Campus mental health: Are we doing enough?

There has been a huge worldwide expansion of the tertiary education system in the last two decades. The higher education sector is a burgeoning field of rapid growth and needs, and addressing the specific mental health issues and challenges facing the university community, including both the student population and faculty staff, should be a major research and service focus in psychiatry. University is a time when academic challenges increase significantly, and self-driven study and learning habits as well as self-determined time management become essential skills to master. Pressure to perform well in assessments and thinking about the future also increase. However, in addition to the many academic pressures, early studies have reported that psychosocial factors are also significant sources of stress for students (Supe, 1998; Saipanish, 2003): students often face social or relational challenges (Kaufman et al., 1993) as well as emotional, physical and family problems, which may affect their learning ability and academic performance (Chew-Graham et al., 2003). Indeed, undergraduates are at the stage of life when higher education can bring its own new stresses and challenges, but they are also at a stage when other developmental issues accompany late adolescence and young adulthood. At university, most young people encounter a drastic change in lifestyle, with potential stressors, including issues relating to establishing new friendships and intimate relationships, their career choices, the pursuit of personal and professional goals, and developing the skills and knowledge to become independent self-supporting adults (de Oliveira et al., 2008; Hicks & Heastie, 2008). Societal and family expectations may also cause tension, and moving away from home also involves the renegotiation of connectedness to family relationships, as university students continue to individuate and become more independent (de Oliveira et al., 2008). Moving out of the family home is often related to markedly increased domestic, health, and financial responsibilities. Often students become involved in political and activist causes as a part of growing into a new “self” and the development/refinement/rejection of their previous beliefs and belief system. Although stress is inherent in every part of life and at every stage of human development, the transition from high school to university/college, and the integration into and management of higher education life is very stressful and requires more independent decision making by young people (Lee & Loke, 2005). In the midst of this dynamic time of life, in their pursuit of greater educational opportunities and employment prospects, higher education students must cope with the pressure of an uncertain future and the stresses of integrating into the university system with concomitant physical, psychological, and sexual and intellectual development. The adverse consequences of stress can impair judgment, reduce concentration and self-esteem, affect academic achievement, and result in physical and mental health problems. Many psychiatric illnesses have their onset in young adulthood (Mowbray et al., 2006), and university students are commonly exposed to circumstances that place them at risk for psychiatric disorders: the importance of the mental health of university students is highlighted by studies that suggest a high prevalence of mental health difficulties in the university student population, including global psychological distress, somatic distress, anxiety, low self-esteem, and depression (Gerdes & Mallinckrodt, 1994), and the rate of depression has been reported to be steadily increasing in the last few years among this age group (Kisch et al., 2005). Blanco et al. (2008) found that psychiatric disorders, particularly alcohol use disorders, are common in the college-aged population in the United States and other studies suggest that university students have higher rates of both substance abuse and alcohol use disorders than their non-college peers (Slutske, 2005). Psychiatric disorders in young adulthood are associated with substance abuse, academic problems, such as reduced attendance and likelihood of successful completion, and other detrimental social outcomes later in life (Eisenberg et al., 2007). Thus, in addition to receiving an education, it is also important to consider the mental health of students during their enrolled years, and students must be taught and overtly encouraged to take responsibility for their psychiatric and psychosocial health. Successful handling of stressful life events leads to human growth and students should be challenged to attain the personal growth and perseverance necessary to cope with life stress and to establish and maintain healthy interpersonal relationships. Many studies have reported significant student stress. In Asia, 73% of Indian students perceived stress at one time or another during medical school enrolment (Supe, 1998), and 61.4% of students in a Thai medical school experienced some degree of stress (Saipanish, 2003). The authors of a cross-sectional Pakistani study (Shaikh et al., 2004) assessed the perception of stress among medical students and found that over 90% reported being stressed at one time or another, which affected academic performance. The common stress factors were inability to cope, helplessness, increased psychological pressure, mental tension, and too much workload, mostly as a result of academic and examination stressors. Common consequences were low mood, inability to concentrate, and loss of temper. In Malaysia, 41.9% of medical students suffered psychological stress, which was significantly associated with depression (Sherina et al., 2004). In Singapore, it was found that among first-year law and medical undergraduates, those living on campus reported significantly higher stressful life events in the past 12 months, with the most common complaints being difficulty in keeping up with reading (84.4%), amount of academic work (82.5%), difficulty with tutorials (66.5%), little time for personal activities (61.6%), difficulty in lectures (46.8%), and peer competition (46.8%) (Ko et al., 1999). A Nepalese study (Sreeramareddy et al., 2007) assessed the prevalence of psychological morbidity, sources and severity of stress and coping strategies among medical students in an undergraduate medical curriculum, and found that the most common sources of stress were related to academic and psychosocial concerns. The most frequently occurring and most severe sources of stress were quality of food in mess, high parental expectations, dissatisfaction with class lectures, vastness of academic curriculum/syllabus, worrying about the future, lack of entertainment in the institution, and frequency of examinations. In Australia, in a study spanning 3 years at the University of Sydney (Mouret, 2002), the main stressors found in medical undergraduates were time management and financial issues. Overall, in the third year of the study, after 6 months, 46.4% of students reported feeling stressed overall. In terms of individual stressors, the most reported stressors were time management (74.1%), financial issues (50.6%), personal issues (44%), new course format (36.1%), living conditions (22.3%), problem-based learning (19.3%), moving residence (10.8%), and using computers (4.8%). An internet-based survey of 202 undergraduates conducted by the University of Sydney (Laing, 2008) found that students struggled to combine study with stressors related to rent, travel, and part-time employment. In the Americas, face-to-face interviews were conducted with college-aged individuals in the 50 states of the USA and the District of Columbia in 2001–2002 (n=2188 attending and n=2904 not attending college in the previous year) (Blanco et al., 2008). Results revealed that the most prevalent disorders in college students were alcohol use disorders (20.37%), followed by personality disorders (17.68%). The authors found that treatment rates were low, and although college attendees were more likely to have an alcohol use disorder, they were significantly less likely to receive treatment for alcohol and drug use disorders than other disorders. Universidade Estadual de Campinas (UNICAMP), a public university in Brazil, established a campus mental health service in 1987. Between 1987 and 2004, the most frequently reported complaints of students seen for at least one session were related to difficulties in interpersonal relationships (31.4%), family conflicts (23.8%), worries about professional future (21.1%), poor academic performance (18.9%), and feeling down (16.6%). Other common complaints were difficulty in making friends (14.5%), lack of self-confidence (14%), difficulty in talking about oneself (12.9%), lack of motivation (12.5%), and doubts about course choice (11.8%) (de Oliveira et al., 2008). The authors found that women, students who came from out of state, students who were living on-campus, students whose main source of income was a scholarship, and undergraduate and Humanities and Arts students were overrepresented among the campus mental health service clients. Only 0.9% of clients complained of sexual abuse, and 2.4% of clients reported recreational drug problems at their first contact. Severe conditions that could suggest psychotic illness were reported by 1% of clients, and suicidal thoughts were expressed by 3% of clients. Coping strategies refer to the specific efforts, both behavioral and psychological, that people employ to master, reduce, tolerate or minimize stressful events (Sreeramareddy et al., 2007). Young adults may have less well-developed coping mechanisms or less experience than older adults with impersonal losses and other stressors, making them particularly vulnerable to the effects of stress. The authors of a Nepalese study (Sreeramareddy et al., 2007) found that students generally used active coping strategies and alcohol and drugs were the least used coping strategies. Commonly used coping strategies were positive reframing, planning, acceptance, active coping, self-distraction and emotional support. Another study from Pakistan reported that sports, music, sleeping, going into isolation, and hanging out with friends were common coping strategies (Shaikh et al., 2004). Ko et al. (1999) found that when faced with a problem, undergraduate students in Singapore generally turned to friends and classmates (more than seven of 10 students). Other avenues of support were family and religion. However, a substantial proportion of students preferred to keep their problems to themselves (37.5% of law students and 31.1% of medical students). A Hong Kong study (Lee & Loke, 2005) found that to maintain a healthy lifestyle, university students need to pay extra attention to balanced diet, regular exercise, maintaining interpersonal relationships, and stress management skills. Unfortunately, alcohol and drug use are common among college-aged individuals, often leading to substance abuse and dependence (Hingson et al., 2006). Studies that have examined coping strategies of students with the stresses of undergraduate education have often identified use of alcohol as a coping strategy (Guthrie et al., 1998). Other studies have reported the use of other substances, such as tobacco and drugs (Ashton & Kamali, 1995). The higher education sector has undergone drastic changes during the past several decades, including increased student enrolments, substantial cuts in human resources and government funding, increased dependence on full fee paying students, and constant restructuring, with ensuing consequences and impact on all employees (e.g. administrative, trades, and faculty). Although many reports have been published regarding general job-related stress, there has been far less research conducted on the mental health of the faculty of college and universities specifically. Gmelch et al. (1986) wrote that “as academicians and researchers, we willingly study other groups, yet we seldom take time to look at our own profession” (p. 266). This paucity of research exists despite the inherent multifaceted demands of being a faculty member, with such disparate roles as teacher, adviser, mentor, researcher, university citizen, and departmental colleague. Early studies found that potentially salient, stress-inducing dimensions of the academic workplace were administrative bureaucracy and red tape, insufficient income (Fahrer, 1978), high levels of self-expectation and self-imposed pressures for achievement (Gmelch et al., 1983), and excessive time pressures and insufficient resources. Another common finding is the general absence of clear and standardized guidelines for judging faculty performance, causing faculty stress in terms of pay rates, promotion, and career advancement and reward structures. Gmelch et al. (1986) investigated the identifiable patterns of faculty stress taking a random selection of 1221 individuals from 40 public and 40 private universities from among 184 eligible doctorate-granting institutions in the USA. Overall, the findings suggested that higher stress levels were associated with lower rank, untenured status, and particular disciplinary clusters, and in the personal domains of being younger and female. Factor analysis of the results revealed uniqueness and a multidimensionality of stress in academe, and interestingly, the authors reported that although teaching, research, and service are the standard areas for which university faculty are responsible, the analysis revealed a collection of stressful circumstances subdivided into distinct areas of perceived stress not reflective of traditional “academic” categories. Rewards and recognition accounted for 55% of the common variance, where inadequate rewards, unclear expectations, and insufficient recognition were common stressors, as well as not having clear criteria for evaluation for service and research activities. Mismatches between individuals, their expectations of, and the perceived reality of the role led to stress and dissatisfaction. Time constraints were stressful (12% common variance) and were related to excessive paperwork, meetings, and interruptions, which meant reduced available time for “real academic” activities. Departmental influence exercised by the individual was also a common stressor (7% of common variance), and was related to the activities of resolving differences with and influencing decisions of the department, and knowing and contributing to evaluative data for promotion. Professional identity (6% common variance) related to the importance of the development of a professional “reputation” and highlighted the stress of publications, presentations, and successful securing of grants, and of excessively high personal aspirations and expectations. Student interaction was also a source of faculty stress (6% of common variance), with stress regarding mentorship, teaching, evaluation, and advising of students, as well as dealing with interpersonal relationships and boundary issues. During the 1986–1987 academic year, Eckhart et al. (1988) analyzed questionnaires from 484 full-time faculty members at Oklahoma State University, and found that there was a major need for improvement in stress management skills. Portuguese teachers were also interviewed from 1999 to 2001 (n=68) and revealed that high impact stress factors were inadequate wage, payment deduction, lack of material and long meetings (Contaifer et al., 2003). Stress levels, in general, varied from mild (61%) to moderate (32%), and the participants perceived stress through tiredness, anxiety and loss of balance. A Canadian research study by Biron et al. (2008) conducted questionnaires and semi-structured interviews on 1086 employees of a Quebec university, and results revealed that the proportion of individuals who reported a high level of psychological distress was double (40%) that reported for a Quebec-wide sample (20%). Work overload, relationship with one's superior and participation in decision making were systematically reported as high risks to employees' health. Recently, a Turkish study by Pirincci et al. (2008) designed to determine the health-related behaviors of university academic staff found that staff showed only intermediate levels of health-promoting behaviors, with reduced levels of health responsibility and strategies for coping with stress. Heavy work burdens may have been responsible for this lower than expected level. Other influences that can impact on faculty stress may involve the increasing necessity of dealing with the politics of funding; this is likely to become more pertinent with the ever-increasing privatization of universities and the development of more collaboration with partners in industry and service sectors, who will likely have their own demands and agendas. Additionally, with access to government funding and grants becoming scarcer and more competitive, issues such as politically driven “research priorities”, and bureaucratic demands to meet a “political” agenda may likely become more prevalent sources of stress. Few reports have been published regarding the study of stressors in students, particularly in faculty members in universities. With the current rapid development of the higher education sector, increasing levels of longstanding and novel stressors are likely to emerge, requiring constant vigilance of the mental health of all concerned. Management practices may not have followed the rapid organizational changes that have affected universities in the past few decades. As teachers and mental health clinicians, we have a duty of care to our students and our colleagues to be alert to stressful factors, and to develop institutional strategies to reduce and manage their feelings of insecurity, anxiety, distress, burnout, pressure, and stress that can lead to more serious psychiatric disorders. Based on the clear published findings regarding stress being common and significant in the university community, there is an obvious need for centralized campus mental health services to enable both university students and staff members to cope better with the demands of tertiary education. Ensuring easy access to mental health care should be indispensable to the achievement of educational goals, and the development and funding of counseling/mental health services/clinics should be made a policy priority. Universities should provide and coordinate campus-wide multicomponent health programs to promote the health of the overall university community, and ensure effective triage, treatment, and support (including ongoing support) for clients. The main goals of campus mental health services should strive to include: Provision of broad-based mental health clinical care, which goes beyond purely academic issues. Services should include therapy, such as psychotherapy (short and long term), and brief interventions and emergency visits. Open-door policy, including self-referral and peer referral. Confidentiality as a major concern. The service should be strictly confidential and university administrators should have access only to statistics. Clients should be assured that any kind of report is confidential, or made only when bound by law, at their request, or in their best interest. Open and transparent advertisement of services to ensure knowledge of service, including the provision of easily accessible information about the campus mental health service (including being distributed in information and orientation packs for secondary school students). Government and university subsidization, which may help fund staff and overheads. Active and reciprocal liaison with other university agencies, such as social services to help students meet their social, financial, and academic needs. Provision of career support for faculty members seeking to establish professional identities. Alcohol and other substance use education, counseling, and intervention, particularly given the lifelong mental and general medical health consequences of substance use disorders. Provision of individualized, group, and organizational interventions designed specifically for staff and students. Interventions should be implemented to help both students and staff cope with physical and psychological issues, for the prevention of burnout, and for students to persist until graduation, which could include information provision, such as training seminars, health education programs, and educational talks on nutrition, exercise, stress management, coping strategies, time management, relaxation techniques, and building life skills. The implementation of effective psychiatric intervention in the university community is an important public health priority and goal. Investment in the introduction and implementation of dedicated campus mental health clinics will go a long way toward identifying and treating mental health issues early (thus reducing the persistence of mental health problems and associated functional impairment, loss of productivity, and increased health care costs), avoiding psychiatric hospitalization and avoiding academic dropout, reducing staff absenteeism, turnover and burnout, and increasing productivity and job satisfaction. The introduction of high quality campus mental health services may also have run-on effects for public health systems and emergency departments, as students and staff will have a known dedicated service to turn to, and students and staff are more likely to seek help earlier if there is a convenient, dedicated university clinic. Moreover, many public health services are poorly equipped to assess mental health issues, and many do not have the resources or availability for psychotherapy. Student and faculty stress factors have significant implications for the higher education sector, including university health administrators, student affairs personnel, counselors, and policy makers. More research and information on the needs of members of the university community can help administrators, curriculum planners, and health professionals design guidelines for structuring and providing a healthier environment, and developing education programs that support both physical and mental health. Overall, reducing stress in university students and staff should be key priorities for health professionals, university officials, and government, as concern for the health of our future generation of leaders will help to produce healthy, well-rounded successful university graduates, equipped with the skills to succeed in life and make lifelong sustained contributions to their society beyond just what their university degrees will offer, as well as improve job satisfaction for those who teach, mentor, and support them.

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