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  REVIEW ARTICLE A Review of Psychological Distress Among UniversityStudents: Pervasiveness, Implications and PotentialPoints of Intervention Jessica Sharp 1 &  Stephen Theiler 2 Published online: 2 February 2018 # Springer Science+Business Media, LLC, part of Springer Nature 2018 Abstract  A review of literature from the past 30 years establishes psychological distress as both a longstanding and current issue affecting university students worldwide. Poorer aca-demic outcomes and problematic health behaviours are linked to students ’  distress, and thesewider implications also highlight the need for appropriate policies and services to support students during what is clearly a challenging time. Further review identified various socio-demographic, situational and academic factors as potential bases of students ’  distress. Un-doubtedly, the demands of the university lifestyle are inherently stressful; yet experiencingthese as distressing is not inevitable. Rather, a review of links between university students ’  psychological attributes and psychological distress indicates such attributes might be ideal points of intervention to ensure students are best equipped to manage the stressors of university, and greater attention in this area is recommended. Keywords  Psychologicaldistress.Universitystudents.Mentalhealth.Highereducation.Academic Introduction Psychological distress is increasingly recognised as a problem among university studentsworldwide. In their initial investigation of the mental health of students in higher education, Int J Adv Counselling (2018) 40:193  –  212https://doi.org/10.1007/s10447-018-9321-7 *  Jessica Sharp jsharp@swin.edu.auStephen Theiler stheiler@swin.edu.au 1 Department of Statistics, Data Science and Epidemiology, Swinburne University of Technology,Hawthorn Campus, Hawthorn, VIC, Australia 2 Swinburne Psychology Clinic, Department of Psychological Sciences, Swinburne University of Technology, Hawthorn Campus, Hawthorn, VIC, Australia  the Royal College of Psychiatrists (RCP 2003) highlighted widespread concern about themental health of university students. More recently, they have emphasised that the issue isnow even more pressing (RCP 2011). Similarly, the 2002 National Survey of CounselingCenter Directors, which aggregates questionnaire data from counseling centres across theUnited States of America, reported that students with severe psychological problems were aconcern at the time for 83% of directors (Gallagher  2002). Now, more than a decade later,93.7% of directors reported that the trend toward greater numbers of students with psycholog-ical problems such as elevated psychological distress continues to be true on their campuses(Gallagher  2014).This concern expressed by practitioners in the field is supported empirically by research, both historical and current, which has investigated psychological distress among universitystudents. The review of prior research presented here demonstrates psychological distress isexperienced among students attending university counseling centres, students from variousacademic fields, and among students within the general university population; a problem that is affecting university students worldwide. Consideration is given to the prevalence of  psychological distress among university students in comparison to the broader population,as well as longitudinal research demonstrating the patterns of psychological distress amonguniversity students over time. The broader implications of elevated psychological distress suchas problematic health behaviours and impaired academic performance among universitystudents are also considered. Key factors associated with students ’  psychological distress areidentified in the literature, and psychological attributes are proposed as ideal points of intervention for reducing students ’  risk of experiencing psychological distress. Evidence of Psychological Distress Among University Students Student Counseling Centre Populations Counseling evaluation research conducted across the United States, United Kingdom andAustralia has indicated problematic levels of psychological distress among students seekingcounseling. Research by Mathers et al. (1993) showed students using university counselingservices at the University of Sheffield experienced a higher level of psychological distresscompared to what was expected in the general population, as indicated by their scores on theGeneral Health Questionnaire (GHQ; Goldberg and Williams 1991). Students were also askedopen-ended questions aboutthe problemsthey wereseekingcounseling for. The most common primary problem was related to mood disturbance, generally about feeling low (14%), and themost common secondary problems were related to symptoms of worry (12%) or not coping(12%).Afurthertroublingfindingfromthisresearchwasthatalmosthalfofstudents(44%)had been experiencing these issues for more than one year prior to seeking counseling, indicating persistent psychological distress within the student population at that time.Similar research conducted by Surtees et al. (1998) in conjunction with the University of Cambridge Counseling Service used both student self-report and counselor reports to assessthe nature and level of students ’  psychological distress. More than three-quarters of students(77%) had substantially higher scores on the GHQ than average scores from other samples of similar age. The most frequent problems reported were symptoms of depression, course-related problems, relationship problems, and feelings of anxiety. The main psychologicalsymptoms reported were depression (62%) and anxiety (53%). A startling 45% of student  194 Int J Adv Counselling (2018) 40:193  –  212  clients reported previously considering suicide. Furthermore, 53% of students were estimatedas meeting criteria for either   ‘ Major Depressive Episode ’  or   ‘ Generalized Anxiety Disorder  ’ ,and approximately 13% met criteria for concurrent diagnoses of both. The findings of thesetwo studies indicate high levels of psychological distress, and highlight symptoms of anxietyand depression as dominant features of psychological distress for many students utilisinguniversity counseling centres.Several studies have also examined the nature, severity and stability of student counselingcentre clients ’  psychological distress over time. For example, Benton et al. (2003) analysedthirteen years (1988  –  2001) of archival Case Descriptor List (CDL) data to examine trends inseverity and type of distress experienced by university students in the US Midwest. Severalinteresting findings regarding the nature and stability of students ’  distress were revealed. Prior to 1994, the most common problem was relationship issues. However, from this time on, stressand anxiety problems were reported more frequently and remained more common thanrelationship issues. The number of students seen each year with depression also doubled.Based on their findings, Benton and colleagues argued that counseling centre clients wereexperiencing more complex problems in the later years of the studies considered; problemsthat included elevated psychological distress, such as anxiety and depression.Additional large scale research conducted with student mental health data obtained fromapproximately 50 different counseling centres in the U.S. came to a similar conclusion: that theseverity and chronicity of the psychological problems university students were seeking helpfor had shown a slight increase over time (Erdur-Baker et al. 2006). Other research did not findincreases in the levels of psychological distress experienced by university students over time;instead psychological distress had stabilised at relatively high levels among university stu-dents. For instance, drawing on information gathered from 2326 US students utilising a largeuniversity counseling centre over several years, Pledge et al. (1998) found relatively highlevels of psychological distress, as indicated by the Computerized Assessment for Psycho-therapy Evaluation and Research (CASPER; McCullough and Farrell 1983). Problem areas for students included depressive and anxiety symptoms, somatic complaints and very high levelsof subjective distress. A large scale study of 3682 students utilising an Australian counselingcentre over several years (Vivekananda et al. 2011), similarly found approximately 80% of students reported clinical levels of psychological distress, as indicated by the OutcomeQuestionnaire (OQ-45; Lambert et al. 1996). Again, students ’  main symptoms related toanxiety, depression and somatic complaints.Cornish et al. (2000) also found significantly high levels of psychological symptoms amongUS student counseling centre clients, as measured by the Revised Symptom Check List   –  90(SCL-90-R; Derogatis 1983). Johnson et al. (1989) also used the SCL-90-R to assess the type and severity of psychological symptoms of all students utilising a US counseling centre duringone year, and approximately 65% of students had scores indicating high levels of psycholog-ical distress. Using a similar measure of psychological distress, the Brief Symptom Inventory(BSI; Derogatis 1993), approximately 65% of a group of students presenting at a USuniversitycounseling centre also had elevated levels of psychological distress (Gunn et al. 2005).Overall, a variety of assessment methods have consistently indicated problematic levels of  psychological distress among student clients of university counseling centres. In particular,general psychological distress, subjective distress, general stress, anxiety, depression, andsomatic symptoms were prominent among the students. The various studies were mixedregarding whether or not increases in distress levels were evident during the time periodsinvestigated. Nevertheless, relatively high levels of psychological distress were prevalent  Int J Adv Counselling (2018) 40:193  –  212 195  across the years investigated. Recently, the current National Survey of Counseling Center Directors (Gallagher  2014) has revealed evidence consistent with these early findings, with thedirectors surveyed estimating that approximately half of their clients had severe psychological problems. A similar survey of Australian and New Zealand heads of counseling services alsorecognised elevated psychological distress as a current issue (Stallman 2012). Different Academic Populations It has long been recognised that students within the medical field experience high psycholog-ical distress and this assumption has been supported empirically among such students world-wide. For instance, research using the GHQ has revealed problematic levels of general psychological distress among university medical students in Nepal (Sreeramareddy et al.2007), Hungary (Bíró et al. 2010), and in Australia (Willcock et al. 2004), with comparisons to population data demonstrating greater prevalence of psychological distress among suchstudents. British medical students have also been shown to experience elevated anxiety anddepression symptoms (Ashton and Kamali 1995; Pickard et al. 2000), as indicated by the Hospital Anxiety Depression Scale (HADS; Zigmond and Snaith 1983). There is no doubt that high levels of psychological distress are experienced among medical field students.Research conducted with graduate students in general and other professional field studentshas, however, established that high levels of psychological distress are also experienced bystudents across a range of academic groups. For instance, Watanabe (1999) administered theGHQ to almost 3000 university students from various faculties and 51% of the students wereexperiencing a high level of psychiatric disturbance, with the highest percentage being amongliberal arts majors. Cross-sectional research examining distress among 955 students at anAustralian university (Leahy et al. 2010) compared distress across disciplines, and found that  psychology and medical students had similarly high levels of psychological distress, while psychological distress was slightly higher among law and engineering students. In a large scalesurvey of several thousand students from a range of academic fields (Larcombe et al. 2016),those in Arts or Veterinary programs were found to have higher odds of experiencing severelevels of anxiety, depression and stress, as indicated by the Depression, Anxiety and StressScales (DASS; Lovibond and Lovibond 1995), compared to those in Engineering. Interest-ingly, the risk of experiencing such symptoms of psychological distress was not differentiated by whether the students ’  programs were undergraduate versus postgraduate, or general versus professional programs of study.Other research has also shown comparable levels of psychological distress among diversegroups of students. For instance, in a case control study with first year students at EdinburghUniversity in Scotland, psychological distress was elevated on the GHQ among both medicaland non-medical students (Carson et al. 2000). Similarly, Helmers et al. (1997) found broader  indices of stress on the Derogatis Stress Profile (Derogatis 1987) as well as depressed moodwere equivalent across different groups of students. Moreover, Stecker (2004) found that,regardless of study field, 25% of graduate and professional students reported clinically relevant levels of depression according to the Diagnostic and Statistical Manual of Mental Disorders(DSM-IV; American Psychiatric Association 1994) criteria during the previous four-week  period. Clearly, high levels of psychological distress are being experienced by students fromvarious academic fields and programs, and it can therefore be considered as being a broader issue experienced by students more generally. Hence, the review now turns to researchinvestigating psychological distress within the general university student population. 196 Int J Adv Counselling (2018) 40:193  –  212  General University Student Population Large-scale research projects have been undertaken to provide insightful descriptive profiles of the type and incidence of psychological distress experienced by university students in general.During the past decade, the American College Health Association (ACHA) has conducted the National College Health Assessment (NCHA), which provides comprehensive data about university students, including their mental health during the prior 12 months (http://www.acha-ncha.org). In the NCHA 2010 Spring survey (  N  =95,712; ACHA 2010), approximately46% of students reported that during the prior 12 months they had felt that things werehopeless, 31% had felt so depressed that it was difficult to function, 38% had felt overwhelming anger, and 48% had felt overwhelming anxiety. More recently, the NCHA2014 Spring survey (  N  =79,266; ACHA 2014) indicated similarly high percentages of current students experiencing those symptoms of psychological distress.The University of Leicester  ’ s Student Psychological Health Project (University of Leicester 2002), which surveyed over 2700 undergraduate students, also examined students ’  concernsand stressors, psychological functioning and a range of health-related behaviours. In thiscohort, approximately 37% of students reported they were negatively impacted by feelingsof sadness, depression and mood changes. Approximately 22% reported concerns about anxieties, phobias or panic attacks. A further 13% of students reported being confused or concerned about suicidal thoughts. In addition, the College Student Mental Health Survey(  N  =939) undertaken by Soet and Sevig (2006) revealed approximately 15% of students had been previously diagnosed with depression and 6% with anxiety. Furthermore, approximately75% of students were concerned about their ability to succeed academically. Comparisons bySoet and Sevig with the NCHA 2004 survey indicated that their findings were consistent andas such presented an accurate picture of universitystudents ’  concerns. These large scale studiesare particularly useful in providing a comprehensive descriptive profile of the incidence andtype of psychological distress experienced by university students.Other research has established there are elevated levels of distress within the generaluniversity student population using validated clinical instruments. One of the earliest endeav-ours was undertaken 30 years ago by Cochran and Hale (1985), who found students ’  averagescores were higher on all the Brief Symptom Inventory (BSI) subscales (e.g., depression,anxiety, somatic symptoms, hostility) than the initial adult norms provided by Derogatis andSpencer (1982). Based on their findings, Cochran and Hale suggested that university studentstend to report higher levels of psychological distress than adults in general.Several similar studies examining psychological distress within the general student popu-lation were also undertaken during the 1990s and 2000s. For instance, Webb et al. (1996)surveyed a large cross-faculty sample of 3075 second-year university students from ten UnitedKingdom universities. Based on scores on the HADS, 12% of men and 15% of womenreported elevated levels of depression, and 23% of men and 35% of women reported elevatedlevels of anxiety. In addition, Rosenthal and Wilson (2008) collected cross-sectional data from1773 diverse undergraduate students at an urban US university over several years, and psychological distress during the preceding two months was assessed. Using the DysphoriaDomain of the Trauma Symptom Inventory (Briere 1995), which focuses on feelings of anxious arousal, depression, and anger/irritability, approximately 74% of students were clas-sified in the moderately distressed category and a further 9% were in the clinically significant distressed category. On average, students ’  scores were higher than for similar-aged adults in anational standardisation sample. Int J Adv Counselling (2018) 40:193  –  212 197
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