9th February 2015

Edward Pinkney, Hong Kong University

Student Mental Health & Peer-Support Program (MHAPS)

Abstract
Universities have a duty of care to students that involves helping those who are struggling, and
protecting and promoting the wellbeing of the general student population. But with increasing
student numbers, stretched financial resources, and greater awareness of mental health issues,
universities are struggling to meet demand for support services. Because of strained resources
and concerns around adding to the burden on support services, at present, universities are doing
little in the way of strategic upstream approach to mental health protection and promotion that are
accessible to a larger proportion of the student community. Unless they address this, support
services are at continued risk of being overwhelmed, and students will continue to be suffer from
not accessing support.
This document explores the opportunity for a digital service that aims to relieve the burden on
support services through increased mental health literacy and peer support among the university
community. The proposed service would consist of an evidence-based mental health & wellbeing
check based on self-reporting, a series of guided self-care and peer support skills training
modules, and a digital community platform for the continuing development of campus mental health
& wellbeing advocates and peer-supporters. The service will complement existing support services
and improve their capacity by helping to manage upstream health protection and promotion.
Background
There has been considerable academic discussion about means of preventing suicide and
promoting good mental health amongst children and young people, not just for the purpose of
addressing present issues but also to support societal wellbeing, in recognition that a large
proportion of cases of adult depression first occur before the age of 20i.
Suicide prevention strategies, and broader public health promotion efforts, typically target either
high-risk groups (individual approach) or broad population groups (universal approach)ii. Universal
approaches tend to be undervalued due to difficulties with measuring impact, a bias towards shortterm results, challenges over resource allocation, and the difficulty of addressing complex social
factors inherent to upstream approaches, but in more homogenous communities such as
educational institutions where students share similar ages, environments, and purposes, universal
upstream approaches offer considerable promise, and a systematic review of mental health
promotion in schools has shown the approach to be effectiveiii.
In recent months, calls for the introduction of mental health education into the UK curriculumiv have
been joined by arguments for universal mental health checks in schoolsv. As politicians and
academics join support for educational interventions that address the 10-20 of young people with
mental health issuesvi, it is perhaps not a question of if, but of how.

Educational institutions have limited funding available for mental health initiatives and while many
institutions offer student counselling services, these tend to be very stretched and, understandably,
prioritising those students most at riskvii. While some services offer group activities open to all
students, these are labour intensive with limited capacity and only reach a small subset of students.
At present, efforts to prevent suicide and promote good mental health in education tend to be
parochial and localised. Institutions are taking it upon themselves to devise initiatives, but the
scope of these are limited by internal expertise and resources, and, invariably do not engage
external services and resources. Institutions have increasingly explored how they can use the
internet to promote good mental health, but, this has largely been limited to passive sharing of
information about services for those who are already looking, rather than a universal approach
employing outreach and intervention initiatives that integrate with wider community services.
The internet offers considerable promise in enabling a more scalable approach to mental health
promotion. Online mental health screening tools such as the World Health Organisations Major
Depression Inventory and the Centre for Epidemiological Studies Depression Scale are already
available and have become more widely used in light of mounting evidence showing their validityviii.
Online interventions involving health education have also been shown to have effectivenessix, and
digital forms of peer-support have shown promise in depressionx. As internet skepticism from public
professionals fades due to growing evidence and increasing use of digital services, concerns move
away from whether such services can be effective and scalable, towards how they can be designed
in a way that is cost effective, complementary to existing services, and has appropriate
consideration for risks.

The Landscape
The role of peer-support and student-led advocacy has gained attention recently due to budget
constraints and rising demand, and institutions across the Western World have seen student
mental health groups and campaigns flourish. In the UK, Mental Wealth UK (now Student Minds)
helped establish student-led mental health groups and campaigns in 40+ institutions, and in the
USA, Active Minds has overseen hundreds of institutions establishing campus student advocacy
groupsxi. While many young people want to contribute to such initiatives, there remains a challenge
of how to train them, ensure they have adequate knowledge of resources and support available,
facilitate their integration and partnership working with professional services, and support ongoing
sustainability and engagement. In this respect, they are yet to capitalise on digital opportunities.
Meanwhile, there are a number of services providing digital peer-support platforms for young
people. These encompass mobile based applications and web applications, such as Big White
Wallxii, Mindfull (The BB Group), TalkLife, Elefriendsxiii, and Kindlyxiv, amongst other startups. The
organisations behind these services vary from established and respected charities with
government support to private startups with venture capital investment that aim to capitalise on
growing interest in health technology consumablesxv. Online support services tend to employ
therapists and psychologists to ensure the safety of the vulnerable young people involved, and
offer forms of one-to-one talking therapies. However they are yet to integrate sufficiently with

educational institutions, or to provide adequate training opportunities for young people to facilitate
self-care and structured peer-support. These downstream services therefore suffer from the same
problem as face-to-face professional support services; namely, capacity issues which hinder ability
to scale, and this has seen a number of services such as Mindfull encounter financial problemsxvi.
At present, there is a gap for services that use technology to build mental health literacy and social
capital amongst young people, and that provide offline and online interaction through close working
with educational institutions. This early-stage intervention wont solve the problem of limited
budgets being available to professional support services, but it offers a potential population-based
approach to mental health promotion that compliments services, increases mental health
disclosures, enables peer-support mechanisms and encourages self-care methods that can help
manage mental health issues before they require involvement with acute services.
The University of Washington has begun to offer a mental health screening tool to its students as a
gateway to accessing professional servicesxvii.

From Theory to Practice

The proposed program incorporates three interlinked components:
1. Mental health checks and reference information
Mental health and wellbeing check(s) based on the Major Depression Inventory and Centre for
Epidemiology Depression Scale. The check(s) will be short, approximately 5 minutes, as is typical
of online inventories, and the outputs will be based on a points system with specific information
displayed based on points total.
Crucially, the purpose of the checks will not be to diagnose, but to give participants a broad
reference point, and to help them to understand more about signs and symptoms of poor/good
mental health and the services available. It can then provide specific core guidance on support
services, crisis services, and suggestions for sharing with trusted friends and family. The nature of
this information, and the level of integration with services, will be subject to consultation with
support services and a delegated staff member will have the ability to edit key institutional
information to ensure it is up to date.
It is proposed that the mental health check can be completed without sharing personal information
in order to allay user concerns about privacy and to make the check as easy and quick as possible
to complete.
2. Guided self-care and peer-support skills training modules
The guided self-care and peer-support skills training will be based on a proven web-based 4 week
intervention involving weekly problem solving tasks and personalised feedback offered by trained
supervisorsxviii. Video seminars will outline central topics weekly, and participants will have access
to a moderated bulletin board where they can engage in discussion on key subjects and participate
in informal peer support to aid in engagement with self-care wellbeing activities and progress
towards completion. It will also allow for sharing of relevant campus based activities. The program

will not be for students with severe mental health issues, and those displaying signs of mental
illness will be advised to seek professional advice first.
3. Community platform for continuing development of mental health advocates and peer-supporters
Those that have completed the skills modules program will be invited to join the community
platform for mental health advocates and peer-supporters. Participants will be provided with
guidelines typical of peer-supporters, such as a non-judgmental attitude and impartiality about
services. They will also receive additional information about services available to their peers so that
they can offer adequate signposting and contribute to the promotion (or facilitation) of any ongoing
initiatives within the institution. Participants will be expected to participate in campus-based mental
health advocacy or peer support activities, and will receive a certificate in recognition of volunteer
contribution.

Key Benefits And Risks

The key opportunities offered by online mental health checks, education, and peer-support
mechanisms involve the following:
1. Self-awareness and recognition of issues that need attention through screenings/checks
Screenings and checks can validate concerns and give young people the sense of confidence to
tackle issues.
2. Awareness of support services and resources
Information provided with the results of screenings/checks can offer relevant signposting to
resources and materials, including crisis services if required.
3. Information tool for use by support services
Student counsellors can advise students to complete the checks before they attend sessions.
4. Students unable to access support services can use online tools
Students that are unable to access counselling services due to geographic constraints, demand of
services, or work/course limitations, can use online services.
5. Online services can be a stepping stone towards use of professional services and face-to-face
activities
For students feeling uncomfortable about seeking professional help or disclosing mental health
concerns publicly, an online service can help validate concerns and build confidence for accessing
of face-to-face services.
6. An online service is scalable
An online service based on a population based approach can accommodate a large number of
users, using automated checks, guided self-help tools, and community platform.
7. Relatively easy to collect data
Data can be collected to support service development and inform strategic changes to improve the
wellbeing of students.

8. A structured, and stepped process of skills-building and community participation

An online, semi-automated program allows for continuous engagement that is largely independent
of term dates and geographic constraints.

The major risks are as follows:

1. Self-stigma or discomfort caused by results of checks
Concerns have been made about diagnostic mental health screenings, which point to the
complexity of mental health, the risk of over-medicalising ordinary emotions, and the need for the
kind of individualised approach that is typical of counselling theoryxix. It is therefore important that
results of any online health checks are communicated in a way that is sufficiently nuanced and
diplomatic to avoid self-stigma, distress, and over-reliance on checks. For this reason, it will be
emphasised that the checks are for reference and informational purposes only, and are no
substitute for seeking a professional opinion.
2. Privacy of personal information
Students will be able to complete mental health and wellbeing checks without providing personal
information, and any personal information about those participating in the program will be kept
strictly confidential in accordance with data protection regulations and the standards expected of a
health-related service.
3. Inappropriate sense of authority provided by training
When any mental health or support training is offered to young people, there is a need to consider
how the personal identity of participants will change, and how they will be perceived by others. In
line with any peer skills training, it will be repeatedly emphasised that participants are not becoming
experts, and that the central value of any peer-led initiative is of non-authoritarianism and nonjudgmentality.
4. Inaccurate sharing of information
As in the previous point, its important that peer-supporters recognise that they are not experts,
and also that they are sharing valid information. Each of these things will be emphasised in the
training. All of the official materials will be based on the drawing together of evidence-based, widely
supported research and health literature, with overall approval from health professionals. Clear
feedback mechanisms and review procedures will ensure that information is kept up to date, and
materials are updated at routine intervals.
4. Flooding of support services
There may be concerns that increased awareness of issues and services may lead to increased
pressure on services. By carefully managing information about services in a manner informed by
consultation, students can be signposted to those services most appropriate based both on the
needs of students and the availability of services. The ability to rapidly adjust online information (in
contrast to printed literature) supports this. It is also plausible that an online program can ease
pressure on services by allowing them to focus more on core activities (ie. provision of

counselling). It may also support the case for improved efficiencies within services and budget
increases.
5. False perception as alternative to support services
Its important to emphasise that these are upstream approaches that are no substitute for
professional services. Even with population-based advances such as greater self-awareness, selfcare, mental health literacy, peer-support skills, and so on, there will continue to be students that
require professional support services. Upstream approaches can help reduce the burden on
services through prevention and cultural alignment with support services, thereby enabling
services to spend more time on core activities.

Consultation with Support Services

It is important that an online mental health and wellbeing program is launched based on
consultation with support services about each of the three components, to ensure adequate
signposting pathways, accurate information, and risk management. There will also be consultation
about how the online platform will connect with tie-in with existing online offerings, and to discuss
appropriate publicity.

Appendix

1. Basi
c

2. A shorter, wellbeing oriented measure, showing alternative possibilities.

version of the Major Depression Inventory from the World Health Organisation, which produces
a simple graded output.

4. Example output based on results of questions (from the University of Washington:

http://www.washington.edu/counseling/resources/online-mental-health-screening/)

3. Example of how questions can be answered (from the University of Washington:

http://www.washington.edu/counseling/resources/online-mental-health-screening/)

References (Abbreviated)

i Fleisher, W. P. & Katz, L. Y. (2001). Early onset major depressive disorder. Paeditrics &
Child Health, 6, 444-448. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2807758/

iiYip, P. S. F. (2005). A Public Health Approach to Suicide Prevention. Hong Kong Journal
of Psychiatry, 15, 29-31. Available from:
http://easap.asia/journal_file/0501_V15N1_p29.pdf

iii Wells, J., Barlow, J., & Stewart-Brown, S. (2003). A systematic review of universal
approaches to mental health promotion in schools. Health Education, 103, 197-220.
Available from: http://www.emeraldinsight.com/doi/abs/10.1108/09654280310485546

iv Morse, B. Lets put mental health education on the school curriculum. (2013). The
Guardian. Available from: http://www.theguardian.com/commentisfree/2013/jul/08/youngpeople-mental-health-school-curriculum

v Faizal, M., Hoagwood, K., Stephan, S., & Ford, T. (2014). Mental health interventions in
schools in high-income countries. The Lancet Psychiatry, 1, 377-387. Available from:
http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366%2814%29703128/abstract

vi University of Oxford. (2014). Schools are key to reaching children with mental health
problems. University of Oxford. Available from: http://www.ox.ac.uk/news/2014-10-08schools-are-key-reaching-children-mental-health-problems

vii Caleb, R. (2014). Uni counselling services challenged by growing demand. Guardian.
Available from: http://www.theguardian.com/higher-educationnetwork/blog/2014/may/27/students-mental-health-risk-cuts-nhs-services

viii Cuijpers, P., Dekker, J., Noteboom, A., Smits, N., & Peen, J. (2007). Sensitivity and
specificity of the Major Depression Inventory in outpatients. BMC Psychiatry, 7. Available
from: http://www.biomedcentral.com/1471-244X/7/39

ix van Straten, A., Cuijpers, P., & Smits, N. (2008). Effectiveness of a web-based self-help
intervention for symptoms of depression, anxiety, and stress: randomized controlled trial.
Journal of Medical Internet Research, 10. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/18364344

x Melling, B., & Houguet-Pincham, T. (2011). Online peer support for individuals with
depression: a summary of current research and future considerations. Psychiatric
Rehabilitation Journal, 34, 252-254. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/21208865

xi Active Minds: http://www.activeminds.org/about

xii Big White Wall: http://www.bigwhitewall.com

xiii Elefriends: http://elefriends.org.uk/

xiv Kindly: http://kindlychat.com/

xv Farr, C. (2015). Exclusive: Apple's health tech takes early lead among top hospital.
Reuters. Available from: http://www.reuters.com/article/2015/02/05/us-apple-hospitalsexclusive-idUSKBN0L90G920150205

xvi Dearden, L. (2014). BeatBullying UK and MindFull charities suspend services as

administrators called in. The Independent. Available from:

http://www.independent.co.uk/news/uk/home-news/beatbullying-uk-and-mindfull-charitiessuspend-services-as-administrators-called-in-9810142.html

xvii University of Washington. Mental health screening. University of Washington. Available

from: http://www.washington.edu/counseling/resources/online-mental-health-screening/

xviii van Straten, A., Cuijpers, P., & Smits, N. (2008). Effectiveness of a web-based selfhelp intervention for symptoms of depression, anxiety, and stress: randomized controlled
trial. Journal of Medical Internet Research, 10. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/18364344

xix Citizens Commission on Human Rights. Facts About the Dangers of Mental Health
Screening in Schools. Citizens Commission on Human Rights. Available from:
http://www.cchr.org/sites/default/files/downloads/facts_about_mental_health_screening_in
_schools.pdf