Mental health promotion, prevention, and early intervention through campus interventions and integrated service centres

Purpose

The purpose of this evidence brief is to outline the available evidence on specific mental health promotion, prevention, and early intervention interventions for transition-age youth (TAY). Although there are a range of interventions for this population, mental health promotion and mental illness prevention interventions for post-secondary students and integrated service centres have been selected as priority areas for this evidence brief. Outcomes related to each of the priority intervention areas are presented, as well as the components of effective programming, as outlined in the literature.

The evidence presented in this brief can be used to inform policy and practice decisions, to promote the mental health of transition-age youth in the province, in support of Phase Two of Ontario’s Mental Health and Addictions Strategy. 

Read the evidence brief below or download the PDF of this document.

Main Messages

Background

Increasingly, the transition into adulthood is a more prolonged and unstable developmental age (McGorry et al., 2013). One in five young people in Canada between the ages of 15 and 24 report experiencing mental health or substance use concerns (British Columbia Integrated Youth Service Initiative, 2015). Those experiencing mental health concerns during this transitional time may also experience poor functioning, homelessness, justice involvement, and challenges with education and employment. These challenges are experienced more acutely by youth from vulnerable populations such as First Nations, Inuit, Métis, and newcomer youth, youth with disabilities, lesbian, gay, bisexual, and transgender youth and  those involved with the justice and child welfare systems (Mental Health Commission of Canada, 2015).

The term transition age youth (TAY) typically refers to individuals between the ages of 16 and 25, however some have adopted a more flexible definition of TAY by identifying them to be as young as 12 years old (Cappelli & Davidson, 2011). Importantly, Cappelli & Davidson (2011) suggest that developmental age, rather than chronological age, should be considered in both the delivery and planning of mental health interventions.

Research from Canada, the United Kingdom, United States, and Australia demonstrates similar findings with respect to the inadequacy of financial and institutional structures at the interface of the child and adult mental health systems (Vloet et al., 2011). It is at this interface that McGorry et al. (2013) states that the mental health system is at its weakest. The Mental Health Commission of Canada (2015) suggests that what is needed to address the needs of TAY is an integrated, accessible, and responsive system that incorporates a spectrum of services, including universal promotion and prevention initiatives, as well as intensive services. Furthermore, economic analysis has demonstrated that there is a significant return on investment in mental health interventions for young people (BC-IYSI, 2015).

TAY require diverse, integrated, and comprehensive supports that promote mental wellness and seek to provide early identification of concerns related to mental health and substance use. As such, mental health promotion, prevention and early intervention supports for TAY must include programs both on campus and in community-based settings.

Context

Addressing the mental health and substance use needs of TAY is currently a high priority in Ontario. Closing critical service gaps for youth at key transition points is one focus of Open Minds, Healthy Minds, Ontario’s comprehensive mental health and addiction strategy (Government of Ontario, 2011; OMHALAC, 2015). The first phase of the strategy focused intensely on children and youth. Ontario is now building on the first phase, expanding it to integrate services for TAY and to improve transitions between youth and adult services, between acute and community services, and between the health and justice systems, as well as between secondary and post-secondary educational settings.

Methodology

To guide the development of this evidence brief, the team established a research question, search strategy and inclusion/exclusion criteria. The research question was: “What does the evidence say about interventions related to mental health promotion, prevention, and early intervention for TAY?” More specifically, the research explored what the outcomes and components are of 1) mental health promotion and prevention interventions for post-secondary students, and 2) integrated service centres for TAY.

Key search terms included the following: mental health; mental health promotion; mental illness prevention; early intervention; campus; post-secondary, college or university students; integrated services; youth, young adult, transition age, or emerging adult.

The team reviewed peer-reviewed and grey literature published in English between 2006 and 2016. The following sources were searched: Google, Google Scholar, HealthEvidence.ca, and the Cochrane database of systematic reviews. In addition, the reviewers consulted with experts in the fields of youth and young adult mental health and conducted hand searching of reference lists.

Only review-level publications, such as meta-analyses and systematic reviews, were included in the search for evidence on campus interventions and interventions for TAY more broadly. The review of evidence on integrated service centres included single studies due to a scarcity of review-level literature.

The Evidence

Integrated Service Centres for Transition-Age Youth

The integration of physical and mental health services for TAY occurs both in community-based and campus settings. Integrated services are focused on early intervention and early identification of mental health and substance use concerns in TAY. They are designed to eliminate typical help-seeking access barriers and provide a ‘soft entry’ into the mental health system. Services provided may address concerns related to physical health, sexual health, mental health, substance use, family and situational issues, and vocational/ employment. TAY with mild to moderate psychological distress are provided with brief intervention and diverse supports, while those with significant mental health concerns are provided with supports to access services supported that are more appropriate to their needs. 

Well-established examples of community-based integrated service centres include headspace in Australia and Jigsaw in Ireland:

Outcomes

Currently, no review level evidence is available on integrated services for TAY focused on prevention and early intervention in either a community or campus setting.

Evaluative studies have been conducted to describe early outcomes of both headspace and Jigsaw, which include increasing access, engagement, and reduction in psychological distress.

Both headspace and Jigsaw have been successful at reaching their target populations:

The following was found with respect to engagement and access:

Outcomes related directly to psychological distress for community-based integrated services are:

Youth that presented with moderate-severe and severe self-reported psychological distress were referred to other services.

There are limitations to these results related to psychological distress. Rickwood et al. (2015b) notes that the absence of a control group means the changes found cannot be attributed specifically to the headspace centres. Jorm (2015) suggests that the changes demonstrated at headspace are similar to outcomes achieved without intervention and as a result, may not be significant. Further research is needed to assess the long term outcomes of integrated service centers. Research is underway in Ontario to compare the performance of recently opened integrated service centres o usual care in youth outpatient psychiatric services.

Components of Effective Programming

The following outlines the components needed to guide the development of successful integrated services for TAY. Services that are guided by these components have the potential to successfully engage TAY and their families in appropriate and high quality care.  They include:

Integrated services for TAY can improve early access to services to address concerns related to mental health, substance use, and physical health, whether in a campus or community setting. Preliminary evidence from community-based settings has demonstrated some effectiveness at reducing psychological distress and providing developmentally appropriate and stepwise care. The following section examines the full breadth of on-campus interventions to promote mental health and prevent mental illness.

Campus Mental Health Promotion and Prevention

Many post-secondary students, both undergraduate and graduate, experience mental health concerns and social difficulties (Conley et al., 2013). Excessive alcohol consumption is also common among university and college students and represents a significant public health concern. These mental health and substance use problems can have a negative impact on academic performance and drop-out rates (Reavley & Jorm, 2010). Campus settings are recognized as providing a unique opportunity for promoting mental health, and identifying and preventing mental illness (Reavley & Jorm, 2010). There is growing realization in the postsecondary sector that approaches to student mental health which focus solely on treatment are neither effective nor sustainable (MacKean, 2011).

With increased understanding of the importance of taking an upstream approach has come the implementation of a number of campus-based interventions to foster self-esteem, improve student coping abilities, and reduce stress and depression. These include programs targeted at individuals with and without mental health concerns, along with systemic approaches to promoting positive mental health at a population level, such as changes to institutional structure and campus environment.

The following section outlines the evidence on the effectiveness of interventions, focused on:

The components of effective interventions are also provided, where possible.

Outcomes and Components of Effective Campus Programming

Campus interventions for psychological distress

Evidence of the effectiveness of campus-based interventions to prevent or intervene early in instances of student psychological distress is diverse, multi-faceted, and sometimes contradictory, depending on the specific type or target of intervention. An evaluative review by Conley et al. (2013) explored controlled universal mental health promotion and prevention (MHPP) interventions involving undergraduate or graduate post-secondary students. Their focus was on programs with three main outcomes: social and emotional skills (e.g. coping, communication, assertiveness, or emotional self- awareness), self-perceptions (e.g. self-esteem/efficacy), and level of emotional distress (e.g. depression or anxiety).

The review found that skill-oriented programs that included supervised practice, composed of behaviour rehearsal and positive feedback, demonstrated the strongest benefits for all outcomes. Similarly, a  meta-analysis by Conley et al. (2015) revealed that skill-training programs including a supervised practice component were significantly more effective than both psychoeducational programs and skill-training programs without supervised practice. They were found to be more effective at reducing symptoms of anxiety, stress, depression, and general psychological distress, as well as improving social-emotional skills, self-perceptions, and academic behaviours and performance (Conley et al., 2015).

Evidence related to the components of skill-training programs with supervised practice is as follows:

It is important to note the high degree of variability in the outcomes of skill-training interventions explored in different studies. Specific features of effective programs are not reported in the literature due to a lack of detailed information in the studies reviewed (Conley et al., 2013; Conley et al., 2015). The factors influencing this variability are unknown and may include:

Furthermore, researchers state that participant motivation or level of engagement in a given intervention may mediate outcomes as much as mastery of the skill being taught in a given program (Conley et al., 2015).

Evidence on other types of campus interventions to prevent or intervene early in instances of student psychological stress can be summarized as follows:

Campus interventions for suicide prevention

A systematic review by Harrod et al. (2014) explored evidence on the effectiveness of interventions for the primary prevention of suicide in post-secondary educational settings. The study compared the impact of classroom instruction, institutional policies, and gatekeeper training programs on number of completed suicides and suicide attempts, suicidal ideation, changes in knowledge and attitudes about suicide, and availability of means of suicide. The authors found the following:

Based on the findings, the authors concluded that there is insufficient evidence to support widespread implementation of any programs or policies targeted at suicide prevention on campus. Because all of the evaluated interventions the authors identified combined primary and secondary prevention components, independent effects of primary prevention were not able to be determined (Harrod et al., 2014).

Campus interventions for alcohol misuse

The evidence of effectiveness for interventions to reduce alcohol consumption among post-secondary students is strongest for multi-component cognitive-behavioural skills-based programs, brief motivational interventions and personalized normative feedback interventions delivered face-to-face or via computer (NSDHW, 2012; Reavley & Jorm, 2011).

The overall findings about the effectiveness of such programs can be summarized as follows (NSDHW, 2012; Reavley & Jorm, 2011):

Less strong evidence of effectiveness has been found for the following intervention components (NSDHW, 2012; Reavley & Jorm, 2011):

Whole campus mental health interventions

A systemic approach to campus mental health is one that considers the whole campus as the domain to be addressed and as responsible for enhancing and maintaining the mental health of campus community members (CACUSS & CMHA, 2013). Furthermore, it involves all stakeholders in the creation of environmental conditions grounded in values of social equity, sustainability, informed choice, and student direction (CACUSS& CMHA, 2013). Comprehensive mental health strategies for the post-secondary student population can have a significant impact on the well-being of students and a high return on investment by decreasing the social and economic costs of mental illness in the broader population (OUCHA, 2009).

While the specific components of whole-campus approaches to mental health promotion, prevention and early intervention are varied, and there is scarce evidence of the links between these components and student outcomes, the following are identified in the literature as being key components for promoting mental health and well-being on campus (CACUSS & CMHA, 2013; CICMH, 2015; Jed Foundation, 2011; MacKean, 2011; Warwick et al., 2008; ACHA, 2010):

Overall, campus-based mental health promotion and mental illness prevention interventions include those targeted at individuals and systemic approaches to promoting positive mental health at a population level. There is an array of outcomes and components associated with the effectiveness of interventions focused on psychological distress, suicide prevention, alcohol misuse, and whole campus mental health promotion.

Limitations

There are several limitations to this evidence brief.  The evidence presented here may not provide a com prehensive overview of knowledge on the broad subject of mental health promotion, prevention, and early intervention for TAY. This is due to  the specificity of the research question, the selected intervention examples, and corresponding search terms, as well as the time constraints on the process of searching for and synthesizing the evidence. The amount of evidence on intervention effectiveness and associated components varies widely across types of interventions. For instance, little research has been done on integrated service centres for TAY. Finally, as a result of the diversity of interventions for TAY, it is difficult to draw conclusions about their comparative effectiveness or about components found consistently across effective interventions.

Conclusion

TAY require an integrated, accessible, and responsive system that incorporates a spectrum of services, including universal promotion and prevention initiatives as well as intensive services (MHCC, 2015). Mental health, promotion, prevention and early intervention supports for TAY must include programs both on campus and in community-based settings.

There are multiple outcomes with respect to interventions for TAY, depending on the intervention and the setting of the intervention. Campus settings are recognized as providing a unique opportunity for promoting mental health, and identifying and preventing mental illness (Reavley & Jorm, 2010). 

Skill-oriented programs that include supervised practice demonstrate the strongest benefits to reduce psychological distress. With respect to reduction of alcohol consumption, evidence of effectiveness is strongest for multi-component cognitive-behavioural skills-based programs, brief motivational interventions and personalized normative feedback interventions delivered face-to-face or via computer (MSDHW, 2012; Reavley & Jorm, 2011).

In community-based settings, there is a need to re-orient existing services to make them more accessible and developmentally appropriate (McGorry et al., 2013, O’Reilly et al., 2015). Integrated services centres have demonstrated that they can increase access and improve psychological distress, primarily with respect to TAY experiencing mild/moderate distress related to depression and anxiety.

Effective components and service infrastructure depend on the target population and issues being experienced by TAY, however there are components that are necessary to develop these comprehensive supports. These include:

This evidence brief has summarized the outcomes and components for mental health promotion, prevention and early intervention for TAY to inform decision making. More specifically, it looked at interventions for post-secondary students and integrated service centres. In summary, providing Ontario’s TAY with diverse and comprehensive supports that promote access to developmentally appropriate services across various settings is essential for preventing additional challenges faced by those with mental health and substance use concerns during an already unstable period of development.

References

American College Health Association (2010). Considerations for Integration of Counseling and Health  Services on College and University Campuses. Linthicum, MD.

British Columbia Integrated Youth Services Initiative (BC-IYSI) Working Group (2015). British Columbia Integrated Youth Services Initiative: Rationale and Overview. Victoria, BC.

Canadian Association of College & University Student Services and Canadian Mental Health Association. (2013). Post Secondary Mental Health: Guide to Systemic Approach. Vancouver, BC.

Cappelli, M. and Davidson, S. (2011).  We’ve got growing up to do: Transitioning youth from child and adolescent mental health services to adult mental health services http://www.excellenceforchildandyou th.ca/ sites/default/files/policy_growing_up_to_do.pdf 

Centre for Innovation in Campus Mental Health (2015). Environmental Scan of Promising Practices and Indicators Relevant to Campus Mental Health. Toronto, ON.

Conley, C. S., Durlak, J. A., & Dickson, D. A. (2013). An evaluative review of outcome research on universal mental health promotion and prevention programs for higher education students. Journal of American College Health, 61(5), 286-301.

Conley, C. S., Durlak, J. A., & Kirsch, A. C. (2015). A meta-analysis of universal mental health prevention programs for higher education students. Prevention Science, 16(4), 487-507.

Government of Ontario. (2011). Open Minds, Healthy Minds: Ontario’s comprehensive mental health and addictions strategy. Ottawa, ON. Retrieved from: http://www.health.gov.on.ca/en/common/ministry/  publications/reports/mental_health2011/mentalhealth_rep2011.pdf 

Harrod, C. S., Goss, C. W., Stallones, L., & DiGuiseppi, C. (2014). Interventions for primary prevention of suicide in university and other post-secondary educational settings. The Cochrane Library.

Howe, D., Batchelor, S., Coates, D., and Cashman, E. (2014). Nine key principles to guide youth mental health: development of service models in New South Wales. Early Intervention in Psychiatry, 8: 190-197.

Jed Foundation (2011). A guide to campus mental health action planning. Retrieved from the Jed Foundation website: http://www.jedfoundation.org/CampusMHAP_Web_final.pdf 

Jorm, A.F. (2015). How effective are ‘headspace’ youth mental health services? Australian & New Zealand Journal of Psychiatry, 49(10) 861–862.

MacKean, G. (2011). Mental health and well-being in post-secondary education settings. In CACUSS preconference workshop on mental health.

McGorry, P., Bates, T., & Birchwood, M. (2013). Designing youth mental health services for the 21st century: examples from Australia, Ireland and the UK. British Journal of Psychiatry, 202, s30-s35.

Mental Health Commission of Canada (2015). Taking the Next Step Forward: Building a Responsive Mental Health and Addictions System for Emerging Adults, Ottawa, ON: Mental Health Commission of Canada.

Nova Scotia Department of Health and Wellness. (2012). Reducing alcohol harms among university students: A summary of best practices. Retrieved from the Centre for Innovation in Campus Mental Health website: http://campusmentalhealth.ca/wpcontent/uploads/2015/10/Reducingalcoholharms among university  students.pdf

Ontario’s Mental Health and Addictions Leadership Advisory Council. (2015). Better Mental Health Means Better Health: Annual Report of Ontario’s Mental Health and Addictions Leadership Advisory Council. Retrieved from: http://www.health.gov.on.ca/en/common/ministry/publications/reports/bmhmbh/ment al_health_adv_council.pdf 

O’Keefe, L., O’Reilly, A., O’Brien, G., Buckley, R., Illback, R. (2015). Description and outcome evaluation of Jigsaw: an emergent Irish mental health early intervention programme for youth people Irish Journal of Psychological Medicine, 1-7.

\O’Reilly, A., Illback, R., Peiper, N., O’Keefe, L, & Clayton, R. (2015). Youth engagement with an emerging Irish mental health early intervention programme (Jigsaw): participant characteristics and implications for service delivery. Journal of Mental Health, 24(5), 283–288.

Ontario University and College Health Association. (2009). Towards a comprehensive mental health strategy: The crucial role of colleges and universities as partners. Retrieved from the OUCHA website: http ://oucha.ca/ pdf/mental_health/2009_1 2_ OUCHA_Mental_ Health _Report .pdf 

Reavley, N., & Jorm, A. F. (2010). Prevention and early intervention to improve mental health in higher education students: a review. Early intervention in psychiatry, 4(2), 132-142.

Rickwood, D.J. et al. (2015b). Changes in psychological distress and psychological functioning in young people visiting headspace centres for mental health problems. The Medical Journal of Australia, 202(10), 537-542.

Rickwood, D.J., Telford, N.R., Mazzar, K.R., Parker, A.G., Tanti, C.J., & McGorry, P.D. (2015a). The services provided to young people by headspace centres in Australia. The Medical Journal of Australia, 202(10), 533-536.

Universities UK. (2015). Student mental wellbeing in higher education: Good practice guide. Retrieved from the Universities UK website: http:/ /www.universitiesu k.ac.uk/policy-and-analysis/reports/Do cuments/2015/ student-mental-wellbeing-in-he.pdf 

Vloet, M., Davidson, S., & Cappelli, M. (2011). Formulating Policies to Reclaim Youth In Mental Health Transitions. Healthcare Quarterly. Vol 14 Special Issue.

Warwick, I., Maxwell, C., Statham, J., Aggleton, P., & Simon, A. (2008). Supporting mental health and emotional well-being among younger students in further education. Journal of Further and Higher Education, 32 (1), 1-13.

 

 

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