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What Is Mental Health Awareness, and Why Does It Matter?

Being aware of your overall health is important so that you can detect any symptoms and seek professional help when necessary. While everyone is familiar familiar with the symptoms and treatment options for common illnesses that affect their loved ones, like the flu, migraines, or and (most recently) COVID-19, many people are unsure how to look after their mental health.

Raising mental health awareness can help you to understand your symptoms, find professional treatment, and, perhaps most importantly, break the mental health stigma that leaves so many people suffering in secret.

Contents

Which Conditions Need Mental Health Awareness?

How Can Mental Health Awareness Help?

1. Understand Your Symptoms

2. More Behavioral Health Resources

3. Break the Mental Health Stigma

Mental Health Services Near You

What are barriers to mental health care?

What are evidence-based practices in mental health care?

How do I take care of my mental health?

Why care about mental health?

Which Conditions Need Mental Health Awareness?

Mental health awareness is something that can help the millions of people who are impacted by mental health issues throughout the United States. According to the National Alliance on Mental Illness (NAMI), one in five adults have had or currently have symptoms of a mental illness. These statistics show just how prevalent living with a mental illness actually is.

This is also why NAMI recognizes Mental Health Awareness Month in May. The goal with a whole month of mental health awareness is to help people with mental illnesses understand that they are not alone in their struggles—and that getting treatment can make all the difference. If we applied this approach to mental health every day of the year, more and more people could benefit from knowing about these common illnesses.

Some common disorders that need more awareness include:

Generalized anxiety disorder

Substance use disorders

Depression

Bipolar disorder

Post-traumatic stress disorder

Schizophrenia

Suicidal ideation

Though all of these mental health conditions have different symptoms, they can impact every aspect of your life. In truth, your mental health influences the way that you think, feel, and behave. This means that your social, professional, and personal life can be greatly impaired.

Many people who have mental health conditions aren’t sure how to cope with their symptoms and resort to unhealthy coping mechanisms to push away their emotional discomfort. As a result, you might also have an addiction to drugs or alcohol. Additionally, if you have one mental illness that goes untreated, you actually are at a greater risk for developing co-occurring disorders and you will need dual diagnosis treatment to fully heal.

Mental health awareness makes all of this information available to you so that you can assess your own risks and find help for any conditions you might have.

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Why students should have mental health days | Hailey Hardcastle

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Calm
An app for sleep, meditation, and relaxation. Also provides music to help you focus, relax or sleep. Offers video lessons on mindful movement and gentle stretching. Includes nature scenes and sounds to enjoy while relaxing, sleeping, studying, or working.
Headspace
Guided exercises, videos and more to help you get healthier and happier. Offers options specific to meditation, sleep & wake up, stress & anxiety, movement & healthy living.
Insight Timer
App for sleep, anxiety, and stress. Includes over 30,000 guided meditations.
Liberate
The largest free & centralized library of dharma talks and guided meditations from Teachers of Color.
Shine
An app and community for individuals experiencing anxiety and depression. Motivating daily affirmation messages. Options to check in with yourself and reflect on your growth.

Down Dog
Select your time, level, focus, voice, and music, and Down Dog creates a unique, personalized yoga practice every time.
Campus Recreation
Students have free access to the campus gyms and group fitness classes, including yoga among others!

Remember that you have access to your RA, CD, advisor, teachers, and friends, too!
Feel Better Yoga
A locally owned yoga studio to offer some curated yoga.
Triangle Yoga
Offers a variety of yoga classes that can help you relax physically and mentally. They also have a student discount rate!
Franklin St. Yoga Center
Offers student discounts on a variety of class packages. They organize their classes by level so you can figure out the best class for you!

Note that there are lots of yoga studios in Carrboro as well!

Discover the Power of Self-Compassion
This three-session video webinar series to learn about the science of self-compassion from Dr. Neff and Dr. Germer. The power of self-compassion: A step-by-step training to bring kindness and inner strength to any moment of your life.
Self-Compassion
Defines self-compassion and provides access to research and personal practices to learn a lot about self-compassion with it's beneficial wellness attributes.

Counseling & Psychological Services
CAPS offers individual counseling and assessment services as well as campus events and small group programs on a variety of topics, including stress and mental health.
Wellbeing Coaching
Wellbeing Coaching, an evidence-based practice, is a partnership between a student and a staff facilitator, designed to help a student self-reflect on their wellbeing.
Emotional Wellness Toolkit
National Institutes of Health bring you an emotional wellness toolkit, that provides checklists and strategies to maintain your emotional wellness.
Mind Tools
The link above will take you to the Mind Tools Stress Diaries page, where you can use their template to track your stress and determine what's affecting you. The rest of the website offers other information on stress and tips and tools for how to manage it.
Virtual Pamphlet Collection
This website, through the University of Chicago, offers a plethora of information on a variety of health topics, including stress and anxiety. The website is a collection of materials used at various university counseling centers across the country.
You Really Need to Relax: Effective Methods
This document from the University of Michigan Health System guides you through progressive muscle relaxation and visualization exercises.
Go Ask Alice!
Go Ask Alice! is a fantastic health resource. The website is maintained by health educators at Columbia University, and it is set up in a Q&A format. If someone has a question, chances are that the folks at Go Ask Alice! have heard it before and have a great answer already on hand. You can submit questions, too! They answer questions about mental health, nutrition, alcohol/drugs, sexuality, relationships, and sexual health.

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Calm An app for sleep, meditation, and relaxation. Also provides music to help you focus, relax or sleep. Offers video lessons on mindful movement and gentle stretching. Includes nature scenes and sounds to enjoy while relaxing, sleeping, studying, or working. Headspace Guided exercises, videos and more to help you get healthier and happier.

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(PDF) The Students' Mental Health Status

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PDF | Definition of mental health is some people have a "stable social network" integrated, Adler (1870) and many sociologists have adopted this... | Find, read and cite all the research you need on ResearchGate

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082737/

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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

11. De Choudhury M, Kiciman E, Dredze M, Coppersmith G, Kumar M. Discovering Shifts to Suicidal Ideation from Mental Health Content in Social Media. Proceedings of the 2016 CHI Conference on Human Factors in Computing Systems; CHI'16; May 7 - 12, 2016; San Jose, CA, US. 2016. May, pp. 2098-110. [[ PMC free article] [ PubMed] [ CrossRef] Google Scholar]

33. O'Malley K, Wheeler I, Murphey J, O'Connell J. Changes in levels of psychopathology being treated at college and university counseling centers. J Coll Stud Dev. 1990;31(5):464-65. [ Google Scholar]

63. Biddle L, Donovan J, Sharp D, Gunnell D. Explaining non-help-seeking amongst young adults with mental distress: a dynamic interpretive model of illness behaviour. Sociol Health Illn. 2007 Nov;29(7):983-1002. doi: 10.1111/j.1467-9566.2007.01030.x. doi: 10.1111/j.1467-9566.2007.01030.x. [[ PubMed] [ CrossRef] [ CrossRef] Google Scholar]

79. Huh J, Ackerman MS. Collaborative Help in Chronic Disease Management: Supporting Individualized Problems. Proceedings of the ACM 2012 conference on Computer Supported Cooperative Work; CSCW'12; February 11 - 15, 2012; Seattle, WA, US. 2012. pp. 853-62. [[ PMC free article] [ PubMed] [ CrossRef] Google Scholar]

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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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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https://schools.au.reachout.com/articles/wellbeing-and-resilience

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Promoting the healthy development of all students, as well as enabling all students to reach their full potential, is a priority for educators across Ontario. Students' health and well-being contribute to their ability to learn in all disciplines, and that learning in turn contributes to their overall well-being.

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What is mind the gap about?

Not all students learn at the same pace or in the same way. In fact, research tells us up to 30 percent of students are struggling with their school work - that's roughly one in three students!

Students with minor learning struggles are often referred directly to a clinician without trying a classroom intervention first. Meanwhile, the child still struggles at school, and the gap in their learning gets wider, and wider and wider.

So, how can we bridge the learning gap?

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https://www.education.vic.gov.au/school/teachers/health/mentalhealth/Pages/promoting-mental-health.aspx

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Disciplinary Approaches to the Conceptualization of Mental Health/IllnessConceptualizations 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).

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Disciplinary Approaches to the Conceptualization of Mental Health/IllnessConceptualizations 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).

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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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In today's competitive academic environment, being a student can be stressful. But managing the many responsibilities of school while struggling with a mental health issue can be even more challenging. According to the National Institute of Mental Health, an estimated 1 in 5 adults in the United States are diagnosed with some form of mental illness. Yet the stigma attached to mental illness prevents many from seeking the appropriate treatment, raising the need for increased awareness about mental health resources for students.

Common Mental Health Issues and Resources for Students

The following are several common mental health issues that students face along with some helpful resources.

Depression

An estimated 300 million people are affected by depression globally. This condition is commonly characterized by sadness, a loss of interest and enjoyment in everyday activities, feelings of low self-worth, and poor concentration, among other symptoms. Depression is often recurrent or chronic and can manifest through physical stress on the body in various ways.
Key Facts About Mental Disorders Rising Teen Depression Depression in Children Ages 6-12 What to Know About Childhood Depression Tips for Parents on Coping with a Child's Depression Diagnosis
Anxiety

While there are many types and manifestations of anxiety, the most commonly diagnosed condition is generalized anxiety disorder (GAD). People with GAD experience excessive worry and stress on more days than not for a period of at least six months. The anxiety can occur in relation to a variety of activities or events, and even simply in anticipation of situations. Common symptoms are physical discomfort, fatigue, difficulty concentrating, irritability, and trouble sleeping.
Childhood Anxiety Treating Anxiety in Children 6 Types of Anxiety in Children What Signs of Childhood Anxiety Should Parents Look For? Cognitive Behavioral Therapy for Anxiety
Panic Disorder

Students with panic disorder are most commonly affected by periodic apprehension or panic attacks, which can present in a variety of ways in the body. The disorder affects about 6 million adults, or 2.7% of the U.S. population, and is twice as likely to affect women as men. Panic disorder can cause students to avoid social situations, as well as other situations (school, work, public speaking, romantic relationships), for fear of having attacks.
Panic Attacks In Children: Types, Symptoms, And Remedies Home Management Strategies for Panic Disorder Effect of Childhood Trauma and Panic Disorder
Obsessive Compulsive Disorder (OCD)

OCD can manifest in obsessions or compulsions. Obsessions are unwanted thoughts that dominate the mind; they often originate in the mind and are not caused by an external situation. A compulsion is the inability to resist doing something. OCD affects 2.2 million adults, or 1% of the U.S. population, and typically begins at a young age.
4 Things Parents Get Wrong About OCD (Podcast) Guide to Helping Your Child with OCD (PDF) Childhood OCD: The Invisible Disorder How OCD Differs in Children and Adults Childhood Moral OCD
Post-traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) affects about 3.5% of the U.S. population. People exposed to various situations are at risk for PTSD, including survivors of: childhood sexual and emotional abuse; war, violence, and torture; and accidents and disasters. It can commonly affect people who have experienced life-threatening illnesses and traumatic childbirth, as well as members of the military and first responders.
Psychotherapies and PTSD PTSD in Ages 6 and Under PTSD from Domestic Violence and Childhood Abuse PTSD and Suicidal Tendencies in Kids
Social Anxiety Disorder

Social anxiety disorder (SAD) causes significant fear in social situations, which often results in distress and the inability to function. SAD is often associated with a fear of being embarrassed or judged by peers and various insecurities. Typically, SAD begins during adolescence and often goes untreated because it isn't as widely recognized as other common psychological disabilities.
How to Help Kids with Social Anxiety Social Anxiety at Preschool Age Signs of Social Anxiety Disorder Parenting with Social Anxiety
Phobias

A phobia is defined as an extreme and persistent fear of a specific object or situation that is out of proportion to the actual danger or threat. Phobias affect nearly 10% of the U.S. population, and typically symptoms begin during childhood. Phobias can be related to a variety of real and theoretical situations but are usually grouped into several subtypes, including animal, natural environment, and situational.
Specific Phobias Age-by-Age Guide to Phobias for Kids The Ultimate List of Phobias and Fears Normal Childhood Fears
Bipolar Disorder

People affected by bipolar disorder experience periods of mania and depression. When manic, they may feel anxious, possibly more capable of achieving realistic or unrealistic things, or a decreased need to sleep. When depressed, they experience typical symptoms of depression but may experience it at a level that affects their personal and professional relationships and responsibilities in a more serious way. Bipolar disorder causes extreme swings between these moods or states of being.
Signs and Symptoms of Bipolar Disorder Early Onset Bipolar FAQ Reducing the Stigma of Bipolar Disorder
Substance Abuse Disorder

Substance abuse disorder is characterized as a disease that causes an individual to become unable to control their use of drugs or alcohol, despite it making them sick or causing them harm. People develop a tolerance to drugs and alcohol when under the frequent influence of them and begin using higher doses or amounts of it to feel well.
Drug Adduction (substance use disorder) The 10 Most Common Signs of Drug Use and Addiction Treatments for Substance Abuse Disorders
Hotlines for Students in Need

Identifying the Root Cause to Help Create Effective Solutions.

Many students often struggle with social and emotional issues during their coming-of-age years, as well as into adulthood. Although some instances may be attributed to heredity and genes, many others are caused by external factors that serve to compound and worsen the fragility of individuals whose emotional well-being may already be compromised.

Identifying some of these pressure points can help families, educators, and mental health professionals approach their treatment options from a mindful perspective. Many of these agitators include:

Bullying (both online and real-world)

Weight concerns

Sexual assault or intimidation

Physical/emotional abuse

COVID-19 isolation

Racial injustice and profiling

Gender dysphoria

Peer pressure

For those looking to provide frontline treatment to individuals most in need, Maryville University offers an online Psychiatric Mental Health Nurse Practitioner program. Under the guidance of expert faculty, students learn ways to provide effective treatment that considers each patient's unique history, addresses their current needs, and provides long-term solutions for their overall health and well-being.

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Mental Health Resources for Students and Educators | Maryville Online

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According to the National Institute of Mental Health, an estimated 1 in 6 people in the United States are diagnosed with some form of mental illness. While awareness about mental illness continues to rise, society has a long way to go to reduce the stigma, requiring increased resources for student mental health.

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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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As adults, we all have diverse needs and different ways of coping with stressful situations. For children, it is the same. Some children will have dealt well with restrictions and school closures caused by the COVID-19 pandemic. For others, it is challenging to cope with all the changes and uncertainty. Some children will return to school having experienced some level of stress, anxiety, isolation and grief. Some may have experienced increased violence at home.

School teachers and personnel are critical in supporting children's transition back to in-person classroom learning, particularly after extended periods of school closure. In addition to continuing to use the different skills teachers have been using to ensure their students' learning and emotional well-being while schools were closed, the following suggestions might be helpful when schools reopen:

1. Listen to children's concerns

COVID-19 and school closures impacted many children and adolescents' mental health and well-being. As teachers, it is essential to listen to students' concerns and demonstrate understanding as well as empathy. Offer your students the opportunity to have a one-to-one conversation with you to reconnect and discuss any concerns that might have arisen when their school was closed. If a child shares anything that is particularly concerning, please follow the protection or child safeguarding systems in place.

2. Check how children are doing

Before teaching new academic content to students, teachers and school personnel should take time to check how children are doing. Remember that children may have difficulty concentrating at first or may need more time to get back into the routine of learning. Provide opportunities for children to take breaks, move around, and re-connect with their friends and peers.

3. Provide children with accurate information around COVID-19

As children return to school, they may have different thoughts and questions about COVID-19. Children want and need factual information. Use child-friendly and age-appropriate resources available in your country/region that is based on scientific evidence to respond to children's questions about COVID-19 accurately.

While it is important to acknowledge the scale of what is happening globally, make sure to emphasize all the efforts made and precautions taken to reduce risks in the school reopening plans. Do not forget to remind children of school safety protocols, including what to do in case there is a COVID-19 case detected in the classroom.

4. Seek suggestions from children on how to create a welcoming, safe and comfortable classroom

Engage children in making the classroom a welcoming, safe and comfortable space. When doing so, make sure to respect school safety procedures and use available material resources.

Children can provide suggestions; help decorate the walls of the classroom with colourful and welcoming messages and work in small groups so they can support each other to catch up on learning. Let them know that being supportive of each other will help them get through this together. Remember to praise children for their contributions and efforts. Teachers can foster feelings of safety and security by interacting and developing positive relationships with each student and using routines during the day to help children feel safe and secure.

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8 ways teachers can support students' mental health during COVID-19 school returns

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Transitioning back to in-person classroom learning during COVID-19

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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.ncbi.nlm.nih.gov/pmc/articles/PMC7082737/

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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

11. De Choudhury M, Kiciman E, Dredze M, Coppersmith G, Kumar M. Discovering Shifts to Suicidal Ideation from Mental Health Content in Social Media. Proceedings of the 2016 CHI Conference on Human Factors in Computing Systems; CHI'16; May 7 - 12, 2016; San Jose, CA, US. 2016. May, pp. 2098-110. [[ PMC free article] [ PubMed] [ CrossRef] Google Scholar]

33. O'Malley K, Wheeler I, Murphey J, O'Connell J. Changes in levels of psychopathology being treated at college and university counseling centers. J Coll Stud Dev. 1990;31(5):464-65. [ Google Scholar]

63. Biddle L, Donovan J, Sharp D, Gunnell D. Explaining non-help-seeking amongst young adults with mental distress: a dynamic interpretive model of illness behaviour. Sociol Health Illn. 2007 Nov;29(7):983-1002. doi: 10.1111/j.1467-9566.2007.01030.x. doi: 10.1111/j.1467-9566.2007.01030.x. [[ PubMed] [ CrossRef] [ CrossRef] Google Scholar]

79. Huh J, Ackerman MS. Collaborative Help in Chronic Disease Management: Supporting Individualized Problems. Proceedings of the ACM 2012 conference on Computer Supported Cooperative Work; CSCW'12; February 11 - 15, 2012; Seattle, WA, US. 2012. pp. 853-62. [[ PMC free article] [ PubMed] [ CrossRef] Google Scholar]

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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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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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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https://schools.au.reachout.com/articles/wellbeing-and-resilience

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Wellbeing and resilience are important in preventing the onset of mental health problems as well as potentially lessening the severity of existing mental health problems. Wellbeing and resilience are vital to developing efficient problem-solving skills, building and maintaining interpersonal relationships and realistic goal setting, all of which greatly enhance an individual's ability to perform and contribute meaningfully in daily life.

What is wellbeing and resilience?

Good health is about more than just the absence of sickness. Focusing on wellbeing and building resiliency is important in establishing a holistic approach to health, addressing both physical and psychological states.

The World Health Organisation defines wellbeing as "the state in which an individual realises his or her own abilities, can cope with normal stresses of life, can work productively, and is able to make a contribution to his or her own community". Wellbeing involves having positive self image and esteem.

Resilience, which is directly related to wellbeing, is about having the ability to cope with and adapt to new situations. Having a sense of resilience and positive wellbeing enables a person to approach other people and situations with confidence and optimism, which is especially important for young people given the enormous changes that occur with the transition into adolescence and adulthood.
Signs of resilience and wellbeing:

confidence to approach new situations and approach new people

realistic optimism

avoiding constant self-blame

ability to set goals

positive self image and self esteem.

How can students focus on wellbeing and resilience?

In a practical sense developing and improving on setting realistic and achievable goals, problem solving and social skills all contribute to wellbeing and resiliency. Other important skills include identifying and becoming aware of one's own strengths and weaknesses.

1. Setting realistic, achievable and measurable goals is a great way to promote self-efficacy. Setting goals should be motivating. One way to increase motivation (and minimise feeling pressure or 'failure') is to set sub-goals, smaller and achievable related targets.

2. Understanding and avoiding negative self-talk as well as actively practicing positive self-talk, is an important tool for building self-esteem. Self-talk, which is essentially internal reflections on personal ability and/or image, can greatly influence self esteem and perceptions about personal ability.

3. Developing and focusing on interpersonal skills, especially learning how to engage with people from different backgrounds, is a valuable tool for young people that will enhance self esteem and ability to maintain personal and fulfilling relationships.

What can teachers do?

create safe and supportive learning environments

provide consistent guidelines for behaviour

model appropriate responses and behaviours

provide opportunities for goal setting, success, failure and reflection.

ReachOut.com resources on wellbeing and resilience

How to help

Talk to young people about their mental health in terms of building strength and resilience.

Suggest self-awareness and resilience strategies, such as mindfulness meditation. Try the Smiling Mind app.

Recommend ReachOut.com content on resilience and wellbeing.

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Wellbeing and resilience are important in potentially preventing the onset of and lessening the severity of existing mental health problems.

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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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[PDF] Identifying and Addressing the Mental Health Needs of Online Students in Higher Education | Semantic Scholar

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“In a traditional classroom setting faculty have the ability to visually observe students, and interact face to face. This direct, experiential contact with students enables faculty to perceive mental health warning signs such as deterioration in hygiene, tardiness and absences, mood changes, bizarr…

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Charlotte SteenblockPeter E. H. SchwarzStefan R. Bornstein

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Discover Mental Health is part of the Discover journal series committed to providing a streamlined submission process, rapid review and publication, and a ...

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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.