Cross-sectional trend analysis of the NCHA II survey data on Canadian post-secondary student mental health and wellbeing from 2013 to 2019

Increasingly, post-secondary students are acknowledged as an at-risk group for poor mental health and the development of mental illnesses. Research has demonstrated that students report a high prevalence of stress [1, 2] and mental illnesses [3‐5]. The 2012 cycle of the Canadian Community Health Survey revealed that young Canadians aged 15–24 years (capturing the majority of post-secondary students) were the most likely to report symptoms of a mental illness or an unmet need for mental health care [6, 7]. The 2016 Global Burden of Disease Study revealed mental illnesses to be among the top four leading causes of loss of disability-adjusted life-years (DALYs) in Canada [8].

Post-secondary students face a wide array of stressors, spanning the academic, financial, and social spheres, placing them at risk for languishing mental health, particularly if they lack effective coping strategies. Chronic stress is highly correlated with negative mental health outcomes and has been shown to have a substantial impact on students’ academic performance [9, 10]. Research suggests that male and female students experience mental health challenges differently, with females more likely to report symptoms consistent with anxiety and depression [11], and males more likely to experience issues related to perceived stigma and help seeking [12‐14]. Flourishing mental health and emotional wellbeing are prerequisites for academic success, and mental health problems are associated with academic failure, dropout, addictions, and even suicide [15‐17], underscoring the importance of monitoring students’ mental health.

Currently, there is no nationally coordinated effort to monitor mental health related data for post-secondary students, though one is currently in development at the University of British Columbia [18]. This is an important gap to be filled, given that the design and implementation of interventions to alleviate stress and promote mentally healthy campuses should be informed by the prevalence and correlates of languishing mental health. In the absence of a Canadian-made surveillance system, the National College Health Assessment Survey II (NCHA II), delivered by the American College Health Association, constitutes the most complete source of data on post-secondary student stress and mental health outcomes currently available. To date, the NCHA II has been conducted on three occasions among Canadian post-secondary students, producing mental health-related data for 2013, 2016, and 2019. To our knowledge, a longitudinal analysis of these data has not yet been conducted. Therefore, the primary purpose of this secondary analysis of cross-sectional data was to examine trends in the overall and sex-specific prevalence of self-reported stress, psychological distress, mental illness, and help seeking behaviours among Canadian post-secondary students from 2013 to 2019.

Data were collected cross-sectionally from students at participating Canadian post-secondary institutions in 2013 (n = 38,171 student responses), 2016 (n = 43,780), and 2019 (n = 55,284). Mean response rates¹ for each year ranged from 19 to 20% [19‐21]. The number of post-secondary institutions that participated in each year were 32, 41, and 58 in 2013, 2016, and 2019, respectively. The NCHA II consists of over 300 questions relating to the overall health of post-secondary students. While the survey is primarily concerned with physical health indicators, a number of questions pertain to students’ emotional and mental health. The NCHA II is administered confidentially through Qualtrics by the ACHA. Each participating institution provides the ACHA with a fee for participation, a letter of information and informed consent, a subject line for the invitation, a copy of the institution’s research ethics board approval, and a sample of students’ e-mail addresses. The sampling method and sample size used is at the discretion of each participating institution. After the initial distribution of the survey, non-responders are sent up to three reminder e-mails. A total of 32 institutions participated in 2013, 41 in 2016, and 58 in 2019.

Table 1 presents the demographic characteristics for each sample. In each year of data collection, the largest proportion of participants were full-time students, female, and reported a GPA in the B range. The majority of students were between 18 and 24 years of age, and studied at the undergraduate level. The amount of missing data for each outcome was low; complete case analysis resulted in the inclusion of at least 97% of students in each model.

Over the past decade, increasing attention has been paid to mental health issues among post-secondary students in Canada, with post-secondary institutions across the country reporting an increasing demand for mental health treatment services that they feel unable to meet. This increase in demand over the past several years has reportedly resulted in lengthy wait times, large caseloads, brief or limited sessions provided to clients, and a high rate of counsellor burnout [22‐24]. Additionally, reports from counsellors suggest that the complexity and severity of students’ presenting issues have increased in recent years [25]. As a result, the question of whether or not a “mental health crisis” has emerged among this population has arisen [26, 27].

We examined multiple indicators for mental health and mental illness among Canadian post-secondary students comparing the data from the NCHA II cross-sectional surveys collected in 2013, 2016, and 2019. We determined whether prevalence estimates for mental health indicators had increased significantly over time, as well as whether the rate of change differed for male and female students. Our analysis revealed that the proportion of Canadian post-secondary students reporting above average stress, symptoms of psychological distress, diagnosed mental illnesses, and help seeking for mental health related challenges indeed significantly increased between the 2013 and 2019 iterations of the survey, with few exceptions. In nearly all cases, higher proportions were observed among female students compared to male students, though the rate of change was only significantly different between sexes for some indicators, indicating that the proportion of students self-reporting mental health challenges has increased at a similar rate for males and females in most cases.

Stress has long been reported among post-secondary students, with a well-established link between excessive stress and negative impacts on mental health [28, 29]. Additionally, associations between poor mental health and declines in academic performance have also been observed [15]. We found that mean stress levels reported by students increased significantly between 2013 and 2019, with female students reporting a higher mean stress level within the past 12 months compared to male students. Categorically, while the proportion of students reporting ‘average stress’ decreased, we observed increases in both the proportion reporting ‘tremendous stress’ and ‘no stress,’ with more male students reporting ‘no stress’ compared to females. This may suggest that while existing stress reduction interventions have resulted in some students improving, other students are getting worse. Recent research suggests that female students experience more frequent and severe stress compared to their male counterparts. Stress remains an imperative area of concern and the need for further investigation into the sources of stress among post-secondary students is clear. Tools such as the Post-Secondary Student Stressors Index (PSSI) [30, 31] have been created to do just this, and aim to enable post-secondary institutions to make evidence-informed decisions regarding the targeting and delivery of their upstream mental health services, including stress reduction programming.

Research among post-secondary students in the USA has revealed an association between common mental illnesses, such as anxiety and depression, and negative academic outcomes [15]. In this study, the proportion of students who reported having been professionally diagnosed with a mental illness increased significantly between 2013 and 2019, with a larger proportion of females reporting diagnoses than males. This finding is consistent with previous research and patterns of sex-based diagnosis in the broader population [32, 33]. Anxiety and depression remain the most common mental illness diagnoses among the student population, consistent with previous research, with the prevalence of these diagnoses appearing to increase over time. Whether or not the increases observed constitute a “true” increase in prevalence, however, is up for debate. It is possible that the observed increases in prevalence may stem from a combination of increased mental health awareness and a reduction in stigma, resulting in more students reporting and seeking help for mental health-related challenges. Another point of consideration is that increasingly, more students seem to be beginning their post-secondary educational careers with pre-existing diagnoses [34]. Therefore, the post-secondary environment is not necessarily creating an increase in the prevalence of mental illnesses, though it may be a contributing factor. Notably, recent research has shown that post-secondary students do not appear to have worse mental health than the general population, therefore challenging the notion of there being a “mental health crisis” among the Canadian post-secondary student population [35]. This is not to say that post-secondary mental health in Canada does not deserve attention, but suggests that mental health care for emerging adults both within and outside of the post-secondary institution must be bolstered.

Improved targeting and bolstering of upstream mental health services, in particular, may alleviate the current burden on downstream services (e.g., counselling, therapy) observed on post-secondary campuses [36] as well as in the general population [37, 38]. Upstream services may include mental health promotion activities and/or toolkits that assist students with bolstering and maintaining resilience in the face threats to one’s mental health. For example, “Surviving to Thriving,” a self-help resiliency toolkit designed for post-secondary students [39], may be a useful resource to distribute to incoming undergraduate students. This toolkit invites students to better understand changes in their mental health, and lay out a plan of action for how to effectively respond to common stressors within the post-secondary setting. Resilience has long been identified as an effective mediator of the relationship between stress and mental health outcomes, with individuals reporting higher levels of resiliency experiencing more positive mental health outcomes when compared to their low resiliency counterparts [40]. Students should also be educated about adaptive coping methods [41]. An oft-cited, maladaptive coping mechanism used by students to manage mental health challenges is substance use. Mental health education campaigns directed at students should emphasize healthier coping mechanisms, including developing strong social support networks and self-care regimens. In addition to the bolstering of upstream mental health services, improved connections between post-secondary institutions and community-based mental health care are warranted to ensure continuity of care beyond the academy [42].

Previous research has investigated mental health help seeking behaviours among the post-secondary student population, identifying a number of barriers including stigma [14, 43], lack of perceived need [44], and doubts surrounding treatment effectiveness [44]. Few studies have explored whether improvements have been observed in students’ willingness to seek help. Our analysis revealed the proportion of students seeking help significantly increased across all sources (with the exception of seeking help from members of the clergy) between 2013 and 2019, regardless of sex. A larger proportion of females than males reported seeking help from nearly all sources, which is consistent with previous research [14, 44, 45]. Increases were also observed in the proportion of students who expressed an intention to seek help in the future if necessary. This may provide support for a reduction in mental illness-related stigma and increase in overall mental health literacy among post-secondary student populations having occurred since 2013, both noted as important factors in the relationship between mental health help seeking attitudes and behaviours [46]. While a larger proportion of female students indicated an intention to seek help in the future, an increase in willingness was also observed among male students. This is notable, given that previous research has revealed a strong reluctance for help seeking among male students as a result of perceived stigma [12, 14, 47, 48]. One area with respect to help seeking on post-secondary campuses that has not been well explored to date is the perceived accessibility of mental health services from the student point of view. Actions have been taken within the broader post-secondary community to increase the availability and degree of services offered (i.e., the Okanagan Charter and the National Standard for Student Mental Health), we are not aware of any rigorous data available (particularly at a national level) regarding students’ perceptions of access to services and whether or not this has improved over time. This may present an interesting opportunity for future research regarding help seeking among this population.

Our analysis indicated that the proportion of students self-reporting mental health related challenges, including stress, psychological distress, and diagnosed mental illnesses increased between the 2013, 2016 and 2019 iterations of the NCHA II conducted among Canadian post-secondary students. However, it is important to note that these results should be interpreted with caution. While we observed an upward trend in the data analyzed here, we cannot say whether this indicates an ongoing trend moving forward. We would be more confident in the results of a trend analysis conducted with more than three time points, particularly given the cross-sectional nature of the NCHA II data and its associated limitations. Overall, improved targeting and bolstering of upstream mental health services at the post-secondary level in addition to improved connections between post-secondary institutions and community-based mental health care are warranted.