Online mental health – revolutionary help in higher education?

A psychology undergraduate in her second year, 'Nora' has recently been on an alarming downward spiral. Three years ago she began experiencing symptoms of depression and anxiety, and she found it hard to stay motivated and focused on her studies. She has lost interest in daily activities and is suffering from a lack of energy. She regularly feels anxious about deadlines and uncompleted work, and as a result, she often chooses to go out with her friends so that she can forget about her studies. The money she spends on these nights out has made her financial situation unstable, further increasing her worries. A breakup with her boyfriend has put further strain on her emotional state. When seeking help from the student support services, she was put on a long waiting list to see a counsellor.

Nora's story is typical of many higher education (HE) students suffering from psychological and/or academic difficulties. According to a recent survey of 1,093 students by the National Union of Students (NUS), 78 per cent experienced mental health issues in the past year, with 33 per cent of participants having suicidal thoughts. NUS research has shown that course deadlines (65 per cent), exams (54 per cent), and financial difficulties (47 per cent) are key triggers of mental distress. Furthermore, only 7 per cent of the surveyed students reported that they were very satisfied with the support received at their institution.

According to Ibrahim and colleagues' 'systematic review of studies of depression prevalance in university students', many of the difficulties experienced stem from moving away from home and the new financial responsibilities that come with transitioning into higher education. Living away from family can seem desirable to young people. However, the sudden lack of social and financial support, as well as unhealthy eating and sleeping habits, often paired with increased alcohol consumption, can lead university students to experience substantially higher rates of depression than those found in the general population. Researchers led by Day found that in addition to moderate anxiety, depression, and stress, some experience more serious mental health issues. Furthermore, Peter Musiat's team noted that university students may be subject to eating disorders, sleep disorders or substance abuse for the above reasons.  

Whether mental health conditions pre-exist in students arriving at university or are triggered by new experiences, it is essential that HE students are aware of the mental health services available to them. According to the NUS survey, one third of student respondents would not know where to get mental health support if they needed it. In addition to this lack of knowledge about available services, perceived stigma and accessibility have been recognised as barriers to help-seeking.

This is all so important in part because mental wellbeing is pivotal to social and academic success. Keyes and others have found that students who underestimate the impact of psychological health are less likely to have social contacts at university, less likely to be satisfied with their studies, and more likely to drop out.

Encouragingly, increasing openness about mental health issues has led to more HE students seeking help in recent years. However, with the sector struggling to meet this demand, there has been an increase in student-led initiatives (e.g., Students Against Depression), awareness raising programs (Student Minds), and partnerships with external agencies (including the NHS and Improving Access to Psychological Therapies). 

Web-based intervention

Recent technological advances have called attention to the concept of web-based mental health interventions as a viable alternative to on-campus services. Elizabeth Barley, professor in health and wellbeing at the University of West London, has argued that 'online therapy is effective for mild to moderate mental health problems in the general population. Online interventions are potentially very useful for students with such problems especially given the desperate shortage of one-to-one support within educational institutions. Furthermore, students' problems are often linked with difficulties managing their studies, online interventions can potentially help address these simultaneously'.

Considering the significant role that technology plays in young people's life, intervention and support through various forms of electronic media, handheld devices, and apps seems an effective way for students to access help. The Royal College of Psychiatrists proposed web-based interactive cognitive behavioural therapy as a suitable option for students with mild to moderate depression and without access to face-to-face therapy (2011). Computerised interventions are not only time- and cost-effective but are readily accessible and provide the comfort of 'handheld support' going wherever the user goes. Furthermore, 2013 research from Farrer et al. suggested that the use of personalised technology increases independence and reduces perceived stigma related to mental health disorders. Encouragingly, recent work by Jones found that students benefitting from web-based interventions are more likely to seek face-to-face help should their needs continue.

Table 1: Key characteristics of web-based support systems that are currently or soon to be available for UK HE students

In sum, there is increasing evidence supporting the efficacy of web-based interventions for mental health disorders. A growing number of people are using the internet for social and emotional support, advice, and guidance with easy access via their smartphone at any time of the day or night. Online interventions can reach struggling young people, who are too embarrassed to directly share their worries. Moreover, internet-based interventions can reach people who can't afford standard therapy fees. With such unprecedented and convenient 24-hour access to help and support, online mental health systems offer a way forward for users – and may be the first step in the direction of more traditional therapy.

MePlusMe

Two years ago I read an article about online mental health care in The Psychologist. Dr Patapia Tzotzoli, CEO of iConcipio, the company developing MePlusMe, was looking for researchers to contribute to the development of the system and to explore ways in which it can be used among university students. She explained that 'higher educational institutions' support mechanisms are currently struggling to meet the increasing demands of students with mental health difficulties. Thus, an alternative means of support is now needed more than ever. No solution makes more sense than an online intervention that has been shown to be effective, is easy to use, is low-cost, and protects students' anonymity.' This struck a chord with me: one of my sons has Type One diabetes, and recent advances in technology have improved his care tremendously. Not only did technological development improve his condition but it also eased the burden on us, his caregivers. It is my hope that the use of technology in mental health care will have similar benefits for patients and their caregivers.

I began my work with iConcipio by researching existing systems and understanding what is currently available. Like some other systems, MePlusMe offers support to students with mild to moderate mental health difficulties and study skills. Having been developed by psychologists and researchers based on research into existing student needs, it supports a needs-driven approach as opposed to a one-size fits all model. As well as individual and personalised support, the system offers a built-in moderated social network, the 'Thoughtwall', which aims to enhance the feeling of belonging to a student community with similar difficulties. When asked about MePlusMe, one user reported 'As a student, it can be hard to find the time to physically go out for help, especially if you're suffering from mental health issues. It makes it a lot harder to find the motivation or confidence to seek and pursue help. It's very easy to just go online for the help and it is much more private. I think young people are much more likely to go online more for support and actually keep up with it.' 

Universities' concern about student dropout rates has been well documented in recent years. Increasing the level of support available to students and recognising early warning signs is in everyone's best interest. However, with so little evidence available about the effectiveness of online intervention systems, student support services at universities have restricted tools available to provide support. Left untreated, mental health problems can not only become more severe, but often lead to other difficulties, including social withdrawal, study skills deterioration, and increased dropout rates. By incorporating an online intervention system in their services, an additional tool will be available to meet the university's pastoral role to students and, potentially, reduce dropout rates.

Reason for optimism?

Meeting the demand for mental health support in higher education is neither a new challenge, nor one that seems to be getting any easier. However, ensuring that the mental health of young people is managed effectively is key to sustaining a functioning mental health care system, increasing individual quality of life, and decreasing the cost of mental illness on society. Independent research has already proven the efficacy of some existing online mental health care systems. On the other hand, when it comes to strategies to improve mental health care, might individual differences and responses to interventions be considered as valid as effectiveness studies? 

Current funding for traditional student support services and accessibility to face-to-face therapy don't suffice to meet the growing demand for mental health support by HE students. Nonetheless, there is reason for optimism. Recent advances in technology, providing online interventions with round-the-clock availability and flexibility, combined with personalised, tailor-made support has the potential to reconfigure the concept of mental health care. Such a revolution in care for mild to moderate problems would ensure that more resources are available to those needing higher levels of support. Harnessing the power of technology and providing evidence for the efficacy of online interventions to meet individual needs will enable us to create a sustainable mental health network for HE students, and ensure that those at risk get the help and support they need. 

- Erika Payne graduated with a MSc in Psychology from the University of Derby in June 2016.

References

Dahlin, M., Joneborg, N. & Runeson, B. (2005). Stress and depression among medical students: A cross‐sectional study. Medical Education, 39(6), 594-604.

Davies, E. B., Morriss, R., & Glazebrook, C. (2014). Computer-delivered and web-based interventions to improve depression, anxiety, and psychological well-being of university students: a systematic review and meta-analysis. Journal of Medical Internet Research, 16(5), e130.

Day, V., McGrath, P. J., & Wojtowicz, M. (2013). Internet-based guided self-help for university students with anxiety, depression and stress: a randomized controlled clinical trial. Behaviour Research and Therapy, 51(7), 344-351.

Farrer, L., Gulliver, A., Chan, J. K., Batterham, P. J., Reynolds, J., Calear, A., ... & Griffiths, K. M. (2013). Technology-based interventions for mental health in tertiary students: systematic review. Journal of Medical Internet Research, 15(5), e101.

Gulliver, A., Griffiths, K.M. & Christensen, H. (2010). Perceived barriers and facilitators to mental health help-seeking in young people: a systematic review. BMC Psychiatry, 10(1), 113. 

Ibrahim, A. K., Kelly, S. J., Adams, C. E., & Glazebrook, C. (2013). A systematic review of studies of depression prevalence in university students. Journal of Psychiatric Research, 47(3), 391-400.

Jones, M., Kass, A. E., Trockel, M., Glass, A. I., Wilfley, D. E. & Taylor, C. B. (2014). A population-wide screening and tailored intervention platform for eating disorders on college campuses: the healthy body image program. Journal of American College Health, 62(5), 351-356.

Keyes, C. L., Eisenberg, D., Perry, G. S., Dube, S. R., Kroenke, K., & Dhingra, S. S. (2012). The relationship of level of positive mental health with current mental disorders in predicting suicidal behavior and academic impairment in college students. Journal of American College Health, 60(2), 126-133. 

National Union of Students. (2015). Mental Health Poll November 2015. Retrieved on March 30, 2017 from https://nusdigital.s3-eu-west-1.amazonaws.com/

Musiat, P., Conrod, P., Treasure, J., Tylee, A., Williams, C., & Schmidt, U. (2014). Targeted prevention of common mental health disorders in university students: randomised controlled trial of a transdiagnostic trait-focused web-based intervention. PloS One, 9(4), e93621.

Royal College of Psychiatrists. (2011). The Mental Health of Students in Higher Education 920 (Council Report CR166) 

Universities UK. (2015). Student mental wellbeing in higher education. Good practice guide. Retrieved on March 30, 2016 from http://www.universitiesuk.ac.uk/