stress among the population, in addition to economic losses [ 12, 13]. Consequently, it is crucial to understand the extent of impact for such pandemics on mental health and other aspects of life [ 14, 15].

Historically, quarantine has been a successful measure adopted worldwide in infectious diseases outbreaks; however, it represents an unfavorable experience for the population. Movement restriction, separation from family or friends, limited freedom and fear of an uncertain future are all factors that may exacerbate negative psychological impact [ 16]. Large scale outbreaks as previously seen in the SARS epidemic have been associated with higher prevalence of psychological symptoms, emotional disturbance, depression, stress, post-traumatic stress symptoms and irritability [ 8]. Similarly, healthcare workers taking care of patients during the MERS-CoV outbreak in Saudi Arabia, reported feeling afraid and nervous, mainly about their safety as well as about colleagues and family, and the availability of infection control guidelines [ 17]. Literature shows that multiple stressors including longer duration of quarantine, fear of infection, distress, loneliness, boredom, confinement, inadequate information and financial loss, play a role in aggravating poor mental health [ 18].

The Middle East and North Africa (MENA) region in general, is a very sensitive area economically, politically, culturally and religiously. There are many challenges to contain the spread of COVID-19 in the region including political conflicts, humanitarian crises, suboptimal transparency, and frequent social and religious mass gatherings [ 19]. Additionally, the ongoing outbreak and the social isolation could have a huge impact on the mental health of individuals in the MENA region. Limited data is available on how people within the MENA region are coping with the COVID-19 pandemic and the extent of its ramifications on their mental health and well-being. Thus, this study aims to examine the impact of the COVID-19 outbreak on the mental health and quality of life among residents of the MENA region. The authors hypothesized that changes in family and social support, lifestyle changes, and increases in negative indicators were associated with higher IES-R total scores.

Methods

1. Study design and participants

A cross-sectional, web-based survey was conducted in the MENA region between 11 May 2020 and 15 June 2020. The sample was drawn from eighteen countries within the MENA region; including Algeria, Bahrain, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Republic of Yemen, Saudi Arabia, Sudan, Syria, Tunisia, and United Arab Emirates. Consenting adults aging 18 years and older were recruited electronically using convenience and snowball sampling methods in order to guarantee a large-scale distribution and recruitment of participants. There was no restriction on the total number of participants, however a minimum target of 100 participants from each country was desired. A total of 6142 participants (32.7% males) completed the survey and their data were included in the analysis.

The psychological impact of COVID-19 among adults was measured on the Impact of Event Scale-Revised (IES-R) and the social and family support impact was assessed using questions from the Perceived Support Scale (PSS) [ 20- 22]. The questionnaires were prepared using Google Document Forms in the English, Arabic and French languages and it was automatically hosted via a unique URL. The electronic survey was pilot tested for clarity in a sample of 26 people from three countries in the MENA region. A few adjustments to wording were made preceding the pilot test to ensure the questionnaire's clarity and applicability. A uniform resource locator (URL) was retrieved for the survey and was distributed formally (using e-mail invitations) and informally (using social media platforms, e.g., LinkedIn ™, Facebook ™, and WhatsApp ™). In addition, researchers involved in this project distributed the survey to their contacts and work colleagues.

An information sheet and a consent form were available on the first page of the questionnaire in all three languages. Participants were free to withdraw at any time without giving explanations and no personal identification was requested to retain information confidentiality. Participants were given no incentives for participating in the questionnaire. The system of Google Forms only provides responses for questionnaires with 100% completion rate. The responses were download as an Excel file and securely stored using a password protected "Cloud" database. The present study followed the ethical code for web-based research [ 23, 24] and conforms to the principles embodied in the Declaration of Helsinki [ 25]. The study protocol was approved by the Social Sciences Research Ethics Committee at United Arab Emirates University (ERS_2020_6115).

2. Survey questionnaire

Information on the socio-demographic characteristics of the respondents was collected including age, gender, country of residence, education level, employment status, marital status, and work or study setting.

2.1 Impact of Event Scale-Revised Scoring (IES-R).

The Impact of Event Scale-Revised (IES-R) was used to assess the psychological impact of COVID-19 among adults residing in the MENA region [ 20, 26]. The IES-R is a self-administered questionnaire containing 22 items and it has been previously translated and validated in the English, Arabic and French languages [ 27- 30]. The IES-R has also been used to measure symptomatology experienced during the COVID-19 pandemic in Saudi Arabia, Egypt, Italy, and China [ 15, 22, 31- 33]. The response for each question was scored based on a five-point Likert scale ranging from 0 (not at all) to 4 (extremely) and generated a total score (ranging from 0 to 88). The total IES-R score was considered normal (from 0 to 23); indicative of mild (from 24 to 32); moderate (from 33 to 36); or severe (≥ 37) psychological impact [ 15]. Three subscale scores were also calculated measuring intrusion (8 items), avoidance (8 items), and hyperarousal (6 items) [ 21].

2.2 Indicators of negative mental health impact.

Six modified and validated questions were asked regarding negative mental health impacts resulting from the COVID-19 pandemic [ 21]. Three questions inquired whether participants felt horrified, apprehensive, or helpless due to the pandemic. The other three questions assessed changes in stress from work, financial stress, and stress from home during the pandemic. The response options to these questions were much increased, increased, same as before, decreased, and much decreased.

2.3 Impact on social and family support.

This section included modified and validated questions from the Perceived Support Scale (PSS) assessing the impact of the COVID-19 pandemic on the support received from family or friends [ 15, 21]. It included five items including support from friends, support from family members, sharing feelings with a family member, sharing feelings with others when blue, and caring for family members' feelings. The response options were much increased, increased, same as before, decreased, and much decreased.

2.4 Mental health-related lifestyle changes.

Participants were also asked to rate whether they were paying less or more attention to mental health related lifestyle changes during the COVID-19 pandemic using modified and validated questions [ 21]. This section included four items; attention to mental health, devoting enough time to rest, to relaxation, and to exercise. The response options were much increased, increased, same as before, decreased, and much decreased.

3. Statistical analysis

Normality of data was tested with the use of Kolmogorov-Smirnov test of normality. Descriptive statistics for the sociodemographic characteristics were reported as numbers and percentages. The IES-R total and subscale scores were presented as Median and Interquartile Range (IQR). A Chi-square (χ ²) test was used to determine the association between IES-R categories (normal, mild, moderate, and severe) with categorical variables. A non-parametric Kruskal-Wallis H test was used to determine differences in IES-R, intrusion, avoidance, and hyperarousal scores between different regions. Followed by post-hoc pairwise comparisons with Bonferroni adjustment. A generalized linear model based on negative binomial distribution was used to assess the confounding effects of sociodemographic factors, negative mental health impact factors, social and family support indicators, and lifestyle factors on continuous IES-R total score. Variables included in the final model were selected using univariant general linear analysis and only factors with a cut-off value of p<0.2 were selected. A p-value <0.05 was considered to be statistically significant. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 26.0 (IBM, Chicago, IL, USA). The minimum sample size (n = 3246) was calculated using G*power software, version 3.1.9.4 (HHU, Germany) to detect a small effect size (0.10), with a power of 0.99, and alpha 0.05.

Results

1. Demographic characteristics

The percentage of participants that completed the survey in the Arabic, English and French languages was 86.4%, 10.2% and 3.3% respectively. The sociodemographic characteristics of the study population are presented in Table 1. The female to male ratio was almost 2:1, with 32.7% males. The majority of surveyed individuals were aged 36-45 years (27.3%), were married (60.8%), had a bachelor's degree (49.3%), worked full-time (44.5%), were working or studying from home (52.6%), and were residing in the Gulf region (48.7%).

2. Impact of Event Scale-Revised Scoring (IES-R)

The overall mean IES-R score was 29.3 ± 14.8 (range 0-84), reflecting a mild stressful impact of the COVID-19 pandemic on the surveyed participants. The overall mean scores for the intrusion, avoidance and hyperarousal scales in participants were 9.5 ± 6.1, 11.8 ± 5.8, and 7.9 ± 5.0, respectively. A Kruskal-Wallis H analysis revealed an expected significant difference in total IES-R scores between the different regions, ( X ² (2) = 102.937, p<0.001), with a mean rank IES-R score of 2897.95 for Gulf region, 3036.45 for Levant region, and 3471.21 for North Africa region ( Table 2). Furthermore, there was a significant difference in intrusion scores between the different regions, ( X ² (2) = 106.650, p<0.001), with a mean rank intrusion score of 2913.00 for Gulf region, 2996.70 for Levant region, and 3486.87 for North Africa region. A significant difference in avoidance scores between regions were observed, ( X ² (2) = 38.410, p<0.001), with a mean rank avoidance score of 2984.50 for Gulf region, 3010.56 for Levant region, and 3322.88 for North Africa region. Moreover, there was a significant difference in hyperarousal scores between the different regions, ( X ² (2) = 109.964, p<0.001), with a mean rank hyperarousal score of 2853.84 for Gulf region, 3142.34 for Levant region, and 3437.78 for North Africa region.

3. Sociodemographic and Impact Event Scale-Revised (IES-R)

The association of IES-R scores with sociodemographic factors is presented in Table 3. A Chi-square analysis revealed significant association between IES-R categories with gender ( X ² = 36.440; p<0.001), age ( X ² = 54.585; p<0.001), education level ( X ² = 32.663; p<0.001), employment status ( X ² = 65.989; p = 0.017), and region of residence ( X ² = 102.244; p<0.001). As expected, the multivariate regression analysis revealed that females (Estimated rate ratio: 9.1%; p = 0.003), participants aged 26-35 years (Estimated rate ratio: 12.2%; p = 0.022), school or college diploma graduates (Estimated rate ratio: 9.4%; p = 0.034), and residence of North Africa region (Estimated rate ratio: 11.8%; p<0.001) were more likely to have higher IES-R scores. However, marital status, employment status and working from home were not significantly associated with changes in total IES-R score.

4. Indicators of negative mental health impact

Table 4 presented the association between IES-R scores and negative mental health indicators. About 40% of the participants reported increased stress from work during the outbreak, 45.3% felt an increased level of stress from financial matters, and 60.3% of participants had increased stress from home during the pandemic. Furthermore, 61.0% of the participants felt horrified, 61.5% felt apprehensive, and 45.2% felt helpless due to the pandemic. A Chi-square analysis revealed significant association between IES-R categories with increased stress from work ( X ² = 387.901; p<0.001), increased stress from financial matters ( X ² = 5197.234; p<0.001), increased stress from home ( X ² = 354.400; p<0.001), feeling horrified ( X ² = 678.749; p<0.001), feeling apprehensive ( X ² = 529.160; p<0.001), and feeling helpless ( X ² = 496.914; p<0.001). The multivariate regression analysis detected that increased stress from work (Estimated rate ratio: 16.6%; p<0.001), increased financial stress (Estimated rate ratio: 6.3%; p = 0.027), increased stress from home (Estimated rate ratio: 10.9%; p<0.001), feeling horrified (Estimated rate ratio: 23.4%; p<0.001), feeling apprehensive (Estimated rate ratio: 9.3%; p = 0.008), and feeling helpless (Estimated rate ratio: 14.1%; p<0.001) were significantly associated with higher IES-R scores.

5. Impact on social and family support

Table 5 showed the association between IES-R score and family and social support. The results showed that 42.1% of the participants reported receiving increased support from family members, 24.3% received increases support from friends, and 48.1% stated increased shared feelings with their family members during the pandemic. In addition, the majority of participants (67.4%) cared more about their family members' feelings following the onset of the pandemic.

A Chi-square analysis revealed significant association between IES-R categories with getting support from friends ( X ² = 265.459; p<0.001), getting support from family members ( X ² = 215.531; p<0.001), sharing feelings with family members ( X ² = 340.216; p<0.001), sharing feelings with others ( X ² = 450.398; p<0.001), and caring for family members' feelings ( X ² = 194.155; p<0.001). The multivariate regression analysis revealed that increased support from friends (Estimated rate ratio: 8.3%; p<0.001), and increased sharing feelings with others (Estimated rate ratio: 7.9%; p<0.001) were significantly associated with higher IES-R scores.

6. Mental health-related lifestyle changes

Table 6 displayed the association of IES-R scores with lifestyle indicators during the pandemic. About 41% of participants reported paying more attention to their mental health since the pandemic started. Additionally, over 40% of the participants reported spending more time to rest and relax. However, 41.8% of the participants reported spending less time exercising during the outbreak. A Chi-square analysis revealed significant association between IES-R categories with paying attention to mental health ( X ² = 312.943; p<0.001), spending time to rest ( X ² = 221.645; p<0.001), spending time to relax ( X ² = 252.510; p<0.001), and spending time to exercise ( X ² = 94.757; p<0.001). As expected, the multivariate regression analysis showed that decreased attention to mental health and decreased time spent to relax were significantly associated with higher IES-R scores ( p = 0.001).

Discussion

This study aimed to investigate the impact of the COVID-19 outbreak on mental health and quality of life among residents of the MENA region. The survey was conducted after two months of lockdown measures implemented in the MENA region. Moreover, the pandemic is not over yet and it is rapidly expanding in many countries of the Middle East. Although many studies have examined the physiological effect of COVID-19, however, to our knowledge, this is the first large-scale study published investigating mental health and quality of life across eighteen countries in the MENA region.

Findings of this study suggested that participants from North Africa region were more likely to have higher stress scores compared to those residing in the Gulf and Levant regions. This study was conducted between May and mid of June 2020. During which, all countries included in the survey have already declared the state of emergency due to COVID-19 [ 34]. The number of confirmed cases by mid of June varied widely between MENA countries and ranged between 127 thousand cases in Saudi Arabia and 177 cases in Syrian Arab Republic [ 35]. Moreover, the number of deaths also varied in the same period and ranged between 972 in Saudi Arabia and 6 cases in Syrian Arab Republic [ 35]. Although, variation in the number of confirmed cases and deaths were observed between countries and sub-regions of the MENA, the greatest number of confirmed cases and deaths were reported in the Gulf region. All countries included in the study implemented strict measures between March 2020 and June 2020 or even longer [ 34]. This study might not reflect the diverse impact on the entire population from the MENA region considering the different stages of the pandemic in different countries.

The results of this study showed that about 40% of the participants in the MENA region had an IES-R score indicating moderate to severe disturbance due to the pandemic. Similarly, a study among Lebanese citizens has shown a rise of Post-traumatic Stress Disorder (PTSD) symptomatology during the fourth week of the COVID-19 quarantine [ 36]. Additionally, an online survey conducted in Saudi Arabia reported mild to moderate rates of anxiety among the general population and a significantly higher level of anxiety among married respondents [ 37]. In the current study females and participants aged 26-35 years were more likely to have higher stress scores. Likewise, a study in Saudi Arabia assessed the psychological impact of COVID-19 using the IES-R, and the Depression, Anxiety, and Stress Scale (DASS-21), and found that health care workers, students and females had higher levels of stress, anxiety and depression symptoms [ 32]. Our results also agree with recent studies from China and Italy which revealed that females are more vulnerable to stress compared to males, and that younger age groups had a higher tendency to be stimulated by the surrounding stressors [ 5, 38].

The biological, social and cognitive processes underlying gender differences in the susceptibility to psychological disorders have not yet been fully understood. However, some evidence indicates that fluctuations in ovarian hormone levels may be responsible for altered sensitivity to emotional stimuli among women [ 39]. Additionally, studies suggest that greater brainstem activation to threat stimuli may contribute to the greater prevalence of PTSD among women, and greater hippocampal activation in men may enhance their capacity for contextualizing fear-related stimuli [ 40, 41]. Telehealth services such as telephone counseling helplines, are useful to provide support to the vulnerable groups and is an appropriate tool for the delivery of mental health services [ 42]. Additionally, implementing community-based strategies to support psychologically vulnerable individuals during the COVID-19 pandemic is essential [ 18]. Likewise, awareness about self-relaxation and self-care measures for participants and their families can be encouraged to lessen social isolation [ 43].

The findings of this study indicated that during the pandemic, over one-third of the participants experienced increased stress related to work and financial matters, and over half of the participants had increased stress related to home matters. Similar trends were reported in a study among Egyptian adults, where 34.1% of participants reported an increase of stress from work, 55.7% had increased financial stress, and 62.7% had increased stress related to home matters [ 33]. Moreover, during the COVID-19 pandemic families were more likely to experience a lack of support from external sources (such as from schools or childcare settings), and financial strain, especially lower-income individuals and those who lost their jobs as a result of the pandemic [ 44]. Furthermore, families were affected by prolonged school closure, requiring online education support and uncertainty about examinations and enrolment arrangements [ 45]. With limited resources and barriers to providing assistance through welfare initiatives, governments and health care professionals must unite their efforts to protect high risk vulnerable people with additional support such as online peer group support sessions, psychoeducation, home-based relaxation techniques and stress management skills with online guidance [ 46].

Additionally, the study found that high school and college educated participants were more likely to have experienced an increased level of stress compared to those with higher education. Conflicting findings about the possible relationship between the level of education and stressful impact were reported in the literature. Some studies suggests that those with a higher level of education might practice better coping strategies and therefore report less stress score [ 47, 48]. Others proposed that highly educated people might be more stressed due to higher self-awareness and discernment of the pandemic severity [ 49, 50].

More than half of the participants in this study felt shock apprehension due to the pandemic, however they did not feel helpless as they reported paying more attention to their mental health and spending more time relaxing and resting during the pandemic. Additionally, the majority of participants reported getting increased support from family members as well as caring more about the feelings of family members during the pandemic. Such positive impacts on mental health may have helped the participants to cope with other negative impacts of the COVID-19 pandemic. The increased family support observed in this study was in line with previous studies from Egypt and China which demonstrated that family and friends were much valued in a time of crisis [ 22, 31, 33]. Researchers suggested that during quarantine, family members had the ability to spend more time together and were also more concerned about their health and family, while less so about leisure activities and friends [ 51]. On the other hand, the World Health Organization Europe member states have reported a 60% increase in emergency calls from women subjected to violence by their intimate partner during the pandemic [ 52]. Domestic violence reports in France have increased by 30% and domestic violence calls in Argentina have increased by 25% [ 53]. Similarly, in New York City the Police Department responded to a 10% increase in domestic violence reports during March 2020 compared to March 2019 [ 54]. Reasons could include job losses, rising alcohol based harm and drug use, stress and fear [ 52].

Unfortunately, about 42% of participants reported spending less time exercising during the outbreak. Recent evidence suggests that levels of physical activity were also negatively affected during quarantine [ 55- 57]. It might be due to the widespread closure of sport facilities and parks, as well as complete lockdowns. Achieving minimum physical activity levels and reducing sedentary behavior during quarantine is a challenge and a necessity for everyone. A study investigating the influence of home confinement during the COVID-19 pandemic outbreak on lifestyle and mental wellbeing among Arab adults revealed that the mental wellbeing score was significantly higher among participants with medium to high physical activity levels [ 58]. Several studies have indicated the positive impact of physical activity as an effective therapy in support of mental and physical health [ 59, 60]. Moreover, physical activity and exercise were recommended as a therapy to fight against the mental and physical consequences of quarantine during the SARS and COVID-19 outbreaks [ 61, 62]. Home-based physical activity interventions are feasible, safe, and an effective way to increase physical activity among the general population [ 63]. Therefore, awareness about different types of home exercises and their benefits on mental health is essential [ 61, 64].

Limitations of this study include the use of self-reported questionnaire which might cause some respondent bias or misreporting of data; and the cross-sectional study design which provides only a snapshot of psychological responses at a particular point in time. Another potential limitation of this study was the use of snowballing sampling strategy, which is a non-probability sampling technique without adjusting for the population size of different countries. Also using an online survey limited the reach to non-social media users which led to less generalizable results. Moreover, information on the stressful impact due to political or economic status prior to the pandemic were not determined in the study. However, due to the time-sensitivity of the outbreak and with a strict quarantine measures in place, using an online survey allowed data collection from eighteen countries in the MENA region. It also guaranteed the anonymity of the participants, therefore reducing the social desirability bias. Another strength of this research project was conducting the survey in multiple languages, which allowed for wider distribution in the MENA region countries.

The current study identified females, younger age groups (26-35 years), people with school or college education and those residing in the North Africa region as high-risk groups to suffer from psychological distress. Additionally, recent studies also revealed that health care workers, students, people with history of medical problems, as well as those infected with COVID-19 and their family members are prone to psychological disorders [ 5, 32, 38, 50, 65]. Therefore, clinical interventions targeted towards vulnerable groups are needed to improve their mental health during the ongoing pandemic.

Conclusion

This large-scale study across 18 countries, is the first study to our knowledge, investigating mental health and quality of life in the MENA region due to the COVID-19 pandemic. The findings of this study indicate that the COVID-19 pandemic was associated with mild psychological impact among adults in the MENA region. However, it also encouraged some positive impacts on family support and mental health awareness. There is a need to increase the awareness among the various media platforms about psychological challenges during pandemics and highlight the importance of seeking help and engaging in physical activity for the management of mental health disorders. Furthermore, an increase in awareness among the health care professionals in identifying and targeting the high-risk groups of the population who are at risk in developing mental health problems is vitally important.

Governments and policymakers must offer moral and financial support for low-income families and those who lost their jobs. Also, regulating working hours is needed to reduce the burden on individuals during the current pandemic. Future large-scale comparable studies among other age groups such as adolescents and children will help public health authorities shape their reactions and interventions in the future in response to similar crises.

Acknowledgments

To Tathqeef Health Treatment Undertakings Services for their support with the dissemination of the survey through their network.

References

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2. 3. WHO. COVID-19 Weekly epidemiological update-16 February 2021: World Health Organization; 2020 [19 February 2021]. https://www.who.int/publications/m/item/weekly-epidemiological-update---16-february-2021.

3. 7. Depoux A, Martin S, Karafillakis E, Preet R, Wilder-Smith A, Larson H. The pandemic of social media panic travels faster than the COVID-19 outbreak. Oxford University Press; 2020. https://doi.org/10.1093/jtm/taaa031 pmid:32125413

4. 20. Weiss DS. The impact of event scale: revised. Cross-cultural assessment of psychological trauma and PTSD: Springer; 2007. p. 219-38.

5. 23. Franzke A, Bechmann A, Zimmer M, Ess C. Internet research: ethical guidelines 3.0 association of internet researchers. 2019.

6. 27. AGOSTINI T, GRASSI M, PELLIZZONI S, MURGIA M, editors. The arabic impact of event scale-revised: Psychometric properties in a sample of Syrian refugees. 13th Alps Adria Psychology Conference; 2018: Horizons of Psychology.

7. 34. UNDP. COVID-19 in the Arab region: United Nations Development Programme; 2020 [19 February 2021]. https://www.arabstates.undp.org/content/rbas/en/home/coronavirus.html.

8. 35. WHO. Coronavirus disease (COVID-19) Situation report-147: WHO; 2020 [19 February 2021]. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200615-covid-19-sitrep-147.pdf?sfvrsn=2497a605_4.

9. 53. Women U. Issue Brief: COVID-19 and Ending Violence Against Women and Girls. 2020.

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Impact of COVID-19 on mental health and quality of life: Is there any effect? A cross-sectional study of the MENA region

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The COVID-19 pandemic is a major health crisis that has changed the life of millions globally. The purpose of this study was to assess the effect of the pandemic on mental health and quality of life among the general population in the Middle East and North Africa (MENA) region.

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

Schools can support students to develop:

social and emotional skills and capabilities that promote life-long mental health and wellbeing

skills to problem-solve and manage the normal stressors of life

healthy relationships and the ability to work cooperatively with others

a sense of autonomy and purpose.

The Schools Mental Health Menu is a list of endorsed programs, staff and resources across 3 tiers of support.

Tier 1 activities form a foundation for Tier 2 and Tier 3. Together, the tiers form layers of support for students. Tier 1 supports remain in place, and schools can add extra supports from Tier 2 and Tier 3 when greater needs are identified.

Tier 1: Universal interventions

Tier 1 Universal interventions help schools to create a positive, inclusive and supportive school climate, building the preconditions for optimal student learning, development and wellbeing. They are the initiatives and programs schools adopt that are good for all students.

Activities can be implemented at a school, year, or classroom level. They are usually delivered by school staff. Community organisations or agencies may be employed to deliver some activities.

Programs include:

adopting a whole school approach to mental health

social and emotional learning

wellbeing animal programs

eating disorders supports

alcohol and drug education

mental health literacy

bullying prevention

local community lead mental health intervention

peer support.

The Schools Mental Health Menu provides a comprehensive information about tier 1 activities (as well as tiers 2 and 3) available to schools.

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School's role in Tier 1 promoting mental health and wellbeing | Victorian Government

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

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Online Therapy: Best 2021 Counseling Services

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BetterHelp offers private, affordable online counseling when you need it from licensed, board-accredited therapists. Get help, you deserve to be happy!

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Mental health problems can affect many areas of students' lives, reducing their quality of life, academic achievement, physical health, and satisfaction with the college experience, and negatively impacting relationships with friends and family members. These issues can also have long-term consequences for students, affecting their future employment, earning potential, and overall health. ¹

Consequences for the Student

Mental health problems can affect a student's energy level, concentration, dependability, mental ability, and optimism, hindering performance. 2 Research suggests that depression is associated with lower grade point averages, and that co-occurring depression and anxiety can increase this association. ² Depression has also been linked to dropping out of school. ²

Many college students report that mental health difficulties interfere with their studies. On the American College Health Association 2015 survey, college students identified the following mental health issues as negatively impacting their academic performance within the last 12 months: ³

Stress (30% of students)

Anxiety (22%)

Sleep difficulties (20%)

Depression (14%)

Consequences for Others

Peers, family members, faculty, and staff may be personally affected out of concern for these students.

Depression and anxiety can have harmful effects on relationships and work productivity.

Suicide and suicidal thoughts can affect the larger campus community.

Roommates, peers, faculty, and staff also experience profound grief over student suicides and suicidal behavior.

Consequences for Campuses

Campuses feel the burden when students with mental health difficulties do poorly on course work and drop out of school.

Colleges and universities must be prepared to address the psychological impact of suicides on other students, as well as on teachers and staff.⁴

Poor student retention can mean losses in tuition, fees, and alumni donations.

Consequences for Communities and the Larger Society

The community is negatively affected when students are unable to finish their degrees and contribute valuable skills in a competitive job market.

One study found that five percent of students do not finish their education due to psychiatric disorders and estimated that 4.29 million people would have graduated from college had they not been experiencing such disorders.⁵

References

1. Eisenberg, D., Gollust, S. E., Golberstein, E., & Hefner, J. L. (2007). Prevalence and correlates of depression, anxiety, and suicidality among university students. American Journal of Orthopsychiatry, 77(4), 534-542.

2. Eisenberg, D., Downs, M., & Golberstein, S. (2009). Stigma and help-seeking for mental health among college students. Medical Care Research and Review, 66(5), 522-541.

3. American College Health Association. (2015). National College Health Assessment II: Spring 2015 reference group executive summary. Hanover, MD: Author. Retrieved from http://www.acha-ncha.org/reports_ACHA-NCHAII.html.

4. Meilman, P. W., & Hall, T. M. (2006). Aftermath of tragic events: The development and use of community support meetings on a university campus. Journal of American College Health, 54(6), 382-384.

5. Kessler, R. C., Foster, C. L., Saunders, W. B., & Stang, P. E. (1995). Social consequences of psychiatric disorders, I: Educational attainment. American Journal of Psychiatry, 152(7), 1026-1032.

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Consequences of Student Mental Health Issues

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Mental health problems can affect many areas of students' lives, reducing their quality of life, academic achievement, physical health, and satisfaction with the college experience, and negatively impacting relationships with friends and family members. These issues can also have long-term consequences for students, affecting their future employment, earning potential, and overall health.

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/health/mentalhealth/Pages/promoting-mental-health.aspx
Mental Health and Well-Being During Pandemic
Mental Health and Well-Being During Pandemic

hsph.harvard.edu
Health and Well-being during COVID-19
https://www.hsph.harvard.edu/india-center/health-and-well-being-during-covid-19/

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cdc.gov
About Mental Health
https://journals.sagepub.com/doi/full/10.1177/08295735211001653
https://journals.sagepub.com/doi/full/10.1177/08295735211001653
https://www.education.vic.gov.au/school/teachers/health/mentalhealth/Pages/promoting-mental-health.aspx
https://www.education.vic.gov.au/school/teachers/health/mentalhealth/Pages/promoting-mental-health.aspx

education.vic.gov.au
Promoting mental health and wellbeing in your school

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Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act, and helps determine how we handle stress, relate to others, and make choices.

Mental health is important at every stage of life, from childhood and adolescence through adulthood. Over the course of your life, if you experience mental health problems, your thinking, mood, and behavior could be affected.

Mental Health Conditions

Mental illnesses are disorders, ranging from mild to severe, that affect a person's thinking, mood, and/or behavior. According to the National Institute of Mental Health, nearly one-in-five adults live with a mental illness.

Many factors contribute to mental health conditions, including:

Biological factors, such as genes or brain chemistry

Life experiences, such as trauma or abuse

Family history of mental health problems

Some mental health topics include:

A Serious Mental Illness (SMI) is a mental illness that interferes with a person's life and ability to function. Despite common misperceptions, having an SMI is not a choice, a weakness, or a character flaw. It is not something that just "passes" or can be "snapped out of" with willpower.

View SAMHSA's Public Message about Serious Mental Illnesses.

Early Warning Signs & Symptoms

Not sure if you or someone you know is living with mental health problems? Experiencing one or more of the following feelings or behaviors can be an early warning sign of a problem:

Eating or sleeping too much or too little

Pulling away from people and usual activities

Having low or no energy

Feeling numb or like nothing matters

Having unexplained aches and pains

Feeling helpless or hopeless

Smoking, drinking, or using drugs more than usual

Feeling unusually confused, forgetful, on edge, angry, upset, worried, or scared

Yelling or fighting with family and friends

Experiencing severe mood swings that cause problems in relationships

Having persistent thoughts and memories you can't get out of your head

Hearing voices or believing things that are not true

Thinking of harming yourself or others

Inability to perform daily tasks like taking care of your kids or getting to work or school

Do you think someone you know may have a mental health problem? Talking about mental health can be difficult. Learn about common mental health myths and facts and read about ways to help you get the conversation started.

Tips for Living Well with a Mental Health Condition

Having a mental health condition can make it a struggle to work, keep up with school, stick to a regular schedule, have healthy relationships, socialize, maintain hygiene, and more.

However, with early and consistent treatment-often a combination of medication and psychotherapy-it is possible to manage these conditions, overcome challenges, and lead a meaningful, productive life.

Today, there are new tools, evidence-based treatments, and social support systems that help people feel better and pursue their goals. Some of these tips, tools and strategies include:

Stick to a treatment plan. Even if you feel better, don't stop going to therapy or taking medication without a doctor's guidance. Work with a doctor to safely adjust doses or medication if needed to continue a treatment plan.

Keep your primary care physician updated. Primary care physicians are an important part of long-term management, even if you also see a psychiatrist.

Learn about the condition. Being educated can help you stick to your treatment plan. Education can also help your loved ones be more supportive and compassionate.

Practice good self-care. Control stress with activities such as meditation or tai-chi; eat healthy and exercise; and get enough sleep.

Reach out to family and friends. Maintaining relationships with others is important. In times of crisis or rough spells, reach out to them for support and help.

Develop coping skills. Establishing healthy coping skills can help people deal with stress easier.

Get enough sleep. Good sleep improves your brain performance, mood and overall health. Consistently poor sleep is associated with anxiety, depression, and other mental health conditions.

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Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act, and helps determine how we handle stress, relate to others, and make choices.

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Wellbeing and mental health - Pascua, Mary joy D. 

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Wellbeing and mental health - Pascua, Mary joy D. 

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https://www.heart.org/en/healthy-living/healthy-lifestyle/mental-health-and-wellbeing

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ABSTRACT

ABSTRACT
Student mental health is a critical issue in higher education. It is understood that higher education can act to trigger or exacerbate mental health difficulties, but research in this area has focused primarily on campus environments, identifying stressors such as halls of residence. Since distance learning students disclose mental health issues at a higher rate than campus students, and completion and progression gaps are on a par with the sector, the barriers and enablers to mental wellbeing in distance learning must be understood. This paper reports on a qualitative study that investigated barriers and enablers to mental wellbeing and study success that students experienced in distance learning. Sixteen distance learning students and five tutors were interviewed using narrative enquiry; students told their own stories and tutors told stories of students they had supported. Barriers and enablers were identified across different aspects of study, skills-development and the distance learning environment, and are presented in a taxonomy of barriers and enablers that suggest a range of implications for distance learning educators and policy developers.

Introduction

There has been much discussion around student mental health in higher education in recent years, as research shows that mental health difficulties have a serious effect on students' attainment, progression and study outcomes (Evans et al., 2018; Hughes & Spanner, 2019; Sick et al., 2019; Thorley, 2017). Students experiencing mental health difficulties are less likely to complete and/or pass a course or module (Mojtabai et al., 2015; Richardson, 2015), more likely to drop out of university (Brown, 2016; Mojtabai et al., 2015; Richardson, 2015), and less likely to attain higher grades (Eisenberg et al., 2009). Additionally, students are more likely to experience or develop mental health problems than non-students, implying that studying and university culture is a significant contributing factor (Brown, 2016; Ribeiro et al., 2018; Tinklin et al., 2005; Winzer et al., 2018).

There are many interventions in place to support students experiencing mental health issues, with an increasing number aiming to proactively promote wellbeing or prevent mental health crises. However, the persistent attainment and progression gaps (Office for Students, 2019), and increasing demand for student counselling and mental health services (P.J. Jones et al., 2018) imply that these interventions are not sufficiently tackling the problem, and a more holistic approach is needed (Hughes & Spanner, 2019). Furthermore, these interventions, or the administrative processes required to access them, tend to be of an 'in person' nature, assuming students are physically based on a campus (Barr, 2014; Brown, 2016). With an increasing number of students taking part in distance learning, it is critical to identify suitable interventions for remote learners, and in order to do this, it is necessary to understand the barriers and enablers to mental wellbeing that students in a distance learning environment experience.

This paper presents the findings from a study aiming to identify barriers and enablers to mental wellbeing in distance learning. Barriers and enablers were identified through interviews with students (N = 16) and tutors (N = 5) in a large UK distance learning institution; these were mapped to a taxonomic wheel. This taxonomy clearly demonstrates that both barriers and enablers to student mental wellbeing in study reside throughout learning environments and study experiences, and supports the contention that holistic approaches are needed to support student mental wellbeing (Hughes & Spanner, 2019).

Mental health in higher education

This section reviews some of the current literature relevant to the issue of student mental wellbeing. However, firstly, and importantly, a note on terminology. For this study, we adopt the World Health Organisation (WHO) definition of mental health:

a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community (WHO, 2014).

We use the terms mental health and mental wellbeing in this paper with slightly different connotations; we use mental health as a broad term that can signify positive mental health, mental health as a societal issue, or can prefix a difficulty, issue, problem or condition. We use mental wellbeing to describe the positive state described in the WHO definition. Finally, we include both 'common' mental health issues, such as depression or anxiety, and also more 'severe' issues, such as schizophrenia or psychosis, in our definition of mental health conditions (Davies, 2013).

Mental health is a worldwide concern (Lozano et al., 2012), and there is an increasing awareness of the need to take a proactive approach to mental illness prevention and mental health promotion, as well as treatment, recovery and rehabilitation (Davies, 2014; WHO, 2013). This combined proactive and responsive approach has been well received in higher education, and various white papers have arisen supporting the need for a greater emphasis on proactive approaches (Houghton & Anderson, 2017; Hughes & Spanner, 2019).

Traditionally, higher education institutions have adopted a reactive approach to well-being and mental health issues; with responsibility for reacting to issues when they arise being placed on the student support team and mental health counsellors (P.J. Jones et al., 2018). However, an increasing number of studies are documenting an emergent, more proactive approach, focusing on mental health promotion through interventions, such as resilience-building programmes (Holdsworth et al., 2018; McAllister et al., 2018), sports-based programmes (Vella et al., 2019), mindfulness activities (Al-Ghalib & Salim, 2018; Galante et al., 2018), mental health literacy programmes (Kern et al., 2017), peer support (Byrom, 2018) and meditation (Crowley & Munk, 2017). However, while the studies we cite here conclude that these interventions have the potential to be beneficial, they concede that greater understanding and wider adoption are needed. For example, Holdsworth et al. argue for an embedded, rather than therapeutic approach:

to support the development of resilience, curriculum structure and content should incorporate complex problem-based activities which are industry focused and are underpinned by a supportive learning environment (Holdsworth et al., 2018).

In spite of this shift towards a proactive approach, many of the interventions in higher education continue to position mental health issues as a problem belonging to an individual, rather than identifying causes or triggers in the environment. For example, when investigating high levels of student 'distress during the examination period,' Galante et al.'s approach was to provide an 8-week mindfulness course, rather than identify and mitigate the causes of the distress (Galante et al., 2018). However, it is increasingly recognised that there are systemic triggers inherent within higher education that have a negative effect on student mental wellbeing (Tinklin et al., 2005). For example, Ribeiro et al. found in a systematic review that 'psychological suffering is inherent in academic life' (Ribeiro et al., 2018), and Jenkins et al. identified that 'negative role models', as well as course-specific issues with placements and assessment, were 'major stressors' for students (Jenkins et al., 2018). Markoulakis and Kirsch performed a systematic review to locate areas where students experienced mental health difficulties, and found areas included the 'learning environment', 'difficulties with their studies', 'structural difficulties imposed by the university', and 'academic outcomes' (Markoulakis & Kirsh, 2013). On a larger scale, a dataset analysis of 80,509 students in the USA, UK and Canada found that 'academic distress', including 'academic performance, pressure to succeed, and postgraduation plans', was the most unique predictor of anxiety in university students (P.J. Jones et al., 2018).

It stands to reason that barriers to mental wellbeing that reside within the higher education culture, systems, structures and learning environments may be addressed through intervention in these areas (Hughes & Spanner, 2019). Furthermore, there is evidence that inclusive design practices such as Universal Design for Learning (UDL) that focus on flexibility and student agency in learning (Rose & Meyer, 2002) can be beneficial for student mental health (Griful-Freixenet et al., 2017; Miller & Lang, 2016). However, this recognition that the issue of mental health in higher education does not reside solely in the student is not yet commonplace in the higher education mental health literature or practice.

In addition to this, there is a lack of research on students' mental wellbeing in a distance learning environment. The majority of the literature on student mental health focuses on a campus-based university environment, but evidence shows that the UK's 200,000+ distance learning students are just as likely to experience mental health issues that impact on their learning (Barr, 2014; Richardson, 2015). For example, in 2017-18, 7.8% of the students studying at the Open University in the UK disclosed a mental health condition, compared to the UK HE average of 2.02% (Higher Education Statistics Agency, 2017), and there is a − 16 percentage point gap in module completion for students (The Open University, 2019), compared to the sector average of −3.4 percentage points (Office for Students, 2019). In spite of this, barriers to wellbeing in distance learning students remain under-researched (Richardson, 2015), and with the current pivot to online teaching, there is a clear need for empirical research that can inform interventions, and ensure distance learning environments engender mental wellbeing.

Our review of the literature indicates that studying at university can have a detrimental effect on the wellbeing and mental health of some students. Whilst there is some agreement that higher education institutions need to be proactive in how they both promote wellbeing and mental health and seek to prevent poor wellbeing and mental health experiences; practices are not yet widespread or systemic in higher education. Furthermore, little attention has been paid to the experience of students studying with distance education universities and the specific implications this might have for the kinds of proactive practices that distance learning institutions might adopt. The study reported in this paper seeks to address this gap in knowledge by investigating the barriers and enablers to the mental wellbeing student experience in distance learning.

Methods

In order to address our research questions, a study was conducted at the Open University (OU), a large, distance learning institution in the UK with over 16,000 students disclosing a mental health issue. The study is modular, OU students study predominantly online or via books, and are supported in their learning by a tutor, regular tutorials, and peer interactions. Performance is assessed via coursework and an end of module assessment of some kind; approximately 40% of the modules use an exam for this. There is a free online mental health support service for students in need, and teams of educational advisors, student support staff, and disability support staff are trained to support students in distress.

The study aimed to capture narratives about barriers and enablers to mental wellbeing students experience during the study. To do this, we interviewed students and associate lecturers (tutors); OU tutors are frequently the first point of contact for students, and we considered their 'collective social expertise' (Suoranta & Moisio, 2006) could add additional insight.

In order to capture narratives from students and tutors, we used convenience sampling to recruit 21 volunteers to the study, 16 students and 5 tutors. The students were:

10 female, 6 male

13 white British, 2 Black British, 1 white European

14 undergraduate, 2 postgraduate

studying social sciences (N = 10), arts (N = 2), business (N = 2), and science (N = 2)

15 of the students had disclosed a mental health condition to the university; the other had severe depression and anxiety but did not formally disclose it.

The tutors taught courses on computing, maths and statistics, chemistry, health and social care and arts and humanities. All had over 10 years' experience and had supported multiple students with mental health issues.

Twenty-one semi-structured interviews were carried out. Interviews ranged from 30 to 90 minutes, resulting in over 19 hours of interview data. Students were asked to share their study experiences and related life experiences, and tutors were asked to share their experience of supporting students experiencing mental health issues. Interviews were recorded and transcribed. Thematic Analysis (Braun & Clarke, 2006) was used to identify emerging themes of barriers and enablers. The emerging themes are detailed in the following section. Approval was given by the institution's ethics committee for this research.

Results

The data were interrogated inductively in NVivo for examples of barriers and enablers to mental wellbeing and success in the study. Barriers were defined as anything that had caused or triggered an issue with mental health; enablers were defined as anything that facilitated a sense of wellbeing. All 21 participants spoke about both barriers and enablers; students recounted those they had experienced themselves, and tutors discussed those their students had experienced.

In total, 60 themes were identified, consisting of 155 sub-themes and 783 coded references. Both barriers and enablers were then clustered into three overall categories and 10 sub-categories (Braun & Clarke, 2006). The coding structure is shown in Figure 1.

Themes from each category are discussed in turn. When quoting directly from our participants we assign a code to enable readers to distinguish between participants (student 1-16; tutor 1-5).

Study-related barriers and enablers

Study-related barriers and enablers occurred within student's studies, in terms of curriculum, tuition and assessment.

The curriculum was a source of both barriers and enablers; 18 of the 21 participants described barriers it presented, and 16 gave examples of enablers within it. Recurrent themes included curriculum content, curriculum design (including use of technology), and types of activities within the curriculum (i.e. groupwork). For example, student 7's mental health issues were triggered by distressing curriculum content. She talked about how trigger warnings did not help:

Student 8 experienced a trigger for suppressed trauma:

Curriculum design was critical; students and tutors both highlighted workload as a barrier: ' Even perceived workload. So, the student's almost like a panic mode; too much to do, can't cope!' (tutor 1). Structure, routine and flexibility within curriculum design were recurrent enablers, for example, student 10 said flexibility in choosing his study days helped because he could not ' consistently say every day I'm going to be fine.'

Activities within the curriculum could be challenging, collaborative activities in particular were mentioned by 6 participants. Student 6 said ' I don't like anything where I have to interact with people.' However, forums were highlighted as an enabler; student 1 said 'there's a lot of support as well, you know, on the forums'.

In the tuition category, tutors were mentioned both positively and negatively. They were enablers if ' they genuinely, genuinely care' (student 10), they were ' full of enthusiasm' (student 1), if ' I knew I had her support' (student 1), if they had ' enthusiasm and commitment' (student 13), or if they were ' very kind and not patronizing' (student 14). Student 13 summed it up:

However, tutors were seen as a barrier if they were ' really not helpful', if they ' told off' the student (student 14), if they were ' stern' (student 15) or if students were given ' different advice from your tutor and the moderators' (student 14).

Within the theme of assessment, participants talked about a range of issues including deadlines, exams, extensions, feedback, scores, marking, presentations, technology, assessment clarity, exam skill development, and tutor support. In this section, we focus on three of these: exams, feedback and unclear assessment instructions.

Exams were exclusively mentioned as a barrier. Students mentioned how both the exam itself and the preparation for the exam could act as a trigger for mental health issues; student 9 recounted her experiences of ' panic attacks' in ' these massive exam halls' and student 2 talked about how being ' worried' and not feeling ' prepared' for the exam led her to feel ' I can't do this', triggering her depression and leading her to defer her module.

Negative feedback, and the fear of negative feedback, were highlighted as barriers. One tutor recounted an experience with a student about fear of feedback:

Her response to this was to develop a relationship based on trust: ' you can trust me not to cut it to ribbons' (tutor 5).

Unclear assessment instructions or criteria were extremely triggering for students. One tutor recounted an experience with a student who:

One student talked about how assessment wording could trigger attacks of panic or anxiety for her:

Skills-related barriers and enablers

Skills-related barriers and enablers related to areas where a lack of skills caused distress or a barrier, and acquirement or confidence in skills were seen as an enabler. This category was broken down into study skills, social skills, and self-management skills.

Social skills refer to how students related to other people in their courses. Barriers were primarily in terms of communication, not asking for help, and fear of participating in forums and tutorials. Participation was mainly related to anxiety. For example, student 3 said ' I was never really able to fully participate because of my anxiety issues and panic attacks and things like that.' Tutors flagged not asking for help as a frequent barrier from their perspective; tutor 4 said ' they also don't ask for help. I've noticed that a lot.' This was corroborated by students; student 15 said ' it takes a lot for me to ask for help', and student 7 said ' it is hard to reach out to your tutor.'

Study skills were both a key enabler when present, and a clear barrier when not. Tutor 1 told the story of a student where ' it wasn't a problem with the material, it was needing help learning how to study effectively ... Once we'd addressed those, that student flew.' Student 1 also referenced this; ' in the early days people were trying to work out how to study. That's my experience of it.' Student 2 gave specific examples of learning how to take notes and how to revise, student 3 talked about learning to concentrate for longer, and student 7 talked about learning time management skills. All three students talked about the barrier it created for them until they learned these skills, and how their increasing confidence in these skills helped their mental health.

Other students talked about skills they had learned that had a positive impact on the study and mental health. Student 1 said she had learned, before a study session, to ' just go for a walk, take that time out every day, just go and look at the trees', and that had a significant impact on her study success and her wellbeing. Student 2 talked about how she breaks ' activities down into tasks', and student 13 talked about learning how to detach; ' you need to get to a point where you need to go, right. Stop. Walk away.' Student 15 talked about learning to prioritise: ' I kind of go, what do I need to know right now? ... Do I need to know that right now?' Students 12 and 3 used music to ' keep me feeling human ' and motivate them to study. These skills were learned through studying, but all had a positive impact on their lives and their wellbeing.

Self-management skills related to positive behaviours, students' confidence and sense of identity, and how they managed their mental health. Students' sense of identity could be a barrier or enabler. Student 10 talked about not belonging: ' I felt very out of place, I felt very alone' and student 3 talked about having no hope: ' I was really like considering suicide because I thought, you know, there's just no hope, you know?' However, an important aspect of identity was recognising growth and success. Student 14 said ' you've got to celebrate achievements, every distinction, you've got to take that minute to go, oh my God, look at me, I did that!' When asked what helped their mental wellbeing most in the study, student 6 said ' the sense of achievement I get when I've got a good score', and student 3 said ' I feel like you keep evolving and you know that literally every year you're gonna evolve. Yeah. That's how it feels. So amazing.' They also talked about how the identity of being a student helped their mental health, with comments like: ' The OU has been eye opening and making me understand more about who I am, as a person ' (student 2). One student said:

Another aspect of identity related to perfectionism and managing expectations of themselves. Student 2 talked about how this impacted on her depression:

'I have to tell myself it's okay, you cannot always get high marks. But to me, as an achiever ... I self-analysed myself, I over-thought, there could have been tipping points where I made my, my depression worse.' (Student 2)

Managing mental health was a barrier for many, with issues such as depression (students 2, 11, 12 and 7, tutor 5), anxiety (students 10, 14 and 3, tutor 3) mood swings (students 2, 15 and 16, tutor 1), psychosis (students 4 and 6), and other mental health issues (students 13, 11, 15 and 5) presenting barriers to wellbeing and study. However, positive behaviours, such as hobbies, volunteering or raising awareness of causes also emerged as key enablers in managing mental health. Taking part in positive activities provided ' escapism', ' made me feel like a real person' (student 10) and had a substantial impact on wellbeing. Souvenirs, reminders and outputs from positive activities were also mentioned as beneficial for sustaining mental wellbeing, including photo albums (' to sort of treasure' - student 10) and social media pages (' I'm currently producing a Facebook page, and it's being rolled out. Which makes me feel whole again, because I feel like I'm helping people.' - student 11).

Environmental barriers and enablers

Environmental barriers and enablers are broken down into four sub-categories: Spaces (both physical and virtual, including social media, classroom environments, VLE and isolation in learning), Systems (university systems, policies and administrative processes), People (both in the university environment and more generally, such as family) and Life (general life events that impact on learning).

An interesting interplay in the themes around spaces was that there was a fine line between the distance environment being a barrier or an enabler. 'Isolation' was a clear barrier for students, with 12 references from 6 students; e.g., student 2 said she dropped out of the study because ' I didn't know anybody else that was studying. It was all done remotely, and you didn't have that link.' However, face-to-face learning environments were also a barrier, with 13 references from 4 students. Student 3 talked about the effect on her anxiety and her learning, saying:

In this case, distance was an enabler: student 10 said: ' the decision I came to is, right, studying from home would be beneficial to me because I could like cope with that.' Furthermore, 6 participants referred to distance learning communities as an enabler; student 14 commented on taking ' pride in the community of people I've met, particularly the people who do the volunteering and stuff with the students association.'

Social media was generally seen as a positive space. Students acknowledged there were issues, student 9 said ' The Facebook groups are a good source of support, but I suppose that you can compare yourself to the people on that as well, can't you?' but student 10 said ' the two closest friends I have, I've met on social media.'

University systems, structures and administrative processes were strongly felt as both barriers and enablers, and could have a substantial impact on a student's mental health and study success. Administrative processes were a barrier, with examples given around disability disclosure (student 16: ' Maybe I was stubborn, I thought I don't have to sign up for that'), reasonable adjustments (student 16: ' I didn't manage to see there was a deadline') and other support (tutor 5: ' they've sent her the forms and she hasn't sent them back. That'd be entirely typical ').

University rules and evidence requirements were also a barrier, especially around deferral processes. Student 11 and student 1 both had deferrals declined in traumatic circumstances, which caused mental health difficulties for them both. Tutors also talked about the speed of processes and the quality of disclosure information being a problem. Policies and systems could be enablers, however. Enablers included credit transfer (' Made things a bit less stressful, that time in [place] wasn't wasted' - student 10), the OU's open entry system (' They didn't actually judge you like based on more prior grades or anything! Like they actually just gave you a chance!' - student 3) and reasonable adjustments made by the university (' they actually printed out the whole of the course syllabus on PDF for me!' - student 4).

Communication from the institution was a barrier for many. Student 2 talked about the need for proactive communication signposting what support students could access, saying ' They do not know what support people can give them with mental health on studies'. Student 3 also talked about the need for proactive pastoral care, saying:

People clearly had the power to be a positive or negative influence on study or wellbeing. Peers were generally an enabler; student 9 said ' I do really, really enjoy engaging with students. Yeah. That's always really helpful.' However, peers were felt to be a barrier if students felt they were ' being really judged and disliked' (student 10), and this could have a long-lasting impression; student 11 said ' one person on there being horrible, and it still sticks with me'.

General life circumstances had enormous potential to be barriers. Barriers included work, bereavement, family or relationship issues, illness, pregnancy and maternity, and also background issues such as economic status and coming to terms with sexuality. The only enablers listed related to time and support; student 1 talked about having time to study, saying ' I was very lucky because for the last module I was able not to work, so that made a massive difference' and student 2 talked about being supported through difficult life circumstances by the student support team: ' I did talk through my options with the OU. I had some support there and I just decided to go for the next presentation.'

Discussion

A wide range of barriers and enablers were identified in the interviews, and these could be mapped to a number of areas in the university or study experience. As there were relationships between themes (i.e. between assessment and study skills, or between study spaces and curriculum), the barriers and enablers are represented as a taxonomic wheel in Figure 2. This figure classifies where barriers reside within distance learning, it maps them to diametrically corresponding enablers, and indicates relationships between adjacent barriers and enablers.

It can be seen from this model that barriers and enablers to mental wellbeing reside within and throughout distance learning environments and aspects of the study, as well as within the skillsets and capabilities of the students. This supports and builds on Tinklin et al.'s work about barriers inherent within higher education (Tinklin et al., 2005), and work by Markoulakis and Kirsh identifying barriers in the learning environment, studies, structures and academic outcomes (Markoulakis & Kirsh, 2013).

A key finding of this study is that barriers and enablers were found in the majority of themes, implying that aspects of the study can be both barriers or enablers for mental wellbeing and study success, depending on who is experiencing them and how. Crucially, this implies that there is potential for many of the barriers students experience to become enablers; for example, assessment feedback was a barrier for students when it was negative, but was an enabler when it was constructive and took place in an environment of trust. Similarly, lack of study skills was a barrier, but confidence in study skills was an enabler. This presents an interesting contrast to individualistic interventions, such as aiming to reduce assessment-related stress with a mindfulness intervention (Galante et al., 2018), implying instead that the assessment design could require investigation. While management of mental health is essential, a key implication for practice is that universities also need to critically examine other areas of practice, such as curriculum, assessment and tuition, and explore inclusive design practices to ensure these support mental wellbeing (Griful-Freixenet et al., 2017; Miller & Lang, 2016). In particular, universities should endeavour to ensure that curriculum content is engaging and that challenges such as collaborative activities and distressing content are scaffolded with suitable support; that assessment instructions are clearly worded and assessment strategies move away from exams. Finally, universities need to recognise how crucial the tutor role is for student wellbeing and ensure tutors are supported to develop skills to help decrease student anxiety and enhance trust.

Additionally, in investigating skills-related barriers and enablers, this study has highlighted a crucial link between mental wellbeing and students' confidence in study skills, as well as the close relationship between study skills and managing their mental health. This represents a clear implication for practice, supporting the contention that resilience should be taught in the curriculum (Holdsworth et al., 2018) and that explicitly teaching, practising and recognising success in study skills can have a positive impact on mental health (Barrable et al., 2018).

University systems and administrative processes also require further investigation, as they represented clear environmental barriers to wellbeing. Studies have found a relationship between university administrative processes and student stress in distance learning (Coughlan & Lister, 2018), and that students' difficulties can be exacerbated when they are required to tackle onerous paperwork in order to access support (E. Jones et al., 2020). A clear implication for practice is for universities to overhaul their administrative processes and systems, such as disability disclosure, deferral and extenuating circumstances processes, to decrease administrative load on students and ensure processes are user-centred and supportive, to enhance student wellbeing.

A final implication for practice relates to the distance learning environment, particularly the intersection between isolation and distance. Isolation was invariably seen as a barrier, while distance and community were enablers to mental wellbeing. Studies on mental health communities outside of higher education support the relationship between online communities and mental health, finding, for example, benefits such as 'greater social connectedness, feelings of group belonging ... personal empowerment and providing hope' (Naslund et al., 2016). A key implication for designers of online spaces, therefore, is to consider how these spaces can avoid isolation and become communities that support student wellbeing.

Limitations and future work

There were several limitations to this work. As a qualitative study, the relatively small number of participants makes it difficult to know how representative they were of the larger cohort. There are plans to address this via a survey to a larger number of students in a later stage of this study, but this will, by necessity, be reported in a subsequent paper. Another limitation is that the study took place within one distance learning institution, and it is difficult to know the extent to which findings apply to other universities. Further work to investigate this more fully or in different contexts would be beneficial.

This study is the first stage of a larger project. This stage aimed to identify barriers and enablers; the next stage focuses on collaboratively designing solutions. Following the analysis of the interview data and the identification of themes, students and staff in different roles were brought together in a series of events to identify solutions or interventions to mitigate these. The data from these events and the evaluation of piloted solutions will be detailed in subsequent publications.

Conclusion

This study has shown that barriers and enablers to mental wellbeing in distance learning are inherent throughout different aspects of higher education, and posits a taxonomic model that represents this. This indicates that therapeutic and individualistic approaches to mental health, while important, are not sufficient to facilitate student mental wellbeing. Findings suggest that universities need to tackle barriers where they reside, including exploring inclusive design practices for curricula and assessment, explicitly teaching study skills, designing systems, and processes that do not cause undue stress and designing learning spaces to be communities. By adopting a holistic approach to mental health in this way, distance learning can begin to be truly conducive to student mental wellbeing.

Disclosure statement

The authors declare no conflict of interest

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Notes on contributors

Kate Lister is a lecturer in education, specialising in mental wellbeing, accessibility and inclusive pedagogy. Jane Seale is a professor of education whose research interests lie at the intersections between disability, technology and inclusion. Chris Douce is a senior lecturer in computing and communication, specialising in accessibility in distance learning and web technologies.

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Mental health in distance learning: a taxonomy of barriers and enablers to student mental wellbeing

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ABSTRACT ABSTRACT Student mental health is a critical issue in higher education. It is understood that higher education can act to trigger or exacerbate mental health difficulties, but research in this area has focused primarily on campus environments, identifying stressors such as halls of residence.

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Mental Health Curriculum Mental Health 101 for Teens is a new book and curriculum for middle school, high school, and college students. Our new Digital Teacher's Guide includes:Classroom Discussion GuidesCollaborative Conversations & Group ActivitiesStudent Journal Prompts Family Discussion Guides available in English, Spanish, and Chinese Request Pricing Increase family engagement with discussion guides in English,...

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Due to the COVID-19 pandemic, schools and colleges all over the US and the world transitioned into online classes. The health and safety of everyone are the utmost priority during the pandemic, and online schooling is the only real option during these times.

At first, it was comfortable and convenient. For parents, this meant no more driving to school or snack prep. Some kids even attend classes in their pajamas. However, in the long run, students, parents, professors, and teachers have realized the challenges of online classes, especially their impacts on individual mental health.

This article explains how online learning environments can affect the mental health of students and parents. It also shares tips on how parents and students can cope with the challenges of online learning.

How Do Online Classes Impact Mental Health?

Online classes affect the mental health of students, parents, and even teachers. They can worsen existing mental health problems in individuals who already have them.

Imagine what it is like for a kid to spend hours in front of Zoom every day without social interaction and playtime with their friends. Parents are now acting like teachers and are more involved in their children's schoolwork. Teachers and professors have increased workloads and are pressured to deliver quality learning without face-to-face classes.

1. Virtual Learning Can Cause Fatigue

There is this newly coined term during the COVID era called "Zoom fatigue." The term Zoom fatigue refers to feelings of exhaustion after long Zoom classes or video conference calls. It may not be a formal diagnosis, but Zoom fatigue does exist, especially in virtual learning. There's information overload during an online class, and facing the screen for prolonged periods is mentally draining.

It's more challenging for students to learn new information, and even though they just sit in front of the computer, they feel physically tired. Virtual learning fatigue is real, and it may lead to anxiety and stress for both students and professors.

2. Students Suffer from Lack of Interaction and Social Isolation

Schools do not only teach new learning from books; it is also where friendship starts and fun memories are created. Communication and social skills are best learned with social interactions. Kids, teens, and even teachers need to connect with their friends and socialize.

But there has been a lack of interaction since the COVID pandemic, which means students are experiencing social isolation. This greatly impacts a student's mental health. The lack of social interaction in online learning leads to feelings of loneliness, lack of motivation, and isolation.

Young adults need social interaction in their formative years. Kids needs play dates with other kids their age to learn how to socialize. These are some of the main reasons why online learning can affect the students' mental health.

3. Students Experience Increased Stress and Anxiety

Students follow a set schedule during school days in the traditional classroom setup. There's a time to wake up, go to school, for class, do homework, interact with friends, and attend extra-curricular activities. This isn't the case with online learning.

Staying focused on online classes is a challenge. Separating home life from class time, not following a routine schedule, and the distractions at home make it difficult for students to concentrate well in their classes.

As a result, students tend to procrastinate and set things aside. Then deadlines are missed. This causes pressure, stress, and anxiety to both students and their parents.

4. The Parent's Mental Health Get Affected, Too

Online learning does not only affect the students but parents as well. Parents have now become proxy educators and tutors and are getting more involved with schoolwork to ensure their kids learn well and maintain good grades. How can a parent tutor physics if it's something they're not good at?

Work-from-home moms and dads who are getting overwhelmed with their jobs now have to assist their kids with their online classes. The additional responsibilities cause them more exhaustion and higher levels of stress.

5. Even the Teachers and Faculty Get Stressed Out

Photos of tenured professors having a hard time teaching their students online have gone viral on social media. These professors have years of experience inside the classroom, but teaching using technology devices has not been their best asset.

Teachers are also pressured and worried about losing their jobs because some schools are closing. Then there's the additional workload to ensure they deliver quality education to their students. These are all causing them anxiety, challenging their mental health in the process.

Online Learning Pros

Although online learning may impact the mental health of students and their parents, it also has its pros, particularly in family bonding and relationships. Online learning encourages more time for bonding at home. Parents who previously could not spend much time with their kids due to busy work schedules can spend more time with their kids. This is helpful, especially when you're trying to understand your teenager.

Some students who experience bullying at school may find online learning a positive experience. They feel safe at home and can be more productive. They can stop feeling the fear of being bullied at school. Online learning, however, may not prevent students from experiencing cyberbullying.

How to Take Care of Your Mental Health

There are many ways to take care of your mental health to avoid the stress of online learning. Here are some strategies parents, students, and teachers can follow to prevent burnout from attending online classes:

Have a designated work/study space. Setting boundaries can help prevent stress caused by distractions. Pick a spot at home with fewer distractions so you can concentrate on work or school. Choose a quiet area and impose a rule at home not to disturb you during work or school hours. This way, you can be more focused and productive.

Encourage healthy habits. One way of taking care of your mental health is to encourage healthy habits. This means eating well, following a regular sleep schedule, getting enough physical activity, and taking care of your physical health. By following healthy habits regularly, you will notice an improved mood, increased energy levels, and better overall mental well-being.

Follow a regular schedule. Routine work for some may be boring, but following a regular schedule brings order and organization to one's life. It enables you to achieve the tasks planned for the day and avoid cramming at the last minute. There will be days you will lose track of time and procrastinate on the tasks that need to get done. Follow a regular schedule: sleep and wake up at the same time every day. Stick to work and school time, designate break times, and follow study time schedules. As you put the organization into your daily schedule, you'll feel more productive and less stressed.

Encourage physical activities. There's not much physical activity for students since learning from home started. Unlike before, kids can run around the playground, climb four flights of stairs to their classroom, or bike from school to home.

Encourage physical activities for kids, perhaps an outdoor activity with the family, like biking, a walk in the park, or any physical activity in the backyard. Physical activity releases feel-happy chemicals in the body that can help improve a person's mental health. Plus, spending time outdoors also eases emotional and mental exhaustion.

Advice For Parents

Set a positive tone at home. For parents, avoid stress and anxiety by setting a positive tone at home. This means talking in a soft tone, avoiding outbursts of anger, and not putting too much pressure on yourself and your kids.

Take breaks. Taking breaks from the daily hustle and bustle is a must. If you're feeling tired of your child's schoolwork, take a power nap, meditate, go outside for a while, and breathe deeply.

Take a short walk and clear your mind. Do not force yourself to meet deadlines if it causes you to lash out at your loved ones. If it's not a school day, set the books aside and take time to enjoy the weekend, have movie nights with your kids, picnic in the backyard, or spend quality time outdoors. You and your kids deserve to enjoy happy moments because of all the hard work that you do.

Practice self-care. Prioritize self-care more than anything else. As parents, you dedicate your life to making your kids happy and healthy. But don't forget to take care of yourself, too. Do things you enjoy, learn a new hobby, catch up with your friends, pamper yourself. You must also be healthy mentally so you can be there for your kids.

Finding Help for Your Mental Health

This COVID-19 pandemic indeed imposed a great challenge for all of us. Face-to-face classes may not be returning soon in some states, and all we have to do is to adjust to these challenges. Along with the ways to take care of your mental health mentioned above, also consider seeking help from a mental health professional.

Thankfully, you don't need to leave your home to talk to a therapist. The telehealthcare service offered by Kentucky Counseling Center is just a few clicks away. Talk to a therapist now and learn how to take good care of your mental health during these trying times. Stay safe and healthy!

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Mental Health Effects of Online Learning

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As much as online classes are conveniently done at home, they can cause mental health struggles. Contact KCC to learn more.

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As a counselor at Charlevoix Middle and High School, Karrie Gaffney has seen students struggle to access the mental health care they need.

"Oftentimes in our area, for students to simply make an appointment with a counselor could take months. And who's going to pick them up? How are they going to pay for it? They give up because there are just a lot of barriers," Gaffney said.

Counselor Karrie Gaffney and her students at Charlevoix Middle/High School in the University of Michigan's TRAILS mental health care program.

A University of Michigan program called TRAILS (Transforming Research into Action to Improve the Lives of Students) works with schools across the state to provide effective mental health resources to students impacted by depression and anxiety. TRAILS is offered in 145 schools across the state, including Gaffney's.

As a precursor to TRAILS, the Peer-to-Peer Depression Awareness Campaign was created to empower students to demystify and normalize mental illness and treatment. In concert, these two programs have created lasting impact in the schools and communities in which they reside.

TRAILS provides clinical training to school mental health staff on cognitive behavioral therapy and mindfulness, then pairs each school with a local, community-based mental health provider who has been trained as a TRAILS coach.

Next, school staff and their coaches work together to co-facilitate student groups on CBT and mindfulness, teaching participants techniques that are evidence-based and proven to reduce symptoms of anxiety and depression.

"The program is a skills-based learning group where students are acquiring lifelong tools, which they can later use in many different situations," said Nicole Montgomery, a TRAILS coach for Charlevoix Middle and High School.

The U-M Depression Center collaborated with Ann Arbor Public Schools to develop TRAILS in 2013, and it has been affecting change in the lives of many ever since. To date, the program has trained more than 380 school mental health professionals in Michigan. The estimated number of students impacted by the program is nearly 3,000.

"This is a win-win from the University of Michigan. I thought, 'How can I not be a part of this to educate kids?' Everything is laid out really clearly in the lessons," Gaffney said. "We focus on relaxation and coping skills. We've learned how to recognize when you are having symptoms of depression and anxiety and how to combat that."

It has been proven that students can make an impact on their peers' understanding of mental health and their attitudes about seeking help for themselves or others, and this is the basis of P2P, which was recently awarded the Gold Award from the American Psychiatric Association.

Over the past 10 years since the program's inception, 850 students have participated directly on P2P teams, more than 175 student-run events have taken place and tens of thousands of students have been reached through its awareness campaigns.

The program was built on the premise that many mental health issues present themselves during adolescence, and teens are more likely to listen to other teens than well-meaning adults. The program also educates middle and high school students about mental illnesses and positive coping mechanisms, while supporting them in creating mental health awareness campaigns for their schools.

With 70% of adolescents reporting mental health as a major problem among their peers, this program component has really taken off.

"The students in the group are getting an incredible education about mental health, mental disorders and mental illness," said Robbie Stapleton, Community High School teacher and P2P group facilitator. "These students then become resources for others because they know how to share these tools with their friends and family when they need them."

Students participating in the program educate their peers regarding mental health, with a primary focus on viewing depression and anxiety as treatable brain illnesses. In addition, the program implores students to immediately report any talk of suicide to a trusted adult.

Schools can also integrate other mental health messages on topics like stress, sleep or substance use, should students think that there is value in addressing them. Each campaign includes a slogan, educational activity and promotional item that reinforces its message. Educational activities can range from classroom presentations, school assemblies, mindfulness sessions and educational posters.

"We want to get the school more aware of the stigmas around depression and other conditions, how we can break stereotypes and how to be effective at letting everyone know there's people who can help them," said Meghana Tummala, a P2P participant at Community High School.

Recent studies have also shown that the benefits of having easily accessible, student-led depression awareness programs are numerous because they allow students to gain confidence in identifying the signs of depression.

Both programs aim to help young people become increasingly comfortable with talking about mental health and inevitably, living the best versions of their lives possible.

"Now when I talk to school staff [about TRAILS], they say they know exactly what resource to use, what to say, and are able to help that student efficiently and get them back to the classroom, where they want to be and really need to be," said Elizabeth Koschmann, TRAILS program director for the U-M Depression Center. "That to me is the most rewarding outcome I could ever get."

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Tackling Teen Anxiety, Depression: U-M Focuses on Mental Health in Schools

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As a counselor at Charlevoix Middle and High School, Karrie Gaffney has seen students struggle to access the mental health care they need. "Oftentimes in our area, for students to simply make an appointment with a counselor could take months. And who's going to pick them up?

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Why good mental health is important for study | Charles Darwin University

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It’s an expression we use every day, so it might surprise you that the term ‘mental health’ is frequently misunderstood. Meagan Miskin is the Health, Wellbeing & Injury Management Consultant at CDU and she shares the importance that good mental health plays when it comes to work, study and life.

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As the world changes and becomes increasingly riddled with uncertainty, so do the issues of thriving in it become more complex. Thriving, not just living. Not merely existing but flourishing, capable of navigating life successfully and progressively.

COVID-19 has made the volatility of thriving all too clear. It has not only emphasized the varying degrees of frailty and strength of the human body; it has also forced the focus on mental health, the other part of human well-being that has been often overlooked and neglected.

The demand for mental health services has dramatically increased. One only needs to try getting an appointment with a counselor, psychologist, or psychiatrist to realize the difficulty of acquiring these services at this time. Using the now clichéd term to describe this pandemic, the demand for mental health services has been unprecedented. Yes, even in UP.

And UP is responding.

Initiatives to strengthen its mental health support system for students began to take root last year and have since been under the umbrella program called Sandigan, Sandalan: Training and Advocacy Programs for Mental Health. Sandigan and sandalan are Filipino words that refer to something that or someone who can be leaned on, relied upon, or can provide support and relief.

Sandigan, Sandalan has four components: the Directory of Mental Health Service Providers, including referral systems for focal persons and faculty members; the Training on Mental Health Promotion in the Teaching-Learning Environment; the Training Program for Peer Mental Health Advocates; and, the Student Mental Health Advocacy Program.

"Our approach to providing support is based on the positive view that mental health is not just the absence of mental illness, but an integral part of a person's overall well-being," revealed Dr. Richard Philip Gonzalo, Assistant Vice President for Student Affairs and Office of Student Financial Assistance Director.

Prof. Dan Paolo Yema of the UP Los Baños Department of Social Sciences explained, "In the past, mental health was only viewed in relation to mental illness and disorders. That is not what mental health is. That kind of thinking only leads to stigmatization. Mental health is about developing a person's capacity to cope, develop potentials, be productive, and contribute to society." Yema leads the Training Program for Peer Mental Health Advocates, where participants were active members of student organizations.

On the institutional side, Prof. Maria Angela Mabale of the UP Manila College of Nursing said that universities are crucial to mental health promotion because "there is expanding evidence indicating that university students are high-risk for psychological distress and mental disorders, and that the prevalence and severity of mental health difficulties is growing across student populations." Mabale, who heads the Training Program for Mental Health Focal Persons, added that the program includes faculty well-being as well. She reported that more than 200 faculty members and staff of student affairs offices across the UP System have completed the program thus far.

The Student Mental Health Advocacy Program was conceptualized to recognize student-led initiatives on mental health promotion, while the Directory of Mental Health Service Providers, as the name indicates, is a listing of persons and institutions that can assist students on their mental health concerns and needs.

The University is hopeful that these mental health support programs will be sustained towards a thriving post-pandemic UP life.

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Sandigan, Sandalan strengthens mental health support for students

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As the world changes and becomes increasingly riddled with uncertainty, so do the issues of thriving in it become more complex. Thriving, not just living. Not merely existing but flourishing, capable of navigating life successfully and progressively. COVID-19 has made the volatility of thriving all too clear.

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JMIR Form Res. 2020 Mar; 4(3): e15962.

Guest Editor (s): Gunther Eysenbach

Reviewed by Christo El Morr and Qi Yuan

Sun Young Park, BA, MS, PhD, #¹ Nazanin Andalibi, BS, PhD, ¹ Yikai Zou, BS, MS, ¹ Siddhant Ambulkar, BS, ² and Jina Huh-Yoo, BA, MS, PhD ³

Abstract

Background

Research shows that emerging adults face numerous stressors as they transition from adolescence to adulthood. This paper investigates university students' lived experiences of maintaining mental well-being during major life events and challenges associated with this transitional period. As we continue to design health technology to support students' mental health needs, it is imperative to understand the fundamental needs and issues particular to this phase of their life to effectively engage and lower the barriers to seeking help.

Objective

This study first aimed to understand how university students currently seek and receive support to maintain their mental well-being while going through frequent life events during this period of emerging adulthood. The study then aimed to provide design requirements for how social and technical systems should support the students' mental well-being maintenance practice.

Methods

Semistructured interviews with 19 students, including graduate and undergraduate students, were conducted at a large university in the Midwest in the United States.

Results

This study's findings identified three key needs: students (1) need to receive help that aligns with the perceived severity of the problem caused by a life event, (2) have to continuously rebuild relationships with support givers because of frequent life events, and (3) negotiate tensions between the need to disclose and the stigma associated with disclosure. The study also identified three key factors related to maintaining mental well-being: time, audience, and disclosure.

Conclusions

On the basis of this study's empirical findings, we discuss how and when help should be delivered through technology to better address university students' needs for maintaining their mental well-being, and we argue for reconceptualizing seeking and receiving help as a colearning process.

Keywords: emerging adults, university students, life events, mental wellbeing, mental wellness, mental health, social support

Introduction

Background

During this transitional phase of emerging adulthood, university students experience various life events at different scales, ranging from entering college, leaving home and moving to a new city, and making new networks, to taking finals and looking for a job [ 4]. These life events become potential stressors as students are expected to increase their personal responsibility and independence and make constant adjustments, including personal, emotional, and social adjustments [ 5]. Research shows that support from peers, family, and health care resources aids their life satisfaction, self-esteem, perceived social acceptance, and well-being [ 6, 7].

We build upon recent work in human-computer interaction (HCI) and Health Informatics [ 13- 17], which approaches university students' struggles and challenges as a mental well-being problem rather than as a clinical, mental illness problem. This approach helps address the problems that students need to engage but often ignore because they consider those problems not to be mental health concerns but "normal" problems that occur during emerging adulthood [ 12]. Focusing on mental well-being helps us understand students' everyday lived experiences of muddling through major life events during their emerging adulthood.

With this perspective, this study first aimed to understand how university students currently seek and receive support to maintain their mental well-being while going through frequent life events during their emerging adulthood. The study then aimed to provide design requirements for how social and technical systems should support the students' mental well-being maintenance practice. In this paper, we report findings from semistructured interviews with 19 students on a university campus. We identified three key needs: (1) the need to receive help that matches the perceived severity of a problem caused by life events, (2) the need to constantly draw on new support givers because of frequent life events, and (3) the need to negotiate the tension between the benefits of self-disclosure and the stigma associated with such disclosure. On the basis of this study's findings and analysis, we make the following contributions:

We extend our knowledge about university students' understandings and perceptions of mental health and coping strategies.

We discuss how students strive to maintain their mental well-being and perceive the boundary between what counts as mental "illness" vs "wellness" in assessing whether to get help.

We present design implications for sociotechnical systems to support the needs of students to better maneuver through this important transitional life phase.

Related Work

The American Psychological Association defines emerging adulthood as the "in-between age," referring to the phase of development between adolescence and adulthood [ 18]. Regardless of socioeconomic prospects, those between the ages of 18 and 29 years commonly struggle with "feeling in between" [ 19]. Emerging adults, particularly those who attend universities, go through a great amount of stress. According to the US Department of Education (2011), student enrollment in college increased to 38% since 1999, reaching its peak. However, the majority of those who drop out of college do so in their first year [ 20], indicating that the transition process is crucial to students' success. In addition to dealing with academic pressure, they are expected to make a series of adjustments, ranging from academic assimilation to personal (eg, changed interests), emotional (eg, home sickness), and social (eg, finding new friends) adjustments [ 5].

What makes emerging adulthood more uniquely challenging than other periods is the intensity of multiple life events mounting up together in a short period. The danger of multiple life events occurring in a short period has been noted in life events research-critical life events (eg, moving, starting a new job, leaving family, and paying new rent or mortgage) and their accumulation can predict long-term medical and psychiatric illness problems [ 21, 22]. The major life events of emerging adults often begin with entering college and leaving home and their old, existing networks. To help such students with the struggles brought by the transitional phase of emerging adulthood, the American College Health Association has identified coping with stress as a high priority issue in the Healthy Campus initiative [ 23]. This initiative takes a multifaceted approach to mental well-being, which includes environmental (eg, managing air quality), physical (eg, eating well), and social (eg, student clubs) health. Universities offer Counseling and Psychological Services (CAPS) with mental health professionals. CAPS further provide campus-wide programs for first-generation college students and underserved students to reduce attrition (eg, drop out) [ 24- 26]. Despite the benefit of these initiatives, the literature still notes the problems of students not utilizing CAPS until emergency situations occur, if they ever do [ 27]. Nearly 80% of the students who die by suicide never participate in counseling services [ 28- 30]. The reasons for this underutilization include lack of awareness [ 31], stigma [ 32], long waiting list times [ 33], and preference for self-management [ 34].

Besides the institutional and national effort to support students, many studies showed that students mostly seek and receive social support from their existing networks in dealing with their struggles. Peer and family support plays a critical role in offering students a sense of belonging [ 7], affirmation of their concerns [ 35], encouragement and empathy [ 36], and facilitation of mental health maintenance as a compensatory measure when other support is unavailable [ 37, 38]. Social support enabled by technology, such as social network sites and Web-based and virtual social communities, has shown the potential benefits to supporting students, such as facilitating students' identity transitions [ 39], offering access to help when lacking in-person support [ 40], addressing unpleasant experiences with negative content on the Web [ 41], and resolving stigmatized concerns [ 42, 43]. However, research indicates that barriers related to seeking and getting social support, including stigma of mental illness [ 44, 45], a sense of autonomy (eg, "I don't need a doctor to solve this problem"), a fear of losing one's positive image (ie, "face") [ 46], and secrecy and negative cultural attitudes toward mental illness [ 47], often suppress help-seeking behaviors [ 48], which hampers students from getting timely and proactive support. These previous studies on emerging adulthood highlight both the critical need for proper support for university students during their stressful life transitional period and the associated barriers that hinder students from seeking and receiving such support.

Researchers developed and evaluated technological interventions for mental health issues such as anxiety and depression. Some examples include Harmony (a mobile health app that assists patients, caregivers, and clinicians in managing serious illnesses) [ 49], DStress (a mobile app that coaches users in balancing compliance and achievement toward daily goals of stress reduction) [ 9], the UPRIGHT project (in which researchers designed and validated resilience-based interventions for promoting early adolescents' mental health) [ 6], and Intellicare (a suite of skill-focused apps that successfully provide users with more flexibility in choosing a suitable treatment) [ 15]. Furthermore, technology-mediated therapies have been implemented (a conversational mobile app, Pocket Skills, that provides Dialectical Behavioral Therapy [ 8] and Web-based cognitive behavioral therapy) [ 50]. Although these interventions have shown their effectiveness and usefulness for treating mental illness, they mainly focus on those who are clinically diagnosed and actively seeking treatment, not those who do not consider their problems as serious mental health conditions but approach them by attempting to maintain their mental well-being.

Upon reviewing the literature on emerging adults' mental health on college campuses, we find examining how students engage everyday life challenges and the everyday maintenance aspect of their mental well-being to be a critical, emerging, and underinvestigated research topic in HCI and Health Informatics communities. As we continue to design health technology to support students' mental health needs, it is imperative to understand the fundamental needs and issues particular to this phase of their life to effectively engage and lower the barriers to seeking help. Building on the previous work summarized here, this study includes the following research questions (RQs):

RQ1: How do university students perceive their problems and maintain their mental well-being while going through various, frequent life events?

RQ2: What are the implications for designing sociotechnical systems that are tailored to meeting university students' unique needs around life events?

Methods

We conducted interviews with 19 university students (6 undergraduate and 13 graduate) from a large US Midwest university for a semistructured interview study. The inclusion criteria were as follows: (1) English speaking, (2) interested in speaking about their mental health or well-being, and (3) enrolled either as an undergraduate or a graduate student of the university. We recruited the participants through school-wide departmental email lists and word of mouth, and we stopped data collection when saturation was reached.

The study was approved by the Institutional Review Board (IRB) of the first author's university, and all coauthors who had access to the transcripts were registered as study team members. Our interview sessions were conducted in private rooms on the university campus. A member of the research team began the interview by informing the participants about the study's goals and interview procedures and assuring them that they could skip any questions they did not feel comfortable answering or stop the interview at any point. The participants were told that confidentiality would be maintained and that they could withdraw their participation at any time without any consequence. This study followed IRB guidelines, which state that if any crisis situation was observed (eg, threats and suicidal posts), the participant would be immediately referred to the staff at the University CAPS. Each participant received US $15 for study participation.

The duration of each interview session ranged from approximately 1 to 1.5 hours. The questions were designed to help us gain further insights that might not be uncovered in public reports on overall campus climate, where we see increases in student struggles with stress, anxiety, depression, and requests for on-campus counseling services. The interview questions probed the students' process of identifying their stressors, their experiences of seeking and receiving support or help, their development and adaptation of coping strategies to maintain mental health or well-being, and the tools and technologies they used in this process. At the end of the interview, the researchers offered information about college counseling services and other mental health support resources available on campus to those who were in need or had no previous experience of them.

All of the interviews were audio recorded and transcribed for the analysis. This study followed all of our institution's confidentiality, privacy, and security policies for handling and storing all the participants' data. Three researchers analyzed the data using the open coding method [ 51], using the Atlas.ti 7 (ATLAS.ti Scientific Software Development GmbH) qualitative coding software program. We conducted axial coding to explore and develop the key attributes and dimensions of each theme particular to the RQs. Working collaboratively, we explored, compared, and revised the themes as the analysis progressed. We revised the themes through a series of discussions and iterations until consensus was reached. We also conducted affinity diagramming [ 52] to generate common themes and identified any breakdowns and design implications during the analysis process. We followed the Contextual Inquiry Design process [ 52] to identify common themes from the affinity diagram to generate design requirements.

Results

Overview

In this section, we first provide demographic information on this study's participants and then present the three needs that were identified in this study. These three needs are critical to understanding how students maneuver through various life events, seek help, and maintain their mental health and well-being.

Study Participants

Table 1 shows the overall participant demographics. The students ranged in age between 20 and 29 years (mean 25 years, SD 4 years), and 13 students were female, and 6 students were male. In all, 7 students were international students. Reported ethnicities were as follows: East Asian (6), non-Hispanic white (6), Indian (5), and African American (2). A total of 14 out of the 19 students had had experiences with professional counseling services. Two (P7 and P19) students were clinically diagnosed with a psychological disorder.

The Need to Receive Help That Aligns With the Severity of the Problem

The participants emphasized the importance of how and when they receive help for their problems based on how they perceived the severity and duration of the problem they were struggling with. We found that knowing or not knowing when a problem would end and having multiple stressful events accumulate at once mainly affected students' perception about the severity of their problems. This perceived severity then affected the students' expectations about help seeking. Below, we describe how life events affected perceived problem severity and what students considered "good help" to be as a result.

The Severity of the Problem Is Perceived Differently Based on Life Events

The problems students struggled with in maintaining their mental well-being included adjusting to new cities and life on new campuses, meeting new people, paying for tuition, examinations, and job searches. Some of these problems involved more certainty in terms of how long they would last, such as final exams; others, on the other hand, seemed to last forever, such as job search-related stress. Accordingly, uncertainty regarding how long their problem would last affected how students perceived the severity of the problem and how they approached it. For instance, until receiving her recent job offer, P3, who was an international graduate student, had been "really, really stressed." She explained the following:

The past year, when I was first year [of the graduate school], I was really stressed... I would never go back to my home [in China] during the time because I can only come back with a job offer.

Here, P3 described the stressful event as having lasted for a year, which significantly affected her mental well-being during that year. She did not previously know, nor could she have predicted, how long the job search would take while it was happening. The job search was stressful, and the fact that it occurred over an indefinite period of time added a considerably increased amount stress. P3 was expressing the severity of the problem in relation to the event duration because she was unable to start or plan other things until her job status was secured, directly affecting her legal status to live in the United States after graduation.

In perceiving the severity of their problem, we found that a few students even put a predefined time boundary on the problem (how long it would last) and remarked that their current problems would pass and there would eventually be closure. This perception helped them get through the problem. For instance, when P3 was having a problem with her boyfriend during her job search period, she mentioned that she had given herself 3 months (a limited amount of time) to deal with the stress and move on when she would start a new job:

I told myself just three months to get over it. I was eating snacks, watching TV shows, and doing exercises.

Starting college as an independent young adult brought multiple problems in school, work, and relationships at the same time. These multiple problems occurring in the same period exacerbated the perceived severity of each individual problem. For instance, P5 experienced a high level of stress when she had a serious problem with her boyfriend while also applying for summer internships and working on her final exams. P8, similarly, shared an extreme, distressing moment because of the stress brought on by multiple, urgent work responsibilities:

There was this one time when I had a very large amount of work to do. I had a part-time job, had one big [class] assignment, and had one [class] project due, all within the next 48 hours. Even if I stayed up the entire 48 hours, there was no way I was going to finish everything. I knew that because of the amount of work involved, and that was really causing me stress because either the assignment, the project or the part-time job had to suffer, and I wasn't sure which. I was being paid for the part-time job, the project was a group project and if I don't do the work then nobody gets a grade, and the assignment was an individual assignment for me, but it was a large part of the grade, so I had to leave at least one.

P8 further explained that he had to seek emotional support from family members and friends and go to his academic advisor for useful advice. As in the case of P8, multiple problems could occur during the same transitional period, thus requiring the student to navigate the different types of support resources available to receive the proper help. This indicates that merely having one therapist may not work well for students.

Seeking Help That Is Accessible and Available at an Appropriate Time

The urgency and timing of seeking help varied together with whether the students framed the problem as having ended or as ongoing. All students in the study commented on the importance of receiving support during the particular period when the struggles were still happening to effectively deal with their struggles. However, ensuring timely support was challenging because seeking support required a great amount of effort in their hectic daily lives. For instance, students mentioned that they often found resource constraints in their existing support environments on campus. Several participants mentioned that existing support resources such as CAPS and other professional services sometimes failed to address their need to receive help at the right time, especially for time-pressured and serious concerns. This was because of tedious nature of scheduling phone calls, long wait times for in-person appointments, inflexible working hours, and an inefficient screening process, all of which made it difficult to access care in a timely manner:

There was a pretty long waiting time. The initial session was I think after a week and a half, and then the next appointment was after a couple of weeks. Time is the only problem [with CAPS], and I realize that the timing is not in their control because of the number of people here.

Another student described his experience:

I decided to go to CAPS, and was kind of disappointed because at first I filled out that whole questionnaire and the first meeting wasn't even an actual meeting it was just going over the questionnaire with a counseling student.

These factors that delayed the timing of receiving help frequently made the students uninterested in reaching out to CAPS for help.

As their perception of the problem severity was time bound, when students were unable to find proper help in a timely fashion, they tried to manage it on their own or consider that the problem might go away some time after they endured that particular stressful event. We found that after a certain amount of time passed, the students did not necessarily want to be reminded of an issue, nor did they feel the need for professional help anymore. Rather, they wanted to put their problems behind them, letting them resolve on their own over time or trying to ignore them. Ensuring help at the appropriate time was particularly tricky for students who were required to change their locations periodically:

I came back home for the summer so I couldn't see them [therapists at CAPS] again. I could have come in the fall but it wouldn't have been the same. It would a long break and I would have thought through some things on my own and stuff like that. I didn't go to them afterwards.

As the participants, including P9, left the campus for summer and winter breaks for various reasons such as internships, vacations, or other duties, many had to leave in the middle of getting help without fulfilling their needs, and they felt that the help that came later was meaningless.

In addition, we found that when seeking and receiving help, some students experienced a discrepancy between what they expected and how the help was actually delivered. Types of problems they had might be similar to those of their peers, as emerging adults on campus were going through similar life events. Although the perceived severity might differ, students felt that their struggles might not look as serious to others as they perceived them to be. In fact, they experienced difficulty in getting proper recognition or serious consideration from others. Consequently, students quickly lost interest or motivation to actively seek help when they did not feel they were getting enough recognition or empathy from others upon initial sharing. P3 mentioned how her problem was not appropriately acknowledged or addressed by the therapists' consultation:

The therapist said, 'Ok it's been one hour, I think we are going to wrap up.' Then I was so surprised, what!? Are we finished? I thought you were going to give me some suggestions. At least some homework for what I am going to do... Then, she [therapist] said, 'no, no you have so many stress to relieve, so this time you just relieve all your tension, you just let your sore come out. And next time we will talk about others.'

In this quote, P3 showed her frustration about how her severe problem was mostly treated as one of the many other stresses without the proper understanding she expected. In this study, this kind of experience, not getting sufficient recognition of the severity of their problems, made even those students who initially sought help consider that their problems might not be serious enough for professional treatment and that they might need to be manage the problem themselves.

Many of the students in the study wanted to receive help in a more casual way through frequent and informal conversations, instead of fixed (regular but limited) and formal conversations. As most students saw their problems as issues that could come and go and get better or worse, and as similar to what their peers were all dealing with, rather than as mental health issues requiring formal diagnoses, they preferred casual and frequent interactions, which allowed them easy access when needed. P15 expressed the need to see mental health practitioners more frequently and informally as a preventative approach, rather than seeing them only when "something was going wrong," such as "when feeling depressed, when feeling anxious, when having maniac episodes whatever it might be."

Similarly, a couple of students proactively managed their stress through frequent hangouts with friends. P14 shared her experience of using her regular get together as an outlet for her distress:

It makes me feel good about how things are. I get to offload my emotional stress. I do that [talk about things in mind/head] once a week when we all get together. But on a daily basis we don't talk as much about anything emotional or anything about our job, just like, have you had food, where are you going, things like that.

P14 designated a weekly time to "talk about things" with a small group of friends who she hung out with on a daily basis as a way to focus on sharing stressful issues, as they might go through similar stressful life events and share similar struggles. Having weekly gatherings with close friends made sharing problems comfortable instead of awkward or uncomfortable.

In sum, students struggled with various problems brought by life events, especially multiple problems concurrently happening during a transitional period, and they tried to look for help that could effectively address the problems. Despite the seriousness of a problem and the critical need for help, the problems students struggled with were mostly considered to be part of normal emerging adulthood-related issues, not "serious" ones, by the students themselves and even by others whom they tried to ask for help. Students thus preferred casual help, or they took a preventative approach so that those "normal" problems would not develop into "serious" ones.

The Need to Build, Rebuild, and Maintain Support Givers for Frequent Life Events

All students participating in the study had recently gone through major life events and changes: they had left their hometowns or relocated, sought or made new friends in college or at work, or made changes in their career-for example, switching majors, changing schools, delaying their degree, and coming back to school from industry. These transitions caused changes in social support structures, exacerbating stress and problems in maintaining their mental well-being. The following quote from P8 illustrates the highly stressful period of transitions and the loss and regaining of social support:

The transition time was very rough because I was used to a place with a lot of people and a lot of activities. When I first came here... I don't know, I found a lot of simple things to be very difficult. I didn't have my own mode of transportation, so had to rely on the bus services. Small experiences like that really added to my stress levels and I found the fact I lived away from the main campus, [which] meant that I had to spend a lot of time on my own, which I didn't like because I like hanging around people. When I was staying alone it was quite difficult for me.

Relationship Building Is Constantly Needed to Have Access to Potential Support Givers

The various life events the participants experienced not only forced them to quickly adjust to new life contexts and rebuild their social connections but also made it difficult to maintain their existing social connections. For this reason, students often felt that the support they wanted was not readily available or workable, but inconsistent; supportive social groups or support givers were likely to come and go. For instance, P18 described her premed group members with whom she initially developed deep relationships, and she described how these relationships were enhanced by their common struggles and active support for each other. Later, she felt helpless and discouraged when all the members of the group transferred to other universities or decided to pursue something else:

I think with pre-med courses, it's nice to have a community where you can be stressed out together and fall on each other for advice and study together and help each other. But then when everybody dropped, and it was just me, I think that's when it got to be very stressful because I was doing everything on my own.

The short-term and inconsistent social support received from their existing support givers was somewhat detrimental to the students' mental health, often resulting in sudden feelings of being lost or alone. Although some relationships were strong and long lasting, the students needed to be prepared to lose connections and relationships they often put a large amount of time and effort into building and rebuilding.

Most of the students in this study experienced the diminishment, disappearance, or replacement of intimate friends they previously relied on to receive support, such as the replacement of high school friends with a small group of close friends from the freshman cohort, or they experienced the quality of relationships with old friends changing over time. P9 explained how the friendships he had with close friends growing up and their support for each other became rather unstable and shifted after 3 years of college as they experienced conflict and disagreement:

These were probably the two people I would go to if I had trouble with school and things, but after I had a disagreement with them, I felt very alone and isolated. Now, I'm a better friend to them but I think because we had that break we're not as close as we used to be. It's always in the back of my mind that we had this fight so I'm not that close to them as much anymore.

This shows that even with existing support givers (eg, intimate friends), effort was still needed to maintain relationships as all parties went through different stages and events of their own lives during emerging adulthood, affecting their current or future situations, viewpoints, and needs.

While going through different life events and needing to seek appropriate help, the students encountered situations where they needed to determine how to disclose and share their problems with the new social connections they had just built or developed. The new social connections were usually people they had recently met in classes, at work, at various events, or where they lived. For instance, P10 shared her experience of sharing her concerns with a new friend she had started to get close with recently:

I talk a lot this semester with Olivia [her classmate], but like until the end of the semester, not really earlier. I feel like this semester, the early part of this semester I'm always alone because I am mostly in Fishbowl to finish 520 assignment or something. (...) She also shares her concern as well. I think for the academic part, we are very similar. In the same situation, I guess. And we haven't got internship yet and we're also worried about finding a project, final exams, so it's hard. Our schedules are more similar. We sometimes work together on weekends.

Having similar situations, interests, or struggles as other individuals helped students quickly build new relationships and potentially share their problems, although the sharing might initially be limited to their common interests.

While sharing problems with newly developed social connections, students did not share their real, deep problems upfront, unless those were the commonly shared issues they already knew about each other (eg, met at a counseling session). They wanted to share problems in a friendship after building a relationship and worried that sharing such issues in the beginning of the relationship could lead to making some "unattractive" or "undesirable" impressions:

I wouldn't necessarily want people to know that to be the first thing they know about me. I want them to know me as a person. I feel like, yes, that's an important thing to know about me in a friendship and stuff, but I don't want that to be the first thing.

Seeking Alternatives to Support Givers on the Web

Owing to the challenges of having a constant change of support givers while going through frequent life events, the students often sought alternative forms of support, such as making new Web-based social connections and asking for help (eg, Facebook groups, mental health-related web forums, and anonymous others on Reddit or Instagram). As Web-based support is always accessible, students found that this served as a support baseline that they could contact regularly or whenever they wanted to check in as a casual (not as structured and serious as a CAPS or professional service) but also steady (with minimum effort to set up) way of maintaining their mental well-being. However, despite the benefits of having Web-based help, students reported issues with the sustainability and the consistency of support based on their experiences. They believed that the size of the group, the qualities of the anonymous members, and whether there was guidance and a moderator within the Web-based communities often affected the quality of the support they received. Many, including P19, mentioned the double-edged sword aspect of anonymity in Web-based groups and communities regarding the anonymous members and expected behaviors:

I don't like Reddit, not at all! 'Cause Reddit is totally about anonymity. And I don't enjoy that. I think anonymity is to some degree dehumanizing. It's really unaccountable. And people allow their worst selves out because they don't understand impact when they're anonymous.

According to the participants, the size of the group mattered for the perceived quality of group dynamics and conversation. When the Web-based support group was too large, the conversation among the group members would become disorganized and derailed by new information, which often made participants feel less valued. In contrast, with small groups, the students often felt they did not get enough diverse opinions, which could lead to a lack of effective solutions or ideas to address their problems. Nearly all of the participants advocated 7 to 10 members as an ideal group size for sharing their concerns and having effective group discussions:

Less than 10 participants [would be good] in order to have sufficient dialogue and participation among everyone.

The personal qualities of the web members were also seen as an important consideration to ensure that the support was sustainable. Students considered being faithful, committed, and respectful of others' privacy the most needed qualities of support members as potential support givers, especially given the relative anonymity of many support spaces. The students also commented on their desire to engage both intimate friends and strangers in their envisioned Web-based support group to receive the most useful help, as each provided different types of support on different subjects. In addition, moderated interactions within support groups were seen as critical for students to better receive quality social support. They remarked that careful moderating and monitoring helped maintain the support environment as a healthy and useful place for everyone to get consistent support for the long term. A few students (P8, P12, P14, and P16) who had never used any Web-based support group expressed their interest in joining a small group conversation moderated by professionals who could understand the members, properly react to what was said in the group, and maintain group positivity:

You have a different mental state when you're talking to a therapist compared to talking to just anonymous people. I might not be able to respond if one [a person] was sad or depressed. In a sense, a therapist response would be much nicer and much more understanding compared to what I can provide.

Similarly, some who already had experience with moderated Web-based support groups also preferred to have a more structured support environment where a moderator provided group therapy or assigned particular goal-oriented tasks to help members achieve their goals. Several advocated for having more than one moderator or professional monitor to track the conversations to ensure that the members would interact appropriately, particularly in anonymous environments.

The Need to Negotiate Tensions Between the Benefit of Disclosure and the Stigma Associated With Disclosure

The last challenge that students mentioned was balancing self-disclosure to seek help and the stigma that prevents such disclosure. To express a need for help, the students attempted to find ways that allowed them to avoid the stigma associated with the disclosure while also maintaining their mental well-being.

Students Hold Tension in Maintaining Desirable Presentations of Self

One common concern related to transitions across frequent life events, particular to emerging adulthood, was maintaining and developing a desirable presentation of self in social interactions. Although wanting to maintain a "positive" image or reputation is a well-known phenomenon in social science research [ 53], it becomes particularly challenging when one's network keeps changing, as was the case for the students participating in this study. Students commented that the stigma associated with sharing personal problems could hinder the development of positive social relationships, often discouraging them from openly sharing their concerns with their social connections, such as friends, family, and the people with whom they had recently developed relationships. Particularly, as many students considered their problems might be trivial and common, they considered that what they were going through should not be overestimated as a serious problem. This thinking process aggravated their stressful situations.

The transitions during emerging adulthood made it difficult to keep up with their original support givers (ie, old and intimate friends), and it forced them to build new connections (ie, new friends). The new social connections students built were the ones with whom they wanted to further develop intimacy. These new connections were critical to their emerging adulthood in that they were the students' most preferred source of support. Thus, to further develop these new relationships in the ways they desired, students did not want to disclose their problems too much, but they preferred to maintain a positive self-presentation toward their new connections. For example, some students wanted to maintain an image of being fun and outgoing. They worried that if they disclosed too much about their depression, sadness, or struggles, their new friends would view them differently and categorize them as "not a fun friend to be around" or "problematic." P2 described hiding his concerns from friends in an effort to maintain the character of being fun and happy:

You have five friends and they expect you to be very fun and outgoing, you can't help but stay in that character. It's very difficult or you feel uncertain that if you were to reveal a little bit [of your] personal self, would they still be the same towards you know, [the] friendship or not.

As in the case of P2 above, many students worried that the negative, long-term impact of sharing their concerns with their social connections, particularly with newer ones, would outweigh the potential benefits, which ultimately prevented them from getting effective help.

Owing to the tension between their need to share with friends and the associated stigma, many students put a lot of effort into sharing their problems in ways they perceived to be less risky. They would slowly and carefully bring their concerns into the conversation or look for the right time to bring up an issue. For example, we saw that some students waited to share their concerns until a friend approached them first, instead of asking for help directly; others tended to hide their true feelings, pretending to live and act in a way that conformed to how their friends viewed them, until they felt more comfortable talking about their problems. P6 explained how long it took him to feel comfortable sharing his struggles with others, explaining that there was a certain time at which such disclosure would be allowed normatively:

At the end of April when everyone is getting ready to [graduate] and started to pull out their hearts and essentially had a very close talk. That was with everyone else, and I was just sitting there and said I'm not graduating, they are, so I should at least tell them something that has been on my mind for the past few years. There was that instance where I felt should tell them.

Here, the fact that his friends were all graduating and would not be around anymore made it easier for P6 to disclose the issues that he was holding onto. His friends' transitions also made it less burdensome to deal with their reactions, which was why he chose to disclose at that time.

Disclosure was difficult when students experienced pressure to follow and meet societal expectations or standards, such as being independent financially, accomplished educationally or professionally, or settled at a culturally expected age. This finding was more apparent among the Asian students, who felt pressured to be "good" or "mature" for their families in their particular culture. For instance, P10 who started her graduate study in her late 20s explained her struggle with feeling stigmatized by her age and financial situation:

I actually borrowed money from my parents. At my age I shouldn't do that, and especially, my parents used their retire money to support me. That's a big issue. After graduation I will definitely have to find a good job and pay back. My family invested [in] me to go abroad, so that means I will have the responsibility to support my family back as well. I think that's a concern I have. (...) The other thing is my age, I would say. I think relationship and marriage is also very...not super stressful, but when I think about it, I will kind of worried about that. Because I've never had a relationship before and right now I'm almost 30. Especially my parents worry about that. I feel everything is related to my family. If my family worry about this then I will worry about that too. I know they want me to have a family in close future, but so far in my situation I don't think I have enough time to do that, seeking one and building a relationship..."

Like P10, even though students talked to their parents every day to share their thoughts, we found that many of them tried not to reveal struggles related to their schoolwork because they wanted to present themselves as a smart, hardworking daughter or son.

Exploring a Casual, Nuanced Way of Sharing Problems

As a way to deal with the stigma associated with sharing problems, students favored communicating with their social connections (potential support givers) through images. Image-based communication included any images, such as the students' own drawings, famous paintings, landscapes, body parts, any artifacts from their daily lives, funny or abstract pictures, and funny memes, shared through mobile or Web-based messages or social network sites. This was popular among the participants, especially for when they just wanted a small amount of casual support that could cheer them up in their daily lives or for when they wanted to provide support for someone else, without anyone explicitly seeking help:

I use Facebook and Instagram basically just to see what people are up to and for funny videos and photos of dogs and videos of dogs. I like memes a lot, so if I see a funny meme I just like it. (...) so like funny pictures and funny comments, internet memes. If I see one, I'll just click like so that my friends will see it, and my friends will start laughing about it. I use that as a stress buster really.

Similarly, sharing dog and cat photos on the Web was also a popular form of support during less energized moods.

Image-based communication allowed the students to indirectly express their nuanced feelings, as they could use some of the affordance images offer to express and share their feelings in a very subtle and subjective way, without directly revealing their true feelings or intentions. It also enabled students to adjust their own moods while sharing or posting images as a way to overcome negative feelings or curate their own feelings. Students (P11 and P16) used their social media as a digital diary, using images to share and record their moods:

I think this semester I post a lot less, but usually I post a lot. Facebook is almost like one kind of my diary. I post everything, [including] not good [ones]. Especially not good things on that. (...) I don't know [the motivation], but I think it's just like, letting it go, away for me to like expressing my anger or depression. Because I feel, if I cannot find a person to talk, because on Facebook it's also a way for me to let it go and let the others know that I'm not good.

Like P11, other participants expected image sharing and posting to enable them to feel more comfortable and embedded during their everyday lives, while reducing the stress and stigma related to their support-seeking behaviors. By using a platform that people use to communicate about everyday situations, the shared problems are portrayed as mundane and normal problems of daily life rather than as serious mental health problems.

Discussion

Overview

University students go through a critical transitional life phase of emerging adulthood between adolescence and young adulthood. This life phase requires increased responsibility, maturity, and independence, causing more stress and problems with maintaining mental well-being. For this reason, there have been increased mental health incidents on college campuses [ 13, 54], and more researchers have been exploring technological interventions for emerging adults on university campuses [ 50]. Below, we describe the maintenance work required for students' mental well-being using the literature on self-disclosure [ 55]. We also discuss the boundary students perceive between mental well-being and illness, which played a critical role in students seeking help. We then discuss implications for potential sociotechnical systems that can support the needs of students in better maneuvering through this important transitional phase of life.

Negotiating Time, Audience, and Disclosure for Mental Well-Being Maintenance Work Across Life Events

This study revealed that students' mental well-being needs constantly shift and evolve as they go through the life events associated with emerging adulthood. These transitions, shaped by life events, critically impact their mental well-being. This study's findings draw attention to how students negotiate the three needs in their lived experiences related to time, audience, and disclosure. The severity and duration of the life events ( time) defined the expectations of how help should be delivered. Students encountered new social relationships, which they had to constantly rebuild and maintain as sources of support. These relationships at the same time served as the audience for whom the students had to balance the tension between the stigma and disclosure of problems and seeking help. As such, these three needs are closely interconnected and constantly negotiated to maintain their mental well-being. This interconnected relationship has been identified in the studies about disclosure in HCI and Communication fields.

For instance, "time" has been found to be a critical component in when, how, and whether disclosures occur, exploring the facilitation and hindrance of disclosures [ 55, 56]. Reasons for delayed disclosure [ 56, 57], a delay between a significant, stressful event and the time of disclosure, include fear that the disclosure will be poorly received and not supported by others as well as moving on from the event and not feeling the need to share or reopen wounds [ 56]. Although delayed disclosures have primarily been studied in the context of abusive and traumatic situations (eg, sexual abuse) [ 58], this study shows that delayed disclosure also happens when students wait for the right "timing" to disclose their problems and seek help. An example from this study's findings showed that one student (P5) waited until his friends' graduation to reveal his issue to reduce the burden of having to manage friends' reactions to his disclosure. Moreover, this was during a moment when the friends had mutually agreed to share intimate experiences as a way to reflect on their college years. The reciprocity norm of mutual self-disclosure in dyadic relationships [ 59] explains this observation of mutual sharing at the right time.

"Audience" is another important factor in explaining why people disclose or do not disclose stigmatizing experiences (eg, depression) in the Disclosure Decision-Making Frameworks [ 55, 56]. The concept of audience connects with our findings on rebuilding relationships, such as the new social connections students need to build. According to Goffman, "audience" refers to the individuals for whom one performs and who might be the recipients of one's direct or indirect disclosures as part of a help request [ 53]. The disclosing person assesses how these individuals, that is, the audience, might react and respond to the disclosure or lack thereof and makes a (non)disclosure decision accordingly. In this study, such an assessment includes balancing the potential benefits of disclosure with the risk of losing the status of being a fun friend to be around, especially when the goal is to rebuild and maintain new relationships with the audience. This negotiation is fraught as these new relationships entail potential disclosure to audiences who can be a source of support.

Furthermore, this study also showed that as a result of the risk of stigma associated with disclosing problems, students used fun and positively valued social media sharing to release stress for themselves and others. Previous work has argued that social media design should facilitate the disclosure of stressful situations directly or indirectly [ 56]. This study added to this conversation by arguing that sharing positive content is not necessarily shallow or "just for fun"; it can, in fact, be part of an activity that releases tension and stress among individuals.

Understanding the Perceived Boundary Between Mental Wellness and Illness as a Collective Effort

In this study's findings, students perceived most of their problems to be either normal or on a continuum between normal and serious. The latter would imply the need for seeking immediate help from a professional source, compared with the former, where the problem may resolve on its own as time passes. Students view the problem as fluctuating day to day, or even hour by hour, and as being influenced by many things in their daily lives, just like physical health. They think normal problems can progress to become serious and serious problems can revert to being normal as time passes (after a certain stressful life event is over). Coupled with stigma and barriers to self-disclosure [ 55], students attempted to avoid as much as possible the need to label their problems as illness problems.

The students in this study tended to consider their problems within the realm of wellness-a state where they think they have abilities to cope with the normal stresses of life and manage on their own. However, students also worried that their wellness problems could potentially develop into more serious ones and become illness problems. To prevent this progression, students actively and proactively tried to seek effective, workable resolutions. This study's findings showed that students set a maximum time (eg, three months and two weeks) in which to resolve problems (eg, relationship breakup and being stressed about grades or job search) to prevent the problems from overwhelming their overall well-being. Having a social network to share their problems with, whereby students could set up regular weekly hangouts with close friends to prevent the problems from progressing into more serious ones helped.

In this study, we reported different perspectives between the mental health literature and findings in terms of when a problem is considered as part of "wellness" vs "illness." This difference makes it difficult to determine when and how we should intervene to support students' help-seeking behaviors effectively. The traditional mental health literature on emerging adulthood problematizes the students' perceived, self-endorsed boundaries between wellness and illness, defining it as a barrier to mental health care and support [ 60]. The literature legitimizes self-management activities for mental health but only to a certain extent. Self-management activities, referring to seeking help from family and friends and going to meditation groups, are largely described as barriers to mental health care access. Rickwood et al [ 61, 62] found that participants preferred to talk to friends and family rather than health care professionals, which might prevent access to health care when added to participants' lack of emotional competence and negative attitudes toward seeking professional help. Biddle et al [ 63] showed that participants continuously self-assessed whether they could accommodate high levels of distress and avoid seeking help.

Where the boundary between wellness (ie, whether a problem is a normal part of emerging adulthood) and illness (ie, a symptom of a serious mental health disorder) lies or whether the boundary should even exist remains an open question. This might be an applicable question for the general population, such as those with mental health issues in the workplace [ 69], but it is the salient case for students as they are especially close to their peers who go through similar types of problems and life events during their emerging adulthood, which can make the students more ignorant or blunt about their problems. The question about the boundary has often been unclear even for health professionals because of individualized, situational factors [ 70]. Health care workers need to individually assess how much the unstable, uncertain experiences of a student should be treated as a healthy part of self-development and how much should be treated as a symptom of a serious mental health disorder [ 70]. This nuanced boundary as well as the differing viewpoints between health care professionals and students can add to maintaining student mental well-being negatively. This problem forces students on college campuses to be tolerant of severe problems and to ignore the need to get help.

We argue that this boundary between wellness and illness needs to be carefully negotiated, evaluated, and coordinated for each individual student through collective efforts among the social systems made up of responsible stakeholders: university students themselves, health care professionals, family, friends, educators, designers, institutions, and the public health sector.

Reconceptualizing a Support Group as a Place for Colearning

In examining the ways in which students received support, including from their groups of intimate friends, Web-based groups, and social media, we noticed that being part of a "support group" had a negative connotation for our students. Many students avoided labeling the wanted help as a "support group," as the term problematizes what should be a normal process of being supportive of each other in a seamless way throughout everyday contexts. The negative connotation associated with support groups served as a barrier to students accessing helpful resources, such as CAPS or related peer groups, on campus. It is worth investigating how to engage and assist students with various stressors in their emerging adulthood more effectively.

Accordingly, this study calls for an urgent need to reconceptualize the existing notion of support as a colearning space where individuals learn to maintain their own mental wellness: how to be aware of it, how to keep it healthy, and how to prevent potential risks. This knowledge is not something normally gained from formal education, although it should be. Importantly, in this reconceptualization, each individual can be a help giver as well as a receiver. This sort of mutual exchange has been discussed in the literature as the helper therapy principle [ 71], which is the central concept for building support groups. In this study, a few of those who wrote blogs or made images related to mental wellness awareness expressed their interest in working with counseling services to help their peers, based on their own experiences. At any given time, one can be a helper for multiple people on different issues, while seeking help for one's own mental well-being maintenance work. This multiparticipatory nature of a support exchange can facilitate accountability among the helpers and the individuals receiving help.

Design Implications

We discussed university students' challenges and efforts to maintain their mental well-being around time, disclosure related to stigma, and the right audience. This study indicated that it is important to facilitate the negotiation of students' own perceived boundaries of where illness begins through self-reflection and evaluation so that they can receive appropriate help. To that end, ideal sociotechnical systems should be designed in more inclusive ways that allow self-reflection to support students in managing their mental health in a casual, informal, and positive manner, rather than approaching the challenge from a mental illness perspective.

This study's findings show value in integrating functionality from such systems to support students' mental well-being maintenance work. They call for investigating how existing systems and applications for the general population can be extended and designed to offer self-reflective and self-evaluative mechanisms for students' mental well-being. For instance, existing practices, such as Expressive Art Therapy (EAT), which offers individuals the opportunity to use any expressive and creative art form (eg, singing, poetry, art, dance, or performance) to reflect on and identify what the root of a problem is, increase self-awareness, enhance social relationships, and foster emotional growth and development [ 73- 75]. EAT can then be integrated into existing everyday systems and applications to provide nonclinical solutions. Specifically, existing media applications for self-expression, such as video blogs, amateur music sharing, sharing creative artwork or images, drawing, or poetry sharing forums, can be used to support these varieties of forms of expression as a form of EAT. Similarly, doodling can be used to benefit the process of mindfulness training with some guidance (eg, "Choose whether to document a current happy moment or think back to a happy time and doodle your memory") [ 76]. Integrating such expressive capabilities into existing applications could enable students to be mindful and aware of their mental health status. In addition, integrating such an approach with Positive Psychology [ 6, 77, 78] can help students release their stress and discover positive moments and strengths, instead of focusing on the problems and the negativities. Examples include enabling the platform to suggest recording a thankful moment from the day through a photo, writing, or drawing and sharing it with friends on Instagram or in a group chat or cocreating humorous internet memes with friends on Sketch as a positive mood booster. These activities can foster emotional growth, enhance social relationships, and improve self-awareness [ 22, 35]. These outcomes will eventually help young adults define their own perceived boundary of mental health and receive proper help when needed.

Upon developing the platform, we argue that it should be designed to facilitate the involvement of a community of all relevant stakeholders in supporting the mental well-being maintenance work of an emerging adult on campus (eg, students, health care providers, practitioners, institutions, designers, and app developers). This platform will not only help students to self-reflect and evaluate their mental well-being maintenance activities but also help stakeholders to easily analyze functionalities, use cases, and user populations of existing applications. It will also help them analyze new applications as they are developed and suggest potential connections to existing therapeutic practices of mental well-being. The platform could show usage trends of user populations, along with new features that these applications might be able to provide. It could also offer a database of EAT curated by health care professionals. The stakeholders could then exchange feedback regarding how these existing and newer applications could work together to support therapeutic mechanisms according to the life events of an individual.

The findings also indicate that it is critical to support the process of navigating and renegotiating time, audience, and disclosure. The aforementioned platform could provide a variety of approaches to requesting as well as receiving situated help, ranging from the immediate and direct to the more casual and abstract. On the basis of the mood or level of activity of a user or a particular life event, a platform could directly intervene by matching or suggesting appropriate helpers or by nudging and casually connecting with family and friends to encourage students to share their struggle with others. This could help with providing support within the appropriate time window when the impact of that event is still active. For instance, the findings showed students did not want to be reminded of their problem after a certain amount of time had passed after the issue occurred. Such a platform could also pick up on and identify potential emotional breakdowns or challenges that might come up, based on their behavioral and emotional patterns. In addition, in terms of suggesting an audience, selecting helpers from social group contacts or outsourcing highly customized help based on the topic or similar interests and needs (eg, nearby peer groups, mentors, and professional consultants) could be done for the user. Matching with others based on similar needs or interests was found to be helpful in previous work using others' life transition trajectories as a form of social support among peer patients [ 79]. The incentive for anyone to become a helper could be established by keeping them informed of both the short-term and long-term positive outcomes of addressing a problem through feedback, thus alleviating tension related to stigma and facilitating the rebuilding and maintenance of relationships between users and new and potential helpers.

Conclusions

We investigated the mental well-being maintenance practices of emerging adults on a university campus: how students perceive problems, set expectations for help, and go through the work of from whom, when, and how to seek help. We identified three needs that are required for students to maintain their mental well-being: (1) getting help at an appropriate time and in an appropriate form that aligns with the severity of the problem, (2) building relationships with potential support givers, and (3) negotiating tension between disclosure and the associated stigma. This formative study informed how sociotechnical system support for this population should be sensitive to how help is framed and offered to make it easier to embrace. We also discussed how and when help should be delivered through technology and argued for reconceptualizing help as a colearning process. This research was conducted with a subsample of emerging adults, focusing on those at a large university in the Midwest. Although the participants do not represent the broader population of emerging adults nor all university students, this study's findings demonstrate a unique set of needs and challenges that should be acknowledged and supported in the population to which these findings theoretically generalize. This study contributes to helping mental health practitioners, researchers, and system designers understand and support students' mental well-being maintenance practices as part of the normal course of life beyond the clinical context.

Abbreviations

CAPS

Counseling and Psychological Services

EAT

Expressive Art Therapy

HCI

human-computer interaction

IRB

Institutional Review Board

RQ

research question

Footnotes

Conflicts of Interest: None declared.

References

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Articles from JMIR Formative Research are provided here courtesy of JMIR Publications Inc.

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Understanding Students' Mental Well-Being Challenges on a University Campus: Interview Study

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Research shows that emerging adults face numerous stressors as they transition from adolescence to adulthood. This paper investigates university students' lived experiences of maintaining mental well-being during major life events and challenges ...

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Teaching is one of the most rewarding professions, but it can also be one of the most stressful. CARE is a unique program designed to help teachers, other educators and administrators learn how to reduce stress and enliven their teaching by promoting awareness, presence, compassion, reflection, and inspiration - the inner resources they need to help students flourish, socially, emotionally and academically.

Cutting-edge neuroscience confirms that practicing mindfulness facilitates awareness and self-regulation and develops the capacity for a calm, focused mind - a mind with the openness, responsiveness and sensitivity for optimal teaching, guiding, and learning. For all educators, these resources can provide the inner strength to be powerfully present and emotionally responsive. As a result, educators become effective guides, and influential models of healthy social and emotional behavior.

CARE Program Design and Delivery

Based upon current research on the neuroscience of emotion, CARE introduces emotion skills instruction to promote understanding, recognition and regulation of emotion. To reduce stress, and to promote awareness and presence applied to teaching, CARE introduces basic mindfulness activities such as short periods of silent reflection, and progresses to activities that demonstrate how to bring mindfulness to challenging situations educators often encounter. Through these activities, educators learn to bring greater calm, mindfulness and awareness into the classroom to enhance their relationships with their students, their classroom management, and curricular implementation. The CARE program also promotes empathy and compassion through caring practice and mindful listening activities.

A new version of CARE has been specifically designed for supporting the personal development and leadership of principals, assistant principals and other school administrators. CARE has also been used with higher education faculty to sharpen their awareness and presence in their teaching.

The CARE program can be presented in a variety of formats depending upon the particular context. The yearly retreat at the Garrison Institutes is a four day-long experience. CARE is also provided as a series of day-long sessions over a period of months with intersession support via internet to support teachers' practice and application of new skills.

"As a teacher educator, I learned and re-learned vital knowledge, skills and attitudes for fostering social, emotional and academic learning in my graduate students, and through them to K-12 student in schools and other learning communities."

The program involves a blend of didactic instruction and experiential activities, including time for reflection and discussion. Educators who have completed the program say they found it relaxing, enjoyable and inspiring. Several educators share their experience with the program in this video. The CARE Program has supported educators in the US, Canada, The Netherlands, China, Croatia, and Germany. All training for CARE is provided by CREATE for Education.

CARE Research

With today's high levels of stress and burnout among teachers, districts are looking for science-tested ways to support their teaching staff. The CARE professional development program is proving to be an effective solution. A series of rigorous Federally funded studies has examined the impacts of CARE on teacher, classroom and student outcomes. The results of this research have been published in a series of peer-reviewed journal articles. Consistently, research has found that CARE significantly improves well-being and reduces stress among teachers who participated in CARE compared to those randomly assigned to a control group. Research findings can be reviewed at https://createforeducation.org/care/care-research/

Funded by the U.S. Department of Education, a large cluster randomized controlled trial conducted in New York City recently involved 224 teachers and over 5,000 students. This study replicated previous results in teacher improvements but also demonstrated that CARE improves important dimensions of the classroom. Classrooms were observed and coded by trained researchers blind to the study aims and the teachers' random assignment. Compared to classrooms in the control group, CARE classrooms were more emotionally positive and the teachers demonstrated greater sensitivity to their students' needs. Finally CARE classrooms demonstrated higher degrees of productivity than controls. A follow-up report found that CARE teachers showed continued significant decreases in psychological distress, reductions in ache-related physical distress, significant increases in emotion regulation and some dimensions of mindfulness. Findings indicate that teachers who participated in CARE reported both sustained and new benefits regarding their well-being at a follow-up assessment almost one-year post-intervention.

These results are particularly significant for several reasons. First, the series of CARE studies all showing improvements for teachers provide clear evidence that CARE is an effective professional development program for reducing teachers' occupational stress and promoting their well-being. Second, the NYC study is the largest and most rigorous study of a mindfulness-based professional development for teachers and the first of its kind to examine intervention effects on the classroom and student outcomes. Third, the results of the NYC study showing impacts on the classroom are important because they demonstrate an important relationship between teachers' well-being and classroom quality. Finally, this study is a "proof of concept" that a mindfulness-based intervention can have impacts on both individuals and their work environment. Tish Jennings discusses some of the findings of the study and their implications here.

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Teaching is one of the most rewarding professions, but it can also be one of the most stressful. CARE is a unique program designed to help teachers, other educators and administrators learn how to reduce stress and enliven their teaching by promoting awareness, presence, compassion, reflection, and inspiration - the inner resources they need to help students flourish, socially, emotionally and...

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Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act, and helps determine how we handle stress, relate to others, and make choices.

Mental health is important at every stage of life, from childhood and adolescence through adulthood. Over the course of your life, if you experience mental health problems, your thinking, mood, and behavior could be affected.

Mental Health Conditions

Mental illnesses are disorders, ranging from mild to severe, that affect a person's thinking, mood, and/or behavior. According to the National Institute of Mental Health, nearly one-in-five adults live with a mental illness.

Many factors contribute to mental health conditions, including:

Biological factors, such as genes or brain chemistry

Life experiences, such as trauma or abuse

Family history of mental health problems

Some mental health topics include:

A Serious Mental Illness (SMI) is a mental illness that interferes with a person's life and ability to function. Despite common misperceptions, having an SMI is not a choice, a weakness, or a character flaw. It is not something that just "passes" or can be "snapped out of" with willpower.

View SAMHSA's Public Message about Serious Mental Illnesses.

Early Warning Signs & Symptoms

Not sure if you or someone you know is living with mental health problems? Experiencing one or more of the following feelings or behaviors can be an early warning sign of a problem:

Eating or sleeping too much or too little

Pulling away from people and usual activities

Having low or no energy

Feeling numb or like nothing matters

Having unexplained aches and pains

Feeling helpless or hopeless

Smoking, drinking, or using drugs more than usual

Feeling unusually confused, forgetful, on edge, angry, upset, worried, or scared

Yelling or fighting with family and friends

Experiencing severe mood swings that cause problems in relationships

Having persistent thoughts and memories you can't get out of your head

Hearing voices or believing things that are not true

Thinking of harming yourself or others

Inability to perform daily tasks like taking care of your kids or getting to work or school

Do you think someone you know may have a mental health problem? Talking about mental health can be difficult. Learn about common mental health myths and facts and read about ways to help you get the conversation started.

Tips for Living Well with a Mental Health Condition

Having a mental health condition can make it a struggle to work, keep up with school, stick to a regular schedule, have healthy relationships, socialize, maintain hygiene, and more.

However, with early and consistent treatment-often a combination of medication and psychotherapy-it is possible to manage these conditions, overcome challenges, and lead a meaningful, productive life.

Today, there are new tools, evidence-based treatments, and social support systems that help people feel better and pursue their goals. Some of these tips, tools and strategies include:

Stick to a treatment plan. Even if you feel better, don't stop going to therapy or taking medication without a doctor's guidance. Work with a doctor to safely adjust doses or medication if needed to continue a treatment plan.

Keep your primary care physician updated. Primary care physicians are an important part of long-term management, even if you also see a psychiatrist.

Learn about the condition. Being educated can help you stick to your treatment plan. Education can also help your loved ones be more supportive and compassionate.

Practice good self-care. Control stress with activities such as meditation or tai-chi; eat healthy and exercise; and get enough sleep.

Reach out to family and friends. Maintaining relationships with others is important. In times of crisis or rough spells, reach out to them for support and help.

Develop coping skills. Establishing healthy coping skills can help people deal with stress easier.

Get enough sleep. Good sleep improves your brain performance, mood and overall health. Consistently poor sleep is associated with anxiety, depression, and other mental health conditions.

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Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act, and helps determine how we handle stress, relate to others, and make choices.

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Alvin Gino M. Bautista Elizabeth S. Manuel

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Mental Health of Students in the Philippines during Pandemic: An assessment | International Journal of Humanities and Education Development (IJHED)

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This research was made to assess the mental health and psychological wellness during the community quarantine of the 500 selected students from the College of Management and Business Technology (CMBT), of Nueva Ecija University of Science and Technology (NEUST). The CMBT was located at Sumacab, Caba…

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Erin McClintock

Throughout the COVID-19 pandemic, teachers, school counselors, and school employees have remained acutely focused on supporting their students and continuing to do their jobs at this time. In some cases, this may mean teaching, care-taking (whether for children or other loved ones), and continuing to work through the same challenges that everyone else faces. While resources related to mental health have been (rightfully) front and center for supporting students, parents, and others, less focus has been paid on maintaining mental wellness for teachers and educators who are also trying to find balance in our new normal. That's why we put together some mental health tips for teachers during COVID-19 and beyond.

10 Mental Health Tips for Teachers Balancing Life and Remote Teaching

Here are ten teacher mental health tips you can start practicing today.

1. Control the Controllable During COVID-19 & Beyond

There are certain things that you simply cannot control right now: who will be impacted by COVID-19, whether it will be you, how things will continue to evolve. But there are some things that you can control: how you spend some of your time, what you choose to prioritize, what types of media you consume (and how frequently) and your mindset, to name a few. By focusing on the things that you can control and prioritizing the ones that are healthy, you can help to put your mental wellness front and center.

Webinar | Mental Health Strategies for Teachers and Students

In honor of Teacher Appreciation Week and Mental Health Awareness Month, experts from the EVERFI team are partnering with the Jed Foundation to ensure you have the resources necessary to support your mental wellness and that of your students. In this webinar, we explore activities and strategies around mental well-being that can be used in the classroom or virtually, as well as providing tips and tricks for educator self-care.

2. Carve Out Time for Self-Care to Maintain Your Mental Health

Now, more than ever, we are acutely focused on remote teaching , physical health, and preventing illness- washing hands and engaging in other healthy practices. But it is just as important, for maintaining mental health, to try to carve out some time to prioritize the other things that help us feel balanced: for some, it is exercise, for others, it is reading, journaling, meditation, or spending time doing a hobby. And, if you are someone who isn't sure what you can do for your self-care, simply the act of doing can help maintain your mental health .

3. Get Your Body Moving to Help Your Mental Wellness

One of the biggest challenges for many educators during this time is how hard it is to be sedentary- you may be used to moving around, physical transitions from one room to another, or even your usual lunchtime walk with a colleague. As you work around your schedule, set a timer or create breaks for you specifically to move around- this might mean moving around your house, or taking a walk around your building or neighborhood- obeying physical distancing recommendations, of course. Anything to get your body moving will help manage your mental wellness .

4. Model Self-compassion

Now, more than ever, we need to be incredibly kind to ourselves to help maintain mental wellness. We teach students this all of the time- the basics of self-compassion, kind self-talk, and growth mindset . Now is the time to also turn it inwards. In doing so, you'll benefit your own mental wellness and also be able to model it for others in your life.

5. Set Reasonable Expectations (for yourself and others)

Collectively, we need to acknowledge that we are still in the midst of a pandemic and distance learning- and that it is not business as usual. Things are going to be different, and that is okay. We can't expect to be as productive, or on top of it, or together as we once could. If you are one of those, like many, who is trying to balance educating with care-taking or educating your students on top of your own kids, there is no possible way that you can be all things to all people all of the time. By setting small, realistic goals and expectations around what you actually could be capable of, you will be setting yourself up to feel much more fulfilled and help maintain your mental health.

Webinar | Empowering from Afar with Social Emotional Learning

Although most of our social interactions these days occur at a distance, helping students work on social emotional skills can still have a big impact. Developing courage and grit, strong communication, and empathy can all help students make the most of their time in quarantine.

6. Communication is Vital for Maintaining Mental Health for Teachers

Let people know what is going on- especially colleagues and supervisors. By being transparent about what you are experiencing, and with what things may be helpful, you can bring them in and potentially expand your own network of resources and support. You may also be modeling healthy communication for other colleagues to follow suit.

We live in an "I'm sorry" culture. Consider how often you apologize, and the ways in which you can stop. Be unapologetic about taking time for yourself, setting realistic goals, setting boundaries, and being clear and transparent about what you are capable of (and what you need). This is one of the hardest things to do for many, but oh so important for maintaining mental health and wellness.

8. A Dedicated Work Space Can Improve Mental Wellness

This is a psychological trick that helps you to both be more productive, and to disconnect from work more easily. When working from home , we can quickly fall into an unhealthy balance between work and life, especially if you are working in the areas of your home in which you're also living. By creating a dedicated workspace: even if it is just one corner of your home that you designate as "work only," you can do two things: you can send an outward message to those in your life that when you are in that space you are working, and also an internal message to your own brain that signals when it is work mode and when it is time to disconnect.

9. Set Office Hours While Remote Teaching

By controlling and identifying specific times in which students or colleagues can reach, you will be able to both set boundaries while remote teaching, and will also provide a designated time in which students know that they can reach you during distance learning. Tools like Class for Zoom can make it easier for 1:1 conversations during class while other LMS platforms allow you to set office hours in the platform. Some districts have done this work for us, but for others remote teaching, it may need to be something that we do ourselves to help maintain our mental health while working from home.

Remote Learning Resources for K-12 Educators

By providing a catalog of digital learning resources focused on the skills needed for life - skills in social-emotional learning, health and wellness, financial capability, and career readiness - you have the tools to bring meaningful remote learning to students.

If you feel like you are having a tough time, and are struggling in any way with enjoying things, balancing your mood, or finding time to take care of yourself- or if you have any thoughts of hurting yourself- please reach out to a counselor. All of the resources that we shared for students can also be utilized by educators. Psychology Today has a fantastic therapist directory, and your health insurance can also help you locate a counselor, most of whom have switched to offering telehealth services. What we are experiencing right now is hard- and trained professionals across the globe continue to mobilize to serve as front-line responders for our minds in the same ways doctors have for our bodies during the COVID-19 pandemic.

Resources:

Crisis Text Line: Text SHARE to 741741

National Suicide Prevention Lifeline: 1-800-273-TALK

SAMHSA National Helpline: 1-800-662-HELP

NAMI HelpLine (M-F 10am - 6pm EST): 1-800-950-6264

Disaster Distress Hotline: 1-800-985-5990 or Text TALKWITHUS to 66746

Erin McClintock lead's EVERFI's impact work in mental health, wellness, and social and emotional learning. She holds a graduate degree in Counseling Psychology, completed her post-masters studies in Trauma and Addiction Counseling, and has extensive experience as a practitioner in community, school, and collegiate mental health.

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10 Teacher Mental Health Tips During COVID-19 & Beyond

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Erin McClintock Throughout the COVID-19 pandemic, teachers, school counselors, and school employees have remained acutely focused on supporting their students and continuing to do their jobs at this time. In some cases, this may mean teaching, care-taking (whether for children or other loved ones), and continuing to work through the same challenges that everyone else faces.

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Well-Being and Mental Health of Students during the COVID-19 Pandemic

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Background: During the COVID-19 pandemic, a decrease in well-being and an increase in mental health problems were registered in medical and psychotherapeutic practices, counseling centers, and clinics. According to previous studies, younger people and women seemed to be particularly affected. The ai…

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Financial Stress and Well-being of Filipino Students: The Moderating Role of External Locus-of-hope

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Financial Stress and Well-being of Filipino Students: The Moderating Role of External Locus-of-hope

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"Among Filipino students, a possible source of stress relates to financial difficulties that students or their families experience. In this study, we inquired into the possible buffering effects of hope on the negative effects of financial stress on life satisfaction of a sample of Filipino students."

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https://journals.sagepub.com/doi/full/10.1177/08295735211001653

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Why good mental health is important for study | Charles Darwin University

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It’s an expression we use every day, so it might surprise you that the term ‘mental health’ is frequently misunderstood. Meagan Miskin is the Health, Wellbeing & Injury Management Consultant at CDU and she shares the importance that good mental health plays when it comes to work, study and life.

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A "RE-FO-MENTAL-BEING" is a site where the student will benefits if you also read also it. It will help us them to give and share new knowledge.
-LSPU-SPCC- YUMANG, BRYAN EVANGELISTA

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Transitioning to adulthood, to college, to a new living situation with new people is difficult. Doing all of this in the midst of a years-long pandemic is even more challenging. The data on mental health among young adults reflects this burden.

A study published in 2021 shows that more than half of college students met criteria for at least one psychiatric condition in the past year. And, according to the Centers for Disease Control and Prevention, over the past two years, half of 18- to 24-year-olds report anxiety, half report a depressive disorder, and almost two-thirds in this age group report both. There's no question that mental health services need to be available and thriving on college campuses to help students.

Indiana University campuses have long had resources and support for its students, including counseling, crisis services, food pantries and financial aid resources. These areas are now getting more attention with the university's new Student Mental Health Initiative. The initiative, led by IU Chief Health Officer Dr. Aaron Carroll, is reviewing current services, making recommendations for improvements and developing long-term plans for monitoring students' mental health.

"Mental health is incredibly important to everyone's overall health and well-being," Carroll said. "Knowing our students are in an age group where mental distress is even more common, we must do more to support them outside of the classroom with resources and services."

Carroll is working with colleagues from across the university to develop and implement recommendations for the future of mental health and well-being resources on IU's campuses. The team, which has included students from the start, has already audited all current services, met individually and collectively with the directors of Counseling and Psychological Services, known as CAPS, on all campuses, and reviewed previously completed task force reports on this topic.

In addition, the team has launched a new online home for mental health and well-being services on all IU campuses. The new site includes a guide of resources searchable by campus and IU role (student, faculty, staff) as well as information about the initiative.

"Through this site, and the future work of our group, we're striving to make mental health resources more visible, more accessible to our students," Carroll said. "We need our students to know how, when and where to seek help if they need it, and to not be afraid or feel ashamed to ask for help."

As part of this initiative, the team will focus on three key areas related to mental health and wellness: Culture and climate, services and support, and policies and protocols. Each focus area will be guided by a task force of diverse individuals from campuses across IU. The task forces each have planned action items and will be working through each of these items, which include both short- and long-term solutions as well as benchmarks for tracking progress and success.

The task forces are beginning to meet now and work through their action items. It's expected for the task forces' work to be complete by June 1.

"We know that mental health care is more than just having services," Carroll said. "It's about creating a culture and environment in which students feel comfortable talking about these issues and seeking services as needed. This, in tandem with having the needed and available resources, is our ultimate goal."

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A renewed focus on students' mental health and well-being

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Transitioning to adulthood, to college, to a new living situation with new people is difficult. Doing all of this in the midst of a years-long pandemic is even more challenging. The data on mental health among young adults reflects this burden.

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https://www.cdc.gov/mentalhealth/learn/index.htm

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Encourage a positive outlook on life.

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Mental Health and Well-Being of University Students: A Bibliometric Mapping of the Literature

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The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975–2020. More specifically, ...

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1. Learn to meditate

At the core of many relaxation routines is meditation, but where should you start? Most involve focusing on a single point, such as the sensation of breathing. Follow this meditation guide for helpful tips.

2. Get mindful

Mindfulness, or a state of active attention on the present, has come to the forefront in recent years as a core component in mental health. It can help you focus on the here and now, form memories, and slow down your thought processes. According to Psychology Today, mindfulness can help even during your busiest moments. Consider enrolling for the next start date of our new online course, The Mindful Semester to explore techniques for managing stress and cultivating self-awareness.

3. Eat right and exercise

We know this one's easier said than done, but the basic components of healthy living have a significant impact on physical and mental health. Meal planning and setting scheduled time to exercise can be great ways to get into a routine.

4. Rest

Getting enough sleep has serious benefits, from reduced stress levels to a healthier body. But when you're juggling work, school and family, how can you reliably get the recommended 7-9 hours a night? Follow these tips for getting a good night's sleep.

5. Socialize

It may be hard to remember with so much to do, but it's important to set aside time to spend responsibly with friends.

6. Set realistic goals

Don't stress if you can't achieve everything all at once. The best way to ensure you're hitting your goals is to make them challenging but reasonable - things you can accomplish without sacrificing the other items on this list!

7. Make time for fun

Have a favorite activity that helps you unwind? Make time for your hobby. Mental health experts agree that penciling yourself in for some "me time" is an important part of anyone's life.

8. Get out of the house

If you're able, go outside for some of the items on this list. According to Business Insider, taking a walk in the wilderness or doing a yoga routine in the sunshine can offer surprising health benefits.

9. Go easy on yourself

It's often easy to forgive loved ones for forgetting to finish a task or misremembering an appointment. But why are we often so hard on ourselves? It's important to hold ourselves accountable, but studies have also shown that self-compassion is an important part of good mental health.

10. Ask for help

Whether it's calling your academic advisor, talking to a loved one, or seeking assistance from a therapist, there is nothing wrong with asking for help. Arizona Online students have access to comprehensive counseling and support services through Launchpad. Whether it's watching a quick video to de-stress or seeking long-term solutions for issues like stress, anxiety or depression, university resources can help.

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10 Mental Health Tips for Online Students

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Being a student is hard, even for those who enjoy the flexibility of a fully online education. Here are a few tips for finding balance in your life.

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50 Resources to Support the Mental Health of Teachers and School Staff

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K-12 teachers are busy supporting others and may overlook their own well being. We collected mental health resources for teachers and school staff.

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

Schools can support students to develop:

social and emotional skills and capabilities that promote life-long mental health and wellbeing

skills to problem-solve and manage the normal stressors of life

healthy relationships and the ability to work cooperatively with others

a sense of autonomy and purpose.

The Schools Mental Health Menu is a list of endorsed programs, staff and resources across 3 tiers of support.

Tier 1 activities form a foundation for Tier 2 and Tier 3. Together, the tiers form layers of support for students. Tier 1 supports remain in place, and schools can add extra supports from Tier 2 and Tier 3 when greater needs are identified.

Tier 1: Universal interventions

Tier 1 Universal interventions help schools to create a positive, inclusive and supportive school climate, building the preconditions for optimal student learning, development and wellbeing. They are the initiatives and programs schools adopt that are good for all students.

Activities can be implemented at a school, year, or classroom level. They are usually delivered by school staff. Community organisations or agencies may be employed to deliver some activities.

Programs include:

adopting a whole school approach to mental health

social and emotional learning

wellbeing animal programs

eating disorders supports

alcohol and drug education

mental health literacy

bullying prevention

local community lead mental health intervention

peer support.

The Schools Mental Health Menu provides a comprehensive information about tier 1 activities (as well as tiers 2 and 3) available to schools.

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School's role in Tier 1 promoting mental health and wellbeing | Victorian Government

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

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Focusing on Student Well-Being in Times of Crisis

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One teacher recommends supporting student safety through three Cs: communication, consistency, and control.

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https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.education.vic.gov.au/school/teachers/health/mentalhealth/Pages/promoting-mental-health.aspx&ved=2ahUKEwjRodKqsKb2AhXHhlYBHT_oBpMQFnoECAQQAQ&usg=AOvVaw2LhouABUIOEHG4QMDAsxhz

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Mental health is equally as important as physical health.

Although you often can't see it with your bare eyes, a mental health problem can cause serious damage to a person's life and well-being. For us to work on mental health issues prevention, we need to raise awareness about these problems. Schools are definitely one of the places where mental health awareness needs to be at a high level.

The importance of mental health awareness in schools is immense. Let's break it down together and take a deeper look at why we need schools on board with spreading awareness about mental health.
1. Closing the Gap
Schools are supposed to help our younger generations prepare for the world that awaits and all the obstacles they might run into.

Most schools today teach:

physical health

nutrition

sex education

However, there's a gap when it comes to mental health. Without proper education, students won't' know how to:

recognize the problem they're experiencing

open up about it

look for help

help other peers with similar or other mental health problem

This gap needs to be closed and the children need to have a chance of dealing with mental health problems just like they'll deal with any other problem.
2. Suicide & Mental Illnesses
Suicide is one of the leading causes of death ages 10-25, world-wide. In addition, most of the people who have committed suicide, have suffered from a mental illness.

To lower the increasing suicide rate and prevent young people from taking their own lives away, we need to raise awareness about mental health in our schools.

Learning about mental health illnesses will leave a positive impact on the students struggling:

they'll learn about therapy and how to treat their problem

they'll be more ready to talk about it

they'll acknowledge that they have a problem

All of the above will hopefully lower the suicide rate and offer the young people a solution other than ending their life.

"Schools need to adopt the policy of advocating mental health awareness and speaking up about your problems. Our students need someone to push them in the right direction and help them start a journey of therapy and healing," says Maya Pearson, a school psychologist and writer at Trust My Paper and Studicus.
3. Early Intervention
Just like with any other disease or health problem, early interventions are important in mental health.

Teachers, school counselors, school psychologists, and peers need to learn about:

detecting the early signs of mental health issues

spotting the meaningful changes in behavior

acting at the first sign of a potential mental health problem

If the mental illness is in its early stage, there's a chance of stopping it from being fully-blown. Everyone involved in a typical school day of a person experiencing mental health problems needs to be on board and help them deal with it.
4. Social Media Influence
While we love using social media to get informed, find entertainment, and connect with our friends, there's a dark side to it that not many people are talking about.

The truth is, social media can leave consequences and deep scars in the minds of the users, especially the younger generations.

Watching rich, famous, successful, and celebrity people on social media can cause mental health problems with young children:

low self-image

body issues

depression

anxiety

Since social media is on its rise, with nearly 3.5 billion active users worldwide, the effect it has on the young people around our schools is mind-blowing.

With this kind of a new threat, schools need to raise the bar in mental health awareness and ensure their students are learning about:

self-love

system of values

loving everyone

not judging people

talking about their insecurities openly

This would be beneficial for the proper development of students and preventing them to feel demoralized or depressed.
5. Eliminating the Cause
While it's important to learn about the negative effects of mental health issues, and how to treat them, it's also important to learn about the main causes.

Learning about the causes of stress, depression, or anxiety is important and the school can be a major trigger for most students experiencing mental health issues.

Students feel stressed out due to:

school pressure

peer pressure

bullying at school

overly strict teachers

too much workload

the pressure to have high grades

If everyone in school knew what stressed out the students the most, they would find a way to eliminate these stress factors and create a warmer and relaxing atmosphere at school.

This will further help the children find their peace and balance and eliminate the feeling of pressure, anxiety, and stress, which could further develop into even more severe mental health issues.
Final Thoughts
It is highly important to raise mental health awareness in schools since young people are seriously affected by mental health issues every day. They need a system they can rely on and a source of information to guide them through the process of dealing with their inner issues.

Schools need to initiate changes and get as many people, students, teachers, and other school employees to work on raising mental health awareness. Start with yourself and initiate a change in your school today.
About the Author:
Kristin Savage nourishes, sparks and empowers using the magic of a word. Along with pursuing her degree in Creative Writing, Kristin was gaining experience in the publishing industry, with expertise in marketing strategy for publishers and authors. Now she works as a freelance writer at SupremeDissertations and GrabMyEssay.

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The Importance of Mental Health Awareness in Schools

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Mental health is equally as important as physical health. Although you often can't see it with your bare eyes, a mental health problem can cause serious damage to a person's life and well-being.

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https://journals.sagepub.com/doi/full/10.1177/08295735211001653

•https://www.tandfonline.com/doi/full/10.1080/02680513.2021.1899907

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https://www.pinerest.org/mental-health-awareness-blog/

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The Importance of Mental Health Awareness - Pine Rest Newsroom

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Mental illnesses affect 19% of the adult population, 46% of teenagers and 13% of children each year. People struggling with their mental health may be in your

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Why good mental health is important for study | Charles Darwin University

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It’s an expression we use every day, so it might surprise you that the term ‘mental health’ is frequently misunderstood. Meagan Miskin is the Health, Wellbeing & Injury Management Consultant at CDU and she shares the importance that good mental health plays when it comes to work, study and life.

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Well-Being and Mental Health of Students during the COVID-19 Pandemic

# data[].attributes.attachment_link.description
Background: During the COVID-19 pandemic, a decrease in well-being and an increase in mental health problems were registered in medical and psychotherapeutic practices, counseling centers, and clinics. According to previous studies, younger people and women seemed to be particularly affected. The ai…

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The common denominator of mental health problems is being out of touch with reality. The more out of touch with reality you are, the more mentally unhealthy you are.

In Unit 5, Positive Action teaches how to deal with your reality and know your strengths and weaknesses; how not to blame others or rationalize; and how to do what you say you will do. In other words, how to take responsibility for your own behavior.

The positive actions taught in the curriculum are holistic; they represent the physical, intellectual, social and emotional areas. These concepts are the basis of all the components of the program, and thus they fit together seamlessly.

In Unit 5 there is a direct focus on mental health when students learn the importance of telling themselves the truth or being honest with themselves and others.

The other units are also important. When students are given the opportunity to practice positive actions in a safe, encouraging environment that reinforces positive actions, they will internalize them over a period of time, and their overall mental health will be greatly improved.

Within Positive Action is a clear understanding and acceptance of the standards of positive behavior with which everyone becomes familiar. Reinforcing those behaviors cements the benefit of doing them, because the philosophy says you feel good about yourself when you do positive actions.

Everyone wants to feel good about themselves, and the only way to get that good feeling is by doing positive actions. Students learn that good mental health leads to success and contributes to their overall happiness in life.

Educators can teach Positive Action with confidence, knowing that a randomized trial in Chicago schools found that Positive Action decreased students' depression and anxiety.

Further reading: Evidence-Based Health Curriculum

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Evidence-Based Mental Health Curriculum & Programs | Positive Action

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The common denominator of mental health problems is being out of touch with reality. The more out of touch with reality you are, the more mentally unhealthy you are. In Unit 5, Positive Action teaches how to deal with your reality and know your strengths and weaknesses; how not to blame others or rationalize; and how to do what you say you will do.

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students well being and mental health - Bing video

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Spotlight on COVID: Student mental health and wellbeing

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Mental health | South China Morning Post

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The latest mental health news including well-being, depression, mindfulness and mental health resources.

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Roughly 50 percent of all mental health conditions begin before people are in their mid-teens even though most go undetected and untreated. Adding to this, suicide is one of the top causes of death in young adults. The unprecedented disruptions of the pandemic has aggravated such problems, especially for younger age groups. All of these factors mean there is no better time to support and strengthen mental health education among teenagers.

In response to these needs, the World Health Organization has recently recommended several evidence-based interventions to protect and promote the mental health of adolescents by strengthening interpersonal and emotional regulation skills. A recent review of literature also suggests ways in which children and young people could be helped by the digital delivery of mental health interventions.

One of the most effective ways of implementing mental health education is through school systems, either as a course module within a class or as a separate class within the school. A lot of research has shown the effectiveness of these programs, but we need continued studies to further develop the best curricula to put in place to supplement existing social and educational programs.

The addition of technology and digitization will ensure more personalization, active participation and the ability to provide greater outreach at affordable costs. The Live Love Laugh Foundation, a mental health nonprofit organization in India, started an adolescent mental health program called You Are Not Alone in 2016. This program aims to educate adolescents and their teachers about stress, anxiety and depression. It also suggests tips to build resilience, provide access to support and normalize conversations about mental health within school settings.

So far, the program has educated more than 200,000 students and 20,000 teachers across the country. Results from a survey revealed that 76.6 percent of students had not attended a mental health awareness session previously. And 90 percent of the students, parents and teachers who responded from 32 schools across 10 Indian states were keen to have mental health sessions conducted. In the wake of the pandemic, this program is being digitized with an educational technology partner to cater to the vast number of Indian teens using a virtual learning platform. A facilitator delivers the session using a designated module while students learn and interact using quizzes, polls, and so on.

Another example is a program run by the Mental Health Association in New York State (MHANYS). In 2016 New York passed a law that made it mandatory for schools to provide mental health instruction as part of K-12 health education. The program offers a component to educate families and caregivers about youth mental health by providing access to webinars and other online resources to promote greater understanding of mental health and to support wellness for the whole family. It is intended to serve as a model for other cities and even for whole countries to follow.

The key factors that determine the success of a digital program are an entertaining design, a high level of interactivity for its users, an ability to reach large numbers of students across diverse regions, availability in numerous languages, and economic sustainability through low-cost or free access. These steps could enable a program to reach nearly two billion children globally, most of whom are in low- and middle-income countries.

To make these projects succeed, organizers must encourage public-private partnerships, collaborations with technology and social media companies, and recruitment of celebrities and other social icons as endorsers. If these elements all coalesce, we can create a revolution in mental health education for teens.

IF YOU NEED HELP
If you or someone you know is struggling or having thoughts of suicide, help is available. Call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK), use the online Lifeline Chat or contact the Crisis Text Line by texting TALK to 741741.

This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.

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School-Based Online Programs Instruct Pupils about Good Mental Health

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Roughly 50 percent of all mental health conditions begin before people are in their mid-teens even though most go undetected and untreated. Adding to this, suicide is one of the top causes of death in young adults. The unprecedented disruptions of the pandemic has aggravated such problems, especially for younger age groups.

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

Schools can support students to develop:

social and emotional skills and capabilities that promote life-long mental health and wellbeing

skills to problem-solve and manage the normal stressors of life

healthy relationships and the ability to work cooperatively with others

a sense of autonomy and purpose.

The Schools Mental Health Menu is a list of endorsed programs, staff and resources across 3 tiers of support.

Tier 1 activities form a foundation for Tier 2 and Tier 3. Together, the tiers form layers of support for students. Tier 1 supports remain in place, and schools can add extra supports from Tier 2 and Tier 3 when greater needs are identified.

Tier 1: Universal interventions

Tier 1 Universal interventions help schools to create a positive, inclusive and supportive school climate, building the preconditions for optimal student learning, development and wellbeing. They are the initiatives and programs schools adopt that are good for all students.

Activities can be implemented at a school, year, or classroom level. They are usually delivered by school staff. Community organisations or agencies may be employed to deliver some activities.

Programs include:

adopting a whole school approach to mental health

social and emotional learning

wellbeing animal programs

eating disorders supports

alcohol and drug education

mental health literacy

bullying prevention

local community lead mental health intervention

peer support.

The Schools Mental Health Menu provides a comprehensive information about tier 1 activities (as well as tiers 2 and 3) available to schools.

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School's role in Tier 1 promoting mental health and wellbeing | Victorian Government

# data[].attributes.attachment_link.description
Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

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Promoting Mental Health in Schools | Tips for Teachers

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For #ChildrensMentalHealthWeek, we’re looking at promoting positive mental health in schools. Find ideas you can easily add to the school routine, here.

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COVID-19 and Student Well-Being: Stress and Mental Health during Return-to-School

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Students have been multiply impacted by the COVID-19 pandemic: threats to their own and their family’s health, the closure of schools, and pivoting to online learning in March 2020, a long summer of physical distancing, and then the challenge…

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Your mental health and wellbeing is just as important as your physical health.
Positive mental health and wellbeing enables you to function well, have meaningful social connections, positive self-esteem and be better able to cope with life's ups and downs.

Keeping our mind healthy is an important part of our overall health and wellbeing.

spend time with friends, loved ones and people you trust

talk about or express your feelings regularly

reduce alcohol consumption

avoid illicit drug use

keep active and eat well

develop new skills and challenge your capabilities

relax and enjoy your hobbies

set realistic goals

Check out our support tools section for mindfulness apps to help you.

If you are feeling down, talk to someone you trust, a support line or contact your GP or health professional about your mental health concerns.

Content last updated: 21 October 2017

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Ways To Maintain Positive Mental Health and Wellbeing

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Your mental health and wellbeing is just as important as your physical health. Here are a few tips that can help to maintain positive mental health and wellbeing!

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Why good mental health is important for study | Charles Darwin University

# data[].attributes.attachment_link.description
It’s an expression we use every day, so it might surprise you that the term ‘mental health’ is frequently misunderstood. Meagan Miskin is the Health, Wellbeing & Injury Management Consultant at CDU and she shares the importance that good mental health plays when it comes to work, study and life.

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There is a growing and unmet need for mental health services for children and youth throughout the community. Examples of issues seen in the school setting include: stress, anxiety, bullying, family problems, depression, learning disabilities and alcohol/substance abuse. Serious mental health problems, such as self-injurious behaviors and suicide are on the rise, particularly among youth. Nationally, numerous school shootings have been linked to untreated mental health issues.

We have learned that schools are an ideal place to provide mental health services. Through school professionals who all know the students, parents and staff, identification of students/families in most need can be done effectively. As a result of these connections between school resources and our Bellin Psychiatric Center resources, students who had been unable to access or did not have the personal/family support available to gain access to traditional outpatient mental health services are now able to receive these vital services in their school. There are no longer the previous barriers to access treatment, such as students missing school and parents missing work for the student's mental health appointments.

Our school based mental health services program was the beneficiary of the 2019 Black Tie Blue Jean event.

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There is a growing and unmet need for mental health services for children and youth throughout the community. Examples of issues seen in the school setting include: stress, anxiety, bullying, family problems, depression, learning disabilities and alcohol/substance abuse. Serious mental health problems, such as self-injurious behaviors and suicide are on the rise, particularly among youth.

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School-based mental health is becoming a vital part of student support systems. According to the most recent data in 2005, over one-third of school districts used school or district staff to provide mental health services, and over one-fourth used outside agencies to provide mental health services in the schools.1 The President’s Now Is the Time plan to improve access to mental health care in our schools and communities emphasizes the urgency to “make sure students and young adults get treatment for mental health issues” through early identification, referral for treatment, training for school teachers in early detection and response to mental illness, assistance for schools to address pervasive violence, and training for additional mental health professionals to provide mental health services in schools.2 Federal agencies such as the President’s New Freedom Commission on Mental Health, the Department of Health and Human Services, and the Institute of Medicine are also calling on schools to enhance early identification methods to assess and connect students with mental health.3

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Why good mental health is important for study

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Why good mental health is important for study

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"Research shows that high levels of mental health are associated with increased learning, creativity and productivity, more pro-social behavior and positive social relationships, and with improved physical health and life expectancy."

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Why good mental health is important for study | Charles Darwin University

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It’s an expression we use every day, so it might surprise you that the term ‘mental health’ is frequently misunderstood. Meagan Miskin is the Health, Wellbeing & Injury Management Consultant at CDU and she shares the importance that good mental health plays when it comes to work, study and life.

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https://www.frontiersin.org/articles/10.3389/fpsyg.2020.01226/full

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Graduate School of Education, Nazarbayev University, Nur-Sultan, Kazakhstan

Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan

Psychological Counseling Center, Nazarbayev University, Nur-Sultan, Kazakhstan

The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975-2020. More specifically, this study uses bibliometric procedures to describe and visually represent the available literature on mental health and well-being in university students in terms of the growth trajectory, productivity, social structure, intellectual structure, and conceptual structure of the field over 45 years. Key findings of the study are that research on mental health and well-being in university students: (a) has experienced a steady growth over the last decades, especially since 2010; (b) is disseminated in a wide range of journals, mainly in the fields of psychology, psychiatry, and education research; (c) is published by scholars with diverse geographical background, although more than half of the publications are produced in the United States; (d) lies on a fragmented research community composed by multiple research groups with little interactions between them; (e) is relatively interdisciplinary and emerges from the convergence of research conducted in the behavioral and biomedical sciences; (f) tends to emphasize pathogenic approaches to mental health (i.e., mental illness); and (g) has mainly addressed seven research topics over the last 45 years: positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement. The findings are discussed, and the implications for the future development of the field are highlighted.

Introduction

The entrance to the university marks a period of transition for young people. Through this transition, students face new challenges, such as making independent decisions about their lives and studies, adjusting to the academic demands of an ill-structured learning environment, and interacting with a diverse range of new people. In addition, many students must, often for the first time, leave their homes and distance themselves from their support networks ( Cleary et al., 2011). These challenges can affect the mental health and well-being of higher education students. Indeed, there is evidence that a strain on mental health is placed on students once they start at the university, and although it decreases throughout their studies ( Macaskill, 2013; Mey and Yin, 2015), it does not return to pre-university levels ( Cooke et al., 2006; Bewick et al., 2010). Also, the probabilities of experiencing common psychological problems, such as depression, anxiety, and stress, increase throughout adolescence and reach a peak in early adulthood around age 25 ( Kessler et al., 2007) which makes university students a particularly vulnerable population.

The interest in mental health and well-being in university students has grown exponentially in the last decades. This is likely due to three interrelated challenges. First, although university students report levels of mental health similar to their non-university counterparts ( Blanco et al., 2008), recent studies suggest an increase and severity of mental problems and help-seeking behaviors in university students around the world in the last decade ( Wong et al., 2006; Hunt and Eisenberg, 2010; Verger et al., 2010; Auerbach et al., 2018; Lipson et al., 2019). Some researchers refer to these trends as an emerging "mental health crisis" in higher education ( Kadison and DiGeronimo, 2004; Evans et al., 2018). Second, psychological distress in early adulthood is associated with adverse short-term outcomes, such as poor college attendance, performance, engagement, and completion (e.g., King et al., 2006; Antaramian, 2015), and others in the long term, such as dysfunctional relationship ( Kerr and Capaldi, 2011), recurrent mental health problems, university dropout, lower rates of employment, and reduced personal income ( Fergusson et al., 2007). Third, there is a widespread agreement that higher education institutions offer unique opportunities to promote the mental health and well-being of young adults as they provide a single integrated setting that encompasses academic, professional, and social activities, along with health services and other support services ( Eisenberg et al., 2009; Hunt and Eisenberg, 2010). However, the majority of university students experiencing mental health problems and low levels of well-being are not receiving treatment ( Blanco et al., 2008; Eisenberg et al., 2011; Lipson et al., 2019) and, while universities continue to expand, there is a growing concern that the services available to provide support to students are not developing at an equivalent rate ( Davy et al., 2012).

In response to the increasing volume of research on the mental health and well-being of university students, there have been several attempts to synthesize the accumulating knowledge in the field and to provide an illustration of the theoretical core and structure of the field using traditional content analysis of the literature (e.g., Kessler et al., 2007; Gulliver et al., 2010; Hunt and Eisenberg, 2010; Sharp and Theiler, 2018). This study aims to extend the understanding of mental health in university students by providing a bird's eye view of the research conducted in this field in recent decades using a bibliometric approach. Bibliometric overviews provide an objective and systematic approach to discover knowledge flows and patterns in the structure of a field ( Van Raan, 2014) reveal its scientific roots, identify emerging thematic areas and gaps in the literature ( Skute et al., 2019) and, ultimately, contribute to moving the field forward. Accordingly, this study employs several bibliometric indicators to explore the evolution of the field based on publication and citation trends, key actors and venues contributing to the advancement of research on mental health and well-being of university students, and the structure of the field in terms of patterns of scientific collaborations, disciplines underlying the foundations of the field, and recurrent research themes explored in the literature. This is important because, despite significant advances in the field, research on mental health and well-being remains a diverse and fragmented body of knowledge ( Pellmar and Eisenberg, 2000; Bailey, 2012; Wittchen et al., 2014a). Indeed, mental health and well-being are nebulous concepts and their history and development are quite intricate, with a multitude of perspectives and contributions emerging from various disciplines and contexts (see section "Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview"). Therefore, mapping research on mental health and well-being in university students is essential to identify contributions and challenges to the development of the field, to help guide policy, research, and practice toward areas, domains, populations, and contexts that should be further explored, and to provide better care of students at higher education institutions ( Naveed et al., 2017).

Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview

This section provides an overview of the different perspectives adopted in the literature to conceptualize mental health, well-being, and other relevant constructs in order to identify the glossary of key terms that will be used in the search strategy to create a comprehensive corpus of documents on mental health and well-being in university students for this bibliometric review.

Perspectives on Mental Health and Mental Illness

There is no general agreement on the definition of mental health. For a long time, the term mental health has been used as a euphemism for mental illness ( Manwell et al., 2015). However, mental health and mental illness are regarded as distinct constructs nowadays and two main perspectives differentiating between mental health and illness are available in the literature. The continuum approach considers that mental health and mental illness are the two opposite poles of a continuum. Thus, there are various degrees of health and illness between these poles, with most of us falling somewhere in between. The categorical approach, on the other hand, represents mental health and illness as a dichotomy. People who manifest mental illness symptoms would belong to that category and labeled correspondingly, while those absent of these symptoms can be considered as mentally healthy ( Scheid and Brown, 2010).

Disciplinary Approaches to the Conceptualization of Mental Health/Illness

Conceptualizations of mental health/illness are largely dependent on the theoretical and paradigmatic foundations of the disciplines from which they emerge. In this context, the field has progressively evolved through the accumulation of knowledge generated in a diverse range of disciplines in the biomedical, behavioral, and social sciences. Biomedical disciplines are grounded in the medical paradigm focused on disease and (ab)normality and often emphasize dichotomous conceptions of mental health/illness ( Scheid and Brown, 2010). Research on mental health and well-being in this domain has been traditionally conducted from a psychiatric perspective, which aims to understand the dysfunctionality in the brain that leads to psychiatric symptoms and to also offer a pharmacological treatment to correct neuronal dysfunctions. Consequently, psychiatrists have historically considered mental health as a disease of the brain (e.g., depression), similar to any other physical disease, caused by genetic, biological, or neurological factors ( Schwartz and Corcoran, 2010). While the prevalence of psychiatric approaches to mental health is currently incontestable, the development of other biomedical disciplines has tremendously contributed to the progression of the field in recent decades. For example, Insel and Wang (2010) argue that insights gained from genetics and neuroscience contribute to the reconceptualization of "the disorders of the mind as disorders of the brain and thereby transform the practice of psychiatry." (1979). In addition to that, other disciplines such as behavioral medicine have made important contributions to the field, although it has recently argued that mental health and behavioral medicine should be as two separate fields ( Dekker et al., 2017).

Within the behavioral sciences, the study of mental health focuses on the distinct psychological processes and mechanisms that prompt thoughts, feelings, and behaviors ( Peterson, 2010). Clinical psychology has the longest tradition in the psychological study of mental health and tends to focus on the assessment and treatment of mental illness and disorders that can alleviate psychological distress or promote positive states of being ( Haslam and Lusher, 2011). However, significant contributions to the field have also emerged from other branches of psychology less focused on psychopathology, including personality and social psychology, psychoanalysis, humanistic psychology, and cognitive psychology ( Peterson, 2010). Despite the diversity of theories, principles, and methodological approaches to understanding mental health within the behavioral sciences, these disciplines acknowledge that mental health have a biological basis and reside in the social context, and tend to prioritize continuum approaches to mental health ( Scheid and Brown, 2010).

Perspectives from the social sciences complement the biomedical and behavioral approaches by considering the influence of social and cultural environments in mental health/illness ( Horwitz, 2010). For example, sociologists are interested in how social circumstances (e.g., level of support available) affect levels of mental health/illness and how social structures shape the understanding and response to mental health issues [see Compton and Shim (2015) for an overview of the social determinants of mental health]. Similarly, medical anthropologists attend to the mental health beliefs and practices that form the cultural repertory within and across populations ( Foster, 1975). Beyond sociology and anthropology, social researchers in the fields of business and economics, family and ethnic studies, and educational research have also played a key role in advancing research on mental health in different directions.

The Importance of the Context in Mental Health

Certainly, most notions of mental health/illness in the literature derive from prevailing psychiatric and psychological traditions developed in Western countries ( Gopalkrishnan, 2018). However, cultural values and traditions do shape how mental health and mental illness are conceptualized across contexts ( Vaillant, 2012). In this regard, Eshun and Gurung (2009) pointed out that "culture influences how individuals manifest symptoms, communicate their symptoms, cope with psychological challenges, and their willingness to seek treatment." (4). Fernando (2019) argued that issues related to the 'mind' developed and are often interpreted very differently in non-Western and Low- and Middle-Income Countries (LMICs). For example, cultures explain the manifestation of certain feelings and behaviors based on a range of motives including biological, psychological, social, religious, spiritual, supernatural, and cosmic. Failure to acknowledge alternative non-Western approaches to mental health and mental illness has resulted in imbalances of knowledge exchange and the permeation of dominating Western narratives into LMICs (i.e., so-called medical imperialism) ( Timimi, 2010; Summerfield, 2013). To address this issue, scholars have advocated for a greater willingness to embrace pluralism in the conceptualization of mental health and illness, which might help people to engage with particular forms of support that they deem to be appropriate for them, and to explore how knowledge and practices developed in LMICs can benefit those living in higher-income countries (i.e., knowledge "counterflow") (see White et al., 2014).

Prioritizing Positive Mental Health: The Science of Well-Being

Despite the diversity of disciplinary and contextual approaches to mental health, current definitions of mental health have two things in common. First, mental health is considered from a biopsychosocial point of view that incorporates biological, psychological, and social factors. Second, mental health implies something beyond the absence of mental illness (e.g., Bhugra et al., 2013; Galderisi et al., 2015). An example is the definition by the World Health Organization which refers to mental health as "a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community" ( World Health Organization, 2004). This definition contributed to substantial progress in research and practice in the field as it expanded the notion of mental health beyond the absence of mental illness and integrated the presence of positive features ( Galderisi et al., 2015).

Research on positive mental health is relatively new but has grown rapidly in the last decades fueled by advocates of positive medicine and psychology, who have argued for a change of paradigm from medical and psychopathological-oriented models of mental health that focus on disorders and illness toward more strength-based approaches, which pay more attention to what is right about people and positive attributes and assets ( Kobau et al., 2011). In this regard, the term mental well-being has been progressively incorporated into the study of mental health to account for the positive aspects of mental health beyond the absence of negative factors. While there is not a universally accepted definition of well-being, two perspectives have dominated the discourses on well-being in the literature: subjective well-being (SBW) and psychological well-being (PWB). SWB is based on hedonic perspectives of pleasure and represents "people's beliefs and feelings that they are living a desirable and rewarding life" ( Diener, 2012). SBW is strongly linked with the idea of happiness and is typically understood as the personal experience of high levels of positive affect, low levels of negative affect, and high satisfaction with one's life ( Deci and Ryan, 2008). PWB is grounded in Aristotelian ideas about eudaimonia, i.e., self-realization, with the ultimate aim in life being to strive to realize one's true potential ( Ryff and Singer, 2008). PWB has been broadly defined as a state of positive psychological functioning and encompasses six dimensions: purpose in life (i.e., the extent to which respondents felt their lives had meaning, purpose, and direction); autonomy (i.e., whether they viewed themselves as living in accord with their own convictions); personal growth (i.e., the extent to which they were making use of their personal talents and potential); environmental mastery (i.e., how well they were managing their life situations); positive relationships (i.e., the depth of connection they had in ties with significant others); and self-acceptance (i.e., the knowledge and acceptance they had of themselves, including awareness of personal limitations) ( Ryff, 1989).

Integrating Mental Health, Mental Illness, and Well-Being

The contribution of positive mental health frameworks to the advancement of the field has been undeniable. However, definitions that overemphasize positive emotions and productive functioning as key indicators of mental health have been recently challenged because of the potential they have to discriminate against individuals and groups that, for example, might not be able to work productively or function within the environment because of individual physical characteristics or contextual constraints ( Galderisi et al., 2015). To address these issues, Keyes has successfully integrated the notions of mental illness, mental health, well-being, and other related terms in the literature into a conceptual framework that allows for a more comprehensive understanding of mental health ( Keyes, 2005, 2007; Keyes and Michalec, 2010). The model argues that neither pathogenic approaches focusing on the negative (e.g., mental illness) nor salutogenic approaches focusing on the positive (e.g., well-being) can alone accurately describe the mental health of a person ( Keyes and Michalec, 2010). Instead, the model proposes that mental illness and well-being represent two correlated but differentiated latent continua in defining mental health. More specifically, mental illness and well-being lie on two separate spectra, the first going from absent to present mental illness and the second running from low to high well-being ( Slade, 2010). The absence of mental illness, therefore, does not necessarily imply high levels of well-being. Correspondingly, low levels of well-being do not always indicate the presence of mental illness. Further, in this model, mental health is defined as not only the absence of mental illness, not the mere presence of high well-being. Complete mental health (i.e., flourishing) is a result of experiencing low mental illness and high levels of well-being. Incomplete mental health (i.e., languishing), on the other hand, refers to the absence of mental illness symptoms and low reported levels of well-being. Two other conditions are possible within this framework. Incomplete mental illness (i.e., struggling) refers to high levels of well-being accompanied by high mental illness symptoms. Lastly, complete mental illness (i.e., floundering) accounts for low levels of well-being and high mental illness symptoms ( Keyes and Lopez, 2002).

The Present Study

In light of the complexity of the constructs of mental health and well-being and the multiple theoretical, disciplinary, and contextual approaches to their conceptualization, this study seeks to map out the terrain of international research and scholarship on mental health and university students for the period 1975-2020. More specifically, this study aims to provide new insights into the development and current state of mental health research in university students by mapping and visually representing the literature on mental health and well-being of university students over the last 45 years in terms of the growth trajectory, productivity, and social, intellectual, and conceptual structure of the field. First, the study describes the development of research mental health and well-being in university students examining the trends in publication and citation data between 1975 and 2020 (i.e., growth trajectory). Second, the study identifies the core journals and the research areas contributing most to the development of the field, as well as the key authors and countries leading the generation and dissemination of research on mental health and well-being in university populations (i.e., productivity). Third, the study outlines the networks of scientific collaboration between authors, and countries (i.e., social structure). Fourth, the scientific disciplines underlying the intellectual foundations of research on mental health and well-being in university settings (i.e., intellectual structure) are uncovered. Fifth, the study elucidates the topical foci (i.e., conceptual structure) of the research on the mental health and well-being of university students over the last 45 years.

Materials and Methods

A bibliometric approach was used in this study to map the literature on mental health and well-being in university students over the last 45 years using metadata extracted from four indexes of the Web of Science (WoS): The Science Citation Index-Expanded (SCI-Expanded); the Social Sciences Citation Index (SSCI); the Arts & Humanities Citation Index (A&HCI); and the Emerging Sources Citation Index (ESCI). Several reasons justified the selection of the WoS database in this study. First, the WoS remains as the standard and most widely used for bibliometric analysis ( Meho and Yang, 2007). Second, the WoS is a multidisciplinary database and includes publications on mental health and well-being emerging from distinctive research areas and disciplines published in more than 20,000 journals ( McVeigh, 2009). Using specialized databases such as PubMed would introduce biases into the search strategy favoring biomedical research disciplines. Still, it is important to note that interdisciplinary databases such as WoS and Scopus discriminate against publications in the Social Sciences and Humanities and publications in languages other than the English language ( Mongeon and Paul-Hus, 2016), so the picture provided by WoS is still imperfect. Third, while other databases might provide wider coverage, WoS includes publication and citation information from 1900. For example, Scopus has complete citation information only from 1996 ( Li et al., 2010). Moreover, Google Scholar provides results of inconsistent accuracy in terms of citations, and citation analyses in PubMed are not available ( Falagas et al., 2008). Fourth, WoS has demonstrated better accuracy in its journal classification system compared to Scopus database ( Wang and Waltman, 2016).

The methodological approach used in this study is presented in Figure 1 and further elaborated in the following paragraphs.

Search Strategy

To create a comprehensive corpus of documents on the mental health and well-being of university students, three parallel searches were performed, which accounted for the multiple approaches and perspectives that have been used in the field, as identified in the Section "Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview." All the searches were conducted in the last week of January 2020. The first search aimed at capturing research on mental health broadly and included one single keyword in the topic field: ["mental health"]. The second search was implemented to capture research focusing on pathogenic approaches to mental health. Key terms used in the literature to refer to the negative side of mental health, as well as the most frequent mental health problems experienced by university students, were introduced in this search in the title field: ["mental illness," "mental disorder ∗," "mental distress," "psychological distress," "psychopathology," "depression," "anxiety," "stress," "suicide," "eating disorder ∗," "substance use"]. In the third search, keywords reflecting salutogenic approaches to mental health were input. These included terms related to mental health from a positive mental health perspective (i.e., well-being). These key terms were added in the title field and included the following: ["well-being," "wellbeing," "wellness," "life satisfaction," "happiness," "positive affect," "purpose in life," "personal growth," "self-determination"].

To retrieve research relevant only to higher education students, another set of keywords was imputed in all three searches in the title field. These included: ["university," "college," "higher education," "tertiary education," "post-secondary education," "postsecondary education," "undergrad ∗ student," "grad ∗ student," "master's student," "doctoral student," "Ph.D. student"]. The Boolean operator OR was used between keywords in all the three searches to secure a higher number of relevant hits. Also, asterisks were used as wildcards to account for multiple variations in several keywords (e.g., disorder and disorder-s). All searches were limited to journal articles published between 1975 and 2020 (both inclusive). No restrictions on language were implemented in the search.

The search strategy retrieved a total of 6,356 hits ( n search 1 = 2782; n search 2 = 2814, n search 3 = 760). After the removal of duplicates, 5,561 research articles were finally selected and retained for the study. For each of the documents obtained in the search, the authors extracted metadata about the title of the paper, the year of publication, the journal, the number of citations, and the authors' name, organization, and country. Also, the title, the abstract, the author's keywords, and cited references were retrieved.

Data Analysis Procedures

The corpus of the literature was then analyzed using descriptive and bibliometric approaches to provide an overall picture of the evolution and current state of the research on mental health and wellbeing in university settings. Frequency counts of the number of publications and citations per year were obtained to describe the growth trajectory of research on the mental health and well-being of university students. Rank ordered tables were produced to describe the productivity of the field in terms of core journals and research areas, as well as leading scholars and countries contributing to the development of the field.

Bibliometric analyses in VOSViewer software were implemented to examine and visually represent the social, intellectual, and conceptual structure of the field. VOSViewer is a freely available computer software for viewing and constructing bibliometric maps. In VOSViewer, the units of analysis are journals, publications, citations, authors, or countries, depending on the focus of the analysis. The units of analysis are represented in the maps as circular nodes. The size of the node accounts for volume (e.g., number of publications in the dataset by an author) and the position represents the similarity with other nodes in the map. Closer nodes are more alike than nodes far apart from each other. The lines connecting nodes represent the relationship between nodes and their thickness indicates the strength of that relationship. Finally, the color of the node denotes the cluster to which each node has been allocated. Nodes are clustered together based on relatedness ( Van Eck et al., 2010). The software uses a distance-based approach to constructing the bibliometric maps in three steps ( Van Eck and Waltman, 2014). In the first step, the software normalizes the differences between nodes. In the second step, the software builds a two-dimensional map where the distance between the nodes reflects the similarity between these nodes. In the third step, VOSViewer groups closely related nodes into clusters ( Van Eck and Waltman, 2014).

A series of co-authorship analyses were performed to examine the social structure of research on mental health and well-being in university students. In these analyses, the units of analysis were authors and countries/territories. Each node in the map represents an author or a country/territory and the lines connecting them reflect the relationship between nodes. Clusters represent networks of scientific collaboration, which might be interpreted as groups of authors or countries frequently publishing together (e.g., research groups in the case of authors).

Co-citation analysis of journals was implemented to explore the intellectual structure of the field. Here, the units of analysis were journals in the dataset and the map reflects co-citation relationships between journals. Two journals are co-cited if there is a third journal citing these two. The more times a pair of journals are cited by other journals, the stronger their co-citation relationship will be. Frequently co-cited journals are assumed to share theoretical and semantical grounds. Therefore, in our study, clusters of frequently co-cited journals can be interpreted as disciplines underlying the foundations of research on mental health and well-being in university students.

Finally, a co-occurrence analysis of keywords was used to uncover the conceptual structure of the field. The units of analysis, in this case, were the authors' keywords. The more often two keywords appear in the same record, the stronger their co-occurrence relationship. Clusters of co-occurring keywords represent in this study the topical foci (i.e., knowledge base) that have been addressed in the literature in mental health and well-being in university students in the last 45 years.

Findings and Discussion

Growth Trajectory: Evolution of Publications and Citations in the Field

The developmental patterns of a particular field can be well demonstrated by trends in publications and citations. The 5,561 publications in the dataset have been cited 87,096 times, with an average of 15.6 citations per item. Figure 2 shows the growth trajectory of publication data of research on mental health and well-being in university students from 1975 to January 2020. Overall, the trends demonstrate a gradual increase in the scholarly interest in the mental health of university students over the last 45 years that can be organized in three stages: an emergence stage, in which publications rose slowly (1975-2000); a fermentation stage, with a notable increase in publications in the field (2000-2010); and a take-off stage, during which the number of records published per year in the field has almost risen 10 times (2010-2020). The steady increase of publications in the last 15 years coincides with the first calls for attention on the increase and severity of mental problems and help-seeking behaviors of college students ( Kadison and DiGeronimo, 2004; Evans et al., 2018), potentially indicating a growing interest in exploring the epidemiology of mental disorders and the role of universities in promoting the mental health and well-being of students. A similar pattern has also been observed in a recent bibliometric study examining global research on mental health both in absolute terms and as a proportion of all papers published in medicine and across disciplines, which certainly reflects an increase in the general interest in the field ( Larivière et al., 2013).

Productivity I: Core Journals and Research Areas

In total, 1,560 journals published the 5,561 records included in the dataset. Table 1 presents the ten core journals in the field. The Journal of American College stands out as the main publication venue in the field, accumulating around 5% of the publications in the dataset ( n = 270). Psychological Reports and Journal of College Student Development also stand out, publishing 119 and 102 studies, respectively. The Journal of Counseling Psychology ranks fourth in the list with 83 records. Despite being an interdisciplinary and relatively young journal, Plos One appears in the top five journal publishing research on mental health and well-being in university students.

The top research areas contributing to the publication of research on the mental health and well-being of university students are presented in Table 2. Nearly half of the records in the dataset are published in psychology journals. Another influential research area in the field is psychiatry, which captures almost 20% of the publications. Journals on education and educational research also accumulate a considerable number of publications in the field (15%). Other relevant research areas in the field are connected with health and medicine, including public environmental occupational health, substance abuse, general internal medicine, neurosciences neurology, health care sciences services, and nursing. Finally, the field is also grounded, although to a lower extent, in the publications emerging from journals in the social sciences, family studies, and social work research.

All in all, the productivity analysis for journals and research areas showed that most research on mental health and well-being in university students is disseminated in journals in the "psy disciplines"' (i.e., psychology and psychiatry) ( McAvoy, 2014), which is consistent with previous research on mental health in general populations (e.g., Haslam and Lusher, 2011). However, our findings demonstrated that the volume of research in psychology doubles that of research emerging from psychiatric journals. This contrasts with the findings by Haslam and Lusher (2011), who demonstrated that psychiatry journals had a greater influence on mental health research compared to clinical psychology journals and that psychiatry journals accumulate a higher volume of research and citations on mental health research. This is probably because our study includes publications emerging from all branches of psychology, unlike the study by Haslam and Lusher, which included only journals in the field of clinical psychology. Additionally, mental health services in higher education are typically provided by counseling centers led and staffed by non-medical professionals (e.g., psychologists, social workers, counselors, and family therapists) who tend to adopt developmental models of practice grounded in the behavioral sciences and focused on adjustment issues, vocational training, employment, and other personal needs rather than diagnosis and symptom reduction, more common in the biomedical sciences (i.e., psychiatry) ( LeViness et al., 2018; Mitchell et al., 2019).

Productivity II: Leading Authors and Countries/Territories

The 5,561 publications in the dataset were published by a total of 16,161 authors from 119 countries worldwide. Table 3 shows the researchers with the highest number of publications in the field. D. Eisenberg appears as the most productive researcher, followed by K. Peltzer and S. Pengpid. Authors on the list come from diverse geographical backgrounds. Five of the authors work at three different American universities (University of Michigan, Harvard Medical School, and Boston University), two researchers work at KU Leuven University (Belgium), and two other authors are affiliated to the same two universities in Thailand and South Africa. Other prolific researchers are affiliated with higher education institutions in the Netherlands, Egypt, and Germany.

Countries and territories leading research on mental health and well-being of university students are presented in Table 4. The United States is the indisputable leader in this field, publishing more than half of the records in the dataset. This is nearly 10 times the number of publications produced in China, which occupies the second position in the ranking and accounts for nearly 6% of the volume of research in the dataset. Three predominantly English speaking countries/territories complete the top five of the ranking: Canada (265 records), Australia (254), and England (243). The rest of the countries in the list are situated in Europe (Spain, Germany, Turkey), Western Asia (Iran), Africa (South Africa), and East Asia (Japan), which demonstrates that research on college students' mental health and well-being is a matter of concern in different regions of the world, at least to some extent.

Overall, the productivity analysis for authors and countries indicated that the research of mental health and well-being of university students occurs in a variety of locations around the world, especially in developed countries, and in a very prominent way, in the United States. This is not surprising since it is in those countries where better infrastructures and more abundant resources for research are available ( Wong et al., 2006), and a more lasting tradition in the study of mental health, in general, exists ( Gopalkrishnan, 2018). However, Larivière et al. (2013) found that the productivity of the United States on mental health research has dropped significantly and remained stable in other two English speaking countries (the United Kingdom and Canada) since 1980. On the contrary, the number of publications from European countries and the five major emerging national economies (Brazil, Russia, India, China, and South Africa), has experienced remarkable growth, and collectively account nearly for half of the publications in the field. Still, the predominance of knowledge generated in the developed world today, which tends to be grounded on psychiatric and psychological perspectives, might be eclipsing non-traditional views on mental health and well-being that are popular in other regions of the world and, therefore, limiting the development of effective initiatives that align better with local norms, values, and needs in LMICs ( Timimi, 2010; Summerfield, 2013).

Social Structure: Networks of Scientific Collaboration

Research collaboration is regarded as an indicator of quality research and a means to improve research productivity and academic impact (i.e., citations) ( Kim, 2006; Abramo et al., 2009). In particular, international research collaboration is considered a key contributor to the social construction of science and the evolution of scientific disciplines ( Coccia and Wang, 2016). There is recent evidence that national and international research collaborations have been accelerating in recent years ( Gazni et al., 2012; Wagner et al., 2015), especially in applied fields such as medical and psychological disciplines ( Coccia and Bozeman, 2016). In this study, co-authorship analyses were performed to find out patterns in the scientific collaboration between researchers and countries/territories on the mental health and well-being of university students.

Figure 3 demonstrates collaborative ties among authors who published at least 5 articles in the dataset ( n = 179). The map shows the existence of multiple productive collaborative networks of five or more researchers contributing to the development of the field. The largest collaboration network (red cluster) represents an international research group composed of 15 scholars affiliated to universities in the United States, Belgium, and Netherlands. This cluster groups some of the leading scholars in the field, including R. P. Auerbach, R. Brauffaerts, R. C. Kressler, and P. Cuijpers. Moreover, researchers in this cluster lead The WHO World Mental Health International College Student (WMH-ICS) Initiative, a large scale international project aimed at promoting the mental health and well-being of college students around the world through generating epidemiological data of mental health issues in university students worldwide, designing web-based interventions for the prevention and promotion of mental health, and disseminating evidence-based interventions ( Cuijpers et al., 2019). The second biggest cluster (green) represents an intra-national research network that includes 10 researchers from eight different higher education institutions in the United States. The dark blue cluster represents an institutional collaborative network, including nine researchers from the School of Public Health, Puerto Rico. Other prominent clusters in the map represent collaborative research networks between eight (olive color) and seven researchers (turquoise, violet, orange, and mellow mauve). This contrasts, however, with the limited collaboration that exists between clusters. Only four of the clusters on the map demonstrate some kind of scientific collaboration in the field (light blue, pink, brown, and yellow).

Cross-country collaboration networks in mental health and well-being of university students study are presented in Figure 4. Research collaborations between countries with 20 or more publications were considered in this analysis ( n = 45). The United States occupies the central position of the map and shares collaborative ties with all other countries/territories, forming a cluster together with China, South Korea, and Taiwan. Overall, the results suggest that international collaborations in the field are framed to a large extent by cultural, linguistic, and geographical proximity. For instance, the largest cluster (red) is formed by two European countries (Spain and Portugal) and other South American countries with whom they share historical and cultural backgrounds. Other European countries form the purple cluster. Similarly, the blue cluster clearly brings together predominantly English-speaking countries and territories, while the green cluster agglomerates a range of Asian countries.

Collectively, the results of our study suggest that research collaboration in the field of mental health and well-being in university students remains relatively scarce and localized to date. The social structure of the field at the author level could be described as an archipelago formed by a large number of islands (research groups) of different composition and size but with few bridges connecting them, which suggests a relatively fragmented research community. Moreover, while the existence of international collaborative networks was evident in the analysis, they seem to be formed within national borders, between researchers in neighboring countries/territories, or between countries that share cultural, linguistic, and historical heritages. This may be due to the important role that cultural and traditional values play in the conceptualization of mental health and well-being across contexts ( Eshun and Gurung, 2009; Vaillant, 2012; Fernando, 2019). Also, language differences, divergent cross-national institutional and organizational traditions, and increased costs of extramural collaboration, have been found to complicate the formation and continuity of research partnerships in health research ( Hooper et al., 2005; Freshwater et al., 2006). Nevertheless, limited within- and between-country research collaboration arguably poses challenges to the development of a field in terms of lost opportunities to challenge assumptions taken for granted and move toward fresh perspectives, push boundaries in methods and techniques, meet diverse groups of people from differing cultures and get immersed in those cultures, share information, resources, and skills, and address common mental health problems through the pooling of resources ( Rolfe et al., 2004; Freshwater et al., 2006).

Intellectual Structure: Disciplines Underlying the Foundations of the Field

Interdisciplinarity is considered as a valuable approach to address the complex and multidimensional nature of health and well-being ( Mabry et al., 2008). Buckton (2015) argues that the integration of medical, psychological, and social sciences have contributed to generate "new insights into theory, practice, and research in mental health and development." (3). To examine the disciplines underlying research on the mental health and well-being of university students, a journal co-citation analysis was performed. In this analysis, only journals with at least 50 citations were considered ( n = 593). The nodes on the map represent journals and their size reflects the number of co-citation relationships with other journals. Colors account for journal clusters, which agglutinate journals with higher co-citation relationships and stronger semantic connectedness. Clusters were interpreted and labeled accounting for the WoS categorization of the journals with the highest co-citation links within each cluster. For example, if the Journal of Personality and Social Psychology, the Journal of Counseling Psychology, and Personality and Individual Differences clustered together, this group was interpreted as the personality, social, and counseling psychology cluster.

In general, the findings of this study suggest that research on mental health and well-being in university students is interdisciplinary, to a certain extent, and mainly emerges from the convergence of research conducted in the behavioral and biomedical sciences, as it has been suggested elsewhere ( Schumann et al., 2014; Wittchen et al., 2014b). More specifically, the map shows that the research in the mental health and well-being of university students is constructed through the integration of knowledge generated in five interconnected disciplines (see Figure 5). To the left of the map, the red cluster integrates journals on personal, social, and counseling psychology. To the right, the blue cluster represents the contribution of psychiatric journals to research to the formation and development of the field. At the top, the yellow cluster groups journals on substance abuse and issues related to alcohol consumption, addiction, and interpersonal violence. At the bottom of the map, journals covering topics on eating behaviors, sleep, and other issues related to physical health converge on the green cluster. At the center of the map is the purple cluster, which includes journals in the area of clinical psychology and behavioral therapy.

More broadly, the findings suggest that biomedical sciences contribute to a large extent to the composition of the field. Psychiatric research emerged in our study as an obvious building block in the study of university students' mental health and well-being, which is not surprising considering the historical contributions of biomedical disciplines to mental health research ( Schwartz and Corcoran, 2010). Within the behavioral sciences, personality and social psychology, which explores processes and mechanisms through which social phenomena influence mental health and well-being ( Sánchez Moreno and Barrón López de Roda, 2003), appears as a key discipline underlying the foundations of the field. Surprisingly, clinical psychology journals occupy a central position in the map and demonstrate co-citation relationships with journals from all other clusters but make up the most dispersed network and account for a considerably lower volume of co-citation relationships in the field. This suggests that clinical psychology journals are more subordinate to journals in other disciplines in terms of citations flows, and ultimately, play a less unique role in research on the mental health and well-being of university students, as suggested by Haslam and Lusher (2011). Interestingly, research arising from the social sciences (e.g., sociology and anthropology) does not seem to make a distinctive contribution to the intellectual structure of the field, which suggests that the influence of social contexts and cultures on university students' mental health and well-being (e.g., inequality, social norms, public policies, cultural beliefs, and values) is an underexplored research area. Still, the density of co-citation network relationships within and between clusters is particularly noteworthy, considering the lack of common language between disciplines, the absence of a shared philosophy of practice on mental health, and the tensions between medical, psychological, and social explanations of mental distress ( Bailey, 2012).

Conceptual Structure: Topical Foci Addressed in the Literature Over the Last 45 Years

The topical foci of research on the mental health and well-being of university students during the 1975-January 2020 period are presented in Figure 6. The map offers a visual representation of the co-occurrence analysis of author keywords of all the publications included in the dataset. Only the most frequently occurring keywords (25+ occurrences) were considered in the analysis ( n = 84). Items that were not related to others and do not belong to the existing clusters were excluded. The size of the nodes indicates the occurrence of author keywords in the dataset and the thickness of edges represents the co-occurrence strength between pairs of keywords.

The most frequent keywords in the dataset, excluding students' descriptors (e.g., college students and university students), refer to common mental health challenges experienced by university students such as depression ( n = 612), anxiety ( n = 353), and stress ( n = 341). Salutogenic-related keywords such as well-being and life satisfaction occurred less often ( n = 138, n = 113, respectively), suggesting that pathogenic approaches to the exploration of mental health issues in higher education are more widespread. More broadly, seven general themes seem to summarize the topical foci of interest in the field of mental health and well-being of university students over the last 45 years. First, there has been a general interest in positive mental health, as denoted by frequently co-occurring key terms such as well-being, self-esteem, life satisfaction, social support, emotional intelligence, and happiness (red cluster). Second, mental disorders stand as another theme widely addressed in the literature, with a special emphasis on depression, anxiety, and to a lesser extent, suicide and suicidal ideation (green cluster). A third topical area in this field has been substance abuse, most predominantly alcohol consumption (blue cluster). The fourth theme reflects college counseling for mental health, including interventions and protective factors such as mindfulness, stress management, spirituality, and help-seeking (yellow cluster). Other topics reflected in the map are mental illness stigma (purple), stress (e.g., psychological distress and coping) (light blue), and mental health measurement (orange).

Conclusion

This study provides a comprehensive overview of the research on university students' mental health and well-being in the last 45 years using bibliometric indicators. In general, the results reveal interesting trends in the evolution of the field over the last four decades and promising scientific patterns toward a better understanding of the mental health and well-being of university students internationally. First, the interest in the mental health and well-being of university students has grown in the last decades and in a very significant way during the last 10 years, indicating that this area has not still reached its maturity period and will continue developing in the future. Second, research in the field is relatively interdisciplinary and emerges from the convergence of research conducted in several disciplines within the behavioral and biomedical sciences. Third, research in this field is produced by a community of productive researchers coming from several regions around the world, most notably in the United States, which secures a generation of scholars that will continue shaping the field in the years to come. Fourth, over the last 45 years, researchers have been able to address a multitude of research topics in the field, including positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement.

However, this study also identified some issues that could be hindering the development of the study of the mental health and well-being of university students. For example, the research available overrepresents theoretical and disciplinary approaches from the developed world. Additional studies on the field from developing economies and LMICs are needed to provide a more comprehensive picture and ensure a fair representation of the multiple perspectives available in the field. Such studies would inform administrators and practitioners on how to broaden and enrich available programs and initiatives to promote mental health and well-being in higher education contexts in order to offer alternative forms of support that university students find appropriate for their social and cultural values. Moreover, the research community contributing to the development of the field is relatively fragmented. There are multiple research groups but little research collaborations between them and, at the international level, these connections tend to be limited by geographic, cultural, and language proximity. In this context, more actions like the WMH-ICS Initiative could provide a partial solution to this problem by strengthening national and international research partnerships and facilitating knowledge exchange across regions. Also, special issues in the core journals in the field inviting cross-cultural studies on the topic could contribute to promoting research collaboration across regions and research in less represented countries. The field would also benefit from a greater volume of research from the social sciences and humanities exploring the influence of social, cultural, economic, and educational factors on the conceptualization, manifestation, and experience of mental health and well-being. Moreover, more studies emerging from disciplines such as sociology, anthropology, business, and education, would likely increase the permeability of positive mental health concepts into the field and contribute to the promotion of salutogenic approaches to the study of mental health and well-being of university students.

This study has several limitations. First, publications were retrieved only from the WoS database, which limits the generalizability of the findings. Second, WoS provides stronger coverage of Life Sciences, Biomedical Sciences, and Engineering, and includes a disproportionate number of publications in the English language ( Mongeon and Paul-Hus, 2016). This could partially explain the low number of publications emerging from the Social Sciences, the Arts, and the Humanities, and research conducted in non-English speaking countries in the present study. Third, only journal articles were retrieved for analysis, excluding other relevant publications in the field such as reviews, book chapters, and conference proceedings. Future studies could replicate the findings of this study using alternative databases (e.g., Scopus and PubMed) or a combination of them, as well as different filters in the search strategy, to provide an alternative coverage of research conducted in the field. Nevertheless, we believe that the bibliometric approach used in this study offers novel insights about the development and current status of the field and some of the challenges that undermine its progression.

Data Availability Statement

The datasets generated for this study are available on request to the corresponding author.

Author Contributions

DH-T and LI contributed to conception and design of the study, organized the database, and performed the statistical analysis. DH-T, LI, and JS wrote the first draft of the manuscript. NL, AC, AA, YN, and AM wrote the sections of the manuscript.

Funding

This research was funded by the Nazarbayev University Faculty-Development Competitive Research Grants Program (Reference Number 240919FD3902).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Footnotes

References

LeViness, P., Bershad, C., Gorman, K., Braun, L., and Murray, T. (2018). The Association for University and College Counseling Center Directors Annual Survey. Available online at: https://www.aucccd.org/assets/documents/Survey/2018%20AUCCCD%20Survey-Public-June%2012-FINAL.pdf (accessed February 24, 2020).
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# data[].attributes.attachment_link.title
Mental Health and Well-Being of University Students: A Bibliometric Mapping of the Literature

# data[].attributes.attachment_link.description
The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975-2020.

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5 Steps to Mental Health and Wellbeing: A Framework for Schools and Colleges

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

Schools can support students to develop:

social and emotional skills and capabilities that promote life-long mental health and wellbeing

skills to problem-solve and manage the normal stressors of life

healthy relationships and the ability to work cooperatively with others

a sense of autonomy and purpose.

The Schools Mental Health Menu is a list of endorsed programs, staff and resources across 3 tiers of support.

Tier 1 activities form a foundation for Tier 2 and Tier 3. Together, the tiers form layers of support for students. Tier 1 supports remain in place, and schools can add extra supports from Tier 2 and Tier 3 when greater needs are identified.

Tier 1: Universal interventions

Tier 1 Universal interventions help schools to create a positive, inclusive and supportive school climate, building the preconditions for optimal student learning, development and wellbeing. They are the initiatives and programs schools adopt that are good for all students.

Activities can be implemented at a school, year, or classroom level. They are usually delivered by school staff. Community organisations or agencies may be employed to deliver some activities.

Programs include:

adopting a whole school approach to mental health

social and emotional learning

wellbeing animal programs

eating disorders supports

alcohol and drug education

mental health literacy

bullying prevention

local community lead mental health intervention

peer support.

The Schools Mental Health Menu provides a comprehensive information about tier 1 activities (as well as tiers 2 and 3) available to schools.

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School's role in Tier 1 promoting mental health and wellbeing | Victorian Government

# data[].attributes.attachment_link.description
Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.