Student mental health research: moving forwards with clear definitions

In the two years since this journal published a special issue on student mental health (Brown, 2018), Universities UK have refreshed their #StepChange framework (2020) in tandem with the Student Minds University Mental Health Charter (Hughes & Spanner, 2019). Both emphasise making student mental health and well-being a university-wide priority; a “whole-university approach” (Universities UK, 2017).

Within the UK, of the eight mental health networks funded by UKRI in 2018, four focus specifically on young people and students (Emerging Minds, SMaRteN, TRIUMPH and eNurture). While this highlights the importance in the UK context, student mental health is an international priority. This is represented in the current issue, with research spanning the United States, Italy, Kazakhstan and Ghana. This global concern about the mental health of our Higher Education students comes with the backdrop of wider concern about young peoples’ mental health (Hunt & Eisenberg, 2010; Wilson, 2020). Arguments for the importance of early detection and intervention among young people, helping them to fulfil their potential, have been made repeatedly (e.g. McGorry & Mei, 2018).

So why focus specifically on student mental health? There is burgeoning literature on student mental health, focusing on the rise in students experiencing mental health difficulties and resulting rising demand for support, the developing evidence-based on determinants and interventions and the challenges (Brown, 2018; Barkham et al., 2019; Wilson, 2020). Typically, the link between youth mental health and student mental health is highlighted, given the large number of young people attending university. Given the overlap between the age of the majority of students and the peak age of onset for a number of mental health disorders, it has been argued that early intervention models that apply to young peoples’ mental health may be implemented within university settings to support students (Brown, 2018; Hunt & Eisenberg, 2010). There is a real opportunity in the Higher Education sector to investigate risk and protective factors for young peoples’ mental health, and to develop and disseminate support for their mental health and well‐being, because students undertake many of their activities (social, educational and recreational) within the university setting (Hunt & Eisenberg, 2010; Royal College of Psychiatrists, 2011) and face unique stressors (Duffy et al., 2019). Further, many students may be struggling, but do not meet criteria for access to formal services, which is a problem for emerging mental health difficulties more generally (Cross et al., 2014; Duffy et al., 2019). This, alongside the fact many students are not permanently resident in their place of study (meaning difficulties with waiting lists, and with continuity of support), has bolstered the argument that universities have a vital role to play in student mental health and well-being (Duffy et al., 2019).

However, it is also important to note that student mental health and youth mental health are not equivalent. At the lower end, youth mental health captures a broader age range than that of the “typical” university student. In the current issue, Ahorsu et al. (2021) reported differences across level of education when comparing high school students, undergraduates and postgraduates, with high school students faring worse for academic stress, depression and suicidal ideation. Research on student mental health (and well-being) should not always seek to extrapolate to “young peoples” mental health’ more broadly, as it is likely there are different determinants of mental health and well-being, and different needs for addressing these, at different points across this relatively small age range (and perhaps differences from age-matched non-university attending peers). This echoes Macaskill (2018), who reported differences even between 1st and 2nd year undergraduate students. This highlights the importance of taking different developmental stages and transitions into account (Barkham et al., 2019).

Typical “cut-offs” at the upper end of youth mental health also do not include the full age range of the university student population. The Higher Education Statistics Agency (2019) reported that 31% of students who enrolled in a UK university during the 2018–2019 academic year were older than 25 years. Research should represent mature students, both undergraduate and postgraduate. There may be challenges shared by students across developmental stages (e.g. emerging adulthood and adulthood), that are unique to their experience as students and not shared by non-university attending peers (Duffy et al., 2019). This again highlights that student mental health research and practice is important in its own right.

With this in mind, the focus of the articles in the current issue is two-fold (as in the previous special issue in this journal; Brown, 2018). First, understanding what influences, and is influenced by, students’ mental health (Ahorsu et al., 2021; Nwachukwu et al., 2021). Second, understanding how we can support students. Specifically, rather than evaluating interventions, these articles focus on how to encourage students to seek support for their mental health (Kosyluk et al., 2021; Lueck & Poe, 2021; Dschaak et al., 2021), or provide support for peers (Spiker & Hammer, 2021). This includes help-seeking more generally (Kosyluk et al., 2021), as well as mental health first aid (Spiker & Hammer, 2021), and help-line support (Lueck & Poe, 2021). Social support continues to be an important protective factor (Taniguchi & Thompson, 2021), whereas mental health stigma has long been a barrier to help-seeking in university students (Eisenberg et al., 2009), and remains a topic of interest in the current issue (Kosyluk et al., 2021; Lueck & Poe, 2021; Spiker & Hammer, 2021).

Across student mental health research, there are several important gaps and issues that are relatively neglected. Policy has shifted towards supporting the whole university, rather than solely those students experiencing mental health difficulties (while recognising this group still require specialist support; Universities UK, 2017). Much research focuses on individual support, or factors that may be linked to poorer mental health and well-being in individuals, rather than institutional level understanding and changes to promote good mental health and well-being. Understanding the determinants of wider (non-clinical) distress and well-being in students, and how these can be supported to help all students to flourish in the ways that are important to them, is also valuable.

Targeted and universal interventions are both part of the whole-university approach advocated by Universities UK (2017), and are emphasised by recent international models of university student mental health as part of “stepped” or “tiered” approaches (Brown, 2018; Duffy et al., 2019). This can include a range of formal (e.g. peer support, personal tutors, modes of learning and assessment) and informal (self-care skills, societies) support (see Brown, 2018). Initiatives designed to increase awareness, improve help-seeking, and reduce stigma may be unhelpful without rigorous approaches to improving mental health literacy, as the lines between “normal” (albeit challenging) stress and negative emotions, and “mental illness”, may become blurred (Duffy et al., 2019). These clear distinctions are important for helping students to know which “level” of support they might find most helpful for their needs (Brown, 2018; Duffy et al., 2019), and to ensure resources are allocated appropriately (for wider discussion, see Barkham et al., 2019; Dodd et al., 2021; Hughes & Spanner, 2019; Piper & Emmanuel, 2019; Universities UK, 2017).

Clear definitions, and appropriate measurement, are crucial to achieving the creation of university communities that both support students with mental health difficulties, and support the well-being of all (Dodd et al., 2021). In addition, while the terms are often conflated, there is evidence that mental health and well-being are distinct, both in large population surveys (Weich et al., 2011) and from the perception of students themselves (Laidlaw et al., 2016). Research among students regularly uses these terms interchangeably. In addition, a range of measures, including self-reported diagnosis, structured diagnostic criteria, clinical symptom inventories and generic well-being measures, are used. Measures of stress and well-being are sometimes used when the research states it is about mental health, and vice versa (Dodd et al., 2021). This makes it difficult to disentangle predictors of mental health difficulties and predictors of well-being, or to evaluate what an intervention is actually helping with – an observation also made in the previous special issue on student mental health in this journal (Brown, 2018). Within the current issue, measures include symptom inventories developed for use in clinical settings (Ahorsu et al., 2021; Lueck & Poe, 2021), generic population measures (Ahorsu et al., 2021), self-identifying as having depression (Taniguchi & Thompson, 2021). Psychological well-being is assessed by several different measures in one paper, including those from the hedonic and eudaemonic traditions as well as a measure of distress (Taniguchi & Thompson, 2021).

A future where we move towards using consistent and uncomplicated definitions of these constructs, and measuring appropriately, will help us to understand the true scale of these problems among students. It will also help us to understand which mechanisms for support work for those students who are experiencing mental health difficulty, and which work for supporting all students with their well-being. Given students associate well-being with everyday experience and mental health with clinical experience (Laidlaw et al., 2016), distinguishing these terms will inform students what support is available to them for their needs at that time. Moreover, a consistent and robust approach to outcome measurement must be used in their evaluation. To evaluate whole-university approaches, moving beyond measures taken at the individual level to university-level outcomes is important.

Mapping on to concerns of students is also likely to make an impact on overall student mental health and well-being. These can include important but generic issues such as finance, the future, support with their learning, and their own academic performance (these concerns have been found in students irrespective of whether or not they are currently experiencing significant mental health difficulties; Macaskill, 2018). As with youth mental health (Wilson, 2020), research into student mental health (and well-being) is influenced by the differing priorities of individual research teams, as well as cultural context, and policy. Moving forward, research should also represent the priorities of students and universities, including a pragmatic focus on factors universities can actually support students with (i.e. support that can actually be implemented), rather than solely determined by the priorities of researchers. Co-production is vital for ensuring the student voice is front and centre of university strategy for promoting and supporting positive mental health and well-being (Hughes & Spanner, 2019; Piper & Emmanuel, 2019).

As a final note, campuses worldwide have changed due to the impact of the COVID-19 pandemic, with a number of challenges either already encountered, or anticipated – including consequences for student mental health (Sahu, 2020). This is an ongoing situation that will be important for student mental health and well-being in the future.

Disclosure statement

No potential conflict of interest was reported by the author(s).