The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie2023, Vol. 68(2) 101‐108© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/07067437221128168TheCJP.ca | LaRCP.ca
AbstractObjective: Access to adequate mental health (MH) services is necessary for nearly half of Canadian youth (18–24 years) who enroll in post-secondary education given the relatively high risk of MH problems. Our objectives were to determine the status of MH services available to students in post-secondary institutions in Canada and to determine the extent to which these services are based on the principles of a high-quality youth MH (YMH) service.
Method: Information on MH services was collected from websites of a representative sample (N = 67) of post-secondary institutions across all provinces. Data were analysed descriptively according to four categories (universities with a Faculty of Medicine (FoM) n = 18, other large universities n = 15, small universities n = 16, and colleges n = 18).
Results: Most institutions provided 24-h crisis line support (84%) and indicated the availability of free counselling or psychotherapy (n = 62 of 67, 92.5%), while only a minority indicated provision of an initial clinical assessment (25%) and provision of multiple sessions of therapy (37%). Wait time for first contact was impressively low (<72 h) in the minority of institutions (40%) which provided this information. Access to either a prescribing physician or psychiatrist was infrequent, though several mentioned an unexplained model of “stepped care” and outside referrals. While relevant information was not uniformly easy to access, larger institutions both with and without a FoM appear to be better poised to provide MH services. None of the institutions appeared to follow all the principles of service delivery recommended for a high-quality YMH, with only two showing early identification activities.
Conclusions: MH services in post-secondary institutions may need a transformation similar to YMH services, including a clear pathway to care, an initial clinical assessment, early identification of MHA disorders, and better utilization of institutional resources through greater collaboration and matching of timely interventions to the presenting problems.
Keywordsstudent health services, early intervention, rapid access, youth mental health services, post-secondary institutions
Enrollment of nearly half of Canadian youth (18–24 years) in post-secondary education is a critical step for their personal, social, and economic success1,2 as well as for the country’s economic growth.3 While entering university or college can be an exciting time of autonomy and development of personal identity,4 it can also be stressful, as students learn to balance academic, financial, and social expectations, and, often, being away from family.5–7
Entry to post-secondary education overlaps with the period of greatest vulnerability to the onset of a range of mental health and addiction (MHA) disorders8–10 and may compound pre-existing stress. The superordinate importance of MHA problems among youth in Canada has been highlighted recently,11 given their high incidence and prevalence12–16 as well as their social, functional, and economic costs.17–19 For post-secondary students, untreated MH disorders may lead to additional academic challenges7,20,21 exacerbated further by the COVID-19 pandemic through increased social isolation, lack of resources, and economic instability.22–24
While demand for youth mental health (YMH) services is increasing16 the response in Canada, as elsewhere, has been inadequate and largely inappropriate25–27 resulting in poor and often delayed access to intervention.26,28 Although school-based mental health (MH) literacy campaigns may be increasing across Canada,29,30 services required to address the needs of students remain variable at best20,31–35 and are often inadequate.22,36 The pandemic has additionally made it increasingly critical for educational institutions to provide MH services to those in need.
Recently, transformation of YMH services is being undertaken in several high-income countries,37 including Canada38,39 with a focus on easy access and improved quality of service. Principles guiding the YMH service transformations include: youth and family engagement in the planning and delivery of services; open and stigma-free access to care; early case identification to reduce delays to appropriate interventions; empowered care, and evaluation of care delivered.11,40 While the Okanogan Charter and the MH Commission of Canada have highlighted, nationally, the critical role of postsecondary institutions in YMH service transformations41,42 it is unclear to what extent these recent developments have influenced students’ access to broadly recommended services.
We conducted the present investigation from the perspective of a student seeking MH services at their post-secondary institution, using a web-based search. Our objectives were to describe: (a) what type of MH services are publicized as being available to students through Canadian post-secondary institutions and how these services vary across institutions with varying internal resources (e.g., with or without Faculty of Medicine (FoM)); and (b) to what extent do institutional webpages indicate adherence to the above-stated principles that guide the new wave of YMH services.
Our sampling strategy was designed to capture the variation in size, and the type of internal resources (faculties and departments) available, factors that are likely to influence MH services available to students. We used the Government of Canada,43 Universities Canada, and Royal College of Physicians and Surgeons of Canada webpages to obtain information on student enrollment for post-secondary institutions. We sampled institutions across each of the 10 provinces (territories not included) to represent large (n ≥ 20,000) and small (n ≤ 10,000) universities and one college. For every institution with a FoM (psychiatry and family medicine), we selected a large university (enrolment n ≥ 20,000) without a FoM but with a department of clinical psychology; one small university (enrolment n ≤ 10,000), and a college with any enrollment size (to include small urban and Northern institutions). Quebec and Ontario samples were larger as each had more than two universities with a FoM.
Data were derived primarily from institutional webpages in the form in which such information would normally be available to a student seeking help. For locating the homepage of each institution, we conducted a general search in Google, using the institution name along with keywords that included “mental health,” “wellness,” and “student services.” To meet our first objective, we specifically examined if the following services were listed: (1) clinical assessment; (2) psychological services including psychotherapy and counselling; (4) medical doctor on campus with a license to prescribe medication; (5) on-campus access to psychiatrists; and (6) referral to services outside the campus.
For our second objective, data were collected on the following: (1) early identification: the presence of mechanisms to identify students with existing or emerging MH and addiction problems including involvement of student union and university residences; (2) rapid referral-free access to a free service such as a walk-in-clinic or a central hub; (3) timely referral to specialist services, if required; (4) involvement of students in the planning and delivery of care; (5) assessment of student satisfaction with the services received; and (6) evaluation of services and quality improvement indicators.
When information on the description of services provided was not available, email or phone contact was attempted. Our analysis of the data is descriptive (means, standard deviation, and range). We examined any special trends in terms of services and access based on the size of the university, and the presence of specific departments and faculties.
Sixty-seven institutions with a total enrollment of 1,032,715 students (see Table 1 for details) were included. By design, all large universities without FoM had departments of clinical psychology. Most small universities contained departments of psychology (n = 13 of 16, 81.25%) but only two had clinical psychology graduate streams.
The availability of information regarding MH services varied between institutions. The majority of institutions had a separate webpage for MH and well-being services, which was navigable via the student services page. In some cases, institutions had an obvious link to MH services from the main homepage, while others had webpages that were more difficult to locate and thus necessitated a website-wide search using keywords such as MH, wellness, and counselling.
Clinical Assessment. Clinical assessment was indicated to be available only in a quarter of institutions, most of which had a FoM (n = 10 of 18, 56%).
Psychological Services (Psychotherapy and Counselling). Almost all institutions (92.5%) indicated the availability of counselling or psychotherapy varying between 100% in large universities without FoM and small universities to 77% in colleges. Less than half of all institutions indicated that counselling was provided as multiple sessions with a maximum upper limit (n = 25 of 67, 37%). This was more common among institutions with FoM (n = 8 of 18, 44%) and large universities without a FoM (n = 8 of 15, 53%) than among small universities (n = 6 of 16, 38%) and colleges (n = 3 of 18, 17%). Other institutions (n = 10 of 67, 15%) simply indicated “short-term” counselling without the number or an upper limit of sessions provided, while others did not indicate the duration of services (n = 24 of 67, 36%). A minority of institutions (n = 4 of 67, 6%), mostly those with a FoM, indicated availability of a “single session” intervention; two offered peer-support online, access to online resources including videos and apps, support groups, workshops (n = 1), virtual group counselling geared towards specific needs (n = 1), including those of international students and a link to a free, 24/7 online counselling service available in several languages.
Medical and Psychiatric Services. A quarter of all institutions indicated the presence of a physician on campus with the ability to prescribe medications and most of these had a FoM (n = 12 of 18, 67%). Overall, a relatively small proportion (n = 7 of 67, 10% total) of institutions, even those with a FoM (27%) indicated access to a psychiatrist on campus. The rest had almost no such access (Table 2).
Referral to Services Outside the Campus. More than half of universities with a FoM (n = 10 of 18, 56%) indicated that students could access referrals to services such as emergency services, longer-term counselling, psychiatrists, and other MH specialists through their MH center. This type of service was available in a relatively lower proportion of other types of institutions ranging from 22% in colleges to 33% in large universities without a FoM.
Early Identification. Most institutional websites provided limited or no information regarding early case identification (early intervention (EI)). Large institutions with a FoM were more likely to indicate mechanisms for early identification (n = 6 of 18, 33%) compared to the other categories.
Access to MH resources housed within local faculty/department buildings and/or student residences known to promote EI was reported in a minority of institutions (FoM n = 3 of 18, 16%, large universities without FoM n = 1of 15, 7%, and colleges n = 2 of 18, 11% and none in small universities). One university with a FoM (n = 1 of 18, 5.5%) specifically indicated that trained MH clinicians were embedded within each individual faculty. Some (5 of 34) small universities and colleges provided spaces, either as a single drop-in hub or distributed around the campus, for the student to be able to speak with a peer-counsellor (n = 5 of 34, 15%). A small proportion of large institutions with and without FoM (n = 7 of 34, 19.7%) engaged students/faculty/staff and parents in activities designed to encourage help-seeking. The latter were mostly training sessions/workshops to encourage “peer support” and were open to instructors, professors, and other community members to learn to “identify” signs of distress, including risk for suicide (n = 6 of 67, 8.9%). Only a single institution provided training for peers and faculty to learn about suicide prevention (n = 1 of 67, 1.5%). Three institutions (4.5%) invited requests from students, faculty, and community members for “wellness checks” in case of concern for the MH of a particular student. Only one institution (with FoM) provided all forms of EI intervention listed here, as well as providing targeted media campaigns. A few institutions (n = 4 of 67, 6%) utilized self-screening tools before or at the time of first contact.
Rapid Access to a Free Service. Most institutions listed 24-h hotlines (n = 56 of 67, 84%) on their websites. Less than half (27 of 67, 40%) mentioned the expected maximum wait time for the first face-to-face contact (11 of 18, 61%; 8 of 15, 53%; 4 of 16, 25%; and 4 of 18, 22%, for institutions with a FoM, other large institutions, small universities, and colleges, respectively). Half of all large institutions, both with and without a FoM, provided rapid access (defined as 72 h) to a service, usually counselling, while small universities and colleges rarely did so (see Table 3).
Services Provided According to Needs. Institutions indicated that following initial contact with the help-seeking student, steps were taken to provide service according to needs. Almost two-thirds of all small universities (n = 10 of 16, 63%), half of the colleges (n = 9 of 18, 50%), a minority of large institutions with a FoM (n = 3 of 18, 17%), and those without FoM (n = 4 of 15, 27%) indicated that they would assess students by way of a “stepped-care” model whereby they would be referred to care equivalent to their needs. No details were available about “stepped care.”
Involvement of Students. Involvement of students in the planning of care was mentioned in a quarter of all institutions (n = 17 of 67, 25%) through student unions contributing to the MH funding, peer-support programs, and peer counsellors put in place on campus. One of the small universities developed its programming with input from student committee members.
Evaluation and Student Satisfaction. While none of the institutions mentioned an evaluation of services and service outcomes, only two institutions (with and without a FoM each) included methods for improving their programming based on information from a student focus group and online “suggestion box.” Overall, student feedback to assess satisfaction was being solicited in a small number of institutions (n = 9 of 67, 13%) through an online “suggestion box,” satisfaction survey, or online feedback form.
The results for the first objective of this study, based on information available to students on the institutional webpages, revealed that there is indeed a large variation in some basic elements of MH services provided by post-secondary institutions to address a range of MH problems among their students. While institutions almost invariably provide a 24-h hotline for crises and most make psychological services (psychotherapy or counselling) available, a formal clinical assessment of the presenting problem and physician services (e.g., prescribing medications) were reported to be available in only a quarter of the institutions, mostly those with a FoM. Other institutions may be providing a general assessment of the presenting problem that is either not specifically clinical or that only assessments offered by a physician are being regarded as clinical. It is equally possible that once a student contacts an MH professional, the latter starts delivering whatever service they consider appropriate or is demanded by the student without a formal assessment. An initial clinical assessment may be important in determining the nature and severity of the presenting problem and in planning the delivery of the most appropriate interventions. The absence of a clinical assessment could result in many students not receiving the most appropriate service or referral to a more specialized service if needed or alternatively receiving therapeutic interventions when not needed. The nature of our data does not allow us to specifically examine the important question of how an MH “case” should be defined (for details see Malla et al.44).
Access to a general physician or psychiatrist was often not indicated even in institutions with a FoM, although a few clearly indicated absence of such access. This means that students with MHA problems may lack ready access to a prescribing general physician and/or a psychiatrist. This may suggest a lack of a formal relationship and collaboration between the student health services and the clinical academic resources available in the institution. For institutions without such a resource, it may be even harder to recruit psychiatrists to work within the student health services either due to a local shortage of psychiatrists or because of other factors such as remuneration systems.
On the whole MH services in post-secondary institutions appear to provide basic services at least as well as generic MH services in the wider community. The emphasis on psychological services may be even greater in post-secondary institutions than seen in general clinical services, while formal clinical assessments may be provided more often in the latter. Most institutions appear to limit the number of sessions available. Additional therapy sessions may be available through referral to therapists outside the institution supported by insurance but are not mentioned. Single session therapy has become increasingly useful for brief and crisis-oriented problems45,46 and appears to be available only in a very small number of institutions. The type of service available appears to be associated with resources available internally within the institution (e.g., medical and psychiatric services in universities with FoM and psychological services in most universities with psychology departments) although even in those institutions adequate utilization of such resources may be lacking. Given the nature of our data, we cannot comment on the type (e.g., cognitive behavioural therapy) or the quality (e.g., manual-based), or the training and expertise of therapists providing therapeutic interventions.
We observed that MH services were not easily identifiable on websites, often located under the “health and wellness” page and not listed in student services, while only a minority of institutions provide a direct link on the homepage. Larger universities were particularly difficult to navigate requiring searches using keywords such as “counselling” and “mental health” and often pathways to “health and wellness” pages were convoluted. Terms such as “wellness” while in popular use, may be confusing for some students in the absence of any mention of MH. While “wellness” has an implied emphasis on health rather than illness, the epistemic problem created may negatively influence access for those with more severe MH problems (for a detailed discussion).47
The results for our second objective revealed relatively low adherence to most of the principles of the new transformation of YMH services. Specifically, early identification (EI) of young people with emerging or established MH problems is a cornerstone of improving delivery of services and outcomes. EI activities, such as embedding MH workers within faculties, interventions to improve MH literacy, and attitudes among students and faculty are rarely mentioned in the description of services. Based on the information available from a minority of institutions (mostly large universities with or without a FoM), it appears most of these provide the first face-to-face contact with a professional within 72 h, often regarded as the benchmark for rapid access.48 If this information is truly reflective of how these few services operate, they meet the standard of rapid access infinitely better than regular MH services in most jurisdictions, where the wait times are well known to be extremely long. However, it is unclear whether such rapid access is available at other institutions that did not provide this information on their websites.
Hotlines (24-h) to reduce the distress associated with a crisis49,50 are available at most institutions and should be considered an essential service. Our data do not allow us to examine whether these hotlines are able to connect the student in distress to a service or an MH professional for further assessment and care.
The ease and speed of referral to a specialist service is another measure of the quality of a YMH service. A higher proportion of smaller universities and colleges (67% and 50%, respectively) claim using a “stepped-care” model to arrange services according to the students’ needs, compared to large universities, with and without FoM (17% and 27%, respectively). Whether the “stepped care” includes referral to specialist care when needed is unclear. Those not reporting “stepped care” may have internal access to specialist services more often and do not use the term. Time to referral for specialist care is not clearly indicated and, therefore, difficult to compare to the Canadian Psychiatric Association benchmark of 30 days.51
While there was no direct student involvement in designing MH services, about a quarter did indicate student involvement through their unions providing funding, peer counsellors, and other support programs. It is possible that some institutions may be undergoing service transformation, including greater student involvement but this information has not yet been provided on their websites. Last, but not least, the absence of reporting evaluation of services and outcomes is not peculiar to student health services in postsecondary institutions but in keeping with the regrettable norm in most MH services with a few exceptions of those that are part of research projects.52–55 However, a small number of institutions did indicate the presence of student satisfaction surveys or online feedback from those who receive services.
To the best of our knowledge, this report is the first to provide a description of MH and addiction services through the lens of a Canadian student looking for access to such a service. The study also provides a web-based assessment of whether the services are utilizing the principles that have been internationally accepted as necessary to transform the quality of MH services to young people.
Our study has several limitations. The results reported here are limited by the nature and quality of information available from the sources listed, mainly institutional websites. No direct survey of the staff or managers was undertaken and direct contacts with institutions were not uniformly informative. While we attempted to capture a representative sample of large and small universities as well as colleges across all Canadian provinces, some institutions not included in our sample may, in fact, provide many more services or adhere more closely to the principles of a high-quality MH service for young people without reporting it on their websites. We were also unable to ascertain to what extent did post-secondary institutions deal with the demands emerging from the pandemic that affected young people differentially. Future studies should involve a detailed survey of a representative sample of post-secondary institutions examining the nature of interventions provided, the model of care used, how these operate in the context of the larger YMH care locally and regionally, and to what extent they utilize key principles of a modern high-quality YMH service.
In conclusion, post-secondary institutions need to make access to information on the provision of MH services more explicitly and easily available through their respective websites, the most likely method the students, especially new entrants, are likely to use when searching for help. Given the high rate of MH problems of varying severity among youth 18–25, providing a high-quality MH and addiction service should be the focus of health services in postsecondary institutions. In order to improve their services, these institutions would benefit from using the recently articulated principles and methods for service transformation of YMH services.56 Providing a comprehensive assessment of the presenting problem to a help-seeking student at first contact to determine the presence, nature, and severity of the MH or addiction problem may be central to this improvement in service delivery followed by a clear pathway between initial contact and appropriate intervention. Students need to know where and for how long services are available. While crisis lines are present in all institutions, rapid access to face-to-face or online assessment and therapeutic interventions needs to be as clearly established and articulated. Improved MH literacy across the institution, activities to promote early identification of emerging and existing MH problems among the student population, and rapid access to their first contact with a professional is likely to be the most important aspects of such reform. Last, but not least, resources available within the institutions (e.g., Family Medicine and Psychiatry) and those in the larger MH system could be better utilized through a collaboration between student health services and these resources.
We would like to thank Dr. Jason Martens for his support and contribution as well as Chelsie Ram and Emily Karlstrom for their assistance.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study received indirect financial support in the form of a scholarship to the first author (A.R.) from Capilano University’s Creative Activity, Research and Scholarship (CARS) program.
Alana Read https://orcid.org/0000-0001-5194-7104
Supplemental material for this article is available online.
1 Department of Psychology, Capilano University, North Vancouver, British Columbia, Canada
2 Department of Psychiatry, McGill University, Montreal, Quebec, Canada
* Co-senior author.
Corresponding author:Danyael Lutgens, MSc, PhD, Department of Psychology, Capilano University, 2055 Purcell Way, North Vancouver, British Columbia, Canada V7J 3H5.Email: daniellelutgens@capilanou.ca
