Professional PaperThe Mental Health ofAustralian University StudentsVivienne BrowneSenior Policy Analyst, OrygenThe National Centre of Excellence in Youth Mental HealthJonathan MunroHead of Counselling & Psychological Support ServicesSouthern Cross UniversityJeremy CassManagerRMIT Counselling Service.AbstractAustralian and international research suggests university students are experiencing heightenedpsychological distress, in part due to academic and financial pressures, isolation, loneliness and poorself-care. University years also often coincide with the critical transition period (between the ages of 17and 25 years) when mental illness is most likely to onset.While the Australian Government’s higher education policies have driven increases in participation andequity, little attention has been given to supporting the ‘mental wealth’ of students and responding toexperiences (and risk factors) of mental ill-health which can place them at risk of academic failure.Further, mental health and suicide prevention policies across all levels of government have focused onproviding educational support within primary and secondary school settings and largely ignored the roleof tertiary education. This is despite the significant numbers of Australian young people engaged in thesesettings.There remains contention about the extent of the problem and whether the core business of highereducation delivery includes supporting students’ mental health and wellbeing. Regardless, universitiesacross Australia have been independently developing policies and programs to respond to mental healthissues presenting on campus. As such, national leadership and guidance is needed to: a) improve datacollection on the prevalence of mental ill-health among university students; b) articulate the reasonableexpectations of universities in responding to students’ mental health issues; c) describe opportunities forpartnership between universities and community mental health services; and d) promote evidence-based,appropriate and acceptable programs and interventions.Keywords: mental health, university students, counselling services, policy, early interventionIntroductionIn May 2017, Orygen, The National Centre of Excellence in Youth Mental Health (Orygen),released the report Under the radar: The mental health of Australian university students (Orygen,2017). The report aimed to:a)Build an understanding of the prevalence of mental ill-health, impact and helpseeking behaviours among university students.b)Identify evidence for effective interventions and good practice.c)Highlight current gaps in policy, program and institution responses.d)Recommend future directions for higher education and mental health policy makers,as well as sector leaders.While the report focuses on issues for university students, the authors recognise that a number ofJournal of the Australian and New Zealand Student Services Association:Number 50, October 201751

JANZSSA: Number 50, October 2017universities are dual sector, in that they deliver both higher education and vocational education andtraining (VET).In April 2016, the Australian and New Zealand Student Services Association (ANZSSA) Heads ofCounselling Services, participated in a symposium hosted at RMIT in Melbourne, Australia. Theorganisers of this event provided Orygen with a valuable opportunity to present to, and consult,attendees. The common experiences of this group, who are at the coal face in delivering supports tostudents, contributed to the recommendation for national action on this issue.PrevalenceThe paucity of Australian research and data on Australian university students’ mental health makesit difficult to accurately describe the extent of the issue. Among the general population of youngpeople we know that one in four will have an experience of mental ill-health in any given year(Australian Bureau of Statistics, 2008) and that 75 % of mental illness onsets before the age of 24years (Kessler et al., 2005).Along with findings from international research, suggesting higher prevalence of depression andanxiety among university cohorts compared to a broader population of 18-24 year olds (Eisenberg,Gollust, Golberstein, & Hefner, 2007; Eisenberg, Hunt, & Speer, 2013), a number of identifiedAustralian-based studies reported high to very high levels of distress among university students(Larcombe, Finch, & Sore, 2014; Leahy et al., 2010; Mulder & Cashin, 2015; Stallman, 2010).However, many of these studies identified limitations regarding the size and diversity of thesamples and in the reliance on self-report measures. Another paper analysing the results from threeAustralian national surveys conducted in 2007-2008 found tertiary students (including highereducation and VET) were more likely to experience mild to moderate levels of psychologicaldistress than non-students, although differences were not found for high distress (Cvetkovski,Reavley, & Jorm, 2012).In April 2017, an Australian survey on the mental health of tertiary students found 65% ofrespondents aged 16-25 years reported high or very high psychological distress while 35.4% hadthoughts of self-harm or suicide (headspace & National Union of Students, 2017). While animportant survey, with over 3000 respondents, the sample was self-selected, suggesting a skew andbias within the data.Aggregating counselling service client data has been difficult due to a lack of standardisedscreening/assessment tools and measures used and other opportunities to build our understandingare being missed. For example, the annual Student Experience survey of over 100,000 highereducation students (QILT Social Research Centre, 2017), which already asks students about theirexperiences accessing support services, could be augmented to include a small sub-set of questionsrelating to experiences of mental health and wellbeing and the perceived factors which influencethis.In this ‘data-thin’ environment, Australian university counselling services provide a valuable sourceof information on the experiences of mental ill-health among students. Many service managers andstaff have described an increase in mental health presentations which are, in some instances,complex and severe in nature (Orygen, 2017). Most counselling service managers across Australiaand New Zealand have indicated that they do not have the capacity to respond to service demand.Emerging issues included urgent presentations, suicidality, eating disorders and levels ofpsychological distress (Andrews, 2016).To further highlight the need for mental health supports on campus, a KPMG evaluation of theJournal of the Australian and New Zealand Student Services Association:Number 50, October 201752

Mental health of Australian university studentsDisability Support Programme found more students were presenting to disability services withmental ill-health and staff were unsure how to support these students. As a result the bulk offunding continued to support the needs of students with physical disabilities (KPMG, 2015).There are most likely a myriad of factors influencing this increased demand for university mentalhealth supports and services. Due to participation targets in higher education policy following theBradley Review recommendations (Bradley, 2008), there is now a significant population ofAustralian university students, 1.4 million in 2015 (Department of Education, 2016). Driventhrough a commendable equity agenda in higher education, an increasing number of these studentsare the first in their family to attend university, from low socioeconomic backgrounds (SES), ruraland regional areas and have an identified disability (including mental ill-health) (UniversitiesAustralia, 2017).Students are also likely to have higher levels of mental health literacy following exposure toawareness campaigns and prevention/early intervention programs in secondary and even primaryschool. More than ever, young people are equipped with the knowledge and skills to identify theirown mental health issues, or mental health issues in their peers, and seek support.Risk factorsA number of specific risk factors contribute to poor mental health among university students.Academic pressures and performance expectations are significant issues facing students (Deasy,Coughlan, Pironom, Jourdan, & Mannix-McNamara, 2014; Kruisselbrink Flatt, 2013). Manystudents are cognisant of the ‘rising bar’ for qualifications in Australia (VicHealth & CSRISO,2015) and are extending study into post-graduate qualifications, while enhancing their resume, andcompetitive edge, through a range of extracurricular activities.Financial pressures and low SES are also associated with higher levels of psychological distress andmental disorders among university students (Cvetkovski et al., 2012; Eisenberg et al., 2013;Stallman, 2010). A Universities Australia (2013) report found that among students, two-thirds wereworried about their financial situation and 17% reported regularly going without necessities(including food) because they were unable to afford them. Many students combine work and study(sometimes full-time loads), impacting on their quality of life, their social relationships and otherrisk factors for mental ill-health including lifestyle – such as poor diet and alcohol use(Kruisselbrink Flatt, 2013) and insufficient sleep (Hershner & Chervin, 2014; Thomee, Harenstam,& Hagberg, 2012). While struggling to ‘make ends meet’ during their time at university, manystudents are also accruing significant future debt. In 2016-17 the estimated average student HELPdebt was 19,100, taking approximately 8.8 years to repay (Department of Education and Training,2016).Rural and regional (Mulder & Cashin, 2015), Aboriginal and Torres Strait Islander (Toombs &Gorman, 2011) and international students (Forbes-Mewett & Sawyer, 2011) appear to be atincreased risk of experiencing poor mental health while at university. For these young people, thestressors of university life can be compounded by relocation from families, friendship and supportnetworks, cultural connections and traditional lands. Analysis of data from the 2013 StudentExperience Survey found low SES, rural/regional and Aboriginal and Torres Strait Islander studentswere more likely to cite health and stress reasons for considering an early course exit, compared tohigh-socioeconomic, metro and non-Aboriginal and Torres Strait Islander students for whom themain reasons for considering an early exit included: boredom, change of direction and careeropportunities (Edwards & McMillan, 2015).Meanwhile, negative and harmful experiences on campus can further impact mental healthJournal of the Australian and New Zealand Student Services Association:Number 50, October 201753

JANZSSA: Number 50, October 2017outcomes and the need for support services. On 2 August 2017 the Australian Human RightsCommission (AHRC) released Change the Course: National Report on Sexual Assault andHarassment at Australian Universities. This report presented the results of the largest ever nationalsurvey of Australian university students on sexual harassment and sexual assault. These resultsincluded that one in five survey respondents had experienced sexual harassment at university in2016 and 1.6% had experienced sexual assault in a ‘university setting’ in 2015 or 2016 (AHRC,2017).Help-seekingAustralian research suggests that among university student populations more than half are unlikelyto seek help for mental health issues (Stallman & Shochet, 2009; Wynaden, Wichmann, & Murray,2013). Students report not wanting to be seen as less capable than their peers and/or not knowingwhere to seek help. Personal stigma is particularly evidenced among young men, students fromculturally and linguistically diverse backgrounds, international students and students from low SESbackgrounds (Eisenberg, Downs, Golberstein, & Zivin, 2009).Young people identify that their preferred sources for seeking help are family and friends (MissionAustralia, 2014). Peer-based programs have flourished on university and college campuses, both inAustralia and internationally including [email protected] (Australia), (Canada) and Student Minds(UK). On some campuses, peer programs appear to have developed through student action and/or agrowing awareness that students themselves can be accessible and acceptable mental healthadvocates and facilitators of help-seeking to appropriate, evidence-based care.Impact‘Mental wealth’ is a term that has gained traction in mental health advocacy and policy discussions(McGorry, 2017). It this context it refers to the social and economic productivity which can beachieved from supporting a mentally healthy population and providing effective and early treatmentof mental ill-health.Under the radar highlights the potentially significant costs of not fostering mental wealth within theuniversity environment. The 2016 Student Experience Survey found that among students who wereconsidering exiting their course, 41% cited health and stress reasons (QILT Social Research Centre,2017). Early course exiting has an obvious individual impact. This includes futuredifficulties/delays entering the workforce and exacerbated experiences of mental ill-health througha perception of failure, damaging self-esteem and self-worth.The impact on university staff and services is already evident through the demand for campuscounselling and disability services. Teaching staff in tertiary education have also reporteddifficulties in determining appropriate responses when mental ill-health impacts a student’scapacity to complete necessary course requirements, including examinations and work-placements(Venville, Street, & Fossey, 2014).Meanwhile, the Australian Government provides a significant amount of funding to highereducation providers, subsidising tuition costs, providing scholarships and funding other programs,such as the Higher Education Participation and Partnerships Program to support participationamong Australians from low SES backgrounds. It is important that these investments not onlyincrease access to higher education but support attainment outcomes for students and the broadercommunity.In Australia, an economic cost-benefit study of investing in university student mental health has notbeen undertaken. However, a study in the United States found a social return of 6.49 on every 1Journal of the Australian and New Zealand Student Services Association:Number 50, October 201754

Mental health of Australian university studentsspent by the government on prevention and early intervention in college student mental health. Thiswas based on mitigating against course incompletion, loss of future workforce potential anddownstream mental health system costs. The study found that for community college students(where we can draw the closest parallels with Australian TAFEs) the net benefits were estimated tobe even higher at 11.39 for each dollar invested (Ashwood et al., 2015).Evidence base for programs and interventionsThere are many universities across Australia taking significant steps to develop programs andservices which respond to mental health issues on campus. These have included: awareness raisingevents and programs, mental health and mindfulness training, comprehensive online portals (suchas The Desk) and peer-based support programs.There is good evidence for the improvement of knowledge and self-perceived capacity to respondamong university staff and students trained in mental health literacy programs such as MentalHealth First Aid (B. Davies, Beever, & Glazebrook, 2016; Lipson, Speer, Brunwasser, Hahn, &Eisenberg, 2014). However, as Lipson et al. (2014) found, effects are not apparent for thetranslation of these improvements into help-seeking behaviours or mental health service utilisationamong students.There is also evidence for the effectiveness of brief interventions (three to four sessions), asdelivered by counselling and student support services, particularly among students who completethe course of therapy. Improvements in educational outcomes among students who accessuniversity counselling services are particularly evident (Connell, Barkham, & Mellor-Clark, 2008;Murray, McKenzie, Murray, & Richelieu, 2016). In the United States, self-report data from studentson the educational and academic impact of accessing counselling services found 71% respondedpositively (Reetz, Krylowicz, Bershad, Lawrence, & Mistler, 2015).There is some evidence for awareness and information programs. Studies have found positive shiftsin attitudes from brief classroom-based education programs delivered to students and staff whichraise awareness of mental health issues and services (Sharp, Hargrove, Johnson, & Deal, 2006) andin behavioural change from the delivery of strengths-based resilience building seminars (Stallman,2011). Awareness raising programs may be more effective when delivered in conjunction withother interventions, such as training. One study found that a multifaceted intervention, includingemails, posters, events and training improved willingness to seek help among students and staff(Reavley, McCann, Cvetkovski, & Jorm, 2014).Given peer-based programs are an emerging field of practice in youth mental health it is notsurprising that limited evidence exists to date regarding their effectiveness in university settings.The potential for these approaches to provide accessible and acceptable mental health supports foruniversity students is significant. However, as found from research into a peer-based supportprogram of university students in the United Kingdom, care needs to be taken to ensure the mentalhealth of peers is not compromised through their task of supporting others (Student Minds, 2016).Role of technologyTechnology has an increasingly important role in mental health service provision across Australia.These platforms respond to information and service preferences (particularly for young people) andaddress the gaps in care that exist outside normal business hours and in rural and regional areas.The Australian Government is soon to release a digital gateway to mental health care and providespeople living in rural and remote areas with Medicare rebates for online videoconferencingconsultations with psychologists (Hunt, 2017a). Further, a number of highly regarded nationalJournal of the Australian and New Zealand Student Services Association:Number 50, October 201755

JANZSSA: Number 50, October 2017mental health online/TeleWeb services already exist including: Lifeline, eheadspace, beyondblueand ReachOut.For university counselling services, technology can provide students with an alternative avenue tohelp-seeking (particularly students less likely to engage directly through conversational means). Itcan also facilitate outreach through accessible and available supports which ‘match students’schedules and not just conform to university business hours’ (Veness, 2016, p. 30). Should studentsfind it difficult to access counselling services for support, the provision of evidence-basedtechnological platforms can mitigate against the risk of them using less effective sources of support,such as peer advice on social media, or not engaging at all (Inglis & Cathcart, 2016). A number ofregional universities have implemented an out-of-hours support service in recent years including:Southern Cross University in 2013, Charles Darwin University in 2015 and Swinburne and GriffithUniversities in 2017.There is evidence for the use of technology-based interventions among university students, withsome studies finding efficacy in targeting certain mental health conditions such as depression,anxiety and stress (E. B. Davies, Morriss, & Glazebrook, 2014; Farrer et al., 2013). Therapistassisted or supported online interventions have also shown efficacy for the general population(Wagner, Horn, & Maercker, 2014) and for university students, particularly when incorporated intothe delivery of other online programs (Sharry, Davidson, McLoughlin, & Doherty, 2013).Where are the gaps?PolicyAt present there is no high level government direction provided to Australian universities regardingtheir role: a) broadly, in promoting and enhancing good mental health and wellbeing across theinstitution and b) specifically, in supporting of students who may be experiencing distress or mentalhealth difficulties.Under the radar also identifies the failure of mental health policies and programs to incorporatetertiary education settings within their focus. Orygen reviewed state, territory and federalgovernment mental health and suicide prevention policies and found very few mentioned tertiaryeducation as settings for action or program delivery. The Australian Government recentlyannounced a 52.6 million National Support for Child and Youth Mental Health Program (Hunt,2017b) to be delivered in early childhood centres, primary and secondary schools. Again tertiaryeducation settings were not included in the program’s remit. This is a significant gap in theprovision of prevention and early intervention at a point of life where experiences of mental illhealth are common and the risk of onset of mental illness peaks.Data drives policy change and the lack of regularly collected and monitored data on the experiencesof mental ill-health among university students may be contributing to the minimal recognition,investment and program activity delivered by governments. What isn’t measured often doesn’tcount and at present it is still possible for politicians, policy makers and university leaders toquestion the extent of the issue and whether it is one that really requires national attention.National guidance for whole-of-institution responsesAs identified by Veness (2016) in his report The wicked problem of university student mentalhealth, very few universities in Australia have developed a whole-of-institution policy response tomental health and wellbeing. While an overarching set of guidelines for supporting tertiarystudents’ mental health and wellbeing was released in 2011 (University of Melbourne & OrygenYouth Health Research Centre, 2011), there is a need to develop more comprehensive and detailedJournal of the Australian and New Zealand Student Services Association:Number 50, October 201756

Mental health of Australian university studentsguidance for universities. This should identify action across the institution and be linked intoexisting policy and legislative frameworks.In the United Kingdom, the peak body, Universities UK, has led this approach, initially through theMental Wellbeing in Higher Education Working Group. Strong support from the peak bodyprovides clear leadership and commitment from university Vice-Chancellors. This sets the ‘tonefrom the top’ for action across all areas of the institution as recommended by Veness (2016). Oneinstitute that has recently responded proactively to this recommendation has been RMIT University.RMIT have adopted the Framework for Enhancing Student Wellbeing (developed through apartnership between Melbourne University, Queensland University of Technology and LatrobeUniversity) as a whole-of-institution policy response. RMIT has also appointed a Project Manager,Student Mental Wellbeing Initiatives, to roll-out this framework over the next three years.There are international examples of national frameworks and guidance which can be leveraged.These include the Student mental wellbeing in higher education: Good Practice Guide (UniversitiesUK & Mental Wellbeing in Higher Education Group, 2015), as well as frameworks developed inCanada (CACUSS and CMHA, 2013) and the United States (The Jed Foundation and EducationDevelopment Center Inc., 2011). However, it is important that this guidance is translated into anAustralian context and recognises the role of the Australian community mental health system.Service provision on and off campusRegardless of opinion on whether the role of universities should extend to mental health careprovision, they do already provide support services including counselling, disability support andaccess to medical practitioners (specifically to provide brief interventions to support the attainmentof educational outcomes).As described earlier in this paper, there are significant concerns about the current capacity ofuniversity counselling services to meet demand. The International Association of CounselingServices Standards for University and College Counseling Services advise one counsellor for every1000-1500 students. However, a 2013 benchmarking survey of Australian university counsellingservices found that, in the majority of institutions, the ratio was one counsellor to every 3000-5000students (Andrews, 2016). Long wait periods for counselling appointments were also key concernsraised in submissions to the AHRC’s National University Student Survey on Sexual Assault andSexual Harassment. The Commission’s report recommended universities conduct an audit of theaverage length of time students are required to wait for non-urgent counselling appointments, aswell as the number of crisis requests, and increase resources where shortfalls were identified as amatter of urgency (AHRC, 2017).There are also instances when the mental health care needs are of an acuity beyond the universityhealth service’s remit, resources and expertise. However, a number of counselling service managersconsulted for Under the radar identified that there was a perception in the community thatcounselling services could provide treatment for students experiencing complex and severe mentalhealth issues and even suicide risk. Stronger linkages with community mental health servicesappear to be needed. This includes a greater ‘reach-in’ by these services into universities to increaseservice awareness, promote access pathways and ensure timely and seamless referrals out ofcounselling services. Some universities have sought assistance from the local health district’smental health service in the form of a Memorandum of Understanding (MOU) to formalise thecollaborative relationship between the services. This agreement recognises that both services play acomplementary role in the provision of care and support to students who experience mental healthissues and defines the continued commitment by both services to work together to achieve agreedjoint outcomes.Journal of the Australian and New Zealand Student Services Association:Number 50, October 201757

JANZSSA: Number 50, October 2017Key RecommendationsUnder the radar recommends a number of areas for future action.1. Policy responses: The Australian Government’s higher education policy agenda must recognisethat to produce a highly skilled and innovative future workforce, the core business of highereducation delivery needs to include supporting the mental wealth of students. Further, mental healthpolicies need to identify universities as settings to deliver mental health and suicide preventionprograms. There is a particular opportunity for existing government-funded school educationprograms to be extended and provide mental health training and resources to frequent contactuniversity staff (such as tutors and administration staff) as well as students. Meanwhile, allAustralian universities should make a concerted effort to develop an institution-wide mental healthstrategy and implementation plan.2. Measure it so it counts: There is a need to establish a baseline data set on university studentmental health from which to benchmark and monitor the impact of future policy and programresponses. Existing survey instruments, such as the Student Experience Survey in higher education,could be augmented to include questions regarding the experiences and influences of mental healthand wellbeing, as well as help-seeking behaviours and experiences. There are also opportunities toaggregate counselling service data to gain a better understanding of the presentations of mental illhealth among students seeking support from these services. This would require nationalcoordination to standardise screening and assessment tools used within these services.3. Leadership and national coordination: Both mental health and higher education sector driversare needed to lead and coordinate a response to this issue in Australia. Under the radarrecommends that Universities Australia and a national mental health organisation partner, such asOrygen, work together to develop a guidance, training and monitoring mechanism of universityresponses to student mental health. Bringing together a steering group of key stakeholders,including Vice-Chancellors, mental health sector leaders and students, to drive this process wouldbe an effective initial step.4. Prioritise partnerships between mental health and higher education service delivery: Thereport recommends creating interdepartmental mechanisms within government to bring togetherhigher education and mental health portfolios. There are also opportunities to develop partnershipsat a regional level by involving universities in the service planning, coordination, research andevaluation activities of the 31 Primary Health Networks, the commissioners of primary youthmental health care in Australia. As is occurring in the United Kingdom, consideration could also begiven to developing guidance for co-commissioning universities and local mental health services toprovide coordinated and seamless student mental health supports.5. Tap into technology: Online supports and interventions are acceptable and effective foruniversity student populations. They also respond to the changing delivery of higher educationwhich is increasingly provided through distance education. Under the radar recommends thatfuture evidence-based online mental health portals developed or funded by the government arepromoted and easily accessed within existing university online student interfaces. It alsorecommends further research and development of online platforms tailored to the needs, help

released the report Under the radar: The mental health of Australian university students (Orygen, 2017). The report aimed to: a) Build an understanding of the prevalence of mental ill-health, impact and help-seeking behaviours among university students. b) Identify evidence for effective interventions and good practice.