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unesdoc.unesco.org.Minding our minds during COVID-19: helping school going children ...

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unesdoc.unesco.org.Minding our minds during COVID-19: helping school going children ...

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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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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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Mind in Somerset | For better mental health

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We are working in partnership to ensure that residents of Somerset get the support they need, when they need it.

Mental health organisations have come together to provide 24/7 support to adults in Somerset. Whatever is worrying you - anxiety, debt, employment, housing, low mood or addiction.

We're here to help

We can support you to live a full life by enabling access to specialist mental health services, housing support, debt and employment advice, volunteering opportunities, community activities and exercise.

Lots of things can impact our mental health. We have have come together to provide 24/7 support to adults in Somerset.

Open Mental Health supports people to live a full life by enabling access to specialist mental health support, debt and employment advice, volunteering opportunities, community activities and exercise.

Our service is accessible for adults in Somerset who are suffering from mental health problems.

Anybody who is in need of mental health support can call Mindline Somerset on 01823 276892, 24 hours a day, 7 days a week or email [email protected] .

The alliance forms part of a wider ecosystem of mental health and wellbeing support across somerset. By working in partnership, we want to ensure that there is 'no wrong door' for anyone who needs help.
DOWNLOAD THE OPEN MENTAL HEALTH INFORMATION LEAFLET HERE DOWNLOAD THE LEAFLET FOR MEDICAL PROFESSIONALS HERE
In partnership with THE BALSAM CENTRE, CHARD WATCH, AGE UK SOMERSET, SWEDA, CITIZENS ADVICE, RETHINK MENTAL ILLNESS, SECOND STEP, SPARK SOMERSET and NHS SOMERSET.

Mindline Trans +

0300 330 5468

Mindline Trans+ is a confidential emotional, mental health support helpline and signposting service for people who identify as Trans, A Gender, Gender Fluid, Non-binary. Find out more

Mindline

0800 138 1692
or 01823 276 892

Our Mindline Emotional support and mental health helpline is open 24 hours a day, 7 days a week. Find out more

Live Chat

Our Emotional support and mental health helpline is now available as a live webchat !
Available every day from 8-11pm.

Find out more

We are grateful for support from:

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Why students should have mental health days | Hailey Hardcastle

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https://mhttcnetwork.org/centers/global-mhttc/responding-covid-19-school-mental-health-resources

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Improving wellbeing and resilience is vital for students to stay mentally healthy. Use ReachOut Schools' resources to support your students wellbeing.

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If you or someone you know is considering suicide, please contact the National Suicide Prevention Lifeline: 1-800-273-TALK (8255), available 24 hours a day, seven days a week. All calls are confidential, and anyone can use this service. For more information, visit SuicidePreventionLifeline.org.
Attending college comes with extra challenges that can impact mental health. Meeting deadlines, managing budgets, and planning for the future may trigger feelings of anxiety or depression. It may also lead to alcohol dependence.

Rather than self-medicating through substance abuse, students experiencing mental health issues should seek extra support during college. Therapy, support groups, and medications can make a big impact on quality of life.

This guide features resources to manage student mental health. Read on to learn common types of mental health challenges and how to seek help for each.

Understanding Student Mental Health

The COVID-19 pandemic has impacted students' mental health. Due to the stigma around mental health, some students may feel less inclined to openly share about their struggles. Despite how it may seem, many students experience mental health issues.

A survey by the Association for University and College Counseling Center Directors shows college student mental health has been a growing concern since 2013. The survey found 95% of college counseling center directors believed the number of students with significant psychological problems was an increasing campus issue.

The directors also reported that 21% of students who visit the campus counseling center presented severe mental health concerns. At the same time, 40% of students presented mild health concerns.

More recent data published in 2021 echoes the same sentiment on mental health for students. The University of Florida's mental health clinic saw a 106% increase of adult patients attending their first appointment in August between 2019 and 2020. The amount increased by another 4% in 2021.

Stress and Anxiety

Symptoms of generalized anxiety disorder may become magnified during high-stress seasons of life. In fact, people are most at risk between childhood and middle age.

Everyone experiences this condition differently. Stress and anxiety may manifest as procrastination, insomnia, worry, and inability to focus. These two conditions may also cause physical symptoms like shortness of breath, headaches, upset stomach, or increased heartbeat.

Some studies show a correlation between stress and healthy hormone levels. People with menstrual cycles may experience irregularities in the length between cycles. Acne levels can also increase.

Where to Get Help

Students can manage their stress and anxiety in many ways. First, they can seek help from a licensed therapist, counselor, or psychiatrist. The Anxiety & Depression Association of America publishes a therapist directory of providers who specialize in this condition.

The Centers for Disease Control and Prevention also offers coping ideas. Many of the recommendations, including meditating and eating nutritiously, benefit general health. Spending time with friends and connecting with nature may also ease symptoms. Students may also explore online support groups.

Depression

Depression ranges from extended periods of mild sadness to prolonged feelings of intense hopelessness. Some students experience depression and anxiety at once. Depression can make people feel lethargic, unmotivated, and uninterested in things they once loved. Some people may have trouble sleeping, while others may sleep too much.

Certain life experiences may trigger depression, which some professionals call situational depression. This may occur after earning a series of bad grades, losing a job, losing a loved one, or undergoing a traumatic experience. Fortunately, medication can work as a temporary or long-term aid for both situational and ongoing depression.

No matter how depression manifests, students should seek help and support from their community and professionals.

Where to Get Help

People experiencing thoughts of suicide or self-harm should immediately contact the Suicide Prevention Lifeline. This organization offers free 24/7 phone and chat assistance. Caller information stays confidential.

Students can join an online support group to manage day-to-day symptoms. People who need assistance from medication should talk to a doctor. The American Psychological Association (APA) publishes a list of licensed care providers.

Drug Abuse and Alcoholism

Some students turn to drugs or alcohol to numb feelings of anxiety or depression. The National Institute on Alcohol Abuse and Alcoholism surveyed college students and found that 33% of college students surveyed say they engaged in binge drinking in the past month. Binge drinking can cause permanent changes in brain chemistry and physical health.

Students should not let feelings of shame surrounding drug abuse and alcoholism prevent them from seeking help. Genetics make some people prone to addiction. With professional help and community support, sobriety is possible.

Where to Get Help

Alcoholics Anonymous is a popular support group with meetings all across America. Students who want more one-on-one or immediate assistance can contact an alcohol and drug rehab hotline.

If talking to someone in person or over the phone seems intimidating, online resources may help. WebMD publishes a directory of types of substance abuse and informative articles about rehab. American Addiction Centers make it easy to locate the nearest rehabilitation center.

Attention Deficit Hyperactivity Disorder

Some people may view ADHD as more of a childhood disorder. However, some people go undiagnosed until adulthood. Researchers believe the condition may manifest between the ages of 10-25 as late-onset ADHD.

ADHD symptoms may appear as hyperactivity, procrastination, an inability to focus, and impulsive behavior. Students who notice a decline in quality of work and grades despite their best efforts should consider pursuing a possible ADHD diagnosis.

Where to Get Help

Students can begin by consulting with a general care practitioner. Primary care physicians may prescribe medicine or make recommendations for lifestyle changes. Or, they may refer the patient to a mental health specialist.

Some students with ADHD find success in completing schoolwork using the body doubling technique. Body doubling occurs when two or more people work on similar independent tasks alongside one another. This may look like a study session with a friend. Additionally, some organizations offer support groups and online resources.

Eating Disorders

Eating disorders impact people regardless of their gender. Students dealing with body image issues or feeling a lack of control in their life may develop an eating disorder. Common types of eating disorders include anorexia and bulimia. Students coping with an eating disorder often skip meals, but they may binge eat after a long period of hunger. These people may feel a sense of guilt when eating foods they deem unhealthy and regurgitate soon after eating.

Orthorexia is a less commonly talked about type of eating disorder. People experiencing orthorexia have an obsession with eating healthy. They excessively avoid many types of foods and check nutrition labels frequently.

Where to Get Help

People managing eating disorders may find accountability and solidarity through an online support group. The National Eating Disorders Association also runs a helpline.

Unfollowing triggering accounts on social media, like fitness influencers or models may benefit some people. Students with a history of disordered eating may need to avoid using calorie-counting apps, which could trigger a relapse.

In some cases, attending rehab can help people achieve a healthy weight and mindset.

Obsessive-Compulsive Disorder

People with OCD experience recurrent and uncontrollable thoughts, also known as obsessions. Some people describe these as urges or as seeing disturbing mental images. These thoughts may lead to repeated actions, also known as compulsions.

OCD manifests in different ways. Some people with the disorder may have a fear of germs or an obsession with order and symmetry. Others may experience uncontrollable thoughts about harming others or unwanted thoughts about sex.

Where to Get Help

A licensed psychiatrist may prescribe medication or offer management techniques for patients with OCD. Engaging in talk therapy with a counselor may also help. These professionals can also offer ideas on managing impulses, especially if the action is physically harmful.

Some people may find it easier to communicate about sensitive topics in the privacy of their homes. The International OCD Foundation offers a list of teletherapy providers. Joining an online support group allows people to share management techniques with their peers.

School Resources

Many colleges and universities may offer special accommodations for learners with OCD. For example, if a type of assignment triggers a compulsion, a student may substitute it with a different assignment. They may also receive permission to access a private testing center to complete exams.

Students receiving treatment for OCD should communicate any absences due to appointments or medication changes. Some professors may waive missed attendance points if learners maintain open communication.

Some schools may facilitate OCD peer groups, where students share techniques and healthy coping skills.

Post-Traumatic Stress Disorder

PTSD occurs in some individuals after experiencing a startling or dangerous event. During a scary moment, distress is a normal response. This fight-or-flight impulse encourages survival.

However, people with PTSD may feel unsafe and afraid long after the event ends. People with this disorder may also feel like they relive the situation through flashbacks. They may also experience recurring dreams about the event.

Fortunately, PTSD may resolve with time. However, many people must seek talk and exposure therapy to face their fears and feel better. Attempting to avoid thinking about the event or avoiding the event's location are symptoms of PTSD.

Where to Get Help

Speaking with other people with PTSD may help a person feel less alone. Even connecting with a moderated social media support group may help. However, some people need professional help to learn coping strategies.

Since PTSD commonly occurs in veterans, the U.S. Department of Veterans Affairs connects them with resources. This government department publishes tools for helping veterans find PTSD therapists.

Insider Perspective: Pursuing My Education With a Mental Disorder

Blake LeVine is a life coach and author with a master's degree in social work from Adelphi University. A bipolar disorder survivor, Blake has been healthy since 2005. He knows the importance of managing mental illness and uses his experiences to help clients deal with conditions like depression, anxiety, and PTSD.

He wrote "Beating Bipolar: How One Therapist Tackled His Illness ... and How What He Learned Could Help You."

Q. What Kind of Mental Health Issues Did You Have as a Student?

I was diagnosed with bipolar I disorder. I was in and out of psychiatric hospitals for two years. It was tough. I missed a lot of school and had trouble with friendships. My family experienced a lot of pressure to find the right treatments to help me rebuild my life. I'm stable now, but it took me a long time to put my life back together.

Q. When Did the Disorder Start to Manifest?

It started to manifest in my teens. I showed the first signs of it around age 15 or 16. I had been doing well in my life and was high-achieving in high school. But things started to unravel. I had my first manic episode that required a hospitalization. I couldn't sleep. I was nervous about my health. I thought I was dying and ended up going to the emergency room.

A few weeks later, I was diagnosed with bipolar. It took two years to find the right treatment. Medicine and therapy would go well, but I'd fall back into an incident again.

Q. Did You Have a Hard Time Functioning Academically?

Before all of this happened, I was in advanced classes and I did well in school. After it happened, it was much harder to attend school. For a short time, I had to go to a special school for kids with special needs. I went from excelling in school to having to reintegrate into school again.

Q. How Did It Affect You Socially?

Before, I was confident and had many friends. Afterwards, I felt knocked down. I was worried that other kids would make fun of me, or if I wanted to date, people wouldn't want to date me because of the illness. I became insecure for a while. Part of what I needed to do in therapy was find the courage to make friends again, potentially start to date, and get ready to be an adult.

Q. What Words of Encouragement Would You Give to Students Struggling With Mental Illness?

When I was sick, I felt so alone and hopeless. I would tell a young person going through it that there are many people experiencing these issues. If you take the right steps, you can have a full life. I'm happily married, I have two children, I've been educated all over the world, and I've written six books.

If I had known when I was so sick that any of that would have happened, it would have kept me a lot more positive. I really believe that if you take care of your mental health, you can do anything you set out to do in life.

The key is to accept what you're facing and get help. I love that all the pain I went through is helping inspire people.

General Tips for Student Wellness

The following general tips may work in conjunction with professional help and group therapy to improve a student's overall mental health. Sometimes, small practices add up to make big differences.

Eat Nutritious and Consistent Meals

Science backs up the idea of brain food. Managing mental health in college involves eating an adequate amount of whole foods. Avoiding meals or eating empty calories depletes energy levels and may negatively impact a person's mood. Eating at the same time every day may also improve digestive health.

Exercise

Exercise benefits physical health, but also mental health. In fact, exercise releases feel-good endorphins. Additionally, exercise can form an avenue for social interactions. Going on outdoor walks with friends may even increase low vitamin D levels. Healthy vitamin D levels may ease depression symptoms.

Find a Creative Outlet

A creative outlet allows for self-expression and mindfulness. Writing, painting, and taking photos may provide enjoyment and stress relief. Sharing meaningful art may help others with similar disorders feel less alone. The American Art Therapy Association publishes an Art Therapist Locator.

Apps That Promote Mental Health

This app helps solve mental health struggles and enhance student mental health. The app features a daily mood and a progress tracker. Users can also journal their feelings and add photos to the entries. The app encourages people to develop a problem-solving plan and schedule actions on a calendar. The video breathing exercises and stress-buster strategies may also help students manage stress. This psychologist-designed app features mental health courses and exercises. Users can track their daily moods. This app best suits people with mild to moderate mental health conditions. While no app can replace therapy or treatment, this tool may aid between appointments. Sometimes, leaving the house to attend an appointment may feel like a big struggle. This app lets people connect with a licensed therapist from home. The app pairs users with therapists with a license in the corresponding state. Users can communicate with their therapist through texts, video calls, pictures, or audio. This app helps people recovering from an eating disorder. The app aims to help people co-manage their eating disorders. Users can celebrate wins by earning rewards and view graphs that display their progress. The app's developers used self-monitoring research for its creation. This app helps users deal with nightmares following a traumatic event. The app uses imagery rehearsal therapy techniques to make nightmares less disturbing. The app especially caters to current and former service members. The creators designed this tool to supplement, but not replace, therapy. Calm provides pleasant bedtime stories, guided meditations, and breathing exercises to promote relaxation and mindfulness. The app helps users with varying goals. These goals include improving sleep quality, general self-improvement, or reducing stress and anxiety. The app offers some free resources, but most of the content requires a paid membership.

Additional Resources for Students

The APA publishes informative articles about types of mental health struggles. Some articles discuss related topics like human rights and immigration. People can use this site as a tool for learning more about their condition. The site also features a provider locator tool. This government website empowers people with knowledge so they can better understand mental health conditions. People with friends or family members impacted by mental health may also benefit from accessing this site. This website publishes guides for having difficult conversations surrounding mental health. Mental Health America provides helpful articles on how to live mentally healthy. People can discover ways to pay for mental health treatment on this site. This organization also publishes research surrounding mental health. Reading through the statistics may make people feel less alone. NAMI provides resources for all types of demographics impacted by mental health disorders. Family members can also find resources. The site publishes warning signs and symptoms of various conditions. People can pledge to be stigma-free and register to volunteer at events. NAMI provides resources for all types of demographics impacted by mental health disorders. Family members can also find resources. The site publishes warning signs and symptoms of various conditions. People can pledge to be stigma-free and register to volunteer at events. NIMH offers research on mental disorders. On the site, people can read through research on new treatments. This organization conducts research on nearly every type of mental health issue. Student researchers studying psychology can even apply for research grants to conduct their own studies. This website features informative articles and helps people find providers. The site divides the articles by types of mental health diagnoses and topics like relationships and personal growth.
DISCLAIMER: The information provided on this website is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment; instead, all information, content, and materials available on this site are for general informational purposes only. Readers of this website should consult with their physician to obtain advice with respect to any medical condition or treatment.

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Mental Health Counseling is a nonprofit, nonprofit provider of mental health counseling services.

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An emotionally well person strives to cultivate awareness, acceptance and management of a full range of thoughts, feelings and behaviors. Emotional Wellness enables a person to feel empowered to engage in self-care, ask for help, grow from experiences, develop autonomy and improve executive functioning.

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An emotionally well person strives to cultivate awareness, acceptance and management of a full range of thoughts, feelings and behaviors. Emotional Wellness enables a person to feel empowered to engage in self-care, ask for help, grow from experiences, develop autonomy and improve executive functioning.

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https://www.education.vic.gov.au › ...Promoting mental health and wellbeing in your school

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https://www.education.vic.gov.au › ...Promoting mental health and wellbeing in your school

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https://studentbehaviorblog.org/tag/mental-health-awareness/

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

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ABSTRACT

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

Introduction

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

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

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

Mental health in higher education

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

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

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

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

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

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

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

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

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

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

Methods

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

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

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

10 female, 6 male

13 white British, 2 Black British, 1 white European

14 undergraduate, 2 postgraduate

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

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

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

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

Results

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

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

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

Study-related barriers and enablers

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

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

Student 8 experienced a trigger for suppressed trauma:

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

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

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

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

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

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

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

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

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

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

Skills-related barriers and enablers

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

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

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

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

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

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

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

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

Environmental barriers and enablers

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

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

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

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

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

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

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

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

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

Discussion

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

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

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

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

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

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

Limitations and future work

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

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

Conclusion

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

Disclosure statement

The authors declare no conflict of interest

Correction Statement

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

Additional information

Notes on contributors

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

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

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

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It is quite normal for us to occasionally experience anxiety, low-mood or feelings of not fitting in. Deadlines, worries about achieving the required standard and the pressures of workload are all expected challenges of study. Making the transition to university and coping with difficulties can be tough, but experiencing stress and difficult emotions does not, in itself, denote the presence of a mental health condition. However, when these difficulties become overwhelming or start to have a serious and negative impact on your day-to-day living, we would encourage you to seek specialist advice and support.

Signs of mental health difficulties or emotional concerns can be very varied but the Samaritans list the following symptoms as possible signs you may be struggling to cope:

A persistent lack of energy or tiredness

A lasting feeling of restlessness and agitation

Regular feelings of tearfulness

Avoidance of / withdrawal from people

Not wanting to do things you usually enjoy

Using alcohol or drugs to cope with feelings

Finding it hard to cope with everyday things

If you are experiencing any of these difficulties or are worried about your mental health, there is lots of support out there:

The University Counselling Service offers a range of support to all students, including face to face counselling, mental health advisors, groups and workshops, and a wide variety of self-help guides, books and websites. They are based at 2-3 Bene't Place, on Lensfield Road. See also - UCS

The Disability Resource Centre offers a range of support to students with mental health difficulties, including specialist 1-1 mentoring, support with funding applications, and discussions around academic-related disability support (such as adjustments to teaching and learning and exam access arrangements). If you would like to speak to a disability adviser or book an appointment email disability@admin.cam.ac.uk or call on +44 (0)1223 332301. More information can be found here.

You can speak to your College Nurse or Tutor if you are worried about your mental health. See also - College support

Your GP can help you with any medical problem, including mental health concerns See also - GPs

The NHS have developed a range of self-help workbooks to help with mental health concerns such as depression and low mood, eating disorders, anger management, anxiety, social anxiety, panic, hearing voices and disturbing beliefs, obsessions and compulsions, PTSD, self-harm, stress and sleeping problems.

MIND is a national organisation offering information about mental health. They have a helpful guide to seeking help for a mental health problem as well as Frequently Asked Questions section on their website and they also provide an A to Z of mental health. You can also read their booklet about mental health and student life.

The Charlie Waller Memorial Trust website has some useful information about depression and mental health support, as well as booklets, videos and guides for those experiencing mental health issues and for those supporting someone experiencing this.

Nightline is a confidential night time listening support service run by students for students available during the night in term time. Find out more

Samaritans offers round the clock 24/7 confidential listening support to anyone who needs it.

The Mix offers a free helpline for under 25s between 11am and 11pm on 0808 808 4994.

For mental health support and advice out of hours, SANE offers specialist emotional support and information to anyone affected by mental illness, including family, friends and carers (open 4.30pm to 10.30pm every day).

Hopeline is run by Papyrus and offers confidential support and advice to people under 35 who may have thoughts of suicide (open 10am to 10pm weekdays and 2pm to 10pm weekends, and 2 to 5 on Bank holidays).

The Student Advice Service offers free, confidential and non-judgmental support to students

Student Minds is the UK's student mental health charity and it offers support, campaigns and research on mental health issues affecting students in the UK.

Stress Analyst is an interactive page which can be helpful if you've just had a stressful experience.
See also - Concern for others, Mental health emergencies and Helpful contacts

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It is quite normal for us to occasionally experience anxiety, low-mood or feelings of not fitting in. Deadlines, worries about achieving the required standard and the pressures of workload are all expected challenges of study. Making the transition to university and coping with difficulties can be tough, but experiencing stress and difficult emotions does not, in itself, denote the presence of a mental health condition.

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Student Wellbeing and Mental Health - EdSystems NIU

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Student Wellbeing and Mental Health A Framework and Resources for Measuring Student Needs and Development During Remote and Blended Learning​ Download the PDF Data on student wellbeing and mental health can help us to understand the magnitude of the effects of the crisis and the disparate impacts it is having on diverse populations.

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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).
Google Scholar

# data[].attributes.attachment_link.title
Mental Health and Well-Being of University Students: A Bibliometric Mapping of the Literature

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

# data[].attributes.attachment_link.title
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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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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Find federal education legislation, regulations, guidance, and other policy documents.

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

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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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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

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

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

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

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

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The Importance of Mental Health Awareness - Pine Rest Newsroom

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

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It's important to notice when your mental wellbeing may be slipping, so that you can take action to boost it.

Here are some questions that you might find helpful to ask yourself if you think that you are experiencing lower mental wellbeing. This is not an exhaustive list of things that you may notice when your mental wellbeing is starting to drop; don't treat it as a checklist where you have to notice a certain number to take action. It's worth taking action as soon as you notice one of these signs.

University can be a busy time, which can make it harder for you to take the time to look after your mental wellbeing. When you're busy, stresses can mount up and really take their toll - so it's important to take the time to prioritise your own mental wellbeing. ​If you have:
Taking the time to look after your mental wellbeing can be a challenge. A powerful way to take positive steps is to write down your intention in a clear, time-specific goal.
Clear, time-specified goals enable us to succeed, as goals can be achieved. Even when goals aren't achieved, this can be used to think specifically about what was difficult and how to adjust these goals to make it easier to try again.

Try choosing one way to prioritise your mental wellbeing this week. It is best to anchor the intention to a known time or other commitment e.g. 'after the biology lecture on Tuesday'. Use the phrase "I will do this specific action on this day at this time." and see how it goes!

Sometimes, the thought of doing anything is just too much. If this describes your situation, don't punish yourself. The great thing about taking small steps is that it doesn't matter how small your goal is. You decide what you want to achieve and what is realistic for you to achieve. That way, the completion of any task - no matter how simple it may seem - is recognised as the achievement that it is.

You may find it useful to record how you felt during/after doing things to support your mental wellbeing in pictures or a journal. Doing this means that you can look back when you next feel low and remind yourself of how the activity helped you.

If you find yourself experiencing mental health difficulties which are preventing you from doing the things you want to do, seek help - whether through friends, family, a doctor, or your university support services.

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​We all have mental health and our mental wellbeing can fluctuate day-to-day . When you're not feeling great, it can feel harder to take action to benefit your wellbeing. However there are small...

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

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Leadership Education in Maternal & Child Public Health |

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The Well-being Indicator Tool for Youth (WIT-Y) was designed by the for youth aged 15-21 years who currently are in or in the past have had contact with the child welfare system. The WIT-Y consists of three components:

1. The WIT-Y assessment, an online tool that youth can complete to explore their well-being across eight domains (Safety and Security, Relationships, Mental Health, Cognitive Health, Physical Health, Community, Purpose, and Environment).

2. The WIT-Y Snapshot, which gives youth a picture of their well-being based on the assessment they completed.

3. The WIT-Y Blueprint, a planning document for youth to use after looking at their WIT-Y Snapshot. The Blueprint helps youth take steps to increase their well-being in a particular area. The Sample WIT-Y Blueprint shows what a completed Blueprint looks like.

For more information about the WIT-Y, download the WIT-Y User Guide
Anu Family Services contracted with the Center for Advanced Studies in Child Welfare (CASCW) at the University of Minnesota to develop the Well-being Indicator Tool for Youth (WIT-Y).
Posted in Child Welfare, Children's Health, Families, Infant/early childhood health, Resources

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Resource: Well-being Indicator Tool for Youth (WIT-Y) | Leadership Education in Maternal & Child Public Health

# data[].attributes.attachment_link.description
The Well-being Indicator Tool for Youth (WIT-Y) was designed by the for youth aged 15-21 years who currently are in or in the past have had contact with the child welfare system.

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Department of Health Professions, Manchester Metropolitan University, Manchester, United Kingdom

Department of Psychology, Manchester Metropolitan University, Manchester, United Kingdom

Transitioning into the university environment can be both exciting and stressful for new and returning students alike. The pressure to perform well academically in an increasingly competitive environment, coupled with a vast array of lifestyle changes, can contribute to suboptimal wellbeing. Over recent years, uptake to wellbeing services within universities in the United Kingdom has grown given the concurrent rise in mental health difficulties reported. Higher education students now have to contend with a drastically altered learning landscape, owing to the discovery of novel coronavirus, Sars-Cov-2, otherwise referred to as COVID-19. In the United Kingdom, universities have moved to close their campuses to both students and non-essential staff in an effort to protect them from contracting the virus. The repercussions of these decisions have been monumental for the delivery of teaching, relationships and, importantly, the provision of student services. Ambiguity remains as to how teaching will be delivered for the forthcoming academic year. The uncertainty caused by the pandemic has yet to be considered in terms of student wellbeing and the new, mostly online, environments that students will be expected to navigate without their typical support networks. For the purpose of this paper, the concept of student wellbeing, a population-level term concerned with positive emotions rather than diagnosed mental health conditions, will be considered in relation to the COVID-19 outbreak. The current paper performs a conceptual analysis on student wellbeing in United Kingdom universities with a specific lens on the psychosocial impact of the global COVID-19 outbreak. Given the unprecedented world that students now learn in, considering the impact of the pandemic on psychosocial outcomes delineates the novel challenges that researchers and practitioners must consider when implementing student wellbeing initiatives moving forward.

Introduction

Transitioning into the university environment represents a significant venture in an individuals' life with feelings such as excitement and, conversely, trepidation. Multiple facets converge during this life event that impact almost all elements of an individuals' life. Beyond the obvious change in academic challenge where students are expected to become more autonomous in their studies, individuals may also relocate to another geographical location within the United Kingdom and, sometimes, internationally. This transition denotes a monumental shift in independence. For many new students, complete control over their behavioral choices becomes the norm for the first time with the potential for either positive or negative change ( Mulye et al., 2009). The student solely decides all elements of their life such as diet, exercise, alcohol consumption and drug use. Previous research has illustrated how behavioral choices tend to cluster together in a student population, whether that be maladaptive or optimal behavior ( El Ansari et al., 2018). For example, students who had a poor diet were found to be more likely to order takeaway food, smoke and engage in less physical activity ( Sprake et al., 2018). These suboptimal choices tend to be compounded by the financial restraints felt by students upon entry, imposed by rising tuition fees and limited disposable income. Money and debt worries are described by students as being the main risk factor for exiting their degree prior to completion ( Nevill and Rhodes, 2004), where financial concern can significantly impact upon social functioning ( Jessop et al., 2020). The social implications of becoming a university student can be disruptive to the students' previous support networks. Moving away from pre-existing support networks that include both family and friends can be especially daunting. Forging new social connections can be exceptionally difficult for prospective students and can lead to periods of loneliness or feelings of disconnectedness. Loneliness in university students has been significantly linked to increased stress, anxiety and depression ( Richardson et al., 2017). Synthesizing the above, the university experience presents multifaceted challenges to prospective students and has the potential to negatively impact upon student wellbeing. Despite this, entry levels to universities in the United Kingdom show no sign of waning. Record entry levels of 34.1% for 18 year olds into undergraduate study after year-on-year decreases ( UCAS, 2020) demonstrate that many young adults still strongly consider Higher Education (HE) as a next step in their life. Adding into this already complex intersection of factors impacting upon student wellbeing, the exponential transmission of novel coronavirus COVID-19 has altered the HE landscape monumentally, from teaching delivery to campus closures. This conceptual analysis will illustrate the intricacies of student wellbeing in Higher Education, why universities interest in this concept has increased over recent years, and how COVID-19 has impacted student wellbeing through its' prodigious impact on both physical life and psychological outcomes.

The mechanisms of daily life changed significantly upon the discovery and subsequent exponential transmission of COVID-19. COVID-19 (or Sars-Cov-2) is a novel coronavirus initially discovered in Wuhan, China in late December 2019. Initially reported as a case of "unknown pneumonia", the escalation of worldwide response has occurred rapidly. COVID-19 can cause the infected person to experience a range of respiratory symptoms but the most commonly reported symptoms include a new continuous cough, fever and a loss of taste and/or smell ( NHS, 2020). As COVID-19 has spread across the globe, the World Health Organization declared a Public Health Emergency of International Concern in January 2020 ( World Health Organisation [WHO], 2020). Community transmission has led to an exponential growth in cases both nationally and internationally, bringing with it stringent new measures to curb the virus' impact. Each nation has approached the COVID-19 problem with varying degrees of zeal and a range of targeted interventions normally centered around social distancing. The most utilized approach has been quarantine or, as colloquially described in the United Kingdom, "lockdown." Whilst this has looked different in each of the devolved nations, the core element of "lockdown" has been the reduction in social interaction of all forms, including typical working practices, shopping habits and education. Universities in the United Kingdom, and across the world, have closed their campuses to protect both their student and staff populations. Tertiary students have had to adapt to a completely novel learning experience as a result. COVID-19 poses both direct and indirect threats to student wellbeing; both as a direct contributor toward poor psychological outcomes and as the underpinning reason behind the stark reduction in social contact that students now cope with. Understanding how student wellbeing may operate during the global pandemic and post-COVID-19 is imperative to implementing new and adjusted measures to better support students in their academic journey. This paper will perform a conceptual analysis of 'student wellbeing' as it was first devised prior to COVID-19 and consider the impact of the 'new normal' on student wellbeing moving forward in the Discussion section. General research concerning wellbeing as a concept will first be considered before applying and synthesizing evidence in the tertiary student domain. One of the underlying principles of conceptual analysis is "the belief that to reach some agreement of that kind is a prerequisite for the development of useful (and/or interesting) knowledge..." ( Furner, 2004). The impact of COVID-19 will be considered in alignment with wellbeing and how student wellbeing may be affected by the global pandemic. Scopus and Web of Science were searched for relevant papers, using a range of search terms and relevant variations such as: wellbeing, student, university, tertiary and concept. Online software was also used to identify pertinent articles within the domain.

The Evolving Field of Wellbeing

The concept of wellbeing has been extensively studied with competing arguments to its' true definition. The foundation of wellbeing discussion is embedded in the World Health Organization's (WHO) early definition that health "...is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity' ( World Health Organization [WHO], 1948). Despite early work discussing two separate approaches of the concept (hedonic ( Young, 1952) and eudaimonic wellbeing ( Rogers, 1961), it is now widely accepted that wellbeing is a multidimensional construct ( Wills-Herrera et al., 2009). Derived in part from the eudaimonic approach to wellbeing, early seminal work by Bradburn (1969) stimulated conversation about the construct. Bradburn proposed that wellbeing was ultimately composed of both positive and negative affect. Agreement has been reached that positive and negative affect are not strictly orthogonal but rather two separate constructs that are independent of one another ( Diener et al., 1995). Further research began to elucidate the underpinnings of wellbeing and 'ill-being' as two distinct constructs. 'Ill-being' was found to be driven by worry, somatic complaints and negative affect, coupled with a personal sense of low competence and external factors such as unfavorable socioeconomic factors. Wellbeing, on the other hand, was associated with personality factors such as extraversion, optimism and an overall sense of personal competence ( Headey et al., 1984). With inextricable links to the notion of wellbeing, happiness has also been explored as a core component. Resources, assessment of needs and comparison of life situation, the authors propose, all contribute toward human happiness ( Shin and Johnson, 1978). Additionally, the notion of 'quality of life' was discussed in relation to happiness, whereby it is argued that true quality of life should be defined by the individual. A review of subjective wellbeing (SWB) illustrated to the author key components of the concept:

"...the happy person is blessed with a positive temperament, tends to look on the bright side of things, and does not ruminate excessively about bad events, and is living in an economically developed society, has social confidants, and possesses adequate resources for making progress toward valued goals." ( Diener et al., 1999, p295).

Whilst subjective wellbeing and psychological wellbeing differentiate, a common thread throughout the progression of the wellbeing literature clearly emerges: wellbeing is a multifaceted concept consisting of both internal and external contributors. An individuals' affect, attitude toward life events and general outlook on life, coupled with environmental factors, contributes toward an improved sense of wellbeing. Happiness and positive affect, as a core tenet of wellbeing, has been found to correlate with a multitude of culturally desirable successes in many core aspects of life, such as love, work and health ( Lyubomirsky et al., 2005). The value of truly understanding, striving toward, and maintaining positive wellbeing is critically important to ensuring that individuals' within society thrive and flourish within their own right.

Attention in the United Kingdom has more recently focused upon the concept on a national level. Resulting from a 6-month National Debate, three domains of national wellbeing emerged: individual wellbeing (such as life satisfaction), factors that directly affect individual wellbeing (such as health, relationships, where we work and where we live) and contextual domains (such as the economy and natural environment) ( Beaumont, 2011). This framework concisely captures factors of wellbeing that have been previously discussed within the academic sphere. However, it has drawn criticism for its lack of conceptual depth. The illusion that the framework creates is that each 'domain' is viewed in silo and without interaction with the others. The academic evidence to date refutes this proposition, as research has consistently demonstrated how individuals possess distinct subjective reactions to each of the domains ( Cooper et al., 2011). Evidently, academic findings have yet to be effectively translated into real-world pieces that undoubtedly inform policy and practice within the United Kingdom.

Student Wellbeing: Before COVID-19

The term wellbeing generally alludes to a range of factors in ones' life that contributes toward fulfillment and good physical health. It has a complex role to play as both a predictor of outcomes for students, such as their academic attainment ( El Ansari and Stock, 2010) but also as an outcome in and of itself influenced by a variety of factors ( Kim and Kim, 2017). An updated definition for wellbeing was generated recently, where it was defined as: '...when individuals have the psychological, social and physical resources they need to meet a particular psychological, social and/or physical challenge' ( Dodge et al., 2012). As noted by GuildHE (2018), defining wellbeing within the Higher Education domain is a challenging prospect owing to the plethora of evidence available and the complexity of the concept. This echoes McNaught's (2011) proposition that wellbeing is a deeply personal, existential experience. The term student wellbeing can also be described as a population-level term encompassing positive emotion and the inner capacity for an individual to cope with the challenges of day-to-day life and their academic journey ( Barkham et al., 2019). In recent years, the student wellbeing sphere has started to embrace core tenets of the positive psychology approach.

Positive psychology, as coined by Seligman (2004), denotes a paradigm shift from the previous model of mental ill health that permeated the psychological domain. Rather than an explicit focus on a deficit-based model of mental illness, positive psychology transmutes the perception that we must fix what is deemed as being 'wrong' with an individual. Instead, it posits three central pillars of wellness and wellbeing: positive emotion, positive traits and positive institutions. Emerging from this early work is the PERMA model of wellbeing ( Seligman, 2011):

1. Positive emotion (P): refers to experiencing and retaining a positive outlook, focusing on life's events in a constructive manner.

2. Engagement (E): ensuring the opportunity for genuine engagement both professionally and personally with activities, adopting a state of flow and immersion in certain instances.

3. Relationships (R): possessing and nurturing a range of meaningful relationships with others and reducing the risk of isolation.

4. Meaning (M): feeling as if one is working toward something that transcends oneself, or believing in something that lends meaning to ones' life.

5. Accomplishment (A): whether in a personal or academic capacity, reaching a desired goal will lead to a sense of accomplishment and thus, contribute to a state of flourishment.

Oades et al. (2011) propose a conceptual framework for integrating PERMA concepts into the university environment, addressing areas such as curriculum, social aspects, faculty and residential domains to achieve a positive university. Similar to the early models rooted within the eudaimonic approach, the PERMA domains capture both internal and external components of ones' life reflecting the multifaceted nature of wellbeing. Recent research has demonstrated how each of the PERMA domains can be incorporated into teaching practices successfully, incorporating an innovative approach to supporting student wellbeing ( Matthewman et al., 2018). Moreover, introducing a positive psychology course to students can improve the PERMA domains in turn, as compared to regular psychology students ( Smith et al., 2020). The potential that the PERMA model holds in underpinning student wellbeing and subsequent services provided has yet to be fully realized given its' relative infancy within the student domain.

Pertinent within the student wellbeing literature is the role of resilience and how this contributes to elevated wellbeing. Resilience has been previously defined as:

"...the process of effectively negotiating, adapting to, or managing significant sources of stress or trauma. Assets and resources within the individual, their life and environment facilitate this capacity for adaptation and 'bouncing back' in the face of adversity" ( Windle, 2011, p163).

Being adaptable when faced with a range of challenges is largely determined by the assets and resources an individual holds, along with their life and environment. Conceptual models have been suggested specific to the role resilience has to play in the HE setting. One of note is the notion of a "coping reservoir" in medical students ( Dunn et al., 2008). The authors suggest that each student possesses their own "coping reservoir" that has an internal structure, made up of the individuals' temperament, personality characteristics and preferred coping style. The "coping reservoir" is subsequently impacted by negative and positive inputs that either deplete or replenish the reservoir. This can lead to either positive or negative outcomes reflective of the students' wellbeing, such as resilience or burnout. It is noted however, that wellbeing is a lot more complex than inputs and outputs. Despite this, evidence supporting the "coping reservoir" model has illustrated its' utility ( Heinen et al., 2017). Recognizing resilience as an outcome of optimal wellbeing is important to consider, as resilient individuals tend to cope with stressors more efficiently which is particularly useful in the university environment. Further to this, elements of the 'PERMA' model of wellbeing have been found to significantly predict higher resilience ( Abiola et al., 2017).

Resilience has also been discovered to be an antecedent of student wellbeing. It has been shown to have a positive relationship to subjective happiness as well as negative relationships with anxiety, depression and stress. Critical to developing resilience capability are the assets and resources that students access within the systems that they participate, such as university, home and work ( Turner et al., 2017). This mirrors the ONS' domains of wellbeing fairly well, placing the individual within a particular environment that contributes toward overall wellbeing ( Beaumont, 2011). The role of resilience as an antecedent and outcome of student wellbeing is important to consider and is captured loosely in Barkham et al.'s (2019) working definition, alluding to a students' inner capacity to cope. Interestingly, aside from the notion of a "coping reservoir," this has not been explicitly alluded to in more general models of wellbeing. Whilst individual wellbeing or personal characteristics frequently form the central pillar of wellbeing, it could be suggested that resilience contributes significantly to wellbeing and warrants greater acknowledgment.

Why Are Universities Interested?

Universities possess a unique organizational structure that incorporate a multitude of competing agendas concerning knowledge production, subsequent translation into real-world impact and financial stability. Ultimately, concentration must be placed on the university as a viable business and thus, means an increased pressure to run as a for-profit business ( Taylor, 2017). The notion of "student wellbeing" therefore, has competed for resources and funding alongside other organizational factors that are often prioritized highly.

The settings-based approach to health and wellbeing encapsulates how the university setting can be critical in promoting improved student wellbeing. For students, university represents a community where they can thrive and hopefully flourish both socially and academically ( Markoulakis and Kirsh, 2013). Embedding health and wellbeing promoting features within the university setting should be a priority given the unique opportunity that the environment offers to support better behavioral choices. The settings-based approach was initially derived from the World Health Organisation [WHO] (1986), where health was described as: "...created and lived by people within the settings of their everyday life; where they learn, work, play and love." Whilst the university environment in itself shares commonalities with other businesses in industry whereby it employs staff, it also possesses a range of unique roles within its' structure that generates a distinctive culture and mission ( Dooris, 1999). The university environment plays a role as a "future-shaper" of students and is a platform for cultural, social and economic change, rendering it as a perfect setting to integrate health promotion ( Cawood et al., 2010). The health-promoting university, otherwise known as the Healthy Universities initiative, draws upon the settings-based approach to embed health into the organizational structure of the institution and instill health into the daily operation. The Healthy Universities initiative aims to achieve key outcomes by:

* Creating healthy and sustainable learning, working and living environments for students, staff and visitors.

* Integrating health and sustainable development as multi-disciplinary cross-cutting themes in curricula, research and knowledge exchange.

* Contributing to the health, well-being and sustainability of local, regional, national and global communities ( Dooris and Powell, 2012).

The Okanagan Charter (2015) has built upon the idea of health promotion infused within the university setting. By embedding health within campuses, universities serve to enhance the success of their institutions whilst promoting equity, wellbeing and social justice. Ultimately, this will strengthen communities economically, socially and ecologically. Through a recent reconceptualization, it was found that developing a supportive ethos and culture, embedding health, targeting the entire university population, embracing challenges and building a broad understanding of health contributes to the status of being a Healthy University ( Dooris et al., 2019). Similarly, students identified that a whole university ethos, coupled with access to health services, is imperative to the initiative ( Holt et al., 2015). Becoming a Healthy University is intrinsically appealing owing to the clear relationship between wellbeing and academic attainment. Previous research suggests that health, health behaviors and health awareness hold relationships with key determinants of academic attainment, such as perceived importance of achieving good grades ( El Ansari and Stock, 2010). The importance of promoting health within the university environment is therefore high, owing to the subsequent gains achieved resulting from improved wellbeing.

Discussion

The global pandemic has shifted the student wellbeing domain considerably due in part to the extensive pragmatic changes that have been introduced to curb the spread of COVID-19. Education, across the board, has experienced drastic changes to teaching delivery. Transition into online learning has occurred rapidly and has presented a range of novel challenges both to staff and students. As noted by Burki (2020), the utilization of virtual learning may well persist until a suitable vaccine for COVID-19 has been developed. Navigating the vast array of technological platforms now being relied upon for telecommunication (such as Zoom, Skype for Business and Microsoft Teams), as well as becoming fully competent using platforms such as Moodle, also stimulates questions surrounding the pragmatic barriers that students may face when attempting to study, collaborate with peers and submit pieces of work. Computer literacy, for example, is understood to be fairly high with the student demographic ( Link and Marz, 2006). Given that teaching has not been a strictly face-to-face endeavor for some time, it is assumed that students will engage with technology seamlessly and with little difficulty. However, it must be considered that a proportion of the student population will now encounter difficulties with the technology-heavy approach to learning. An individuals' sense of personal competence can contribute to suboptimal wellbeing and a perceived sense of decreased wellbeing should a student feel a loss of capability when it comes to their studies. Universities should strive to provide comprehensive support to their students in terms of navigating their new learning experience and extensive resources to underpin the transition to online learning.

Preliminary work has demonstrated that, even in simulation-based scenarios, it is possible to deliver functionally similar sessions that allow students to attain their educational objectives ( Torres et al., 2020). Fully scoping the requirements for each individual session should be paramount to retaining similarity between an on-campus and online scenario, ensuring that functionality is truly aligned with the objective of each session. However, the authors do note that barriers do occur, with practical elements such as internet speed providing challenges to the learning experience. Conversely, Da Silva (2020) suggests that virtual learning could contribute to greater attendance and participation with sessions, removing the anxiety associated with asking questions in front of course peers. This claim is corroborated by recent student surveys indicating that students value online learning for its flexibility and the ability to study at a time convenient to them ( Lall and Singh, 2020). Interestingly, 10% of students surveyed described the lack of face-to-face contact as one of the main strengths of online learning. This could be linked to the idea of reduced anxiety surrounding learning in general but also highlights the importance of others in conceptual frameworks of wellbeing. The concept of others may not always refer to positive relationships held with others but the presence of social judgment, especially concerning perceived stigma relating to mental health. This is, however, counteracted by 26% of the sample disliking online learning as they are unable to meet with friends. Clearly, the transition to virtual learning and assessment comes with both advantages and disadvantages. The technological move could potentially compromise the notion of Accomplishment, one of the five tenets of Seligman's (2011) PERMA model. Each university has approached assessment differently as a result of the pandemic, deploying novel methods that many students have not experienced before such as open-book examinations. The uncertainty surrounding assessment will inevitably provoke anxiety within the student population. Coupled with this uncertainty is the anxiety of completing assessments in a completely novel fashion, where students may worry that the new forms of assessment used will not truly capture their ability, especially when compared to traditional methods. Graduation ceremonies were not exempt from cancelation, negating a significant life event that celebrates the student's achievements after years of hard work. This also calls into question the notion of Meaning stipulated in the PERMA model. Seligman (2011) posits that a state of flourishment can be attained by working for something that transcends oneself. Research has demonstrated that education and career are one of the main sources of meaning for undergraduate students ( Hill et al., 2013). If students feel as if their work is not meaningful, especially given that their studies will occur in a predominantly isolated fashion, detrimental wellbeing could ensue. Ensuring that students are fully informed of new assessment protocols, as well as moving to celebrate their successes in an engaged way, could potentially mitigate the risk of suboptimal wellbeing in this instance. Institutions and, more importantly, researchers should consider the transition in a balanced fashion to truly understand the role virtual learning has on student wellbeing over the course of the COVID-19 pandemic and beyond.

The environment in which the student now resides and studies will provide unique barriers to a streamlined learning experience. Considering the drastic shift in environment that students have experienced, perhaps the biggest potential contributor to poor student wellbeing is the change in physical location. Currently, all academic content is delivered through technological means whilst campuses remain closed. The impact of this change is significant and far-reaching, deviating from the typical university experience that students have become accustomed to. A lack of physical contact with academic staff, coupled with their reduced capacity associated with the technological shift, has put students under increased pressure to meet deadlines without the typical access to support that they would normally experience. Prior to COVID-19, students may have sought advice by physically meeting with a supervisor or module lead. Staff should, in the wake of the pandemic, consider offering virtual office hours to sustain and promote frequent engagement with students to mitigate the disruption they are experiencing to their studies ( Zhai and Du, 2020). The absence of physical contact is not limited to teaching staff. Students are now faced with a prolonged period of time without their friends and course companions. Where group work and collaborative projects are now a mainstay of many university courses, the opportunity for students to work with fellow students has been reduced and become more challenging. The likelihood that students will experience more frequent and intense feelings of loneliness, anxiety and isolation is high, owing to the disconnectedness many will feel as a result of leaving the university campus ( Zhai and Du, 2020). As previously stated, loneliness has been found to be significantly associated with stress, anxiety and depression in students ( Richardson et al., 2017). In addition to education and career, undergraduate students consider relationships as a main contributor to meaning ( Hill et al., 2013), considered integral to wellbeing according to the PERMA model. The importance of combatting feelings of loneliness should be considered owing to the highly detrimental effect this has on student wellbeing. For many, the university campus is home and moving away due to the COVID-19 pandemic represents a significant upheaval for the individual.

Wellbeing described more generally often stresses the importance of the individuals' lived environment and how this impacts upon individual wellbeing, such as the places that we work and live ( Beaumont, 2011). In this instance, the place where students study, as opposed to work, has evolved considerably. The way in which the lived environment has interacted with how we experience relationships during the pandemic is important to note as access to friends and family has practically ceased due to nationwide restrictions to curb the spread of COVID-19. For some students, the ability to return to the familial home to self-isolate together has been near impossible, especially for international students. There are instances of students remaining in university halls or accommodation throughout the pandemic, living independently but without the social support networks they previously possessed as their cohabiting peers have returned home. The impact that this isolation has on student wellbeing is monumental, as the lived environment and accessibility to social support across the globe has ultimately nullified the possibility of physical contact with loved ones. Thankfully, the digital era that we now live in offers online methods of sustaining regular contact with those within our social networks. Paradoxically, early research suggested that increased engagement with the internet was to the detriment of social relationships, exacerbating feelings of loneliness and depression ( Kraut et al., 1998). The use of social media specifically has been found to have both positive and negative effects on psychosocial wellbeing, identity and belonging in adolescents ( Allen et al., 2014). In current circumstances where physical loneliness may be impossible to avoid, the positive elements of internet use and social media engagement should be considered. As long as social media usage is engaged with as a means to sustain existing relationships and forge new connections, it can be a powerful tool in reducing an individuals' feelings of loneliness ( Nowland et al., 2018). Whilst the lockdown measures continue to persist within the context of the pandemic, the use of social media will be key in maintaining appropriate support networks for students. In the absence of offline social activities, social media could play a crucial role in alleviating feelings of loneliness within the student population. Given the importance that social connectedness and relationships play relative to a students' wellbeing, digital solutions provide a good substitution for face-to-face interaction.

Whilst the COVID-19 pandemic has had pragmatic implications relating to campus closures and a transition to virtual learning, the virus itself creates a degree of uncertainty that is unprecedented. COVID-19, as a novel coronavirus, is being studied at a phenomenal pace with more scientific information becoming readily available with each passing day. Understanding the transmission, prevalence and symptoms of the virus is critical to keeping the virus under control but until that information becomes clearer, ambiguity surrounding the virus is high. Misinformation has been spread exponentially throughout the duration of the pandemic through a variety of mediums. Social media platforms such as WhatsApp have experienced an overwhelming level of viral messages, with one particular message purporting to contain the cure for the virus, which involved mixing garlic and boiling water ( Clarke, 2020). A headline published in the BMJ in late April 2020 ( Wise, 2020) is a prime example of how information can be taken out of context and contribute to elevated public anxiety and fear. The article headline stated: "A third of COVID-19 patients admitted to United Kingdom hospitals die," with a remark added when shared by the BMJ on Twitter that the fatality rate was "on par with Ebola." This information was disseminated widely in the United Kingdom press despite the Ebola claim being factually incorrect when case fatality rates (CFRs) are directly compared - Ebola's CFR is approximately 50%, whereas COVID-19's CFR is around 6.5% with significant underreporting of milder cases ( Winters et al., 2020). Further to this, over 25% of COVID-19 related videos on YouTube were found to contain nonfactual information totaling over 62,000,000 cumulative views ( Li et al., 2020). The infodemic that has ensued has been overwhelming for the general population and for students especially. Amongst the false information being circulated is legitimate scientific knowledge. Many news outlets are providing around the clock coverage of the pandemic and how it is affecting countries and communities across the globe. Accessing and assimilating information relating to COVID-19, whether factual or not, is incredibly easy. For students, relating this to their personal circumstances and how it impacts upon their studies can be detrimental to their wellbeing. Contextual domains are compromised where the economic and educational landscape are now unrecognizable. The unpredictability of the pandemic will undoubtedly contribute to suboptimal mental health outcomes for the general population ( Zandifar and Badrfam, 2020). Tertiary students worldwide are facing unmitigated uncertainty in regard to their studies, ranging from fear of contracting the virus once campuses eventually open to the unknown quantity surrounding the completion of their studies. A range of interventions have been posited thus far to combat the onset of poor mental health outcomes including the provision of online mental health resources, online provision of self-help and counseling services, and the deployment of online surveys to understand the prevalence of poor mental health outcomes ( Rajkumar, 2020). Universities should consider their resources and provision throughout the pandemic and beyond. Not only in terms of content, but in their accessibility to students' from a variety of demographic backgrounds. The negative affect associated with the pandemic has the potential to impact on student wellbeing for the foreseeable future, therefore further research is required to understand what provision would be most suitable for the HE context. The use of newly produced psychometric measures with university students could facilitate greater understanding of the mental health impact of COVID-19, such as the Coronavirus Anxiety Scale ( Lee, 2020) or the Fear of COVID-19 Scale ( Ahorsu et al., 2020).

There are limitations to this piece of work and the evidence synthesized. Mainly, research produced during the COVID-19 pandemic is sparse, varied and conducted within a plethora of different scenarios. Studies have originated primarily from Asia where the epicenter of the COVID-19 pandemic can be traced. Little research has been completed thus far within the United Kingdom specifically as Europe's peak of the pandemic arrived later than in Asia. The vast cultural differences observed, alongside the diverse set of methods deployed to explore the impact of COVID-19, means that it is difficult to extrapolate findings directly into the HE setting within the United Kingdom. Only as time passes and more research is conducted in relation to COVID-19 will more concrete conclusions be available. The long-term impact of the virus on student wellbeing, and wellbeing of the general population, is unknown.

Synthesizing the evidence to date in relation to pre-existing models of wellbeing suggests that the psychological impact of the virus will be far-reaching. Whilst students face an unknown length of time living with uncertainty regarding their studies, research teams should move quickly to understand student wellbeing in these unprecedented times and beyond. Considering the negative implications of COVID-19 is intuitive, however, small victories may emerge. The shift to virtual learning and student services could encourage greater participation now that stigma and peer judgment has been significantly reduced. The collective trauma experienced by the university community during the pandemic must not be underestimated, but the potential to rebuild stronger is now more likely than ever ( Wilton, 2020). The lessons learnt during this period will undoubtedly contribute toward more online services, greater awareness of the impact of loneliness on the student experience and an increased need to diversify services to suit a variety of student demographics.

Author Contributions

DB conducted the analysis and drafted the manuscript. ND and MH reviewed the manuscript and provided feedback prior to submission and formed the Ph.D. supervisory team. All authors contributed to the article and approved the submitted version.

Funding

The lead authors' Ph.D. program is fully funded by a strategic partnership held between Nuffield Health and Manchester Metropolitan University.

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

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Assessing the Impact of the COVID-19 Pandemic on Student Wellbeing at Universities in the United Kingdom: A Conceptual Analysis

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Transitioning into the university environment can be both exciting and stressful for new and returning students alike. The pressure to perform well academically in an increasingly competitive environment, coupled with a vast array of lifestyle changes, can contribute to suboptimal wellbeing.

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https://www.edutopia.org/article/focusing-student-well-being-times-crisis

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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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Grace Zurielle C. Malolos, 1 ,* Maria Beatriz C. Baron, 1 Faith Ann J. Apat, 2 Hannah Andrea A. Sagsagat, 3 Pamela Bianca M. Pasco, 1 Emma Teresa Carmela L. Aportadera, 4 Roland Joseph D. Tan, 1 , 5 Angelica Joyce Gacutno-Evardone, 6 and Don Eliseo Lucero-Prisno III 7 , 8

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has subjected the mental health and well-being of Filipino children under drastic conditions. While children are more vulnerable to these detriments, there remains the absence of unified and comprehensive strategies in mitigating the deterioration of the mental health of Filipino children. Existing interventions focus on more general solutions that fail to acknowledge the circumstances that a Filipino child is subjected under. Moreover, these strategies also fail to address the multilayered issues faced by a lower-middle-income country, such as the Philippines. As the mental well-being of Filipino children continues to be neglected, a subsequent and enduring mental health epidemic can only be expected for years to come.

Keywords: Mental Health, Philippines, COVID-19, Psychology, Child, Child care, Health services, Social problems

Introduction

The Philippine Development Plan for 2017-2023 highlights that children are among the most vulnerable population groups in society, including them in strategies for risk reduction and adaptive capacity strengthening.1 Approximately 40% of the total Philippine population is comprised of Filipinos below 18 years of age.2 Despite having a large portion of the Philippine population declared as vulnerable, concerning issues involving them still persist and remain unaddressed.

Among Filipino children aged 5 to 15, 10% to 15% are affected by mental health problems.3 According to the World Health Organization (WHO), 16.8% of Filipino students aged 13 to 17 have attempted suicide at least once within a year before the 2015 Global School-based Student Health survey.4 This is just one of the many indicators showing the state of mental health of these children. These statistics involving children's mental health are concerning as childhood is a crucial period where most mental health disorders begin. Efforts should be made to identify these issues early for proper treatment in prevention of negative health and social outcomes.4 Childhood mental and developmental disorders also frequently persist into adulthood, making it more likely for them to have compromised growth with greater need for medical and disability services and higher risk of getting involved with law enforcement agencies.5 In this context, the COVID-19 pandemic threatens to worsen these numbers, affecting the delivery of the Philippines' health care services, including those for children's mental health.

Since the beginning of the pandemic, children have been subjected to multiple threats to their mental health. Adding insult to injury, several concurrent factors in the Philippine society exacerbate this. While these are experiences shared by all people regardless of age, impediments to emotional and social development are greater in children than in adults.6 They may also be more vulnerable to developing mental health issues such as depression and anxiety.7 Together with these circumstances and the weakened health care system, children's vulnerability towards mental health problems may be worsened by the pandemic, leading to more new cases and exacerbating existing ones.2

Status of mental health system for children in the Philippines

According to the National Statistics Office (NSO), mental health illnesses rank as the third most common form of morbidity among Filipinos.8 In the assessment conducted on the Philippine mental health system, a prevalence of 16% of mental disorders among children was reported.9 With this alarming number of cases, it is surprising to see how the Philippines is currently responding to this problem. To date, there are only five government hospitals with psychiatric facilities for children, 84 general hospitals with psychiatric units, and 46 outpatient facilities from which there are only 11 that are designated for children and adolescents. Additionally, there are only 60 child psychiatrists practicing in the Philippines, with the majority of them practicing in urban areas such as the National Capital Region. Hence, children with mental health problems who are in rural areas have less access to such services.10

As the pandemic continues, combined with the menace of the typhoon season, thousands of children are placed in a situation where the future is uncertain. A local study showed that youth age and students are among those with significant association to a greater psychological impact due to the pandemic.11 In addition, UNICEF also reports that children nowadays face a trifecta of threats which include direct consequences of the disease itself, interruption in essential services, and increasing poverty and inequality. All of these can lead to higher incidences of stress, anxiety, and depression.12

General mental health implications of COVID-19 on Filipino children

The fear and anxiety of contracting the virus, the suspension of physical classes, the disruption of regular daily routine, and the decrease of social support from school peers collectively add burden to the mental well-being of children.7,13 The shift to online classes increases the burden on the mental well-being of children. Excessive use of these technologies has been associated with developmental delays and has resulted in sleep schedule disruptions.14 This situation is aggravated by the strict implementation of the confinement of children at home. Children living with preexisting mental health concerns,13 and living in cramped households and communities face worse circumstances.

Militarization of the Philippine COVID-19 response

Aside from being regarded as one of the countries with the longest lockdown, the Philippines has also been called out by the United Nations for employing a highly militaristic approach in response to the COVID-19 pandemic.15Militarization may come across as threatening, because it implies a potential for violence.16 Furthermore, few studies abroad have reported that children and adolescents may tend to view police forces as punitive figures whom they fear.17,18 While these qualitative studies were conducted long before the current health crisis began, it may be possible for increased military presence in communities to exacerbate the fears already emanating from the pandemic itself; this can negatively impact a child's psychological development.4 Still, local evidence to confirm these associations, especially in the context of the pandemic, is lacking. Many studies have already documented the impact of lockdown on children, but none of them have looked into how the strategies for implementation may also be contributory to their mental health or well-being.

Typhoons and the mental health of Filipino children

The Philippines has been hit by 22 tropical typhoons during the COVID-19 pandemic, leaving thousands of families homeless.19 Children who are already frightened of COVID-19 and previous tropical storms have had to relive their experience with each new typhoon that came. In addition, children in crowded evacuation centers are at increased risk of contracting diseases and experiencing gender-based violence.20 Given how past typhoons of similar strength and destruction have caused lasting adverse mental health effects on children,21 the same or even worse, may be expected as a result of the more recent calamities. Super typhoons Goni and Vamco have caused further disruptions in schooling and livelihood, therefore leaving more children vulnerable to the effects of the pandemic. Those who have been forced to seek refuge in evacuation centers are at an increased risk of acquiring COVID-19, among other diseases.20

Child Labor and Abuse in the Time of COVID-19

The COVID-19 crisis caused an unprecedented reduction in economic activity and working time, thus increasing poverty. Fewer employment opportunities and lower wages drive exploitative work. Further suppression of wages induces child labor. There may be deliberate recruitment of children to cut costs and boost earnings.22

In addition to the threats of child labor, a study entitled The Hidden Impact of COVID-19 on Children reported that violence occurred in nearly one-third (32%) of households. Lesser household incomes were associated with more reports of violence towards children.23 According to UNICEF, the Philippine government saw a 260% increase in online child abuse reports from March-May. Many victims are first abused by their parents, who livestream sexual violence for predators in wealthy Western nations. This occurrence resulted from job and income loss and more time spent at home due to strict quarantine measures. The abuse in children occurs at an average of 2 years before being rescued.24

Strategies Addressing the mental health implications of COVID-19 on Filipino children

Numerous strategies have been utilized to address the mental health impacts of COVID-19 on Filipinos. With the mental health implications predicted at the beginning of the pandemic, the Psychological Association of the Philippines has compiled a list of free telemedicine consultations. As of August 24, the Philippine Red Cross has also established a COVID-19 hotline with 9790 helpline volunteers to address mental health and other similar concerns. The Department of Health has also conducted nationwide campaigns in observance of the National Mental Health Week.25

Albeit present, these interventions are limited to the general population, and strategies specific to addressing the mental health situation of children remain scarce and staggered. Compounding factors of classifying among the lower- to middle-income countries of militarization, natural disasters, and child labor and abuse have yet to be considered. In addition, it is also important to consider that happiness, with its multifactorial nature, is a vital component of an individual's overall wellbeing.26

Conclusion

The already-challenged state of mental well-being of Filipino children has been worsened by the pandemic and the lack of good mental health policies by the government. While there is increasing awareness for mental health, children-centered interventions remain deficient. Approaches must integrate commonly-known mental health effects on children with existing and anticipated Philippine societal issues. Without doing so, it may be expected that as the COVID-19 pandemic is mitigated, a mental health epidemic will replace it.

Competing interests

The authors have no conflicts of interest.

Ethical approval

Not applicable.

Authors' contributions

GZCM and DELP were involved in the conception of the paper. GZCM led the writing of the manuscript and acted as corresponding author. GZCM, MBCB, FAJA, HAAS, PBMB, ETCA and RJDT wrote sections of the manuscript. AJGE and DELP reviewed and edited the initial draft of the manuscript prior to submission. All authors have reviewed and agreed to the final version of the paper.

References

4. Golberstein E, Wen H, Miller BF. Coronavirus disease 2019 (COVID-19) and mental health for children and adolescents. JAMA Pediatr. 2020;174(9):819-20. doi: 10.1001/jamapediatrics.2020.1456. [[ PubMed] [ CrossRef] Google Scholar]

5. Scott JG, Mihalopoulos C, Erskine HE, Roberts J, Rahman A. Childhood mental and developmental disorders. In: Patel V, Chisholm D, Dua T, Laxminarayan R, Medina-Mora ME, eds. Mental, Neurological, and Substance Use Disorders: Disease Control Priorities. 3rd ed. Vol 4. Washington, DC: The International Bank for Reconstruction and Development, The World Bank; 2016. 10.1596/978-1-4648-0426-7_ch8 [ PubMed] [ CrossRef]

14. Hageman JR. Children's and families' behavioral and mental health during COVID-19. Pediatr Ann. 2020;49(10):e405-e6. doi: 10.3928/19382359-20200922-05. [[ PubMed] [ CrossRef] Google Scholar]

16. Lieblich E, Shinar A. The case against police militarization. Mich J Race Law. 2018;23(1-2):105-3. [ Google Scholar]

17. Powell MB, Skouteris H, Murfett R. Children's perceptions of the role of police: a qualitative study. Int J Police Sci Manag. 2008;10(4):464-73. doi: 10.1350/ijps.2008.10.4.099. [[ CrossRef] Google Scholar]

18. Beckett H, Warrington C, Ackerley E, Allnock D. Children and Young People's Perspectives on the Police's Role in Safeguarding: A Report for Her Majesty's Inspectorate of Constabularies. England: University of Bedfordshire; 2015.

19. Rocha ICN, Dos Santos Costa AC, Islam Z, Jain S, Goyal S, Mohanan P, et al. Typhoons during the COVID-19 pandemic in the Philippines: impact of a double crises on mental health. Disaster Med Public Health Prep. 2021:1-4. 10.1017/dmp.2021.140 [ PMC free article] [ PubMed] [ CrossRef]

21. Horiguchi H, Nakazawa M. Long-Lasting Effects of the 2013 Yolanda Typhoon on Overall Health of Mothers and Children. Disaster Med Public Health Prep. 2020:1-8. 10.1017/dmp.2020.40 [ PubMed] [ CrossRef]

26. Heizomi H, Allahverdipour H, Asghari Jafarabadi M, Safaian A. Happiness and its relation to psychological well-being of adolescents. Asian J Psychiatr. 2015;16:55-60. doi: 10.1016/j.ajp.2015.05.037. [[ PubMed] [ CrossRef] Google Scholar]

Articles from Health Promotion Perspectives are provided here courtesy of Tabriz University of Medical Sciences

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Mental health and well-being of children in the Philippine setting during the COVID-19 pandemic

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The coronavirus disease 2019 (COVID-19) pandemic has subjected the mental health and well-being of Filipino children under drastic conditions. While children are more vulnerable to these detriments, there remains the absence of unified and comprehensive ...

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Why you should take a break: Prioritizing mental health in schools | Hailey Hardcastle | TEDxSalem

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Focusing on Student Well-Being in Times of Crisis

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

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https://www.edutopia.org/article/focusing-student-well-being-times-crisis

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Mental health awareness is an important issue for all educators, who are often the first line of defense for their students. Education professionals have recognized the impact that a student's mental health has on learning and achievement, and they realize that there's a great deal that can be done to help students with mental health issues. As a high school teacher with more than 23 years of experience, I welcome the fact that mental health awareness is finally becoming an important part of a school's function and curriculum.

Seeing the Signs in My Student

A few years ago, a student in my senior class changed drastically in a short period of time. I noticed that Melina no longer did her homework, and she didn't even try on her essays. Previously meticulous in her appearance, Melina would come to school disheveled, wearing the same clothes. When I tried to speak to her, she was uncharacteristically distant and withdrawn. Because I had some training in mental health awareness, I knew Melina was in some sort of trouble.

Luckily, my school had social workers on staff who could speak to Melina and assess her issues. They discovered that Melina was depressed and suicidal, and she needed an immediate psychiatric intervention. Melina was hospitalized for a period of time, but she was able to return to my classroom a few months later. With the help of medication and therapy, she managed to graduate with her class.

Understanding the Impact

The National Alliance on Mental Illness estimates that one in five people live with some sort of mental disorder or disease. Despite the fact that the average age of early signs of mental illness is 14, most individuals don't seek help until adulthood. Underlining the seriousness is the fact that 60 percent of high school students with mental illness don't graduate.
Further reading: Ease Student Anxiety in the Classroom
New York mental health experts recognized that earlier intervention could result in more positive outcomes for these students. Beginning in July 2018, New York will be the first state in the nation to require mental health education for all students. The overall mission of New York's School Mental Health (SMH) program is to promote healthy social, emotional, and behavioral development of students, and "break down barriers to learning so the general well-being of students, families, and school staff can be enhanced in collaboration with other comprehensive student support and services."

The SMH program supports the emotional health and academic growth of all students with the following:

Integrating comprehensive services and support throughout every grade level

Assessing mental health needs through universal, selective, and targeted interventions

Providing access to behavioral and mental health services and programs

Leveraging higher-level personnel, such as those working with the Department of Education, for necessary support and services

Building collaborative relationships between the school and students' families and communities

Spreading Awareness Across the Nation

Until mental health education is a mandatory aspect of all schools, teachers and administrators can work to promote awareness with their students. Key elements to shine a light on include the concept of self-care and responsibility for one's own mental health and wellness, with an emphasis on the fact that mental health is an integral part of health, and the concept of recovery from mental illness.

Teachers and students should be provided with ways to recognize signs of developing mental health problems, and there should be opportunities around the awareness and management of mental health crises, including the risk of suicide or self-harm. Further, instruction should address the relationship between mental health, substance abuse, and other negative coping behaviors, as well as the negative impact of stigma and cultural attitudes toward mental illness.
Further reading: Social-Emotional Learning
Because teens spend most of their day at school, it just makes sense to have mental health awareness and education become part of the curriculum. When we empower students with knowledge, and encourage dialogue, students will be able to get the help they need.

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The Importance of Mental Health Awareness in Schools

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Mental health awareness is an important conversation few schools have with their students. Introducing the right resources can make a huge difference.

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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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This chapter provides best-practice ways to create a learning community that is inclusive of all students, a community where students are valued and feel safe and supported. It explores why and how teachers should implement positive social and emotional learning practices that promote student wellbeing and mental health in the classroom and schoolwide. The Grattan Report highlighted that many Australian students are consistently disengaged, and it estimated that approximately 40 per cent of all students in Australian classrooms are unproductive in a given year. Fostering and documenting a student's skills in the core social and emotional learning components can contribute to positive outcomes for a student's academic achievement, mental health and school engagement. Schools can play a key role in providing students with the opportunity to gain greater social and emotional awareness through positive learning practices that promote student wellbeing and positive mental health in the classroom.

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Promoting student wellbeing and mental health through social and emoti

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This chapter provides best-practice ways to create a learning community that is inclusive of all students, a community where students are valued and feel safe

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this song is about mental health (feat. Travis Atreo)

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this song is about mental health (feat. Travis Atreo)

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https://www.auroraarizona.com/node/2524

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Many people struggle with mental health, and they should not have to struggle alone. Raising mental health awareness can help combat the stigma around mental health issues.

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Why students should have mental health days | Hailey Hardcastle

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Design thinking is making its way into training and development as practitioners shift their thinking away from training events to learning experiences. Join Sharon Boller and Laura Fletcher, authors...

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Importance of Student Mental Health in Higher Education - TimelyMD

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According to a recent survey, 94% of student affairs professionals said that they believe mental health is the most important issue in higher education.

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

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

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

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The Handbook of Student Affairs Administration

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What issues and trends affect higher education and student affairs today? In this fully updated handbook, leading experts discuss the answer to this and other essential questions. They provide a definitive reference for student affairs professionals at all levels of administration and management.

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Leadership Education in Maternal & Child Public Health |

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The Well-being Indicator Tool for Youth (WIT-Y) was designed by the for youth aged 15-21 years who currently are in or in the past have had contact with the child welfare system. The WIT-Y consists of three components:

1. The WIT-Y assessment, an online tool that youth can complete to explore their well-being across eight domains (Safety and Security, Relationships, Mental Health, Cognitive Health, Physical Health, Community, Purpose, and Environment).

2. The WIT-Y Snapshot, which gives youth a picture of their well-being based on the assessment they completed.

3. The WIT-Y Blueprint, a planning document for youth to use after looking at their WIT-Y Snapshot. The Blueprint helps youth take steps to increase their well-being in a particular area. The Sample WIT-Y Blueprint shows what a completed Blueprint looks like.

For more information about the WIT-Y, download the WIT-Y User Guide
Anu Family Services contracted with the Center for Advanced Studies in Child Welfare (CASCW) at the University of Minnesota to develop the Well-being Indicator Tool for Youth (WIT-Y).
Posted in Child Welfare, Children's Health, Families, Infant/early childhood health, Resources

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Resource: Well-being Indicator Tool for Youth (WIT-Y) | Leadership Education in Maternal & Child Public Health

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The Well-being Indicator Tool for Youth (WIT-Y) was designed by the for youth aged 15-21 years who currently are in or in the past have had contact with the child welfare system.

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Department of Psychiatry and Psychotherapy, Medical Faculty, Leipzig University, Leipzig, Germany

Background: The COVID-19 pandemic has been affecting everyone's daily life in unknown measures since its outbreak. Nearly all Universities around the globe were affected. Further, young people and University students in particular, are known to be vulnerable for developing mental disorders. This study aims to examine the mental health social and emotional well-being and perceived burdens of University students during COVID-19 pandemic lockdown in Germany.

Materials and Methods: This cross-sectional and anonymous online survey among University students assessed mental health status with standardized measures (depressive symptoms, alcohol and drug consumption, and eating disorder symptoms), attitudes toward the COVID-19 pandemic and perceived burdens, and social and emotional aspects of the pandemic (social support, perceived stress, loneliness, and self-efficacy).

Results: In total, N = 3,382 German University students participated. Nearly half of the students (49%) reported that they are worried or very much worried about the COVID-19 pandemic. The majority supports the governmental lockdown measures (85%). A Patient Health Questionnaire-9 (PHQ-9) sum score of 10 or above, indicating clinically relevant depressive symptoms, was reported by 37% ( n = 1,249). The PHQ-9 sum score was on average 8.66 ( SD = 5.46). Suicidal thoughts were indicated by 14.5% of the participants. Levels of depressive symptoms differed significantly for the different self-rated income changes during the pandemic (increase, decrease, no change in income). Further, levels of depressive symptoms and suicidal ideation differed significantly for students from different faculties. Multiple regression analyses revealed that not being a parent, having no indirect social contact one or two times a week, higher perceived stress, higher experienced loneliness, lower social support, and lower self-efficacy significantly predicted higher scores of depressive symptoms, also higher hazardous alcohol use, and higher levels of eating disorder symptoms. Other aspects of lifestyle such as social and cultural activities, dating, and hobbies were reported to be negatively affected during the pandemic.

Conclusion: The present study implies that University students are vulnerable and due to elevated depressive symptoms at risk, being hit hard by the pandemic, but are in general coping adaptively. Low-threshold online interventions promoting help-seeking and also targeting various mental health conditions might bridge the gap the COVID-19 pandemic opened up recently.

Introduction

It is widely known that 75% of all severe mental illnesses occur before the age of 24 ( 1). Students in particular seem to have an increased risk of developing mental health problems [e.g., ( 2- 4)]. Academic pressure ( 5), financial worries ( 6), and fear of the future ( 7) are just some of the stressors in everyday student life that can promote the occurrence of a mental illness.

Due to the outbreak of the COVID-19 virus ( 8), which occurred in China for the first time at the end of 2019 and which has now expanded into a global pandemic ( 9), another stress factor for the mental health of students was added. Students around the globe are affected by the pandemic in various areas of their life, but especially due to closing of campuses and face-to-face (f2f) teaching being replaced by online formats, reduction or elimination of social contacts and cultural activities.

Over the last months, a number of empirical studies in various countries has investigated the influence of the pandemic on students, attempting to answer the "timely call for action to further research on students' mental health" ( 10). A longitudinal study showed that Chinese students between the ages of 12 and 21 reported stronger signs of psychological stress than other age groups ( 11). A cross-sectional study from the UK replicated these findings; increased depression and anxiety were associated with being young, but also with being female, living alone, and being in a medical risk group ( 12). Another Chinese study in college students revealed that 24.9% of the 7,143 participants reported fear of the COVID-19 virus ( 13). The reported COVID-19 related stressors, which were associated with higher levels of anxiety in students, were a. financial turmoil, b. changes in daily life, and c. academic delays ( 12). A survey in Turkish students showed that 38% of respondents were worried about COVID-19 ( 14). Further, Greek students reported increased levels of anxiety (42.5%), depression (74.3%), and suicidal thoughts [63.3%; ( 15)].

Our present survey aims to provide a comprehensive overview about how the pandemic is affecting University students. University students are in general at risk for developing common mental health disorders around the globe ( 16- 19) therefore screening instruments for depressive symptoms, alcohol and drug consumption, and eating disorders symptoms had been included. Addressing especially pandemic-related potential additional stressors (affecting individuals via lockdown measures), the concepts of social support ( 20), loneliness ( 21), self-efficacy ( 22, 23), perceived stress and resilience ( 24) had been included in the assessment for this explorative study. Further, there is a growing literature body on medical students' mental health [e.g., ( 25)], but comparably little is known about other faculties' students mental health or about a comparison between faculties. Since curricular organization (e.g., requirements regarding mandatory courses and hence the impact on students' life) differ between faculties, it seems to be important to assess these parameters.

To our knowledge the present study about mental health status and COVID-19 pandemic aspects among University students in the University of Leipzig is the first in Germany-except for a survey of the University of Konstanz, Germany, which was, however, conducted with the main focus on students' experience with digital teaching ( 26). While in this study, the majority of the participants (74%) reported that all their planned lectures took place, the students reported both positive and negative side effects of digital teaching, with flexibility being a positive (60%) and lack of social dialogue with other students (80%) being a negative effect. The University of Leipzig with ~30,000 students and 14 faculties, ranging from medicine to theology, can be considered representative for a full-scale University in Germany and Europe. This study aims to investigate the mental health status and perceived burdens of University students during COVID-19 pandemic lockdown in March and April 2020 in Germany in an anonymous online survey. Further, potential predictors of mental health status will be investigated exploratively.

Lockdown measures in Germany in spring 2020 were comparable to other European countries, e.g., Italy, Spain, or Great Britain. Students had been asked to answer retrospectively how they experienced this time period. At the time point of the survey there were still several lockdown measures in place, such as forbidden or limited mass or group events, wearing masks, social distancing, and tests for contact person.

Materials and Methods

Participants and Procedure

The cross-sectional study was conducted online in July and August 2020, during the last weeks of the ongoing summer semester (and before the exam period). A total of N = 3,382 University students (15% of all students at the University of Leipzig) completed the online survey. The survey was set up in the online-survey-tool LimeSurvey ® (Version 3.22.27) in German and English language. All students at the University were invited via email and the social media channels of the University to participate. All participants provided informed consent prior to participation. The only inclusion criterion was being currently enrolled as a student, there were no exclusion criteria. The Ethics Committee of the Medical Faculty, University of Leipzig, waived ethical approval for this study because of anonymity of the survey (06-22-2020).

Measures

Respondents were asked about socioeconomic information (their faculty, income, and change in income, residential situation, relationship status, migration status, and being parent), chronic physical illness status, times of personal and indirect social contact and their media, and social media use. In addition, the following measures were used:

COVID-19 Pandemic: Attitudes and Perceived Burdens

University students were asked about their attitudes toward the COVID-19 pandemic, psychosocial consequences and estimation of individual proximity of the pandemic as well as perceived burdens due to the regulations and lockdown measures. Additionally, positive and negative aspects of the pandemic were assessed in free text format and whether or not stockpile behavior was present. Items were based on an existing questionnaire battery previously used in a cohort study and adapted for the pandemic and lockdown situation ( 27).

Mental Health Measures

Depressive symptoms over the past 2 weeks were assessed with the Patient Health Questionnaire-9 [PHQ-9; ( 28)]. Symptoms were rated on a 4-point Likert scale from 0 = "not at all" to 3 = "nearly every day." The total sum score ranges from 0 to 27, with higher scores indicating higher levels of depressive symptoms.

Further, respondents were asked about lifetime mental disorders (psychiatric diagnoses) as well as past and current treatments for mental disorders.

Alcohol and drug consumption was assessed using the Alcohol Use Disorders Identification Test [AUDIT-C; ( 29)]. Respondents were asked to report the frequency for having alcoholic drinks on a 5-point Likert scale ranging from "never" to "4 or more times a week." Further, they were asked about the number of standard drinks on a typical day when drinking. The subscale "Hazardous alcohol use" had been calculated. With respect to the special situation of the COVID-19 pandemic, a new item was added, asking respondents for a potential change in drinking behavior during the COVID-19 pandemic (no change, drinking less, drinking more). To assess drug consumption, the AUDIT items and the additional item on change in consumption were rephrased to "drug or substance use."

The Short Evaluation of Eating Disorder [SEED; ( 30)] was used to investigate key eating disorder symptoms, except for weight and height. There are five items with different answer cues. "Are you afraid of becoming fat or gaining weight?" is answered on a 5-point Likert scale from 0 = "not at all" to 4 = "constantly." Four items are asking about body perception and body image, e.g., "In what way do you perceive your body?" with a 5-point Likert scale with answers ranging from 1 = "much too thin" to 5 = "much too fat." In the present analysis the calculation of the severity index for anorexia symptoms has not been applied, as weight and height had not been assessed. Items will be analyzed descriptively. The severity index for bulimia nervosa symptoms (BN-TSI) had been calculated.

Additionally, respondents were asked if their body weight had changed during the pandemic and if they attributed changes in body weight to the pandemic and lockdown situation.

Social and Emotional Aspects of the COVID-19 Pandemic

Social support was assessed using the ENRICHED Social Support Inventory [ESSI; ( 31)] with five items rated on a 5-point Likert scale from 1 = "none of the time" to 5 = "all of the time" with the total score ranging from 5 to 25. Higher scores indicate a higher level of social support.

Experienced loneliness was assessed with the UCLA 3-Item Loneliness Scale ( 32). Items are answered on a 4-point Likert scale ranging from "never" to "often," with higher values indicating more experienced loneliness.

The General Self-Efficacy Scale [GSE; (33)] assesses with ten items the general sense of perceived self-efficacy in regards to coping with daily hassles and adaptation after experiencing stressful life events. Answering format was on a 4-point Likert scale from 1 = "not true at all" to 4 = "exactly true" to statements like: "If someone opposes me, I can find the means and ways to get what I want." Items are added to a score from 10 to 40. Higher values indicate higher self-efficacy.

The Brief Resilience Scale [BRS; (34)] was administered to measure resistance to illness, adaptation, and thriving, the ability to bounce back or recover from stress on six items with a 5-point Likert scale from1 = "strongly disagree" to 5 = "strongly agree." A mean score is calculated, with higher values indicating higher levels of resilience.

The Perceived Stress Scale [PSS-4; (35)] assesses with four items the extent to which individuals appraise situations in their lives as excessively uncontrollable and overloaded. Statements like "In the last month how often have you felt you were unable to control the important things in your life?" were answered on a 5-point Likert scale from 0 = "never" to 4 = "very often." Higher sum scores indicate more perceived stress.

Frequency of personal or indirect contacts during the period of contact ban (March and April 2020) was measured with items developed by the research team asking to rate the frequency of contacts, e.g., "How many times per week did you personally meet with people (family members, friends, neighbors, etc.) beside your own household?" or "How many times per week did you have indirect contact, e.g., via phone, with other persons (family members, friends, neighbors, etc.) beside your own household?" on a 6-point Likert scale from 1 = "not at all" to 6 = "multiple times a day."

Further, students were asked to report the extent to which various aspects of their lifestyle (social and cultural activity, healthy eating, dating behavior, and sexual activity) were affected by the governmental restrictions during lockdown.

Statistical Analysis

Statistical analyses were performed using IBM SPSS Statistics version 26.0. A two-tailed α = 0.05 was applied to statistical testing. First, descriptive statistics were performed for socioeconomic variables, attitudes toward the COVID-19 pandemic and perceived burdens, mental health status measures, and ratings on social and emotional aspects of the pandemic. Second, a one-way ANOVA was performed to assess differences in depressive symptoms (PHQ-9 sum score) between three groups of students with different self-rated income changes due to the COVID-19 lockdown (no change, decreased income, and increased income).

Also, a one-way ANOVA was performed to test potential differences between students with different faculty affiliations in PHQ-9 sum score in an explorative way, as curricular organization varies substantially between faculties. An asymptotic Kruskal-Wallis- H-test was conducted to test if the number of students answering the PHQ-9 item 9 (suicidality) ≥1 differed between the Humanities, Medicine, Natural Science, and Social Studies faculties. Also, a t-test was performed to test potential differences in the mean PHQ-9 sum score between students being enrolled in two or more than two faculties and students being enrolled in only one faculty; and a Mann-Whitney- U-test to test potential differences in the number of students answering PHQ-9 item 9 ≥ 1 between between the aforementioned two groups.

A multiple linear regression was calculated to predict depressive symptoms (PHQ-9 sum score) based on socioeconomic variables (marital status, residential relationship, being parent), self-rated number of direct and indirect contacts, perceived stress (PSS-4), loneliness (UCLA-3), social support (ESSI), and self-efficacy (GSE). Categorical variables with more than two categories were either dichotomized (marital status, residential status, being parent) or recoded into dummy variables (direct and indirect contacts). All predictor variables were entered simultaneously. The assumption of multicollinearity was not violated (Variation Inflation Factor [VIF] ≤ 10; correlation matrix check [ r ≤.85]). All effect sizes were interpreted as suggested by Cohen ( 36). Further, two multiple linear regression analyses were calculated to predict alcohol consumption and bulimia nervosa symptom severity based on socioeconomic variables (marital status, residential relationship, being parent), self-rated number of direct and indirect contacts, perceived stress (PSS-4), loneliness (UCLA-3), social support (ESSI), self-efficacy (GSE) and depressive symptoms (PHQ-9 sum score).

Results

Sociodemographic characteristics are displayed in Table 1. Of the N = 3,382 participating students, 70.2% were female, 28.6% male, and 1.2% diverse with an age range of 17-61 years ( M = 23.98, SD = 4.66). Next to the N = 3,382 participating students, N = 491 were drop-outs. Socioeconomic data was available of N = 256 of the drop-outs. There were significant differences between the drop-outs with socioeconomic data ( N = 256) and completers ( N = 3382) regarding migration status [16% in drop-outs, 5% in analyzed sample, χ ²(1) = 44.117, p < 0.001), relationship status [59% single in drop outs vs. 50% single in analyzed sample; 33% living in a partnership in drop-outs vs. 44% living in a relationship in analyzed sample; χ ²(5) = 64.869, p < 0.001]. Other socioeconomic data (age, gender, being parent, faculty enrolment, and income) did not show any significant differences.

Table 1. Characteristics of the total sample ( N = 3,382).

In total, n = 551 (16.3%) indicated that they suffered from a chronic medical condition. Regarding their financial situation, n = 2,699 (79.8%) of the students reported that their financial situation during the COVID-19 pandemic remained stable, n = 551 (16.3%) of the respondents indicated that it had worsened, and n = 132 (3.9%) reported an increase. The most frequently reported reason for a decrease in income was job loss, including failure of contract renewal/extension ( n = 380, 68.9%). The most frequently reported reason for an increase were additional or new jobs (e.g., in pandemic management) or salary increases ( n = 105, 79.5%).

A one-way ANOVA was conducted to compare the three groups of students with different self-rated income changes (no change, decreased income, increased income) on their levels of depressive symptoms (PHQ-9 sum score). These groups showed the following PHQ-9 scores: no change: M = 8.38, SD = 5.32; decreased income: M = 10.23, SD = 5.87; and increased income: M = 7.92, SD = 5.34. The level of depressive symptoms differed significantly between the three groups, Welch's F(2, 24.757) = 317.441, p < 0.001, η ² = 0.04. Post-hoc-analysis revealed that the significant main effect was based on higher PHQ-9 sum scores in the group of students reporting a decreased income. There was no significant difference between the group reporting no change and the group reporting increased income.

COVID-19 Pandemic: Attitudes and Perceived Burdens

In total, n = 1,658 (49.0%) reported that they were worried or very much worried about COVID-19, whereas, almost the same number ( n = 2,052, 60.7%) reported not to feel personally in danger at present. The vast majority of respondents ( n = 2,859, 84.5%) supported the governmental lockdown measures.

In total, n = 1,594 (47.1%) agreed or fully agreed to the statement that they were being hit hard by the COVID-19 pandemic and that governmental lockdown measures hit students particularly hard ( n = 1,472, 43.5%). Almost all respondents ( n = 3,243, 95.9%) disagreed with the statement that the pandemic was part of a larger conspiracy.

N = 427 (12.6%) reported stockpiling behavior when grocery shopping. N = 1,679 (49.6%) indicated to know at least one person being infected with COVID-19.

During the lockdown period in Germany, n = 1,572 (46.5%) did report not to have any direct personal contact to other people (beyond the ones living together), n = 1,339 (39.6%) indicated to have had personal contact one or two times per week and n = 471 (13.9%) three times or more per week; n = 2,813 (83.2%) reported to have indirect contact (e.g., phone or video calls) seven times or more per week.

Overall, n = 2,541 (75.1%) of the students indicated that they had experienced positive aspects during the COVID-19 pandemic, n = 3,150 (93.1%) reported that they experienced negative aspects. As positive aspects of COVID-19 pandemic on their personal life, more free time, less social pressure, higher flexibility due to digital teaching, less air pollution (as positive side effect of lockdown measures), more time to focus and reflect on "what really matters in life," were mentioned the most. The following negative aspects of COVID-19 pandemic on personal life were mentioned the most: financial problems/unemployment, missing friends and family, uncertainty of the future, impossibility to travel for vacation purposes/missing national and international traveling in general, and impossibility to travel for studying purposes (international internship or semester abroad).

Mental Health Measures

More than one third of the students reported a PHQ-9 sum score of 10 or above, indicating clinically relevant symptoms ( n = 1,249, 37.0%). The PHQ-9 sum score of the total sample was on average 8.66 ( SD = 5.46). Almost every seventh student reported suicidal thoughts on at least several days per week over the past 2 weeks ( n = 490, 14.5%).

N = 644 (19.0%) of the students reported to have been diagnosed with a mental disorder in the past: unipolar depression ( n = 334, 9.9%), bipolar disorder ( n = 12, 0.4%), anxiety disorder ( n = 228, 6.7%), obsessive-compulsive disorder ( n = 46, 1.4%), personality disorder ( n = 62, 1.8%), eating disorder ( n = 127, 3.8%), and others ( n = 93, 2.7%).

Of all students reporting a mental disorder ( n = 644), half of them ( n = 378, 58.7%) indicated not to receive any treatment, whereas n = 56 (8.7%) currently took medication, n = 145 (22.5%) were in psychotherapeutic treatment, and n = 65 (10.1%) reported to take both medication and receiving psychotherapy.

A substantial amount of the students ( n = 1,130, 33.0%) reported binge eating at least once per week, n = 117 (3.5%) reported vomiting as compensatory behavior minimum once per week, n = 34 (0.1%) usage of laxative minimum once per week, n = 844 diet or calorie food (25.0%) minimum once per week, and n = 941 (28.0%) reported excessive exercising minimum once per week. The bulimia nervosa severity index (BN-TSI, SEED) of the sample was M = 0.35 ( SD = 0.44) ( N = 3,380). Further, n = 1,548 (45.8%) reported weight changes during the COVID-19 lockdown, n = 885 (26.2%) reported weight gain, n = 663 (19.6%) weight loss. Of those reporting any weight change, over 63% attributed this to the pandemic and lockdown.

Reported alcohol and drug consumption are displayed in Table 2.

Table 2. Alcohol and drug consumption and changes during COVID-19 pandemic.

To investigate potential differences in faculty affiliation and PHQ-9 sum score, a one-way ANOVA was conducted to compare students of the four major faculty groups (Humanities, Medicine, Natural Science, and Social Studies) regarding their levels of depressive symptoms (PHQ-9 sum score). The following mean PHQ-9 sum scores were found: Humanities M = 10.06 ( SD = 5.65), Medicine M = 6.64 ( SD = 4.94), Natural Science M = 8.84 ( SD = 5.57), and Social Studies M = 8.4 ( SD = 5.23). The level of depressive symptoms differed significantly between the four groups, Welch's F(4, 1193.105) = 42.995, p < 0.001, η ² = 0.09. Further, an asymptotic Kruskal-Wallis- H-test was conducted to test if the number of students answering the PHQ-9 item 9 on suicidal thoughts ≥1 (see Table 3) differed between the Humanities, Medicine, Natural Science, and Social Studies faculties. There was a statistically significant difference in the number of students answering PHQ-9 item 9 ≥ 1 between the four groups, H = 29.018, p < 0.001 (see Table 3).

Table 3. University faculties, PHQ-9 sum score and PHQ-9 item 9 on suicidal thoughts.

An exploratory multiple regression analysis examined predictors of depressive symptomatology (see Table 4). Not being a parent ( p = 0.010), having no indirect contact one or two times a week ( p = 0.005), higher perceived stress ( p < 0.001), higher experienced loneliness ( p < 0.001), lower social support ( p < 0.001), and lower self-efficacy ( p < 0.001) significantly predicted higher levels of depressive symptoms. All other predictors were unrelated to depressive symptoms (all p > 0.05). The overall model fit was R ² = 0.523 (adjusted R ² = 0.521).

Table 4. Linear regression analysis for predictors of depressive symptoms (PHQ-9).

Further, two multiple regression analyses examined predictors of reported alcohol consumption (AUDIT-C, hazardous alcohol use subscale) and predictors of bulimia nervosa severity index (BN-TSI, SEED) (see Supplementary Tables A,B, Supplementary Material). Not being a parent ( p < 0.001), having no direct contact ( p < 0.001) or direct contact one or two times a week ( p = 0.01), no indirect contact ( p = 0.16), higher perceived stress ( p = 0.001), higher experienced loneliness ( p < 0.001), lower social support ( p < 0.001), lower self-efficacy ( p = 0.001) and higher depressive symptoms ( p = 0.004) significantly predicted higher levels of reported alcohol consumption. All other predictors were unrelated to reported alcohol consumption (all p > 0.05). The overall model fit was R ² = 0.061 (adjusted R ² = 0.06). Not being a parent ( p = 0.018), higher perceived stress ( p = 0.001), lower self-efficacy ( p = 0.007) and higher depressive symptoms ( p < 0.001) significantly predicted higher severity of bulimia nervosa related symptoms. All other predictors were unrelated to bulimia nervosa severity index (all p > 0.05). The overall model fit was R ² = 0.206 (adjusted R ² = 0.203).

Social and Emotional Aspects of the COVID-19 Pandemic

Descriptive statistics of perceived stress, social support, loneliness, and self-efficacy are displayed in Table 1.

When being asked how much the restrictions affected certain aspects of lifestyle, the majority of students rated that their social ( n = 2,357, 80.2%) and cultural activities ( n = 2,662, 90.7%), hobbies ( n = 1,302, 44.3), and dating behavior or partner search ( n = 2,208, 75.2%) were significantly restricted during the COVID-19 pandemic as compared to before. Restrictions were rated not to affect or not being relevant for the following areas: healthy eating ( n = 2,693, 91.7%) and sexual activity ( n = 1,716, 58.3%).

Regarding media use, the internet and social networks were rated to be used daily by n = 2,346 (69.4%) of the students, music streaming services by n = 1,206 (35.7%), and video streaming by n = 356 (10.5%) on a daily basis. Reported usage of messenger services (daily by n = 3,088, 91.3% of the respondents) was evaluated as increased during the pandemic.

Discussion

The 3,382 participants in this online survey provide a unique insight into mental health, attitudes and social and emotional aspects regarding COVID-19 pandemic of University students.

It can be summarized based on the results, that the University students in this sample seem to cope adaptively with the pandemic and drastically changed life circumstances. Nevertheless, the COVID-19 pandemic appears to be a significant burden and students seem to suffer from lockdown measures.

The sample can be considered as representative for German University students, as the University of Leipzig (second oldest University in Germany) is a large full-scale University, providing an array of all faculties and a remarkable sample size. Existing differences between drop-outs and completers can be considered as not relevant for the performed analysis and not hampering the generalizability of the results. Minor differences between the analyzed sample and all University students exist regarding gender (70% female in this sample vs. 60% female students being enrolled at the University of Leipzig) and migration status [5% vs. 11% of the students enrolled ( 37) statista.com, 2018]. The University of Leipzig has, compared to the average of other Universities in Germany more female students ( 38). Further, the students in the present sample reported more income, especially in the category 500-1000 Euro compared to German University students overall (34% in Germany vs. 41% in the present sample) ( 39). Further, the mental health status of this sample seems highly comparable to previous epidemiological studies in this population, which estimate that 12-46 % of all University students are affected by mental disorders in any given year ( 40, 41).

For the majority of the students (80%) the financial situation did not change due to the pandemic. Nevertheless, for those where it deteriorated, the consequences might be extensive. Post-hoc analysis revealed a significant difference in depressive symptoms in this sample for the three groups of students: where the income had stayed stable, income had increased, and income had decreased. Next to a major change in social life due to governmental restrictions, financial challenges seem to be a major stress factor for students indeed. It has long been known that part-time jobs (next to state funding and parental support) play a key role in financing the livelihood of students ( 42). But, during the lock-down situation in Germany over 800.000 part-time jobs were abolished. About 120,000 students applied for state funded emergency aid between June and September of 2020 ( 43). The pandemic certainly took a major toll on the financial situation of students, next to other issues. Consistent with present results a job loss can lead to lower psychological well-being ( 44).

COVID-19 Pandemic: Attitudes and Perceived Burdens

Half of the students in this survey reveal that they are worried or very much worried about the COVID-19 pandemic, but not feeling in personal danger. This mirrors the overall picture in most European countries during spring and summer 2020.

Also, half of the sample frankly indicated that the perceived burden by the pandemic and the lockdown measures was very high. It seems that direct and indirect contacts had been restricted tremendously, as governmental restrictions have prescribed.

Mental Health Measures

The level of depressive symptoms in this sample is comparable to recent instigations of University students in other countries ( 45), or even higher in this sample compared to other studies ( 46), whereas, the sample size here was enormously smaller ( N = 369) ( 46).

The mean PHQ-9 sum score in this sample is to be considered as status with mild depressive symptoms (PHQ-9 sum score between 5 and 9), above 10 is considered to represent clinically relevant depressive symptoms ( 28). Every seventh student in this sample reported suicidal thoughts over the past 2 weeks on at least several days, this is comparable to other studies in this population [e.g., ( 47)], but remarkably higher than in the general population ( 48). Students in the Humanities faculties scored highest on depressive symptoms and on suicidal ideation as well, medical students the lowest.

Further, half of the students who indicated that they had been diagnosed with any mental disorder in the past, reveal that they did not receive any treatment. This probably also holds true for all subclinical forms of mental disorders (e.g., in this sample sublinical levels of depressive symptoms and a substantial, (but comparable to other studies) amount of subclinical eating disorder symptoms ( 49). This substantial gap between present symptoms of mental disorders and received treatment could be filled by available low-threshold online interventions, especially during this pandemic ( 46).

Regarding alcohol and drug consumption, the results reveal that a substantial proportion (appr. 80 %) of the respondents indicate that they consumed less or equal amounts, which could be explained by fewer occasions (e.g., parties or events) and potential places to meet (e.g., bars and restaurants) due to lockdown measures and safety issues. Next to this, every 5th student of the sample reported that they drank more alcohol, presumably alone and serving as a compensatory means during a time of contact bans and reduced social activities. This could eventually lead to alcohol dependency in the medium or long-term for a subset of individuals and should therefore be addressed by preventive (online) efforts.

The regression analyses surprisingly revealed that being a parent seems to be a protective factor for depressive symptom load, alcohol consumption and some eating disorder symptoms in University students. This contradicts some widespread beliefs that it is a dual burden for parents in general to work/study in home office and to take care of children, when day care and schools are being closed. Marital status (being in a relationship vs. not) and residential status (living alone vs. living in a shared flat) seem not to be associated with depressive symptoms, alcohol consumption and bulimia nervosa symptoms. As expected, perceived high stress, high experienced loneliness, low rated social support and fewer self-efficacy beliefs are predicting higher depressive symptoms, also higher alcohol consumption and higher eating disorder symptoms in this sample. Also, neither form of contact (direct and indirect) beyond the people living in the same household and close family seem to be associated with higher depressive symptoms, which is in line with the main-effect and buffering model in the social support theory by Cohen ( 20, 50). The main effect model assumes a generally positive influence of social integration on psychological well-being ( 20). In contrast, the buffering effect model assumes a mitigating effect of the consequences of stress, through social support, in times of high psychological stress.

Even without a global pandemic, students' mental health care situation seems challenging ( 16, 51- 53) with several unmet needs ( 54), it is even described as a "student mental health crisis" in some countries ( 55). Nevertheless, this pandemic could be an opportunity to improve mental health services as well ( 56).

Social and Emotional Aspects of the COVID-19 Pandemic

Levels of perceived stress, social support, loneliness, and self-efficacy were all elevated, but comparable to other studies in University students [e.g., ( 46) reporting elevated PSS-4 scores >8 in half of the sample of US students]. University students are being hit hard in their daily social life by lockdown measures, as they prevent the majority of social experiences. They are in turn essential for perceived autonomy, competence, and relatedness. A lack of these important components of self-determination might lead to decreased well-being ( 57), under non-pandemic conditions and is present in this study presumably under pandemic-conditions as well.

Further, under non-pandemic conditions peer support, social support ( 58, 59) and self-efficacy ( 60) are next to other factors crucial for general well-being, life satisfaction, and also academic performance ( 60- 62) especially in University students. Due to the lockdown measures and social distancing, especially the peer and social support (rather than family support) dropped out, which can explain the present results. As expected, the respondents in this sample reported a medium to high usage of social media and online resources, also an increased usage of IT technologies (as also expected and prominent in the majority of the general public) during the pandemic. Next to the advantages of an increased "being online," the lockdown with the attached loss of social contacts and a regular daily routine, the digitalization of University teaching has been and still represents an unprecedented challenge for students.

Limitations

The present study has a remarkably high sample size and applies to a vast majority standardized measurements. Due to the cross-sectional study design, no causal inferences can be drawn. Several statistical tests had been applied, but due to the explorative character of the analysis multiple testing is considered not to be an issue.

Conclusion

University students are, besides a general adaptive coping with the COVID-19 pandemic and the associated lockdown, a vulnerable group and are at risk for mental disorders. This study implies that Universities and health care providers need to take action to continuously assess, prevent, identify, and manage mental health conditions of University students in an adequate manner, as other studies among University students in China claimed already ( 45). Supporting the health, mental health and well-being of all students should be of high priority in pandemic and post-pandemic times ( 63). Online programs, especially focusing on help-seeking behavior ( 64), chat interventions (e.g., with messenger services) and other low-threshold support programs or self-management interventions seem promising, easy to implement and are evidence-based for nearly all common mental health conditions.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors upon reasonable request, without undue reservation.

Ethics Statement

The Ethics Committee of the Medical Faculty, University of Leipzig, waived ethical approval for this study because of anonymity of the survey (22.06.2020). The patients/participants provided their written informed consent to participate in this study.

Author Contributions

EK, SB, and CR-K designed the study. RM, SB, and EK performed the statistical analysis. S-LK organized the recruitment and contributed to the literature overview. EK, RM, SB, S-LK, and CR-K discussed the results and contributed to the final manuscript. All authors have approved the final manuscript.

Conflict of Interest

CR-K received lecture honoraria from Recordati and Servier outside and independent of the submitted work.

The remaining 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.

Acknowledgments

We acknowledge support from Leipzig University for Open Access Publishing.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2021.643957/full#supplementary-material

References

9. World Health Organization. Coronavirus Disease (COVID-19) Outbreak. Geneva: WHO (2020).
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26. Lörz M, Marczuk A, Zimmer L, Multrus F, Buchholz S. Studieren unter Corona - Bedingungen: Studierende bewerten das erste Digitalsemester. Deutsches Zentrum für Hochschul- und Wissenschaftsforschung (DZHW) (2020).

43. dpa. Fast eine Milliarde Euro Schulden in Corona-Krise: Studienkredite. Forschung und Lehre (2020).

46. Aiyer A, Surani S, Gill Y, Iyer R, Surani Z. Mental health impact of Covid-19 on students in the USA: a cross-sectional web-based survey. J Depress Anxiety. (2020) 9:375. doi: 10.35248/2167-1044.20.9.375
CrossRef Full Text

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Mental Health, Social and Emotional Well-Being, and Perceived Burdens of University Students During COVID-19 Pandemic Lockdown in Germany

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Background: The COVID-19 pandemic has been affecting everyone's daily life in unknown measures since its outbreak. Nearly all Universities around the globe were affected. Further, young people and University students in particular, are known to be vulnerable for developing mental disorders.

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

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School resources from Mental Health Awareness Week and beyond!

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For teachers to be able to provide wellbeing support to their students, they need to refill their own wellbeing mugs. This Mental Health Awareness Week, we've gathered a range of resources to support both teacher and student mental health.

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"I recommend it for those who are entering the field of student conduct practice as well as for those who are seeking more depth in their understanding of the student conduct process." --The Review of Higher Education"Includes the thinking of notable experts in the profession and offers a smorgasbord of practical, insightful, up-to-date information for student conduct and larger student affairs community.

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Recent studies reveal that the mental health impact of the COVID-19 pandemic is particularly significant on students preparing to transition into college. Most notably, 61% of teenagers said that the pandemic has increased their feelings of loneliness. And 7 out of 10 teenagers reported that they struggle in some way with mental health challenges. Additionally, many said they experience excessive stress (45%) and depression (43%). As a consequence, this mental health crisis has changed the way students evaluate colleges and universities. Now, many young people are paying more attention to the campus mental health resources offered when deciding which school they will attend.

A recent survey of prospective college students found that 50% have changed their views on the importance of mental health support for students. Additionally, 60% of prospective students said that mental health services are a very important factor when selecting which school they will attend. Although 74% of students indicated that their opinions haven't changed specifically because of COVID-19, the pandemic has clearly increased mental health awareness when it comes to enrollment.

Why higher education should invest in student mental health services

A December 2020 survey conducted by the American Council on Education (ACE), revealed that 68% of university presidents expressed that the mental health of their student population is one of their most pressing issues. According to the American Psychological Association (APA), 58% of college presidents said they would hire additional staff members in counseling centers, if possible. Campus counseling centers are beneficial but not a one-size-fits-all solution to student mental health.

Consider these reasons that higher education should invest in campus mental health and student wellness:

1. Improve student academic performance

Mental health problems can impact the academic performance and success of a college student. Poor mental health contributes to lack of motivation and problems focusing which can lead to failing grades. Campus-wide mental health resources for students to seek support could be the key to their academic success. A national survey found that 66% of college students felt counseling services improved their academic performance.

2. Support student mental well-being

College is already a stressful environment for students, especially after a year-long pandemic. As students return to campus, there will be a wide variety mental health concerns that can't be solved with traditional counseling alone. Active Minds found that 39% of students struggle with a significant mental health issue while in college. Providing students, faculty, and staff with proper tools on how to manage mental and emotional well-being will help create a supportive campus culture.

3. Suicide prevention

The Jed Foundation (JED) recommends a community-based model for protecting student emotional health and suicide prevention on campus. A number of students are returning to campus having lost a loved one from COVID-19 or still suffering from mental health challenges, such as depression, from the pandemic. A report from the Centers for Disease Control and Prevention (CDC) found that one out of 4 people aged between 18 and 24 considered suicide in the last 30 days. In times like these, it's essential to have a campus that promotes suicide prevention and educates everyone on ways to help those who are struggling.

4. Increase student retention

Higher education will likely look very different in the years to come following COVID-19. According to the American Council of Education, enrollment is expected to decrease, which could greatly impact colleges and universities. The National Alliance on Mental Illness (NAMI) also found that 64% of young adults who dropped out of college dropped out due to mental illness. Data also shows that counseling services have a positive impact on retention. As measured by student self-report, 63% of students who received counseling stated that counseling services helped them stay in school. It's crucial for higher education to prioritize student mental health. Otherwise, schools risk decreasing graduation rates, enrollment, and academic success.

As prospective students now place a higher priority on mental health services before they even set foot on campus, an investment in mental health can impact future enrollment, current student academic performance, and retention rates.

Supporting college mental health on and off campus

As campuses plan for future semesters, colleges and universities must take into account that the needs of students have changed since the start of COVID-19. A survey from Healthy Minds found that 60% of college undergraduates were having trouble accessing any type of mental health care.

College students now have a greater demand for mental health resources that are accessible on and off-campus. Although 43% of students still find in-person counseling centers important, 46% of students said virtual counseling is a useful mental health resource. Additionally, both the CDC and American College Health Association ( AHCA) recommended that higher education find ways to offer both in-person and virtual counseling services to support student well-being.

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Importance of Mental Health Services on College Campuses - TimelyMD

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Recent studies reveal that the mental health impact of the COVID-19 pandemic is particularly significant on students preparing to transition into college. Most notably, 61% of teenagers said that the pandemic has increased their feelings of loneliness. And 7 out of 10 teenagers reported that they struggle in some way with mental health challenges.

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

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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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"I recommend it for those who are entering the field of student conduct practice as well as for those who are seeking more depth in their understanding of the student conduct process." --The Review of Higher Education"Includes the thinking of notable experts in the profession and offe…

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Social & Emotional Learning (SEL)

Teachers in the early grades can guide young students to better understand, express, and handle their emotions.

Allison Shelley / American Education

Social and emotional learning is often spoken of as the "missing piece" in education, but integrating SEL into academics is essential to a healthy, harmonious classroom. Checking in emotionally with students is a simple, effective way for teachers to connect with students and begin to equip them with lifelong tools to communicate their feelings and needs. As students are grappling with the major changes and potential traumatic experiences caused by the pandemic, this practice is more important than ever.

While teaching at an urban Title 1 elementary school in Central Los Angeles, I witnessed firsthand the power of SEL and how crucial emotional skills development and practicing emotional check-ins were to my students' success. At the beginning of the 2019-20 school year, getting through a lesson while putting out fires was a constant challenge. My first-grade students had big emotions but lacked the words to communicate their feelings and needs. Their frustration caused multiple meltdowns, and academic collaboration usually ended up in arguments or even physical fights.

Age-Appropriate SEL

According to the Los Angeles Unified School District, many of the students in the district were at risk for traumatic stress before the pandemic, so I knew I had to provide a safe, trauma-informed classroom space. I also knew I had to integrate foundational SEL skills in ways that were appropriate for my students' age.

Simply put, being able to first identify and then express how they feel sets children up to successfully manage and cope with emotions. These skills are the foundation of emotional literacy, and we need them at any age.

Understanding Moods and Feelings
Courtesy of Julia Richardson
To lay this groundwork, I began inviting students to share how they felt and why, if they were comfortable, during our daily morning circle. To teach my students the vocabulary to identify and express their feelings, I designed a Feelings Chart labeled with a vocabulary of emotions and accompanying photos of children's facial expressions.

I adapted the visual concept of the Yale Center for Emotional Intelligence Mood Meter, a tool for identifying and sorting emotions for people of all ages. The Mood Meter sorts emotions on a gradient scale ranging from high to low energy, pleasant to unpleasant, and gives equal representation for positive and negative emotions.

While looking for ready-made flash cards or photos of children's emotional expressions for my chart to help my emerging readers, I was disappointed to find resources that depicted nearly all white children. I gathered an assortment of public domain photos to reflect the racial demographics of our Los Angeles population. Our Feelings Chart is sorted into four zones: high-energy pleasant yellow zone (energized, joyful, curious, enthusiastic); high-energy unpleasant red zone (angry, stressed, frustrated, nervous); low-energy pleasant green zone (at ease, content, grateful, serene); and low-energy unpleasant blue zone (tired, worried, down, sad). To create the color background, I cut out and pasted paint swatches together on poster board.

Increasing the Vocabulary of Emotions

After only two days, the majority of my students went from saying they felt "good" or "tired" to saying they felt "energized," "down," "serene," or "joyful." We talked about what the words meant, and my students worked together in groups to sort photos of children's facial expressions into the color zones. Once my students understood how to identify emotions, we talked about what strategies to use to positively shift how they feel in various situations: asking for help from an adult, taking a break in a dedicated calm classroom space, using words during a conflict, etc.

Gradually, I noticed this vocabulary showing up in students' conversations and collaboration. Arguments didn't solely end in students just walking away; with some support, they could talk it out and keep working together in class. After three months, we moved on to reflective listening. During circle time, students paired up with an elbow partner, and, using a visual anchor chart I created, they took turns expressing how they felt, mirroring their partner's language and recalling a time when they felt similarly, if possible.

Over the course of the year, I noticed the atmosphere of my classroom slowly transform. Our academic time became richer and significantly more cohesive. Some students stepped into the role of peer supporter using the work I had modeled for them, asking each other how they felt and offering helpful suggestions when they looked upset.

SEL and Classroom Management

There are huge implications in this related to class management. Devoting time to social and emotional subjects seemed to send the message to students that their emotions are valid and welcome in the classroom and that their emotional well-being is important. As we engaged in discourse, we created a language of understanding influenced by each community member.

During the first wave of the pandemic, when our school campus transitioned to online learning, my students continued using the vocabulary naturally from our Feelings Chart even without the visual aid. Students expressed that they felt disappointed because they couldn't see their friends or felt sad because they were lonely. We continued our practice of brainstorming strategies to feel better, and other students seamlessly stepped in to share ideas. This practice had become part of our classroom culture.

In-person classes are back in session for most schools, and who knows what students have encountered in the last year. According to the American Academy of Pediatrics, more than 140,000 children in the United States have lost a parent or grandparent caregiver to Covid-19, and countless others have lost vital supports while combating the ongoing stress, fear, grief, and uncertainty created by the pandemic.

Emotionally checking in daily with students allows educators to respond to students' trauma and get them the at-school support and counseling they need, work that I continue daily. I saw my students lean on these strategies we explored as a class while living through uncertainty and change, which speaks to the power of these practices-not only for young students but for students of all ages.

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Supporting Young Students' Emotional Well-Being

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Teachers in the early grades can guide young students to better understand, express, and handle their emotions.

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https://www.ncbi.nlm.nih.gov › pmc
Understanding Students' Mental Well-Being Challenges on ... - NCBI

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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://journals.sagepub.com › fullCOVID-19 and Student Well-Being: Stress and Mental Health during Return-to-School

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https://journals.sagepub.com › fullCOVID-19 and Student Well-Being: Stress and Mental Health during Return-to-School

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Despite relatively high levels of psychological distress, many students in higher education do not seek help for difficulties. This study explored undergraduate student understanding of the concepts of mental health and mental well-being and where undergraduate students would seek help for mental well-being difficulties. Semi-structured interviews were carried out with 20 undergraduate students from 5 different subject areas. Interviews were transcribed and thematically analysed. Results highlighted that the majority of participants viewed mental health and mental well-being as two distinct concepts but their views did not affect where they would seek help for mental well-being difficulties. Medical students reported public stigma relating to help seeking for mental well-being difficulties. Undergraduate students are most likely to seek help for mental well-being difficulties from peers, but whether this experience is useful is less clear. How such an approach impacts upon the individual from whom assistance is sought is also not well understood.

Acknowledgements

This research was conducted at the University of St Andrews.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The authors would like to thank the Medical School, University of St Andrews for funding this study.

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Understanding undergraduate student perceptions of mental health, mental well-being and help-seeking behaviour

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Despite relatively high levels of psychological distress, many students in higher education do not seek help for difficulties. This study explored undergraduate student understanding of the concepts of mental health and mental well-being and where undergraduate students would seek help for mental well-being difficulties.

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How children can be brave and support their friends mental health

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How children can be brave and support their friends mental health https://t.co/ZSCkqIMoHQ

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Most people face mental health challenges at one point or another in their lifetime. Occasional grief, stress, and sadness are normal. But if you're experiencing persistent or severe mental health challenges, it's time to get help.

"Help is available," advises Dawn Brown, director of information and engagement services at the National Alliance on Mental Illness (NAMI). "Whether you're feeling unsafe or a situation begins to escalate into a crisis, reaching out for help is important."

When should you get help?

The following symptoms might be signs of an underlying mental health condition:

thoughts of hurting yourself or others

frequent or persistent feelings of sadness, anger, fear, worry, or anxiety

frequent emotional outbursts or mood swings

confusion or unexplained memory loss

delusions or hallucinations

intense fear or anxiety about weight gain

dramatic changes in eating or sleeping habits

unexplained changes in school or work performance

inability to cope with daily activities or challenges

withdrawal from social activities or relationships

defiance of authority, truancy, theft, or vandalism

substance abuse, including alcoholism or use of illegal drugs

unexplained physical ailments

If you're thinking about hurting yourself or someone else, get help right away. If you have other symptoms on this list, make an appointment with your doctor. Once they've ruled out a physical basis for your symptoms, they may refer you to a mental health specialist and other resources.

Are you making plans to hurt yourself or another person? That's a mental health emergency. Go to a hospital emergency department or contact your local emergency services right away. Dial 911 for immediate emergency help.

Suicide prevention hotlines

Have you been thinking about hurting yourself? Consider contacting a suicide prevention hotline. You can call the National Suicide Prevention Lifeline at 800-273-8255. It offers 24/7 support.

There are many types of healthcare providers who diagnose and treat mental illness. If you suspect you might have a mental health condition or need mental health support, make an appointment with your primary physician or a nurse practitioner.

They can help you determine what type of provider you should see. In many cases, they can also provide a referral.

For example, they might recommend seeing one or more of the healthcare providers below.

Providers who prescribe medicine

Therapist

A therapist can help diagnose and treat mental health conditions. There are many different types of therapists, including:

psychiatrists

psychologists

psychoanalysts

clinical counselors

Therapists often specialize in certain areas, such as addiction or child behavioral issues.

Only some types of therapists prescribe medications. To prescribe medications, they need to be either a physician or nurse practitioner. In some cases, you may also see a physician's assistant or a doctor of osteopathic medicine.

Psychiatrist

If your doctor suspects you have a mental health condition that requires medication, they might refer you to a psychiatrist. They often diagnose and treat conditions such as:

depression

anxiety disorders

obsessive-compulsive disorder (OCD)

bipolar disorder

schizophrenia

Prescribing medications is often their primary approach to providing treatment. Many psychiatrists don't offer counseling themselves. Instead, many work with a psychologist or other mental health profession who can provide counseling.

Nurse psychotherapist

Nurse psychotherapists generally diagnose and treat psychiatric disorders. They may also treat other health conditions.

Nurse psychotherapists have an advanced nursing degree. They are trained as clinical nurse specialists or nurse practitioners. Clinical nurse specialists can't prescribe medications in most states. However, nurse practitioners can. They often use a combination of medications and counseling to treat patients.

Psychologist

If your doctor thinks you might benefit from therapy, they might refer you to a psychologist. Psychologists are trained to diagnose and treat mental health conditions and challenges, such as:

depression

anxiety disorders

eating disorders

learning difficulties

relationship problems

substance abuse

Psychologists are also trained to give psychological tests. For example, they might administer an IQ test or personality test.

A psychologist can potentially help you learn to manage your symptoms through counseling or other forms of therapy. In some states (Illinois, Louisiana, and New Mexico), they can prescribe medicine. However, when they can't, psychologists can work with other healthcare providers who can prescribe medications.

Providers who can't prescribe medicine

Marital and family therapist

Marital and family therapists are trained in psychotherapy and family systems. They often treat individuals, couples, and families who are coping with marital problems or child-parent problems.

Marital and family therapists aren't licensed to prescribe medication. However, they often work with healthcare providers who can prescribe medications.

Peer specialist

Peer specialists are people who've personally experienced and recovered from mental health challenges. They provide support to others who are going through similar experiences. For example, they may help people recover from substance abuse, psychological trauma, or other mental health challenges.

Peer specialists act as role models and sources of support. They share their personal experiences of recovery to give hope and guidance to others. They can also help people set goals and develop strategies to move forward in their recovery. Some peer specialists work for organizations as paid employees. Others offer their services as volunteers.

Peer specialists can't prescribe medications because they aren't clinical professionals.

Licensed professional counselor

Licensed professional counselors (LPCs) are qualified to provide individual and group counseling. They can have many titles, based on the particular areas they focus on. For example, some LPCs provide marriage and family therapy.

LPCs can't prescribe medication because they're not licensed to do so.

Mental health counselor

A mental health counselor is trained to diagnose and treat people coping with difficult life experiences, such as:

Mental health counselors provide counseling on an individual or group basis. Some work in private practice. Others work for hospitals, residential treatment centers, or other agencies.

Mental health counselors can't provide medications because they're not equipped with a license. However, many work with healthcare providers who can prescribe medications when needed.

Alcohol and drug abuse counselor

Alcohol and drug abuse counselors are trained to treat people with alcohol and drug addictions. If you've been abusing alcohol or drugs, they can help guide you on the path of sobriety. For example, they can potentially help you learn to:

Alcohol and drug abuse counselors can't prescribe medications. If they think you might benefit from medications, they might advise you to talk to your family doctor or nurse practitioner.

Veterans counselor

VA-certified counselors have been trained by the Department of Veterans Affairs. They offer counseling to military veterans. Many veterans return from service with injuries or stress-related illnesses. For example, you might come home with post-traumatic stress disorder (PTSD). If you're a veteran, a VA-certified counselor can help you:

VA-certified counselors can't prescribe medication. If they think you might need medication, they may encourage you to talk to your family doctor, nurse practitioner, or psychiatrist.

Pastoral counselor

A pastoral counselor is a religious counselor who is trained to provide counseling. For example, some priests, rabbis, imams, and ministers are trained counselors. They typically have a postgraduate degree. They often combine psychological methods with religious training to promote psycho-spiritual healing.

Spirituality is an important part of recovery for some people. If your religious beliefs are a pivotal part of your identity, you might find pastoral counseling helpful.

Pastoral counselors can't prescribe medication. However, some develop professional relationships with healthcare providers who can prescribe medications when needed.

Social worker

Clinical social workers are professional therapists who hold a master's degree in social work. They're trained to provide individual and group counseling. They often work in hospitals, private practices, or clinics. Sometimes they work with people in their homes or schools.

Clinical social workers can't prescribe medication.

If you start to experience symptoms of a mental health condition, don't wait for them to get worse. Instead, reach out for help. To start, make an appointment with your family doctor or nurse practitioner. They can refer you to a specialist.

Keep in mind that it can sometimes be challenging to find a therapist who meets your needs. You might need to connect with more than one therapist before you find the right fit.

Consider these factors

Before you look for a therapist, you'll want to know the answer to these questions:

What type of a mental health support are you looking for?

Are you looking for a healthcare provider who can offer therapy?

Are you looking for someone who can prescribe medication?

Are you looking for both medication and therapy?

Contact your insurance provider

If you have health insurance, call your insurance provider to learn if they cover mental health services. If they do, ask for the contact information of local service providers who accept your insurance plan. If you need support for a specific condition, ask for providers who treat that condition.

Other questions that you should ask your insurance provider include:

It's always a good idea to ask for the names and contact information of multiple providers. The first provider you try might not be the right fit for you.

Look for therapists online

Your family doctor, nurse practitioner, and insurance provider can help you find a therapist in your area. You can also look for therapists online. For example, consider using these databases:

Schedule an appointment

It's time to book an appointment. If you're reluctant to make the call, you can ask a friend or family member to call on your behalf. A few things to do:

1. If it's your first time visiting a therapist, let them know that. They may want to schedule a longer appointment to provide more time for introductions and diagnosis.

2. If the first available appointment time is far in the future, take that appointment time but ask to be put on a waiting list. If another patient cancels, you might get an earlier appointment. You can also call other therapists to learn if you can get an earlier appointment with them.

3. While you wait for your appointment, consider looking for other sources of support. For example, you might be able to find a support group in your area. If you're a member of a religious community, you might be able to get support from a pastoral counselor. Your school or workplace might also offer counseling services.

If you're in a crisis and need immediate help, go to a hospital emergency department or call 911.

Find the right fit

Once you've met with a therapist, it's time to reflect on whether they're the right fit for you. Here are some important things to consider:

How much education and professional experience do they have? Have they worked with other people going through similar experiences or coping with a similar diagnosis? They should be qualified to provide the services that they're offering. Most of the providers discussed previously should have at least a master's degree, or in the case of psychologists, a doctoral degree.

Do you feel comfortable with them? What "vibe" do you get from them? The personal questions that your therapist asks you might make you uncomfortable sometimes, but that person shouldn't make you feel uneasy. You should feel like they're on your side.

Do they understand and respect your cultural background and identify? Are they willing to learn more about your background and beliefs? Consider following NAMI's tips for finding culturally competent care.

What processes does the therapist expect you to follow to establish mental health goals and evaluate your progress? What kind of improvements can you expect to see? You may be more comfortable with one approach to providing care over another.

How often will you meet? How hard will it be to get an appointment? Can you contact the therapist by phone or email between appointments? If you can't see or talk to them as often as you need, another service provider might be better suited to you.

Can you afford their services? If you're concerned about your ability to pay for appointments or meet your insurance copays or deductibles, bring it up with your therapist when you first meet them. Ask if you can pay on a sliding scale or at a discounted price. Doctors and therapists often prefer to prepare for potential financial challenges in advance because it's important to continue treatment without interruption.

If you feel uncomfortable with the first therapist that you visit, move on to the next one. It's not enough for them to be a qualified professional. You need to work well together. Developing a trusting relationship is critical to meeting your long-term treatment needs.

Distance therapy can be conducted by voice, text, chat, video, or email. Some therapists offer distance therapy to their patients when they're out of town. Others offer distance therapy as a stand-alone service. To learn more about distance counseling, visit the American Distance Counseling Association.

Many hotlines, online information services, mobile apps, and even video games are available to help people cope with mental illness.

Hotlines

Many organizations run hotlines and online services to provide mental health support. These are just a few of the hotlines and online services that are available:

An online search will turn up more services in your area.

Mobile apps

A growing number of mobile apps are available to help people cope with mental illness. Some apps facilitate communication with therapists. Others offer links to peer support. Still others provide educational information or tools to promote good mental health.

You shouldn't use mobile apps as a replacement for your doctor or therapist's prescribed treatment plan. But some apps might make a helpful addition to your larger treatment plan.

Free apps

Breathe2Relax is a portable stress management tool. It provides detailed information on how stress affects the body. It also helps users learn how to manage stress using a technique called diaphragmatic breathing. It's available for free on iOS and Android devices.

IntelliCare is designed to help people manage depression and anxiety. The IntelliCare Hub app and related mini apps are available for free on Android devices.

MindShift is designed to help youth gain insight into anxiety disorders. It provides information about generalized anxiety disorder, social anxiety disorder, specific phobias, and panic attacks. It also provides tips for developing basic coping strategies.

PTSD Coach was designed for veterans and military service members who have PTSD. It provides information about PTSD, including treatment and management strategies. It also includes a self-assessment tool. It's available for free on iOS and Android devices.

SAM: Self Help for Anxiety Management provides information about managing anxiety. It's available for free on iOS and Android devices

TalkSpace seeks to make therapy more accessible. It connects users to licensed therapists, using a messaging platform. It also provides access to public therapy forums. It's free to download on iOS and Android devices.

Equanimity is a meditation app. It may help you develop a stress-relieving meditation practice. It's available to download for $4.99 on iOS devices

Lantern offers sessions designed to boost emotional well-being. It's a subscription-based service. (Email customer support for current pricing.) Although the service is web-based, you can also download a free supplemental app for iOS devices.

Worry Watch is designed to help users document and manage experiences with chronic worry, anticipatory anxiety, and generalized anxiety disorder. It's available on iOS for $1.99.

Paid apps

For information about other mental health apps, visit the Anxiety and Depression Association of America.

Video game therapy

Video gaming is a popular leisure activity. Certain doctors also use video games for therapeutic purposes. In some cases, immersing yourself in virtual worlds might help you take a break from everyday anxieties.

Some game designers have created games specifically geared toward mental health. For example:

Depression Quest aims to help people with depression understand that they're not alone. It also illustrates how the condition can affect people.

Luminosity uses games to strengthen players' cognitive abilities.

Project EVO was designed to provide daily therapy to people with brain disorders, such as attention deficit hyperactivity disorder (ADHD) and autism.

Sparx is a role-playing game. It strives to promote positive affirmations through interactions among players. It's currently available only in New Zealand.

SuperBetter aims to increase resilience. This is the ability to stay strong, motivated, and optimistic in the face of difficult obstacles.

Ask your doctor for more information about the potential benefits and risks of video gaming.

Whether you're grieving the loss of a loved one or coping with mental illness, many nonprofit organizations offer support. Consider connecting with one of the organizations listed below. Or conduct an online search to find an organization in your area.

Alliance of Hope for Suicide Loss Survivors provides support to suicide survivors. It also helps those who've lost a loved one to suicide.

American Foundation for Suicide Prevention provides resources to people affected by suicide.

Candle Inc. offers programs designed to prevent substance abuse.

Child Mind Institute provides support to children and families coping with mental health and learning disorders.

Children's Health Council provides support services to children and families coping with a variety of mental health and learning disorders.

Finding Balance is a Christian organization. It strives to help people develop a healthy relationship with food and weight.

Hope of Survivors offers support to victims of clergy sexual abuse and misconduct. It also provides education to clergy and churches.

Knights of Heroes Foundation runs an annual wilderness adventure camp for children who've lost their parents during military service.

Mental Health America is dedicated to promoting good mental health among Americans. It promotes prevention, diagnosis, and treatment for people at risk of mental illness.

National Alliance on Mental Illness promotes the well-being of Americans affected by mental illness. It offers education and support resources.

National Child Traumatic Stress Network strives to improve care for children and youth who've been exposed to traumatic events.

National Federation of Families for Children's Mental Health promotes policies and services to support families of children and youth who are coping with emotional, behavioral, or mental health challenges.

Treatment Advocacy Center promotes policies and practices to improve psychiatric care. It also supports research on mental illnesses.

The Trevor Project provides support for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth. It focuses on crisis and suicide prevention.

Soaring Spirits International offers peer-based support programs to people coping with grief.

Sober Living America provides structured living environments for people who are trying to recover from alcohol and drug abuse.

Washburn Center for Children provides support to children with behavioral, emotional, and social problems.

To find more nonprofit organizations that focus on mental health, visit:

Support groups focus on a wide variety of conditions and experiences. In a support group, you can share your experiences with others and give and provide emotional support. To start your search, consider exploring these links:

Al-Anon/Alateen runs meetings for friends and family members of people with a history of alcohol abuse.

Alcoholics Anonymous runs meetings for people with a history of alcohol abuse.

Anxiety and Depression Association of America maintains a directory of support groups for people with anxiety and depression.

Attention Deficit Disorder Association offers support group services to members of the organization.

The Compassionate Friends provides support to families that have lost a child.

Depression and Bipolar Support Alliance runs meetings for people with depression and bipolar disorder.

Dual Recovery Anonymous runs meetings for people who have both substance abuse issues and an emotional or psychiatric illness.

Gamblers Anonymous runs meetings for people with gambling problems, as well as their family members and friends.

International Obsessive Compulsive Disorder Foundation maintains a directory of support groups for people with OCD, as well as their loved ones.

Mental Health America maintains a directory of peer support programs for people with different mental health conditions.

Narcotics Anonymous runs meetings for people with a history of drug addiction.

National Alliance on Mental Illness runs meetings for people with mental illness.

National Eating Disorders Association maintains a directory of support groups for people with eating disorders.

Overeaters Anonymous runs in-person, telephone, and online meetings for people with a history of disordered eating, such as food addiction.

Postpartum Support International runs meetings for families coping with perinatal mood and anxiety disorders, such as postpartum depression.

S-Anon International Family Groups runs meetings for family and friends of people with a sexual addiction. It offers in-person, online, and phone meetings.

Sex Addicts Anonymous runs meetings for people with a sexual addiction. It facilitates in-person, online, and phone meetings.

Survivors of Incest Anonymous runs meetings for people who've survived incest.

Well Spouse Association facilitates support groups for people who act as caregivers for partners with a chronic illness.

You might be able to find local organizations that provide mental health support in your area. Ask your doctor, nurse practitioner, or therapist for information about local services. You can also check the bulletin boards and resources at clinics, hospitals, libraries, community centers, and other sites. They often provide information about local organizations, programs, and events.

Many of the organizations listed in the "Finding therapy," "Nonprofit organizations," and "Support groups" sections of this article operate local chapters. Some of them maintain directories of local services. For example, Mental Health America maintains a directory of local services and affiliates. MentalHealth.gov and SAMHSA also maintain directories of local services.

If you can't find local support, consider exploring the resources listed in the "Online and phone" section.

Types of care

Depending on your condition, you might receive the following care:

If you receive outpatient care, you'll generally be treated at an office, without staying overnight at a hospital or other treatment center.

If you receive inpatient care, you'll stay overnight at a hospital or other treatment center to get treatment.

If you undergo partial hospitalization, you'll receive treatment over the course of multiple days, generally for several hours each day. However, you won't stay overnight at the hospital or other treatment center.

If you receive residential care, you'll be admitted to a residential setting and live there on a temporary or ongoing basis. You'll be able to access 24-hour support there.

You can look for treatment facilities online. For example:

For additional directories, explore the resources listed in the "Finding therapy" section.

If you can't afford a private psychiatric hospital, ask your doctor for information about public psychiatric hospitals. They often provide acute and long-term care to people who would have financial difficulties paying for treatment.

Psychiatric hold

Psychiatric hold is a procedure that allows healthcare professionals to hold patients at a treatment center. You may be put on a psychiatric hold under the following conditions:

Mental health professionals will examine you to determine a diagnosis. They may offer you crisis counseling, medications, and referrals for follow-up care. Laws vary by state in terms of involuntary admission, but you may be held anywhere from a few hours to a few weeks, depending on the severity of your symptoms.

If you think you might pose an immediate risk to your own safety or someone else's, go to a hospital emergency department or call 911.

Psychiatric advance directive

If you have a severe mental health condition, consider establishing a psychiatric advance directive (PAD). A PAD is also known as a mental health advance directive. It's a legal document that you can prepare when you're in a mentally competent state to outline your preferences for treatment in the case of a mental health crisis.

A PAD can potentially help you do the following:

Promote your autonomy.

Improve communications between you, your family, and your healthcare providers.

Protect you from ineffective, unwanted, or potentially harmful interventions.

Reduce the use of involuntary treatment or safety interventions, such as restraints or seclusion.

There are multiple types of PAD. Some examples:

An instructive PAD provides written instructions about the specific treatments that you'd like to receive if you experience a crisis that leaves you unable to make decisions.

A proxy PAD names a healthcare proxy or agent to make treatment decisions on your behalf in cases when you're unable to do so yourself.

If you decide to establish a proxy PAD, choose a family member, spouse, or close friend who you trust to advocate for you. It's important to discuss your wishes with them before designating them as your proxy. They'll be in charge of your care and treatment plans. They need to fully understand your wishes to act as an effective proxy.

For more information on PADs, visit the National Resource Center on Psychiatric Advance Directives or Mental Health America.

Clinical trials are designed to test new approaches to providing medical care. Through clinical trials, researchers can potentially develop new ways to diagnose, prevent, detect, and treat diseases.

To conduct clinical trials, researchers need to recruit volunteers to act as study subjects. There are two main types of volunteers:

Volunteers who don't have any significant health problems.

Patient volunteers who have a physical or mental health condition.

Depending on the type of study, researchers may recruit regular volunteers, patient volunteers, or both.

To participate in a clinical trial, you must meet the eligibility criteria. These criteria vary from one study to another. They can include criteria related to age, sex, gender, and medical history.

Before volunteering for a clinical trial, it's important to understand the potential benefits and risks. These vary from one study to another.

For example, here are a few of the benefits of participating in clinical trials:

Participating in clinical trials can also pose risks:

There might be unpleasant, serious, or even life-threatening side effects associated with some types of experimental treatments.

The study might require more time and attention than standard treatment would. For example, you might have to visit the study site multiple times or undergo extra tests for research purposes.

You can find more information about clinical trials in your area by searching online. To begin your search, consider exploring the websites listed here:

If you're outside of the United States, you might find the list of resources at the Centre for Global Mental Health website helpful.

As well, try the links below for mental health resources if you happen to be in one of these countries:

Canada

United Kingdom

India

Mental health challenges can be difficult to tackle. But support can be found in many places, and your treatment plan is one that is unique to you and your mental health journey. It's important that you feel comfortable with your treatment plan and seek resources that will aid your recovery. The most important thing is to take that first step to get help, and then stay active in your treatment plan.

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Mental Health Resources: What You Need to Know

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Don't face mental health challenges alone. Instead, learn how to get the support you need to thrive.

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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).
Google Scholar

# data[].attributes.attachment_link.title
Mental Health and Well-Being of University Students: A Bibliometric Mapping of the Literature

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

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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.

# data[].attributes.attachment_link.title
School's role in Tier 1 promoting mental health and wellbeing | Victorian Government

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

# data[].attributes.attachment_link.readable_text
Cara Skikne
Guest post: Borna Nemet, Human Rights and Solidarity Coordinator
For every individual, social, economic, mental, and physical health are vital elements of their overall life quality. As reported by the World Health Organization (2001), one in every four individuals will suffer from a mental health problem at some point in their lives, with 450 million people worldwide suffering at any one time.

Special consideration should be paid to our student population as we continue to experience challenges brought about by the pandemic.

The mental health and welling of all students across Europe is a serious, growing concern that we have to address. Usually, students can frequently interact with peers, friends, and professors. When "contact teaching" practice was replaced with virtual learning, their ability to socially integrate into the academic world was lost. This has adversely affected their quality of life and wellbeing. In May 2020, UNESCO reported that more than 160 countries implemented nationwide closures, which impacted over 70% of the world's student population.

The idea that quality of life adds intrinsic value associated with high academic outcomes isn't new. There have been many research projects and evidence confirming the positive connections between quality of life and academic achievement. The most recent studies have discussed the importance of students' mental health and the appropriate measures to be taken to improve learning outcomes. In an older study by Ainley (1991), it was also suggested that students' quality of life is directly related to their academic achievement. Quality of life evaluation will depend on the subjective perception of every single individual, but we already know it has a huge impact on other areas of human life.

How we talk about mental health and wellbeing in post-Covid society will also change. Students may be more proactive about finding appropriate help to ensure their own wellbeing. In order to fight the negative impacts of the pandemic, we need to make sure that students have a free and easily accessible mental health support platform built to cope with the losses and transitions of the past year. Putting the focus on good mental health practices from counseling opportunities, building trust between professors and students, and many other factors should be the focus for universities and the global academic community.

Universities should work towards opening a student wellbeing service that will offer help and guidance to students when they are experiencing different challenges, or are in need of some extra support. Wellbeing advisers should work with academic tutors and other university staff to plan for and address any personal and emotional difficulties students might experience, ensuring that students can focus on their academic work without pressure.

Peer-to-peer support also has a role in helping students to address mental health and wellbeing issues. Student councils should encourage the development of a peer support scheme that will enable students to talk confidentially to a fellow student about anything that is troubling them.

Providing student-led, confidential assistance creates a space for students to be reassured that others are experiencing the same things.

Thirdly, students should be encouraged to practice self-help by making resources and materials available on LMS platforms that can be accessed by anyone at any time.

Since the beginning of the pandemic, the issues of mental health and the wellbeing of students have become an increasingly prevalent theme in research studies. Although many European universities already have specific assistance and counseling mechanisms for students in need, we have to continue to thoroughly and continuously emphasize the importance of promoting the mental health and general wellbeing of students in academia. Processes involving changes and improvements in the current situation are still in their infancy, and their full implementation will surely take several more years.

References:

Ainley, J., Foreman, J., & & Sheret, M. (1991). High school factors that influence students to remain in school. The Journal of Educational Research , pp. 69-80. Retrieved from https://doi.org/10.1080/00220671.1991.10702816

UNESCO. (2020, May). COVID-19 educational disruption and response. Retrieved from https://en.unesco.org/themes/education-emergencies/coronavirus-school-closures

W orld Health Organization. (2001). The world health report 2001 - Mental Health: New Understanding, New Hope. Geneva: WHO: Mental Health.

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# data[].attributes.attachment_link.title
Wellbeing and Mental Health Support Should be Available to University Students | Studyportals

# data[].attributes.attachment_link.description
Guest post: Borna Nemet, Human Rights and Solidarity Coordinator For every individual, social, economic, mental, and physical health are vital elements of their overall life quality. As reported by the World Health Organization (2001), one in every four individuals will suffer from a mental health problem at some point in their lives, with 450 million people ...

# data[].attributes.headline
www.frontiersin.orgMental Health and Well-Being of University Students: A Bibliometric ...

# data[].attributes.subject
www.frontiersin.orgMental Health and Well-Being of University Students: A Bibliometric ...

# data[].attributes.attachment_link.readable_text
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.

# data[].attributes.attachment_link.title
School's role in Tier 1 promoting mental health and wellbeing | Victorian Government

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