A case for college mental health services.

College represents a crucial developmental period, fraught with numerous challenges across the academic, social and personal domains. Most students successfully overcome these challenges to achieve their potential. However, in a significant proportion, these stressors interact with genetic and psychosocial adversities, increasing the likelihood of mental health issues1.

Mental health issues are prevalent among college students. There are robust and consistent reports from across the world that students in colleges have higher rates of depression, anxiety and substance use1234. The World Mental Health Survey among college students across 21 countries has reported that a fifth (20.3%) had experienced DSM-IV/CIDI (The Diagnostic and Statistical Manual of Mental Disorders-IV/ The Composite International Diagnostic Interview) psychiatric disorders in the preceding 12 months1. Similar findings have also been reported from various States in India234. Late adolescence and early adulthood also have a greater incidence of severe mental illness owing to the neurodevelopmental trajectory. It is estimated that 75 per cent of those with severe mental illness would have experienced significant symptoms by the age of 25 yr5. Thus, a sub-group of students are likely to experience the onset of severe mental illness during their time in college. The higher rates of suicide among college students also correlate with mental illness6. Worldwide, the annual rates for suicidal ideations, plans and attempts among college students have been estimated to be 16, 3 and 1.2 per cent, respectively6. In 2018, as many as 10,000 student suicides have been reported in our country7. Of atmost concern, is the consistent finding of increased vulnerability among students from the lower socio-economic strata, minorities or disadvantaged communities189.

Mental health issues in young individuals ‘cluster’ with physical underactivity and unhealthy diet which increase the risk of non-communicable diseases (NCD)10. Additional lifestyle choices like tobacco and alcohol use, and high-risk sexual behaviour are also part of this cluster10. Higher levels of distress have been associated with increased food intake, poor diet quality and consequent obesity. Globally, these risk behaviours concurrently account for almost two-thirds of cardiovascular deaths and a 3.35-fold increase in cancer mortality11.

Mental health issues in colleges across the world have been showing a marked increase both in numbers and severity1213, presumably owning to rapid socio-economic transitions, migration, the disintegration of social networks and substance use813. Educational factors like intensive curriculum, heightened competition, academic difficulties and poor competence of instructors also contribute to distress14. Although many of these factors remain understudied in the Indian context, the cross-cultural commonalities of risk factors suggest that this is likely to be applicable here too. Mental health problems have a profound impact on college students. In addition to drop-outs and poor academic achievement, it can also have long-term adverse impacts on employment, social relationships and health1815.

Although this period has a confluence of risk factors, it also presents a window of opportunity for prevention, health promotion and early interventions18. Most colleges in India and many parts of the world, do not currently have the infrastructure to address mental health problems among its students141617. Ideally, all higher educational institutions should have an accessible, culturally and developmentally integrated system of mental health support18. Clinical triaging at the first point of contact needs to ensure that the vast majority of students presenting with transient situational crises are provided the least resource-intensive counselling interventions on campus. Considering the increasing body of evidence supporting its effectiveness, internet-based interventions can be made available to bridge the shortage in mental health resources18. Most college students are familiar with newer technologies, and these have additional advantages of easy accessibility with minimal stigma18. As social and academic vulnerabilities also contribute to distress, counsellors can facilitate scholarships, additional academic support, and provide links to support groups for further help919. Access to off-campus (community) mental healthcare including psychiatric inputs should not be delayed in those with severe mental illness, uncontrolled substance use, or high risk of suicide20. This sub-group may require emergency psychiatric care, in-patient input and continued psychotropic medications (Figure). This stepped care approach will ensure access to appropriate interventions within our resource-limited setting. Considering the profound heterogeneity across Indian institutions, a ‘one size fits all’ strategy is unlikely to work. A broad framework may be prescribed; with individualized protocols for the different target groups, resources and priorities of each institution.

Figure

Suggested framework for college mental healthcare.

The preventive and promotional public health programmes that can be implemented through higher educational institutions can have a long-term public health impact. If the deliverables are comprehensive, these can deter the emergence of risk factors (i.e., increase awareness of healthy lifestyle, keeping stress under control, regular exercise, appropriate diet and adequate sleep), and reduce existing risk factors/increase health-promotional behaviours (e.g., quit substance use, practise yoga/relaxation). Further, as the links between risk behaviours, mental health problems and later NCDs are robust, promotional strategies can explicitly and jointly target risk behaviours for chronic diseases and mental health problems. Preventive interventions delivered through colleges, before the entrenchment of risk behaviours, can equip young individuals with optimal decision-making capacity. This would enable them to make the right choices, improve physical and mental well-being and reduce the risk of subsequent chronic disease18.

Another factor that requires to be addressed is the low rate of help-seeking in institutions with existing mental health services. Only about 15 per cent of students with mental health disorders were noted to have received any form of mental health intervention in the preceding year21. Factors proposed to account for this include, personal stigma, lack of awareness, not perceiving a requirement for intervention, lack of time and inaccessible services21. Tackling these issues would require a multi-pronged strategy that improves awareness and reduces stigma. All counselling units need to be provided with separate offices to ensure privacy. Students need to be assured of the confidentiality of the information shared, with the understanding that this may be breached when there is a risk to self or others. Course coordinators, teachers and student leaders can be trained as gatekeepers to identify and direct individuals with risk of mental health issues and suicide, to accessible treatment settings1822. College festivals, performing arts, posters, etc., that highlight mental health issues can improve awareness1822. In addition to increasing awareness, technology-enabled services can also address key barriers of stigma and avoidance (anxiety) related to accessing services18.

Ensuring increased access to higher education has been a priority for the Government of India in the previous few decades23. Consequently, the gross enrolment ratio (GER) in higher education for the 18-23 yr age group, has shown a 2.5-fold increase from 10 per cent in 2004-2005 to 27.1 per cent in 2020. This translates to an estimated 38.5 million students currently enrolled in colleges23. India’s new educational policy 2020, aims to achieve a GER of 50 per cent by 203524. In this scenario, the UGC proposal of 2018, to constitute a ‘Students Counselling System’ with teachers as counsellors may prove inadequate to address the increased numbers and complex mental health needs of students25.

Overall, a structured mental health inputs at the college level provide clear benefits for both students and the larger society. The lack of such a system in our country is clearly a public mental health gap. Colleges, the department of higher education, and statutory bodies like the University Grant Commission, hence need to take a lead role in the development of an integrated system of student mental healthcare in India. Currently, many elite educational institutions in India like the Indian Institutes of Technology, Science, and Management, Tata Institute of Social Sciences, and National Law School have been offering in-house counselling and mentorship programmes2627. Services provided are free and accessible to all students enrolled. Help when provided to others like faculty or dependents are mostly advisory. Face-to-face services are available only during working hours with information being provided on the nearest mental health facility or out-of-hours telephonic support for emergencies. Student support networks, peer-support models and layered counselling service models have been implemented in such colleges2627. However, mental health support systems are sparse in a vast majority of institutions, especially those in semi-urban and rural areas. Although small, a significant step to bridge this gap was recently taken by the Department of Collegiate Education, Government of Kerala. ‘Jeevani’ is a structured comprehensive college mental health project launched in all Government Arts and Science Colleges in Kerala28. It is the first State-wide intervention in the country that provides for therapy units manned by qualified mental health counsellors. Currently, there is no published literature on outcomes/audit of college mental health programmes from India. Although much needs to be done, these programmes represent small steps in the right direction.

To conclude, mental health issues are prevalent among college students and if left unaddressed lead to long-term negative personal, social, academic and occupational outcomes. This is a key public health priority for India as the number of students enrolling in our higher educational institutions is increasing. Hence developing structured evidence-based mental health services in all higher educational institutions with provision for continuous evaluation of effectiveness is the way forward.