The mental health of university students is a source of ongoing concern, with reports of rising rates of mental illness and suicide among young people the world over. Much concern has also been expressed about the mental well-being of students in South Africa and the need for an evidence-based, strategic and coordinated national response.
One example of such a response is the South Africa National Student Mental Health Survey, funded by the South African Medical Research Council and initiated by Universities South Africa, with the support of the vice-chancellors of all universities in the country. It uses the best available scientific methods to assess the mental health needs of the country’s university students and collected data required to plan effective interventions.
The survey was conducted at the start of 2020 by scientists from the South African Medical Research Council, Stellenbosch University and the University of Cape Town, in consultation with researchers from Harvard Medical School as part of the World Health Organisation’s World Mental Health International College Student Initiative.
They collected data from undergraduate students at 17 institutions. More than 70 000 students responded to the survey, making it one of the biggest national student mental health surveys in the world and the first study of its kind in South Africa to collect data from many universities and assess a wide range of mental health problems.
A total of 11 common mental disorders were assessed, which goes well beyond the typically narrow focus on depression and anxiety. The survey is also novel in that rather than just screening for symptoms of mental disorders (as is usually done in studies of this kind), it made use of the best available survey methods and statistical analysis modelling in psychiatric epidemiology to identify the proportion of students who would likely meet diagnostic criteria for the most common mental disorders.
The first results of the survey were recently published in the Journal of Affective Disorders, and provide good evidence of both the scale of the problem and where interventions are most needed. These results focus on the prevalence of mental disorders among students in the preceding 30 days and are an analysis of data from the 28 268 students out of the 70 000 who responded and who provided information about which university they attend.
The findings suggest that as many as 16.3% of students met diagnostic criteria for a mood disorder (either major depressive disorder or a bipolar mood disorder) in the 30 days prior to assessment, while 10.9% experienced a generalised anxiety disorder.
Furthermore, 21% of students reported clinically significant symptoms of posttraumatic stress disorder, highlighting the disturbingly high rates of trauma among the country’s young people. Also of concern was that 6.6% are likely to meet diagnostic criteria for a substance use disorder and 21% reported marked symptoms of attention deficit hyperactivity disorder.
The finding that as many as 6.6% of students are likely to meet diagnostic criteria for a substance use disorder reminds us of the urgent need to address alcohol and other drug use among young people in South Africa. Notably, these prevalence estimates are unlikely to reflect the full extent of hazardous alcohol use as they do not include students who engage in heavy episodic drinking – binge drinking – but do not meet other diagnostic criteria for a disorder.
Alcohol use among students should be the focus of ongoing research and should be high on the list of priorities for universities and the government. Likewise, the liberalisation of cannabis laws in South Africa is likely to have some negative impacts on students, given the scientific evidence that suggests that adolescent brains are likely to be adversely affected by exposure to cannabis.
Students were also screened for other disorders, including social anxiety disorder and eating disorders. While screening instruments are not very accurate at identifying people who are likely to meet all the diagnostic criteria for a disorder, they do provide a fair indication of the number of people experiencing symptoms of a disorder.
The screening instruments showed that 22.7% of students reported symptoms of an eating disorder and 24.5% reported symptoms of social anxiety in the past 30 days. These are certainly overestimating the proportion of students who would be diagnosed with these conditions, but nonetheless, the findings show that these are areas where students also need help.
Interestingly, the distribution of disorders varied significantly across institutions, with disorders consistently more prevalent in historically white universities. For example, while 22.5% of students at these institutions reported a mood disorder in the past 30 days, at historically disadvantaged universities the prevalence was significantly lower at 16.5%.
The risk of a mental disorder was marginally elevated among gender nonconforming and female students relative to males. Sexual minority students (including gay, lesbian and bisexual students as well as those who are questioning their sexual orientation or prefer not to label their orientation) are also more likely to have mental health problems compared to heterosexual students.
Risk was weakly related to parents’ education, with students more likely to report mental health problems if their parents had lower levels of education. These patterns of increased risk were consistently observed across all institutions.
Black students attending historically white institutions had a slightly elevated risk for a mental disorder relative to white students, however, no significant differences in the distribution of disorders across population groups were observed at historically disadvantaged institutions or universities of technology.
The mental health of our country’s students is a key priority, not least of all because mental disorders may lead to lower academic attainment and given that higher education is integral to economic growth and human development. Reliable epidemiological data about mental disorders is required to help plan effective campus-based interventions, formulate context-sensitive policies, establish priorities, especially in resource-constrained environments, and ensure that limited resources can be allocated to where they are most needed.
The initial results from the survey are an important step towards identifying where interventions are needed, what kinds of problems students are struggling with and the number of students who need help. As more of the data is analysed and published, it will become even more clear how services need to be delivered and what interventions are required to support the psychological well-being of our country’s students.
The results of the survey do not provide reasons for the increased vulnerability to mental disorders observed among female, gender non-conforming and sexual minority students at all institutions, as well as black students in historically white universities.
It could be possible that the marginally increased risk among these groups reflects experiences of marginalisation, discrimination and/or alienation which can only be addressed through systemic interventions aimed at transforming the culture of institutions. Increasing students’ access to counselling will not help to change institutional cultures, personal attitudes and institutionalised practices that compromise student wellbeing.
While the findings of the survey draw attention to the proportion of students who require mental health services, they obscure the reality that the vast majority of students do not have mental disorders. In fact, most students in South Africa reported that they are in good or excellent mental health.
It is important not to forget that while interventions are needed for the approximately 20-30% of students with diagnosable mental disorders, there are also approximately 70-80% of students who are coping well and demonstrating resilience.
It is easy for conversations about student mental health to create the impression that all students are struggling, but this is simply not true and it would be a grave error to think of all students as patients in need of treatment. Most students are coping well and even flourishing, although they face a wide range of problems including housing insecurity, food insecurity and financial and academic stress.
This is not to say that students don’t face adversity and that they don’t experience high levels of stress, but encountering the normal struggles of being a student (like dealing with a broken heart or battling to find a balance between academic commitments and social life) are not the same as having a mental disorder.
Nonetheless, we need more resources for student mental health services on our campuses, and we must identify scalable and sustainable alternatives to traditional one-on-one therapies, including the appropriate use of digital technologies and peer-to-peer support.
Professor Jason Bantjes is a chief specialist scientist in the alcohol, tobacco and other drug research unit at the South African Medical Research Council. He also holds an extraordinary appointment as an associate professor at the Institute for Life Course Health Research at Stellenbosch University.
Professor Dan J Stein is head of the department of psychiatry at the University of Cape Town, and director of the South African Medical Research Council’s Unit on Risk & Resilience in Mental Disorders.
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