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Access to Mental Health Care by Graduate Students and Barriers Encountered
CHAPTER ONE
OVERVIEW OF THE STUDY
Having access to mental health care is a worldwide problem. One population that is affected are graduate students, who typically suffer undue pressure because of an academic focus of success; there is a significant amount of academic pressure that exists simply due to the amount of material and knowledge that is placed upon graduate students when they are pursuing their degrees. Not only do graduate students encounter academic pressure, they also may experience social pressure, financial pressures, and often familial or work-related responsibilities. All of this can contribute to stress and anxiety (Hoover & Lucas, 2023).
Graduate students may experience unfavorable impacts due to unexpected training periods, financial and food hardship, competitive tenure-track markets, and demanding publication criteria. Mental health issues in graduate students can impact their physical health, relationships, academic achievement, and professional performance, and can contribute to students leaving their programs (Satinsky et al., 2021). Additionally, Hoover and Lucas (2023) state that Graduate students encounter several pressures, including the expectation to publish their research findings, all the while navigating the emotional challenges associated with the potential for rejection. All these pressures while transitioning into new environments and habits by graduate students contribute to distress as they struggle to adjust to academic life which contributes to stress and anxiety (Lischer et al., 2021; Paula et al., 2020).
One potential approach to mitigate the experience of stress and anxiety involves seeking mental health care. The current techniques aimed at addressing stress and anxiety differ between on-campus and remote learning environments, indicating a lack of universality. Models for mental health treatment within universities consist of short-term counseling with various theoretical models (Duffy et al., 2019). The purpose of this study is to determine what problems exist in graduate students and what services are available to help treat them. A scoping review will contribute to a better understanding of the mental health needs of graduate students’ and their relationship to access of services.
Background of the Problem
According to the United States Census, the population of California as of April 2020 was recorded as 39,538,223. Regarding educational attainment, it was observed that 84.2% of individuals aged 25 years and above had successfully acquired a high school diploma or a higher level of education during the period spanning from 2017 to 2021. Furthermore, according to data from the U.S. Census Bureau (2020) it was found that throughout the period from 2017 to 2021, approximately 35.3% of the population in California possessed a bachelor’s degree or a higher level of education. This statistic pertains explicitly to individuals who were aged 25 years or older.
Furthermore, according to the National Center for Science and Engineering Statistics, a survey conducted on individuals who have obtained advanced degrees, it was found that in the year 2021, there was a global population of 1,185,750 individuals who possessed a research doctorate in the fields of science, engineering, or health (SEH) from an academic institution in the United States. This figure represents an increase of 36,950 individuals, or 3.2%, compared to the data from 2019. Within this particular cohort, a total of 1,023,650 individuals, including 86.3% of the group, were residing within the United States. Conversely, 162,100 individuals lived overseas during the specified period (National Center for Science and Engineering Statistics, 2023).
However, the Coronavirus pandemic of 2019 disrupted several areas of life for the general population and graduate students who already struggle with increased stressors that accompany striving for an advanced degree. As a result, any additional changes to this can contribute to an increase in mental health needs by this population. Browning et al. (2021), wrote that college students are particularly vulnerable to the effects of COVID-19 because of anxiety about their academic performance, their ability to find a job after graduation, and their ability to maintain social relationships while attending university. Anxiety, depression, low self-esteem, physical health issues, substance misuse, and thoughts of suicide were all on the rise among students worldwide long before the pandemic.
It is well known that mental health disorders affect individuals regardless of racial,
ethnic, cultural, or socioeconomic background. The Diagnostic and Statistical Manual of Mental Disorders V (DSM-V) defines mental disorders as a syndrome characterized by clinically significant disruptions in behavior, cognition, or emotional regulation that suggest an abnormality in the developmental, genetic, or emotional mechanisms underlying mental functioning. Mental disorders are commonly accompanied by significant distress or impairment in areas such as employment, social functioning, or other essential activities. Culturally acceptable or expected reactions to significant distressing events or losses, such as the bereavement of a loved one, do not meet the criteria for diagnosing a mental disorder (American Psychiatric Association, 2013).
Significant distress in graduate students would be aiming for higher education while maintaining several other facets of their lives, such as employment, family, and social life. As such, emphasis shall be placed on the mental health needs of graduate students and barriers to receiving and accessing mental health services. As discussed earlier, graduate students encounter abundant stress as they aim to achieve a higher level of education. At the same time, many struggle to provide for their families amidst the uncertainty of grades and achievement of degrees (Satinsky et al., 2021)
Statement of the Problem
It is critical to comprehend the challenges graduate students encounter while trying to access mental health services, as there has been an increase in those seeking advanced degrees and graduate students struggling with mental health disorders (U.S. Census Bureau, 2022; World Health Organization, 2022). According to the U.S. Census Bureau (2022) the number of people with a doctoral degree increased significantly to 4.7 million between 2011-2022. The number of people with postgraduate degrees rose by 54.5%. The adult population with an advanced degree rose from 10.9% in 2011 to 14.3% in 2021. According to Fabina et al. (2023), there was a significant rise in the enrollment of graduate students from 2011 to 2019, with a total growth of 195,000 students. Subsequently, between 2019 and 2021, graduate enrolment was further increased, amounting to 273,000 students. The observed growth in graduate enrollment was evident in both public and private educational institutions for the period spanning from 2019 to 2021.
Additionally, in 2019, 1 in every 8 people, or 970 million people worldwide, lived with a mental disorder; anxiety and depressive disorders were seen as the most common. 301 million people had an anxiety disorder, and 280 million had depression (World Health Organization, 2022). These numbers include graduate students as well. The Healthy Minds Study gathers information from 373 sites nationwide and reports that more than 60% of college students had at least one mental health problem during the 2020–2021 school year (Healthy Minds Network, 2021).
Furthermore, Chrikov et al. (2020) reported in 2020, the incidence of major depressive disorder in graduate and undergraduate students was twice as high as that observed in 2019. Also, the anxiety disorder rate was 1.5 times higher in 2020 compared to the previous year. According to data from The Center for Collegiate Mental Health (2021), for over 700 counseling centers in colleges and universities, there was an escalating demand for mental health needs and unmatched services due to increased caseloads. Centers average more than 300 students per fulltime college counselor, but the national average is 120. The increase in caseload does not allow for adequate assessment of students struggling with pressing mental health issues, which can lead these students to feel discouraged.
Therefore, this study aims to investigate the current state of mental health among graduate students, identify the barriers that prevent adequate support and care from being provided, and propose potential solutions to these challenges. The consequences of not addressing this problem include not knowing the extent of mental health concerns within the graduate population and not having solutions to help implement changes.
Purpose of the Study
The purpose of this study is to explore the current state of mental health treatment among graduate students, identify the barriers that prevent adequate support and care from being provided, and propose potential solutions to these challenges. A scoping review will be conducted in which existing data will be gathered and analyzed. Data could encourage allow mental health professionals to evaluate, and institute change for improved delivery of service.
Research Questions
RQ1. What are the barriers that prevent graduate students from seeking treatment?
RQ2. What is the extent of mental health treatment for graduate students on campus?
RQ3. Does an individual’s socioeconomic status, background, and ethnicity have any impact on a person’s ability to seek mental health treatment?
Theoretical Framework
The theoretical model for this research study is the health belief model (HBM). The HBM theorizes that health-related behaviors depend on several inter-dependent factors, including susceptibility and severity, threat, and benefits and barriers perceptions (Kagee & Freeman, 2017). It explains why individuals do not adopt specific preventive health behaviors. According to HBM, individual’s behavioral change depends on three co-occurring behaviors: (a) the individual’s recognition of sufficient reasons for health concerns (susceptibility and severity perceptions); (b) the individual’s understanding of being susceptible to an illness or an adverse health outcome (threat perception); (c) the individual’s recognition of the need for behavioral change and the benefits of such change outweighing the costs (benefits and barriers perceptions) (Oguamanam & Oguamanam, 2018).
HBM was applied as a conceptual framework in related research studies. Henshaw and Freedman-Doan (2009) used it as a framework for mental healthcare utilization conceptualization – exploring factors that encourage or inhibit an individual’s mental health services utilization. Nobiling and Maykrantz (2017) applied HBM to explain college students’ perceptions concerning mental illnesses and the use of mental healthcare services. Oguamanam and Oguamanam (2018) applied it as a theoretical framework for exploring mental healthcare providers’ perceptions concerning the barriers to utilizing mental health services. A more recent research study used the model to identify factors influencing mental healthcare-seeking or mental health services utilization or seeking beliefs in college students with depression (Lilly et al., 2020).
The HBM will also be applied in this research study, which is based on the theoretical concepts underlying the development and application of the model and evidence from previous mental health research studies. The HBM will be applied in this research study to explore and identify the barriers to adequate mental health care support among college students. Having identified the barriers, HBM will be used to inform the potential solutions to address them.
Significance of the Study
The issue of graduate students’ access to mental health care has significant implications for both individuals and families. The comprehensive understanding of the direct and indirect impacts of mental health care accessibility on this particular demographic remains incomplete. Consequently, the objective of this study is to address this knowledge gap by investigating the correlation between graduate students’ access to mental health care, or the absence thereof, and the subsequent effects of such care on their mental well-being.
One notable factor contributing to the strain experienced by graduate students is the need to effectively balance other facets of their lives, such as work, familial responsibilities, and social commitments, alongside their pursuit of an advanced academic degree. These stresses have the potential to lead to the development of mental health disorders, such as stress and depression (Hoover & Lucas, 2023). Therefore, it is imperative to prioritize the psychological well-being of graduate students and address the obstacles they encounter in accessing and utilizing mental health treatments.
Anxiety and depression were the most frequent mental disorders in 2019, affecting 1 in 8 persons (970 million worldwide). 301 million experienced anxiety and 280 million depression (WHO, 2022). The increase in mental disorders also affects graduate students and services provided at college and university centers. The rise in demand for mental health services leads to an escalation in case volumes at community centers, potentially resulting in inadequate provision of necessary services to those in urgent need. Consequently, this study can offer valuable insights to guide the development of more efficient policy approaches. Furthermore, these findings have the potential to contribute to the enhancement of access and provision of care for graduate students who are experiencing challenges related to mental health illnesses.
A scoping review is planned to be performed, where existent data will be collected and assessed. Data enables mental health providers to assess and implement modifications aimed at enhancing the delivery of services. The primary research question to be answered is what are barriers that prevent graduate students from seeking treatment? The hypothesis is that graduate students refrain from seeking mental health treatment due to the stigma associated with mental health disorders.
Limitations and Delimitations of the Study
This study will be based on a scoping review as such limitations in the literature include data gathering from secondary sources versus gathering information from individuals. In this case, graduate students. Additionally, the information being collected is from organizations such as the World Health Organization and U.S. Census Bureau. Yet, mental health services are sought primarily by mental health clinicians and practitioners who are not being surveyed.
This study is limited by the fact that it is based on a scoping review and no other methodology will be employed. Additionally, this study will only focus on graduate students and those who have attempted to access mental health treatment and may have or have not encountered a barrier to treatment. In addition, only graduate candidates in the United States will be examined.
Definitions and Key Terms
Cohort
A cohort is a group of subjects. In a cohort study, the cohort is made up of subjects who meet the study selection criteria (Andrade, 2022).
Coronavirus
Coronavirus disease 2019 (COVID-19) is a newly emerged disease that has become a
global public health concern as it rapidly spread around the world (Paudel, 2020).
Ethnic Background
The family background they come from that shapes their inalterable characteristics such
as their genetics, race, the social culture they were brought up in and their heritage (Hamer et al.,
2020).
Mental Illness
Mental disorder (earlier entitled “illness” or “disease”) is ascribed to deviations from normal thoughts, reasoning, feelings, attitudes, and actions that are by their subjects, or by others, considered socially or personally dysfunctional and apt for treatment (Radden, 2019).
Stigma
Stigma was initially theorized by Goffman (1963) as an individual’s experience of disgrace, a kind of mental identification, a “spoiled identity” resulting from processes of discrimination (Murney et al., 2020)
Susceptibility
Differential susceptibility theory stipulates that some individuals are more susceptible than others to the positive and the negative effects of, respectively, supportive, and adverse developmental experiences (e.g., harsh parenting) and environmental exposures (Belsky et al., 2022).
Systematic Review
Systematic reviews and meta-analyses present results by combining and analyzing data from different studies conducted on similar research topics (Ahn, 2018).
Theoretical Model
A theoretical framework is a logically developed and connected set of concepts and premises—developed from one or more theories (Varpio et al., 2020).
Vulnerable
The literal meaning of the term “vulnerability” is the state or condition of being weak or poorly defended. The concept vulnerability with regard to young people implies the ones who are more exposed to risks than their peers (Ferreira et al., 2021).
Organization
The subsequent sections of the research paper will be discussed consequently, beginning with Chapter Two, which comprises the literature review. This chapter will undertake an analysis of the existing research concerning the correlation between mental health among graduate students and the presence or absence of barriers to care. The primary question to be identified is what are barriers that prevent graduate students from seeking treatment? Additionally, identification of any literature gaps and discussion of the research question will both be included.
The methodology that was applied to this investigation will be discussed in Chapter Three. This study made use of a process known as scoping for its methodology. This approach involves searching for articles that contain certain terms, such as “mental health in graduate students,” filtering through articles, compiling and highlighting important concepts and theories, as well as identifying gaps in the research.
Chapter Four will primarily focus on the outcomes of the study as a direct consequence. This chapter will include a comprehensive analysis of the findings, along with a detailed examination of the collected data. An examination of the themes and patterns that will be discovered shall be conducted. In consideration of the research topic at hand, which pertains to the identification of obstacles impeding graduate students from obtaining therapy, then proceed to examine the obtained results in connection with this inquiry.
In conclusion, Chapter Five will entail a comprehensive analysis and interpretation of the findings obtained in the preceding chapter. This study will delve into the implications of the study, as well as explore potential avenues for future research pertaining to the mental health of graduate students, including the identification of barriers or the absence thereof in accessing appropriate treatment. Furthermore, it is recommended additional research be undertaken in order to further develop the subject of study.
CHAPTER TWO
LITERATURE REVIEW
The educational transition might be challenging because the transitioning students are exposed to a new life experience, which includes a new academic environment, an extra academic load, and new social requirements (Thompson et al., 2021). According to Sarrico (2022), the estimated number of young adults who will enroll and gain admission to a doctorate program was estimated to increase by 2.3%. In the United States, the number of graduate student enrollment increases annually. Zhou and Gao (2021) reported the number of graduate school applications in the United States rose by 7.3% between 2019 and 2020. This includes an increase in public school admission applications by 6.1% and private school admission applications by 9.2%. According to the authors, the increase in graduate school admission applications was significantly higher compared with the last decade. Graduate students face several educational challenges, including academic challenges, economic or financial challenges, sociocultural challenges, and psychological challenges (Laframboise et al., 2023; Oduwaye et al., 2023). Such challenges impact several aspects of the student’s life, particularly their mental health. Evidence has revealed such factors, including psychological, academic, social, and economic factors, are risk factors for stress, anxiety, and depression – significantly contributing to graduate students’ poor mental health (Beasy et al., 2020; Guthrie et al., 2019; Pyhältö et al., 2022; Takarangi, 2019).
Evidence concerning the high prevalence of adverse mental health conditions, including anxiety, depression, stress, and psychological distress, has increased public health concerns; therefore, there is growing interest in exploring the mental health of students (Lubega et al., 2023). According to Snyder (2014), reviewing the literature concerning a research topic is crucial because it helps identify research gaps regarding the contradicting research evidence and the dissimilarities in previous research findings – informing the researcher of the unexplored problem and need for clarification by subsequently integrating previous findings to address the research questions. Therefore, in this chapter the literature regarding the mental health conditions of graduate students, including master’s and doctoral students will be reviewed. It will include a review of the challenges graduate students face in accessing adequate and high-quality mental health care or the obstacles hindering them from having access to adequate mental health care. As such, this literature review starts with reviewing the mental health issues and the risk factors for mental health illness among graduate students. This chapter also reviews mental health help-seeking attitudes and behaviors of graduate students. Ultimately, the literature review will include a review of the graduate students’ mental health challenges and how they impact their academic performances and achievements. This chapter concludes with a summary of the literature review revealing the identified relationships and the identified gaps concerning the research topic in the literature and providing the link with the theoretical framework.
Mental Health in Graduate Students
Research evidence has indicated the prevalence of mental health issues among graduate students. Several research studies, including empirical research studies and systematic reviews, have revealed graduate students face significant challenges concerning different types or forms of mental health issues in the student population. Ward (2013) reported it is important to identify and understand the prevalence of health issues in a given population and at a particular location to develop a suitable or proper plan for providing for the population’s health and mitigate the incidence of the health issues. More importantly, conducting a prevalence study contributes to the development of early intervention because it provides information concerning the disease baseline risk in the target population, having a positive impact on the effect measures (Harder, 2014). It is also used to provide credible evidence for investigators and contributes to making effective disease prevention policies to address the disease burden and its impacts on the population (Aldrich et al., 2015; Banks et al., 2023; Erismann et al., 2021). Therefore, this section is crucial as it reviews the prevalence of mental health disorders, including depression and anxiety, mental health risk factors such as academic stress, low postgraduate training satisfaction, and food insecurity.
Graduate Mental Health Compared with Other Populations
Researchers have compared the prevalence of mental health problems in graduate students with other populations, including undergraduates, the general population, and the working population. Evidence from such research studies has indicated the higher prevalence and severity of mental health problems in graduate students compared with the comparison populations, revealing graduate students are at higher risks of mental health problems compared with other populations (Pelayo, 2018). Additionally, Woolston 2017 investigated all the dimensions of the PhD students’ lives and their job ambitions. The research study involved multiple surveys investigating the prevalence of mental health problems in postgraduate students. The findings indicated the PhD students expressed mental health as a significant area of concern with their studies. It was stated that more than 25% of the Ph.D. students reported mental health problems as their major concern with their academic pursuits. Based on the research results, the prevalence rate of mental health problems in graduate students surpasses the prevalence rate in the general population as the mental health problem prevalence rate in graduate students was approximately 47%, significantly higher than the prevalence rate of mental health problems (18.5%) in the general population (Woolston, 2017). These findings were corroborated by findings from other researchers that investigated the prevalence rates of mental health problems in graduate students compared with the general population. In a related study by Pelayo (2018), the researchers surveyed 279 graduate students from 234 universities in 26 countries to validate survey dimensions and scales for assessing anxiety and depression. Results corroborated Woolston’s (2017) results, revealing 56% of the graduate students reported experiencing anxiety, while the risk of developing depression and anxiety in graduate students is six times higher than the risk of developing depression and anxiety in the general population (Pelayo, 2018).
Gallea et al. (2021) investigated work-related mental health problems in graduate student populations. The cross-sectional research study involved 153 PhD students. The students completed the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 (GAD-7) scale, and the Maslach Burnout Inventory-General Survey (MB-GS) to collect the data concerning the students’ mental health variables, including anxiety, depression symptoms, and burnout. The research results revealed significantly high prevalence rates of anxiety and depression in the study population. The prevalence rate of anxiety symptoms was 68% and the prevalence rate of depression symptoms was 50%. The researchers compared mental health variable scores between the graduate students and the general population and similarly reported a higher prevalence rate of mental health issues among the graduate students compared with the general population.
In another related research study, Levecque et al. (2017) examined the prevalence of mental health issues in Ph.D. students and compared the data with the general populations of well-educated individuals and well-educated workers. Mental health problem severities of the research participants were assessed using a survey questionnaire, the 12-Item General Health Questionnaire (GHQ-12). The findings indicated the proportion of post-graduate students at risk of developing mental health or psychiatric illnesses, more particularly depression, in the postgraduate students was 32%. It was similarly found the prevalence rate of mental health illnesses in postgraduate students was significantly higher compared with the comparison groups – being 1.6 to 4 times higher anxiety and depressive symptoms compared with the general populations of well-educated individuals and well-educated workers. This supports Woolston (2017), Pelayo (2018), and Gallea et al. (2021) that mental health disorders in graduate students are higher compared with the general population.
Similar findings concerning higher prevalence and risks of mental health symptoms in graduate students compared to the age-matched general population were reported. Barry et al. (2018) compared the prevalence and severity of mental health symptoms, including stress, anxiety, and depressive symptoms, between doctoral students and an age-matched general population. The study involved 81 PhD students who were administered validated survey instruments to collect data concerning their levels of stress, anxiety, and depressive symptoms. The data analysis results revealed significantly high scores of stress, anxiety, and depressive symptoms in the doctoral students. Furthermore, it was found the levels of stress, anxiety, and depression in the PhD students were higher compared to an age-matched general population.
A similar trend of higher prevalence and higher risks of mental illnesses in graduate students compared with other populations, including undergraduate students and working populations, has been reported in other research studies. Moss et al. (2022) hypothesized postgraduate students are at significant risk of having mental health problems and providing early intervention and preventive procedures, specifically improving the students’ mental health literacy, might help mitigate the risk. The researchers explored the association between the postgraduate students’ mental health literacy and specific mental health-related variables, including psychological distress, and also compared the data with that of undergrads. The research involved 241 postgraduate students who completed a survey questionnaire. The survey findings showed a considerable proportion (70%) of the postgraduate students expressed high distress levels. The research results further showed psychological distress levels in postgraduate students are higher compared with the distress levels in undergraduate students. Furthermore, based on the research results, graduate students are at a higher risk of mental health illness symptoms compared with undergraduate students.
Another study by Hazell et al. (2021) assessed the mental health status of Ph.D. students in the United Kingdom and compared the prevalence rate of mental health problems in the population with the working populations in the United Kingdom. Data regarding the study participants’ mental health problems, including depression and anxiety, were collected using PHQ-9 and GAD-7, respectively. The research results showed the prevalence rates of moderate to severe depression and anxiety in graduate students were significantly higher compared with the working populations. Similarly, the severities of depression and anxiety in the graduate students were significantly higher in the graduate students than in the working populations (Hazell et al., 2021). However, contrary data regarding higher prevalence rates of mental health disorders in graduate students compared with undergraduates were reported in other research studies.
Wyatt & Oswalt (2019) investigated the associations between mental health, stress, and academic performances of college students. The research study was based on the data collected from 27,387 university students who completed the American College Health Association-National College Health Assessment (ACHA-NCHA) in the Fall of 2009. The results report a significant difference in the mental health of graduate and undergraduate students. This contradicts Moss et al. (2022) findings. Wyatt Oswalt (2019) reported the overall prevalence rate of mental health disorders in postgraduate students is lower than the prevalence rate of mental health disorders in undergraduate students.
In another research study, Naceanceno et al. (2021) conducted a causal-comparative research study to assess the levels of anxiety in college students and compared the levels of anxiety between graduate and undergraduate students. The research study involved 104 university students, including undergraduate and postgraduate students from 22 universities in the United States. A survey questionnaire, Zung Selfrating Anxiety Scale, was administered to collect data concerning the study participants’ anxiety levels. Contrary to Moss et al.’s (2022) findings, the data analysis results showed there was no significant difference between the graduate and postgraduate students’ anxiety levels.
Depression and Anxiety
According to Eisenberg et al. (2007), depression is a mood, which entails feeling hopeless, helpless, or worthless. Shete and Garkal (2015) defined anxiety as an emotional experience of unpleasant inner feelings associated with caution, worry, nervousness, and complaints. Copious evidence from the literature indicates the prevalence of mental health disorders, including depression and anxiety, in graduate students. This includes evidence from empirical and experimental research studies and evidence from non-empirical or non-experimental research studies. Depression and anxiety have been identified as the most prevalent mental health symptoms in students in different countries and all educational disciplines (Farrer et al., 2016; Feng et al., 2016; Shete et al., 2015; Tanya & Kumar, 2015).
Anxiety and depressive symptoms can have significant impacts on humans, including the impacts on behavior, emotional and physical health, career success, sleep, general well-being, and students’ academic performance (Farrer et al., 2016). Furthermore, the impacts of anxiety and depressive symptoms on suicide ideation in students have been reported (Garcia-Williams et al., 2014; Meng et al., 2013; Smith et al., 2015; Tang et al., 2018). This section reviews evidence concerning the prevalence rates of depression and anxiety in graduate students based on findings/results of empirical and experimental research studies and evidence from non-empirical or non-experimental research studies.
Friedrich et al. (2023) explored the mental health status of doctoral students at a German University. The research study used a mixed-method approach, involving both qualitative and quantitative analysis study procedures. The research participants, consisting of 589 PhD students, completed an online questionnaire which was used to collect information concerning the study participants’ mental health condition, including anxiety and depression, and also the need for mental health improvement and the study participants’ well-being. The research findings indicated at least 33% of the graduate students who participated in the research study reported experiencing high levels of depression. Furthermore, they reported low satisfaction and feeling of insecurity with their job are the risk factors for anxiety. Moss et al. (2022) found no less than 70% of the postgraduate students who participated in the research study reported mild to severe levels of psychological distress.
Kılıç & Karahan (2023) conducted a descriptive research study to explore depression, anxiety, and academic stress in postgraduate students. The research study involved 459 postgraduate students, including master’s and PhD students, from Turkish universities. An electronic survey questionnaire, Counseling Center Assessment of Psychological Symptoms (CCAPS), was administered to collect data concerning the study participants’ psychological symptoms, including anxiety, depression, and stress symptoms in graduate students. Results of the research study revealed high levels of anxiety/depression (43.25 ± 12.75) and considerable levels of academic stress (16.35 ± 3.13) in the graduate students. Furthermore, the research study revealed a significantly high correlation between anxiety, depression, and stress in the students. A related research study involving a descriptive research design also found high prevalence rates of severe depression symptoms (48.7%) and mild to severe anxiety symptoms (39.6%) in graduate students who participated in the research study (Hoying et al., 2020).
Findings of a cross-sectional research study also supported the prevalence rate of anxiety and depression in graduate students is considerable. The cross-sectional study conducted by Algeel et al. (2021) involved 1,005 postgraduate students. The study participants completed the Patient Health Questionnaire for Depression (PHD9) and GAD7 to retrieve data concerning their depression and anxiety levels, respectively. The research findings showed the prevalence rate of anxiety in graduate students was 23.6% while the prevalence rate of depression was 27.4%. Barreira et al. (2020) explored the mental health prevalence in economics postgraduate students at a United States university. At least 18% of the graduates reported mild to severe anxiety with an increase in depression. At least 25% of the graduate students who had spent more than five years in the doctoral program reported an increase in depression and anxiety symptoms over time compared with the first-year graduate students.
Vasugi & Hassan (2019) reported the highest prevalence rates of anxiety, depression, and stress in graduate students compared to the results of other research studies in this review. The Depression, Anxiety, and Stress Scale – 21 Items (DASS-21) was used to assess the study participants’ anxiety, depression, and stress levels. The results revealed significantly high prevalence rates of depression, anxiety, and stress in graduate students. It was found 62.6% of the graduate students reported mild to extremely severe depression, 76% of the students reported mild to extremely severe anxiety, and 78% of the respondents reported mild to extremely severe stress.
Apart from research evidence indicating the significantly high prevalence rates of mental health problems, including depression and anxiety, in graduate students, non-empirical or non-experimental research studies also provide evidence revealing the prevalence of depression and anxiety in graduate students, including the master’s and Ph.D. students. Chi et al. (2023) performed a systematic review and meta-analysis of evidence from the literature concerning the prevalence rate of anxiety among graduate students. The results indicated approximately 44.5% of the graduate students experienced mild to severe anxiety, while the prevalence rate of anxiety in Ph.D. students (34.3%) was higher than the prevalence rate in master’s students (29.2%). Satinsky et al. (2021) also systematically reviewed and meta-analyzed evidence from the literature concerning the prevalence rates of depression and anxiety in postdoctoral students. Results of the research study similarly reported high prevalence rates of depression (24%) and anxiety (17%) in 23,469 and 15,626 doctoral students from the 32 research studies reviewed.
Risk Factors
Researchers have explored factors impacting the mental health of graduate students. Findings revealed several risk factors for graduates’ mental health problems. That includes academic stress, dissatisfaction or low postgraduate training satisfaction, and food insecurity, which will be reviewed in this sub-section.
Several researchers have investigated the impact of low graduate students’ satisfaction with their postgraduate training and reported the significant adverse impacts on graduate students’ mental health. Research evidence has revealed graduate students’ satisfaction with their training is significantly linked to the student’s relationship with their supervisors (Khuram et al., 2023; Le et al., 2021). According to Zile et al. (2023), the graduate student-supervisor relationship has a significant impact on postgraduate students’ mental health and well-being. Say a bit more.
Academic Stress
According to Travis et al. (2022), the correlation between academic stress, including anxiety and depression, and students’ psychological health is significant. Barbayannis et al. (2020) explored whether academic stress impacts the mental health of graduate students. The survey research study involved 843 study participants and used the Short Warwick-Edinburgh Mental Well-Being Scale (SWEMWBS) and Perception of Academic Stress Scale (PAS) to assess the study participants’ mental well-being and academic stress levels, respectively. The results of the research study showed higher academic stress levels significantly correlated with poor mental health problems in the postgrads. The research results indicate academic stress is a significant risk factor for poor mental health in graduate students.
Sokratous et al. (2023) conducted a cross-sectional research study aimed to explore the association between academic stress and graduate students’ mental health conditions. The research study involved 90 master’s students from the nursing and midwifery department. The study participants’ mental health and academic stress levels were assessed by administering the General Health Questionnaire-28 (GHQ-28) and the Life Events Scale for Students (LESS) scale, respectively. The research results revealed the study participants expressed significantly high levels of mental health symptoms, including psychological distress and depressive symptoms that correlated with their academic stress. The research results indicated a significant association between academic stress and the student’s mental health problems, revealing academic stress is a significant risk factor for poor mental health in graduate students (Sokratous et al., 2023). Hoying et al. (2020) explored the risk factors for anxiety and depression in graduate students. The descriptive correlational research study involved 197 health science college graduate students. The study participants completed the Participants completed a personal wellness assessment (PWA), consisting of survey questionnaires, including the GAD-7 and the Brief Inventory of Perceived Stress, to assess several variables, including the students’ depression, anxiety, and stress levels. The research findings showed a significant association between high academic stress levels and depression, indicating academic stress is a significant predictor of the student’s mental health. The research results showed academic stress is a risk factor for depression and anxiety in graduate students. According to Friedrich et al.’s (2023) research results, Ph.D. students who participated in the research study also expressed high levels of academic stress, indicating it as a significant risk factor for their mental health issues and revealing low satisfaction and feelings of insecurity with their job significantly contributed to their experience of stress they experience in the Ph.D. program.
According to the American Psychological Association [APA] (2020), anxiety is an outcome of reacting to stress. The APA’s (2020) definition of anxiety indicates a relationship between stress and mental health problems because anxiety, including depression, is a mental health condition/disorder (Centers for Disease Control and Prevention [CDC], 2022). Several research studies have reported a significant correlation between stress and mental health issues, including anxiety and depression. Vasugi’s & Hassan’s (2019) research findings revealed academic stress significantly correlates with anxiety and depression in postgraduate students.
Zhang et al. (2022) explored whether stress impacts depression in postgraduate students; in other words, the researchers investigated the association between graduate students’ academic stress levels and depressive symptoms. The research involved 51 study participants and used Hari’s Stress Inventory to assess the respondents’ stress levels and Beck’s Depression Inventory to assess their depressive symptoms. Results showed there is a significant correlation between graduate students’ stress levels and depression levels. Their findings revealed increased stress levels resulted in increased levels of depression in postgraduate students (Sahoo & Dass, 2012). In a cross-sectional survey research study exploring the influence of student’s perceived academic stress on depression, Gil et al. (2022) surveyed 6,480 students, including graduate students, and found the correlation between perceived academic stress and depression is significant. This indicates the significant influence of academic stress on depressive symptoms in the student. The results corroborated the findings that there is a significant positive correlation between academic stress and depressive symptoms in students, indicating increased academic stress results in increased depressive symptoms in graduate students.
According to the National Institute of Mental Health [NIH] (2023), substance use is a mental disorder. Zegeye et al. (2018) explored the impact of postgraduate study stress on postgraduate students’ mental health, hypothesizing that academic stress is a predictor for substance use disorders, including drug abuse, smoking, and alcohol consumption. The cross-sectional research study involved 256 graduate students. The research findings showed postgraduate students experience a high-stress level, and the association between stress and substance use disorders in graduate students is significant.
Low Satisfaction with Postgraduate Training
Rowe (2023) reported doctoral supervisory procedures are the leading risk factor for PhD students’ mental health problems, including anxiety and depression. This sub-section provides a review of evidence from the literature concerning the impact of students’ postgraduate training satisfaction on their mental health.
Naumann et al. (2022) explored the PhD students’ mental health status and their satisfaction with the PhD training. The researchers also investigated the predictors of mental health conditions, including anxiety and depression in the study participants. The cross-sectional research study involved 222 PhD researchers. The research results indicated a high prevalent rate of depressive symptoms in doctoral students – more than 20% of the graduate students expressed depression and significantly low satisfaction with the doctoral training. Results of the study revealed there is a significant link between the students’ low doctoral training satisfaction and mental health conditions reporting their low doctoral training satisfaction is a risk factor for poor mental health conditions, including anxiety and depression, in graduate students.
Liu et al. (2019) conducted a cross-sectional research study to explore the prevalence rate of PhD students’ mental health symptoms, including depression and anxiety, and the potential predictor factors associated with depression and anxiety in graduate students. The research study involved 325 medical PhD students at a university. The Generalized Anxiety Disorder 7 scale and the Patient Health Questionnaire 9 survey questionnaires were used to collect data concerning the respondents’ anxiety and depression symptoms. The research results revealed up to 23.7% of the doctoral students indicated depression symptoms, while 20.0% indicated anxiety symptoms. The results revealed a negative association between the student’s relationship with their mentors and the depression and anxiety levels they experienced, indicating the negative impact of postgraduate training on graduate students. Furthermore, the research findings showed the students’ relationship with their mentors is a factor mediating the association between the students’ self-confidence in conducting and completing their research activities (research self-efficacy) and the levels of depression/anxiety they experience. The research findings show the graduate students’ doctoral training satisfaction is a significant risk factor for their mental health problems.
Friedrich et al. (2023) corroborated Liu et al.(2019) revealing PhD students who participated in the research study reported their lack of satisfaction with their PhD supervision was a significant risk factor for their mental health problems. According to Barreira et al. (2020), graduate students expressed significant dissatisfaction with their relationship with their advisers. They reported great regrets in their relationship with their advisers; they noted issues with their advisers. The graduate students expressed displeasure with their meetings with the advisers and the meetings with their advisers did not yield the expected results for their doctoral program. Approximately 20% of the students who expressed their regrets about the choice of their adviser reported suicide ideation.
González-Betancor & Dorta-González (2020) explored the risk of PhD training interruption and the link between the doctoral students’ mental health conditions, including anxiety and depression. The risk measures included the PhD students’ desire to change their supervisor due to their dissatisfaction with their supervisor. The researchers used the Nature PhD survey data collected in 2019 to statistically analyze the risk and the association with the PhD students’ mental health. The researchers found the students’ desire to change their supervisors, including their inability to contact their supervisors, is a significant risk factor for their reported poor mental health conditions. Cornér et al. (2017) investigated the quality of Ph.D. training supervision and the association with poor mental well-being, including stress/burnout in the PhD students. The cross-sectional survey involved 245 PhD students who completed the Doctoral Experience Survey. The research results showed the study participants reported they experienced an extremely low level and frequency of supervisors’ supervision. Similar findings were reported by Fátima & Sadia (2019) who explored the association between university supervisors’ support and depression in university students, including master’s and doctoral students. The research study involved 154 students who were administered the Self-Management sub-scale of the Self-Management Scale, Postgraduate Research Experience Scale, and the Depression Anxiety and Stress Scale. The results of the research study revealed the correlation between supervisors’ support for the students and depression.
White et al. (2023) investigated the hypothesis that the relationship of postgraduate students with their supervisors significantly impacts the students’ mental health and psychological well-being. The researchers pulled qualitative data from a large survey and thematically analyzed the data to determine the role of the graduate student-supervisor relationship on the student’s mental health conditions. The research results revealed the significant role of supervisors’ relationship with postgraduate students contributing to the students’ poorer mental health. The research findings reviewed revealed a significant connection between the graduate students’ low satisfaction with their PhD training satisfaction and the high levels of academic stress they experienced.
Food Insecurity
Evidence has indicated up to 11.5% of Americans are affected by food insecurity (Coffino et al., 2021). Food insecurity in graduate students is well-studied, but there is a paucity of information concerning food insecurity in graduate students (Coffino et al., 2021). However, research that investigated the prevalence rate of food insecurity in graduate students revealed 17.8% of postgraduate students were affected by food insecurity (Soldavini et al., 2019). Due to the age-related requirements of graduate students, their demands for resources might be different; they have greater financial expenses/responsibilities but their financial assistance opportunities are limited (Baum et al., 2018). Therefore, they might be at higher risk of mental health problems due to food insecurity as research evidence has revealed food insecurity is associated with higher levels of mental health symptoms, including depression and anxiety (Coffino et al., 2021). Hence, this sub-section reviews the literature regarding the association between food insecurity and mental health, and food insecurity and mental health problems in graduate students.
Several research studies have investigated the relationship between food insecurity and mental health and evidence from such research studies revealed the association between food insecurity and mental health is significant (Burruss et al. 2021; Fang et al. 2021; Liebe et al. 2022). In other words, food security has a significant impact on mental health. Fang et al. (2021) examined the relationship between food insecurity and mental health conditions, including anxiety and depression, in low-income populations during the coronavirus pandemic in the United States. The survey research involved 2714 low-income individuals in the United States. The results revealed a significant relationship between food insecurity and anxiety and depression was significant. It was found food insecurity that resulted from the pandemic caused high risks of anxiety (257%) and depression (253%). A cross-sectional analytical research study conducted by Burruss et al. (2021) also reported a significant relationship between food insecurity and mental health disorders. According to the research findings, food-insecure individuals are at higher risk of developing major depressive disorder. The results corroborate Liebe et al.’s (2022) results, confirming individuals who are food insecure are at higher risk of developing mental health issues.
In a related cross-sectional research study, Liebe et al., 2022 posited food insecurity might have severe impacts on mothers’ mental health. The research study involved 1029 American mothers in the United States. The findings showed food insecurity had a significant impact on the participants’ mental health, suggesting food-insecure mothers are at a higher risk of having mental health disorders (Liebe et al., 2022). A related research study by Zahidi et al., 2022 explored the relationship between food insecurity and mental health disorders in reproductive women. The research results similarly reported the higher prevalence rate of food insecurity (69.6%) observed in the participants was significantly associated with depression, anxiety, and stress in the study population, indicating food insecurity is a significant risk factor for mental health disorders, including anxiety and depression (Zahidi et al., 2022).
Myers (2020) reviewed current evidence from recent research studies to explore how food insecurity is associated with psychological distress. The review findings revealed a significant interconnection between food insecurity and several psychological distress variables. Myers’ (2020) research results showed food insecurity is a risk factor for mental health disorders. In a related research study by……that involved a systematic narrative review, evidence was synthesized from the literature retrieved from four electronic databases to explore the impact of food insecurity on the mental health of West Africans. It was found food insecurity is significantly associated with West African mental health disorders, including anxiety, distress, and psychological instability (Ae-Ngibise et al., 2021).
Several research studies have tested the hypothesis that food insecurity influences mental health. A research study was carried out by Smith et al. (2023) in low-income countries and middle-income countries (e.g., name a couple). The researchers assessed the relationship between food insecurity and symptoms of depression based on the hypothesis that food insecurity might be a risk factor for depressive symptoms. The researchers used the Global School-Based Student Health Survey to collect data concerning depressive symptoms from 48,401 respondents. The research results supported the hypothesis that food insecurity is a risk factor for depression. The results indicate the prevalence of depression was 29.3% and revealed a significant relationship between food insecurity and depressive symptoms in the study participants from low-income countries and middle-income countries. Trudell et al. (2021) conducted a systematic review based on the hypothesis that food insecurity significantly impacts mental health to assess the influence of food insecurity on the mental health of Africans. They reported similar findings that food insecurity adversely impacts mental health, resulting in poor mental health conditions, indicating food security is a risk factor for mental health problems. Another systematic review by…… also assessed the hypothesis that exposure to food insecurity has significant impacts on mental health outcomes. Similar findings were reported that food insecurity influences mental health outcomes, revealing food insecurity is a risk factor for mental health problems (Sparling et al., 2022). Copious evidence from several other research studies, including research studies carried out in the United States, consistently indicate food insecurity significantly impacts mental health outcomes and show it is a risk factor for mental health outcomes, including depression, anxiety, and stress (Cain et al., 2022; Ciciurkaite et al., 2022; Fang et al., 2022; Jones, 2017; Nagpaul et al., 2022; Tarasuk et al., 2018; Pourmotabbed et al., 2020; Reeder et al., 2022; Santos et al., 2022; Wolfson et al., 2021).
Loneliness and Isolation
It is generally believed that loneliness and isolation can elevate the risk of poor mental health and psychological well-being. Several researchers have tested the hypothesis by statistically analyzing the association between the correlates and mental health disorders in graduate students. Evidence from such research studies also suggests loneliness and isolation in graduate students is a risk factor for mental health disorders, including anxiety and depression, in the postgraduate student population.
Wei et al. (2023) conducted a cross-sectional survey research study to determine whether loneliness and social isolation elevate the risk for mental health disorders in medical postgraduate students. The researchers explored the relationship between loneliness and social isolation and medical residents’ mental health conditions. The research study involved 1,338 study participants. More than 24% of the medical residents reported they felt lonely, while more than 44% reported they were socially isolated. The experience of major depression in the study participants was approximately 13% and major anxiety was approximately 10%. A significant relationship between loneliness and major depression and major anxiety was reported; the research results indicated the medical residents’ reported loneliness elevated the risk for major depression and anxiety. Similar results of a significant association between social isolation and major depression and loneliness were reported; the research results indicated social isolation increased the medical residents’ risk for major depression and major anxiety.
Similar results were reported by other research studies. A research study investigated the correlation between university students’ loneliness and depressive symptoms. The researchers, Kundu et al. (2021), conducted a cross-sectional pilot study to explore the prevalence rates of loneliness and depression in graduate students and the factors associated with depressive symptoms in the student population. The research study used the Patient Health Questionnaire-9 (PHQ-9) to assess the students’ depressive symptoms and the University of California, Los Angeles (UCLA) Loneliness Scale to collect data concerning the study participants’ reported loneliness. The prevalence rates of depression and loneliness in the study participants were 52% and 43% respectively. The research results showed a significant positive correlation between loneliness and depression in the study participants, revealing that loneliness is a significant risk factor for depressive symptoms in graduate students. In a related research study, Weber et al. (2021) explored the mental health levels of university students, including postgraduate students, and factors associated with the student’s mental health. The research study involved 368 students, among whom 53.6% were postgraduate students. The study participants were administered the Generalized Anxiety Disorder Scale (GAD-7) and Patient Health Questionnaire (PHQ-8). The research findings showed the prevalence rates of anxiety and depression in the study participants were 25.6% and 38.8%, respectively. It was found the increased levels of loneliness in the students were significantly associated with the increased levels of anxiety and depression in the students. Another related research study conducted by Giovenco et al. (2022) also investigated the prevalence rate of psychological distress and its relationship with social isolation in university students, including postgraduate students, at a university in the United States. The research study included 12,016 postgraduate students among the study participants who were administered the 10-item Center for Epidemiological Studies Depression Scale (CES-D-10) to assess their depressive symptoms. The 3-item Loneliness Scale (UCLA-3) and the 4-item Perceived Stress Scale (PSS-4) were used to assess the study participants’ levels of loneliness and stress, respectively. The students reported significantly high prevalence rates of social isolation (64%) and depression (64%). It was found the association between the students’ self-reported loneliness and depressive symptoms was significant, indicating social isolation is a significant risk factor for depressive symptoms in students. There is evidence from other research studies reporting the strong interconnection between loneliness, social isolation, and mental health conditions, including anxiety, depression, and psychological distress in graduate students. The research evidence suggested loneliness and social isolation are significant risk factors for mental health problems in graduate students (Girmay & Singh, 2019; Malik et al., 2022).
Discussion
Graduate students face several challenges that result in mental health issues. These include mental health risk factors like academic stress, dissatisfaction with postgraduate training, and food insecurity. Reduced graduate satisfaction has an adverse impact on the mental well-being of graduate students. The interaction between graduate students and their supervisors significantly influences the mental health and wellbeing of the students (Zle et al., 2023). Graduate students have varying resource needs based on their age, as they have greater financial obligations and limited financial assistance options (Baum et al., 2018). Research indicates individuals may be more prone to mental health problems due to the correlation between food insecurity and elevated levels of mental health symptoms including depression and anxiety (Coffino et al., 2021). Loneliness and social isolation significantly increase the likelihood of students experiencing depressive symptoms. Loneliness, social isolation, and mental health problems like anxiety, depression, and psychological distress are strongly connected in graduate students. Studies show loneliness and social isolation significantly impact the mental health of graduate students (Girmay & Singh, 2019; Malik et al., 2022).
Academics and Mental Health
Mental health is important for an individual’s psychological well-being and overall health, while it is an important element of learning. Evidence has linked a high level of educational attainment and achievement to good mental health, establishing the causal relationship between academic achievement and variables of mental health (Lipson et al., 2018; Müller et al., 2022; Substance Abuse and Mental Health Services Administration [SAMHSA], n.d.). Similarly, evidence has indicated the significant adverse impact of poor academic performance and achievement of students to poor mental health or mental health problems (SAMHSA, n.d.). Therefore, providing adequate mental health services for students – promoting and supporting the students’ mental health and psychological well-being is beneficial because it contributes to improving the students’ mental health and the associated academic correlates (Department of Education, 2021; Hammoudi Halat et al., 2022).
Mental Health Services
Mental health experts have realized the importance of providing early intervention for combating mental health problems in students, suggesting early mental health intervention would be more efficacious to yield the desired outcomes for the students. Therefore, the provision of mental health services, including mental health education, to improve the students’ mental health support and promote early intervention for students’ mental health has been proposed (New York Office of Mental Health, 2018). Students’ mental health services are primarily delivered within the schools (school-based mental health services). However, outside-school mental health services are also available for students.
Evidence from research studies has reported the significance of providing mental health services for students. Berger et al. (2022) published the results of a systematic review of evidence from the literature regarding the advantages of providing mental health interventions for students in school. The researchers conducted a synthesis of evidence regarding the benefits of school-based mental health interventions from 74 eligible research articles. The research results indicated school-based mental health programs are associated with long-term outcomes for the psychological and mental health and well-being of the students. The most identified school-based mental health therapy from the literature is cognitive behavioral therapy (CBT). Copious evidence from several research studies has reported findings concerning the benefits of providing mental health services for students in schools. The school-based mental health services, including CBT and mindfulness-based therapy, and evidence regarding the benefits of school-based mental health programs are reviewed in this section.
School-Based Mental Health Services
School-based mental health services entail providing mental health support and promotion for students within the school. It involves establishing a school-arranged mental health center within the school premises or close to the school (Richter et al., 2022). It is an interventional approach to applying clinical mental healthcare procedures and strategies specific to improving students’ psychological, mental, social, and behavioral functioning (Fazel et al., 2014). The connection between education and health is strong and the school has several factors that impact students’ health; therefore, schools are responsible for providing healthcare support for students to ensure physical and psychological development of the students (Dalsgaard et al., 2020). Moreover, the school compulsory programs compel the students to attend schools and spend a considerable part of their time in schools; hence, the school should be an ideal location for students to conveniently access mental health services, thus, helping the students to identify their mental problems earlier and providing them with early intervention before their mental health problems escalate into a serious problem (Lai et al., 2022). In addition to ease of access to mental healthcare for the students, providing mental health services for students in the school is associated with several other benefits. The school-based mental health services help students overcome the barriers, including mental healthcare professional shortages, transportation issues, mental healthcare disparities, high cost, and stigma associated with mental health services (Lai et al., 2022; Love et al., 2019; Sullivan et al., 2022).
A significant proportion of students prefer school-based mental health services – preferring the mental health support provided by the school to those provided outside the school (Duong et al., 2021; Swick & Powers, 2018). The school-based mental services might vary in approach, but the fundamental approach entails the school collaborating with mental healthcare providers or services to provide support for the students, including the students at risk of mental health problems (Doll et al., 2017; Richter et al., 2022).
Apart from the school-based mental health services’ effectiveness in preventing and addressing students’ mental health problems and improving the students’ mental health outcomes, including psychological, mental, social, and behavioral functioning, it might have beneficial impacts on students’ academic performance and achievements. Researchers have explored the impact of school-based mental health support on student’s mental health outcomes and academic achievement. Cefai et al. (2022) published the results of a school-based mental health service evaluation targeting the improvement of students’ psychological learning and emotional resilience in a mental health program, which includes the prevention of social and behavioral issues. The school-based mental health program evaluation involved 7,789 students, starting from kindergarten to college at 124 schools in six European countries. The classroom teacher and parents were also involved in the program evaluation. The study participants were divided into two groups, the experimental group, and the control group according to the classroom. The experimental group (classrooms) received the school-based mental health intervention, while the control group (classrooms) did not receive the intervention. The research results revealed a significantly larger increase in improvement in the students’ overall mental health conditions, which included improved emotional and prosocial functioning, and mitigated mental health problems in the intervention group compared with the control group.
Ross et al. (2020) supported Cefai et al.’s (2022) findings concerning the effectiveness of school-based mental health intervention in improving students’ mental health. Ross et al. (2020) investigated the impact of school-based mental health services in treating students’ mental health problems in public schools. The retrospective research study used data retrieved from the school’s archived mental health service’s electronic medical records, starting from 2017 and 2018. The leading mental health problems identified in the data are anxiety, depressive symptoms, and trauma. It was found the mental health status of students who received the school-based mental health intervention significantly improved compared to the students who did not receive the intervention. According to the research results, the mental health status improvement of the school-based mental health treatment recipients was fifteen times higher compared with the mental health status of the non-recipients of the mental health treatment.
Findings from Shahraki-Sanavi et al. (2020) also indicated the effectiveness of school-based mental health services in improving students’ mental health conditions. The interventional quasi-experimental research study conducted by Shahraki-Sanavi et al. (2020) administered a survey questionnaire, the General Health Questionnaire 28 (GHQ-28) to collect data from 420 respondents. The study participants were divided into the intervention group, consisting of students who received the school-based mental health intervention, and the control group, comprising students who did not receive the intervention. The intervention was applied for one year. Results of the research study indicated the difference in mental health improvement between the intervention group and the control group was statistically significant post-intervention. The mental health problems in the intervention group significantly decreased compared with the control group.
Despite the copious evidence indicating the significant impact and effectiveness of school-based mental health services in improving students’ mental health outcomes, there is limited and inconclusive evidence indicating the effectiveness of mental health services in improving student’s academic outcomes. According to Cefai et al.’s (2022) research findings, the differences regarding academic outcomes between the groups of students who received the school-based mental health intervention and the students who did not receive the intervention were not significant. Similar findings were reported by Rasiah et al. (2023) and Smith & McKenzie (2020) who also explored the impacts of school-based mental healthcare support on students’ academic performance and achievement.
Rasiah et al. (2023) conducted a quasi-experimental cohort study, analyzing publicly available education data of students’ standardized test scores and grades pre-and post-implementation of the school-based mental health services. The research results showed there were improvements in the student’s grades over time post-implementation of the school-based mental health services compared with the pre-implementation time, but the differences were not significant. Therefore, the research findings corroborated Cefai et al.’s (2022) findings, indicating no evidence concerning the significant effectiveness of school-based mental health centers in improving students’ academic achievement. Smith & McKenzie (2020) also explored the impacts of school-based mental healthcare support on students’ academic performance and achievement. The quasi-experimental research study analyzed publicly available education data. The research results similarly revealed school-based mental health services resulted in higher academic performance, but the difference was not significant.
Walker et al. (2010)found school-based health centers have a significant beneficial effect on students’ academic performance . The researchers examined the impact of a school-based health center on the student’s academic outcomes by statistically analyzing data and comparing outcomes between the users of school-based health services and the non-users over five academic semesters. The research results revealed significant academic improvements for the recipients of the school-based health services compared with non-recipients. It was found school attendance was significantly higher in the students who used the school-based health service compared with the students who did not use the health service. Also, the average grade point significantly increased for users compared with non-users. Lime et al. (2023) conducted a recent research study analyzing data from seventeen schools with school-based health centers and reported improvements in the student’s attendance over time and more significant changes in students with mental health problems in the users of the school-based mental health centers compared to the non-users. However, the impact of the school-based health centers on the students’ academic improvement was not reported (Lime et al., 2023). Furthermore, findings from more recent systematic reviews by Arenson et al. (2019) and Thomas et al. (2020) revealed research on the association between school-based mental health services and students’ academics is limited and the findings from the few available research studies are inconclusive, suggesting future research studies should explore the impact of school-based mental health services on academic outcomes . The school-based mental health service interventions include peer/social support, mental health education, mindfulness-based intervention, mental health promotion and outreach programs, psychotherapy, and counseling (Gotlib et al., 2019; Huang et al., 2018; Jaworska et al., 2016).
Cognitive-Behavioral Therapy
CBT is a psychotherapeutic paradigm based on the learning and cognition theories, combining both behavioral therapeutic and cognitive therapeutic approaches, for effectively treating mental health problems (APA, n.d.). Findings of several research studies, including randomized controlled trials, systematic reviews, and meta-analyses, have revealed the effectiveness of CBT for treating several mental health problems, including anxiety disorders, depressive symptoms, substance abuse, and many other severe mental health disorders (Changklang et al., 2023; Huang et al., 2018; Nakao et al., 2021; Rajasree Katta et al., 2023; Renganathan et al., 2023; Wang et al., 2023). In this sub-section, the effectiveness of CBT, including school-based CBT, in addressing mental health problems, including anxiety and depressive symptoms is reviewed.
A quasi-experimental research study by Changklang et al. (2023) explored the impact of CBT on anxiety, depression, and stress in university students. The research study included 31 students who were administered the Thai-translated version of the DASS-21 to assess the study participants’ depression, anxiety, and stress levels before and after they received the CBT intervention. The pre-test and post-test analysis was performed and the research results showed the students’ anxiety, depression, and stress improved after they received the CBT. A related quasi-experimental study involving pre-test post-test design conducted by Renganathan et al. (2023) reported similar findings, revealing CBT effectively improved anxiety and stress levels in the study participants identified with high levels of anxiety and stress.
A systematic review and meta-analysis by Huang et al. (2018) explored effective interventions for mental health problems, including anxiety, depression, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). The researchers included only evidence from randomized controlled trials (RCTs). They found CBT is an effective intervention for treating GAD and depression, but not PTSD and OCD. Nakao et al. (2021) also reviewed the evidence concerning CBT’s effectiveness as an intervention for mental health problems and stress-related conditions. The research findings revealed many RCTs reported CBT is an effective therapy for combating several mental health disorders and behavioral problems in students. In a related meta-analysis conducted by Wang et al. (2023), evidence from RCTs assessing the efficacy of CBT for improving the mental health of patients with inflammatory bowel disease. The findings showed CBT significantly improved the patient’s mental health conditions, including anxiety disorders and depressive symptoms. Another study conducted by Rajasree Katta et al. (2023) synthesized evidence from the literature concerning the effectiveness of CBT for treating psychological problems, including anxiety and depression, associated with heart failure. The results revealed CBT is an efficacious therapy for addressing the mental health problems associated with heart failure and it is superior to conventional interventions.
Research evidence has also indicated the application of CBT for school-based mental health services and its effectiveness in improving the mental health conditions of students. Haugland et al. (2020) investigated the effectiveness of school-based CBT intervention for treating students with anxiety disorders. The RCT consisted of 313 students randomly divided into two groups – a brief CBT intervention group and a standard CBT intervention group. The research findings showed both brief and standard CBT interventions were efficacious for improving the study participants’ mental health conditions, revealing the effectiveness of the school-based CBT intervention for improving students’ mental health conditions. A related research study by Eneogu et al. (2023) investigated the efficacy of a school-based CBT for improving psychological problems, specifically academic stress, in economic students. The pre-test and post-test RCT involved 168 students who were administered the Economics Academic Stress Questionnaire (EASQ). The research findings revealed the school-based CBT intervention was efficacious in improving the students’ psychological problems, including academic stress.
Tse et al. (2023) systematically reviewed evidence from the literature regarding the efficacy of school-based CBT in treating students with anxiety disorders and social anxiety disorder (SAD). Evidence from research studies, including RCTs and quasi-experimental research studies, in four electronic databases was systematically reviewed. Contrary to copious findings from several research studies concerning the effectiveness of school-based CBT in improving students’ mental health problems, including anxiety disorders, the research findings revealed the school-based intervention was not superior to other interventions, showing no significant effects for reducing SAD symptoms in the students. Takizawa et al. (2023) conducted meta-analyses of evidence concerning the efficacy of universally accepted school-based interventions in combating mental health problems of students. The meta-analytic research study involved the analysis of 85 school-based mental health interventions with control groups to assess the effectiveness of the interventions. The research results showed the interventions have insignificant overall effects in addressing the students’ social-psychological problems, including social-emotional skills and social behaviors. That corroborated Tse et al.’s (2023) findings that school-based CBT intervention was not effective in improving social psychological symptoms. However, the small effects might be due to biases in the school-based program implementation procedures (Takizawa et al., 2023).
Mindfulness-Based Therapy
Mindfulness entails being aware of one’s internal state and external environment to help evade destructive and involuntary actions and responses through the development of the skills for observing one’s thoughts and emotions, including experiences, and being able to remain calm and not disquiet in the presence of the experiences (APA, 2018, 2023). Therefore, it is being applied in therapeutic interventions – in mindfulness-based therapies, including mindfulness-based cognitive therapy (MBCT), mindfulness meditation, and mindfulness-based stress reduction (MBSR) (APA, 2023). Research evidence has indicated the effectiveness of mindfulness-based interventions in improving mental health conditions. Huang et al. (2018) found mindfulness-based therapy is an effective intervention for treating GAD and depression.
A pilot study was conducted by Musa et al. (2019) to determine the efficacy and feasibility of MBCT in managing patients with depressive symptoms. The researchers systematically reviewed evidence from research studies, including RCTs and non-RCTs, from fifteen eligible research studies in eight electronic databases. The results of the research study showed MCBT is a promising and efficacious intervention for managing patients with depressive symptoms. In a related systematic review published by Maddock & Blair (2021) regarding the effectiveness of mindfulness-based mental health programs in improving anxiety and depressive symptoms and psychological distress, evidence was systematically reviewed from eleven eligible research studies retrieved from six electronic databases. Results of the systematic review showed mindfulness-based interventions, including MBCT and MBSR therapy, were effective in treating and improving anxiety and depression.
In another research study, Galanate et al. (2023) conducted a systematic review and reported similar findings concerning the effectiveness of mindfulness-based therapy in improving mental health conditions. The researchers aimed to determine the effectiveness of mindfulness-based interventional programs for preventing or favorably modifying psychological distress. Evidence was systematically reviewed from fifteen recent RCTs based on specifically identified primary outcome measures of psychological distress, including anxiety and depression. The research results revealed mindfulness-based programs have significant effects on improving psychological distress and mental health conditions, including anxiety and depression. In a related meta-analytical research study conducted by Riquelme-Marín et al. (2022), the aim was to examine the effectiveness of mindfulness-based intervention for treating patients with OCD. Evidence was extracted from eleven eligible research articles and the effect size of the intervention was analyzed for obsessive-compulsive symptoms, including depressive symptoms, was determined. Results of the research study showed a significant reduction in obsessive-compulsive and depressive symptoms, indicating the effectiveness of mindfulness-based interventions for treating patients with obsessive-compulsive and depressive disorders.
Zou et al. (2020) also corroborated findings from other systematic reviews supporting the effectiveness of mindfulness-based interventions for treating patients with mental health problems, including anxiety, depression, and stress. Zou et al. (2020) systematically reviewed and meta-analyzed evidence from RCTs focusing on the effectiveness of mindfulness-based interventions for treating anxiety, depression, and stress. Evidence was retrieved from six eligible RCTs from seven electronic databases. The research results revealed significant reductions in the patient’s anxiety, depression, and stress compared to the controls, indicating mindfulness-based interventions are effective treatments for mental health problems, including anxiety, depression, and stress.
An RCT conducted by Nasrollahi et al. (2022) investigated the therapeutic impact of MBSR on anxiety, depression, and stress. The pre-test and post-test design research study involved 106 study participants who received the MBSR intervention. The study participants were randomly distributed into two groups – the intervention group and the control group. All the study participants were administered the DASS21 questionnaire pre- and post-intervention to assess their anxiety, depression, and stress levels. The research results revealed statistically significant differences concerning the improvement in anxiety, depression, and stress levels of the study participants in the intervention group compared with the study participants in the control group.
Similar findings from experimental and non-experimental research studies concerning the effectiveness of mindfulness-based interventions for students have been reported. A systematic review and meta-analysis of evidence from the literature was conducted by Zuo et al. (2023) to examine the effectiveness of mindfulness-based programs in mitigating university students’ mental health, including anxiety, depression, and stress. Evidence was retrieved from eleven eligible RCTs in twelve electronic databases. The research results revealed all the RCTs indicated significant positive effects of mindfulness-based interventions in improving depression, anxiety, and stress, including sleep quality, in university students. A scoping review published by Parsons et al. (2022) explored the effectiveness of school-based mindfulness-based training programs in helping students manage their anxiety, stress, and depressive symptoms. Evidence concerning the effectiveness of mindfulness-based training was extracted and reviewed in the literature. Results of the research study showed the school-based mindfulness training programs were effective in assisting the students in managing their anxiety, stress, and depressive symptoms.
Evidence from experimental research studies, including RCTs, indicated the effectiveness of mindfulness-based interventions for improving students’ mental health conditions, including anxiety, stress, and depressive symptoms. An RCT conducted by El Morr et al. (2020) revealed the effectiveness of a web-based or virtual mindfulness-based training program in improving students’ anxiety, stress, and depressive symptoms. The study participants were randomly distributed into the intervention group and the waitlist control group. Data concerning the respondents’ anxiety, stress, and depressive symptoms were collected by using validated survey questionnaires. The research findings revealed the mindfulness-based program reduced the students’ anxiety, stress, and depressive levels. The difference in the effectiveness of the intervention in improving the students’ anxiety and depressive symptoms was significant between the groups, but no significant difference was reported for stress reduction in the intervention group compared with the control group.
Moreno-Gómez et al. (2023) conducted an RCT based on a pretest-posttest quasi-experimental design to assess the effectiveness of a mindfulness-based intervention for improving students’ emotional characteristics and mental health. The research study included 137 university students who received the mindfulness-based intervention and included a control group. The study participants were randomly assigned to the intervention group and the control group. The research findings indicated the students in the intervention group reported significantly improved dispositional and emotional characteristics and significant improvements in their mental health conditions.
A pretest-posttest design quasi-experimental research study concerning the effectiveness of MBSR intervention in improving students’ cognitive avoidance of test anxiety was published by Malehmir et al. (2021). The research study included purposively selected thirty students clinically diagnosed with test anxiety in the experimental group that received the mindfulness-based intervention and with a control group that did not receive the intervention. The research results indicated the effectiveness of the mindfulness-based intervention in significantly reducing the students’ cognitive avoidance of test anxiety, revealing the effectiveness of mindfulness-based interventions in reducing exam stress and anxiety and improving the students’ mental health while learning and preparing for tests/exams. A related conducted by Shahidi et al. (2017) also investigated the effect of MBSR intervention in reducing test anxiety in students. The RCT included fifty students who participated in the research study, and they were randomly distributed into the intervention group that received the mindfulness-based therapy and the control group that did not receive the therapy. Both groups were administered the Test Anxiety Scale and the Cognitive Emotion Regulation Questionnaire. The research results revealed that the MBSR intervention showed significant effects in reducing the students’ text anxiety and improving their emotion regulation and corroborated Malehmir et al.’ (2021) findings.
Barriers and Obstacles to Mental Health Services
Research studies have explored factors that mitigate persons’ access to mental health services and factors that prevent them from seeking help for mental health care. Evidence from the literature has identified such factors, including stigma, poor awareness or knowledge of mental health, poor mental health help-seeking attitude, and other factors that are barriers to accessing or seeking mental health interventions (Alluhaibi & Awadalla, 2022). This section reviewed the literature regarding the obstacles/barriers, including stigma and mental health perception/knowledge, and mental health help-seeking attitudes/behaviors, preventing individuals from accessing mental health services or seeking mental health assistance.
Stigma
Stigma is a well-recognized global public health problem that impacts mental health intervention success, being associated with adverse treatment-related behaviors and constituting a significant barrier to accessing mental health services or seeking mental health help (Cerully et al., 2018; Corrigan et al., 2014; Griffiths et al., 2014; Hack et al., 2020). According to Kranke et al. (2016), stigma is a significant barrier preventing individuals suffering from mental health problems from accessing and seeking mental health services; therefore, it is crucial to understand the critical role of stigma in perpetuating mental health problems to raise awareness and design interventions that will help mitigate the impact of stigma on people with mental health challenges. The impact of stigma as a barrier to mental health services access and help-seeking behavior is reviewed in this sub-section.
Wainberg et al. (2017) reviewed the literature regarding the strategies for addressing mental health and the barriers to global mental health. The findings of the review identified stigma as a significant barrier to accessing and seeking mental health treatment services. According to the review findings, stigma poses a significant obstacle to uptaking mental health services. Similar findings were reported in a systematic review published by Choudry et al. (2021). The systematic review examined the factors preventing and/or factors facilitating access to mental health services by individuals with mental health problems. The research study systematically reviews evidence retrieved from thirteen eligible research studies in nine electronic databases. Data retrieved from the research studies were thematically analyzed. The research findings indicated stigma as one of the leading barriers to accessing mental health care in individuals with mental health problems. The researchers concluded that reducing stigma is one of the strategies that can help improve the help-seeking attitudes/behaviors of people with mental health problems.
Muhorakeye & Biracyaza (2021) conducted a mixed method, including qualitative and cross-sectional study design, research study to explore the barriers to accessing and utilizing mental health services. The research findings revealed stigmatization as one of the factors mitigating access to mental health services and preventing mental health service utilization in patients with mental health illnesses. Corrigan et al. (2014) investigated the impact of stigma associated with mental health problems on mental health care services seeking and utilization. The researchers reviewed the literature to understand how stigma prevents people with mental health disorders from seeking and utilizing mental health interventions. The research findings revealed that has a significant negative impact on mental health care seeking and utilization by individuals with mental health problems. In a related research study, Sheikhan et al. (2023) conducted a qualitative research study to explore the impact of stigma on mental health treatment-seeking decisions in youths with mental health problems. The extracted qualitative data were inductively analyzed. It was found that stigma prevented the study participants from contacting the mental healthcare system for assistance, delayed them to seek mental health services, and made them refuse to seek mental healthcare. Based on the research results, stigma has a significant adverse impact on mental healthcare seeking and utilization by individuals with mental health problems.
A research study published by Wao et al. (2023) explored the association between mental health services availability and the factors that are barriers to accessing and utilizing the available mental health services for psychological distress in students at university. The researchers employed a mixed-method research design, which included qualitative research and a cross-sectional research survey. The study participants were administered the Kessler Psychological Distress Scale (K10) to assess their psychological distress levels. Results of the research study indicated a high prevalence rate of psychological distress (76.8%) in the students, while a significant proportion of the students were aware of the available school-based mental health services (87%), including social support (84%) and peer counseling program (60%) in the school. The research findings revealed that the associations between stigma as a barrier to accessing mental health services and the psychological status of the students were not significant. That contradicts findings from the research studies reviewed above; nevertheless, that might be due to the significantly high awareness of the availability of school-based mental health services in the school, neutralizing the impact of stigma as a barrier to accessing and utilizing mental health services by the students. The research findings revealed the significance of the knowledge of mental health and treatment services in preventing the adverse impact of stigma on students’ mental health services access and utilization.
Research studies have identified stigma as a leading factor preventing individuals, including students, mental health challenges from seeking mental care help. A cross-sectional study conducted by Broglia et al. (2021) investigated the factors hindering students from seeking help for their mental health conditions. The research study included 1,956 university students who were administered Counseling Center Assessment for Psychological Symptoms – 34 (CCAPS-34), the short version of CCAPS-62 and answered specific open-ended questions to collect data regarding the students’ mental health profiles and help-seeking intentions and behaviors. The research results revealed that the students self-reported a high prevalence rate of mental health problems and identified stigma, including self-stigmatizing belief and stigmatization experiences from the school staff, as a leading barrier preventing them from seeking mental healthcare help. In another cross-sectional research study published by Alluhaibi & Awadalla (2022), the individuals’ psychological help-seeking attitudes and the association of the impact of stigma on help-seeking attitudes were investigated. The research study included 218 study participants that completed two questionnaires, the Stigma Scale for Receiving Psychological Help (SSRPH-A) and Attitudes Toward Seeking Professional Psychological Help Scale-Short Form (ATSPPH-SF-A) to collect data regarding the study participants’ stigma and levels and psychological mental health help-seeking attitudes. The research results showed that the correlation between the students’ help-seeking attitudes and stigma was significantly negative, indicating that students with higher stigmatization levels were less likely to seek help for their mental health challenges.
Mental Health Perception and Knowledge
According to Sanjaya & Sukarmin (2019), mental health perception is individuals’ interpretation of their mental health problems, while mental health knowledge refers to how individuals respond and behave in response to their mental health problems. According to Choudry et al. (2021), low mental health knowledge is one of the leading factors preventing people with mental health problems from seeking mental health treatment assistance and preventing them from accessing mental health treatment services. This sub-section reviewed evidence from the literature regarding the association between mental health perception and knowledge and the access and utilization of mental health services. In other words, the impacts of mental health perception and knowledge on mental health services access and utilization determine whether mental health perception and knowledge are barriers to accessing and utilizing mental health services.
Muhorakeye & Biracyaza (2021) also found that the lack of mental health services awareness is a significant barrier to accessing or utilizing mental health services by patients with mental health illnesses. According to Corrigan et al.’s (2014) findings, mental health illness knowledge moderates the impact of stigma on seeking and utilizing mental health treatment services. The research findings revealed that increasing the knowledge of mental health will help overcome stigma and its adverse impact on mental health treatment service seeking and utilization. The findings suggest that low mental health knowledge is a significant barrier to seeking and utilizing mental health services.
Based on the hypothesis that low mental health knowledge and perception significantly contribute to high prevalence rates of mental health challenges, Kihumuro et al. (2022) conducted a cross-sectional research study to examine the hypothesis. The research study included 259 university students. The research results showed that approximately 77% and 47% of the study participants had significant mental health knowledge and perception, respectively. Furthermore, it was that the associations between the students’ mental health and mental knowledge and perception were significant. The research showed that worse mental health knowledge and perception were associated with reduced mental health service access while better mental health knowledge and perception were associated with increased mental health service access.
In another cross-sectional research study published by Vinutha & Jose (2022), the aim was to determine the impact of mental health awareness interventional programs on students’ knowledge and attitude towards mental health illnesses and the student’s perception of mental health programs in the school. The cross-sectional research study included 143 students who were administered an online survey questionnaire to assess their mental health awareness and attitude and the students’ perception concerning the school-based mental health program. The research results showed that the mental health awareness program improved the students’ knowledge of mental health and their perceptions of the need for accessing and utilizing school-based mental health services.
A research study published by Khombo et al. (2023) used a qualitative approach to explore students’ knowledge and attitudes toward mental health and examined how the students’ mental health knowledge and attitudes impact their uptake and utilization of mental health services. The research study included 15 students who were administered a survey questionnaire to collect data concerning their knowledge and attitudes toward mental health services and their uptake of mental health services. Data collected were thematically analyzed. The research results showed high awareness of mental health services but with misrepresented information or knowledge of the mental health services. It was found that the mental health services were poorly utilized by the students, suggesting the poor mental health service utilization was due to the students’ misrepresented knowledge of the mental health services. The research findings revealed that mental health knowledge has a significant impact on students’ mental health services utilization.
Graduate Students’ Mental Health Help-Seeking Attitudes and Behaviors
Mental health problem help-seeking refers to the experience of adverse mental health, identification of the symptoms, and development of the intention for treatment, and finally seeking actual help to address the identified mental health problem (McLaren et al., 2021; Tomczyk et al., 2020). Several research studies have investigated mental health help-seeking and the impact on accessing and utilizing mental health services. This sub-section reviews the literature concerning evidence indicating the students’ mental health help-seeking and factors preventing them from seeking help with mental health services. Also, the perceived benefits of the students’ mental health help-seeking behavior were reviewed.
Copious evidence revealed that help-seeking behaviors do not directly impact their access or utilization of mental health services, but help-seeking behavior indirectly influences access and utilization of mental health services via other factors, including stigma, the lack of mental health, and mental healthcare awareness, lack of knowledge of mental health, preventing individuals with mental health challenges from seeking mental health care help. In other words, such factors that are barriers to mental healthcare help-seeking mitigate access and utilization of mental healthcare services (Noorwali et al., 2022; Salaheddin & Manson, 2916; Aguirre Velasco et al., 2020). This sub-section reviews the help-seeking behavior of students with mental health, identifying barriers to help-seeking behavior and the impacts on access and utilization of mental health services.
A research study published by Al Omari et al. (2022) investigated the association between mental health knowledge and attitude, and mental help-seeking behavior to identify facilitating factors and factors that are barriers to mental health-help-seeking in individuals with mental health challenges. The cross-sectional descriptive research involved 424 study participants who were administered survey questionnaires and answered open-ended questions to collect data concerning the study participants’ help-seeking behavior and the associated barriers and facilitators. Results of the research study revealed that mental health attitude was positively associated with mental health help-seeking, indicating that positive mental health attitude was associated with higher help-seeking behaviors, while negative mental health attitude was associated with lower help-seeking behaviors. It was also found that lack of mental health knowledge is a barrier to help-seeking behavior that adversely impacts the patients’ access and utilization of mental health services.
According to Gebreegziabher et al. (2019), help-seeking behavior among students suffering from common mental health disorders is low as less than 30% sought mental health help. Hence, the researchers investigated factors influencing mental help-seeking in the student population. The research study involved 260 university clinically diagnosed students with common mental health disorders. The study participants completed the 0-item Kessler Psychological Distress Scale, assessing their common mental health disorders. The research findings revealed that mental health help-seeking is closely associated with knowledge and satisfaction with mental health care. Results of the research study showed that students with good knowledge and high satisfaction with mental healthcare were more likely to seek mental health help. Contrarily, students with poor knowledge and low satisfaction with mental healthcare were less likely to seek mental health help, suggesting that they were less likely to utilize mental health services in the school.
A cross-sectional research study conducted by Milanzi et al. (2023) aimed to determine students’ help-seeking intention and factors influencing the students’ mental health help-seeking behavior. The cross-sectional research study involved 137 clinical students who were administered Barriers to Access Care Evaluation (BACE-3), General Help-Seeking Questionnaire (GHSQ), and Perception of Stigmatization of Others for Seeking Help Scale (PSOSH) to collect data regarding the students’ mental health care access, help-seeking intention, and perceived stigma, respectively. The research results indicated low help-seeking intentions, revealing that the students were less likely to access and utilize mental health services in the school, as more than 60% of the students were less likely to seek help from school-based mental health services. The students’ perceived stigma was identified as a leading barrier to the students seeking mental health help and preventing them from accessing or utilizing school-based mental health services. It implies that the students’ help-seeking intentions had significant impacts on the students’ access and utilization of the school-based mental health services, while the effects on the mental health service access and utilization were influenced by the barriers, including stigma, to their help-seeking intentions.
Alternatively, students’ perception of the benefits of seeking mental healthcare help may have an impact on their accessing and utilizing mental health services. If students perceived that they derived benefits from seeking help for their mental health, they are more likely to access and utilize the mental health services; however, the students are less likely to access and utilize the mental health services if they did not perceive benefits of seeking help for their mental health (Milanzi et al., 2023). This sub-section reviewed evidence from the literature regarding the impacts of students’ perceived benefits of seeking mental health care help on accessing and utilizing mental health services.
Villamor & Felicidad (2022) investigated the impact of students’ perceived benefits of seeking help for their mental health problems and the barriers to help-seeking behaviors on their preferred mental health help sources. The research study included 96 students. The research results revealed a significant relationship between students’ perceived benefits of mental health help-seeking and the barriers to mental health help-seeking, including their preferred source of mental health help sources. The research findings imply that the students’ preference for accessing and utilizing a mental health service depends on the perceived help-seeking benefits they derived from the mental health service. Andrade et al. (r2014) explored the mental treatment barriers in individuals with mental health disorders. The researchers analyzed the data retrieved from World Health Organization (WHO) World Mental Health (WMH) surveys. The research findings revealed that the study participants’ perceived dissatisfaction with the students’ treatment effectiveness and adverse experiences with the mental health providers significantly contributed to the study participants’ dropping out of the mental health treatment. It implies that the study participants’ perceived lack of benefits from the help they sought from the mental health treatments was a barrier to seeking or utilizing the mental health services.
Academic Implications of Mental Health Issues
According to Rattermann et al.’s (2021) research findings from the analysis of social determinants of health (SDH) data, students’ ill health has significant adverse impacts on the students’ academic performance and the implications for the students’ poor academic achievement. Several research studies have reported that issues have significant academic implications. Based on copious evidence from the literature, the association between students’ mental health and academic outcomes is significant. The findings of such research studies revealed a significant relationship between the mental health of students and their academic performance and achievements (Chu et al., 2023). This sub-section reviewed evidence from the literature concerning the academic impacts of mental health problems on students.
Grøtan et al. (2019) examined the relationship between students’ mental health conditions, including psychological distress, and academic outcomes, including the student’s academic progress. The research study included 2430 students who were administered the Norwegian Students’ Health and Welfare survey 2014 (SHOT 2014) to collect the students’ academic self-efficacy and psychosocial data. The study participants were also administered the Hopkins Symptom Checklist (HSCL-25) to collect data regarding their mental distress symptoms. The research results revealed a significant association between the student’s mental health condition and their academic performance. The reported academic efficacy was four times lower in students who reported severe mental distress symptoms compared with students who reported moderate mental health distress symptoms. Academic progress delay was two times higher in students who reported severe mental distress symptoms compared with students who reported moderate health distress symptoms.
Another research study published by Chu et al. (2023) assessed the relationship between mental health and students’ university academic performance. The cross-sectional research study included 1823 study participants who were assessed over a 4-year follow-up. Data regarding the study participants’ mental health status was collected by administering the six‐item Kessler Psychological Distress Scale (K6). The research results a significant association between the student’s impaired mental health status and poor academic performance. Based on the research results, there were high levels of mental health impairments in the university students and reported the significant predictive impact of the high mental health impairment levels on the students’ poor academic performance. Other research studies that examined the relationship between mental health and students’ academic performance reported similar findings concerning the significant relationship between students’ mental health status and their academic outcomes (Agnafors et al., 2021; Duncan et al., 2021; Zada et al., 2021).
Discussion
School-based mental health programs enhance individuals’ psychological, social, and behavioral health. Institutions with mental health services help students overcome staff shortages, transportation issues, disparities, high costs, and stigma. According to Cefai et al. (2022), those who received a school-based mental health treatment had greater psychological well-being than those who did not. Behavioral therapies such as Mindfulness and CBT increase students’ mental health. Self-awareness and external awareness in CBT alleviate generalized anxiety disorder and depression. The use of mindfulness-based cognitive behavioral therapy (MBCT), meditation, and Mindfulness-Based Stress Reduction (MBSR) can effectively treat anxiety and depression (Zou et al., 2020; Parsons et al., 2022). Studies indicate that stigma hinders mental health services, access, and therapy and makes individuals reject services. However, reducing stigma and enhancing mental health awareness and understanding may promote mental health support and services. Wao et al. (2023).
According to Broglia et al. (2021), students reported an elevated prevalence of mental health disorders. They cited stigma, particularly self-stigmatizing views and school staff stigma, as a critical obstacle to seeking mental health help. Alluhaibi & Awadalla,2022; and Muhorakeye & Biracyaza, 2021, found that mental health patients’ lack of knowledge inhibits service usage. However, Corrigan et al. (2014) demonstrated that mental health education decreases stigma and promotes treatment service usage. Vinutha and Jose (2022) and Khombo et al. (2023) found that mental health awareness programs improved students’ knowledge and views of school-based mental health care.
Theoretical Framework
The theoretical model underlying the design and implementation of this research study is the HBM. According to APA (2021), HBM is based on the socio-cognitive perspective indicating people’s tendency to engage in a specific health-related behavior based on the belief of the serious outcomes of a problem on their daily life activities because of their belief of the intervention’s effectiveness and the perception of minimal barriers to taking the action. Based on HBM, an individual’s health-related behavior depends on some interrelated factors. Such factors are the perceived severity, susceptibility, threat, benefits, and barriers. The model elucidates the reason why an individual rejects specific preventive health behaviors. The HBM model reveals a person’s behavioral modification is dependent on three overlapping behaviors: (a) Susceptibility and severity, referring to a person’s awareness of adequate reasons for health concerns; (b) threat perception, meaning the person’s knowledge of being predisposed to developing the illness or an unfavorable health outcome; and (c) benefits and barriers perceptions, referring to the person’s awareness of the importance of behavioral modification and the benefits of the modified behavior outweighing the associated costs (Oguamanam & Oguamanam, 2018).
The application of the model to utilizing mental health services offers the structural plan to develop and evaluate a program design to augment mental health awareness and improve mental health utilization (APA, 2001). Researchers hypothesized HBM might be linked to treatment utilization in young adults with depressive symptoms. A survey study was conducted by………………..to explore the hypothesis. Results of the research study revealed a significant association between the utilization of depressive symptoms treatment in the entire HBM domains, indicating significantly high perceived benefits, self-efficacy, and cues-to-action levels association with the utilization of depressive symptoms treatment. Based on the research findings, the HBM was identified as a useful tool for predicting depression treatment help-seeking behavior. This indicated the appropriateness and significance of applying HBM as an underlying theoretical framework for this research study. Evidence from other research studies has indicated the HBM is a theoretical framework useful for gaining better insight into help- and treatment-seeking behaviors of individuals with mental health conditions (Castilla-Puentes et al., 2022; Castonguay et al., 2016). The HBM recognizes the importance attached to wellness maintenance or treatment seeking in the presence of illnesses and individual’s beliefs regarding the impact of taking an action, positing the impact would result in desired outcomes (Janz et al., 2008). Besides, the HBM has been adopted as a well-applied model underlying previous research studies’ conceptual framework.
Henshaw & Freedman-Doan (2009) have applied the model in developing the framework for conceptualizing mental health services utilization to explore the individual’s barriers to accessing and utilizing mental health services. Also, Nobiling & Maykrantz (2017) adopted the model for elucidating the relationship between the students’ perceived mental health challenges and mental health service utilization. Oguamanam & Oguamanam (2018) used the HBM to formulate a theoretical framework for investigating the mental healthcare professionals’ perceived barriers to mental health service utilization. In a more recent research study, Lilly et al. (2020) used the HBM as the theoretical framework for identifying barriers to mental health help-seeking and barriers to accessing and utilizing mental health services in students with depressive symptoms.
Hence, based on the HBM’s tenets and evidence indicating the application of the model in previous research studies concerning mental health, the HBM model is the model for the theoretical framework in this research study. The model will be used to investigate and identify factors challenging the provision of adequate mental health care interventions for students and the barriers to accessing and utilizing mental health services by the students. Based on the identified challenges and barriers, the HBM will be used to inform effective solutions to address the challenges and barriers.
Summary
Students in higher education, particularly the graduate students, including the master’s and PhD students, face more mental health concerns due to the demands and challenges, including the academic, economic or financial, sociocultural, and psychological, associated with postgraduate studies. Therefore, the prevalence rate of mental health disorders in postgraduate students is considerable and it is projected it will rise over time. Research evidence has revealed several factors contributing to graduate students’ poor mental health, leading to the increasing prevalence rates of mental health problems, including anxiety, stress, and depressive symptoms in graduate students, increasing public health concerns, and growing interest in exploring graduate students’ mental health. Hence, the reviewed research demonstrates evidence from the literature concerning the prevalence rate of mental health conditions and the associated factors.
Copious evidence from several research studies, including the empirical and non-empirical research studies, reviewed indicated significant high prevalence rates of adverse mental of mental health illnesses, including anxiety, stress, psychological distress, and depressive symptoms, in graduate students. The evidence indicates the prevalence rates of mental health illnesses, including anxiety, depression, and academic stress, in graduate students were significantly higher compared with other populations including undergraduates, working populations, and the general population. It was found the prevalence rate and severity of mental health problems increased over time during the years of graduate studies.
Researchers reported several risk factors for mental health illnesses in graduate students. Such reported evidence reveals an association between mental illnesses in graduate students and mental health conditions. Based on copious evidence from several research studies reviewed in this chapter, the significant risk factors for poor mental health conditions include academic stress, low postgraduate training satisfaction, including dissatisfaction with the choice of supervisor or poor relationship with the supervisor, food insecurity, loneliness, and social isolation. Research evidence revealed a significant association between the identified risk factors and the prevalence and severity of mental health illnesses in the students.
This chapter also reviewed mental health services, including school-based mental health services, and different types of mental health interventions, including CBT and mindfulness-based therapies, effective for addressing students’ mental health challenges. Evidence from the literature review revealed that both CBT and mindfulness-based therapies, including MBCT, mindfulness meditation, and MBSR, are effective mental health interventions for students with mental health problems. This chapter also reviewed evidence in the literature regarding the barriers and obstacles to mental health and mental health services. The identified barriers and obstacles in the literature include stigma, mental health perception and knowledge, mental health service awareness, graduate-students help-seeking attitudes and behaviors, and perceived benefits of seeking mental health help. Evidence from the research studies revealed that the identified barriers significantly impact mental health and the access and utilization of mental health services. The research evidence revealed stigma and mental health knowledge and perception as leading factors adversely impacting students’ mental health and their access and utilization of mental health services. Besides, research findings indicated a significant association between help-seeking behaviors and attitudes and stigma and mental health knowledge and perception, mitigating access and utilization of mental health services. Based on the evidence from this literature review, the impact of help-seeking behavior on mental health and access or utilization of mental health services is mediated by stigma and mental health knowledge and perception. Perceived benefits of mental health help-seeking are also an important barrier to accessing and utilizing mental health services, but the impact and association with mental health and mental health service access and utilization are understudies.
Copious evidence from the literature revealed the negative association between mental health issues and students’ academic outcomes. The research findings indicated that students’ mental health problem has significant adverse impacts on the student’s academic outcomes, including academic performance, study progress, and academic efficacy. The theoretical framework for this research study was based on the HBM, which has been successfully applied in other related research studies. Based on the HBM-based theoretical framework, findings from the review identified the prevalence of mental health illnesses (severity), predisposing factors to mental health illnesses (susceptibility and threat perception), barriers to mental health and mental health services access and utilization (barrier perception), and mental health and mental health service knowledge and awareness (benefits perception).
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