Investing in Our Future: Importance of Postsecondary Student Mental Health Research

Student mental health has become a focus of attention in Canada and across the Western world as postsecondary institutions grapple with how to respond to an unprecedented increase in demand for mental health services. Universities and other postsecondary learning institutions have an obligation to provide a healthy environment that fosters student well-being and scholarship whilst ensuring appropriate resources are in place to support those with existing or emerging mental illness. Over 50% of high school graduates now attend postsecondary institutions, and therefore the student population increasingly resembles the emerging adult general population. The transition from high school to university life comes at a critical time of accelerated brain, intellectual, and psychosocial development coupled with exposure to a number of academic, social, lifestyle, and financial stressors. Moreover, adolescence and early adulthood represent the peak risk period for onset of mental illness. Until the developing brain fully matures at around age 25, transitional age youth require and benefit from external support and advice from parents, mentors and coaches—to guide and promote healthy self-regulatory behaviour and adaptive coping with stress and disappointment. Yet in the transition to university, students are exposed to a number of risk factors, including alcohol and recreational drugs. At the same time, students have to regulate their sleep, diet, and study schedules and form new peer relationships—all mostly on their own as some societal rite of passage and out of sync with the stage of their brain development.

Suicide is the most devastating outcome associated with emotional distress and mental illness in young people. Parents, friends, and teachers are left grappling with the irreconcilable question as to why a young person, with so much potential and possibility ahead of him or her, would make the decision to end his or her life. Self-harm and suicide are complex outcomes associated with a variety of distal risk factors, including early adversity and biological and genetic variants—each of which may act directly and/or indirectly through an association with emerging mental illness. ¹ More proximal risk factors include psychological distress coupled with poor or underdeveloped coping strategies; prime sources of distress in postsecondary students relate to academic and/or interpersonal difficulties. However, these associations largely derive from retrospective clinical or cross-sectional studies of the adolescent general population, and longitudinal data informing risk and protective pathways related to self-harm in Canadian postsecondary students are lacking. In this issue of the Canadian Journal of Psychiatry, Goodday and colleagues ² examine the cumulative incidence of serious suicidal thoughts and attempts in Canadian youth ages 11 to 25 years using the National Longitudinal Survey of Children and Youth. They estimated a high cumulative incidence of serious suicidal thoughts in 29% of females and 19% of males. Similarly, the rate of suicidal attempts was found to be higher than previous reports that relied only on hospital data, with an estimated cumulative incidence of 16% in females and 7% in males. Alarmingly, the onset of the majority of serious suicidal thoughts and attempts occurred on or before age 16 years. As the authors point out, suicide is the second leading cause of death in 15- to 29-year-olds in Canada and worldwide. Moreover, suicidal ideation and attempts in young people are a major risk factor for subsequent attempts and eventual suicide completion. Therefore, health professionals need to be aware and able to identify self-harm–related risk, and this knowledge should be applied in school-based early intervention programs.

Substance misuse is a major risk factor associated with poor school performance and attrition, as well as worsening the course and outcomes in youth with emergent or existing mental illness. In Canada, the recent legalization of cannabis ahead of adequate public health education may have increased the risk of misconception by youth that cannabis is a benign substance. However, there is ample evidence that the cannabis available today is much more potent in the tetrahydrocannabinol (THC) component associated with neurocognitive deficits and neurotoxic effects—to which the still maturing adolescent/emerging adult brain appears especially susceptible. ³ Cannabis is also strongly associated with an increased risk of psychotic experiences and disorders, as well as increased refractoriness of established psychosis to treatment. ⁴ The adverse outcomes associated with cannabis in youth are compounded in the presence of comorbid alcohol misuse. Alcohol abuse in the form of binge drinking is a common problem in the adolescent and emerging adult population and a major problem on Canadian campuses. One large US study reported that most college students with psychiatric disorders had onsets prior to entering university or college, the exception being substance use disorders, which tended to onset after entry into college. ⁵

As discussed in this issue of the journal by Brownlie and colleagues, ⁶ substance use in adolescents is associated with poor outcomes, including worsening health, relationship problems, and lower academic achievement—especially when co-occurring in the context of other mental health problems. In their Ontario school study, they found that a substantial proportion of adolescents with above-threshold internalizing and externalizing symptoms and almost a third of those reporting suicidal thoughts had not received any mental health services within the past 12 months. Furthermore, many adolescents who did receive services attended fewer than 6 sessions, suggesting that their mental health needs remained unmet even after speaking to a professional. These findings highlight the need for effective and engaging school-based education initiatives, improved access to mental health services, and youth-focused engaging early intervention programs that target both mental health and substance use disorders in student populations.

While clinical depression and substance use are strongly associated with self-harm in youth, another important contributor is psychological distress associated with social exclusion. As reported in this issue by Kim and colleagues, ⁷ a study using the Ontario Student Drug Use and Health Survey data found that cyberbullying victimization was associated with increased psychological distress, suicidal ideation, and delinquent behaviour among male and female students in grades 7 to 12. Their results also provided evidence that cyberbullying victimization was more prevalent among female students and associated with an increased risk of substance abuse. This research highlights the importance of considering psychosocial factors contributing to psychological distress in the student population, which are associated with poor outcomes in part through underdeveloped coping strategies.

A major limiting factor to informed planning and development of resources targeting youth mental health is a lack of data within and across provinces in Canada. We have no direct estimate of these costs that are spread across a wide variety of different public institutions and agencies. In this issue, Jacobs and Lesage ⁸ provide one of the first broad assessments of Alberta’s mental health expenditures for youth. They estimated that in the 2014/2015 fiscal year, 9.2% of youth in Alberta identified as having used mental health– or addiction-related services. The cost for over 27,000 youth who used such services was estimated at $175 million, equating to $6460 per youth. Public school supplements were the largest expense, accounting for 30% of total costs and supporting almost 7000 students who were identified as having moderate to severe emotional problems.

Most of the research on student mental health has been completed on high school populations using cross-sectional survey data. There is a clear need for specific data describing the mental health needs of our postsecondary student population. Ideally, studies would take a longitudinal approach to understand causal pathways leading to both positive and negative academic and mental health outcomes. Queen’s University in collaboration with the University of Oxford has just launched the U-Flourish study (http://www.queensu.ca/studentwellness/health-promotion/u-flourish-student-health-project). The study surveys incoming students across all programs and colleges at the beginning and at the end of first year and tests a comprehensive model of the determinants of emotional well-being and academic success during this transition to university life. To our knowledge, this is the first time that important family, personal, lifestyle, and environmental factors, along with access to student academic and mental health resources, will be assessed together in a single prospective study in first-year university students. The baseline survey, completed in September 2018, had an unprecedented recruitment rate of 3029 first-year students (almost 60% of the target population), setting this study apart from prior student surveys. We feel that the student-informed and student-led awareness campaign in collaboration with the local Queen’s Jack chapter of Jack.org fostered this level of student engagement. In March 2019, a follow-up survey will be administered, and student transcripts and academic data will be linked to survey responses at the end of the 2018/2019 academic term. We hope that this study will be a first step towards a more comprehensive understanding of the mental health needs of postsecondary students. Findings will inform the development of effective prevention and intervention programs targeting healthy lifestyle choices and coping, along with effective and engaging resources for students at risk for mental health problems and in need of student mental health resources.

In summary, more research is needed to inform our understanding of how to best support the emotional and physical well-being of postsecondary students and reduce the incidence of mental illness, substance use, and self-harm. The transition to university life comes at a critical time in biological and psychosocial development in youth who are not equipped from a neuroscience and psychological developmental perspective to navigate this step entirely on their own. At present, there are limited data to inform postsecondary institutions about how to address the spectrum of need for an increasingly diverse student population—from providing evidence-informed and accessible resiliency and academic support programs to developing effective and engaging crisis intervention and treatment programs for students in distress or with evolving mental illness. Recognizing the importance of a focused and substantial investment in student mental health research, the Canadian Journal of Psychiatry has rightly dedicated an entire issue to this topic.