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Mental health issues such as anxiety and depression are a profound problem for society. It has been reported that university students have higher rates of depression than the general population1. In fact, depression and anxiety on college campuses have been found to be higher for university students than the general population for both low2-6 and middle-income countries.7,8
Despite these findings, the Royal College of Psychiatrists in the UK indicated that only 4 percent of UK university students utilize university counseling services.9 The problem for university students is that they are often presented with a unique set of circumstances. For example, they are often away from home for the first time in their lives, needing to make new friends and deal with stress-evoking events like exams, student debt, and finding a job after graduation. These problems are often compounded by the fact that students are sometimes not able to attend an appointment with a mental health care worker due to exam scheduling and holiday breaks.
Given these issues, there has been a growing call for more innovative pathways for mental health support of university students.10 One option is to use eHealth in the form of delivering a psychological intervention over the telephone or internet.11
One type of therapy which has shown to be effective for a number of mental health disorders, including anxiety, stress, and depression, is called acceptance and commitment therapy (ACT).12 This is what is known as a third-wave therapy, meaning it is one of the more recent types of therapies to have been developed. Its approach is to build something called psychological flexibility in an individual by developing six key processes: a sense of being mindful in the present moment, openness and acceptance, realizing that thoughts are just thoughts and not to buy into them (called cognitive defusion), commitment to values orientation (in a flexible way), and to develop a flexible transcendent self where you are an observer of your thoughts rather than a product of them (i.e., you are not your thoughts).
Psychological flexibility is developed in order for the client to work towards a meaningful life despite the ongoing problems life generates. So, this approach encourages openness and acceptance rather than avoidance and is beneficial, as avoidance can often lead to harmful rigidity of behavior. This is very different than the more traditional second-wave therapy called cognitive-behavioral therapy (CBT), which focuses on the mental reconstruction of faulty thoughts.
In Wales, where I am based, mental health services in the National Health Service (NHS) are provided through tiers that provide different levels of treatment intensity at each tier. The tiers start at 0, which involves low-level interventions, such as a self-referral program called "Living Life Well" and consists of a CBT course called stress control, as well as an ACT course called Activate Your Life (AYL). These courses are available to the public and are psychoeducational in the sense that they are presented by trained presenters, and members of the public essentially learn the ACT or CBT principles.
This approach is consistent with the National Institute for Health Care Excellence (NICE) guidelines, which indicate that low-level interventions should be sought first before more complex (and expensive) interventions are considered. However, though these courses are successful in that they are effective at reducing stress and anxiety, they are not always accessible to students with their unique set of circumstances.
Some work that has involved utilizing technology in the form of eHealth applications delivering ACT and other third-wave therapies have been found to be effective.3 One example of this includes an ACT web-based internet application of several 40-minute sessions called You Only Live Once (YOLO),14 and at my own lab, we have developed a very short (10-minute sessions) online ACT psychoeducational course called Bite of ACT (BOA).15
Providing greater options such as YOLO or BOA may provide students easy, accessible resources for mental health that do not replace normal pathways, such as counseling services and referrals to GP or NHS courses. Instead, they may offer some support to students when these usual pathways are not always readily accessible.
Hopefully, these kinds of flexible mental health support pathways can be made available to students in the future. They could be implemented through the usual student and counseling services as well as university websites, which would provide students with greater flexibility in terms of treatment options. Students could access these services at any time of the day, and any day of the week, whether they are on or off-campus.
Finally, therapies such as ACT are transdiagnostic, meaning that they are useful for many types of populations with different mental health conditions. For this reason, there is scope for these types of therapies to be made available to the general population, too, for those who may benefit from them.
References
1. Ibrahim, A.K., et al., A systematic review of studies of depression prevalence in university students. Journal of psychiatric research, 2013. 47(3): p. 391-400.
2. Mayer, F.B., et al., Factors associated to depression and anxiety in medical students: a multicenter study. BMC medical education, 2016. 16(1): p. 282.
3. Mkize, L., N. Nonkelela, and D. Mkize, Prevalence of depression in a university population. Curationis, 1998. 21(3): p. 32-37.
4. Asante, K.O. and J. Andoh-Arthur, Prevalence and determinants of depressive symptoms among university students in Ghana. Journal of affective disorders, 2015. 171: p. 161-166.
5. Othieno, C.J., et al., Risky HIV sexual behaviour and depression among University of Nairobi students. Annals of general psychiatry, 2015. 14(1): p. 16.
6. Ovuga, E., J. Boardman, and D. Wasserman, Undergraduate student mental health at Makerere University, Uganda. World Psychiatry, 2006. 5(1): p. 51.
7. Dyrbye, L.N., M.R. Thomas, and T.D. Shanafelt, Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Academic medicine, 2006. 81(4): p. 354-373.
8. Hope, V. and M. Henderson, Medical student depression, anxiety and distress outside N orth A merica: a systematic review. Medical education, 2014. 48(10): p. 963-979.
9. Callender, J., et al., Mental health of students in higher education. London: Royal College of Psychiatrists, 2011.
10. Randall, E.M. and B.M. Bewick, Exploration of counsellors' perceptions of the redesigned service pathways: a qualitative study of a UK university student counselling service. British Journal of Guidance & Counselling, 2016. 44(1): p. 86-98.
11. Sucala, M., et al., The therapeutic relationship in e-therapy for mental health: a systematic review. Journal of medical Internet research, 2012. 14(4): p. e110.
12. Hayes, S.C., Get out of your mind and into your life: The new acceptance and commitment therapy. 2005: New Harbinger Publications.
13. O’Connor, M., et al., The efficacy and acceptability of third-wave behavioral and cognitive eHealth treatments: A systematic review and meta-analysis of randomized controlled trials. Behavior therapy, 2018. 49(3): p. 459-475.
14. Levin, M.E., et al., Web-based acceptance and commitment therapy for mental health problems in college students: A randomized controlled trial. Behavior Modification, 2017. 41(1): p. 141-162.
15. Edwards, D.J., et al., Novel ACT-based eHealth psychoeducational intervention for students with mental distress: a study protocol for a mixed-methodology pilot trial. BMJ open, 2019. 9(7): p. e029411.
