mental health literature review example

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• Ghana Med J
• v.46(2 Suppl); 2012 Jun

Mental Health Research in Ghana: A Literature Review

1 Department of Anthropology, University College London, 14 Taviton St, London, UK, WC1H 0BW

2 P O Box 060, Institute of Psychiatry, King's College London, Denmark Hill, London, SE5 8AF

Context/Background

Mental health is a neglected area in health care in Ghana. With few clinicians and trained researchers in the field, research has been limited both in quantity and quality.

A search of the available literature revealed 98 articles published between 1955 and 2009. Sixty-six are reviewed in this paper.

Topics covered included hospital and community-based prevalence studies, psychosis, depression, substance misuse, self-harm, and help-seeking. Much of the research was small in scale and thus largely speculative in its conclusions. Epidemiological data is scarce and unreliable and no large-scale studies have been published. There are very few studies of clinical practice in mental health.

Conclusions

The existing literature suggests several important areas for future research to inform the development of targeted and effective interventions in mental health care in Ghana.

Introduction

Psychiatry in Ghana is neglected in health care and research. In 1972 Adomakoh proclaimed in this journal ‘There is a dearth of detailed knowledge of psychiatric illness in this country’. 1 Nearly 40 years later the research record has expanded, but accurate data on epidemiology, treatment and outcomes is still sorely needed. In the absence of reliable evidence, the gaps are filled by data extrapolated from international research, “guesstimates”, and anecdotal evidence.

The first study of mental illness in the then Gold Coast was commissioned by the Colonial Office to study ‘the forms of neurosis and psychosis among West Africans’. Four hundred cases of mental disorder were identified with the help of census enumerators and chiefs. 2 This was followed in the 1950s by ethnographic research of people with mental disorder attending rural shrines. 3 Following independence and the training of Ghanaian psychiatrists, local psychiatrists began to publish clinically-based research. However with limited resources and research expertise, the studies were small and output was limited. This situation has persisted until recently. The majority of research in mental health has been undertaken by the country's few psychiatrists, occasionally assisted by expatriate researchers or clinicians and has remained small in scale.

Recently a new impetus for mental health in Ghana has seen the establishment of mental health NGOs, the drafting of a new mental health bill, increased training for psychiatrists and psychiatric nurses, proposals for training new cadres of primary health care specialists in mental health, and increased media attention. There has also been an increase in the number of research projects and publications on mental health from a diversity of disciplines including psychology, sociology and anthropology.

The Kintampo Health Research Centre has supported studies of risk factors for psychosis, mental disorders among older people, an ethnography of psychosis, 4 , 5 and an epidemiology of postnatal depression. The Mental Health and Poverty Project , which conducted research on mental health policy in four African countries including Ghana, 6 has produced several publications in indexed journals. 7 , 8 , 9 , 10 , 11

The PubMed indexing of the African Journal of Psychiatry and the online publication of the Ghana Medical Journal (GMJ) present new opportunities for mental health research in Ghana to provide a much-needed contribution to regional and international research on African mental health. This paper aims to provide an overview of the current state of research on mental health in Ghana, and a critical review of published research papers. The findings of these papers are synthesised to highlight priority areas for mental health research in Ghana which should be of value to both clinicians and researchers in the field.

A literature search was conducted of social science and medical journals in Ghana and the UK. The authors conducted an on-line search of Pubmed using MeSH terms ‘ psychiatry AND Ghana ’, ‘ mental disorders AND Ghana ’ ‘ mental health services AND Ghana ’, ‘ mental health AND Ghana’, ‘self-injurious behaviour AND Ghana’ , in addition to a manual search of the libraries of Korle-Bu Teaching Hospital (KBTH), the Institute of Psychiatry, UK, and the London School of Hygiene and Tropical Medicine (LSHTM).

Ninety-nine articles published between 1955 and 2009 were identified. Thirty-three articles were excluded (see Table 1 ). Sixty-six were included in this review. Articles were grouped under the most relevant topics however there was overlap in some papers (see Table 2 ).

Papers excluded from the review

Reviewed papers by topic

Epidemiology

Early researchers and clinicians predicted an increase in mental disorders in Ghana as a result of the presumed stresses of industrialisation and ‘acculturation’. 12 , 13 Yet to date the true prevalence of mental illness in Ghana remains uncertain. Epidemiological studies are based on small numbers and rely on clinical case-finding methods. Prevalence rates drawn from such data are below expected rates from international comparative studies and in the absence of data from population-based epidemiological studies are likely to be an underestimation.

Since psychiatric hospitals are the most easily accessible research sites, particularly for hard-pressed clinicians, a number of studies have been undertaken drawing on records at Accra Psychiatric Hospital (APH). In a study of first admissions to APH between 1951 and 1971 Forster observed a sharp increase in admissions from 265 in 1951 to 2284 in 1967 followed by a decline to 736 in 1971. 15 This change was attributed this to the political crisis between 1961–1966, however since then admissions approximate to the 1960s figure despite political stability and economic development in recent years. Hospital admissions are unreliable indicators of psychiatric morbidity since they are confounded by population growth and increased awareness and exclude many cases who do not attend psychiatric services. 14

The few community-based prevalence studies do not employ standardised research diagnoses or methods. 12 , 16 , 17 , 18 epidemiological In Kumasi 194 participants were interviewed using the mental state examination (MSE) and the Self-Reporting Questionnaire (SRQ). Thirty-eight were diagnosed with depressive illness, of which 33 were women. Five women were diagnosed with schizophrenia and five men with somatisation disorder. Despite the limitations of the methodology, the author calculated an overall prevalence of psychiatric illness of 27.51%. 18 Noting the popularity of prayer camps and shrines in the treatment of mental disorders, Turkson suggests that epidemiological studies of mental illness in Ghana should include these. 19

chizophrenia/psychosis

In 1968 Field stated there had been an explosive increase in schizophrenia within the last 20 years (p.31). 20 However she had no data with which to substantiate such a claim. Her longitudinal study of hundreds of cases attending rural shrines in Ashanti and Brong Ahafo 12 , 20 , 21 provided a wealth of clinical and contextual detail however she did not quantify most of her work. In one exception she approached chiefs and elders of rural towns and villages and identified 41 cases of chronic schizophrenia in 12 villages with a combined population of 4,283. In the 1960s Fortes and Mayer, conducted a study of psychosis among the Tallensi in Northern Ghana. Mayer diagnosed 17 cases of psychosis, eight men and nine women. 17

In the 1980s a study of the prevalence of schizophrenia in Labadi, Greater Accra using clinical interviews and a review of medical records identified 28 cases of schizophrenia including 19 males in a population of 45,195. Thirty-one vagrants were also found to be psychotic. 16 Methods were restricted to tracing cases from APH and Pantang Hospital, screening patients at the polyclinic, visiting a shrine and assessing 175 vagrants. No house-to-house case-finding was conducted.

Studies at APH consistently record schizophrenia and psychosis as the most commonly recorded diagnosis for about 70-75% of inpatients. 1 , 22 In the only identified study of mentally disordered offenders at APH, most had been diagnosed with psychotic illness including 31% with schizophrenia, 20.2% with drug-induced psychoses, and 13.3% with non-specified psychosis. Most of those charged with murder or attempted murder had been diagnosed with psychotic illness, nearly half (48.6%) with schizophrenia. 23

The preponderance of schizophrenia as a diagnosis among inpatients continues to the present day. This is probably since only the most severe cases are admitted. The symptoms of acute psychosis also present grave difficulties for family members to manage at home, and are likely to prompt help-seeking. A Delphi consensus study of resource utilisation for neuropsychiatric disorders in developing countries, including Ghana, suggested that acute psychosis, manic episodes, and severe depression were the most common disorders treated within inpatient psychiatric care. 14

Colonial psychiatrists asserted the virtual absence of depression among Africans, which was later challenged by Field among others. Field surmised that the self-accusations of women who confessed to witchcraft were akin to the self-reproach expressed by women with depression in Britain. 3 , 21 and that ‘Depression is the commonest mental illness of Akan rural women’ (p. 149). 3 Two studies of psychiatric morbidity in general hospitals and clinics suggest that more neurotic and affective disorders may be seen in these facilities than in the psychiatric hospitals although numbers are small. 24 , 25 In a survey of psychiatric morbidity at 6 polyclinics in Accra, of 172 patients, 27 were found to have psychiatric illness, with a further seven having physical illness with concomitant psychiatric illness. Of these 23 (72%) were diagnosed with ‘neurosis’. 24 Lamptey recorded no cases of depression, however it is possible these may have been missed due to the prominence of somatic symptoms such as palpitations, burning sensations and insomnia. In another study of 94 patients referred to a psychiatric out-patient clinic at KBTH the majority were diagnosed with affective (23) and neurotic/stress related disorders (11). 25

To address the lack of cross-cultural data on depression in the early 1980s the World Health Organization sponsored a study utilising the Standardized Assessment for Depressive Disorders (SADD). Fifty patients were assessed using SADD, Thirty-three were female. Anxiety and tension were the core symptoms expressed, with 35% reporting feelings of guilt and self-reproach. Feelings of sadness and loss of interest and enjoyment were commonly reported. Forty reported somatic symptoms including headaches, bodily heat, and generalised body pain. 26

The authors argue that there has been a change in the presentation of depression in Africa compared to earlier data. However, whilst the population of Ghana is more widely educated than in the 1950s, the study recruited a highly selective English-speaking sample who had already interpreted their symptoms in such as way as to approach psychiatric hospital. Indeed Turkson and Dua's study with a larger, less well-educated sample produced contrasting results. They studied 131 female outpatients with a diagnosis of depression using the Montgomery-Asberg Depressive Rating Scale (MADRS). They noted a high degree of somatic symptoms, in particular headaches (77.86%) and sleeplessness (68.7%). In contrast to the SADD study, there were fewer reported psychological symptoms such as pessimistic thoughts (20.61%) and sadness (12.97%). Only 10 (7.3%) reported suicidal thoughts. 27 However the MADRS has fewer psychological items than the SADD and therefore elicits different symptoms, highlighting one of the limitations of standardised instruments, particularly where they have not been validated with the local population.

Osei explored the incidence of depression among 17 self-confessed ‘witches’ at three shrines in the Ashanti region of Ghana. All were diagnosed with depression according to ICD-10. Three also had serious physical health problems. As in the previous studies, many described physical complaints such as a burning sensation or persistent headaches. The women also expressed ideas of guilt relating to having harmed someone in the family through the use of witchcraft. 28 Like Field, Osei suggests that guilt feelings arising from depression might prompt women to confess to witchcraft.

Such research raises interesting issues for the study of mental illness within the context of widespread belief in witchcraft and other supernatural phenomena in Ghana.

Turkson and Dua hypothesise on a link between socioeconomic status and depression, however without a control group and with inadequate numbers they could provide little substantive evidence. A qualitative study of 75 women in the Volta region is highly suggestive of a link between social factors and psychological distress. 29 – 31 Whilst this study did not set out specifically to research mental disorders, almost three quarters of the women interviewed described ‘thinking too much’ or ‘worrying too much’. Importantly, such symptoms were more prominent in women's accounts of their health than physical health problems.

Most participants complained of stresses arising from multiple responsibilities in the arenas of family and work, as well as financial hardship. 30 Headaches, bodily aches and pains, and sleep disturbance were commonly reported. A similar link between such experiences of poverty and possible symptoms of mental illness such as excessive thinking, worry and anxiety, as well as persistent physical symptoms such as headaches, has been made in a study of migrant squatters in Accra. 32 It is probable that some of these women may have met the criteria for a psychiatric diagnosis of depression.

The prominence of somatic symptoms among Ghanaian women diagnosed with depression is notable. Turkson notes that in 1988 32% of all new patients at APH presented with primarily somatic symptoms such as headaches, burning sensations, tiredness and bodily weakness with the majority diagnosed with anxiety, depression and somatisation disorders. 25 This highlights the importance of screening measures which have been locally validated and can identify somatic and non-somatic symptoms. A study of depression and life satisfaction among Nigerian, Australian, Northern Irish, Swazi and Ghanaian college students utilising the Beck Depression Inventory (BDI) for example, found that Ghanaians had significantly lower depression scores than other groups. 33

Aside from sleeplessness and loss of appetite, the BDI items are mostly concerned with psychological aspects of depression such as worthlessness and guilt. In a study of the comparative validity of screening scales for post-natal common mental disorders Weobong provides evidence for the cross-cultural validity and reliability of a Twi version of the Patient Health Questionnaire (PHQ-9). 34

Significantly the study showed that a mixture of somatic and cognitive symptoms best discriminated between cases and non-cases for all scales evaluated.

Given the high birth rate in Ghana, Weobong's study of post-natal depression will provide much-needed data on a condition which has been little researched. The only previous study identified described four cases of psychiatric disorders associated with childbirth treated at APH, including post-partum psychosis and manic-depressive psychosis. The author observed that few cases were referred to the psychiatric hospital and queried whether post-partum mental disorders were being recognised within antenatal wards. He also noted the influence of social factors such as marital problems and financial difficulties. 35

The literature reveals that women are generally underrepresented in psychiatric hospitals in Ghana. In Forster's study of APH inpatient admissions between 1951–1971 males consistently outnumbered females by about 3:1. 15 It has been suggested that when men become acutely mentally unwell they may be more difficult to manage at home, and so are more likely to be brought to the psychiatric hospitals for treatment. 16 18 36 37 Women in Ghana appear to be underserved by mental health services and the majority of women suffering from mental disorders, particularly depression, remain untreated or under the care of churches and shrines. Research at facilities such as polyclinics, shrines and churches may provide a more accurate picture of the numbers of women with mental disorders and their clinical presentation.

Suicide and self-harm

There is very little research on self-harm in Ghana. Roberts and Nkum examined the case notes of 53 patients admitted to Komfo Anokye Teaching Hospital (KATH) over a 5 year period. 38 The most common means of self-harm was ingestion of pesticides (22), and other harmful substances. 10 used ‘physical methods’ including self-stabbing (4). 6 cases were diagnosed with psychosis and 28 with acute reactions to social stresses such as marital and financial problems. The authors found an increase in deliberate self-harm during the five year period compared to an earlier study 39 from 0.3 cases per 1,000 admissions between 1965–1971 to 1.32 cases per 1,000 admissions in 1987. Based on their findings the authors estimated a crude annual incidence of 2.93 per 100,000. However this figure is likely to be an underestimate given that some cases may not reach medical services.

A number of studies comparing suicidal ideation among Ghanaian and Caucasian students in the USA showed significantly lower rates of self-reported suicidal ideation among the Ghanaian sample, as well as more negative attitudes towards suicide. 40 41 A larger survey compared 570 Ghanaian students with students from Uganda and Norway utilising the Attitudes Toward Suicide Questionnaire. Thirty (5.4%) of the Ghanaian sample reported making suicide attempts, significantly lower than either Uganda or Norway. Nine of the respondents reported a completed suicide in the family, and 91 among non-family members, again markedly lower than those reported by the Ugandan and Norwegian respondents. 42

Though these studies seem to suggest a low rate of suicidal ideation in Ghana, generalisation is cautioned since all the studies were conducted with young, urbanised, highly-educated participants. There is also no published research on completed suicides in Ghana. It is possible that the lower reported rates of suicidal ideation or suicide attempts may in part reflect likelihood that Ghanaian students would be less likely to report suicidal ideation due to negative attitudes towards suicide. This is supported by the finding of Hjelmeland et al that 31% of their sample felt that suicide should not be talked about. 42

However these studies also point to possible factors in Ghanaian society which could be employed in suicide prevention including family support, religious belief, and an emphasis on the value of the group. Qualitative studies related to beliefs and attitudes towards suicide, as well as risk factors, would greatly enhance the quantitative data and enable an exploration of some of the correlations observed. 41 There is one recent study on anorexia nervosa among female secondary school students in North East Ghana, a condition which has been considered rare in non-Western cultures.

The researchers completed a clinical examination of physical and mental health, two standard measures of eating behaviour and attitudes, and a depression screen. Of 666 students, 29 were pathologically underweight of which 10 were diagnosed with morbid self-starvation based on clinically significant indicators such as denial of hunger, self-punishment and perfectionist traits. The majority of the participants, both Christian and Muslim, reported regularly engaging in religious fasting. For the 10 engaged in morbid self-starvation, this fasting was particularly frequent, at least once a week, and associated with feelings of self-control and self-punishment. Since self-starvation was not associated with a desire to be thin or a morbid fear of fatness, a diagnosis of anorexia nervosa according to DSM-IV or ICD-10 criteria could not be made.

However the authors suggest that in Ghana fasting rather than dieting may provide the cultural context within which morbid self-starvation occurs. 43 As suggested by the role of somatic symptoms in the presentation of depression in Ghana, this study has important implications regarding the limitations of standardised psychiatric diagnoses and the need to recognise cultural influences on the presentation of mental illness.

Substance misuse

It is notable that the highest number of published papers in this review concerns substance abuse. 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 This may reflect more on the interests of researchers than the severity of the problem. In his sociological study Affinnih claims there has been an increase in the use of drugs such as cocaine and heroin in Accra and other urban centres. 45 , 46 However data from the psychiatric hospitals suggests that cannabis and alcohol are the most frequently used substances and may be a risk factor for the development of psychosis amongst young men. 23 , 25 , 54 , 53

There is limited research on the mental health implications of substance use in Ghana. A study of substance abusers admitted to a private clinic in Accra excluded those with co-morbid mental illness. 49 Importantly only two papers were identified which were primarily concerned with alcohol misuse, one of which is a social history of alcohol use in Ghana. 44 The only epidemiological study of alcohol misuse was conducted with 350 psychiatric outpatients in Kumasi using the WHO Alcohol Use Disorders Identification Test (AUDIT).

The researchers found a prevalence of only 8.6% for hazardous drinking, significantly lower than comparable studies in the West. 53 The link between substance misuse and mental disorders may be exaggerated in the public imagination and the media and there is a tendency to make speculative assertions based on limited evidence. Affinnih for example quotes a minister of health as saying that ‘drugs are responsible for 70% of the cases in local psychiatric hospitals’ (p.397), 45 a figure which is not substantiated by hospital records. More research is needed in this area from a specifically mental health perspective.

Help-seeking

The popularity of traditional healers in the treatment of mental illness has been noted since the earliest studies of mental illness in Ghana and continues to the present day. 55 A study of 194 people attending three shrines in the Ashanti region stated that 100 (51.55%) of these were suffering from a mental illness, the majority (64 (32.99%)) with depression. Another 14 were diagnosed with somatisation, and 19 with psychotic illness, including 6 with schizophrenia, 4 with acute psychosis and 3 with cannabis-induced psychosis. 28 36

Though data is limited, two papers suggest a change in the pattern of help-seeking over the last thirty years, with a greater role for Christian healers. In 1973 a study of 105 patients at APH diagnosed with psychosis showed that almost all (97(92%)) had sought another form of treatment before attending the psychiatric hospital. 67 (64%) patients had consulted a herbalist, 28 (26%) a healing church, and only 2 a fetish priest. 56

A study in 2004 of the use of traditional healers and pastors by 303 new patients attending state and private psychiatric services in Kumasi found that a smaller proportion of patients had consulted other forms of treatment and a greater number reported consulting a pastor than a traditional healer (43 (14.2%) and 18 (5.9%) respectively). There also appeared to be more use of medical facilities in the treatment of mental illness. 14 patients had seen a family doctor and 6 had visited another psychiatric hospital. Nearly a quarter (24.4%) had previously attended one of the other mental health centres in Kumasi. 57

Limited research has been conducted on beliefs and attitudes towards mental illness in Ghana which may influence help-seeking behaviour, though there is much speculation on the spiritual attribution of mental illness amongst the general population. 7 Two studies conducted in the early 1990s suggest a more varied and complex picture. A quantitative survey of 1000 women in Accra found that most (88%) said they would seek help from the psychiatric hospitals and only a minority (8.2%) said they would consult traditional healers.

The most important socio-demographic factors influencing the orientation towards help-seeking were area of residence, ethnicity, migration status, and prior use of medical services. Women who perceived the cause of psychosis to be natural or stress-related were more likely to seek help from mental hospitals than those who identified supernatural causation. 58 Similarly, a study of the effect of social change on causal beliefs of mental disorders and treatment preferences among teachers in Accra found that rather than emphasising spiritual causation for mental illness in Ghana, respondents attributed multiple causal factors to mental illness drawn from biological, social and spiritual models.

The authors attributed this in part to ‘acculturation’ but cautioned that participants may have wished to present themselves as educated and therefore have been less willing to disclose supernatural beliefs.

They also hypothesised that such beliefs may only come into play as an ‘indirect attribution’. 59 In both studies participants were urban residents and most were educated. Using semi-structured interviews with 80 relatives of people with mental illness, and 10 service providers, Quinn explored beliefs about mental illness in Accra and Kumasi, and two rural areas in the Ashanti and Northern regions and how these influenced family responses to mental illness.

In line with the urban ‘acculturation’ thesis, 2 , 17 Quinn reported that in urban areas most respondents attributed mental illness to ‘natural’ causes such as work stress. In the Northern region however, spiritual attributions were more common. The Northern samples were also significantly less educated with 14 out of 19 respondents having no education. Caution should be exercised in generalising these results as the sample size in each area was small. There were also many ‘don't knows’ - 22 out of 80. 60 This may be a reflection of more complex aetiological beliefs and uncertainty around the cause of mental illness than reflected in a binary spiritual/natural schema, as earlier studies have suggested. 37 , 59

Quinn's study claims that there was greater reliance on traditional healing in the North due to beliefs in a spiritual origin of mental illness; however it does not explore these issues in sufficient depth to support this assertion. The lower education of those in the Northern sample as well as their long distance from the psychiatric hospitals was other factors which may have influenced help-seeking. The study also reports that respondents in the Northern Region described greater acceptance of people with mental illness by families and communities with little evidence of stigma, echoing earlier reports. 2 , 17 Quinn's finding however is based on only 19 respondents, 17 of which were male. Since mothers are likely to provide most of the caring role they might have provided differing opinions on the impact of the illness. 60

None of these studies allow for in-depth exploration of possible influences on help-seeking behaviour for mental illness. However they suggest some interesting hypotheses regarding the reputation of traditional healers in treating mental illness, the stigma attached to mental illness and psychiatric hospitals, and the scarcity of psychiatric services.

In common with other mental health researchers and professionals in Africa, these studies recommend collaboration with traditional and faith healers in the treatment of mental illness, such as training healers in recognising severe mental illness, and referring patients to psychiatric services. However traditional healers and pastors may be unwilling to pass on their customers to biomedical practitioners or admit to failings in their intervention. Claims for the efficacy of traditional healers also tend to be anecdotal and speculative and are seldom based on rigorous longitudinal data. Most authors highlight the role of traditional healers in addressing the psychosocial aspects of mental illness and their resonance with cultural beliefs. 37 , 56 , 61 , 62 , 63

Whilst some present a rather idealised picture, 61 others note the inhumane treatment of people with mental illness by traditional healers. 4 , 36 , 62 One paper points to the role of the family in caring for patients within traditional shrines and churches, and shows how this model was replicated within psychiatric facilities by enabling family members to stay with the patient in hospital. 64 Further research is needed on the practices of traditional and faith healers to inform interventions to address the maltreatment of people with mental illness, and ensure that those with mental illness receive the best quality treatment from both psychiatric facilities and informal services.

This review shows that mental health research in Ghana remains limited in both quantity and quality. In the absence of comprehensive research, much is assumed based on scant evidence, and services are heavily influenced by the results of research conducted elsewhere, most often in high-income settings. Whilst researchers have used their findings to argue for more resources for mental health, such pleas would be more forcefully made were there more accurate epidemiological data. It is difficult to estimate the true prevalence of mental disorder and plan effectively for mental health promotion and treatment without more rigorous, large-scale population-based studies. However the published research on mental disorders such as psychosis, depression, substance misuse and self-harm provides insights for future research on the cultural context of these disorders in Ghana, including risk factors, with important implications for clinical intervention and mental health promotion.

A major omission in the literature regards studies of the practice and efficacy of psychiatric treatment in Ghana. Given the scarcity of psychosocial interventions, psychotropic medication is the mainstay of treatment and has been the topic of four papers. 65 , 66 , 67 One study reports that adherence to medication is poor among many patients 68 suggesting the need for further research into the reasons for this, and methods by which to improve both access and adherence.

Most research in Ghana has been conducted by psychiatrists and there is very little published research by psychologists, psychiatric nurses and social workers. The only published study identified on counselling argued for consideration of notions of self-identity, as well as the influence of the multi-lingual post-colonial environment when importing talking therapies, 69 a topic which would benefit from further research. Multidisciplinary research is also needed on the particular social and psychological factors which play an important part in the aetiology and course of mental disorders within Ghana and how these might be addressed.

Research on beliefs and attitudes towards mental illness suggests that these influence not only help-seeking behaviour but also stigma, care-giving and social inclusion. Research in this area may not only point to the roots of stigma, social exclusion and human rights abuse, but also to potential resources for the support and social integration of those with mental disorders. Most importantly research on mental health in Ghana needs to focus on experiences of the mentally ill and their caregivers. Existing research suggests a high social, financial and psychological burden for patients and carers, 4 , 30 , 31 , 60 and further research in this area could provide a powerful tool to argue for greater attention to mental illness as a neglected public health concern.

The studies reviewed have been small in scale and of limited generalizability. Nonetheless, they provide important insights into the development of mental health care in Ghana, and suggest directions for future research. Based on this review we suggest the following priorities for mental health research in Ghana:

• Population-based epidemiological studies of mental disorders - including attention to shrines and churches.
• Research on mental disorders, in particular psychosis, substance use, depression, somatisation, and self-harm including risk factors, clinical picture, course and outcome.
• Outcome studies of interventions within psychiatric services, primary care and other service providers e.g. NGOs
• Experiences of people with mental illness and their family members, including the psychosocial and financial impact, help-seeking and treatment experiences.
• The practices of traditional and religious healers and potential for collaboration.

Evidently these topics call for both quantitative and qualitative methodologies across disciplines in both medicine and social science. However an important caveat remains as to who will conduct this research given the pressures on clinicians and the limited research expertise. For too long mental health research has been dominated by experts in high-income countries with the consequent risk of cultural bias.

There remains a need for capacity building among clinicians across all disciplines to conduct clinically-based research, and for researchers trained in psychiatric epidemiological methods. Collaboration with mental health researchers in Africa and elsewhere, including the Ghanaian diaspora is one suggestion. 70 Above all high quality large-scale research requires funding. Given the burden of mental illness suggested by existing research in Ghana and elsewhere in the region, there is a strong case for international funding for mental health research to provide an evidence-based foundation for targeted and culturally relevant interventions.

Recommendation 22 Literature Review Summary

• Mental health literacy encompasses knowledge about mental health symptoms, interventions, and resources available, as well as positive attitudes and willingness to intervene when others are struggling.
• Literacy campaigns targeted at mental health have been positively received in post-secondary institutions, though it is unclear how they might affect behavioural outcomes.
• Mental health training can improve knowledge, attitudes and self-efficacy. However, improvements often diminish over time, and it is unclear how actual gatekeeping behaviours are affected.
• Barriers to participating in training programs include lack of awareness, time constraints, resource limitations, and uncertainty about the benefits of training.

Literature Review Findings

Mental health literacy is broadly defined as knowledge of mental health symptoms, interventions, and resources available, as well as positive attitudes and self-efficacy toward helping others in need. Many students were aware of counselling services and symptoms related to depression, but fewer recognized other campus resources and types of mental health conditions. Health promotion and prevention of mental health issues were under-recognized; students only endorsed help-seeking actions when symptoms were severe. Additionally, students experiencing high levels of depression and distress were less likely to recognize symptoms of mental illness than others.

Various mental health literacy campaigns have been implemented in post-secondary settings. Feedback collected through focus groups and surveys tended to be positive, though response rates were often low and outcomes following exposure were minimal. Campaigns utilizing visual promotion materials are more effective when they are designed appealingly and with a student audience in mind. There is also a need for campaigns targeted at groups at higher risk of experiencing mental distress, such as LGBTQ+ and racialized student groups.

Mental health training programs are associated with short-term increases in self-reported knowledge, attitudes, and self-efficacy. However, there is mixed evidence supporting changes to actual behaviours; (quasi-)experimental studies found few differences in skills following training. Training programs that included components such as experiential learning exercises and scenarios tailored to post-secondary settings were the most effective at improving outcomes. Limitations of studies on training programs include low participation and response rates, lack of long-term follow-up assessments, and the use of instruments that have not been empirically validated.  

Faculty, staff and students described barriers to participating in training programs, such as lack of awareness about training opportunities, limited time and resources, and uncertainty about the benefits of training given the role of the person. Support from peers and leaders in the community was a strong enabling factor for participating in training.

Implications for Practice 

Mental health literacy campaigns need to be embedded into a larger policy and service framework that emphasizes health promotion and prevention as well as intervention and crisis management. Tailored campaigns for high risk groups, such as minority student populations and those experiencing high levels of mental distress, are recommended.

As part of a mental health literacy strategy, training programs need to be available to all members of the university community. Training programs that are specialized for post-secondary settings, incorporate experiential exercises, and which receive institutional resources and ongoing support, are likely to have the most impact.

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This paper is in the following e-collection/theme issue:

Published on 9.6.2020 in Vol 7 , No 6 (2020) : June

Peer Support in Mental Health: Literature Review

Authors of this article:

• Reham A Hameed Shalaby * , MD   ; 
• Vincent I O Agyapong * , MD, PhD  

Department of Psychiatry, University of Alberta, Edmonton, AB, Canada

*all authors contributed equally

Corresponding Author:

Reham A Hameed Shalaby, MD

Department of Psychiatry

University of Alberta

1E1 Walter Mackenzie Health Sciences Centre

8440 112 St NW

Edmonton, AB, T6G 2B7

Phone: 1 4034702050

Email: [email protected]

Background: A growing gap has emerged between people with mental illness and health care professionals, which in recent years has been successfully closed through the adoption of peer support services (PSSs). Peer support in mental health has been variously defined in the literature and is simply known as the help and support that people with lived experience of mental illness or a learning disability can give to one another. Although PSSs date back to several centuries, it is only in the last few decades that these services have formally evolved, grown, and become an integral part of the health care system. Debates around peer support in mental health have been raised frequently in the literature. Although many authors have emphasized the utmost importance of incorporating peer support into the health care system to instill hope; to improve engagement, quality of life, self-confidence, and integrity; and to reduce the burden on the health care system, other studies suggest that there are neutral effects from integrating PSSs into health care systems, with a probable waste of resources.

Objective: In this general review, we aimed to examine the literature, exploring the evolution, growth, types, function, generating tools, evaluation, challenges, and the effect of PSSs in the field of mental health and addiction. In addition, we aimed to describe PSSs in different, nonexhaustive contexts, as shown in the literature, that aims to draw attention to the proposed values of PSSs in such fields.

Methods: The review was conducted through a general search of the literature on MEDLINE, Google Scholar, EMBASE, Scopus, Chemical Abstracts, and PsycINFO. Search terms included peer support, peer support in mental health, social support, peer, family support, and integrated care.

Results: There is abundant literature defining and describing PSSs in different contexts as well as tracking their origins. Two main transformational concepts have been described, namely, intentional peer support and transformation from patients to peer support providers. The effects of PSSs are extensive and integrated into different fields, such as forensic PSSs, addiction, and mental health, and in different age groups and mental health condition severity. Satisfaction of and challenges to PSS integration have been clearly dependent on a number of factors and consequently impact the future prospect of this workforce.

Conclusions: There is an internationally growing trend to adopt PSSs within addiction and mental health services, and despite the ongoing challenges, large sections of the current literature support the inclusion of peer support workers in the mental health care workforce. The feasibility and maintenance of a robust PSS in health care would only be possible through collaborative efforts and ongoing support and engagement from all health care practitioners, managers, and other stakeholders.

Introduction

Peer support services (PSSs) are novel interventions recently adopted in mental health systems worldwide. It is believed, however, that PSSs date back to more than three centuries to the moral treatment era [ 1 ], albeit on an informal basis. Diverse definitions and classifications for PSSs have been provided in the literature [ 2 - 4 ], and numerous reports have praised and supported the service provided by peer support workers (PSWs) [ 5 - 8 ]. However, other literature suggests the neutral effects of PSSs, with weak associated evidence to support such services [ 9 , 10 ]. The potential impact of PSWs on their peers [ 11 - 14 ] has received considerable attention in the literature.

PSSs have been introduced in different contexts, such as family PSWs [ 15 - 19 ], the forensic field [ 20 , 21 ], and online PSSs. A considerable number of strategies were proposed to generate an effective PSS in the mental health field amid a number of associated concerns and challenges [ 22 - 25 ].

This general review sheds light on PSWs’ experiences, benefits, challenges, opportunities to expand access to quality addiction, and mental health care using PSSs. The review was conducted through a general search of the literature on MEDLINE, Google Scholar, EMBASE, Scopus, Chemical Abstracts, and PsycINFO. Search terms included peer support, peer support in mental health, social support, peer, family support, and integrated care. We began the review with an examination of the definitions, origins, and types of peer support contributions and within different clinical contexts, aiming at deepening the view to the diverse effects of such a workforce. We then continued with examining the transition from a patient role to a PSW role and their incorporation into mental health systems. Thereafter, we provided a conceptual framework for the effects of peer support and stigma in relation to PSWs. We concluded the review by examining the benefits and challenges associated with PSSs and provided a commentary on future directions for PSSs in mental health.

Definitions

Peer support has diverse meanings in the literature. For example, it is a system of giving and receiving help founded on key principles of respect, shared responsibility, and an agreement of what is helpful [ 26 ]. A peer is defined as an equal , someone with whom one shares demographic or social similarities, whereas support refers to “the kind of deeply felt empathy, encouragement, and assistance that people with shared experiences can offer one another within a reciprocal relationship” [ 3 ]. The Mental Health Foundation in the United Kingdom defined peer support in mental health as “the help and support that people with lived experience of a mental illness or a learning disability can give to one another” [ 27 ]. Peer employees were also defined as “individuals who fill designated unique peer positions as well as peers who are hired into traditional MH positions” [ 28 ]. In 1976, authors defined self-help groups as “voluntary small group structures for mutual aid in the accomplishment of a specific purpose...usually formed by peers who have come together for mutual assistance in satisfying a common need, overcoming a common handicap or life-disrupting problem, and bringing about desired social and/or personal change” [ 28 ]. Although the mutual relationship was sometimes overlooked and rather described as an asymmetric or nearly one-directional relationship [ 29 ], it is emphasized upon as 1 of the 4 main tasks for peer support accomplishments, which are mutuality, connection, worldwide, and moving toward rather than moving away [ 30 ].

Origin and Growth of Peer Support

Davidson et al [ 11 ] have expressed the paradigm that calls for new models of community-based practice, which turned away from case management and from conceptualizing old practices under new terms. In the 1990s, peer support was formally introduced as a service in community mental health care. However, there is evidence of its practice throughout history, including during the moral treatment era in France at the end of the 18th century [ 1 ]. Recently, peer support has been rapidly growing in many countries and could attract a considerable amount of research [ 22 ]. Although Lunatic Friends’ Society is known as the earliest peer support group in mental health, which was founded in England in the middle of the 19th century [ 31 ], self-help groups were described as the oldest and most pervasive of peer support types [ 28 ]. Some peer-run groups also formed in Germany in the late 19th century, which protested on involuntary confinement laws. In addition to this, several individuals in the 18th and 19th centuries publicized their protests about their treatment in autobiographies and petitions [ 32 ]. The origin of peer support even reaches further back than the earliest asylums [ 33 ]. Some authors suggest that peer support is not based on psychiatric models and diagnostic criteria [ 3 ]; however, it is about “understanding another’s situation empathically through the shared experience of emotional and psychological pain” [ 34 ]. In the United States, the start of legitimacy for peer support was ignited in 2007 by considering the conditions under which PSSs could be reimbursed by Medicaid [ 35 ]. Although this reform was entailing a recovery model, which has been adopted by health care providers and stakeholders in many “English-speaking” countries, it was not the case in many other countries, in which this reform was yet to be well formulated [ 36 ].

Transformational Concepts in Peer Support Service

Intentional peer support: informal to formal peer support evolution.

Intentional peer support (IPS) is described as a philosophical descendant of the informal peer support of the ex-patients’ movement in the 1970s [ 3 ]. It depends on a way of communication that immerses the provider into the recipient experience by stepping back from one’s story and being eagerly open to others’ stories [ 30 ]. In the field of psychiatry, trauma is blamed for playing a pivotal role in the experience, diagnosis, and treatment, and peer support is described as the logical environment for disseminating trauma-informed care (TIC) or service, which enables building relationships based on mutuality, shared power, and respect [ 37 ]. In the same context, trauma-informed peer support usually begins with the main question, “What happened to you?” instead of “What is wrong with you?” [ 30 ]. TIC is an explanatory model that identifies PSWs sharing lived experiences, ensuring safety and functioning as an advocate, and a liaison to patient management plans, where empowerment and intervention models are strongly emphasized upon [ 38 , 39 ]. The shift from a traditional biomedical model to recovery-oriented practice is meant to perceive trauma as a coping mechanism rather than a pathology [ 38 , 40 ]. This clearly entails training of all service providers for better acknowledgment and comfort in dealing with trauma survivors , with an understanding of trauma as an expectation rather than an exception [ 41 ]. Although the TIC concept has evolved over the years, it still lacks guidance, training, staff knowledge, and governmental support, which are necessary to ensure successful policy implementation [ 40 ]. The role of PSWs also extended to support those at risk of trauma events because of the nature of their work, including child protection workers, who are at risk of posttraumatic stress disorder or anxiety disorder [ 42 ]. Although IPS grew from the informal practices of grassroots-initiated peer support, it differs from earlier approaches because it is a theoretically based, manualized approach with clear goals and a fidelity tool for practitioners [ 14 ]. It instead focuses on the nature and purpose of the peer support relationship and its attention to skill building to purposefully engage in peer support relationships that promote mutual healing and growth [ 3 ]. Transitioning from informal to formal roles provides not only well-formulated expectations of the role but also a better chance to identify the potential conflict of the PSWs’ mixed identity [ 43 ].

Research conducted on PSWs has been conceptualized throughout history [ 22 ]. Starting with feasibility studies, at the initial stage, it is followed by studies comparing peer staff with nonpeer staff and, finally, the studies that answer questions such as the following:

• Do interventions provided by peers differ from those provided by nonpeers?
• What makes peer support a unique form of service delivery?

If so, to the previous question, what are the active ingredients of these aspects of peer support, and what outcomes can they produce?

Studies that provide answers to the latter set of questions are expected to provide a deeper understanding of the philosophical underpinnings of the IPS concept for PSSs.

The Transformation From Patient to Peer Support Providers

The shift from being a service recipient to a service provider has been contributing as a driving force to restore fundamental human rights, especially among those with serious mental illnesses (SMIs) [ 22 ]. Telling the personal lived experience leads to a profound shift, from telling an “illness story” to a “recovery story” [ 4 ]. This involved an identity transformation from being perceived as a victim or a patient to a person fully engaged in life with various opportunities ahead [ 4 ]. This transition is seen as a gradual process and one that is supported by several other personal changes with expected challenges [ 44 ]. Moving a full circle to include PSWs as the service provider has been undertaken by mental health services to further exceed the transformational role, which was primarily the main aim of providing such a service [ 45 ]. A liminal identity was given for PSWs as laying between several roles, being service users, friends, and staff. Thus, the professionalism of the PSW role might not be a successful way to ensure individual well-being or to promote the peer support initiative [ 46 ]. Thus, successful transitioning from the patient to PSW role involves fundamental functional shifts achieved through overcoming multiple barriers at the personal, health system, and societal levels.

Effects of Peer Support Service in Different Contexts

Trained PSWs or mentors can use communication behaviors useful to different client groups. Many studies showed the effectiveness and feasibility of applying for peer support as follows:

Severe or Serious Mental Illness

Generally, the evidence for peer support interventions for people with SMIs has been described as moderate to limited with mixed intervention effects [ 2 , 47 ]. On the one hand, adding PSSs to intensive case management teams proved to improve activation in terms of knowledge, skills, confidence, and attitudes for managing health and treatment. Hence, patients become healthier, report better quality of life (QOL), engage in more health care practices, and report more treatment satisfaction [ 48 , 49 ]. On the other hand, a systematic review of randomized controlled trials (RCTs) involving adults with SMIs, while showing some evidence of positive effects on measures of hope, recovery, and empowerment at and beyond the end of the PSS intervention in this review, did not show any positive effects on hospitalization, satisfaction, or overall symptoms [ 10 ]. Similarly, a Cochrane systematic review of PSSs for people with schizophrenia found inconclusive results, with a high risk of bias in most of the studies and insufficient data to support or refute the PSS for this group [ 50 ].

Addiction and Drug Users

In recent years, peer recovery support services have become an accepted part of the treatment for substance use disorders, providing a more extensive array of services that are typically associated with the mutual supportive intervention [ 51 ]. This is in contrast to the use of peer support for SMIs where evidence is still developing. The Substance Abuse and Mental Health Services Administration (SAMHSA) defined peer recovery support for substance use disorders as “a set of nonclinical, peer-based activities that engage, educate, and support individuals so that they can make life changes that are necessary to recover from substance use disorders” [ 51 ]. Despite the long-term nature of substance abuse, immersion in peer support groups and activities and active engagement in the community are considered the 2 critical predictors of recovery for more than half the dependent substance users [ 52 ].

A number of trials studied the peer support effect on drug users, especially in the emergency department [ 53 , 54 ]. Another randomized trial found that a socially focused treatment can affect change in the patient’s social network and hence increase support for abstinence, for example, an increase of one nondrinking friend in the social network is translated into a 27% increase in the probability of reporting abstinence on 90% of days or more at all follow-up visits, which extended to 15 months [ 55 ].

Forensic Peer Support Service

The forensic peer system refers to the engagement of peer specialists who have histories of mental illness as well as criminal justice involvement and who are trained to help other patients sharing similar accounts [ 20 ]. As referred to by Davidson and Rowe [ 20 ], “Forensic Peer Specialists embody the potential for recovery for people who confront the dual stigmas associated with SMI and criminal justice system involvement.”

They offer day-to-day support for those released early from jail by accompanying them to initial probation meetings or treatment appointments and referring them to potential employers and landlords, helping people to negotiate and minimize continuing criminal sanctions and training professional staff on engaging consumers with criminal justice history [ 20 , 21 ]. PSWs with incarceration histories could successfully identify the liminal space in being supportive rather than providing support for the criminal offense, in contrast with the conventional methods that directly confront criminality [ 56 ]. In fact, having criminal history is the “critical component” for achieving recovery [ 56 ]. Multiple initiatives have been introduced to facilitate a reentry process for people recently released from incarceration, including Forensic Assertive Community Treatment, Assertive Community Treatment, Critical Time Intervention, and Women’s Initiative Supporting Health Transitions Clinic, through diverse community support groups involving PSWs [ 57 , 58 ].

A peer support program undertaken by older community volunteers was effective in improving general and physical health, social functioning, depression parameters, and social support satisfaction, especially in socially isolated, low-income older adults [ 59 ]. The Reclaiming Joy Peer Support intervention (a mental health intervention that pairs an older adult volunteer with a participant) has the potential for decreasing depression symptoms and improving QOL indicators for both anxiety and depression [ 60 ]. Engaging the community in health research could be of a high value in acknowledging their own health needs [ 61 ].

Youth and Adolescents

Peer support programs are mostly needed for university students, where challenges with loneliness and isolation are well recognized [ 62 ]. Hence, a need emerged for training peers to support their peer adolescents with the prospective challenges at this age [ 63 ]. Trained peer support students without necessarily having a lived experience were also examined in England [ 64 ]. The study included university students measuring the acceptability and impact of the volunteer peer support program through 6 weekly sessions. Students with lower mental well-being were more likely to complete the course, and an improvement in mental well-being was recorded for those who attended more frequently. Overall, peers remain to be an essential source of support for young people experiencing mental health and substance use problems [ 65 ].

Medically and Socially Disadvantaged Subgroups

A peer-led, medical self-management program intervention has been beneficial for medically and socially disadvantaged subgroups [ 60 ]. The Reclaiming Joy Peer Support intervention has the potential for increasing QOL and reducing depression in low-income older adults who have physical health conditions [ 60 ]. Similarly, for those who are “hardly reached,” it was indicated that the PSS provided is even more effective in these marginalized populations [ 66 ]. A Health and Recovery Peer program was delivered by mental health peer leaders for people with SMIs, resulting in an improvement in the physical health–related QOL parameters such as physical activity and medication adherence [ 49 ]. Peer-delivered and technology-supported interventions are feasible and acceptable and are associated with improvements in psychiatric, medical self-management skills, QOL, and empowerment of older adults with SMIs and or chronic health conditions [ 67 , 68 ].

Persons With Disabilities

The United Nations’ Convention on the Rights of Persons with Disabilities (CRPD) was adopted in 2007 and stated that “persons with disabilities should have equal recognition before the law and the right to exercise their legal capacity” [ 69 - 71 ]. Therefore, a positive emphasis upon the supported decision making and the fight against discrimination is evident through the convention. Nevertheless, these initiatives have been perceived as incomplete considering many challenges such as the community social status and ongoing perceived stigma of people with disabilities (PWDs) [ 70 , 72 ]. “Circle of support” is an elaborate example of an applicable peer support model for PWDs that has helped in decision making and facilitating communication [ 70 , 73 , 74 ]. This is clearly aligned with the paradigm shift from the biomedical to the socially supportive model of disability, which was provided by CRPD [ 70 ].

Peer Support for Families

Families may act either as sources of understanding and support or stigmatization through ignorance, prejudice, and discrimination, with subsequent negative impact [ 19 ]. In addition, the distress and burden associated with caring for a family member with mental illness are evident, where 29% to 60% endure significant psychological distress [ 17 ]. Family support can be financial or emotional; however, moral support was perceived as the substantial motivating factor for relatives who are ill [ 19 ]. In the last few decades, consistent and growing evidence that supports the inclusion of family members in the treatment and care of their misfortunate relatives has been developed. This has been mainly evident in the youth mental health system that urged the transformation change, which incorporates family members in the health care service provided to their youth [ 18 , 75 ]. Many PSWs have been engaged in family psychoeducation as family peers or parent partners, especially for those with the first episode of psychosis [ 76 ]. Although familial education is crucial and needs to be provided through different scales [ 19 ], an extensive matching of PSWs and the caregivers has not been perceived as a necessity to create a successful volunteer mentoring relationship [ 77 ]. Multiple initiatives have taken place all over the world. In India, a program titled “Saathi” was established for family members of residential and outpatient mental health service users that had dual goals of offering information and developing a peer support mechanism for family members of people with different mental health conditions [ 19 ]. In Melbourne, Australia, “Families Helping Families” was developed, where family PSWs are positioned in the service assessment area and in the inpatient unit to ensure early involvement [ 18 ]. An impressive peer support guide for parents of children or youth with mental health problems is provided by the Canadian Mental Health Association, British Colombia Division [ 15 ]. In Ontario, family matters programs are provided through provincial peer support programs [ 16 ].

The term “transforming mental health care” entails active involvement of families in orienting the mental health system toward recovery [ 78 ]. Family members are to have access to timely and accurate information that promotes learning, self-monitoring, and accountability [ 79 ]. The inclusion of family members as partners of the medical service is the new philosophy, with a subsequent shift from the concept of clinic-based practice to a community-based service approach [ 78 ].

Peer Support Service in Low- and Middle-Income Countries

Several initiatives took place in low- and middle-income countries, such as in rural Uganda, where a trained peer-led team provided 12 successful training sessions of perinatal service for a group of parents over a 6-month period, which resulted in better maternal well-being and child development, compared with another control group [ 80 ]. Similarly, successful community peer groups were conducted in rural India and Nepal, with high feasibility and effectiveness rates, and perceived as “potential alternative to health-worker-led interventions” [ 81 - 83 ]. In addition, adding counseling and social support groups entailing PSWs to the conventional medication treatment for patients with psychotic disorders was tried in a cohort study in Uganda; however, the results were not significantly different from those who received only medications [ 84 ]. This might be because of the underpowering of community services offered, compared with the robust medication regimens [ 85 ].

It is evident from the aforementioned information that there is mixed evidence on the effectiveness of PSW interventions in different contexts. For example, for patients with SMIs, systematic reviews suggest that there is some evidence of positive effects on measures of hope, recovery, and empowerment but no positive effects on hospitalization, satisfaction, or overall symptoms [ 10 ]. Similarly, for patients with addiction issues, although being involved in a peer network did not reduce social assistance for alcohol, they somewhat increased behavioral and attitudinal support for abstinence as well as involvement with Alcoholics Anonymous [ 55 ]. Furthermore, although many observational studies support the PSW role in the other contexts described above, there is a current dearth of literature involving RCTs and systematic reviews reporting on the effectiveness of PSWs in these specific contexts. Thus, there exist opportunities for conducting RCTs in the described contexts.

The Conceptual Framework for the Effects of Peer Support Service

The conceptual framework is based on empirical evidence, suggesting that the impact of PSWs reflects upon the recipients of such a service [ 4 , 76 , 86 - 90 ], the global health system [ 22 , 47 , 76 , 86 , 91 , 92 ], and the PSWs themselves [ 13 , 28 , 76 , 93 ], as shown in Figure 1 . The framework has, therefore, been developed by authors through a general review of the literature that examines the effects of PSSs on patients, health care systems, and also PSWs themselves so as to provide evidence-based material supporting all possible effects of PSW roles.

Supportive social relationships can have a dual opposing effect on individuals’ lives, either as a family member or as social and professional networks through sharing their disappointments and pains or their joy and successes [ 11 ]. Useful roles for PSSs are identified in many studies. For example, adding 3 peer specialists to a team of 10 intensive case managers provided better QOL with greater satisfaction [ 12 ], stigma reduction, and less health service utilization [ 89 , 91 ]. The economic impact of PSSs has been extensively studied in the literature, concluding cost containment for the health care system in terms of reduction of readmission rates, emergency visits, and fewer hospital stays, which altogether substantially exceed the cost of running a peer support program [ 92 ]. Moreover, PSWs are looked at as providers of a service at a cheaper cost compared with other health care providers [ 94 , 95 ]. For example, about US $23,000 is paid to PSWs in the United States compared with around US $100,000 for a nurse practitioner [ 96 ]. However, a PSS is not posited as a substitute for clinical services, rather it is perceived as an intrapersonal and social service that provides a dual role of effective service and with humanizing care and support [ 14 , 26 , 97 ]. This role extends to cover PSWs themselves, in terms of improved overall well-being and self-confidence, reframing identity, and enhancing responsibility either toward themselves or their peers [ 13 , 93 ].

Although PSWs can play a variety of tasks, managers who hire them may want to ensure that improving patient activation is included in their range of duties [ 48 ]. In 2 concurrent studies, a significant increase in QOL satisfaction, reduction of rehospitalization rates, and reduction in the number of hospital days were recorded when adding PSSs to usual care [ 22 , 98 ]. In another study engaging 31 peer providers in diverse mental health, agencies identified 5 broad domains of wellness, including foundational, emotional, growth and spiritual, social, and occupational wellness [ 4 ]. In a systematic literature review for people with SMIs, peer-navigator interventions and self-management were the most promising interventions [ 47 ]. PSWs’ effects are diversified through sharing in different contexts. For example, positive impacts on the physical health of their peers have been recorded [ 49 ]. Peer-based approaches have been used to deliver behavioral weight loss interventions [ 90 ]. For young students, structured peer support for depression may have benefits in improving students’ mental well-being [ 64 ]. In the case of crisis houses, greater satisfaction was achieved through a provided informal PSS [ 99 ]. Robust studies, therefore, recommend implementing peer support programs [ 10 , 18 ].

On the other hand, authors found that PSSs met moderate levels of evidence and that effectiveness varied across service types, for example, with “peers in existing clinical roles” was described as being less effective than the “peer staff added to traditional services” and “peer staff delivering structured curricula” [ 3 ]. Other reviews suggested that current evidence does not support recommendations or mandatory requirements from policy makers to offer programs for peer support [ 9 , 10 ].

Peer Support Workers’ Satisfaction and Challenges

PSWs experience different problems alongside their diverse job roles, including low pay, stigma, unclear work roles, alienation, struggling with skill deficits, lack of training opportunities, emotional stress in helping others, and, on top of that, maintaining their personal physical and mental health wellness [ 100 , 101 ]. Researchers found that PSWs experience discrimination and prejudice from nonpeer workers, in addition to the encountered difficulties of how to manage the transition from being a patient to a PSW. As a result, high attrition rates were noted among PSWs in mental health settings [ 102 , 103 ]. Peer job satisfaction is strongly dependent on several factors [ 100 , 104 , 105 ]. Role clarity and psychological empowerment, organizational culture, and working partnership with peers were the most significant predictors of PSW job satisfaction, while professional prejudice was not perceived as a significant predictor [ 106 , 107 ]. Other studies noted that the main problems were experiencing marginalization, lack of understanding, and a sense of exclusion [ 108 - 110 ]. Payment could also contribute to the amount of satisfaction of PSWs [ 76 ], as compensation helps through facilitation and engagement motivation [ 109 ]. Nevertheless, it seems that not the payment, which ranged from US $10 to US $20 per hour, but the lack of recognition and acknowledgment are the causes for job nonsatisfaction [ 104 ].

An interesting literature review grouped these challenges and barriers facing PSWs during fulfilling their assigned roles into 6 main categories: nature of the innovation, individual professional, service user, social context, organizational context, and economic and political contexts [ 111 ].

It is evident from the abovementioned information that the PSW role is challenged at multiple levels, including at the personal, societal, and organizational levels. These challenges have a direct bearing on PSW satisfaction, and the successful integration of the PSW role into the health care system depends to a great extent on how these challenges are overcome.

Novel Technology in Peer Support Service (Online and Telephone)

Online support groups are usually conducted through bulletin boards, emails, or live chatting software [ 28 ]. Online groups are familiar with people whose illnesses are similar to SMIs or affecting the body shape that have forced them to experience embarrassment and social stigmatization [ 23 , 24 ]. Therefore, they split from the social contexts and redirect toward novel ways of help, such as PSWs and online support groups, and web-based communities provided a suitable medium for people with SMIs by following and learning from their peers on the web, which positively helped them to fight against stigma, instilling hope and gaining insight and empowerment for better health control [ 25 ]. Increasingly, social media grew as a target for individuals with SMIs, such as schizophrenia, schizoaffective disorder, or bipolar disorder, seeking advice and supporting each other [ 112 - 114 ]. For someone with SMIs, the decision to reach out and connect with others typically occurs at a time of increased instability or when facing significant life challenges [ 115 ]. In a qualitative study, popular social media, such as YouTube, appeared useful for allowing people with SMIs to feel less alone, find hope, support each other, and share personal experiences and coping strategies with day-to-day challenges of living with mental illness through listening and posting comments [ 114 ]. Mobile phone–based peer support was found to be a feasible and acceptable way to the youngsters during their pregnancy as well as in the postpartum period [ 116 ]. In addition, when coupled with frequent face-to-face meetings with PSWs and with “text for support,” it could be of high value for patients with different mental illnesses [ 117 ]. Although online peer networks actively fight against discrimination and stigma, their accessibility to diverse patients’ sectors regarding their income and ethnicity is still questionable [ 25 ].

Future of Peer Support Services

Potential new roles, such as community health workers, peer whole health coaches, peer wellness coaches, and peer navigators, have been suggested for such a workforce [ 76 ]. They are described as an “ill-defined potential new layer of professionals” [ 118 ]. Through an initiative undertaken by SAMHSA via its “Bringing Recovery Supports to Scale Technical Assistance Center Strategy,” a successful identification of abilities and critical knowledge necessarily required for PSWs who provide help and support for those recovering from mental health and substance abuse was noted [ 76 ]. At present, peer support is seen as a growing paradigm in many countries, including the United Kingdom, Canada, New Zealand, France, and the Netherlands [ 103 , 119 ]. As an evolving culture, peer support has the opportunity to forge not just mental health system change but social change as well [ 37 ]. A novel peer support system termed “Edmonton peer support system” (EPSS) is currently being tested in a randomized controlled pilot trial [ 117 ]. In this study, investigators are evaluating the effectiveness of an innovative peer support program that incorporates leadership training, mentorship, recognition, and reward systems for PSWs, coupled with automated daily supportive text messaging, which has proven effectiveness in feasibility trials involving patients with depression and alcohol use disorders [ 120 , 121 ]. Previous studies have examined the effect of PSSs in different contexts, including outpatient departments [ 122 ], emergency departments [ 53 , 54 ], community mental health clinics [ 123 , 124 ], and inpatient sites [ 125 ]. On the contrary, the EPSS study focuses on patients who have been discharged from acute care hospitals. These patients are being randomized into 1 of the 4 main groups: enrollment in a peer support system, enrollment in a peer support system plus automated daily supportive and reminder text messages, enrollment in automated daily supportive and reminder text messages alone, or treatment as usual follow-up care. The research team hypothesizes that patients who are assigned to a peer support system plus automated daily supportive and reminder text messages will show the best outcome.

Organizations may facilitate peer support through their values, actions, and oversight [ 119 ] and through a robust supervision system with available educational access, which could be the adequate path for creating a positive and risk-free environment for PSWs throughout their complex workloads [ 126 ]. On the other hand, ethics committees play essential roles in the inclusion of PSWs in applied research studies by avoiding repetition of the work of other trusted agencies and considering the ethical validity of consent procedures for peer support interventions [ 127 ].

There is an internationally growing trend to adopt PSSs within addiction and mental health services, and despite the ongoing challenges, large sections of the current literature support the inclusion of the PSWs into the mental health care workforce. The literature suggests that the benefits of PSSs impact not only the recipients of mental health services but also extend to the PSWs and the whole health care system. Although the expected benefits of PSSs might be directly measured in terms of service utilization or patient improvement indicators, this could also extend to include wellness and empowerment for PSWs, who may still be fragile, vulnerable, and in need of ongoing acknowledgment and recognition. Thus, the potential for PSSs to be embedded into routine care and the opportunities for the development of innovative models of care for addiction and mental health patients such as the EPSS, which incorporates PSSs and supportive text messaging [ 117 ], are evidently a high valued priority. However, the feasibility and maintenance of a robust PSS in health care would only be possible through collaborative efforts and ongoing support and engagement from all health care practitioners, managers, and other stakeholders.

This literature review has several limitations. First, the review is not a systematic review or meta-analysis, and as such, there were no well-defined inclusion or exclusion criteria of studies, which potentially could lead to the exclusion of some essential related studies. Second, the search was conducted in English publications only. Consequently, there is a high probability of missing critical related publications published in non-English languages. Finally, as the review depended mainly on the available literature from the aforementioned sources, which showed marked variability in their design and covered diverse ideas under the central theme, the different weights for each idea throughout the review could be noted.

Acknowledgments

This work was supported by Douglas Harding Trust Fund and Alberta Health Services.

Conflicts of Interest

None declared.

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Abbreviations

Edited by J Torous; submitted 21.07.19; peer-reviewed by F Mahomed, K Machin; comments to author 27.07.19; revised version received 06.09.19; accepted 15.02.20; published 09.06.20

©Reham A Hameed Shalaby, Vincent I O Agyapong. Originally published in JMIR Mental Health (http://mental.jmir.org), 09.06.2020.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Mental Health, is properly cited. The complete bibliographic information, a link to the original publication on http://mental.jmir.org/, as well as this copyright and license information must be included.

• Research article
• Open access
• Published: 01 May 2020

A systematic literature review of existing conceptualisation and measurement of mental health literacy in adolescent research: current challenges and inconsistencies

• Rosie Mansfield   ORCID: orcid.org/0000-0002-8703-5606 1 ,
• Praveetha Patalay 2 &
• Neil Humphrey 1  

BMC Public Health volume  20 , Article number:  607 ( 2020 ) Cite this article

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With an increased political interest in school-based mental health education, the dominant understanding and measurement of mental health literacy (MHL) in adolescent research should be critically appraised. This systematic literature review aimed to investigate the conceptualisation and measurement of MHL in adolescent research and the extent of methodological homogeneity in the field for meta-analyses.

Databases (PsycINFO, EMBASE, MEDLINE, ASSIA and ERIC) and grey literature were searched (1997–2017). Included articles used the term ‘mental health literacy’ and presented self-report data for at least one MHL domain with an adolescent sample (10–19 years). Definitions, methodological and contextual data were extracted and synthesised.

Ninety-one articles were identified. There was evidence of conceptual confusion, methodological inconsistency and a lack of measures developed and psychometrically tested with adolescents. The most commonly assessed domains were mental illness stigma and help-seeking beliefs; however, frequency of assessment varied by definition usage and study design. Recognition and knowledge of mental illnesses were assessed more frequently than help-seeking knowledge. A mental-ill health approach continues to dominate the field, with few articles assessing knowledge of mental health promotion.

Conclusions

MHL research with adolescent samples is increasing. Results suggest that a better understanding of what MHL means for this population is needed in order to develop reliable, valid and feasible adolescent measures, and explore mechanisms for change in improving adolescent mental health. We recommend a move away from ‘mental disorder literacy’ and towards critical ‘mental health literacy’. Future MHL research should apply integrated, culturally sensitive models of health literacy that account for life stage and acknowledge the interaction between individuals’ ability and social and contextual demands.

Peer Review reports

Around 50% of mental health difficulties have their first onset by age 15 [ 1 , 2 ] and are associated with negative outcomes such as lower educational attainment and physical health problems [ 3 ]. Approximately 10–20% of young people are affected worldwide, and many more will experience impairing mental distress at varying degrees across the mental health continuum [ 4 , 5 , 6 , 7 , 8 ]. Adolescence is a critical period of transition, characterised by physical, cognitive, emotional, social and behavioural development [ 9 ]. It has therefore been identified as a particularly important developmental phase for improving ‘mental health literacy’ (MHL) and promoting access to mental health services [ 10 , 11 ]. However, better understanding of the conceptualisation and measurement of MHL in this population is needed.

MHL was first defined as ‘ knowledge and beliefs about mental disorders which aid their recognition, management or prevention’ ( [ 12 ] pp 182) and consisted of six domains: ‘1) the ability to recognise specific disorders or different types of psychological distress; 2) knowledge and beliefs about risk factors and causes; 3) knowledge and beliefs about self-help interventions; 4) knowledge and beliefs about professional help available; 5) attitudes which facilitate recognition and appropriate help-seeking, and 6) knowledge of how to seek mental health information’ ( [ 13 ] pp 396). Domains were later revised to include early recognition, prevention and mental health first aid skills [ 14 ]. The most recent definition comprises four broad domains aligned with current definitions of health literacy: ‘1) understanding how to obtain and maintain positive mental health; 2) understanding mental disorders and their treatments; 3) decreasing stigma related to mental disorders, and 4) enhancing help-seeking efficacy (knowing when and where to seek help and developing competencies designed to improve one’s mental health care and self-management capabilities’ ( [ 15 ] pp 155).

In a review of MHL measurement tools, O’Connor et al. revealed that the most commonly assessed domain was recognition of mental disorders. No studies assessed either knowledge of how to seek information or knowledge of self-help interventions [ 16 ]. The focus on recognition of mental disorders, along with knowledge about risk factors, causes and appropriate treatments, has been criticised for promoting the psychiatric and biogenetic conceptualisation of mental illness [ 17 , 18 ]. Despite being found to reduce blame, biogenetic explanations and attributions can lead to misconceptions about dangerousness and unpredictability and pessimism about recovery [ 19 ]. Early research also suggested that biogenetic causal theories increase a desire for social distance [ 20 , 21 ]. MHL modelled on recognition of psychiatric labels, and diagnostic language such as ‘disorder’, often leads to psychosocial predictors being ignored, and more negative attitudes towards individuals experiencing mental distress [ 22 , 23 ].

These criticisms, in line with broader socio-cultural approaches to literacy [ 24 ] understand MHL as a socio-political practice used to communicate, and make dominant, the psychiatric discourse. This appears to undermine attempts to reduce stigma, the most common outcome of school-based MHL interventions [ 25 ]. In their review of MHL measurement tools, O’Connor et al. excluded all disorder specific scales, claiming that ‘ MHL by definition should encompass knowledge and attitudes relating to a range of mental health disorders and concepts .’ ( [ 16 ] pp 199). Chambers et al. further criticised current MHL definitions for being narrow in focus with a predominantly mental-ill health approach, ignoring the complete mental health state that goes beyond the dichotomy of illness and wellness [ 26 , 27 ]. The difference between literacy about mental disorders and the ability to seek out, comprehend, appraise and apply information relating to the complete mental health state is an emerging point of discussion, and has seen MHL re-defined to include self-acquired knowledge and skills relating to positive psychology [ 28 , 29 ]. This aligns with the World Health Organisation’s (WHO) definition of mental health, which includes subjective wellbeing, optimal functioning and coping, and recognises mental health beyond the absence of disorder [ 30 ].

In response to increasingly inclusive definitions of MHL, Spiker and Hammer presented the argument for MHL as a ‘multi-construct theory, rather than a multi-dimensional construct’ ( [ 31 ] pp 3). The proposal suggested that by stretching the MHL construct, researchers have reduced the consistent use of the definition across studies, resulting in heterogeneous measurement [ 32 ]. Reviews of the psychometric properties of MHL measurement tools support this argument, and conclude that more consistent measurement with valid scales is needed [ 33 , 34 , 35 , 36 ]. Spiker and Hammer also outline problems with construct irrelevant variance [ 31 ], in which measures capture more than they intended to. Furthermore, they note that construct proliferation or the ‘jingle jangle fallacy’ [ 37 ], in which scales may have different labels but measure the same construct, and vice versa, increase problems with discriminant validity. Understanding MHL as a multi-construct theory could help delineate between its broad domains: recognition, knowledge, stigma and help-seeking beliefs, and acknowledge their complexity.

Internationally, there is growing political interest in child and adolescent mental health promotion and education [ 6 , 38 ]. Despite limited evidence, it is suggested that educating the public by improving their ability to recognise mental disorders, and increasing help-seeking knowledge, can promote population mental health [ 39 , 40 ]. Furthermore, a reduction in stigmatising attitudes is consistently reported to improve help-seeking [ 41 , 42 ]. MHL, by definition, includes these interacting domains. However, despite a comprehensive set of reviews that assess the psychometric properties of MHL measurement tools [ 33 , 34 , 35 , 36 ], there is no systematic literature review, to date, that assesses the current conceptualisation and measurement of MHL across adolescent research. Being able to clearly operationalise what is meant by a MHL intervention and meta-analyse their effectiveness, will have implications for the investment in school and population level initiatives. Similarly, being able to conduct time trend analyses that plot possible improvements in adolescents’ MHL against mental health outcomes, will reveal the extent to which population level improvements in MHL promote mental health. First though, we must have a clear picture of the understanding of MHL in adolescent research and how it is currently being measured.

Objectives and research questions

The aim of the current study was therefore to examine the ways in which MHL has been conceptualised and measured in adolescent research to date, and explore the extent of methodological homogeneity in the field for meta-analyses. We set out to answer the following research questions: 1) What are the most common study designs, contexts, and aims? 2) How is MHL conceptualised? 3) What are the most commonly measured domains of MHL, and do these vary by study design and definition usage? 4) To what extent do articles use measures that have evidence of validity for use with adolescent samples? 5) Is there enough methodological homogeneity in the field to conduct meta-analyses?

A protocol was published on PROSPERO in December 2017 (reference: CRD42017082021 ), and was updated periodically to reflect the progress of the review. Relevant PRISMA guidelines for reporting were followed [ 43 ].

Eligibility criteria

Articles were included with adolescent samples aged between 10 and 19 [ 44 ]. Samples with a mean age outside of this range were excluded. If no mean was presented and the age range fell outside of the criterion, articles were only included if results were presented for sub-groups (e.g. 12–17 years from a sample aged 12–25). General MHL and diagnosis-specific literacy research was included. Articles with quantitative study designs and extractable self-report data for at least one time point measurement of any MHL domain were eligible. These criteria ensured that only articles with extractable data from adolescents, who had not yet received any form of intervention were included. At the full text screening phase, articles published before 1997, based on the date of the first MHL definition [ 12 ], and those that did not explicitly use the term ‘mental health literacy’ or a diagnosis-specific equivalent (e.g. ‘depression literacy’) were excluded. By applying this criterion, the current study was able to present the number of articles that measured domains without referring to MHL. Identifying cases where researchers measure the same construct but use different labels is important when considering conceptualisation and meta-analyses.

Only articles available in English were included. Specific populations such as clinical/patient populations and juvenile offenders were excluded, as were university students. In contrast to schools in most countries, universities are not universal, with only a sub-set of young people entering higher education. University samples were therefore not seen as representative and often included participants outside the age criterion. Post-partum and later life neurocognitive disorders (e.g. Alzheimer’s disease) were removed given their limited relevance for this age group. In line with other MHL reviews [ 33 ], articles with a focus on substance abuse were excluded to avoid reviewing a large number of adolescent risk behaviour studies and substance abuse prevention programmes.

Search strategy

The search strategy was developed to include a number of combinations of terms to ensure that literature relating to different domains of MHL were captured. Population terms such as ‘adolescen*’ or ‘young people*’ had to be present and mental health related terms (e.g. ‘mental health’ and ‘mental disorders’) were exploded to capture general MHL and diagnosis-specific studies. Similarly, outcome terms (e.g. ‘health literacy’ and ‘health education’) were exploded, and domain specific terms included (e.g. ‘knowledge’, ‘recogni*’, ‘attitud*’, ‘stigma*’, ‘help-seek*’, ‘prevent*’ or ‘positive*’). See Additional File 1 . for an example search strategy.

Data sources

The following databases were searched from their start date to the search dates (November 2017): PsycINFO, EMBASE, MEDLINE, ASSIA, and ERIC. Key authors were also contacted to identify grey literature. References were harvested from related reviews and all papers identified in the search. Hand searches of key authors’ publication lists were also conducted, and Google Scholar was used to find studies known by the authors but not identified in the database searches.

Article selection

Results from the database searches were saved to Endnote and duplicates were removed. The lead author screened the article titles and abstracts to identify those that met the inclusion criteria. Full texts were then screened and reasons for exclusion were recorded. Any uncertainties were resolved through discussion with other members of the research team. A sub-set of 20 articles were screened at full text stage by the third author, and a strong level of agreement was found (k = .78, p  = .001).

Data extraction

Research was assessed on an article level (rather than by study) for the purposes of investigating the conceptualisation of MHL. The fact that authors break MHL down into component parts to write separate articles is support for identifying which domains are more commonly associated with the use of the term. Data on the following methodological factors were extracted from eligible articles using a uniform data extraction form: year of publication, country and setting (community (research conducted outside of the school setting e.g. population level surveys) vs. school-based research), study design (intervention vs. population-based), primary aims, MHL definition and use of the term, general MHL vs. diagnosis-specific literacy, number/types of MHL domains measured, and measurement tools (e.g. vignette, yes/no, Likert scales).

Data analysis

A content analysis was conducted using NVivo 12 to organise articles by their primary aim and understand the conceptualisation of MHL based on the definition presented and use of the term. Frequencies and percentages for each group were calculated and articles coded based on whether they included items related to general MHL or diagnosis-specific literacy. Existing definitions of MHL [ 12 , 13 , 14 , 15 , 28 ] were used to create a coding framework that clearly delineated its broad constituent domains (e.g. recognition, knowledge, stigma and beliefs), the object of these domains (e.g. mental illnesses, mental health prevention and promotion, and help-seeking), and their directionality (e.g. self vs. other) – see Fig.  1 .

MHL Coding Framework

Mental illness stigma was assessed using existing conceptualisation i.e. personal and perceived stigma relating to self (intra-personal) and others (inter-personal), and broad domains (e.g. attitudes and beliefs, emotional reactions, and social distancing) [ 45 ]. The coding of help-seeking beliefs was informed by the theory of planned behaviour [ 46 ], assessing not only help-seeking intentions but also help-seeking confidence and self-perceived help-seeking knowledge, perceived helpfulness of referrals, help-sources and treatments, help-seeking stigma and perceived help-seeking barriers. A distinction was also made between help-seeking beliefs for self (intra-personal) vs. others (inter-personal). Although not explicitly included in any MHL definition, help-seeking behaviour was also assessed as the term is sometimes confused with help-seeking intentions. Domains were coded at an item level due to many articles presenting this form of data (e.g. % of sample that answered each item correctly as opposed to a scale mean). Frequencies and percentages were produced across all articles and by study design and definition usage.

Assessment of measures

An assessment of all MHL related measurement tools was conducted in order to assess methodological homogeneity across articles, and whether there was evidence that the measures were psychometrically valid for adolescent samples. In order to present instruments with the most comprehensive psychometric assessments, measures were coded based on whether an article existed with the primary aim of establishing its psychometric properties with an adolescent sample.

Article selection and characteristics

In total, 206 articles were identified that presented extractable adolescent data on at least one MHL domain. Of these, 91 articles (44%) used the term ‘mental health literacy’. Those that did not use the term ( N  = 115, 56%), were therefore not perceived to have intended to explicitly measure the construct and were not included beyond this point. (see Fig.  2 . for a PRISMA flowchart of articles, Additional File 2 . for the full set of coded articles, and Additional File 3 . for the reference list of included articles).

PRISMA Flowchart of Included Studies

Synthesised findings

Design, context and aims.

Figure  3 shows the number of publications by year and country. Australian research dominated the field up until 2013, at which point there was an increase in research being published globally. Australia (34%), USA (15%), Canada (9%), Republic of Ireland (9%) and the UK (8%) have published the majority of research between 2003 and 2017.

Publication Count by Year and Country

Table  1 presents a summary of articles’ study design, context and primary aim. The majority of articles reported on school-based studies. Articles with the primary aim of describing levels of MHL also included variables such as age, school year, gender, education, socio-economic variables, occupation, urbanicity, mental health status and previous mental health service use.

• Conceptualisation

Of the 91 articles that used the term ‘mental health literacy’, only 41 (45%) defined it. The most common definition, presented by 29 out of 41 (71%) articles, was that coined by Jorm and colleagues [ 12 ]. A further 3 articles (7%) used a simplified or adapted version of this definition [ 47 , 48 , 49 ]. Four articles (10%) defined MHL as related to knowledge only (e.g. ‘knowledge of mental health problems as well as the sources of help available’ ; ( [ 50 ] pp. 485) . The full list of MHL domains presented by Jorm and colleagues [ 13 ], was included in over a third ( N  = 14, 34%) of articles that defined the term. However, there was some variation. For example, very few of these articles ( N  = 2, 14%) referred to different types of psychological distress as well as mental disorders when presenting the recognition domain. Furthermore, in most cases ( N  = 11, 79%), ‘knowledge and beliefs’ was replaced with ‘knowledge’ only, for domains relating to causes and risk factors, self-help strategies and professional help available.

A small number of articles that defined MHL ( N  = 5, 12%) presented Jorm’s additional domains relating to mental health first aid skills and advocacy [ 14 ]. Some articles ( N  = 4, 10%) provided examples of specific MHL domains, namely recognition of mental disorders and knowledge and beliefs about appropriate help-seeking and treatment, as opposed to presenting a comprehensive list. An emerging group of articles ( N  = 5, 12%) either acknowledged mental health promotion as a component of MHL or presented Kutcher and colleagues’ four broad domains including ‘understanding how to obtain and maintain good mental health’ ( [ 15 ] pp 155).

Regardless of whether a definition was provided, approximately one third of identified articles ( N  = 31, 34%) referred to MHL as a construct separate to mental illness stigma, with some suggesting that MHL predicts stigma. For example, articles described the measurement of these constructs as separate (e.g. ‘All respondents were then asked a series of questions that assessed sociodemographic characteristics, mental health literacy, stigma …’; ([ 51 ] pp. 941), and referred to or presented a relationship between the two constructs (e.g. ‘Participants with higher MHL displayed more negative attitudes to mental illness’ ; ( [ 52 ] pp. 100) . There were also instances where articles presented MHL as a predictor of help-seeking intentions and attitudes (e.g. ‘Studies indicate that in general, mental health literacy improves help seeking attitudes’ ; [ 53 ] (pp. 2), or used the term MHL to refer only to improved knowledge (e.g. ‘to assess the extent to which the students had learned the curriculum and developed what we called ‘depression literacy’ ; ([ 54 ] pp. 230).

• Measurement

Thirty-nine (43%) articles included items relating to general MHL. The exact terminology varied across studies e.g. mental disorder [ 55 ], mental illness [ 56 ], mental health problem [ 57 ], and mental health issue [ 58 ]. Few articles included items relating to mental health as opposed to mental ill-health. Bjørnsen et al. developed and validated a scale to assess adolescents' knowledge of how to obtain and maintain good mental health [ 28 ]. Kutcher et al. and McLuckie et al. also included an individual knowledge item that assessed an understanding of the complete mental health state (e.g. ‘People who have mental illness can at the same time have mental health’ ) [ 59 , 60 ].

Table  2 . presents the frequency and percentage of articles that assessed different types of diagnosis-specific literacy. In line with this focus, 57 (63%) articles utilized a vignette methodology, basing questions on descriptions, stories and scenarios relating to an individual meeting diagnostic criteria for a given mental disorder. Of these articles, 12 (21%) used comparator vignettes describing individuals with physical health problems (e.g. asthma or diabetes), control characters with good academic attainment, or ‘normal issues’ or mental health problems relating to stressful life events (e.g. the death of an elderly relative or the end of a romantic relationship). Table  3 . presents the frequency and percentage of articles that assessed different domains of MHL.

Measurement tools were too heterogeneous to conduct meta-analyses. As noted in Table 1 , four articles (4%) had the primary aim of validating MHL related measures with adolescent samples [ 28 , 55 , 61 , 62 ]. The scales assessed in Bjørnsen et al. and Pang et al. measured only one broad domain of MHL; knowledge of mental health promotion and mental illness stigma respectively [ 28 , 62 ]. Hart et al. assessed the psychometric properties of a depression knowledge questionnaire and found a one factor general knowledge latent structure to be the best fit to the data [ 61 ]. Campos et al. aimed to provide a more comprehensive assessment of MHL, and by psychometrically assessing a pool of items, developed a 33-item tool with three latent factors: first aid skills and help seeking, knowledge/stereotypes, and self-help strategies [ 55 ]. A further 22 articles (24%), stated that some items or scales had been developed for the purpose of the study.

Thirty-nine articles (43%) stated that they based their items on Jorm and colleagues original MHL survey or later 2006 and 2011 versions [ 12 , 63 ]. Furthermore, two articles (2%) included items from the Mental Health First Aid Questionnaire (MHFAQ) as detailed by Hart et al. [ 64 ]. However, there is no evidence of the validity of these surveys as whole scales, and researchers commonly selected and modified items. The Friend in Need Questionnaire, similar to Jorm and colleagues MHL survey in that it covers multiple MHL domains, was developed by Burns and Rapee to avoid leading multiple-choice answers. Instead, open-ended responses were coded in order to quantify levels of MHL [ 65 ]. Despite finding six articles (7%) that utilised a version of this questionnaire, no published validation paper was found. As part of the Adolescent Depression Awareness Programme (ADAP), an Adolescent Depression Knowledge Questionnaire (ADKQ) was developed and later validated [ 61 ]. Six articles (7%), including the validation paper, presented data using versions of the ADKQ.

Due to the multi-faceted nature of stigma, a range of measurement tools were identified across articles. The Attribution Questionnaire (AQ-27) was originally developed by Corrigan and colleagues [ 66 , 67 ] along with a brief 9-item scale (r-AQ) covering the following emotional reactions: blame, anger, pity, help, dangerousness, fear, avoidance, segregation and coercion. A similar 8-item version (AQ-8-C) was also developed for children [ 68 ]. The r-AQ was adapted by Watson et al. for use with middle school aged adolescents [ 69 ], and a 5-item version was more recently validated by Pinto et al. [ 70 ]. Four articles (4%) identified in this review used variations of the r-AQ.

Link et al. developed the 5-item Social Distance Scale (SDS) [ 71 ], which was later adapted for young people [ 72 ]. This version was more recently validated with a large sample aged 15–25 [ 73 ]. Five articles (5%) cited this version of the SDS. Seven articles (8%) used variations of the World Psychiatric Association’s (WPA) social distance items [ 74 ]; however, no adolescent validation paper was found. This review also found factual and attitudinal WPA scales presented by Pinfold et al. including the Myths and Facts About Schizophrenia Questionnaire. In total, these scales, or modified versions, were used in eight articles (9%), but no validation papers were found. The Reported and Intended Behaviour Scale (RIBS) [ 75 ] was utilised in three articles (3%). This scale has been translated into Japanese and Italian, and there is evidence of its validity with adult and university student samples [ 76 , 77 ]. The evidence of its validity with an adolescent sample was mixed [ 78 ].

The Depression Stigma Scale (DSS) was developed by Griffiths et al. to measure personal and perceived depression stigma [ 79 ]. Yap et al. later validated the DSS and confirmed that personal and perceived stigma were distinct constructs comprised of ‘weak-not-sick’ and ‘dangerous/unpredictable’ factors in a sample aged 15–25 [ 73 ]. Six articles (7%) utilised a version of the DSS, more commonly the items relating to personal stigma. Items from the Opinions about Mental Illness Scale (OMI) were used in two articles (2%). The original scale was cited by both [ 80 ], however, a Chinese version of the OMI has been tested for validity with a sample of secondary school students [ 81 ]. Other validated stigma scales identified included: the Attitudes Toward Serious Mental Illness Scale–Adolescent Version (ATSMI-AV) [ 82 ] ( N  = 1, 1%) and the Subjective Social Status Loss Scale [ 83 ] ( N  = 1, 1%). Measures of help-seeking attitudes and intentions were often not validated with adolescent samples. Two articles (2%) modified the General Help Seeking Questionnaire (GHSQ), previously validated for use with high school students [ 84 ]. A further two articles (2%) utilised the Self-Stigma of Seeking Help (SSOSH) scale; however, tests of its validity have only been conducted with college students [ 85 ].

The aims of this review were to investigate the conceptualisation and measurement of MHL in adolescent research, and scope the extent of methodological homogeneity for possible meta-analyses. The review clearly shows an increase in school-based MHL research with adolescent samples in recent years. This makes sense given that adolescence is increasingly identified as an important period for improving MHL and access to mental health services [ 6 , 10 , 11 , 38 ]. However, the field is still dominated by research from Western, developed countries and takes a predominantly mental-ill health approach. Furthermore, numerous challenges and inconsistencies have emerged in the field over the past 20 years.

Included articles were required to use the term ‘mental health literacy’ or a diagnosis-specific equivalent. However, by first including all articles that presented data for at least one MHL domain, a large number of articles that measured domains without referring to MHL were revealed. Researchers were measuring the same constructs but providing different labels indicating problems with discriminant validity [ 31 , 37 ]. It must be acknowledged that some of the articles included in the final set may have used the term without intending to measure the whole construct, and some articles were removed that measured multiple domains. For example, 16 intervention studies, previously included in a systematic literature review of the effectiveness of MHL interventions [ 25 ], were excluded from this current review because they did not use the term. Despite the exclusion of some potentially relevant data on a domain level, this criterion was considered most appropriate given one of the aims was to assess the conceptualisation of MHL.

Although under half of the articles identified defined MHL, those that did predominantly used definitions from Jorm and colleagues [ 12 , 13 , 14 ]. However, the various adaptations and interpretations of the original definition has clearly led to a lack of construct travelling in the field, in particular, confusion about the inclusion of beliefs and stigma related constructs as MHL domains. Furthermore, few articles referred to mental health and varying degrees of psychological distress in addition to mental illness, supporting the argument that current MHL definitions take a predominantly mental-ill health approach [ 16 , 26 ].

Although an adolescent specific definition of MHL may not be necessary, definitions frequently adopted by articles in this review were developed for adults. It is important for future research to consider not only cognitive development but also the unique social structures and vulnerabilities of adolescents in the conceptualisation and assessment of MHL. Given that the definition of adolescence in the current study ranges from 10 to 19 years, it is clear that even within this age range, different developmental factors could be considered. Applying integrated models of generic health literacy to MHL that acknowledge the life course and social and environmental determinants should therefore be a future priority [ 86 , 87 ].

Around a third of articles measured recognition of specific mental illnesses, with the majority using open-ended questions such as ‘ What, if anything, do you think is wrong …’, and calculating the % of correct responses. Knowledge of mental illnesses was measured more frequently than knowledge of prevention and promotion, therefore an understanding of the complete mental health state was often neglected [ 27 ]. More research is needed to develop and validate measures that assess the ability to seek out, comprehend, appraise and apply information relating to the complete mental health state as opposed to only assessing literacy of mental disorders. By using measurement tools that predominantly focus on psychiatric labels, there is evidence to suggest that stigma could be increased [ 22 , 23 ]. Given that over three quarters of intervention studies identified in this review included a measure of stigma, future research should consider the way in which mental-ill health approaches to MHL, in terms of intervention content and study measures, may influence stigma related outcomes.

It is perhaps unsurprising that the MHL field continues to be modelled on psychiatric labelling given the influence of Jorm and colleagues early work in Australia that came out of the National Health and Medical Research Council (NHMRC) Social Psychiatry Research Unit [ 12 ]. Kutcher and colleagues MHL definition also has its origins in psychiatry, but more explicitly includes understanding of mental health promotion and stigma reduction [ 15 ]. A growing body of research relating to eating disorders literacy also emphasises the need to distinguish between health promotion, prevention and early intervention initiatives in reducing the population health burden of eating-disordered behaviour and to prioritise mental health promotion programs, including those targeting stigma reduction [ 88 , 89 , 90 ]. This review identified an emerging group of articles that included understanding of how to obtain and maintain good mental health in their conceptualisation of MHL. However, this domain was rarely measured.

Just under half of the articles included items relating to general MHL. However, terminology was varied (e.g. mental illness, mental disorder, mental health problem, mental health issue). Leighton revealed that young people have a lack of conceptual clarity when it comes to these mental health related terms, unsurprising given the lack of consistent definitions in practice [ 91 ]. The range and subjectivity of mental health related terms reduces the meaningfulness of comparisons across MHL studies. Similarly, over half of the articles identified in this review assessed mental illness stigma, but the complexity of the construct caused heterogeneity in measurement. Intentions to seek help were the most commonly measured help-seeking belief; these findings support previous assessments of MHL measurement tools [ 16 ]. Measuring only intentions to seek help, without capturing knowledge of what help is available, will not provide a true picture of actual behaviour change. Findings also suggested that recognition and help-seeking related beliefs may be more directly associated with the MHL construct and, in line with previous literature [ 25 ], mental illness stigma was found to be a common outcome measure in MHL related interventions.

It is worth considering whether the MHL construct should continue to be stretched or whether we should accept that the multiple domains exist in their own right. For example, self-acquired knowledge and skills relating to positive psychology are being investigated, but are only just starting to emerge under the MHL construct [ 28 , 29 ]. Similarly, stigma and help-seeking knowledge and beliefs are assessed as part of, and independently from, the MHL framework. Adopting a multi-construct theory approach to MHL, as suggested by Spiker and Hammer [ 31 ], would see increased focus on developing and validating measures of specific MHL domains in order to better understand the way in which these domains relate to each other.

Developing better MHL theory will help provide clear logic models and theories of change for MHL interventions aiming to improve adolescent mental health, something currently lacking in the field. Although it should be acknowledged that the aims of MHL interventions will vary based on the scope, setting and cultural context, an increased number of validated measures as well as improved MHL theory could inform decisions about the most appropriate domain to measure as the outcome i.e. is the main aim of the intervention to reduce stigma or improve help-seeking. This is particularly important for school-based evaluations of MHL interventions for which respondent burden is often a concern.

We acknowledge that there were some articles in this review that adapted adult measures and tested for face and content validity with child and adolescent mental health professionals, and internal reliability and comprehension with adolescent samples. However, in general there was a lack of psychometric work to assess factor structure of scale-based measures in this age group, with large numbers of articles presenting data on an item level. More research should be conducted like that of Campos et al., working with young people to develop and psychometrically test pools of MHL items to identify latent factors [ 55 ]. This will help to inform future conceptualisation and measurement in this age group.

Even when there was evidence of a measure’s validity for use with adolescents, many articles selected only the items relevant for their study or adapted the scale to fit the cultural context. This may, in part, be an attempt to reduce the number of items and therefore the response burden. However, adaptation to measures based on the cultural discourse around mental health aligns with school-based mental health promotion approaches that account for children’s social, cultural and political contexts [ 92 ]. This raises the important question as to whether we should be trying to test and compare mental health related knowledge across cultures, particularly given the ongoing levels of disagreement amongst mental health professions between and within countries. A previous review of cross-cultural conceptualisations of positive mental health concluded that future definitions should be inclusive and culturally sensitive, and that more work was needed to empirically validate criteria for mental health [ 93 ]. Future research should consider conducting measurement invariance on existing MHL measures across different cultures. A comparison of knowledge items and their pre-defined correct answers, could help understand cultural differences in the discourse around mental health and what it means to be mental health literate across contexts.

Given the increased political interest in mental health promotion and education [ 6 , 38 ], we recommend that MHL research focuses on increasing understanding of ways to promote and maintain positive mental health, including subjective wellbeing, optimal functioning, coping and resilience [ 30 , 94 ]. Examples of knowledge items with true/false responses were identified in the current review and many aligned with a biogenetic conceptualisation of mental illness. Not only could these ‘truths’ cause more negative attitudes towards individuals experiencing mental health difficulties [ 19 ], many mapped directly onto the content of interventions and therefore do not provide any evidence of adolescents’ ability to critically appraise mental health information. To enhance individual and community level critical mental health literacy, the MHL field should apply models of public health literacy that aim to increase empowerment and control over health decisions, and acknowledge the interaction between an individual’s ability and their social and contextual demands [ 86 , 95 , 96 , 97 ]. Given that mental health is a key component of health, it is also worth questioning the usefulness of this separation moving forward; a MHL field that is playing catch up with more developed health literacy approaches could further exaggerate the existing lack of parity of esteem.

MHL research with adolescent populations is on the rise, but this review has highlighted some important areas for future consideration. Increasingly stretched definitions of MHL have led to conceptual confusion and methodological inconsistency, and there is a lack of measures developed and psychometrically tested with adolescents. Furthermore, the field is still dominated by a mental-ill health approach, with limited measures assessing the promotion of positive mental health. We suggest that the MHL field moves away from assessing ‘mental disorder literacy’ and towards critical ‘mental health literacy’. A better understanding of what MHL means for adolescents is needed in order to develop reliable, valid and feasible measures that acknowledge their developmental stage and unique social and contextual demands. In conclusion, by treating MHL as a multi-construct theory, more could be understood about the mechanisms for change in improving adolescent mental health.

Availability of data and materials

Link to PROSPERO review protocol included in the manuscript, example search strategy included as supplementary material.

Abbreviations

• Mental health literacy

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RM designed the systematic literature review and wrote the protocol published on PROSPERO. RM conducted the initial database search and grey literature search and was responsible for all stages of screening and data extraction. Any uncertainties relating to screening and data extraction were resolved through discussion with NH and PP. A sub-set of articles were screened at full text stage by NH to determine levels of agreement. RM wrote the first draft of the manuscript with input from NH and PP. All authors read and approved the submitted version.

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Mansfield, R., Patalay, P. & Humphrey, N. A systematic literature review of existing conceptualisation and measurement of mental health literacy in adolescent research: current challenges and inconsistencies. BMC Public Health 20 , 607 (2020). https://doi.org/10.1186/s12889-020-08734-1

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Original research article, mental health and well-being of university students: a bibliometric mapping of the literature.

• 1 Graduate School of Education, Nazarbayev University, Nur-Sultan, Kazakhstan
• 2 Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan
• 3 Psychological Counseling Center, Nazarbayev University, Nur-Sultan, Kazakhstan

The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975–2020. More specifically, this study uses bibliometric procedures to describe and visually represent the available literature on mental health and well-being in university students in terms of the growth trajectory, productivity, social structure, intellectual structure, and conceptual structure of the field over 45 years. Key findings of the study are that research on mental health and well-being in university students: (a) has experienced a steady growth over the last decades, especially since 2010; (b) is disseminated in a wide range of journals, mainly in the fields of psychology, psychiatry, and education research; (c) is published by scholars with diverse geographical background, although more than half of the publications are produced in the United States; (d) lies on a fragmented research community composed by multiple research groups with little interactions between them; (e) is relatively interdisciplinary and emerges from the convergence of research conducted in the behavioral and biomedical sciences; (f) tends to emphasize pathogenic approaches to mental health (i.e., mental illness); and (g) has mainly addressed seven research topics over the last 45 years: positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement. The findings are discussed, and the implications for the future development of the field are highlighted.

Introduction

The entrance to the university marks a period of transition for young people. Through this transition, students face new challenges, such as making independent decisions about their lives and studies, adjusting to the academic demands of an ill-structured learning environment, and interacting with a diverse range of new people. In addition, many students must, often for the first time, leave their homes and distance themselves from their support networks ( Cleary et al., 2011 ). These challenges can affect the mental health and well-being of higher education students. Indeed, there is evidence that a strain on mental health is placed on students once they start at the university, and although it decreases throughout their studies ( Macaskill, 2013 ; Mey and Yin, 2015 ), it does not return to pre-university levels ( Cooke et al., 2006 ; Bewick et al., 2010 ). Also, the probabilities of experiencing common psychological problems, such as depression, anxiety, and stress, increase throughout adolescence and reach a peak in early adulthood around age 25 ( Kessler et al., 2007 ) which makes university students a particularly vulnerable population.

The interest in mental health and well-being in university students has grown exponentially in the last decades. This is likely due to three interrelated challenges. First, although university students report levels of mental health similar to their non-university counterparts ( Blanco et al., 2008 ), recent studies suggest an increase and severity of mental problems and help-seeking behaviors in university students around the world in the last decade ( Wong et al., 2006 ; Hunt and Eisenberg, 2010 ; Verger et al., 2010 ; Auerbach et al., 2018 ; Lipson et al., 2019 ). Some researchers refer to these trends as an emerging “mental health crisis” in higher education ( Kadison and DiGeronimo, 2004 ; Evans et al., 2018 ). Second, psychological distress in early adulthood is associated with adverse short-term outcomes, such as poor college attendance, performance, engagement, and completion (e.g., King et al., 2006 ; Antaramian, 2015 ), and others in the long term, such as dysfunctional relationship ( Kerr and Capaldi, 2011 ), recurrent mental health problems, university dropout, lower rates of employment, and reduced personal income ( Fergusson et al., 2007 ). Third, there is a widespread agreement that higher education institutions offer unique opportunities to promote the mental health and well-being of young adults as they provide a single integrated setting that encompasses academic, professional, and social activities, along with health services and other support services ( Eisenberg et al., 2009 ; Hunt and Eisenberg, 2010 ). However, the majority of university students experiencing mental health problems and low levels of well-being are not receiving treatment ( Blanco et al., 2008 ; Eisenberg et al., 2011 ; Lipson et al., 2019 ) and, while universities continue to expand, there is a growing concern that the services available to provide support to students are not developing at an equivalent rate ( Davy et al., 2012 ).

In response to the increasing volume of research on the mental health and well-being of university students, there have been several attempts to synthesize the accumulating knowledge in the field and to provide an illustration of the theoretical core and structure of the field using traditional content analysis of the literature (e.g., Kessler et al., 2007 ; Gulliver et al., 2010 ; Hunt and Eisenberg, 2010 ; Sharp and Theiler, 2018 ). This study aims to extend the understanding of mental health in university students by providing a bird’s eye view of the research conducted in this field in recent decades using a bibliometric approach. Bibliometric overviews provide an objective and systematic approach to discover knowledge flows and patterns in the structure of a field ( Van Raan, 2014 ) reveal its scientific roots, identify emerging thematic areas and gaps in the literature ( Skute et al., 2019 ) and, ultimately, contribute to moving the field forward. Accordingly, this study employs several bibliometric indicators to explore the evolution of the field based on publication and citation trends, key actors and venues contributing to the advancement of research on mental health and well-being of university students, and the structure of the field in terms of patterns of scientific collaborations, disciplines underlying the foundations of the field, and recurrent research themes explored in the literature. This is important because, despite significant advances in the field, research on mental health and well-being remains a diverse and fragmented body of knowledge ( Pellmar and Eisenberg, 2000 ; Bailey, 2012 ; Wittchen et al., 2014a ). Indeed, mental health and well-being are nebulous concepts and their history and development are quite intricate, with a multitude of perspectives and contributions emerging from various disciplines and contexts (see section “Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview”). Therefore, mapping research on mental health and well-being in university students is essential to identify contributions and challenges to the development of the field, to help guide policy, research, and practice toward areas, domains, populations, and contexts that should be further explored, and to provide better care of students at higher education institutions ( Naveed et al., 2017 ).

Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview

This section provides an overview of the different perspectives adopted in the literature to conceptualize mental health, well-being, and other relevant constructs in order to identify the glossary of key terms that will be used in the search strategy to create a comprehensive corpus of documents on mental health and well-being in university students for this bibliometric review.

Perspectives on Mental Health and Mental Illness

There is no general agreement on the definition of mental health. For a long time, the term mental health has been used as a euphemism for mental illness ( Manwell et al., 2015 ). However, mental health and mental illness are regarded as distinct constructs nowadays and two main perspectives differentiating between mental health and illness are available in the literature. The continuum approach considers that mental health and mental illness are the two opposite poles of a continuum. Thus, there are various degrees of health and illness between these poles, with most of us falling somewhere in between. The categorical approach, on the other hand, represents mental health and illness as a dichotomy. People who manifest mental illness symptoms would belong to that category and labeled correspondingly, while those absent of these symptoms can be considered as mentally healthy ( Scheid and Brown, 2010 ).

Disciplinary Approaches to the Conceptualization of Mental Health/Illness

Conceptualizations of mental health/illness are largely dependent on the theoretical and paradigmatic foundations of the disciplines from which they emerge. In this context, the field has progressively evolved through the accumulation of knowledge generated in a diverse range of disciplines in the biomedical, behavioral, and social sciences. Biomedical disciplines are grounded in the medical paradigm focused on disease and (ab)normality and often emphasize dichotomous conceptions of mental health/illness ( Scheid and Brown, 2010 ). Research on mental health and well-being in this domain has been traditionally conducted from a psychiatric perspective, which aims to understand the dysfunctionality in the brain that leads to psychiatric symptoms and to also offer a pharmacological treatment to correct neuronal dysfunctions. Consequently, psychiatrists have historically considered mental health as a disease of the brain (e.g., depression), similar to any other physical disease, caused by genetic, biological, or neurological factors ( Schwartz and Corcoran, 2010 ). While the prevalence of psychiatric approaches to mental health is currently incontestable, the development of other biomedical disciplines has tremendously contributed to the progression of the field in recent decades. For example, Insel and Wang (2010) argue that insights gained from genetics and neuroscience contribute to the reconceptualization of “the disorders of the mind as disorders of the brain and thereby transform the practice of psychiatry.” (1979). In addition to that, other disciplines such as behavioral medicine have made important contributions to the field, although it has recently argued that mental health and behavioral medicine should be as two separate fields ( Dekker et al., 2017 ).

Within the behavioral sciences, the study of mental health focuses on the distinct psychological processes and mechanisms that prompt thoughts, feelings, and behaviors ( Peterson, 2010 ). Clinical psychology has the longest tradition in the psychological study of mental health and tends to focus on the assessment and treatment of mental illness and disorders that can alleviate psychological distress or promote positive states of being ( Haslam and Lusher, 2011 ). However, significant contributions to the field have also emerged from other branches of psychology less focused on psychopathology, including personality and social psychology, psychoanalysis, humanistic psychology, and cognitive psychology ( Peterson, 2010 ). Despite the diversity of theories, principles, and methodological approaches to understanding mental health within the behavioral sciences, these disciplines acknowledge that mental health have a biological basis and reside in the social context, and tend to prioritize continuum approaches to mental health ( Scheid and Brown, 2010 ).

Perspectives from the social sciences complement the biomedical and behavioral approaches by considering the influence of social and cultural environments in mental health/illness ( Horwitz, 2010 ). For example, sociologists are interested in how social circumstances (e.g., level of support available) affect levels of mental health/illness and how social structures shape the understanding and response to mental health issues [see Compton and Shim (2015) for an overview of the social determinants of mental health]. Similarly, medical anthropologists attend to the mental health beliefs and practices that form the cultural repertory within and across populations ( Foster, 1975 ). Beyond sociology and anthropology, social researchers in the fields of business and economics, family and ethnic studies, and educational research have also played a key role in advancing research on mental health in different directions.

The Importance of the Context in Mental Health

Certainly, most notions of mental health/illness in the literature derive from prevailing psychiatric and psychological traditions developed in Western countries ( Gopalkrishnan, 2018 ). However, cultural values and traditions do shape how mental health and mental illness are conceptualized across contexts ( Vaillant, 2012 ). In this regard, Eshun and Gurung (2009) pointed out that “culture influences how individuals manifest symptoms, communicate their symptoms, cope with psychological challenges, and their willingness to seek treatment.” (4). Fernando (2019) argued that issues related to the ‘mind’ developed and are often interpreted very differently in non-Western and Low- and Middle-Income Countries (LMICs). For example, cultures explain the manifestation of certain feelings and behaviors based on a range of motives including biological, psychological, social, religious, spiritual, supernatural, and cosmic. Failure to acknowledge alternative non-Western approaches to mental health and mental illness has resulted in imbalances of knowledge exchange and the permeation of dominating Western narratives into LMICs (i.e., so-called medical imperialism) ( Timimi, 2010 ; Summerfield, 2013 ). To address this issue, scholars have advocated for a greater willingness to embrace pluralism in the conceptualization of mental health and illness, which might help people to engage with particular forms of support that they deem to be appropriate for them, and to explore how knowledge and practices developed in LMICs can benefit those living in higher-income countries (i.e., knowledge “counterflow”) (see White et al., 2014 ).

Prioritizing Positive Mental Health: The Science of Well-Being

Despite the diversity of disciplinary and contextual approaches to mental health, current definitions of mental health have two things in common. First, mental health is considered from a biopsychosocial point of view that incorporates biological, psychological, and social factors. Second, mental health implies something beyond the absence of mental illness (e.g., Bhugra et al., 2013 ; Galderisi et al., 2015 ). An example is the definition by the World Health Organization which refers to mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” ( World Health Organization, 2004 ). This definition contributed to substantial progress in research and practice in the field as it expanded the notion of mental health beyond the absence of mental illness and integrated the presence of positive features ( Galderisi et al., 2015 ).

Research on positive mental health is relatively new but has grown rapidly in the last decades fueled by advocates of positive medicine and psychology, who have argued for a change of paradigm from medical and psychopathological-oriented models of mental health that focus on disorders and illness toward more strength-based approaches, which pay more attention to what is right about people and positive attributes and assets ( Kobau et al., 2011 ). In this regard, the term mental well-being has been progressively incorporated into the study of mental health to account for the positive aspects of mental health beyond the absence of negative factors. While there is not a universally accepted definition of well-being, two perspectives have dominated the discourses on well-being in the literature: subjective well-being (SBW) and psychological well-being (PWB). SWB is based on hedonic perspectives of pleasure and represents “people’s beliefs and feelings that they are living a desirable and rewarding life” ( Diener, 2012 ). SBW is strongly linked with the idea of happiness and is typically understood as the personal experience of high levels of positive affect, low levels of negative affect, and high satisfaction with one’s life ( Deci and Ryan, 2008 ). PWB is grounded in Aristotelian ideas about eudaimonia, i.e., self-realization, with the ultimate aim in life being to strive to realize one’s true potential ( Ryff and Singer, 2008 ). PWB has been broadly defined as a state of positive psychological functioning and encompasses six dimensions: purpose in life (i.e., the extent to which respondents felt their lives had meaning, purpose, and direction); autonomy (i.e., whether they viewed themselves as living in accord with their own convictions); personal growth (i.e., the extent to which they were making use of their personal talents and potential); environmental mastery (i.e., how well they were managing their life situations); positive relationships (i.e., the depth of connection they had in ties with significant others); and self-acceptance (i.e., the knowledge and acceptance they had of themselves, including awareness of personal limitations) ( Ryff, 1989 ).

Integrating Mental Health, Mental Illness, and Well-Being

The contribution of positive mental health frameworks to the advancement of the field has been undeniable. However, definitions that overemphasize positive emotions and productive functioning as key indicators of mental health have been recently challenged because of the potential they have to discriminate against individuals and groups that, for example, might not be able to work productively or function within the environment because of individual physical characteristics or contextual constraints ( Galderisi et al., 2015 ). To address these issues, Keyes has successfully integrated the notions of mental illness, mental health, well-being, and other related terms in the literature into a conceptual framework that allows for a more comprehensive understanding of mental health ( Keyes, 2005 , 2007 ; Keyes and Michalec, 2010 ). The model argues that neither pathogenic approaches focusing on the negative (e.g., mental illness) nor salutogenic approaches focusing on the positive (e.g., well-being) can alone accurately describe the mental health of a person ( Keyes and Michalec, 2010 ). Instead, the model proposes that mental illness and well-being represent two correlated but differentiated latent continua in defining mental health. More specifically, mental illness and well-being lie on two separate spectra, the first going from absent to present mental illness and the second running from low to high well-being ( Slade, 2010 ). The absence of mental illness, therefore, does not necessarily imply high levels of well-being. Correspondingly, low levels of well-being do not always indicate the presence of mental illness. Further, in this model, mental health is defined as not only the absence of mental illness, not the mere presence of high well-being. Complete mental health (i.e., flourishing) is a result of experiencing low mental illness and high levels of well-being. Incomplete mental health (i.e., languishing), on the other hand, refers to the absence of mental illness symptoms and low reported levels of well-being. Two other conditions are possible within this framework. Incomplete mental illness (i.e., struggling) refers to high levels of well-being accompanied by high mental illness symptoms. Lastly, complete mental illness (i.e., floundering) accounts for low levels of well-being and high mental illness symptoms ( Keyes and Lopez, 2002 ).

The Present Study

In light of the complexity of the constructs of mental health and well-being and the multiple theoretical, disciplinary, and contextual approaches to their conceptualization, this study seeks to map out the terrain of international research and scholarship on mental health and university students for the period 1975–2020. More specifically, this study aims to provide new insights into the development and current state of mental health research in university students by mapping and visually representing the literature on mental health and well-being of university students over the last 45 years in terms of the growth trajectory, productivity, and social, intellectual, and conceptual structure of the field. First, the study describes the development of research mental health and well-being in university students examining the trends in publication and citation data between 1975 and 2020 (i.e., growth trajectory). Second, the study identifies the core journals and the research areas contributing most to the development of the field, as well as the key authors and countries leading the generation and dissemination of research on mental health and well-being in university populations (i.e., productivity). Third, the study outlines the networks of scientific collaboration between authors, and countries (i.e., social structure). Fourth, the scientific disciplines underlying the intellectual foundations of research on mental health and well-being in university settings (i.e., intellectual structure) are uncovered. Fifth, the study elucidates the topical foci (i.e., conceptual structure) of the research on the mental health and well-being of university students over the last 45 years.

Materials and Methods

A bibliometric approach was used in this study to map the literature on mental health and well-being in university students over the last 45 years using metadata extracted from four indexes of the Web of Science (WoS): The Science Citation Index-Expanded (SCI-Expanded); the Social Sciences Citation Index (SSCI); the Arts & Humanities Citation Index (A&HCI); and the Emerging Sources Citation Index (ESCI). Several reasons justified the selection of the WoS database in this study. First, the WoS remains as the standard and most widely used for bibliometric analysis ( Meho and Yang, 2007 ). Second, the WoS is a multidisciplinary database and includes publications on mental health and well-being emerging from distinctive research areas and disciplines published in more than 20,000 journals ( McVeigh, 2009 ). Using specialized databases such as PubMed would introduce biases into the search strategy favoring biomedical research disciplines. Still, it is important to note that interdisciplinary databases such as WoS and Scopus discriminate against publications in the Social Sciences and Humanities and publications in languages other than the English language ( Mongeon and Paul-Hus, 2016 ), so the picture provided by WoS is still imperfect. Third, while other databases might provide wider coverage, WoS includes publication and citation information from 1900. For example, Scopus has complete citation information only from 1996 ( Li et al., 2010 ). Moreover, Google Scholar provides results of inconsistent accuracy in terms of citations, and citation analyses in PubMed are not available ( Falagas et al., 2008 ). Fourth, WoS has demonstrated better accuracy in its journal classification system compared to Scopus database ( Wang and Waltman, 2016 ).

The methodological approach used in this study is presented in Figure 1 and further elaborated in the following paragraphs.

Figure 1. Methodological framework.

Search Strategy

To create a comprehensive corpus of documents on the mental health and well-being of university students, three parallel searches were performed, which accounted for the multiple approaches and perspectives that have been used in the field, as identified in the Section “Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview.” All the searches were conducted in the last week of January 2020. The first search aimed at capturing research on mental health broadly and included one single keyword in the topic field: [“mental health”]. The second search was implemented to capture research focusing on pathogenic approaches to mental health. Key terms used in the literature to refer to the negative side of mental health, as well as the most frequent mental health problems experienced by university students, were introduced in this search in the title field: [“mental illness,” “mental disorder ∗ ,” “mental distress,” “psychological distress,” “psychopathology,” “depression,” “anxiety,” “stress,” “suicide,” “eating disorder ∗ ,” “substance use”]. In the third search, keywords reflecting salutogenic approaches to mental health were input. These included terms related to mental health from a positive mental health perspective (i.e., well-being). These key terms were added in the title field and included the following: [“well-being,” “wellbeing,” “wellness,” “life satisfaction,” “happiness,” “positive affect,” “purpose in life,” “personal growth,” “self-determination”].

To retrieve research relevant only to higher education students, another set of keywords was imputed in all three searches in the title field. These included: [“university,” “college,” “higher education,” “tertiary education,” “post-secondary education,” “postsecondary education,” “undergrad ∗ student,” “grad ∗ student,” “master’s student,” “doctoral student,” “Ph.D. student”]. The Boolean operator OR was used between keywords in all the three searches to secure a higher number of relevant hits. Also, asterisks were used as wildcards to account for multiple variations in several keywords (e.g., disorder and disorder-s). All searches were limited to journal articles published between 1975 and 2020 (both inclusive). No restrictions on language were implemented in the search.

The search strategy retrieved a total of 6,356 hits ( n search 1 = 2782; n search 2 = 2814, n search 3 = 760). After the removal of duplicates, 5,561 research articles were finally selected and retained for the study. For each of the documents obtained in the search, the authors extracted metadata about the title of the paper, the year of publication, the journal, the number of citations, and the authors’ name, organization, and country. Also, the title, the abstract, the author’s keywords, and cited references were retrieved.

Data Analysis Procedures

The corpus of the literature was then analyzed using descriptive and bibliometric approaches to provide an overall picture of the evolution and current state of the research on mental health and wellbeing in university settings. Frequency counts of the number of publications and citations per year were obtained to describe the growth trajectory of research on the mental health and well-being of university students. Rank ordered tables were produced to describe the productivity of the field in terms of core journals and research areas, as well as leading scholars and countries contributing to the development of the field.

Bibliometric analyses in VOSViewer software were implemented to examine and visually represent the social, intellectual, and conceptual structure of the field. VOSViewer is a freely available computer software for viewing and constructing bibliometric maps 1 . In VOSViewer, the units of analysis are journals, publications, citations, authors, or countries, depending on the focus of the analysis. The units of analysis are represented in the maps as circular nodes. The size of the node accounts for volume (e.g., number of publications in the dataset by an author) and the position represents the similarity with other nodes in the map. Closer nodes are more alike than nodes far apart from each other. The lines connecting nodes represent the relationship between nodes and their thickness indicates the strength of that relationship. Finally, the color of the node denotes the cluster to which each node has been allocated. Nodes are clustered together based on relatedness ( Van Eck et al., 2010 ). The software uses a distance-based approach to constructing the bibliometric maps in three steps ( Van Eck and Waltman, 2014 ). In the first step, the software normalizes the differences between nodes. In the second step, the software builds a two-dimensional map where the distance between the nodes reflects the similarity between these nodes. In the third step, VOSViewer groups closely related nodes into clusters ( Van Eck and Waltman, 2014 ).

A series of co-authorship analyses were performed to examine the social structure of research on mental health and well-being in university students. In these analyses, the units of analysis were authors and countries/territories. Each node in the map represents an author or a country/territory and the lines connecting them reflect the relationship between nodes. Clusters represent networks of scientific collaboration, which might be interpreted as groups of authors or countries frequently publishing together (e.g., research groups in the case of authors).

Co-citation analysis of journals was implemented to explore the intellectual structure of the field. Here, the units of analysis were journals in the dataset and the map reflects co-citation relationships between journals. Two journals are co-cited if there is a third journal citing these two. The more times a pair of journals are cited by other journals, the stronger their co-citation relationship will be. Frequently co-cited journals are assumed to share theoretical and semantical grounds. Therefore, in our study, clusters of frequently co-cited journals can be interpreted as disciplines underlying the foundations of research on mental health and well-being in university students.

Finally, a co-occurrence analysis of keywords was used to uncover the conceptual structure of the field. The units of analysis, in this case, were the authors’ keywords. The more often two keywords appear in the same record, the stronger their co-occurrence relationship. Clusters of co-occurring keywords represent in this study the topical foci (i.e., knowledge base) that have been addressed in the literature in mental health and well-being in university students in the last 45 years.

Findings and Discussion

Growth trajectory: evolution of publications and citations in the field.

The developmental patterns of a particular field can be well demonstrated by trends in publications and citations. The 5,561 publications in the dataset have been cited 87,096 times, with an average of 15.6 citations per item. Figure 2 shows the growth trajectory of publication data of research on mental health and well-being in university students from 1975 to January 2020. Overall, the trends demonstrate a gradual increase in the scholarly interest in the mental health of university students over the last 45 years that can be organized in three stages: an emergence stage, in which publications rose slowly (1975–2000); a fermentation stage, with a notable increase in publications in the field (2000–2010); and a take-off stage, during which the number of records published per year in the field has almost risen 10 times (2010–2020). The steady increase of publications in the last 15 years coincides with the first calls for attention on the increase and severity of mental problems and help-seeking behaviors of college students ( Kadison and DiGeronimo, 2004 ; Evans et al., 2018 ), potentially indicating a growing interest in exploring the epidemiology of mental disorders and the role of universities in promoting the mental health and well-being of students. A similar pattern has also been observed in a recent bibliometric study examining global research on mental health both in absolute terms and as a proportion of all papers published in medicine and across disciplines, which certainly reflects an increase in the general interest in the field ( Larivière et al., 2013 ).

Figure 2. Growth of research on mental health and well-being of university students.

Productivity I: Core Journals and Research Areas

In total, 1,560 journals published the 5,561 records included in the dataset. Table 1 presents the ten core journals in the field. The Journal of American College stands out as the main publication venue in the field, accumulating around 5% of the publications in the dataset ( n = 270). Psychological Reports and Journal of College Student Development also stand out, publishing 119 and 102 studies, respectively. The Journal of Counseling Psychology ranks fourth in the list with 83 records. Despite being an interdisciplinary and relatively young journal, Plos One appears in the top five journal publishing research on mental health and well-being in university students.

Table 1. Core journals ranked by number of records.

The top research areas contributing to the publication of research on the mental health and well-being of university students are presented in Table 2 . Nearly half of the records in the dataset are published in psychology journals. Another influential research area in the field is psychiatry , which captures almost 20% of the publications. Journals on education and educational research also accumulate a considerable number of publications in the field (15%). Other relevant research areas in the field are connected with health and medicine, including public environmental occupational health , substance abuse , general internal medicine , neurosciences neurology , health care sciences services , and nursing . Finally, the field is also grounded, although to a lower extent, in the publications emerging from journals in the social sciences , family studies , and social work research.

Table 2. Top research areas ranked by number of records.

All in all, the productivity analysis for journals and research areas showed that most research on mental health and well-being in university students is disseminated in journals in the “psy disciplines”’ (i.e., psychology and psychiatry) ( McAvoy, 2014 ), which is consistent with previous research on mental health in general populations (e.g., Haslam and Lusher, 2011 ). However, our findings demonstrated that the volume of research in psychology doubles that of research emerging from psychiatric journals. This contrasts with the findings by Haslam and Lusher (2011) , who demonstrated that psychiatry journals had a greater influence on mental health research compared to clinical psychology journals and that psychiatry journals accumulate a higher volume of research and citations on mental health research. This is probably because our study includes publications emerging from all branches of psychology, unlike the study by Haslam and Lusher, which included only journals in the field of clinical psychology. Additionally, mental health services in higher education are typically provided by counseling centers led and staffed by non-medical professionals (e.g., psychologists, social workers, counselors, and family therapists) who tend to adopt developmental models of practice grounded in the behavioral sciences and focused on adjustment issues, vocational training, employment, and other personal needs rather than diagnosis and symptom reduction, more common in the biomedical sciences (i.e., psychiatry) ( LeViness et al., 2018 ; Mitchell et al., 2019 ).

Productivity II: Leading Authors and Countries/Territories

The 5,561 publications in the dataset were published by a total of 16,161 authors from 119 countries worldwide. Table 3 shows the researchers with the highest number of publications in the field. D. Eisenberg appears as the most productive researcher, followed by K. Peltzer and S. Pengpid. Authors on the list come from diverse geographical backgrounds. Five of the authors work at three different American universities (University of Michigan, Harvard Medical School, and Boston University), two researchers work at KU Leuven University (Belgium), and two other authors are affiliated to the same two universities in Thailand and South Africa. Other prolific researchers are affiliated with higher education institutions in the Netherlands, Egypt, and Germany.

Table 3. Leading authors ranked by number of records.

Countries and territories leading research on mental health and well-being of university students are presented in Table 4 . The United States is the indisputable leader in this field, publishing more than half of the records in the dataset. This is nearly 10 times the number of publications produced in China, which occupies the second position in the ranking and accounts for nearly 6% of the volume of research in the dataset. Three predominantly English speaking countries/territories complete the top five of the ranking: Canada (265 records), Australia (254), and England (243). The rest of the countries in the list are situated in Europe (Spain, Germany, Turkey), Western Asia (Iran), Africa (South Africa), and East Asia (Japan), which demonstrates that research on college students’ mental health and well-being is a matter of concern in different regions of the world, at least to some extent.

Table 4. Leading countries/territories ranked by number of records.

Overall, the productivity analysis for authors and countries indicated that the research of mental health and well-being of university students occurs in a variety of locations around the world, especially in developed countries, and in a very prominent way, in the United States. This is not surprising since it is in those countries where better infrastructures and more abundant resources for research are available ( Wong et al., 2006 ), and a more lasting tradition in the study of mental health, in general, exists ( Gopalkrishnan, 2018 ). However, Larivière et al. (2013) found that the productivity of the United States on mental health research has dropped significantly and remained stable in other two English speaking countries (the United Kingdom and Canada) since 1980. On the contrary, the number of publications from European countries and the five major emerging national economies (Brazil, Russia, India, China, and South Africa), has experienced remarkable growth, and collectively account nearly for half of the publications in the field. Still, the predominance of knowledge generated in the developed world today, which tends to be grounded on psychiatric and psychological perspectives, might be eclipsing non-traditional views on mental health and well-being that are popular in other regions of the world and, therefore, limiting the development of effective initiatives that align better with local norms, values, and needs in LMICs ( Timimi, 2010 ; Summerfield, 2013 ).

Social Structure: Networks of Scientific Collaboration

Research collaboration is regarded as an indicator of quality research and a means to improve research productivity and academic impact (i.e., citations) ( Kim, 2006 ; Abramo et al., 2009 ). In particular, international research collaboration is considered a key contributor to the social construction of science and the evolution of scientific disciplines ( Coccia and Wang, 2016 ). There is recent evidence that national and international research collaborations have been accelerating in recent years ( Gazni et al., 2012 ; Wagner et al., 2015 ), especially in applied fields such as medical and psychological disciplines ( Coccia and Bozeman, 2016 ). In this study, co-authorship analyses were performed to find out patterns in the scientific collaboration between researchers and countries/territories on the mental health and well-being of university students.

Figure 3 demonstrates collaborative ties among authors who published at least 5 articles in the dataset ( n = 179). The map shows the existence of multiple productive collaborative networks of five or more researchers contributing to the development of the field. The largest collaboration network (red cluster) represents an international research group composed of 15 scholars affiliated to universities in the United States, Belgium, and Netherlands. This cluster groups some of the leading scholars in the field, including R. P. Auerbach, R. Brauffaerts, R. C. Kressler, and P. Cuijpers. Moreover, researchers in this cluster lead The WHO World Mental Health International College Student (WMH-ICS) Initiative, a large scale international project aimed at promoting the mental health and well-being of college students around the world through generating epidemiological data of mental health issues in university students worldwide, designing web-based interventions for the prevention and promotion of mental health, and disseminating evidence-based interventions ( Cuijpers et al., 2019 ). The second biggest cluster (green) represents an intra-national research network that includes 10 researchers from eight different higher education institutions in the United States. The dark blue cluster represents an institutional collaborative network, including nine researchers from the School of Public Health, Puerto Rico. Other prominent clusters in the map represent collaborative research networks between eight (olive color) and seven researchers (turquoise, violet, orange, and mellow mauve). This contrasts, however, with the limited collaboration that exists between clusters. Only four of the clusters on the map demonstrate some kind of scientific collaboration in the field (light blue, pink, brown, and yellow).

Figure 3. Collaborative research networks between researchers. Only researchers with five or more publications were considered in the analysis ( n = 179).

Cross-country collaboration networks in mental health and well-being of university students study are presented in Figure 4 . Research collaborations between countries with 20 or more publications were considered in this analysis ( n = 45). The United States occupies the central position of the map and shares collaborative ties with all other countries/territories, forming a cluster together with China, South Korea, and Taiwan. Overall, the results suggest that international collaborations in the field are framed to a large extent by cultural, linguistic, and geographical proximity. For instance, the largest cluster (red) is formed by two European countries (Spain and Portugal) and other South American countries with whom they share historical and cultural backgrounds. Other European countries form the purple cluster. Similarly, the blue cluster clearly brings together predominantly English-speaking countries and territories, while the green cluster agglomerates a range of Asian countries.

Figure 4. Collaborative research networks between countries and territories. Only countries with 20 or more publications were considered in the analysis ( n = 45).

Collectively, the results of our study suggest that research collaboration in the field of mental health and well-being in university students remains relatively scarce and localized to date. The social structure of the field at the author level could be described as an archipelago formed by a large number of islands (research groups) of different composition and size but with few bridges connecting them, which suggests a relatively fragmented research community. Moreover, while the existence of international collaborative networks was evident in the analysis, they seem to be formed within national borders, between researchers in neighboring countries/territories, or between countries that share cultural, linguistic, and historical heritages. This may be due to the important role that cultural and traditional values play in the conceptualization of mental health and well-being across contexts ( Eshun and Gurung, 2009 ; Vaillant, 2012 ; Fernando, 2019 ). Also, language differences, divergent cross-national institutional and organizational traditions, and increased costs of extramural collaboration, have been found to complicate the formation and continuity of research partnerships in health research ( Hooper et al., 2005 ; Freshwater et al., 2006 ). Nevertheless, limited within- and between-country research collaboration arguably poses challenges to the development of a field in terms of lost opportunities to challenge assumptions taken for granted and move toward fresh perspectives, push boundaries in methods and techniques, meet diverse groups of people from differing cultures and get immersed in those cultures, share information, resources, and skills, and address common mental health problems through the pooling of resources ( Rolfe et al., 2004 ; Freshwater et al., 2006 ).

Intellectual Structure: Disciplines Underlying the Foundations of the Field

Interdisciplinarity is considered as a valuable approach to address the complex and multidimensional nature of health and well-being ( Mabry et al., 2008 ). Buckton (2015) argues that the integration of medical, psychological, and social sciences have contributed to generate “new insights into theory, practice, and research in mental health and development.” (3). To examine the disciplines underlying research on the mental health and well-being of university students, a journal co-citation analysis was performed. In this analysis, only journals with at least 50 citations were considered ( n = 593). The nodes on the map represent journals and their size reflects the number of co-citation relationships with other journals. Colors account for journal clusters, which agglutinate journals with higher co-citation relationships and stronger semantic connectedness. Clusters were interpreted and labeled accounting for the WoS categorization of the journals with the highest co-citation links within each cluster. For example, if the Journal of Personality and Social Psychology , the Journal of Counseling Psychology , and Personality and Individual Differences clustered together, this group was interpreted as the personality, social, and counseling psychology cluster.

In general, the findings of this study suggest that research on mental health and well-being in university students is interdisciplinary, to a certain extent, and mainly emerges from the convergence of research conducted in the behavioral and biomedical sciences, as it has been suggested elsewhere ( Schumann et al., 2014 ; Wittchen et al., 2014b ). More specifically, the map shows that the research in the mental health and well-being of university students is constructed through the integration of knowledge generated in five interconnected disciplines (see Figure 5 ). To the left of the map, the red cluster integrates journals on personal, social, and counseling psychology . To the right, the blue cluster represents the contribution of psychiatric journals to research to the formation and development of the field. At the top, the yellow cluster groups journals on substance abuse and issues related to alcohol consumption, addiction, and interpersonal violence. At the bottom of the map, journals covering topics on eating behaviors, sleep, and other issues related to physical health converge on the green cluster. At the center of the map is the purple cluster, which includes journals in the area of clinical psychology and behavioral therapy .

Figure 5. Map of clustered network journals based on co-citation data. Only publications with 50 or more citations were considered in the analysis ( n = 593).

More broadly, the findings suggest that biomedical sciences contribute to a large extent to the composition of the field. Psychiatric research emerged in our study as an obvious building block in the study of university students’ mental health and well-being, which is not surprising considering the historical contributions of biomedical disciplines to mental health research ( Schwartz and Corcoran, 2010 ). Within the behavioral sciences, personality and social psychology, which explores processes and mechanisms through which social phenomena influence mental health and well-being ( Sánchez Moreno and Barrón López de Roda, 2003 ), appears as a key discipline underlying the foundations of the field. Surprisingly, clinical psychology journals occupy a central position in the map and demonstrate co-citation relationships with journals from all other clusters but make up the most dispersed network and account for a considerably lower volume of co-citation relationships in the field. This suggests that clinical psychology journals are more subordinate to journals in other disciplines in terms of citations flows, and ultimately, play a less unique role in research on the mental health and well-being of university students, as suggested by Haslam and Lusher (2011) . Interestingly, research arising from the social sciences (e.g., sociology and anthropology) does not seem to make a distinctive contribution to the intellectual structure of the field, which suggests that the influence of social contexts and cultures on university students’ mental health and well-being (e.g., inequality, social norms, public policies, cultural beliefs, and values) is an underexplored research area. Still, the density of co-citation network relationships within and between clusters is particularly noteworthy, considering the lack of common language between disciplines, the absence of a shared philosophy of practice on mental health, and the tensions between medical, psychological, and social explanations of mental distress ( Bailey, 2012 ).

Conceptual Structure: Topical Foci Addressed in the Literature Over the Last 45 Years

The topical foci of research on the mental health and well-being of university students during the 1975–January 2020 period are presented in Figure 6 . The map offers a visual representation of the co-occurrence analysis of author keywords of all the publications included in the dataset. Only the most frequently occurring keywords (25+ occurrences) were considered in the analysis ( n = 84). Items that were not related to others and do not belong to the existing clusters were excluded. The size of the nodes indicates the occurrence of author keywords in the dataset and the thickness of edges represents the co-occurrence strength between pairs of keywords.

Figure 6. Topical foci in mental health and well-being of university students research. Only keywords with 25 or more occurrences were considered in the analysis ( n = 84).

The most frequent keywords in the dataset, excluding students’ descriptors (e.g., college students and university students), refer to common mental health challenges experienced by university students such as depression ( n = 612), anxiety ( n = 353), and stress ( n = 341). Salutogenic-related keywords such as well-being and life satisfaction occurred less often ( n = 138, n = 113, respectively), suggesting that pathogenic approaches to the exploration of mental health issues in higher education are more widespread. More broadly, seven general themes seem to summarize the topical foci of interest in the field of mental health and well-being of university students over the last 45 years. First, there has been a general interest in positive mental health , as denoted by frequently co-occurring key terms such as well-being, self-esteem, life satisfaction, social support, emotional intelligence, and happiness (red cluster). Second, mental disorders stand as another theme widely addressed in the literature, with a special emphasis on depression, anxiety, and to a lesser extent, suicide and suicidal ideation (green cluster). A third topical area in this field has been substance abuse , most predominantly alcohol consumption (blue cluster). The fourth theme reflects college counseling for mental health , including interventions and protective factors such as mindfulness, stress management, spirituality, and help-seeking (yellow cluster). Other topics reflected in the map are mental illness stigma (purple), stress (e.g., psychological distress and coping) (light blue), and mental health measurement (orange).

This study provides a comprehensive overview of the research on university students’ mental health and well-being in the last 45 years using bibliometric indicators. In general, the results reveal interesting trends in the evolution of the field over the last four decades and promising scientific patterns toward a better understanding of the mental health and well-being of university students internationally. First, the interest in the mental health and well-being of university students has grown in the last decades and in a very significant way during the last 10 years, indicating that this area has not still reached its maturity period and will continue developing in the future. Second, research in the field is relatively interdisciplinary and emerges from the convergence of research conducted in several disciplines within the behavioral and biomedical sciences. Third, research in this field is produced by a community of productive researchers coming from several regions around the world, most notably in the United States, which secures a generation of scholars that will continue shaping the field in the years to come. Fourth, over the last 45 years, researchers have been able to address a multitude of research topics in the field, including positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement.

However, this study also identified some issues that could be hindering the development of the study of the mental health and well-being of university students. For example, the research available overrepresents theoretical and disciplinary approaches from the developed world. Additional studies on the field from developing economies and LMICs are needed to provide a more comprehensive picture and ensure a fair representation of the multiple perspectives available in the field. Such studies would inform administrators and practitioners on how to broaden and enrich available programs and initiatives to promote mental health and well-being in higher education contexts in order to offer alternative forms of support that university students find appropriate for their social and cultural values. Moreover, the research community contributing to the development of the field is relatively fragmented. There are multiple research groups but little research collaborations between them and, at the international level, these connections tend to be limited by geographic, cultural, and language proximity. In this context, more actions like the WMH-ICS Initiative could provide a partial solution to this problem by strengthening national and international research partnerships and facilitating knowledge exchange across regions. Also, special issues in the core journals in the field inviting cross-cultural studies on the topic could contribute to promoting research collaboration across regions and research in less represented countries. The field would also benefit from a greater volume of research from the social sciences and humanities exploring the influence of social, cultural, economic, and educational factors on the conceptualization, manifestation, and experience of mental health and well-being. Moreover, more studies emerging from disciplines such as sociology, anthropology, business, and education, would likely increase the permeability of positive mental health concepts into the field and contribute to the promotion of salutogenic approaches to the study of mental health and well-being of university students.

This study has several limitations. First, publications were retrieved only from the WoS database, which limits the generalizability of the findings. Second, WoS provides stronger coverage of Life Sciences, Biomedical Sciences, and Engineering, and includes a disproportionate number of publications in the English language ( Mongeon and Paul-Hus, 2016 ). This could partially explain the low number of publications emerging from the Social Sciences, the Arts, and the Humanities, and research conducted in non-English speaking countries in the present study. Third, only journal articles were retrieved for analysis, excluding other relevant publications in the field such as reviews, book chapters, and conference proceedings. Future studies could replicate the findings of this study using alternative databases (e.g., Scopus and PubMed) or a combination of them, as well as different filters in the search strategy, to provide an alternative coverage of research conducted in the field. Nevertheless, we believe that the bibliometric approach used in this study offers novel insights about the development and current status of the field and some of the challenges that undermine its progression.

Data Availability Statement

The datasets generated for this study are available on request to the corresponding author.

Author Contributions

DH-T and LI contributed to conception and design of the study, organized the database, and performed the statistical analysis. DH-T, LI, and JS wrote the first draft of the manuscript. NL, AC, AA, YN, and AM wrote the sections of the manuscript.

This research was funded by the Nazarbayev University Faculty-Development Competitive Research Grants Program (Reference Number 240919FD3902).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords : mental health, mental illness, well-being, psychological distress, university students, higher education, bibliometric review, VOSViewer

Citation: Hernández-Torrano D, Ibrayeva L, Sparks J, Lim N, Clementi A, Almukhambetova A, Nurtayev Y and Muratkyzy A (2020) Mental Health and Well-Being of University Students: A Bibliometric Mapping of the Literature. Front. Psychol. 11:1226. doi: 10.3389/fpsyg.2020.01226

Received: 03 March 2020; Accepted: 11 May 2020; Published: 09 June 2020.

Reviewed by:

Copyright © 2020 Hernández-Torrano, Ibrayeva, Sparks, Lim, Clementi, Almukhambetova, Nurtayev and Muratkyzy. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Daniel Hernández-Torrano, [email protected] ; [email protected]

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Literature Review on Depression

Depression alters one’s mood, making one feel sad and lose interest in people, events, and objects, and thus may cause physical and emotional problems. It may involve treatment in the long run if it persists, which includes medication and psychotherapy. This paper will focus on a detailed summary of other researchers’ work addressing the issue of depression using several databases and carry out a curative study on depression in full text. The following literature review is based on selected articles meeting the criteria of inclusion.

According to Lim et al. (2018), depression in the general population is a common mental health condition. It is highly associated with sadness, low self-esteem, poor concentration, anxiety, interest loss, and a feeling of being a quilt. The study also shows that the World Health Organization (WHO) predicted that depression will be ranked as the second global disease burden by 2020. The research also covered the nomothetic and idiographic measures of depression, which means that the assessed item is common to every person at different degree levels. In contrast, the idiographic measure is based on the distinct features and views of the patient. The study concludes that during the patient assessment on the defined objective of treatment, idiographic measures are preferred due to being more relevant.

An investigation done by Bernaras et al. (2019) states that depression is the main cause of disability-related illness in the world. The research focused on depression among children and adolescents since these two groups are agilely associated with high incidence. It also analyses the theories that construct and explain depression and provides an overview of disorders among children and adolescents. In this study, the authors conclude that depression in terms of the mental distinction between adults and children has no difference, and thus, the theory of explanation is highly taken into account to elaborate a better understanding of depression. The research further stated that treatment and prevention should be multifactorial (Bernaras et al., 2019). Besides, it is estimated that universal programs can be more efficient considering their wide application. The research results are limited in providing a good conclusion and fail to demonstrate any solid long-term efficacy.

Bernaras et al.(2019) in their examination found that biological factors such as tryptophan have a strong influence on the appearance of a depressive disorder. The increase seen in the prevalence of depression is explained by having negative interpersonal relations and the relationship with one’s surroundings accompanied by social-cultural changes. Additionally, the authors conclude that many instruments can be applied in elevating depression, but it is more important to have a continued test to diagnose the condition at the early stages. Regarding the prevention programs, the study suggested that they should be implemented at early initial ages, and finally, most depression treatments are more rigorous and effective.

Additionally, Health Quality Ontario (2017) suggests that the most diagnosed disorders in Canada on depression are major depressive and generalized anxiety disorders that are mostly associated with high disorders and economic hardship. It is important to note that the treatment of the two conditions is known to include pharmacological and psychological preventions. The highly used psychological interventions include cognitive-behavioral therapy (CBT), supportive therapy, and interpersonal therapy.

The study supports the fact that depression is the world’s second-largest health problem based on illness-induced disability. The three most used psychotherapeutic treatments which are well explained in this research include CBT, interpersonal therapy, and supportive therapy. CBT focuses on helping patients understand how automated thoughts on beliefs, expectations, and attitudes have a major contribution to anxiety and sadness. Interpersonal therapy aims to identify and solve problems through the establishment and maintenance of a satisfying relationship. Lastly, supportive therapy is an unstructured approach that relies on the basic interpersonal skills of the therapist.

Research conducted by Lu (2019) on adolescent depression on the topic of national trends, health care disparities, and risk factors shows that in the US, depression is a major cause of suicide among adolescents in aged between 10 and 19. Suicide is marked as the third major cause of death in the US, and research reflects that depression is the major factor in these cases. According to Lu (2019), depression is mostly underdiagnosed among adolescents, although mental health treatment is available. Lu (2019) states that if depression is not treated at the early age of an adolescent, it can have substantial negative effects on health and social results in late adolescence and adulthood.

Findings from the study revealed a growing number of untreated adolescents with major depression from 2011 to 2016 from the National Survey on Drug Use and Health (NSDUH) data. The research outcomes highlighted some of the major causes of depression among young people. Such factors include some sociodemographic, school, and family parameters, and the underutilization of mental health services. The study findings also highlight the importance of family and school in the treatment of depression. Finally, it was proved that adolescents with less family attention were more vulnerable to depression and less likely to receive mental and medical treatment.

The treatment of depression among adults in the United has been covered by a study done by Olfson et al. (2016). Based on the national survey conducted from 2001 to 2003, it was approximated that 49.5 percent of adults with a history of depression had not received any treatment, and about 48.4 percent had not received mental treatment over the past year (Olfson et al., 2016). According to the study, the US Preventive Service Task Force (USPSTF) has recommended adult screening on depression and a follow-up on the treatment that should be provided through a clinical setting arrangement.

The study findings showed that although there is the increased use of antidepressants, there still exists a gap in the treatment of depression. The number of adults who received screening for depression did not receive treatment that year. The research also showed that there was a low hood on receiving treatment to racial /ethnic minority groups. Regarding the application of antidepressants, the patient who had less serious depression had a high likelihood of receiving antidepressants than seriously depressed patients.

Antipsychotics, anxiolytics and mood stabilizers were mostly used to treat patients with higher than lower degrees of distress. Olfson et al. (2016) stated that this type of medication was mostly kept to treat patients with more complicated and resistant to treatment conditions. Antipsychotic treatment is suitable for patients with resistance to the use of antidepressants. Anxiolytics largely aid in managing anxiety problems that do not respond to the use of antidepressants. Finally, mood stabilizers help in the adjustment of agitations related to depression.

Research by Stark et al. (2018) on the issue of depression perspective in older primary care patients, treatment, and depression management opportunities showed that depression in old age is very common and has health-related consequences on the elderly. Research findings showed that symptoms like sadness and withdrawal are associated with older people. The consequences of depression can lead to death through suicide, social isolation, loss of family and work, and low esteem. The causes of the condition, as stated by Stark et al. (2018), are classified based on changing life events and internal factors.

According to Stark et al. (2018), depression does not only occur at young age people but is also a threat to older people. In age-related causes, the increased incidence of deaths among relatives can cause loneliness and boredom. Treatment of depression among older adults is possible. The main obstacles to the successful recovery from depression among the elderly, according to research, include beliefs on there is no treatment for depression among older people as well as fear of stigmatization. Similarly, it is believed that people should only care about their problems.

Research on adolescent depression, in particular, the one conducted by Lu (2019), has greatly contributed to literature work. Vrijen et al. (2016) have concentrated their research on predicting depression through the slow identification of facial happiness during early adolescent stages. As seen from previous research, depression remains a major concern in mental health problems. The study proved how facial emotions in the early ages of depression could predict depressive disorders and symptoms.

Research findings suggested that facial emotion identification prejudice may be a symptom corresponding trait marker for depressive disorder and anhedonia. The associations were found only based on multi-emotional models. The study found that individuals who portray sadness in comparison to happy ones are more likely to develop depression or anhedonia symptoms. The emotion identification effects on depressive disorders are mainly seen as carried by the symptoms of anhedonia but not symptoms of sadness. There is a relationship between symptoms of anhedonia and facial emotion identification (Vrijen et al., 2016). On the elimination of adolescents, the research findings were stronger on the predictive value on the identification of facial reactions for individuals with depressive disorders related to anhedonia and despair and may inversely be connected with facial identification of emotions.

Furthermore, depression and depressive symptoms among outpatients showed that the features are very common in people with mental disorders and gave a considerable number of effects on patient quality of health. The results of previous studies vary from the consideration presented in the research by Wang et al. (2017). In this study, it was found that the number of outpatients from otolaryngology clinics was higher, marking 53.0 %. The research also highlighted that depression was a mediator among conditions in otolaryngology.

The outcomes also have shown that there is a psychoneuroimmunology link between medical illness and depression. Besides, stroke burdens were found to cause depression among patients and their caregivers. For patience with stroke, it was found that novel rehabilitation interventions might reduce depression. A medical professional often overlooks depression or depressive symptoms due to not having been offered specific mental health training. In this research, it was found that outpatients between the age of 30 and 40 had related depression prevalence as compared to outpatients between the age of 80 and 90 years old. The result contradicts research done by Benaras et al. (2019) on depression among children and adolescents, which focused on the rise of the incidence of suicide cases caused by depression. Yang’s study showed that depression levels declined with age. The author presents different results as he stresses that there was no pattern on depression centering his argument on age.

Depression has been a global problem that has raised concerns among employees and employers. According to McCart and Nesbit (2020), the number of days of absenteeism in jobs results from depression is higher than those related to diseases like heart attack and hypertension all put together. According to the study, billions of dollars are spent on medical care, mortality due to suicide, and the loss of productivity as a result of depression. McCart and Nesbit (2020) have discussed a connection between disorders caused by depression and such chronic conditions as the unemployment period and the total income.

In the employment setting, research has shown that some reasons make it difficult to diagnose depression. In the workplace, employees can avoid diagnosis because of the lack of skills by physicians, stigma, unavailability of treatment and providers, restrictions on drugs, psychotherapeutic care, and limitations due to third-party coverage. The study results from most organizations lack a way of huddling the employee’s depression. Education institutions were found to be having programs that help depressed personnel. Other organizations stated that depression is a personal issue, and unless an employee asks for help, the services are not openly offered.

Among pregnant women, depression has been found to affect both the mother and the unborn child. Looking at both depression and anxiety during the period of antenatal and post-natal, there is a notable effect of depression among these groups. According to Smith et al. (2019), there is a preference in pregnant women for non-pharmacological treatment options; instead, they prefer the use of therapies and complementary medicines to manage the symptoms.

Martínez-Paredes and Jácome-Pérez (2019) conducted a similar study on depression among pregnant women, which confirmed that depression in this group is common psychiatric mobility. Diagnosis of depression is based on guidelines by the DSM-5 to validate scales like the Edinburgh Postnatal Depression Scale. According to medical professionals, the research also shows negative effects on the treatment, diagnosis, and recognition of the fetus. The study concluded that depression is a common condition among pregnant women, though it is underlooked as its symptoms are linked to pregnancy.

Several personal and mental effects are caused by depression among patients of total knee arthroplasty. Findings of the research have indicated that patients with higher education levels have less depression and are happier before surgery. Results have also illustrated that people with depression and anxiety were found to improve at a low rate than other groups. It also stated that patients with greater health were seen to have a considerable improvement in mental health. The conclusion of the research showed that the main determinant of physical, mental, and functional outcomes was depression.

Depression remains to be among the top five illnesses in the world, and research works have reflected that age does not matter, with everyone being at risk of developing the condition. In most studies, it is indicated as the main cause of suicide and death among children and adolescents. There are ways to help individuals suffering from despair such as the use of antidepressants among people with low depression levels. Likewise, early detection and treatment of the disorder can help individuals in their late adolescent stages and adulthood. Families can offer their support instead of contributing and worsening this condition.

Bernaras, E., Jaureguizar, J., & Garaigordobil, M. (2019). Child and adolescent depression: A review of theories, evaluation instruments, prevention programs, and treatments .  Frontiers in Psychology, 10 (543), 1-24. Web.

Health Quality Ontario. (2017). Psychotherapy for major depressive disorder and generalized anxiety disorder: A health technology assessment. Ontario Health Technology Assessment Series, 17 (15), 1-167.

Lim, G. Y., Tam, W. W., Lu, Y., Ho, C. S., Zhang, M. W., & Ho, R. C. (2018). Prevalence of depression in the community from 30 countries between 1994 and 2014 . Scientific reports , 8 (1), 1-10. Web.

Lu, W. (2019). Adolescent depression: National trends, risk factors, and healthcare disparities . American Journal of Health Behavior, 43 (1), 181-194. Web.

McCart A, & Nesbit, J. (2020). S trategies to support employees with depression: Applying the Centers for Disease Control health scorecard . Journal of Depression and Anxiety, 9 (5), 1-4. Web.

Martínez-Paredes, J. F., & Jácome-Pérez, N. (2019). Depression in pregnancy . Revista Colombiana de Psiquiatría (English ed.) , 48 (1), 58-65. Web.

Moghtadaei, M., Yeganeh, A., Hosseinzadeh, N., Khazanchin, A., Moaiedfar, M., Jolfaei, A. G., & Nasiri, S. (2020). The Impact of depression, personality, and mental health on outcomes of total knee arthroplasty . Clinics in Orthopedic Surgery, 12 (4), 456-463. Web.

Olfson, M., Blanco, C., & Marcus, S. C. (2016). Treatment of adult depression in the United States . JAMA Internal Medicine, 176 (10), 1482-1491. Web.

Smith, C. A., Shewamene, Z., Galbally, M., Schmied, V., & Dahlen, H. (2019). The effect of complementary medicines and therapies on maternal anxiety and depression in pregnancy: A systematic review and meta-analysis . Journal of Affective Disorders , 245 , 428-439. Web.

Stark, A., Kaduszkiewicz, H., Stein, J., Maier, W., Heser, K., Weyerer, S., Werle, J., Wiese, B., Mamone, S., König, H., & Bock, J. O. (2018). A qualitative study on older primary care patients’ perspectives on depression and its treatments-potential barriers to and opportunities for managing depression . BMC Family Practice, 19 (1), 1-10. Web.

Vrijen, C., Hartman, C. A., & Oldehinkel, A. J. (2016). Slow identification of facial happiness in early adolescence predicts the onset of depression during eight years of follow-up. European Child & Adolescent Psychiatry, 25 (11), 1255-1266. Web.

Wang, J., Wu, X., Lai, W., Long, E., Zhang, X., Li, W.,… & Wang, D. (2017). Prevalence of depression and depressive symptoms among outpatients: a systematic review and meta-analysis . BMJ Open , 7 (8). Web.

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