BENEDICT

INTRODUCTION

World Health Organization defines bullying as a threat or physical use of force, aiming at the
individual, another person, a specific community or group which can result in injury, death,
physical damage, some development disorders or deficiency. The concept of bullying at school is
not new; however it has been increasing in recent years. There is a crucial increase in studies
conducted and the number of news on bullying at school in mass media (1-3). Bullying in
schools is an issue that continues to receive attention from researchers, educators, parents, and
students. Despite the common assumption that bullying is a normal part of childhood and
encompasses minor teasing and harassment (4), researchers increasingly find that bullying is a
problem that can be detrimental to students' well-being (5-7). This report focuses not only on the
prevalence of bullying, but also on those subsets of students who reported being the victims of
direct, and indirect bullying, and both of them. Different types of bullying may affect different
groups of students, occur in different types of schools, or affect student behavior in different
ways. These distinctions allow readers to differentiate between students who were either
physically (directly) or socially (indirectly) bullied, and also to identify those students who were
bullied both physically and socially (4). Additional analysis describes the characteristics of
students affected by these types of behavior and the characteristics of schools in which these
behaviors occur. Because of prior research that suggests victims of bullying may resort to
aggressive behaviors in response to being bullied, the extent to which reports of bullying are
related to victim behaviors such as weapon carrying, physical fights, fear, and avoidance are
explored. Finally, for educators, the academic success of students is of paramount importance.
For this reason, self-reported academic performance of bullied students is also examined (5,8).
The main aim of this research is to investigate the prevalence of bullying behaviour, its victims
and the types of bullying and places of bullying among 14-17 year-old adolescents in a sample of
school children in Bursa, Turkey. Bullying is a psychological and pedagogical problem
connected with public health. It must be solved by various professionals immediately.

METHODOLOGY

A cross-sectional survey questionnaire was conducted among class 1 and class 2 high school
students for identification bullying. Research was planned as sectional descriptive study. All
class 1 and class 2 high school students from Bursa provincial center were included in the study.
The questionnaire form was created by the experts after literature survey. The questionnaire form
prepared consisted of 2 sections. The first section encompassed 7 items concerning
sociodemographic characteristics of the family, and the second section had 37 items related to
the determination of violence among peers. The questionnaire was administered to students in
collaboration with school counselors. In guidance of school counselors, after a brief nondirective
description, questionnaire was administered to students wishing to participate as volunteers in
the study. Total 6127 students agreed to participate in the study. The questionnaire was
performed in resting hours under the supervision of school counselors in classrooms by students
themselves. For statistical analysis, SPSS forWindows 13.0 was used. Variables have been
presented on the basis of average and standard deviation and frequency (%). Pearson chi-square
TEST, Student's t-test, Spearman's correlation analysis, univariate and multivariate logistic
regression analyses were used. P-value < 0.05 was considered significant for all tests.

DISCUSSION

Bullying in schools is an issue that continues to receive attention from researchers, educators,
parents, and students (4). This study focuses not only on the prevalence of bullying, but also on
those subsets of students who reported being the victims of physical, verbal and/or emotional
bullying.

Sociodemographic Characteristics

Our study population consisted of male students with a mean age of 15.68 ± 0.72 years (range:
14-17 years). As for sociodemographic properties, lower educational level, possesion of a job of
inferior quality have been revealed to be important factors in the exertion of bullying behaviours
(Table (Table1).1). Prevalence of being both aggressors, and victims was reportedly higher
among students aged between 8-16 years. In a study conducted on 62 adolescents aged 16 years,
15% of the male, and 7% of the female students demonstrated violent behaviours. Again, 72
adolescents (12%), 13% of boys, and 12% of the girls were detected to be victims of violence,
while 13 adolescents were both perpetrators, and victims of violence. Persistency of being both
perpetrators, and victims of violence was investigated among adolescents aged between 8-16
years, and 18 of 38 girls at 16, and 27 of 30 girls at 8 years of age were detected to be victims of
violence. Educational levels, socioeconomic status, composition of the families, and changes in
the marital status (divorce, re-marriage etc) were observed for a period of 8 years, and a
correlation between being a victim of violence at 8 years of age, and infliction of violence at age
16 could not be detected (9). In compliance with our study, studies performed in Turkey have
emphasized that demonstration of violence was encountered mostly among adolescents aged 15-
16 years (2,10).

Students involved in violence as aggressors or victims

Majority (99.2%; n = 3223) of male, and female (93.9%; n = 2703) students were detected to be
involved in one form of bullying behaviours as aggressors or victims at one time of their lives.
For a male student, the likelihood of being involved in violent behaviours was detected to be
nearly 8.4 times higher when compared with a female student (p < 0.001). A statistically
significant correlation was not found between the involvement in violence, and age of the
student, familial unity, level of education, and occupation of the parents (p > 0.05). A total of
5926 students involved in violence, demonstrated physical (95.8%; n = 5667), emotional (48.5%;
n = 2875), and verbal (25.3%; n = 1499) bullying behaviours. The students involved in violence
were also suffered from physical (41.2%; n = 2441), emotional (64.1%; n = 3801), and verbal
(47.3%; n = 2805) bullying behaviours (Figure (Figure1).1). A survey conducted in 1994, 1998,
and 2002 in Lithuania detected that one in every 3 children were the victims of various types of
violence exerted regularly by their peers. (During all three surveys conducted in 1994, 1998 and
2002, about one in three students reported that they had been a victim of regular bullying. A
higher percentage of boys (36%) reported being bullied than girls (32%, p < 0.05). This study
demonstrated that students living in rural areas were 1.5 times more frequently bullied than those
in the cities, and 40% the boys and 28% of the girls inflicted violence on their peers. When
incidence rates of bullying in different countries were examined, the highest rate was detected in
Lithuania, followed by Austria, Swiss, Germany, and Russia in decreasing frequency (11-14).

Aggresors

The incidence of physical, emotional or verbal violence by a male student was found to be higher
(8.1, 2.6, and 3.1 times more frequent, respectively) in comparison with a female student (p <
0.001). Usage of physical, emotional, and verbal violence increased with age (p < 0.001). When
compared with a student aged 14 years, a 17-year old student resorted more frequently to
physical (almost 2.2 – fold increase; p = 0.01), emotional (1.6 fold increase; p = 0.01), and verbal
(almost 2 fold increase; p = 0.007) assaults.

A concordance was detected between lower educational level of the family, and verbal, physical,
and emotional aggression. Students with employed parents were found to be more prone to resort
to physical bullying. In a study, 5% (n = 305) of the students reported that they had carried
cutting, and penetrating instruments such as pocket knives, and knives with the intention of
bullying. An 8% (n = 253) of the boys, and 2.2% (n = 52) of the girls using physical violence
carried cutting, and penetrating instruments such as pocket knives, and knives for the intention of
bullying (p < 0.001). A survey among 500 children detected evidence of bullying in 31.4% of the
cases. In schools for girls, the incidence of bullying was detected to be 18%, while it was 38.2%
in coeducational mixed schools. The incidence of bullying increased with age, and higher grades.
Bullying was mostly encountered in the form of verbal violence such as nicknaming, followed
by abusive language, rumoring, insult, and isolation Infliction of physical harm was seen at a rate
of 16 percent. Feeling oneself badly, desiring to be left alone, and tearing his/her clothes etc.
were also observed. School phobia, vomiting, and sleeping disorders were seen in these children.
Frequently, headache was seen to be a cardinal symptom of girls, and boys subjected to bullying
behaviours (15).

Victims

Statistically significant correlations were seen between types of physical, emotional, and verbal
bullying and gender, and age of the students. The likelihood of being a victim of physical,
emotional, and verbal bullying was higher among male students rather than female students
(almost 2, 1.4, and 2 fold increase respectively; p < 0.001). A study demonstrated that physical
and verbal victimization decreases with age (p < 0.05). Minimal degree of physical victimization
was observed among students whose mothers were lycée (36.3%), or university (38.8%)
graduates. The student whose parents had a lower level of education carries a higher potential of
being a victim of bullying. In the study group where male students with a mean age of 13
consisted 50 % of the study population, cases were attending primary (40%), secondary (26%) ,
and higher levels of (34%) education These students were subjected to violence at least once for
a duration of one year. This incidence was 3 times higher than those found in other studies. Male
students were more frequently involved in bullying behaviours. In higher education male
students were more frequently involved in bullying behaviours, while in primary, and secondary
education there was no difference between genders. The frequency of bullying behaviours
decreased in higher grades. Bullying was more frequently observed in families with separated
parents or in the absence of two biologic parents (16).

Students both as victims and perpetrators of violence

Many students were detected to be both victims, and perpetrators of physical (41.7%), emotional
(79.9%), and verbal (80.7%) violence (Figure 6).

Compared with a female student, the probability of being both perpetrator, and victim of a
physical, emotional, and verbal bullying for a male student was increased by 2.2 (p < 0.01), 2.3
(p < 0.001) and 2.3 (p < 0.001) times, respectively. The incidence of being a victim decreased
with age. Among students whose parents were lycée (35%) or university (37.1%) graduates,
physical aggressiveness, and victimhood have been observedly at a minimal level. Compared
with a schoolchild of an unemployed father, and a housewife mother, the child of employed
parents was 1.6-fold more likely to be both victim, and a perpetrator of a verbal bullying (p =
0.001). According to investigations conducted in Italy, boys were resorting to bullying more
frequently than girls, while both genders were becoming victims of violence with a similar
incidence. Boys were more likely to inflict direct physical aggression with the intent of causing
physical harm, whereas girls were more likely to inflict indirect forms of aggression with the
intent of causing psychological harm. However, there were no significant gender differences in
direct verbal aggression. Researches have indicated that bullying is often exerted in the
classrooms, but it is also encountered in other parts of the school, like corridors, and rest rooms,
as well. Overall, 56.7% of all students had never been bullied in the last 3 months, 13.9% were
bullied once or twice, 14.7% sometimes and 14.7% once a week or more often. Girls tended to
be victimized more than boys; 34_5% of girls, and 24_8% of boys, had been victimized
sometimes or more often. Boys were significantly more likely to suffer from various types of
direct bullying, whereas girls were slightly more likely to suffer from indirect forms of bullying
(e.g. being rejected, rumours spread about them). Significant differences emerged as for types of
direct bullying, especially for being threatened and marginally for being physically hurt. There
were no significant gender differences between direct verbal and indirect bullying; boys were
almost as likely as girls to suffer from indirect bullying. An 18.5 % of the girls, and 20.4 % of
the boys were subjected to bullying behaviours exerted by both girls, and boys. Over half of all
students had bullied others, and nearly half had been bullied in Italy. Boys bullied more than
girls, and girls were somewhat more likely than boys to be bullied sometimes or more often (17).
In conclusion, a multidisciplinary approach involving affected children, their parents, school
personnel, media, non-govermental organizations, and security units is required to achieve an
effective approach for the prevention of violence targeting children in schools as victims and/or
perpetrators. In consideration of the impact of child's familial, and environmental cultural
factors, and school ambiance on violence as well, educational efforts should be exerted both to
eliminate potential adversities and also prevent bullying behaviours in schools.

SAHAYAH

Introduction

The Covid-19 pandemic has brought unprecedented stress to the educational system in the US,
not least to colleges and their students. Colleges have faced the difficult decision of whether to
reopen in the 2020/21 academic year and risk becoming a super spreader of the virus or to take
classes online in face of potential losses of revenue and diminished ability to support the most
vulnerable students. Many colleges are facing significant financial stress regardless of the chosen
path [1].

The pandemic has also brought unprecedented stress to college students, starting with the
transition to online instruction over spring break 2020 at many universities [2]. This is further
exacerbated by the long summer of social isolation from the pandemic for many, lost
employment, and uncertainty about the structure of courses and living arrangements in the
2020/21 academic year [3, 4]. Exploiting data collected for the same students pre- and during the
pandemic, we provide new evidence on the effects of the pandemic on mental health of first-year
college students, focusing particularly on the effects of different Covid-stressors.

Even prior to these events, universities nationwide were struggling with a growing mental health
crisis on their campuses. Research finds that young adults 18–25 in the US experienced large
increases (63 percent over the past decade) in major depressive episodes [5]. In a national sample
of universities, the rate of mental health treatment increased from 19% to 34% between 2007 and
2017 [6]. Among students seeking mental health treatment on campuses, anxiety and depression
were the most frequent concerns [7]. The trends for adolescents are particularly troubling given
the far-reaching impact of mental illness on physical health, educational outcomes, and
employment outcomes well into adulthood [8–11]. This study focuses on a diverse sample of
first-year students. The first year is understood to be a particularly challenging year for students
given the transition to a new school environment and the increased independence students
experience [12, 13]. We surveyed first-year students enrolled in a large public university in
North Carolina both before (October 2019-February 2020) and after (June/July 2020) the start of
the Covid-19 pandemic. We estimate an overall effect of the pandemic by comparing changes in
anxiety/depression for the same student from pre- to during the pandemic. Because of multiple
rounds of data collection prior to the pandemic, we are able to test that changes in
anxiety/depression are not driven by pre-existing trends in anxiety/depression over the first year
of college. We exploit rich data on Covid-19-related stressors (e.g., work reductions by either
students or their parents, Covid-19 diagnosis or hospitalization of oneself, family members, or
friends, distanced learning, and social isolation) to establish the extent to which changes in
anxiety/depression symptoms were predicted by pandemic-related factors. These stressors are
motivated by a prior literature showing the importance of financial stress [14], academic stress
[15], and social isolation for mental health [16].

The main contribution of our study is to provide early estimates of the effect of the Covid-19
pandemic on anxiety/depression symptoms of US college students in their first year at university.
Other studies have also estimated how mental health symptoms for college students have
changed from pre- to during the pandemic. For instance, a repeated cross-section study of US
college students compared depression and anxiety rates in Fall 2019 for 58 campuses to late
March-May 2020 for 16 campuses and found small increases in depression from 35.7 to 40.9%
and no changes in anxiety [17]. Another cross-sectional study found that 19% of college students
in Fall 2020 reported that their emotional health was far worse since the pandemic began [18].

A growing number of cross-sectional studies raise concerns about the effect of the pandemic on
college student mental health [17–26], and some speak to potential factors that are related to our
Covid-19 related stressors. One study found that depression and anxiety rates for undergraduates
in 9 US public research universities in May/July 2020 were higher for those who had trouble
adapting to distanced learning [25]. Another conducted at a public university in the US in April
2020 found that worse mental health was associated with employment losses, difficulties
focusing on academic work and concern about Covid-19 [24]. Two studies of college students in
China using post-pandemic data found that family income stability was negatively associated
with anxiety symptoms and that Covid-19 diagnosis of family or friends was positively
associated with anxiety and depression symptoms [27, 28]. A study of college students in Turkey
found that students were more anxious about the effects of Covid-19 on relatives than on
themselves [29]. Another study based on a sample of young adults in India found significant
associations between mental health and economic stressors [30].

Our study extends the previous research by focusing on first-year students, a particularly
vulnerable population, examining the effects of a broad set of Covid-related stressors, and using
longitudinal data. Using longitudinal data is an important extension for several reasons. First, it
directly addresses differential selection into survey participation during the pandemic compared
to pre-pandemic, which would affect the internal validity of repeated cross-section designs. It
also addresses concerns about imperfect recall that may exist in cross-sectional designs where
respondents are asked to compare current mental health to a previous point in time. Second, it
permits us to investigate underlying causes after accounting for key confounds, namely pre-
existing mental health and psychosocial resources.

We are only aware of two longitudinal surveys of college student mental health. One compares
anxiety and depression symptom severity in April 2020 for 205 college students at a large public
university and found significant increases in severity compared to 2 to 8 months earlier [31].
They found that cognitive and behavioral avoidance, online social engagement and problematic
internet use were predictors of these changes. Another compares wellness behaviors at the
beginning to the end of Spring semester 2020 for first-year students and finds modest effects of
the pandemic [32]. An important contribution relative to these studies is that we consider the
effects of a different set of determinants, namely job loss, changes in social isolation, challenges
with distanced learning and health. These stressors help inform the difficult decisions
universities have faced about whether to invite students back to campus or to take classes online
and additional support students may need during the pandemic.

We hypothesize that among first-year college students both anxiety and depression symptoms
will increase after the onset of the Covid-19 pandemic. In addition, the magnitude of changes in
anxiety and depression symptoms will vary by race/ethnicity, female/male sex, sexual/gender
minority (SGM) identity, and first-generation college (FGC) student status. Pandemic-related
stressors such as work reductions, distance learning, Covid-19 diagnoses and hospitalizations,
and social isolation will also vary across these student populations and will be associated with
increased anxiety and depression symptoms.

Methods

Data

This study was approved by the University of North Carolina-Chapel Hill’s Institutional Review
Board (reference 19–1947). Survey data were collected via two 25-minute Qualtrics surveys
completed on-line as part of Waves I and II of the Transitions Study. Consent was obtained by
virtue of agreeing to participate in the on-line Qualtrics survey and data were analyzed
anonymously. Wave I was initiated in October/November 2019 with an email invitation to a
random sample of in-state, first-year college students age 18 or older and enrolled in the selected
public university. In January/February 2020, we expanded the sample to include all enrolled
first-year students. Participants who did not respond to the initial email invitation were sent a
follow-up invitation offering a $10 gift card to participants. In June/July 2020, roughly four
months after the start of the pandemic, we invited 738 of our Wave I respondents who indicated
a willingness to participate in additional surveys to complete a follow-up survey and offered
participants a $15 gift card. Consistent with many online surveys [33], our Wave I response rate
was 32% (N = 1124). Our Wave II response rate was 64 percent (N = 472). Our analytic sample
for this study includes 419 participants who completed both the Wave I and II surveys and who
have no missing data on mental health measures or Covid-19 stressors.

Setting

Data for this study were collected at a large public university in NC. In NC, the Governor issued
a stay-at-home order in late March. At about the same time, the university made the decision to
send most students home and moved classes online for the remaining five weeks of the semester
and summer sessions. Until mid-May, confirmed Covid-19 cases in NC were initially below an
average of 500 per day [34]. After the stay-at-home order was lifted in mid-May, average cases
per day in NC rose to 2000 [34].

Measures

Mental health.

We measured depression and anxiety symptoms at both Waves I and II. To measure depression,
we used the Patient Health Questionnaire Depression Scale (PHQ-8), a measure of eight
depression symptoms occurring “not at all” (0) to “nearly every day” (3) over the past two weeks
[35]. To measure anxiety symptoms, we used the Generalized Anxiety Disorder scale (GAD-7),
a measure of seven anxiety symptoms occurring “not at all” (0) to “nearly every day” (3) over
the past two weeks [36]. For both measures, we summed across responses to create a continuous
measure of symptoms and also created a dichotomous measure of moderate-severe symptoms for
scores of 10 or more [35, 36]. To ease interpretation in our regression analyses, measures of
anxiety and depression symptoms were standardized to have a mean of zero and standard
deviation of one. In our sample, Cronbach’s alphas were .90 and .88 for the GAD-7 and PHQ-8,
respectively.

Covid-19 stressors.

First, we measure two economic stressors–student and parent work reductions. Students were
first asked whether they were employed at Wave I. Then, at Wave II, students were asked
whether they or their parents had lost a paid job, were furloughed, or had their hours reduced.
Second, we measured educational stressors by asking students to rate the difficulty of engaging
in nine activities on a 4-point Likert scale. An exploratory factor analysis of their responses
identified two factors–distance learning and educational technology. For each factor, we utilized
standardized factor scores with means of zero and standard deviation of one. The higher factor
scores for distance learning indicate greater difficulties with finding support needed for courses
(e.g. tutoring and office hours), accessing the learning materials needed, adapting to the
distanced learning format, finding a quiet space to work, and making time for course work.
Higher factor scores for education technology indicate greater difficulties with accessing the
internet and obtaining the technology (e.g., computers and software) needed for distance
learning. Third, we measured Covid-19 health stressors. Covid-19 diagnosis and hospitalization
identified, respectively, whether students, their family members, or their friends had been
diagnosed with Covid-19 or hospitalized with Covid-19. Finally, at both Waves I and II, we
measured whether a student felt isolated from others either always/usually or rarely/never [37].

Psychosocial resources.

At Wave I, we included three measures to identify students’ psychosocial resources. We

measured resilience averaging responses to six items (accounting for reverse-coding) measured
on a 5-point Likert scale using the Brief Resilience Scale (BRS).[38] The measure was
standardized to have a mean of zero and standard deviation of one in the full Wave I sample.
Similarly, we measured coping using the 4-item Brief Resilient Coping Scale (BRCS) [39].
Based on the sum of these items, we defined three categories–low-resilient copers with scores
less than 13, medium-resilient copers with scores of 13–17, and high-resilient copers with scores
greater than 17. Using the Multidimensional Scale of Perceived Social Support (MSPSS), we
measured perceived social support in three domains–family, friend and significant other [40]. For
each domain, we averaged four domain-specific questions whose responses ranged from 1
(strongly disagree) to 5 (strongly agree). Measures of psychosocial resources had Cronbach’s
alphas ranging from .60 for the BRCS to .85 for the BRS and .89-.93 for each domain of the
MSPSS.
Demographic characteristics.

Wave I data include key demographics–race/ethnicity, male/female sex, sexual orientation and
gender identity, and whether the student received free or reduced-price lunch in high school. Free
or reduced-price lunch status provides a rough proxy for low-income. We classified students as
Hispanic if they report Hispanic ethnicity regardless of race, non-Hispanic (NH) Black, NH
White, NH Asian and NH Other for any other race/ethnicity, including mixed-race students. We
defined a sexual or gender minority (SGM) student as a student who reported any sexual
orientation other than heterosexual, a transgender identity, or a gender identity other than their
sex at birth. We defined a first-generation college (FGC) student to be one for whom neither
parent had completed a 4-year post-secondary degree.

Analysis

In this study, we first evaluated mean differences in the characteristics of participants at Wave I
(pre-pandemic) and participants who also completed Wave II (four months into the pandemic).
Second, we investigated whether an upward trend in anxiety and depression symptoms existed
pre-pandemic by examining whether symptoms were significantly higher in January/February
compared to October/November. Third, we examined differences in Covid-19 stressors by
demographic groups. Finally, we estimated the associations between Covid-19 stressors and
moderate-severe symptoms using logistic regressions. These models control for mental health,
social isolation, psychosocial resources, and demographic characteristics at Wave I. Models also
include an indicator variable for the week of the follow-up survey. In additional analyses, we
estimated models separately by those with and those without anxiety and depression symptoms
at Wave I and dropped controls for Wave I symptoms. In supplemental analyses, we compare
these results to continuous models of anxiety/depression symptom severity using ordinary least
squares regressions.

Discussion

Using longitudinal data, this study examined the effects of the Covid-19 pandemic on the mental
health of first-year college students. We found that rates of moderate-severe anxiety increased
39.8 percent and rates of moderate-severe depression increased 47.9 percent from before to mid-
pandemic. We also found that these changes were not driven by increasing trends in anxiety and
depression symptoms resulting from typical first year stressors prior to the pandemic. With one-
quarter of students experiencing moderate-severe anxiety and nearly one-third experiencing
moderate-severe depression four months into the pandemic, Covid-19 will place new stress on an
already stressed college system.

The difficulties associated with distance learning and the social isolation engendered by the
pandemic contributed most substantially to the observed increases in anxiety and depression
symptoms among first-year college students. Hispanic, FGC, and SGM students experienced the
greatest difficulties with distance learning. But neither Hispanic nor FGC students experienced
significant increases in moderate-severe anxiety or depression. SGM students, on the other hand,
experienced significant increases in both. Among SGM students, moderate-severe anxiety
increased 59% and moderate-severe depression increased 50%. Social isolation also increased
precipitously for SGM students (23.9% to 43.4%) as well as Black students (29.6% to 39.3%).
Clearly, social isolation contributed to the 89% increase in depression that we observed among
Black students. For Hispanics and FGC students, feelings of social isolation actually declined
from 24.2% to 17.1% and 35.3% to 27.4%, respectively as these students left the university and
returned to their homes. For these students, returning home may have helped to reduce the risk
for mid-pandemic increases in depression and anxiety symptoms. This result is consistent with
research showing lower income students, many of whom may be FGC and Hispanic, experience
greater social isolation under typical university conditions [44].

Though this research provides critical insights into the effects of the Covid-19 pandemic on the
mental health of first-year college students, several limitations will need to be addressed in future
research. First, our results are limited to a single university and first-year students. Research on
the mental health of students should be expanded to other years and to include other universities
within the US. Second, our relatively small sample size prohibits us from separately evaluating
the effects of stressors and psychosocial resources on mental health among the populations most
at risk. Future research should explore how race/ethnicity and SGM identity modify the
associations identified in this study. Finally, there could be other time-varying factors that
contribute to the increase in mental health symptoms between our survey waves. Most
importantly, the increased media attention to police killings of Black Americans and their daily
experiences of discrimination, harassment and microaggressions may have heightened a sense of
vulnerability between Waves I and II, particularly for Black college students [45]. While this
study cannot speak to the mental health consequences of persistent structural violence towards
Black Americans, our results underscore the disparate impacts of Covid-19-related stressors on
first-year students’ mental health [46, 47].

Colleges across the country have had to make difficult decisions about whether to maintain an
in-person semester in the face of the potential concerns of virus transmission or to make classes
virtual. As they make these decisions, attention should be paid to college student mental health.
Regardless of the choice made, colleges will need to be ready to provide additional counseling
support and explore new ways of offering that support virtually [48]. They will need to be
creative in providing support for distance learning and helping students to connect safely with
each other. They will especially need to thoughtfully engage with Black and SGM students to
reduce feelings of social isolation and address sources of structural inequality.

GABRIELLE

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

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.

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).

Conclusion
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.

Jassiem

Introduction

Adolescents and younger adults navigate a crucial developmental period marked by rapid
biological and social changes. Almost half of all mental disorders begin in adolescence. 1 Today’s
adolescents and younger adults report increasingly high levels of depressive symptoms, stress,
and loneliness as compared to adolescents and younger adults in older cohorts. 2, 3 There are
multiple possible explanations for these concerns. First, this trend may be a result of the mentally
and emotionally straining aspects of modern culture, including the increased use of technology
and a more sedentary lifestyle.4 Second, the reduction in stigma associated with having a mental
health condition and/or seeking mental healthcare that has occurred in recent decades may have
led to more understanding and identification of mental health needs overall. 5 Third, while today’s
adolescents and younger adults are navigating a crucial developmental period, they are
concurrently responding to the stressors of an economic recession and a global pandemic. 6 A
combination of developmental changes, high levels of depressive symptomology, and unique
stressors related to the current events of the world suggest that this population may have different
mental health needs compared to other age groups.

Despite the increasing number of people in need of services, the US Department of Health and
Human Services estimates that there is a shortage of mental healthcare providers—something
which will only progress in the upcoming years. 7 Subsequently, researchers have called for the
development and uptake of nontraditional mental health services. Projections from nearly a
decade ago noted that the traditional model of delivering services (i.e., one-on-one sessions with
a mental health provider) could not possibly keep up with the demand for care. 8 In response to
this gap in care, many nontraditional services and tools have been introduced in recent years to
either support or replace traditional care. The most common include mobile applications
(“apps”), online support communities, self-help books, and peer counseling.9–12

While these services and tools have been widely studied for their efficacy, there is a lack of
research investigating how adolescents and younger adults perceive them: (1) in comparison to
traditional mental health services or (2) in comparison to each other. In previous research, young
adults (ages 18–25) reported a preference to speak to their general practitioner or doctor about
mental health concerns rather than mental health professionals. 13 Similarly aged cohorts also
endorsed a preference for speaking to mental health professionals over using digital mental
health tools when seeking mental health–related information and treatment for mental health
difficulties.14, 15 Beyond these noted preferences, there is a need to investigate how this
population feels about nontraditional mental health services and tools.

Furthermore, there is limited research in the mental health field on the differences between
Millennials (born between 1981 and 1996) and Generation Z’s (born between 1997 and 2012),
although the topic is gaining more interest.16, 17 While Millennials adopted a widespread
technology, such as mobile apps and online social media in their adolescence and adulthood,
Generation Z’s have been familiar with these technologies since childhood. 18 Compared to
Millennials, Generation Z’s spend more time using electronic communication and less time
engaging in face-to-face interactions.17 These generational differences could have implications
regarding healthcare service utilization, with Generation Z’s potentially being more willing than
Millennials to use digital tools over face-to-face services.

This study was designed to fill in the gaps in the literature by examining the mental healthcare
preferences of adolescents and younger adults (i.e., Millennials and Generation Z’s). There were
three main goals: (1) determine how willing adolescents and younger adults are to use
nontraditional services or tools, (2) determine what barriers may be keeping them from using
nontraditional services or tools, and (3) identify any major differences between the preferences
of Millennials and Generations Z’s.

Methods

Participants

This study used data from a survey conducted in Chicago during November and December of
2019. A total of 203 participants between the ages of 17 and 37 (M = 25.01, SD = 5.04) who were
fluent in English participated in the survey. For the purposes of this study, adults up to age 37
were included to fully represent the Millennial generation (born between 1981 and 1996). The
subset of individuals between ages 18 and 37 is referred to as “younger adults” so as to
distinguish them from adults in older generations (e.g., Generation X and Baby Boomers) and
what is typically defined as a young adult cohort (i.e., 18–25 years of age).

Participants were recruited using convenience sampling strategies. Recruitment took place
through print advertisements posted in community areas, posts on online community boards (i.e.,
Craigslist and Reddit), mass emails on ResearchMatch, and through direct contact with local
college and university student organizations. All study procedures were approved by the
Northwestern University Institutional Review Board (IRB) before enrolling participants, and all
participants provided informed consent.

Survey

Participants were asked to complete a survey that was designed by study staff at Northwestern
University. The survey asked all participants questions regarding demographics, perceived
accessibility and reliability of services/tools, self-reported willingness to use services/tools, and
comparative rankings of services/tools. Participants aged 18 and older were asked about their
mental health history. Due to IRB concerns about the reliability of information from participants
under the age of 18, that subset of participants was not asked questions regarding their mental
health status. However, participants that were under the age of 18 and willing to provide data
outside of mental health status were still included in the present analyses so as to gather as much
information about the preferences of individuals from Generation Z. These participants answered
all questions in the survey besides those inquiring about mental health history.

The mental healthcare services/tools examined included mental health professionals (e.g.,
psychiatrists, psychologists, and licensed counselors), primary care providers (e.g., medical
doctors, nurse practitioners, and physician assistants), self-help books, mobile apps, online
support communities (e.g., Tumblr, Reddit), and peer counselors. Participants were provided
with a detailed description of each service/tool included in the survey (e.g., “Peer counselors are
individuals without a formalized degree or certification who offer support for mental health
concerns by providing active listening and problem-solving services”) prior to their completion
of the survey.

Perceived accessibility and reliability of services/tools

Participants indicated how accessible they believed each mental health service/tool to be on a 5-
point Likert scale (i.e., 1 = very accessible to 5 = very inaccessible; see Supplementary Materials
for full item list). Participants indicated how much they agreed with statements regarding barriers
to care for each mental health service/tool (e.g., “Cost of care keeps me from talking to my
primary care provider about stress or mental health”) on a 5-point Likert scale (i.e., 1 = strongly
agree to 5 = strongly disagree). To represent both attitudinal and structural barriers to care, three
main barriers were assessed: cost, time constraints, and fear of judgment. These barriers are
among the most commonly reported by individuals as impeding their ability to receive traditional
care.19 Participants indicated how reliable they believed information about stress or mental health
is coming from each mental health service/tool on a 5-point Likert scale (i.e., 1 = very reliable to
5 = very unreliable).

Self-reported willingness to use services/tools

For each mental health service/tool, participants indicated how much they agreed with statements
regarding their willingness to use the service/tool for mental health concerns (e.g., “If I had a
mental health condition, I would be willing to talk to a peer counselor about it”) on a 5-point
Likert scale (i.e., 1 = strongly agree to 5 = strongly disagree).

Comparative rankings of services/tools

Participants ranked which of the services/tools they would most prefer to use to manage mental
health conditions on a 6-point Likert scale (e.g., 1 = most preferred to 6 = least preferred).

Data analysis

Descriptive statistics were used to characterize the study sample and to report participants’
current use of nontraditional services/tools, their reported willingness to use each service/tool,
and their rankings for which services/tools they preferred most. For each mental health
service/tool, Kendall’s Tau correlation analyses were used to test the strength of the relationship
between reported willingness to use the service/tool and the following five variables: perceived
accessibility, perceived reliability, perceived time barrier, perceived cost barrier, and perceived
stigma barrier. Kendall’s Tau was used due to (1) the Likert-type questions producing ordinal
data 20 and (2) its ability to handle ties. 21 Wilcoxon-Mann-Whitney tests were conducted to
determine if there were significant differences in reported willingness to use services/tools,
perceived reliability of services/tools, or perceived barriers between Millennials and Generation
Z’s. Participants were divided into generations based on their date of birth. As such, participants
born between 1981 and 1996 were considered Millennials, while participants born during or after
1997 were considered Generation Z’s.18 Wilcoxon-Mann-Whitney tests were also conducted to
determine if there were significant differences in reported willingness to use services/tools,
perceived reliability of services/tools, or perceived barriers between participants who indicated
they had at least one diagnosed mental health condition and participants who indicated they did
not have any mental health conditions.

Discussion

There is an increasing need to look for cost-effective and scalable services outside of traditional
face-to-face mental health services. Indeed, serious psychological distress increased 71% among
young adults between 2008 and 2017 and rates of major depressive episodes increased 63%
among young adults between 2009 and 2017. 3 To the authors’ knowledge, this study is the first
to examine how adolescents and younger adults perceive multiple types of nontraditional
services, in comparison to traditional services and in comparison to each other. It is also the first
study to examine what differences might exist between the nontraditional care preferences of
Millennials (born between 1981 and 1996) and Generation Z’s (born between 1997 and 2012).

The present findings indicate that the majority of participants are willing to use nontraditional
services (with the exception of peer counseling) to treat and/or manage mental health conditions,
but that traditional mental health services are preferred as a first-choice treatment. This is
consistent with a previous work indicating a preference for traditional services. 14, 15, 22 At the same
time, most participants with a mental health condition indicated using multiple methods to treat
and/or manage their condition. These results add to a growing body of literature suggesting that
young people are not interested in nontraditional services as a replacement for traditional
services, but as a supplement or enhancement to care.23, 24

Results showed high rates of willingness to speak with a primary care provider about mental
health, potentially supporting the use of collaborative care models to connect individuals in need
with both traditional and nontraditional services. 25 Results showed lower rates of willingness to
use peer counseling services than other services or tools. This could be in part due to the
perceived stigma associated with disclosing mental health information to a peer. The results did
indicate a significant relationship between perceived stigma and willingness to use peer
counselors, but the effect size was weak. Alternatively, while there are multiple types of peer
counseling and peer specialist services available in various settings, it could be possible that
participants were not previously exposed to peer counseling and not familiar with it. Only
13.46% of participants with a mental health condition indicated using peer counselors within the
past 6 months. Furthermore, nearly one-fourth of participants answered “neither agree nor
disagree” when asked about peer counselors, possibly indicating a lack of knowledge.

When peer counseling was first developed and studied, it was primarily within university and K-
12 settings, suggesting that individuals not enrolled in school would not be likely to access peer
counselors.26–28 In recent years, however, peer counseling and peer specialist services have
expanded to other settings including inpatient, outpatient, and online settings. 12, 29, 30 While peer
counseling may not be as widely accessible or familiar to individuals in younger generations as
traditional services, there is evidence to suggest that peer counselors are likely to become more
widely available in the next few years, particularly as mental healthcare provider shortages
increase.31 In populations which are exposed to peer counselors, acceptability is generally high,
suggesting that willingness could increase as individuals in younger generations become more
exposed.32 Future research may examine how usage and perception of peer counselors in younger
generations changes as services become more available.

Accessibility was expected to impact participants’ perceptions of services. For this reason, it is
not surprising that perceived accessibility positively correlated with willingness to use each
evaluated service. This finding supports the literature surrounding perceived accessibility as a
facilitator to treatment.33, 34 Previous research has found stigma to be a barrier to mental health
treatment for young people.35 Results showed negative correlations between perceived stigma
and willingness for multiple services, but there was a particularly strong correlation for mental
health professionals. This could confirm the hypothesis that nontraditional services serve to
minimize the stigma around mental health treatment.14, 22

Perceived reliability was associated with willingness to engage with each service; this effect was
strong for self-help books and online communities. Concerns over the reliability of the
information presented in both self-help books and online communities have previously been
voiced.36, 37 The current findings suggest that participants may be aware of these concerns and
take them into consideration when determining their willingness to use these tools. Results also
indicated significant differences between participants with a mental health condition and
participants without a mental health condition in perceived reliability of primary care providers,
peer counselors, and online communities. Participants with a mental health condition
were less likely to rate primary care providers and peer counselors as reliable, but more likely to
rate online communities as reliable.

It is possible that participants may expect information about mental health coming from online
communities to be more realistic or unembellished, while information from peer counselors or
primary care providers is framed to serve a specific clinical purpose. Previous research suggests
that online communities are perceived as helpful for finding information from others with first-
hand experience with health problems.38 In an ideal model, peer counselors have first-hand
experience with mental health concerns, giving them credibility over the subject matter and a
sense of connection to others with a mental health condition. 39 However, peer counselors still
generally operate in a professional capacity, which could alienate them from clients. It is also
possible that the participants in this sample with mental health conditions had previous negative
experiences discussing mental health concerns with primary care providers or peer counselors,
which could have impacted their reported perceptions. For each of these findings, effect sizes
were relatively small. Future work should attempt to determine if these findings are consistent
across multiple studies.

There were surprisingly few differences between Millennials and Generation Z’s. The
differences that did emerge were related to perceived stigma, with Generation Z’s being more
likely to identify perceived stigma as a barrier than Millennials. This contrasts with the
suggestion that mental health stigma is decreased in Generation Z, compared to other
generations.40 It is worth noting, however, that the effect sizes were relatively small. Another
potential explanation could be that perceived stigma is more directly related to age or education
level (e.g., older generations may have completed their education, whereas Generation Z may
still be enrolled as students) than to generational differences. Future research should investigate
the interplay between generational status and mental health stigma as a barrier to treatment.

Limitations and future directions

This study had several limitations. First, the current sample appears to be more representative of
a help-seeking population rather than a general population of adolescents and younger adults.
Approximately half of the participants reported a mental health condition; this rate is nearly
double the reported rate of young adults with any mental illness in a national sample. 41 It is
possible that the participants were more familiar with mental health services than the general
population, and expressed a greater willingness to use services as a result. On the other hand,
previous research has shown that individuals with a history of a mental health referral are more
reliant on avoidant coping strategies such as “distraction” and more self-stigmatizing than those
without a history of mental health referral. 42 This raises the potential that the current participants
were less open to receiving support than the general population. Future research using a more
normative sample of both healthy individuals and individuals with an identified mental health
condition is needed. Of the conditions reported by participants, major depressive disorder and
generalized anxiety disorder were the most common. Another area for future research may be in
targeting individuals with serious mental illnesses (e.g., psychosis) to determine if perceptions of
nontraditional and traditional services differ from those reported in this study.

Second, many participants were recruited through online registries, such as ResearchMatch, and
online communities, such as Reddit. As a result, these findings may be less representative of
individuals with low familiarity with digital technology.

Third, there was a small number of participants under the age of 18 (n = 5). Data from
incomplete surveys indicated that approximately 40 participants under the age of 18 began the
survey, but exited once it requested parental contact information. Future research may benefit
from requesting a waiver of parental consent when assessing the treatment preferences of
adolescents.

Fourth, the sample was predominantly white and female-identifying. The recruitment methods
for this study relied heavily on online recruitment, which have been documented in previous
studies as leading to overrepresentation of white and female-identifying
populations.43, 44 Furthermore, common mental health problems, such as depression, are
diagnosed at nearly twice the rate in women compared to men. 45 This study’s findings should be
interpreted in light of these concerns. Future investigations can more accurately represent the full
population by recruiting a more racially diverse sample and by recruiting more males. Potential
strategies include using a stratified recruitment technique, targeting online ads to regions with a
higher proportion of minority groups, or partnering with community-based
organizations.46 Additionally, a more diverse sample could allow for investigations regarding
potential cultural differences in nontraditional service preferences.

Fifth, there was missing information regarding date of birth for several participants, which made
detecting differences based on generation more difficult. Sixth, while the survey assessed
participants’ self-reported barriers to receiving mental health services, it did not collect data on
participants’ insurance status or geographical location, two commonly reported barriers to
traditional mental health services.19 Future work may focus on identifying whether a lack of
medical insurance or lack of nearby services plays a role in participants’ interest in nontraditional
mental health tools.
Lastly, the data included in this study were collected prior to the COVID-19 pandemic and the
associated physical distancing and public health measures in the USA. The extent of the
pandemic’s impact on young people’s mental health is not yet fully known, but preliminary
evidence suggests that the pandemic has resulted in increased stress, anxiety, and depression. 47 It
can be expected that mental healthcare will be in even higher demand as a
result.48 Nontraditional services such as those investigated in the current study could serve to
overcome the barriers associated with face-to-face service delivery. It is possible that usage and
acceptability of nontraditional services has increased due to the necessity of finding alternatives
to traditional care. Future research should investigate how usage and preferences of traditional
and nontraditional services have changed since the onset of the pandemic.a

Ian Dave Yamaro

Introduction
Mental illness is quickly becoming one of the most serious and prevalent public health problems
worldwide [1]. Around 25% of the population of the United Kingdom have mental disorders
every year [2]. According to statistics published by the World Health Organization, more than
350 million people have depression. In terms of economic impact, the global costs of mental
health problems were approximately US $2.5 trillion in 2010. By 2030, it is estimated that the
costs will increase further to US $6.0 trillion [3]. Mental disorders include many different
illnesses, with depression being the most prominent. Additionally, depression and anxiety
disorders can lead to suicidal ideation and suicide attempts [1]. These figures show that mental
health problems have effects across society, and demand new prevention and intervention
strategies. Early detection of mental illness is an essential step in applying these strategies, with
the mental illnesses typically being diagnosed using validated questionnaires designed to detect
specific patterns of feelings or social interaction [4-6].

Online social media have become increasingly popular over the last few years as a means of
sharing different types of user-generated or user-curated content, such as publishing personal
status updates, uploading pictures, and sharing current geographical locations. Users can also
interact with other users by commenting on their posts and establishing conversations. Through
these interactions, users can express their feelings and thoughts, and report on their daily
activities [7], creating a wealth of useful information about their social behaviors [8]. To name
just 2 particularly popular social networks, Facebook is accessed regularly by more than 1.7
billion monthly active users [9] and Twitter has over 310 million active accounts [10], producing
large volumes of data that could be mined, subject to ethical constraints, to find meaningful
patterns in users’ behaviors.

The field of data science has emerged as a way of addressing the growing scale of data, and the
analytics and computational power it requires. Machine learning techniques that allow
researchers to extract information from complex datasets have been repurposed to this new
environment and used to interpret data and create predictive models in various domains, such as
finance [11], economics [12], politics [13], and crime [14]. In medical research, data science
approaches have allowed researchers to mine large health care datasets to detect patterns and
accrue meaningful knowledge [15-18]. A specific segment of this work has focused on analyzing
and detecting symptoms of mental disorders through status updates in social networking websites
[19].

Based on the symptoms and indicators of mental disorders, it is possible to use data mining and
machine learning techniques to develop automatic detection systems for mental health problems.
Unusual actions and uncommon patterns of interaction expressed in social network platforms
[19] can be detected through existing tools, based on text mining, social network analysis, and
image analysis.

Even though the current performance of predictive models is suboptimal, reliable predictive
models will eventually allow early detection and pave the way for health interventions in the
forms of promoting relevant health services or delivering useful health information links. By
harnessing the capabilities offered to commercial entities on social networks, there is a potential
to deliver real health benefits to users.

This systematic review aimed to explore the scope and limits of cutting-edge techniques for
predictive analytics in mental health. Specifically, in this review we tried to answer the following
questions: (1) What methods are researchers using to collect data from online social network
sites such as Facebook and Twitter? (2) What are the state-of-the-art techniques in predictive
analytics of social network data in mental health? (3) What are the main ethical concerns in this
area of research?

Methods:We performed a systematic literature review in March 2017, using keywords to search
articles on data mining of social network data in the context of common mental health disorders,
published between 2010 and March 8, 2017 in medical and computer science journals.

Results:The initial search returned a total of 5386 articles. Following a careful analysis of the
titles, abstracts, and main texts, we selected 48 articles for review. We coded the articles
according to key characteristics, techniques used for data collection, data preprocessing, feature
extraction, feature selection, model construction, and model verification. The most common
analytical method was text analysis, with several studies using different flavors of image analysis
and social interaction graph analysis.

Conclusions:Despite an increasing number of studies investigating mental health issues using

social network data, some common problems persist. Assembling large, high-quality datasets of
social media users with mental disorder is problematic, not only due to biases associated with the
collection methods, but also with regard to managing consent and selecting appropriate analytics
techniques.