Mental Health as a Polysemic Construct? Revisiting the Debate about University Students’ Unmet Needs

“Mental health” is on everyone’s lips, although it remains an ambiguous or at least misinterpreted construct. A well-known quote from Lewis Carroll’s Through the Looking-Glass sharply applies here:

Despite much debate about the urge to address mental health, many calls to action seem to miss the point. It would be helpful to revisit classic six-step problem-solving [1] and start by specifying the object of debate.

It became commonplace that mental health is not just the absence of illness (loosely defined as subjective awareness of suffering), but let us go back to the WHO definitions, repeated over and over without full impact [2‒4]. Mental disorders are a range of mental or behavioural conditions falling within international classifications of diseases or related health problems. Mental health is conceptualised, in turn, as a state of well-being in which the individual realises their own abilities, can cope with normal stresses in life, can work fruitfully, and is able to make a contribution to the community [3]. Nonetheless, mental health is also often used as a euphemism for mental disorders with the risk of becoming a misnomer.

This issue of the journal is timely by featuring original research addressing relevant concerns on mental disorders and mental health [5‒7]. Two papers regard Portuguese settings, providing interesting clues internationally. Pedrosa et al. [7] report findings on supported accommodations for people with serious mental disorders, collected during a major crisis: the COVID-19 pandemic. Supported accommodations were developed in consequence of the deinstitutionalisation movement, to help people with schizophrenia and other chronic psychoses to go back to living in the community or as an alternative to hospital long-term admissions. They provide housing and psychosocial rehabilitation for people with complex needs and disabilities, developing daily living skills, autonomy, and connectedness, i.e., recovery or, broadly speaking, mental health. Another paper, by Marques et al. [6], describes the process and preliminary results of a stepped care approach to foster university students’ access to mental health care. The authors rightly acknowledge the need to tackle more broadly the need for mental health promotion, while the paper focuses on the primary and secondary prevention of psychological distress and common mental disorders (anxiety and depression) and how to improve access to services within the university framework.

No doubt, a major problem for (mental) health care worldwide concerns barriers to access and use of services, even when they are available and their quality acceptable. This is a main determinant of the mental health gap and a hot topic in different fields: psychoses, mood and anxiety disorders, or cognitive disorders, including dementia [2, 8, 9]. In Portugal, there is now solid epidemiological and clinical evidence on mental health and neurocognitive disorders as highly prevalent conditions among the leading causes of disability and premature death, accounting for a high proportion of the global burden of disease [10‒13]. Although mental health policies and services remain under-resourced (and despite shortcomings related to broader issues of the National Health Service, Social Security, or their articulation overall), there has been significant progress, particularly during recent years. After the drafting of the pioneer National Mental Health Plan in 2007, the Technical Commission for the Monitoring of Mental Health Reform set priorities in 2017 to overcome the major constraints identified, and the National Coordination of Mental Health Policies is now conducting a structural and innovative reform [13]. Besides remarkable achievements during only 3 years (e.g., publication of a new Mental Health Law, reorganisation of mental health services), community mental health teams and services are being steadily implemented (targeting adults with serious mental disorders, or children and adolescents, and their families), and there are efforts towards a stepped care, collaborative model between primary care and mental health services (focusing on people with common mental health disorders) [13]. However, the quest for public mental health promotion, as for primordial or primary prevention, must move from a solely individual level to the population level [14]. The National Coordination has developed health promotion and disease prevention activities through institutional initiatives and funding for nonprofit organisations [13], but such endeavour cannot be conducted by mental health stakeholders or services alone¹. This is a point I would like to elaborate on, coming back to Marques et al. [6] and the university context.

In fact, Marques et al. make a reasoned and cogent argument for their work at the University of Coimbra, and its relevance is several-fold. Firstly, a major problem is underlined: university students’ mental health issues, and difficulties on how to address them. There is a generalised concern regarding the prevalence of distress, “burnout,” or affective symptoms in university students. Harmful use of alcohol and substances may also arise, mostly as maladaptive coping. A systematic review and meta-analysis estimated the pooled prevalence of depression and suicide-related outcomes (mainly suicidal thoughts) in 25% (95% CI: 17–35%) and 14% (95% CI: 0–44%), respectively [15]. These studies were conducted previously to COVID-19, and the pandemic may have worsened a trend already existent during the last decade [16]. Recent Portuguese cross-sectional research has raised similar concerns [17, 18]. Secondly, the described model [6] aligns with current recommendations [19]. “Stepped care” means a sequential and multiprofessional approach in treatment, applying interventions of increasing intensity according to the level of severity of conditions. It has been successfully implemented in different mental health scenarios and primary care, proving cost-efficiency [20, 21]. Its rationale goes beyond adequately addressing the increased demand of services in low-resourced contexts; it also avoids reinforcing unjustified demand. Therefore, stepped care approaches are recommended by the Programme for Mental Health Promotion in Higher Education [19] that brought together experts from different professional backgrounds (e.g., psychology, psychiatry, education) and students’ associations. Recently issued under the aegis of the National Coordination of Mental Health Policies, the report includes an excellent state of the art and a summary of best practices in several Portuguese universities and internationally, along with the major needs to be met and priorities for intervention [19]. It also specifies how – in advanced steps – the articulation between university services and the National Health Service may need should be made. Marques et al. [6] emphasise that the efficacy of the approach should be further investigated. Regardless of whether they should rather focus on efficacy, effectiveness, or efficiency to further assess outcome, their paper is much welcomed by analysing the process. Besides, one will not need a classical randomised and controlled trial to document all benefits, and pragmatical approaches may be considered alternatively [22]. Finally, Marques et al.’s project will hopefully lead to replications and refinements by other teams, as concerted actions within the programme.

Building on students’ mental health issues and the need for tailored interventions, two points are worth discussing. The first one could come from the devil’s advocate: of course, worries about young students’ distress must be taken seriously and toxic positivity avoided, but too much pessimism and alarm are not without caveats. On the one hand, the latest evidence rather consistently suggests an increase in levels of psychological symptoms and even mental health disorders across samples of university students [16, 23, 24]. Undoubtedly, there is an increasing demand for psychological support, reflecting not only high distress levels but also some awareness of mental health issues. On the other hand, does this necessarily mean a generalised increase of the prevalence of mental disorders in higher education? Marques et al. [6] report that at least 40% of their 295 (self) referrals (for 2 years and among the entire university population) eventually received no clinical diagnosis, despite reporting emotional difficulties. Moreover, considering both national and international literature, studies’ limitations are seldom highlighted upon mass media dissemination. Regarding original research, online/self-report surveys predominate; many conclusions are hindered by selection/nonresponse bias, or by an overreliance on questionnaire cutoffs whose validity is far from universal. Regarding reviews and meta-analyses, and paraphrasing Sheldon et al. [15], student mental health is a heterogeneous research area, hampered by the use of imprecise terms for outcomes; this limits the extent to which datasets can be meaningfully synthesised. But even if we are not overpathologising, thinking catastrophically may bias our reasoning and potentially undermine everyone’s morale. After all, entering the university should be a golden opportunity that only a few were given in the past. Duffy et al. [25] describe not only negative feedback loops (from loneliness and other risk factors towards depression) but also positive loops that emphasise how adaptive coping skills, hope, support, and sense of belonging may lead to flourishing.

The second point concerns the shortcomings of individually based responses. Quoting the 2024 Lancet Psychiatry Commission on Youth Mental Health, “arguably, young people communicate the warning signs of our modern world and are indicating that our society and world are in serious trouble” [24]. Thus, should we privilege individual, case-based approaches, instead of systemic, ecological perspectives? Today’s college students, as individuals, carry the heavy burden of societal megatrends and biopsychosocial challenges that differ to a considerable extent from those that previous generations faced. Just to name a few, regardless their variable impact: the consequences of COVID-19; climate changes; economic recession, insecurity of employment, competition for fewer opportunities, social/intergenerational inequities; family disruption, tension between individualism and social-focused objectives; risks associated with smartphone and social media overuse, including fear of missing out; alienation, social isolation, loneliness; dealing with parental overprotection, pressure to achieve academically, negative perfectionism, fear of (perceived) failure, or over-idealised expectations. There may not be a “generation clash,” but there is certainly a risk of increasing the “generation gap” with a major toll for emerging youth.

Research regarding university students identified multiple mental health risk factors, including the academic ones [26, 27]. The transition to university coincides with a critical period in biopsychosocial development, including of the brain. Sometimes, pre-existing vulnerabilities of a mainly biological nature (some of them less acknowledged in the past, such as autism or attention-deficit and hyperactivity disorders spectra) may become an issue when youngsters face the challenges of higher education. Notwithstanding, the psychological, social, financial, and lifestyle factors seem to play the major role [26, 27]. For instance, parent separation or past sexual harassment are among predictors of depression, whereas childhood adversity and financial difficulties significantly predict suicide-related outcomes [15]. Regarding research on mental health determinants in general, they relate to individual, family, community, and structural levels [28]: there will be no real answers without paying due consideration to the main social determinants of health such as employment, income, inequities, or social support [29]. Therefore, there are pitfalls in focusing on services in the short-medium term only, neglecting “the long and winding road” of a public health perspective. In line with this argument, Ormel et al. [30] discussed the limitations of depression treatment, arguing that prerequisites to eradicate it include starting early in life and targeting both personal and environmental determinants. Furthermore, no particular population, from childhood to old age (including university students), will benefit from isolated strategies unless a societal commitment prevails towards the prevention of mental disorders and the promotion of mental health [14]. This is no easy task: it can only be accomplished by international collaboration and longstanding efforts, guided by a collective reflection that we can no longer postpone. Hence, the need for a systemic, public health view, aiming at moving mental health beyond the health sector and integrating it into general policies. As always, we ought to step back and take some perspective; otherwise, we risk losing sight of the forest for the trees, regardless of the legitimacy of individual approaches.