Towards improving the mental health of students at South African universities

Findings of one of the largest student mental health surveys ever undertaken in the world – which was initiated by Universities South Africa (USAf) and launched in April 2020 – were unpacked during a recent Higher Education Leadership and Management (HELM) Engage webinar, which focused on mental health at South Africa’s universities.

Funded by the South African Medical Research Council (SAMRC), this national project was endorsed by vice-chancellors and deans of students at a number of universities. The study forms part of the World Health Organisation’s World Mental Health International College Student Initiative, an international network of experts working to promote the mental health of university students across the globe.

HELM Engage is an online platform hosted and managed by Universities South Africa’s Higher Education Leadership and Management (HELM) programme – a capacity development facility  focusing on middle to senior / executive leadership of public universities.  The webinar on students’ mental health was the sixth in a series started in 2021 to facilitate high level inputs and discussions on topical leadership and management issues affecting South Africa’s higher education.

Although  all 26 publicly funded South African universities were invited to participate, in the end only 19 took part, with a total of 29 000 students fully completing the survey.

He emphasised that he and the large team working on this study regarded these findings, termed preliminary, as a snapshot of what’s going on in the country, which was by no means the final word. Said Professor Bantjes: “The demographic profile of the survey respondents matched the demographic profile of students in the country; so, the study was representative.”

“Students were asked to rate their mental health at that moment,” Professor Bantjes stated. “I think it is noteworthy that 82 percent of South African students at any point in time during the CoVID pandemic reported that they had good or excellent mental health. However, there are about 20 percent of students who have poor mental health and that is a significant number who need support.

“It is inaccurate to position all students as ‘patients in need of therapy’ – doing so contributes to an unhelpful narrative of positioning all students as ‘diminished’ and ‘vulnerable’. A small group of students (about four percent) require specialised clinical services. A larger group of students with fair mental health (around 14 percent) require low-intensity psychosocial support. Strategies to support students with poor mental health are different from those needed to help students with fair mental health. Not all students are in the same place when it comes to their mental health,” he explained.

“Rates of major depressive disorder was about 15.4 percent, generalised anxiety disorder about 10.9 percent, panic disorder at 7.2 and bipolar spectrum disorder at 1.8. The 30 day prevalence of other mental health problems were attention difficulties (21 percent), drug abuse (5.1 percent), alcohol dependence (2.5 percent) and post-traumatic stress disorder (PTSD), (21 percent).

He emphasised that the social political history of South Africa created an educational landscape with different types of universities ranging from historically white institutions (HWI) to historically disadvantaged institutions (HDI) and distance learning universities.

“The prevalence rates of  anxiety disorders are consistently higher at historically white institutions with these students reporting much higher levels of distress. Unisa has the lowest proportion of individuals who would meet a criteria for a psychiatric disorder. That makes sense given that a large number of students at Unisa are over the age of 35. At historically white institutions, there are a lot of students who are under the age of 19. Younger students experience higher levels of psychological distress, probably because they are adjusting to university. However, those with psychological symptoms are likely to drop out of university during their undergraduate years. So by the time we sample students who are aged 20 to 23, the ones with mental illness have already been lost to the system. And so you see declining rates of psychological distress in older students.”

Furthermore, black African students, and those who identified as Asian or coloured who attended historically white institutions, were at higher risk of mental illness compared to white students: “I think that’s something perhaps about the culture of these institutions and about levels of alienation and marginalisation. The survey doesn’t provide insight into exactly why we’re seeing this higher risk but it does flag it for us as something that requires more investigation.”

Professor Bantjes said psychological disorders were also elevated among gender non-conforming students; sexual minorities in relation to heterosexual students and those with lower parental education. However, he emphasised that these were moderate risk factors.

“We had data from pre-CoVID pilots which were done at the University of Cape Town and at Stellenbosch University in 2015 and 2017,” Professor Bantjes mentioned. “There were no significant differences in increased prevalence for a major depressive episode, generalised anxiety disorder or suicidal ideation between 2017 and 2020. However, the rates of psychological distress among first year students at UCT were already high in 2017. This was hot on the heels of things like Fees Must Fall which had significantly disrupted university campuses in 2017. What this highlights is that while CoVID was distressing and disruptive for universities, students were experiencing distress before then. Rates of mental illness among students were already steadily increasing from 2015,” he said.

He further said the age of onset for many mental health disorders is between 16 and 18 with the symptoms either starting before students enter university or emerging during the first year.

“We can’t begin to talk about the mental health of university students without talking about the mental health of high school students. What we find between 2015, 2017 and 2020 is that more students were arriving at university with pre-existing conditions. It may be possible to screen students on registration or early in their in their first year for those with histories of psychiatric conditions and target them for particular interventions.”

He emphasised that the screening would be done sensitively. “In Belgium, for example, on registration, students are prompted to do a mental health survey and they’re given feedback immediately. They can opt out immediately or receive information on services that may help them. There is no stigma and no profiling.”

Among numerous possible causes of psychological disorders, Professor Bantjes cited the following:

With 66 to 77 percent of students with common mental health disorders not getting help, Professor Bantjes said this presents a crisis.

He said this called for a review of traditional treatment models.  For example, one-on-one therapy is not always a sustainable or feasible solution. Aside from depression and anxiety, other issues such as post-traumatic stress disorders (PTSD), attention difficulties and substance abuse also have to be focused on.

Another finding was that suicidal behaviour is high — with 8.6 percent of students saying that they made a suicide plan and 2.3 percent admitting they had made a suicide attempt. “These are significantly higher than we would observe in the general population,” said Professor Bantjes, also emphasising that it is not altogether unusual for young adults to think about life and death.

For why students do not access psychological services, Professor Bantjes cited reasons including:

• Limited access to affordable services
• Reluctance to receive help from professionals
• The stigma surrounding mental health and perceptions of therapy’s ineffectiveness
• Time and financial constraints
• Not realising that support is needed

“We find that students’ first preference is to sort out the problem on their own or to access support from their peers and they’re less likely to reach out to mental health professionals as the first port of call. Adding more services isn’t the solution if there are barriers to wanting to access the service in the first place. Students generally only seek out help when they are in dire distress and disengage once they start feeling better. We need them to reach out sooner and stay in therapy.”

Mental health services need to be aligned with the developmental trajectory of students, Professor Bantjes reiterated, stating:

• We need to address the topic of mental health and the perceived stigma surrounding it
• We need to provide psycho-education about when and where to access help
• Peer-to-peer and self-help interventions may find more traction than “clinical” interventions for some students. It gives students more autonomy
• A range of interventions will be important, if we’re going to take the developmental stage of students seriously.

“Since 2020, we have started to look at alternative modes of intervention using technology. There are some students who appear to be open to the idea of receiving help via the Internet or via Apps. We piloted a semi-guided web based intervention that consists of different modules around depression and anxiety, and learning to regulate your emotions, healthy sleep, healthy habits, those kinds of things. There is a coach on the other end who checks in with you. We could scale this up quickly and reasonably cheaply.”

He talked of a web-based programme called Talk Campus which offers virtual counselling with students 24 hours a day, seven days a week with a real student offering the support.

If mental health is to become a priority at South African universities, then institutions are going to have to work closer together, with less bureaucracy. Said Professor Bantjes: “It took us a year, just to get permission from universities and agreements from everyone to do this study. It was a year of lost time with a huge amount of resources that went into this initial phase. This is a serious barrier against ongoing research in the future, particularly as we move towards testing scalable interventions across universities. We are going to have to find a way to streamline the permission processes.

“I do think that by collaborating across universities, there are economies of scale and economies of scope. And what I mean by that is that if we plan interventions across three or four campuses, we can have a wider variety of interventions. We can have a web-based intervention, we can have a virtual group, we can have app based interventions, we can have mood monitoring intervention. This level of collaboration is a long game. It requires a dedicated, and focused research effort. This is not going to be done by some researcher working in isolation. It’s only going to be possible if funding is earmarked, the research is prioritised and support groups and facilities are put in place.”

From a Universities South Africa perspective, it was fitting to present the findings of this study on a HELM Engage platform. Also being home to a Student Success programme within USAf, it is important that HELM facilitates understanding on some barriers to student performance and success, so as to inform conceptualisation of suitable and holistic strategies to student success, which address individuals’ psychosocial needs in their unique contexts.

Janine Greenleaf Walker is a contract writer for Universities South Africa.