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The Silence of Mental Health Issues Within University Environments: A Quantitative Study

Published:September 02, 2014DOI:https://doi.org/10.1016/j.apnu.2014.08.003

      Abstract

      A descriptive study was used to examine the attitudes and experiences of staff and students towards mental health problems. Staff completed the "Attitude towards mental illness survey", and students who self-identified having a mental health problem completed the "Stigma scale". Using an online collection process, data from 270 staff and 201 students showed that the "silence" surrounding mental health problems permeates the university environment and impacts on help seeking behaviors, the provision of support and on the recovery and wellbeing of affected individuals. Universities must decrease stigma and foster social inclusion to build self-esteem in people who have mental health problems.
      International research into self-reported and objectively rated levels of psychological distress in university students confirms that mental health problems are common in this population (
      • Bayram N.
      • Bilgel N.
      The prevalence and socio-demographic correlations of depression, anxiety and stress among a group of university students.
      ,
      • Burris J.L.
      • Brechting E.H.
      • Salsman J.
      • Carlson C.R.
      Factors associated with the psychological well-being and distress of university students.
      ,
      • Field T.
      • Diego M.
      • Pelaez M.
      • Deeds O.
      • Delgado J.
      Breakup distress in university students.
      ,
      • Khawaja N.G.
      • Dempsey J.
      Psychological distress in international university students: An Australian study.
      ,
      • Leahy C.
      • Peterson R.
      • Wilson I.
      • Newby J.
      • Tonkin A.
      • Turnbull D.
      Distress levels and self-reported treatment rates for medicine, law, psychology and mechanical engineering tertiary students: Cross sectional study.
      ,
      • Stallman H.M.
      Psychological distress in university students: A comparison with general population data.
      ,
      • Wynaden D.G.
      • Wichmann H.M.
      • Murray S.
      A synopsis of the mental health concerns of university students: Results of a text-based online survey from one Australian university.
      ,
      • Yorgason J.B.
      • Linville D.
      • Zitzman B.
      Mental health among college students: Do those who need services know about and use them?.
      ), and appear to be increasing (
      • Hunt J.
      • Eisenberg D.
      Mental health problems and help-seeking behaviour among college students.
      ). An Australian study identified that more than 50% of students across three universities had levels of psychological distress indicative of mental illness in the 4 weeks prior to accessing professional help. Their level of distress was greater than reported data for the general population (
      • Stallman H.M.
      • Shochet L.
      Prevalence of mental health problems in Australian university health services.
      ) and was significantly associated with the number of days they were unable to meet their work and study commitments (
      • Stallman H.M.
      Prevalence of psychological distress in university students - Implications for service delivery.
      ). Despite the interference to their capacity, young people continue to delay or fail to seek help for their problems. Therefore, at any one time there are students trying to complete their studies while managing an existing or emerging mental illness or high levels of psychological distress that are causing them increasing concern (
      • Wynaden D.G.
      • Wichmann H.M.
      • Murray S.
      A synopsis of the mental health concerns of university students: Results of a text-based online survey from one Australian university.
      ).
      In managing the distressing symptoms associated with a mental health problem, students may draw on past coping mechanisms. For example, they may use alcohol and drugs or access health care services with somatic expressions such as headaches, general malaises, and/or sleep disturbances (
      • Ahern N.
      Risky behavior of adolescent college students.
      ,
      • Mori S.
      Addressing the mental health concerns of international students.
      ). However, if the underlying cause remains unresolved, it may continue to impact on the individual, interfere with social interactions with others and reduce their overall level of functioning (
      • Raunic A.
      • Xenos S.
      University counselling service utilisation by local and international students and user characteristics: A review.
      ). Unresolved problems may also affect students' ability to meet educational goals and lead to increased levels of stress, lowered productivity and/or increased absenteeism (
      • Cook L.J.
      Striving to help college students with mental health issues.
      ). Low treatment rates for mental health problems in a study of 955 tertiary students suggested that traditional models of support might not be adequate or appropriate for tertiary cohorts (
      • Leahy C.
      • Peterson R.
      • Wilson I.
      • Newby J.
      • Tonkin A.
      • Turnbull D.
      Distress levels and self-reported treatment rates for medicine, law, psychology and mechanical engineering tertiary students: Cross sectional study.
      ). Furthermore, the increasing numbers of domestic and international students from Indigenous and culturally and linguistically diverse backgrounds require culturally sensitive and safe models of support.
      Attitudes and stigma determine help seeking intentions (
      • Wynaden D.
      • Chapman R.
      • Orb A.
      • McGowan S.
      • Yeak S.
      • Zeeman Z.
      Factors that influence people from Asian communities access to and delivery of mental health care.
      ) and one of the most cited reasons why people do not seek help for mental health problems is the fear of experiencing discrimination and stigma (
      • Michaels P.
      • López M.
      • Rüsch N.
      • Corrigan P.
      Constructs and concepts comprising the stigma of mental illness.
      ,
      • Zartaloudi A.
      • Madianos M.
      Stigma related to help-seeking from a mental health professional.
      ). Mental health-related stigma can be separated into: discrimination (being treated unfairly/differently) and prejudice (stigmatizing attitudes) (
      • Clement S.
      • Lassman F.
      • Barley E.
      • Evans-Lacko S.
      • Williams P.
      • Yamaguchi S.
      • Thornicroft G.
      Mass media interventions for reducing mental health-related stigma.
      ). Stigma and discrimination also reduce students' initiative to engage in help seeking behavior (
      • Henderson C.
      • Evans-Lacko S.
      • Thornicroft G.
      Mental illness stigma, help seeking, and public health programs.
      ).
      It is important that universities facilitate early intervention for, and improved support to these students (
      • Kim E.
      • Coumar A.
      • Lober W.
      • Kim Y.
      Addressing mental health epidemic among university students via web-based, self-screening, and referral system: A preliminary study.
      ). While it is unrealistic to expect all university staff to have the level of expertise to provide effective support, university environments need to foster more supportive and accepting attitudes and improved pastoral care to reduce the impact of the unwanted consequences on students' long term level of wellbeing (
      • Galbraith N.D.
      • Brown K.E.
      • Clifton E.
      A survey of student nurses' attitudes toward help seeking for stress.
      ) and academic outcomes (
      • Storrie K.
      • Ahern K.
      • Tuckett A.
      A systematic review: Students with mental health problems–a growing problem.
      ).
      To increase awareness of the impact of mental health problems on student educational outcomes, research was conducted at two Australian universities during mental health week in October 2013. Emails with information about the study and an invitation to participate were sent. Staff were asked to complete the “Attitude towards mental illness survey” (
      • Health & Social Care Information Centre
      Attitudes to mental illness.
      ); and students who self-identified as having a mental health problem were asked to report their stigma experiences using the Stigma Scale developed by
      • King M.
      • Dinos S.
      • Shaw J.
      • Watson R.
      • Stevens S.
      • Passetti F.
      • Serfaty M.
      The stigma scale: Development of a standardised measurement of the stigma of mental illness.
      .

      Method

      Ethics approval was obtained from the two universities, and approval to conduct the research was provided by the university management.

      Staff Survey

      Permission to use the “Attitude towards mental illness survey” was obtained from the National Health Service Health and Social Care Information Centre in the United Kingdom. This survey has been used annually in the United Kingdom since 2007 to measure community attitudes toward mental illness with an average of 1700 participants per annum (
      • King M.
      • Dinos S.
      • Shaw J.
      • Watson R.
      • Stevens S.
      • Passetti F.
      • Serfaty M.
      The stigma scale: Development of a standardised measurement of the stigma of mental illness.
      ). The survey is reviewed annually to maintain a high level of content validity (
      • King M.
      • Dinos S.
      • Shaw J.
      • Watson R.
      • Stevens S.
      • Passetti F.
      • Serfaty M.
      The stigma scale: Development of a standardised measurement of the stigma of mental illness.
      ). An online format was used in this current research.
      The 20 question survey took approximately 10 minutes to complete and was comprised of four categories: (a) fear and exclusion of people with mental illness, (b) understanding and tolerance of mental illness, (c) integrating people with mental illness into the community, and (d) causes of mental illness. Each category included statements, and respondents were asked to rate their agreement or disagreement with each of the statements, with (1) = strongly agree to (5) = strongly disagree. Additional questions covered topics such as descriptions of people with mental illness, relationships with people with mental illness, personal experience of mental illness, and perceptions of mental health-related stigma and discrimination.

      Student Survey

      The Stigma Scale used qualitative data obtained from mental health service users to develop the 28 item self-report scale (
      • King M.
      • Dinos S.
      • Shaw J.
      • Watson R.
      • Stevens S.
      • Passetti F.
      • Serfaty M.
      The stigma scale: Development of a standardised measurement of the stigma of mental illness.
      ). The scale had a high level of internal consistency (Cronbach's alpha was 0.87) (
      • King M.
      • Dinos S.
      • Shaw J.
      • Watson R.
      • Stevens S.
      • Passetti F.
      • Serfaty M.
      The stigma scale: Development of a standardised measurement of the stigma of mental illness.
      ) and in the current study was 0.70 reflecting an acceptable level (
      • George D.
      • Mallery P.
      SPSS for Windows step by step: A simple guide and reference. 11.0 update.
      ).
      The survey is in the public domain, and students who self-identified as having a mental health problem were invited to participate. The survey had a three-factor structure: 1) discrimination, 2) disclosure and 3) potential positive aspects of mental illness. The questionnaire took 10 minutes to complete and was scored on a five point rating scale, with (1) = strongly agree and (5) = strongly disagree. While the researchers were confident that students would not experience distress by completing the survey, safeguards were designed to address the possibility that some may. Contact details of the principal researcher were provided if students wanted to make contact: a) prior to starting the survey or b) regarding their experiences of completing the survey. In the event that completing the survey triggered a response to previous negative experiences, students were able to obtain professional support from counseling services at each university. Information to encourage students to seek help for the problems they were experiencing was also provided at the beginning and end of the survey.

      Data Storage

      Data for both studies were collected using a secure Survey Monkey Website which was password protected and only accessed by two members of the research team. When the survey closed, data were transferred to the researcher's password protected computers at the university.

      Data Analysis

      Data were analyzed using the Statistical Package for Social Sciences, Version 22.0 (SPSS for Windows, SPSS Inc., Chicago, IL, USA) (
      • Statistical Package for Social Sciences
      Statistical Package for Social Sciences (Version Version 22.0).
      ). Descriptive statistics and chi square determined relationships between students with mental health problems and their experiences of discrimination and stigma. Descriptive statistics were used to identify staff attitudes toward mental illness.

      Results

      Staff Attitudes Toward Mental Illness Survey

      Staff response = 270 with 25% (n = 67) male, 67% (n = 180) female and 8% (n = 23) identifying as other; 51% (n = 138) were academic staff, 49% (n = 132) professional staff and 58% (n = 156) had been working at the university for 5 years. In line with the 2011 Survey Report from the National Health Service in the United Kingdom, the 23 attitude statements were grouped into four categories for analysis purposes.

      Fear and Exclusion of People With Mental Illness

      Very positive responses toward people with mental illness were recorded for all questions within this category. Staff responses ranged from 93% (n = 251) agreeing that ‘people with mental illness should not be excluded from taking public office’ to 86% (n = 232) disagreeing that ‘locating mental health facilities in a residential area downgrades the neighbourhood’. Staff responses indicated less fear of people with mental illness with 95% (n = 256) agreeable to living next door to someone with a mental illness, and this was reflected in 96% (n = 259) disagreeing that ‘signs of mental disturbance require hospitalisation’.

      Understanding and Tolerance of Mental Illness

      Staff responses showed 90% (n = 243) agreement that ‘we have a responsibility to provide the best possible care for people with a mental illness,’ and 90% (n = 243) acknowledged that ‘anyone can develop a mental illness’. University rules of conduct promote tolerance, equity and social justice and increase staff awareness of diversity and discrimination reflected in the 92% (n = 248) agreed response to the question ‘we need to adopt a far more tolerant attitude toward people with mental illness in our society’.

      Integrating People With Mental Illness into the Community

      The percentage of staff who agreed with integrating people with mental illness into the community varied across questions. The opinions ranged from 42% (n = 113) who agreed that ‘mental hospitals were an outdated means of treating mental illness’ to 89% (n = 240) agreeing that ‘people with mental problems should have the same rights to a job as anyone else’. However only 50% (n = 135) agreed that there ‘should be less emphasis placed on protecting the public from people with mental illnesses’, and only 50% (n = 135) agreed ‘most women who were once patients in a mental hospital could be trusted as babysitters’.

      Causes of Mental Illness

      In the fourth category, 96% (n = 259) disagreed that ‘lack of self-discipline and will power were the main causes of mental illness,’ and 96% (n = 259) disagreed that ‘there was something about people with mental illness that makes them easy to identify from normal people’. The respondents were then asked to what extent they agreed/disagreed that each of the following was a type of mental illness: schizophrenia; depression; stress; grief; bipolar disorder (manic depression); drug addiction. The highest response was 78% (n = 210) to depression as the most descriptive of a person with mental illness. Only 24% (n = 65) of respondents attributed violence to people who had a mental illness. Seventy two percent (n = 194) agreed that ‘people with a mental illness were responsible for their actions and inferred that mental illness does not preclude taking personal responsibility. See Fig. 1 for more information on responses to the types of mental illness.
      Figure thumbnail gr1
      Fig. 1Responses to identified types of mental illness.
      The questions about relationships with people with mental illness identified that staff were more likely to be involved with someone who had a mental illness and more likely in the future to be associated with someone with a mental illness. In response to the question “who is the person closest to you who has or has had some kind of mental illness”, the staff responses indicated an increased contact and association with someone with a mental illness including themselves. Staff recognition of family members, friends and work colleagues with mental health problems possibly highlights the success of media campaigns to disclose and seek help for mental health problems to decrease the stigma associated with mental illness. Fig. 2 provides the breakdown of staff response to knowing someone with a mental illness.
      Figure thumbnail gr2
      Fig. 2Percentage of staff responses to “Who is the person closest to you who has or has had some kind of mental illness.”
      Finally, staff indicated that talking to friends and family about their level of mental health remained difficult, with 54% (n = 146) responding that they would feel uncomfortable discussing mental health problems with family and friends. Eighty nine percent (n = 240) reported that they did not feel comfortable discussing issues related to their mental health with their employer. Their response to perceived changes in mental health related stigma and discrimination over the past year revealed that 50% (n = 135) of staff saw no change.

      Student Stigma Survey Results

      A total of 201 students completed the online survey: 78% (n = 157) were female, 22% (n = 44) males; 88% (n = 177) were undergraduate students and 12% (n = 24) were completing master and/or doctoral degrees. Ninety five percent of participants were Australian students (n = 191), and five percent (n = 10) were international students. Participant ages ranged from 17 to 51+ years with mean age of 28 years. In reporting the results for the stigma scale and its subscales, the higher the mean the more agreement there was with the statement in that category. Results are provided in Table 1.
      Table 1Student Responses.
      Sub scalesItemsMean (SD)Range
      Stigma scale282.87 (.395)2.00–4.79
      Discrimination sub scales133.17 (.64)1.31–5.0
      Disclosure sub scales102.82 (.45)1.4–4.8
      Positive aspects sub scales52.21 (.62)1.0–4.2
      Not informing employers that they had a mental health problem was the most frequently reported finding with more than three quarters or 76% (n = 153) of students not disclosing their problem when applying for a job. Furthermore, 84% (n = 169) of participants agreed that having had a mental health problem made them a more understanding person. There were no significant differences between undergraduate and postgraduate students for any category, but more than 69% (n = 137) of Australian students agreed that they “felt alone because of their mental health problems” while only 30% (n = 60) of international students acknowledged this experience.
      Discrimination was experienced across all student age groups, but mainly in the older age group. Since the P value is less than 0.05, older students experienced significantly greater discrimination in response to the following questions: “I have been discriminated against in education because of my mental health problems” X2 (df, 28, n 201) = 46.967, p = 0.014; “Sometimes I feel that I am being talked down to because of my mental health problems” X2 (df, 28,n, 201) = 44.032, p = 0.027; “I have been discriminated by employers because of my mental health problems” X2 (df, 28,n 200) = 55.376, p = .002. Since the p value is less than 0.01, a significant positive relationship existed between stigma and discrimination (r = 0.866, n 201, p = 0.00) from one side and disclosure and stigma from other side (r = 0.323, n 201, p = 0.00). Students who responded that they had experienced discrimination because of their problems also experienced stigma associated with fear of disclosure of these problems. The participants perceived limited positive outcomes from their mental health problems. A significant negative correlation was found between discrimination and positive aspects of mental illness (r = −0.193, n 201, p = 0.006).

      Discussion

      A theme highlighted in the findings of both surveys was the ‘silence’ associated with mental health problems, and it permeated the university environment in many ways. ‘Silence’ was identified through the low participation rates by staff and students to research extensively promoted at the two universities. Based on the “Australian National Survey of Mental Health and Wellbeing” data (2007), it was estimated that up to 20% of the university population would have experienced a mental illness in the last 12 months but due to the low response rates obtained, the extent of the experiences could not be accurately explored (
      • Australian Bureau of Statistics
      National survey of mental health and wellbeing: Users guide, 2007.
      ). The low response rates are recognized as limitations of the research.
      While there has been an increase in the awareness of mental health problems in university student populations (
      • Hunt J.
      • Eisenberg D.
      Mental health problems and help-seeking behaviour among college students.
      ,
      • Khawaja N.G.
      • Dempsey J.
      Psychological distress in international university students: An Australian study.
      ,
      • Leahy C.
      • Peterson R.
      • Wilson I.
      • Newby J.
      • Tonkin A.
      • Turnbull D.
      Distress levels and self-reported treatment rates for medicine, law, psychology and mechanical engineering tertiary students: Cross sectional study.
      ,
      • Stallman H.M.
      Psychological distress in university students: A comparison with general population data.
      ,
      • Wynaden D.G.
      • Wichmann H.M.
      • Murray S.
      A synopsis of the mental health concerns of university students: Results of a text-based online survey from one Australian university.
      ), the findings identified a new dimension of ‘silence’ surrounding mental health problems in university staff, and the resulting impact on staff and university productivity requires further investigation. As mental illnesses are a leading cause of disability burden an increased awareness of the social and economic impact of mental health problems on university staff is strategically important (
      • Begg S.
      • Vos T.
      • Barker B.
      • Stevenson C.
      • L., S.
      • Lopez A.
      The burden of disease and injury in Australia 2003.
      ).
      The majority of participants stated that they would not inform their employer of their problem creating another dimension to the ‘silence,’ non-disclosure. Researchers in New Zealand also reported that 57% of participants concealed or hid their mental health problems from others (
      • Thornicroft C.
      • Wyllie A.
      • Thornicroft G.
      • Mehta N.
      Impact of the “Like Minds, Like Mine” anti-stigma and discrimination campaign in New Zealand on anticipated and experienced discrimination.
      ). Students in this current study showed a positive correlation between stigma, discrimination and disclosure, and this was supported by further international research (
      • Eisenberg D.
      • Downs M.F.
      • Golberstein E.
      • Zivin K.
      Stigma and help seeking for mental health among college students.
      ). The failure to disclose mental health problems to employers for fear of being discriminated against is transferable to the university. As a result, affected students experience isolation, loneliness and struggle as they try to meet their study requirements with many withdrawing from programs (
      • Wynaden D.G.
      • Wichmann H.M.
      • Murray S.
      A synopsis of the mental health concerns of university students: Results of a text-based online survey from one Australian university.
      ). International students may also fear that their student visa and course enrolment may be cancelled.
      While effective support is fundamental to mental health recovery, other researchers have found that universities struggle to cope successfully with the increased severity and numbers of students requiring mental health support (
      • Cook L.J.
      Striving to help college students with mental health issues.
      ,
      • Khawaja N.G.
      • Dempsey J.
      Psychological distress in international university students: An Australian study.
      ,
      • Mowbray C.T.
      • Megivern D.
      • Mandiberg J.M.
      • Strauss S.
      • Stein C.H.
      • Collins K.
      • Lett R.
      Campus mental health services: Recommendations for change.
      ,
      • Stallman H.M.
      Psychological distress in university students: A comparison with general population data.
      ).
      When non-professional support is provided, it is a ‘silent’ contribution from staff, and their willingness to engage with students is balanced against their own mental health needs, their competing workload and an increasingly challenging and complex work environment (
      • Galbraith N.D.
      • Brown K.E.
      • Clifton E.
      A survey of student nurses' attitudes toward help seeking for stress.
      ,
      • McAllister M.
      • Wynaden D.
      • Walters V.
      • Flynn T.
      • Duggan R.
      • Byrne L.
      • Happell B.
      An exploration of the experiences of university staff in working with students who are managing a mental health problem Final Report.
      ).
      There is a strategy to increase the mental health literacy of staff through educational programs such as Mental Health First Aid (
      • Jorm A.F.
      • Korten A.E.
      • Jacomb P.A.
      • Christensen H.
      • Rodgers B.
      • Pollitt P.
      "Mental health literacy": A survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment.
      ). Mental health literacy includes the ability to recognize specific disorders, knowledge of causes and risk factors, of self-treatments, and of professional help available and attitudes that promote recognition and appropriate help-seeking (
      • Jorm A.F.
      • Korten A.E.
      • Jacomb P.A.
      • Christensen H.
      • Rodgers B.
      • Pollitt P.
      "Mental health literacy": A survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment.
      ). Research on the use of Mental Health First Aid with high school teachers reported positive changes in attitudes to people with mental health problems and an increased awareness and knowledge of help seeking behaviors in students (
      • Jorm A.F.
      • Kitchener B.A.
      • Sawyer M.G.
      • Scales H.
      • Cvetkovski S.
      Mental health first aid training for high school teachers: A cluster randomized trial.
      ). However, results from a systematic review of mental illness-related beliefs and attitudes in the general population found that increasing public understanding of the causes of mental illness does not necessarily result in improved social acceptance of persons with mental health problems (
      • Schomerus G.
      • Schwahn C.
      • Holzinger A.
      • Corrigan P.W.
      • Grabe H.J.
      • Carta M.G.
      • Angermeyer M.C.
      Evolution of public attitudes about mental illness: A systematic review and meta-analysis.
      ). Some researchers argue that such campaigns may support medicalized agendas and take over from the voices of those who have experienced stigma (
      • Yap M.B.H.
      • Reavley N.
      • Mackinnon A.J.
      • Jorm A.F.
      Psychiatric labels and other influences on young people's stigmatizing attitudes: Findings from an Australian national survey.
      ). Stigma and discrimination attached to mental health problems persist, and the current resources do not appear to change this or increased help seeking, nor does it mean people have understood what constitutes a mental health problem (
      • Arria A.M.
      • Winick E.R.
      • Garnier-Dykstra L.M.
      • Vincent K.B.
      • Caldeira K.M.
      • Wilcox H.C.
      • O'Grady K.E.
      Help seeking and mental health service utilization among college students with a history of suicide ideation.
      ,
      • Bell J.S.
      • Aaltonen S.E.
      • Airaksinen M.S.
      • Volmer D.
      • Gharat M.S.
      • Muceniece R.
      • Chen T.F.
      Determinants of mental health stigma among pharmacy students in Australia, Belgium, Estonia, Finland, India and Latvia.
      ). Other aspects of community support need to be promoted and incorporated into university strategic initiatives, particularly those that promote that mental health recovery is possible. Furthermore, the general public maintains a low level of mental health literacy (
      • Corrigan P.W.
      • Rao D.
      On the self-stigma of mental illness: Stages, disclosure, and strategies for change.
      ,
      • Evans-Lacko S.
      • Brohan E.
      • Mojtabai R.
      • Thornicroft G.
      Association between public views of mental illness and self-stigma among individuals with mental illness in 14 European countries.
      ,
      • Munizza C.
      • Argentero P.
      • Coppo A.
      • Tibaldi G.
      • Di Giannantonio M.
      • Picci R.L.
      • Rucci P.
      Public beliefs and attitudes towards depression in Italy: A national survey.
      ). A review of the effectiveness of anti-stigma mass media campaigns showed prejudice towards people with mental health problems decreased, but there was limited evidence to show a change in discrimination (
      • Clement S.
      • Lassman F.
      • Barley E.
      • Evans-Lacko S.
      • Williams P.
      • Yamaguchi S.
      • Thornicroft G.
      Mass media interventions for reducing mental health-related stigma.
      ). There is also evidence that stigmatizing attitudes can impact on young people's initiative to provide mental health support to their peers experiencing problems (
      • Yap M.B.
      • Jorm A.F.
      The influence of stigma on first aid actions taken by young people for mental health problems in a close friend or family member: Findings from an Australian national survey of youth.
      ). Similarly, health professionals were found to maintain a level of discrimination against people who presented with mental health problems (
      • Reavley N.J.
      • Mackinnon A.J.
      • Morgan A.J.
      • Jorm A.F.
      Stigmatising attitudes towards people with mental disorders: A comparison of Australian health professionals with the general community.
      ) further decreasing this groups' willingness to engage in help seeking behaviors (
      • Shrivastava A.
      • Bureau Y.
      • Rewari N.
      • Johnston M.
      Clinical risk of stigma and discrimination of mental illnesses: Need for objective assessment and quantification.
      ). A review of public attitudes in the United Kingdom showed that despite improvements in mental health literacy, negative public attitudes and desire for social distance from people with mental problems have remained stable over time (
      • Evans-Lacko S.
      • Henderson C.
      • Thornicroft G.
      Public knowledge, attitudes and behaviour regarding people with mental illness in England 2009-2012.
      ).
      The avoidance of help-seeking of staff and students experiencing mental health problems is of strategic importance to universities as social inclusion is central to mental health recovery and a person's ability to complete their education program or work commitments. Research has shown that close interactions with someone who has a mental illness, empathy (
      • Rusch N.
      • Muller M.
      • Lay B.
      • Corrigan P.
      • Zahn R.
      • Schonenberger T.
      • Rossler W.
      Emotional reactions to involuntary psychiatric hospitalization and stigma-related stress among people with mental illness.
      ) and increased social activism to promote the importance of mental health and wellbeing are also effective ways of decreasing stigma (
      • Corrigan P.
      • Morris S.
      • Michaels M.
      • Rafacz D.
      • Rüsch N.
      Challenging the public stigma of mental illness: A meta-analysis of outcome studies.
      ), for example, inviting the input of mental health service users who have successfully completed tertiary studies in education and training with staff and students could be another option to change attitudes, in addition to offering Mental Health First Aid (
      • Repper J.
      • Perkins R.
      Social inclusion and recovery: A model for mental health practice.
      ). This approach has been trialed with nursing students with success in Australia and internationally (
      • Blackhall A.
      • Schafer T.
      • Kent L.
      • Nightingale M.
      Service user involvement in nursing students’ training.
      ,
      • Byrne L.
      • Happell B.
      • Welch T.
      • Moxham L.J.
      ‘Things you can't learn from books’: Teaching recovery from a lived experience perspective.
      ,
      • Gutmana C.
      • Kraiema Y.
      • Cridena W.
      • Yalon-Chamovitz S.
      Deconstructing hierarchies: A pedagogical model with service user co-teachers.
      ), and demonstrated that mental health service users reduced the level of stigma through their educational and training programs and were a source of support for both students and staff experiencing mental health problems (
      • Ochocka J.
      • Nelson G.
      • Janzen R.
      • Trainor J.
      A longitudinal study of mental health consumer/survivor initiatives: Part 3- a qualitative study of impacts of participation on new members.
      ).
      Mental health week and World Mental Health Day are also opportunities for universities to focus on identifying and recruiting champions to talk about their experiences and recovery strategies. Innovative ways to increase help seeking, privacy and timely access for students with mental health problems and provision of realistic support for staff are also urgent priorities (
      • Leahy C.
      • Peterson R.
      • Wilson I.
      • Newby J.
      • Tonkin A.
      • Turnbull D.
      Distress levels and self-reported treatment rates for medicine, law, psychology and mechanical engineering tertiary students: Cross sectional study.
      ). Specific mental health issues for indigenous, gay, lesbian, bisexual, transgender and intersex (GLBTI) and CALD students, particularly those from a refugee background that have experienced trauma in their resettlement need culturally appropriate responses (
      • Eley D.
      • Young L.
      • Hunter K.
      • Baker P.
      • Hunter E.
      • Hannah D.
      Perceptions of mental health service delivery among staff and indigenous consumers: it's still about communication.
      ,
      • Hannah J.
      Refugee students at college and university: Improving access and support.
      ). Embedding recovery orientated mental health information in first year units across disciplines could be a significant step towards social inclusion and advocacy for this group (
      • Salzer M.S.
      A comparative study of campus experiences of college students with mental illnesses versus a general college sample.
      ). Reducing the stigma and discrimination attached to mental illness can also be achieved through the evolving language used to describe the experiences that people have. Increasingly, the term mental health challenge is being used as an alternative to problem, illness and disorder. The term is viewed as consistent with mental health recovery, and a strengths based term that recognizes the challenge faced by the individual can be overcome, and the person can achieve their goals and live productively within the community (
      • Australian Health Ministers Advisory Council
      A national framework for recovery orientated mental health services: Policy and theory.
      ).
      To build university environments that foster mental wellbeing, orientation week could include a variety of programs including mental health literacy, access to mental health service users through support programs, orientation to online helping resources such as self-help, online mentors, FAQs and online counseling for students. Staff support and opportunities to learn how to offer reassurance, emotional strength, and acceptance to students with mental health problems could be part of orientation to all new staff and available through the counseling services on a regular basis for current staff (
      • Substance Abuse
      • Mental Health Services Administration
      Developing a stigma reduction initiative. SAMHSA Pub No. SMA-4176.
      ).
      Developing a safe and secure Web based help line with online messaging links with a health service provider would also offer a confidential avenue for students who are reluctant to access on campus health services for their mental health problems and has proved useful in several other studies concerning health information access (
      • Alishahi-Tabriz A.
      • Sohrabi M.R.
      • Kiapour N.
      • Faramarzi N.
      Addressing the changing sources of health information in iran.
      ,
      • Lau A.Y.
      • Proudfoot J.
      • Andrews A.
      • Liaw S.T.
      • Crimmins J.
      • Arguel A.
      • Coiera E.
      Which bundles of features in a Web-based personally controlled health management system are associated with consumer help-seeking behaviors for physical and emotional well-being?.
      ).

      Limitations

      The limitations of the research are connected to the ‘silence’ around mental health problems. All staff and students at both universities were invited to complete the online survey, but less than 10% responded. The reasons could be both personal and work related and while the results are not able to be generalized to other university settings, they do give a trend that warrants further research.

      Conclusion

      Universities are increasingly diverse environments with opportunities to enhance knowledge development and cultural enrichment. For this enrichment to occur and for individuals to reach their learning potential, health and wellbeing must be enabled. Health is much more than the absence of disease, and includes mental health. This paper highlights the ongoing barriers to health including hidden and overt sources of stigma. Overcoming these social problems requires multi-pronged proactive measures, including mental health literacy and empathy programs, expansion of health and pastoral service provision, and the engendering of a culture that appreciates difference.

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