4 Mainstreaming Upstreaming: Mental Health in the First-Year Curriculum

Matthew MacLean

Introduction

The mental wellbeing of Canadian post-secondary students (PSSs) has experienced a progressive and substantive decline over the last decade, with an increasing number of students reporting significant psychological distress and diagnoses of mental illness (Auerbach et al., 2018; Linden, Boyes & Stewart, 2021; Lipson, Lattie, & Eisenberg, 2018). It’s easy to name a number of potential factors to blame, from social media (Twenge et al., 2020) and COVID-19 (Moghimi et al., 2023) to socioeconomic disparity (Cullinan, Walsh, & Flannery, 2019) and climate change anxiety (Auchincloss et al., 2024).

Despite the nature and complexity of these challenges, post-secondary institutions have a unique opportunity to intervene in a meaningful way. Students provided with opportunities to learn and practice positive coping and effective stress management techniques are likely to experience lower levels of anxiety and depression, improved academic performance, and higher levels of engagement with their studies and campus activities (Halladay et al., 2019; Viskovich & Pakenham, 2019; Vizoso, Rodríguez & Arias-Gundín, 2018). However, the implementation of efforts designed to improve mental health outcomes among post-secondary students must consider other related issues, namely (1) the large percentage of students experiencing some degree of psychological distress (Linden, Boyes & Stewart, 2021) and (2) numerous barriers to accessing intervention, including the lack of time and the stigma associated with seeking out mental health support (Dunely & Papadopoulos, 2019).  The convergence of these challenges, along with evidence indicating that students in psychological distress face even greater obstacles (Cage et al., 2018), creates a situation where many could benefit from support but are hindered by numerous barriers from accessing it.

Recognizing the potential for both immediate and long-term benefits for students, there’s a compelling argument for integrating universal prevention efforts—designed for all students, regardless of their risk profile or current level of psychological distress—into the core post-secondary education experience as a compulsory element. Such an approach would ensure that every student can gain from these interventions, simultaneously tackling many of the obstacles that prevent engagement.

What Do We Know About Post-Secondary Student Mental Health in Canada

To provide a picture of the current state of mental health among Canadian post-secondary students, this review provides a rather broad set of data, including sources that examined the mental health of other populations. This includes data on Canadian youth populations (ages 15-30 but not specific to those attending post-secondary, as well as Canadian 10–14-year-olds and Canadians in grades 7-12) and American post-secondary students. Although these data sets report on populations whose generalizability to Canadian PSSs is uncertain, they do provide a more complete picture of the equally significant and parallel trends in mental wellbeing decline amongst young people in North America.

In presenting data to answer the titular question of this section, I have attempted to draw upon larger scale studies and/or systematic reviews where available. Unfortunately, there are some areas where there is a lack of data specific to Canadian post-secondary students of this variety. In cases where a larger study or meta-analysis was not available, I have used data from other countries with similar socio-demographic profiles to Canada.

Canadian Youth Mental Health

Over the past two decades, the mental health of Canadian youth has significantly worsened. This is highlighted by various studies including the Canadian Community Health Survey (CCHS), which shows a continuous decline in mental health among young people aged 15 to 30 since 2009 (Statistics Canada, 2021). This downward trend is echoed in the Ontario Student Drug Use & Health Survey (OSDUH), with an increase in poor mental health indicators among Ontario students in grades 7 to 12 between 2017 and 2019 (Centre for Addiction and Mental Health, 2021). Furthermore, research on suicide trends reveals a troubling increase in the suicide rate among Canadian girls aged 10-14 years, surpassing that of boys since 2011, with the rate for girls compared to boys increasing from 0.85 in 2009 to more than double by 2018 (Mitchel et al., 2023).

North American Post-Secondary Student Data

The Healthy Minds Study, launched in 2007 with over half a million respondents from 530 colleges, primarily in the U.S., has shown a notable increase in mental health issues among post-secondary students in North America from 2007 to 2017, including a rise in lifetime diagnoses of mental illness from 22% to 36% and an increase in past-year treatment from 19% to 34% (Lipson, Lattie, & Eisenberg, 2018). Similarly, the WHO World Mental Health International College Student project across eight countries found that roughly one-third of first-year students reported common mental disorders, with those disorders being widely distributed across different socio-demographic groups (Auerbach et al., 2018). Adding to the concern, data from the Center for Collegiate Mental Health’s (CCMH) indicates significant increases in anxiety, trauma, and depression among post-secondary students seeking mental health treatment from 2012 to 2022, reflecting a trend of escalating mental health challenges in higher education settings (Center for Collegiate Mental Health, 2023).

Canadian Post-Secondary Students

In an analysis of National College Health Assessment II (NCHA-II) survey data from Canadian Institutions for the years 2013, 2016 and 2019, Linden, Boyes & Stewart (2021) found significant increases over time for nearly all areas of reported psychological distress, mental illness diagnoses and help-seeking. The dataset examined by Linden et al. is robust, consisting of a large number of respondents (n=38,171 for 2013, n=43,780 for 2016, and n=55,284 for 2019), and offers one of the clearest indications of growing levels of poor mental wellbeing among post-secondary students. For example, the NCHA-II data set showed that from 2013 to 2019 a greater percentage of students reported hopelessness (+11%), sadness (+7%), loneliness (+6%) and anxiety (+13%). A greater percentage of students also reported considering (from 10% to 17% for females and 9% to 14% for males) and attempting (from 1% to 3% for both) suicide. The NCHA-II data also showed that the percentage of respondents who reported a diagnosis for mental illness within the last 12 months also increased. This included diagnoses for anxiety (16% to 30% for females; 8% to 14% for males) and depression (11% to 22% for females; 7% to 12% for males). To add context to these numbers, consider some of the nature of the statements contained in the NCHA-II, such as feeling “so depressed it was difficult to function” or “overwhelming anxiety”, that respondents endorsed to indicate increases in sadness and anxiety, respectively.

Additional large-scale datasets help complete the picture. For example, the Canadian University Survey Consortium (CUSC) conducts annual surveys of Canadian university students. In their 2022 survey of first-year students (n=15,157), they found that 66% felt they “can handle stress” (and, lest we think that this was the result of pandemic, the 2019 results were only marginally better at 71%), 20% of respondents indicated a mental health disability, and 6% of those with a mental health disability reported daily impairments to their functioning.

Loneliness and social isolation

In addition to an increase in poor mental health, loneliness and social anxiety have also increased among young people. Twenge et al. (2021) observed a significant increase in loneliness amongst 15- to 16-year-olds across 36 out of 37 countries between 2012 and 2018, with the issue becoming nearly twice as prevalent in 2018. This rise in loneliness was more pronounced among girls and in countries with consistent measurement standards. Interestingly, higher smartphone and internet use were associated with greater loneliness. From an analysis of the 2022 Canadian Campus Wellbeing Survey, Fagan et al. (2023) found that 31% of participants reported experiencing loneliness, with higher odds among individuals with non-heterosexual orientations and those experiencing mental distress.

Wang et al. (2018) highlighted the critical role of social support in the mental health outcomes of individuals with various mental disorders. The pandemic exacerbated these trends, increasing mental health challenges and loneliness, as indicated by the Healthy Minds Network and the CCMH. However, the pandemic alone did not cause these increases; the CCMH data shows that rates of Social Anxiety started increasing in 2010 and in 2022 Social Anxiety showed the greatest 12-year increase among all concerns and was also closely linked to other mental health issues.

Indigenous Students

Indigenous Canadians continue to be underrepresented amongst post-secondary entrants and graduates at nearly all levels of educational attainment (Statistics Canada, 2023). While analyses of the 2013 NCHA-II survey (total n = 34,039 with 1,110 or 3.3% self-identifying as indigenous) conducted by Hop Wo et al. (2020) revealed that Indigenous students report higher rates of intentionally injuring themselves, seriously considering suicide, attempting suicide, or having been diagnosed with depression or anxiety when compared with non-Indigenous students.

Similarly, a survey of post-secondary students (n=2,000) in May 2022 conducted by the Canadian Alliance of Student Associations (CASA) and the Mental Health Commission of Canada (MHCC) showed that 62% of Indigenous respondents strongly agreed with the statement “Over the Course of My Time At Post-Secondary, I’ve struggled With My Mental Health” compared with 36% of Non-Indigenous (combining strongly agree and somewhat agree provides 88% for Indigenous respondents vs. 74% for non-Indigenous).

Racialized Students

Research indicates that racialized students face higher levels of depression and anxiety compared to their non-racialized peers, with particularly pronounced symptoms among female racialized students (Lal et al., 2021). Moreover, exposure to ethnic discrimination is linked with increased symptoms of depression and PTSD in racialized students, emphasizing the necessity for protective institutional measures (Tamaian et al., 2023).

Students with Disabilities

Mental health as a disability and the intersection of mental health and accessibility is a significant issue in post-secondary education. Research highlights that post-secondary students with disabilities often face greater academic-related distress and mental health issues, including anxiety and depression, compared to their non-disabled peers (Coduti et al., 2016). students with mental health disabilities encounter difficulties in obtaining appropriate academic accommodations due to the episodic nature of their conditions, requiring more flexible and retroactive accommodations not commonly provided (Condra et al., 2015). Additionally, students with invisible disabilities, such as dyslexia and attention-deficit hyperactivity disorder, report feeling misunderstood and unsupported within the university environment, leading to social and academic barriers (Mullins & Preyde, 2013).

International Students Studying in Canada

International student enrolment at Canadian post-secondary institutions has increased substantially in the last decade. The Canadian Bureau for International Education reports that in 2022 there were 807,550 international students studying at all levels (not just PS) in Canada and that Canada saw a 31% increase in international students from 2021 to 2022. While at the time of writing, the Federal government of Canada has enacted measures to reduce these numbers, the percentage of international students studying at Canadian post-secondary institutions is likely to remain high for the foreseeable future. Accordingly, we need to consider the possibility of unique challenges and dynamics impacting this population’s mental wellbeing and their access to services.

The large presence of students from countries outside of Canada has several possible impacts on the landscape of student wellbeing and service delivery. In reviewing the literature on this topic, Prieto-Welch (2016) describes how perspectives on mental health and seeking psychological help among international students may create additional barriers due to higher levels of perceived stigma and mistrust of service providers. A cross-sectional study comparing the mental health-related knowledge, attitudes and behaviors of international and domestic students among Australian post-secondary students (LaMontagne et al., 2023) found that international students scored lower on indicators of mental health knowledge. The study authors do note, however, that this gap was smaller than had been reported in previous studies. A closer look at the responses in this study showed that international students were less aware that psychological treatment was a confidential service.

In terms of differences in self-reported levels of psychological distress, there have been mixed reports from studies with some showing elevated levels of distress (Forbes-Mewett & Sawyer, 2016) and others showing no differences or even lower levels of distress (Lamontagne et al., 2023). In their 2022 report, “The New Abnormal”, the Canadian Alliance of Student Associations (CASA) and the Mental Health Commission of Canada (MHCC) reported that 54% of international students strongly agreed that “Over the course of my time at post-secondary, I’ve struggled with my mental health” compared with 39% of domestic students. This study took place in 2022 during which the impacts of the COVID-19 Pandemic were still being felt, which other studies have indicated disproportionately affected the wellbeing of international students (Jamshaid et al., 2023).

Access to Treatment and Prevention

Rates of Treatment Utilization

Increases in rates of psychological distress and diagnoses over time have also been accompanied by increasing rates of treatment utilization. For instance, data provided by the CCMH shows that between fall 2009 and spring 2015, counseling center utilization increased by an average of 30-40%, while enrollment only increased by 5% among the network of Post-Secondary Institution counseling centers providing data to the CCMH (which again are predominantly U.S. sites). A recent meta-analysis and systematic review that looked at university students’ use of mental health treatment worldwide estimated that “1/3 of students use services overall while attending university, with around 1/5 of students using outpatient services” (Osborn et al, 2022), but also noted significant heterogeneity depending on institution type, country of origin and service types available. A look at the Healthy Minds Study (HMS) data from 2007 to 2017 by Lipson, Lattie, & Eisenberg (2018) showed that the rate of treatment increased from 19% to 34% over the 10-year period examined, with the most common location for receiving services being on campus (usage of off-campus services also increased). Similarly, rates of psychiatric emergency service use increased from 0.3% to 1.0%.

Barriers to accessing treatment

Despite the increased rates of treatment utilization, a substantial number of first-year post-secondary students who could benefit from mental health treatment do not receive it, as highlighted by an international study by Bruffaerts et al. (2019) which did not include Canada. This study found low treatment rates for mental disorders and suicidal thoughts and behaviors among students, with a very low portion of severe cases receiving adequate treatment. However, a scoping review by Dunely & Papadopoulos (2019) which looked at studies that included Canadian post-secondary students, identified various barriers to seeking professional support, including institutional, sociocultural, and personal factors, with a notable study at the University of Calgary revealing significant reasons for not seeking treatment included not recognizing the distress and not having enough time. Furthermore, a survey by Moghimi et al. (2023) in Ontario found that over 60% of students reported poor mental health and inadequate coping strategies while also facing numerous barriers to accessing treatment like financial constraints, long wait times, and stigma, among others. Additionally, a systematic review by Radez et al. (2021) identified key barriers across individual, social, and systematic levels, including stigma and preference for self-management. Despite these challenges, studies like those by Lipson, Lattie, & Eisenberg (2018) indicate a decline in stigma related to mental health treatment, suggesting evolving perceptions that could potentially improve help-seeking behaviors among students.

How should we respond to this data?

In their commentary, Bantjes, Hunt, & Stein (2023) caution against the use of the label “crisis” when describing post-secondary students’ mental health. In criticizing this label, the authors present evidence that, while there is a need for a greater focus (and associated resourcing) on students’ mental wellbeing, we should be wary of pathologizing the experiences of young people in the face of “everyday” or “expected” stressors, conflating normal reactions to routine stressors with serious pathology and risk the potential of misidentifying all post-secondary students as needing psychological intervention or as “patients in waiting”. They cite other reasons for avoiding this label, such as under-emphasizing resilience and the positive role that stressors play in early adulthood, or the phenomenon of “prevalence inflation”, whereby increasing awareness of high rates of mental illness may cause some to interpret their mild and normal forms of distress as something more serious. This is an important consideration, as nearly all the findings presented in this chapter come from self-reported data. It is also important to note that the “prevalence inflation hypothesis” coined by Foulkes and Andrews (2023) does not yet have the backing of evidence, although Foulkes and Andrews do point to studies that did demonstrate a similar effect in other populations, such as teaching cognitive behavioral therapy principles to adolescents leading to an increase in internalizing symptoms compared to control groups.

There are no standard criteria needed to establish the presence of a crisis in student mental health. In some respects, this is an important evaluation to make. If it is agreed that, yes, there is a crisis, that evokes the need for significant, perhaps even drastic re-allocation of resources to address the crisis. In other words, a mental health crisis could be seen as the proverbial “house fire” for which an immediate and sustained response is needed until the “fire” is put out. Consider then, also, the risk of not declaring a crisis when there is one: the house burns down. In the scenario in which there is, in fact, a crisis and we fail to act with sufficient responsiveness, we risk great harm to our young. Conversely, there are also risks associated with declaring a crisis when there isn’t one, such as the pathologizing of normal reactions or allocating resources to a degree beyond what is necessary.  In their commentary, Bantjes et al. (2023) point to a possible “Industry of Student Mental Health Research” resulting in an overabundance of research on student mental health and the further possibility of intentional overstating of the poor state of student mental health.

At this point, we are no closer to knowing if the current state constitutes a crisis. Yet, the question “what should our response to this data be?” remains. In other words, it needs to be determined if the seemingly sudden and swift decline in youth mental health described in this chapter should be taken at face value and cause us to make similarly sudden and swift responses; or does it represent an inflation or mischaracterization, intentional or otherwise, and should be subjected to further scrutiny before deciding on a response.

However, another team of researchers, Jonathan Haidt, Jean Twenge and Zach Rausch, using an ‘open-source literature review’[1], have stated unequivocally that, yes, there is a mental health crisis. Moving beyond self-report measures, Haidt and colleagues point at hospital admissions for non-fatal self-harm among girls in the U.S., which increased by 189% for 10–14-year-olds, 62% for 15–19-year-olds, and 17% for 20–24-year-olds between 2001 to 2015. Also cited are large increases in the suicide rate for teen girls in the U.S. (77% for older teen girls; up 151% for younger teens between 2000 and 2017). For Canadian populations, Gardner et al. (2019) show that rates of youths with self-harm visits to Ontario ERs fell 32% from 2003 to 2009 but rose 135% by 2017. Another analysis of Ontario ER visits by Chiu et al. (2020) revealed that mental health or addiction–related visits by youth increased by 89.1% between 2006 and 2017. Finally, recalling data mentioned earlier in this chapter by Mitchel et al. (2023) showing that from 2009 to 2018, the rates of suicide for adolescent girls went from 0.85 of the rate for adolescent boys to 2.08 times that rate. The presence of data showing increases in verifiable harm in the form of ER visits, self-injury and suicide experienced by our young people supports that the same increases we are seeing in self-reported psychological distress are more likely to themselves be “real” and not an artifact generated by inaccurate self-report or other causes.

If we now proceed based on the idea that the increases in psychological distress among post-secondary students as reported in the literature are indicative of an actual increase in distress, perhaps even accepting the existence of a “crisis”, we can now turn to ideas on how the post-secondary sector can respond appropriately. Societally, we are already experiencing a high cost of poor psychological health among our youth vis a vis higher rates of suicide. While it is less clear what the impact is on young Canadians attending post-secondary institutions, as we don’t have data on suicide rates in this population, we might infer from the increases in reported psychological distress reported by PSSs that there are also similar increases in suicides, non-suicidal self-injury, ER visits for mental health concerns, etc. for this population. Indeed, the 2023 CCMH report showed that between 2012 to 2023, non-suicidal self-injury increased 5.4%, serious suicidal ideation increased 4.4% and suicide attempts rose 2.0%.

Prevention

Recent guiding documents on mental health and Canadian post-secondary institutions produced by national organizations such as the National Standard of Canada for Mental health and Well-Being for Post-Secondary (MHCC, 2022), and the earlier Post-Secondary Student Mental Health: Guide to a Systemic Approach (CACUSS and CMHA, 2013), highlight the important role of prevention in mental health. Prevention aims to reduce the likelihood or severity of mental health issues by employing a range of interventions, from promoting mental health awareness and encouraging positive behavioral changes to utilizing media platforms and workshops for education and screening. Early detection and intervention have been shown to significantly enhance treatment outcomes and efficiently utilize resources, as evidenced by the benefits of prevention programs across multiple contexts (Singh, Kumar, and Gupta, 2022). These programs have proven effective in addressing subclinical levels of mental disorders, demonstrating the value of investing in targeted prevention efforts (Conley et al. 2017).

Despite the proven effectiveness of both universal and indicated prevention programs, a study by Read, Lutgens & Malla (2023) reveals a scarcity of early identification programs across Canadian post-secondary institutions, with only a small percentage offering such services (according to their websites). This gap suggests a potential underutilization of effective mental health strategies in educational settings..  The limited adoption of prevention and early intervention programs in Canada highlights a significant opportunity for improvement in addressing the mental health needs of post-secondary students. It should be noted that the lack of prevention for mental health challenges is not unique to the post-secondary sector; a systematic review of public health literature revealed that a very small portion (2.2%) of published articles discussed this topic (Waechter et al., 2023).

There are numerous types of prevention, including those meant for the entire population (universal) or those meant for individuals at a higher risk of developing a disorder (sometimes called “selected” or “indicated” depending on the nature of the risk). In the context of mental health, prevention can also be broadly defined as efforts that promote (1) appropriate help-seeking behavior (individuals seek out the appropriate support in a timely manner by both recognizing the need for treatment, as well as the means to receive it); (2) protective factors (elements that reduce the likelihood or severity of mental illness); or (3) effective self-management of mental health challenges, including both subclinical and clinical disorders.

The Case for Prevention in Higher Education

The basic argument for prevention can be summarized by the adage that “an ounce of prevention is worth a pound of cure”. Far from simply being a folksy saying, the idea that earlier and less resource intensive efforts yield “savings” down the line is well established (Singh, Kumar, and Gupta, 2022). While meta-analyses of universal and indicated prevention in higher-education settings found comparable levels of effectiveness as those found in other contexts (Conley, Durlak & Kirsch, 2015; Conley et al., 2017).

Similarly, it is well established that about half of mental illnesses develop by the mid-teens and three quarters by the mid-20s (Solmi et al., 2022). This overlap with the typical undergraduate student age range makes the PS setting an important context for both prevention and treatment. Adding the large portion of students reporting diagnoses (20.4% for all disorders in their lifetime, and anxiety at 18.4% and depression at 14.7% within the last 12 months; Linden, Grey & Stuart, 2018) suggests that universal and indicated prevention programs are relevant for many students.

Mental Health in the First-Year Curriculum

Incorporating mental health promotion programming into first-year curriculum may represent a rational, effective, and efficient option for addressing both the growing number of students reporting poor mental health and some of the barriers associated with accessing treatment, as well as low rates of prevention programming across Canadian post-secondary institutions. By incorporating prevention in the curriculum, a greater number of students (or perhaps all students, if made a mandatory program requirement) receive the potential benefit of mental health prevention while not adding an additional obligation on students’ time, energy, etc. Even without the imperative to find responses to current levels of poor mental health, it can also be argued that mental health is one of the key components of the human experience and that all individuals, regardless of risk level or current mental health status, benefit from greater knowledge in this area.

Embedding Conditions for Wellbeing in Existing Courses

This approach invites consideration both for how the learning environment and its demands impact the mental, physical and social well-being of students, as well as ways to promote wellbeing through course assignments and activities. In Canada, Simon Fraser University (SFU), through their Healthy Campus Community project, has done work researching and promoting this perspective and area of practice, which can be accessed at their website[2]. Citing research that positive wellbeing is associated with improved academic outcomes, the SFU project argues that incorporating practices that promote wellbeing into the learning environment does “double duty” by both promoting wellbeing and improving the attainment of other curricular outcomes. This approach can mean providing experiences that are solely designed to improve wellbeing, but also includes designing learning activities that achieve existing course/program outcomes in a manner that simultaneously promotes wellbeing. An example taken from the SFU website, features an activity that allows students to engage both in reflective learning and encourages social connectedness through a “Two Minute Write & Reflect Activity”. In this activity, students are given time at the start of each class to write about their progress in the course, but also about the general state of their mind. Students are then invited to share with the class a portion of their reflections.

Stand Alone Mental Health Curriculum

In their article, “It’s Time to Bring Mental Health Literacy Education into the Postsecondary Curriculum”, authors Christine Zaza[3] & Ryan Yeung (2023) argued that we should move beyond promoting mental health knowledge (they use the term, “Mental Health Literacy”) solely via extra-curricular means and instead provide entire courses devoted to mental health. This idea could also be a shift that our students are actively seeking. In a survey conducted with post-secondary students in Ontario, Moghimi et al. (2023) found a strong desire among respondents for mental health-focused courses that include learning activities aimed at fostering positive coping mechanisms. This interest in mental health topics is further supported by the findings of the 2022 CASA survey, in which 79% of participants expressed enthusiasm for exploring these subjects. My own experience as a clinician and mental health educator is that a large portion of students simply do not have a sufficient understanding of fundamental mental health concepts (even among those that have struggled with significant mental health challenges) and that nearly all students I encounter would both benefit and welcome such courses.

Evidence on the effectiveness of prevention in the classroom

While the evidence concerning the effectiveness of prevention in higher education outside of the curriculum has some support (Conley et al. 2017; Horne et al., 2024; Patalay et al., 2017; and, Reis et al., 2022) with studies suggesting that increases in mental health literacy may drive increases in help-seeking behavior, which in turn may decrease psychological distress, the evidence supporting the efficacy of explicitly classroom-based prevention in higher education is sparse. While we shouldn’t ignore the possibility that embedding mental health prevention in a course format might impact its effectiveness (for example, attaching grades and evaluation to health promoting activities could conceivably deter some), there is also the possibility that these benefits would translate. One explicit classroom-based example we have comes from Zaza & Yeung (2023) who have reported on the outcomes described by students of the Mental Health Literacy course. These outcomes included positive shifts in both attitudes (such as reduced stigma towards seeking mental health treatment) and behavior (such as implementing self-care[4] and reducing social media usage).

Clearly, there is a need for greater scrutiny of the possible benefits of classroom-based mental health prevention; however, the balance of probabilities—coupled with the considerable potential for significant benefit in the face of pervasive and harmful challenges—supports the implementation (and evaluation of outcomes) of such courses. In other words, the adoption of positive mental health promotion/mental illness prevention, especially when coupled with an evaluation and improvement lens, may represent a high reward, low risk strategy in our current context.

References

Auerbach, R. P., Mortier, P., Bruffaerts, R., Alonso, J., Benjet, C., Cuijpers, P., Demyttenaere, K., Ebert, D. D., Green, J. G., Hasking, P., Murray, E., Nock, M. K., Pinder-Amaker, S., Sampson, N. A., Stein, D. J., Vilagut, G., Zaslavsky, A. M., & Kessler, R. C. (2018). WHO World Mental Health Surveys International College Student Project: Prevalence and distribution of mental disorders. Journal of Abnormal Psychology, 127(7), 623–638. https://doi.org/10.1037/abn0000362

Banerjee, Ananya & Lau, Ashley & Bender, Jacqueline. (2022). Poor health disparities among racialized students in a Canadian university. Journal of American College Health. 72. 1-5. 10.1080/07448481.2022.2047702.

Bantjes, J., Hunt, X., & Stein, D. J. (2023). Avoiding the ‘crisis’ narrative: rethinking mental health in post-secondary students. International Journal of Mental Health Systems, 17(1), 23. https://doi.org/10.3390/ijerph20064859

Bruffaerts, R., Mortier, P., Auerbach, R. P., Alonso, J., Hermosillo De la Torre, A. E., Cuijpers, P., Demyttenaere, K., Ebert, D. D., Green, J. G., Hasking, P., Stein, D. J., Ennis, E., Nock, M. K., Pinder-Amaker, S., Sampson, N. A., Vilagut, G., Zaslavsky, A. M., Kessler, R. C., & Collaborators, W. W.-I. (2019). Lifetime and 12-month treatment for mental disorders and suicidal thoughts and behaviors among first year college students. International Journal of Methods in Psychiatric Research, 28(2), e1764. https://doi.org/10.1002/mpr.1764

Centre for Addiction and Mental Health. (2021). Ontario Student Drug Use and Health Survey (OSDUHS): Mental Health and Well-Being Report. Centre for Addiction and Mental Health. Retrieved from https:// https://www.camh.ca/en/science-and-research/institutes-and-centres/institute-for-mental-health-policy-research/ontario-student-drug-use-and-health-survey—osduhs

Center for Collegiate Mental Health (CCMH). (2023). Annual Report 2023. Penn State University. Retrieved from https://ccmh.psu.edu/annual-reports

Changing Rates of Self-Harm and Mental Disorders by Sex in Youths Presenting to Ontario Emergency Departments: Repeated Cross-Sectional Study—William Gardner, Kathleen Pajer, Paula Cloutier, Roger Zemek, Lisa Currie, Simon Hatcher, Ian Colman, Dayna Bell, Clare Gray, Mario Cappelli, Daniel Rodriguez Duque, Isac Lima, 2019. (n.d.). Retrieved April 4, 2024, from https://journals.sagepub.com/doi/full/10.1177/0706743719854070

Coduti, W., Hayes, J., Locke, B. D., & Youn, S. (2016). Mental health and professional help-seeking among college students with disabilities. Rehabilitation Psychology, 61 3, 288–296. https://doi.org/10.1037/rep0000101

Condra, M., Dineen, M., Gills, H., Jack-Davies, A., & Condra, E. (2015). Academic accommodations for postsecondary students with mental health disabilities in Ontario, Canada: A review of the literature and reflections on emerging issues. The Journal of Postsecondary Education and Disability, 28, 277-291

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. https://doi.org/10.1007/s11121-015-0543-1

Conley, C. S., Shapiro, J. B., Kirsch, A. C., & Durlak, J. A. (2017). A meta-analysis of indicated mental health prevention programs for at-risk higher education students. Journal of Counseling Psychology, 64(2), 121–140. https://doi.org/10.1037/cou0000190

Cullinan, J., Walsh, S., & Flannery, D. (2020). Socioeconomic Disparities in Unmet Need for Student Mental Health Services in Higher Education. Applied Health Economics and Health Policy, 18(2), 223–235. https://doi.org/10.1007/s40258-019-00529-9

Dunley, P., & Papadopoulos, A. (2019). Why Is It So Hard to Get Help? Barriers to Help-Seeking in Postsecondary Students Struggling with Mental Health Issues: a Scoping Review. International Journal of Mental Health and Addiction, 17(3), 699–715. https://doi.org/10.1007/s11469-018-0029-z

Fagan, M. J., Wunderlich, K., Wu, C., Fang, M., & Faulkner, G. (2023). Lonely but not alone: Examining correlates of loneliness among Canadian post-secondary students. Journal of American College Health, 0(0), 1–10. https://doi.org/10.1080/07448481.2023.2245496

Forbes-Mewett, H., & Sawyer, A.-M. (2016). International Students and Mental Health. Journal of International Students, 6(3), Article 3. https://doi.org/10.32674/jis.v6i3.348

Government of Canada, S. C. (2021, December 1). Chapter 4: Indigenous Youth in Canada. https://www150.statcan.gc.ca/n1/pub/42-28-0001/2021001/article/00004-eng.htm

Government of Canada, S. C. (2023, July 28). From high school, into postsecondary education and on to the labour market. https://www150.statcan.gc.ca/n1/pub/81-595-m/81-595-m2023004-eng.htm

Haidt, J., Twenge, J. M., & Rausch, Z. (2023). An open-source literature review on the mental health crisis among young people. Retrieved from https://www.thecoddling.com/better-mental-health

Halladay, J. E., Dawdy, J. L., McNamara, I. F., Chen, A. J., Vitoroulis, I., McInnes, N., & Munn, C. (2019). Mindfulness for the Mental Health and Well-Being of Post-Secondary Students: A Systematic Review and Meta-Analysis. Mindfulness, 10(3), 397–414. https://doi.org/10.1007/s12671-018-0979-z

Hop Wo, N. K., Anderson, K. K., Wylie, L., & MacDougall, A. (2020). The prevalence of distress, depression, anxiety, and substance use issues among Indigenous post-secondary students in Canada. Transcultural Psychiatry, 57(2), 263–274. https://doi.org/10.1177/1363461519861824

Lally, J., Conghaile, A. ó, Quigley, S., Bainbridge, E., & Mcdonald, C. (2013). Stigma of mental illness and help-seeking intention in university students. The Psychiatrist, 37, 253–260. https://doi.org/10.1192/PB.BP.112.041483

LaMontagne, A. D., Shann, C., Lolicato, E., Newton, D., Owen, P. J., Tomyn, A. J., & Reavley, N. J. (2023). Mental health-related knowledge, attitudes and behaviours in a cross-sectional sample of australian university students: A comparison of domestic and international students. BMC Public Health, 23(1), 170. https://doi.org/10.1186/s12889-023-15123-x

Linden, B., Boyes, R., & Stuart, H. (2021). Cross-sectional trend analysis of the NCHA II survey data on Canadian post-secondary student mental health and wellbeing from 2013 to 2019. BMC Public Health, 21(1), 590. https://doi.org/10.1186/s12889-021-10622-1

Lipson, S. K., Lattie, E. G., & Eisenberg, D. (2019). Increased Rates of Mental Health Service Utilization by U.S. College Students: 10-Year Population-Level Trends (2007–2017). Psychiatric Services, 70(1), 60–63. https://doi.org/10.1176/appi.ps.201800332

Mitchell, R. H. B., Kozloff, N., Sanches, M., Goldstein, B. I., Amini, J., Bridge, J. A., & Sinyor, M. (2023). Sex Differences in Suicide Trends Among Adolescents Aged 10 to 14 Years in Canada. Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie, 68(7), 547–549. https://doi.org/10.1177/07067437231173370

Moghimi, E., Stephenson, C., Gutierrez, G., Jagayat, J., Layzell, G., Patel, C., McCart, A., Gibney, C., Langstaff, C., Ayonrinde, O., Khalid-Khan, S., Milev, R., Snelgrove-Clarke, E., Soares, C., Omrani, M., & Alavi, N. (2023). Mental health challenges, treatment experiences, and care needs of post-secondary students: A cross-sectional mixed-methods study. BMC Public Health, 23(1), 655. https://doi.org/10.1186/s12889-023-15452-x

Mullins, L., & Preyde, M. (2013). The lived experience of students with an invisible disability at a Canadian university. Disability & Society, 28, 147-160.

Osborn, T. G., Li, S., Saunders, R., & Fonagy, P. (2022). University students’ use of mental health services: A systematic review and meta-analysis. International Journal of Mental Health Systems, 16(1), 57. https://doi.org/10.1186/s13033-022-00569-0

Patalay, P., Annis, J., Sharpe, H., Newman, R., Main, D., Ragunathan, T., Parkes, M., & Clarke, K. (2017). A Pre-Post Evaluation of OpenMinds: A Sustainable, Peer-Led Mental Health Literacy Programme in Universities and Secondary Schools. Prevention Science, 18(8), 995–1005. https://doi.org/10.1007/s11121-017-0840-y

Radez, J., Reardon, T., Creswell, C., Lawrence, P. J., Evdoka-Burton, G., & Waite, P. (2021). Why do children and adolescents (not) seek and access professional help for their mental health problems? A systematic review of quantitative and qualitative studies. European Child & Adolescent Psychiatry, 30(2), 183–211. https://doi.org/10.1007/s00787-019-01469-4

Read, A., Lutgens, D., & Malla, A. (2023). A Descriptive Overview of Mental Health Services Offered in Post-Secondary Educational Institutions Across Canada. The Canadian Journal of Psychiatry, 68(2), 101–108. https://doi.org/10.1177/07067437221128168

Simon Fraser University. (n.d.). Healthy Campus Community: Embedding Well-being into Campus Culture. Retrieved from https://www.sfu.ca/healthycampuscommunity.html

Singh, V., Kumar, A., & Gupta, S. (2022). Mental Health Prevention and Promotion—A Narrative Review. Frontiers in Psychiatry, 13, 898009. https://doi.org/10.3389/fpsyt.2022.898009

Tamaian, A., Anstey, H., Kokokyi, S., & Klest, B. (2024). The Impact of Ethnic Discrimination and Institutional Betrayal on Canadian University Students’ Mental Health. Journal of Trauma & Dissociation, 25(2), 185–201. https://doi.org/10.1080/15299732.2023.2233506

The New Abnormal: Student Mental Health Two Years Into COVID-19. (n.d.). Canadian Alliance of Student Associations. Retrieved April 2, 2024, from https://www.casa-acae.com/the_new_abnormal_report

Twenge, J. M., Blake, A. B., Haidt, J., & Campbell, W. K. (2020). Commentary: Screens, Teens, and Psychological Well-Being: Evidence From Three Time-Use-Diary Studies. Frontiers in Psychology, 11. https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2020.00181

Twenge, J. M., Haidt, J., Blake, A. B., McAllister, C., Lemon, H., & Le Roy, A. (2021). Worldwide increases in adolescent loneliness. Journal of Adolescence, 93(1), 257–269. https://doi.org/10.1016/j.adolescence.2021.06.006

Viskovich, S., & Pakenham, K. I. (2020). Randomized controlled trial of a web-based Acceptance and Commitment Therapy (ACT) program to promote mental health in university students. Journal of Clinical Psychology, 76(6), 929–951. https://doi.org/10.1002/jclp.22848

Vizoso, C., Rodríguez, C., & Arias-Gundín, O. (2018). Coping, academic engagement and performance in university students. Higher Education Research & Development, 37(7), 1515–1529. https://doi.org/10.1080/07294360.2018.1504006

Waechter, R., Gallant, C., De Wilde, K., Arens, G., Brady, T., Custodio, J., Wakita, Y., Landon, B., Boateng, Y., Parthab, N., & Bhagat, A. (2023). Prevention of mental illness within public health: An analysis of progress via systematic literature review and a pathway forward. Preventive Medicine Reports, 34, 102249. https://doi.org/10.1016/j.pmedr.2023.102249

Wang, J., Mann, F., Lloyd-Evans, B., Ma, R., & Johnson, S. (2018). Associations between loneliness and perceived social support and outcomes of mental health problems: A systematic review. BMC Psychiatry, 18(1), 156. https://doi.org/10.1186/s12888-018-1736-5

Zaza, C., & Yeung, R. C. (2023). It’s Time to Bring Mental Health Literacy Education into the Postsecondary Curriculum. The Canadian Journal for the Scholarship of Teaching and Learning, 14(1), Article 1. https://doi.org/10.5206/cjsotlrcacea.2023.1.13663