Received: 16 September 2019 Revised: 19 December 2019 Accepted: 27 January 2020

DOI: 10.1111/eip.12939

ORIGINAL ARTICLE

Mental health need of students at entry to university: Baseline

findings from the U-Flourish Student Well-Being and Academic
Success Study

Nathan King1 | William Pickett1 | Steven H. McNevin2 | Chris R. Bowie3 |

4 5 3
Daniel Rivera | Charlie Keown-Stoneman | Kate Harkness |
Simone Cunningham3 | Melissa Milanovic3 | Kate E. A. Saunders6 |
6 7
Sarah Goodday | Anne Duffy on behalf of the U-Flourish Student Well-Being and
Academic Success Research Group

1
Department of Public Health Sciences,
Queen's University, Kingston, Ontario, Canada Abstract
2
Division of Student Mental Health, Queen's Aim: Transition to university is associated with unique stressors and coincides with
University, Kingston, Ontario, Canada
the peak period of risk for onset of mental illness. Our objective in this analysis was
3
Department of Psychology, Queen's
University, Kingston, Ontario, Canada to estimate the mental health need of students at entry to a major Canadian
4
Life Sciences, Queen's University, Kingston, university.
Ontario, Canada
Methods: After a student-led engagement campaign, all first year students were sent
5
Dalla Lana School of Public Health, University
of Toronto, Toronto, Canada
a mental health survey, which included validated symptom rating scales for common
6
Department of Psychiatry, University of mental disorders. Rates of self-reported lifetime mental illness, current clinically sig-
Oxford, Oxford, United Kingdom nificant symptoms and treatment stratified by gender are reported. The likelihood of
7
Department of Psychiatry, Division of
not receiving treatment among those symptomatic and/or with lifetime disorders
Student Mental Health, Queen's University,
Kingston, Ontario, Canada was estimated.
Results: Fifty-eight per cent of all first-year students (n = 3029) completed the base-
Correspondence
Anne Duffy, Department of Psychiatry, line survey, of which 28% reported a lifetime mental disorder. Moreover, 30% of stu-
Queen's University, Division of Student
dents screened positive for anxiety symptoms, 28% for depressive symptoms, and
Mental Health, Mitchell Hall, Queen's
University, Kingston, Ontario, Canada. 18% for sleep problems with high rates (ffi45%) of associated impairment. Only 8.5%
Email: anne.duffy@queensu.ca
of students indicated currently receiving any form of treatment. Females were more
Funding information likely to report a lifetime diagnosis, anxiety and depressive symptoms, as well as cur-
Canadian Institutes of Health Research
rent treatment. Over 25% of students reported lifetime suicidal thoughts and 6% sui-
cide attempt(s). Current weekly binge drinking (25%) and cannabis use (11%) were
common, especially in males.
Conclusions: There is limited systematically collected data describing the mental
health needs of young people at entry to university. Findings of this study underscore
the importance of timely identification of significant mental health problems as part
of a proactive system of effective student mental health care.

KEYWORDS

anxiety, depression, early intervention, mental disorders, prevalence, prevention,

psychopathology, substance use disorders, university student mental health

286 © 2020 John Wiley & Sons Australia, Ltd wileyonlinelibrary.com/journal/eip Early Intervention in Psychiatry. 2021;15:286–295.

KING ET AL.
1 | I N T RO DU CT I O N
Transition to university coincides with an important developmental
period characterized by increasing responsibility for regulating
behaviour, making important life choices, and forming new social
networks; all while beginning to separate from core family influence
and support (Chung & Hudziak, 2017). Many students attend uni-
versity far from home and have to navigate concentrated study
periods in a competitive environment—all while coping with unique
stressors and financial pressures (Universities UK, 2018). Until
recently, it has been assumed that university students were a rela-
tively privileged group of young people with low rates of mental ill-
ness. However, recent reports of a high prevalence of mental health
problems in postsecondary students have challenged this assump-
tion (Auerbach et al., 2016; Auerbach et al., 2018). University enrol-
ment and the diversity of the student population are increasing
(Universities Canada, 2011, 2018). Further, transition to university
coincides with the peak period of risk for the onset of mental illness
(Kessler et al., 2007; Merikangas et al., 2010). Recognition of emer-
gent mental illness and differentiation from situational or transient
distress is of paramount importance. Untreated or inadequately
treated mental illness is associated with significant burden in this
population including school failure, interpersonal problems, sub-
stance abuse and suicide (Hawton, Saunders, & O'Connor, 2012;
Kessler, Foster, Saunders, & Stang, 1995; McGorry, Purcell, Gold-
stone, & Amminger, 2011).
Consistent with recent epidemiological studies (Auerbach et al.,
2016; Auerbach et al., 2018; Blanco et al., 2008) and contempora-
neous with initiatives to reduce stigma (Linden, Grey, & Stuart,
2017; Stuart, 2016), there has been a significant increase in
demand for student mental health services which threatens to
overwhelm resources as currently organized. Such trends, docu-
mented both in Canada (Report of the Principal's Commission on
Mental Health Queen's University, 2012; Universities Ontario,
2017) and internationally (Royal College of Psychiatrists, 2011; Uni-
versities UK, 2018), represent a major challenge for clinicians, edu-
cators, university administrations and students. The Canadian
evidence base available to inform the development and planning of
university student mental health services is limited; with existing
studies suffering from low response rates, reliance on measures
that sometimes lack validity, and study designs that limit the ability
to characterize trajectories or identify important contributors to
outcomes. To address these gaps, we launched the U-Flourish Stu-
dent Well-Being and Academic Success Study (U-Flourish Study)
with the overarching aim to understand what factors contribute to
individual differences in mental health and the implications of men-
tal health problems for academic success and resource planning
(Goodday et al., 2019). Although longitudinal in design, this analysis
focused on the baseline survey (ie, Fall 2018) data to describe the
burden of mental illness in students at entry to university and cur-
rent treatment rates. We expected that the lifetime rates of psy-
chopathology would be comparable to those of large international
epidemiological studies.
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287
2 | METHODS
2.1 | Overview of baseline survey
The full protocol for the U-Flourish Study is published elsewhere
(Goodday et al., 2019). Briefly, after a student-led engagement cam-
paign at the commencement of the fall term, all first year undergradu-
ate students (including those in law and medicine) were sent an email
link to complete the U-Flourish Well-being and Academic Success
Survey that asked about family, personal, environmental risk and pro-
tective factors. The survey included brief validated symptom screen-
ing scales for common mental disorders. In this analysis, we focus on
the demographic, self-report lifetime history of mental disorders,
symptom-rating scores and self-reported receipt of treatment, as
described below. This research was conducted in accordance with the
World Medical Association Declaration of Helsinki and ethics approval
for this study was received from the Queen's University and Affiliated
Teaching Hospitals Research Ethics Board (PSIY-609-18).
2.2 | Key variables
2.2.1 | Demographic
Age in years was calculated based upon the difference between the
date of survey administration and registered date of birth. Gender
was self-identified categorically. Ethnicity was indicated from a stan-
dard list, with participants asked to check all categories that applied.
Domestic or international status was determined with supplemental
items asking, where applicable, for home province of residence. Stu-
dents also reported the highest level of education completed by either
parent or parent figure. Programme of study was acquired from the
university database linked through student number.
2.2.2 | Symptoms of common mental disorders
Anxiety symptoms were measured using the Generalized Anxiety Dis-
order 7-item Scale (GADS-7) (Spitzer, Kroenke, Williams, & Lowe,
2006). Participants rated responses (ie, 0 = “Not at all” to 3 = “Nearly
every day”) to seven questions. Total scores of 10 or more were con-
sidered screening positively for clinically significant symptoms (Lowe
et al., 2008). In students screening positive, associated functional
impairment was considered present if anxiety symptoms were rated
as making it “very difficult” or “extremely difficult” to do work, take care
of things at home, or get along with other people.
Depressive symptoms were measured using the Patient Health
Questionnaire (PHQ-9) (Kroenke, Spitzer, & Williams, 2001).
Response options to 9 questions were rated using self-reported
responses identical to the GADS-7 (above). Total scores of 10 or more
were considered screening positively for clinically significant symp-
toms. Associated functional impairment was captured using the same
ratings as described above for anxiety-related impairment.
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288 KING ET AL.

Substance misuse was operationally defined as engaging in at 2.3.2 | Statistical analysis

least one of the following behaviours, at least once per week in the
past month: binge drinking (ie, 4 or more drinks on a single occasion), All analyses were completed using SAS Version 9.4 (SAS Institute Inc.,
cannabis use, use of non-prescribed sleeping or wake-up pills or stim- 2017). To assess representativeness, the demographics of participants
ulants, use of pain killers or opiates and illicit drugs (psychedelics and
other recreational drugs such as cocaine). TABLE 1 Demographic profile of the cohort (n = 3029)
Attempted suicide or suicide ideation was identified by responses
n (%)a
to the following questions taken from the Columbia Suicide Rating
Age
Scale (Posner et al., 2011): “Have you ever had any thoughts about end-
≤17 586 (19.4)
ing your life?” and “In your entire lifetime, have you made any attempts
to end your life?” Self-harm was identified by responses to the ques- 18-19 2252 (74.4)

tion: “Have you ever harmed yourself without the intent of ending ≥20 191 (6.3)

your life?” Gender

Quality of sleep was measured using the Sleep Condition Indica- Male 978 (32.4)
tor (Espie et al., 2014) an 8-item rating scale assessing sleep quality Female 2012 (66.7)
and quantity, and the effect of poor sleep on daytime functioning. Other identity 17 (0.6)
Items were summed (possible range of 0-32) and a total score of Prefer not to say 8 (0.3)
16 or less indicated “clinically significant” poor sleep quality or Ethnicity
insomnia.
White 2000 (67.0)
Asian 607 (20.3)
Multiple 285 (9.5)
2.2.3 | Lifetime mental disorders and learning
Black 43 (1.4)
disabilities
Other 43 (1.4)

Participants reported whether they had ever been diagnosed with a Indigenous 9 (0.3)

mental disorder or learning disability from a provided list: “Mood disor- International student 297 (9.9)

der (e.g., depression, dysthymia, bipolar disorder)”, “Anxiety disorder Domestic student 2694 (90.1)
(e.g., PTSD, social phobia, generalized anxiety disorder, etc.)”, “Psychotic Ontario 2218 (82.7)
disorder (e.g., schizophrenia, drug induced psychosis)”, “Eating disorder British Columbia 227 (8.5)
(e.g., bulimia nervosa, anorexia, etc.)”, “Neurodevelopmental disorder Alberta 105 (3.9)
(e.g., autism, ADHD, Asperger's)”, “Sleep disorder (e.g., insomnia)”, “Sui- Nova Scotia 39 (1.5)
cidal ideation/attempt”, “Substance misuse (e.g., cannabis, alcohol)” or Quebec 37 (1.4)
“Learning Disorder”.
Other province or territory 57 (2.1)
Programme of study
Arts, humanities and social sciences 1052 (34.7)
2.3 | Mental health treatment
Life and physical sciences 853 (28.2)
Engineering and applied science 469 (15.5)
Participants reported whether they were currently receiving treatment
or support for a mental health condition (“Yes” or “No”), and then if Yes Business 342 (11.3)

asked to specify what type of treatment or support: “Pharmacological Computing 111 (3.7)

(medication)”, “Psychological (counselling)” or “Both”. Nursing 75 (2.4)

Medicine 65 (2.1)
Law 62 (2.0)
2.3.1 | Mental and physical health Parental education level, highest
completed
Participants rated their current mental and physical health status Degree in professional school or 691 (24.0)
on a 5-point scale: “very poor” through “average” to “very good”. doctorate

They were asked to report if they had ever suffered from any Master's degree 685 (23.8)
condition listed in a standard list of physical illnesses. Body mass Bachelor's degree or trades/ 1131 (39.3)
index (BMI) was calculated from self-reported height and weight, apprenticeship

and categorized into adiposity subgroups, with age- and sex- Completed high school or less 372 (12.9)
adjusted thresholds for those <18 years of age (Cole, Flegal, Note: All variables missing <5%.
a
Nicholls, & Jackson, 2007). Percentage based on non-missing responses.
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KING ET AL. 289

TABLE 2 Self-reported physical and mental health status of the cohort, overall and by gender

Full sample (n = 3029) Male (n = 978) Female (n = 2012) Other (n = 25)

n (%) n (%) n (%) n (%)

Physical health indicators
Self-rated physical health status, below averagea 143 (4.8) 38 (3.9) 103 (5.2) 2 (8.0)
a
History of physical health conditions 1385 (49.5) 391 (43.3) 979 (52.4) 15 (60.0)
Body mass index (BMI)a
Underweight 261 (9.0) 45 (4.7) 212 (11.0) 4 (17.4)
Normal weight 2168 (74.4) 686 (71.8) 1468 (75.8) 14 (60.9)
Overweight 378 (13.0) 180 (18.9) 196 (10.1) 2 (8.7)
Obese 107 (3.7) 44 (4.6) 60 (3.1) 3 (13.0)
Mental health indicators
Family history of a mental disordera 1213 (43.0) 297 (33.1) 898 (47.3) 18 (75.0)
Self-rated mental health status, below averagea 426 (14.3) 89 (9.2) 325 (16.4) 12 (48.0)
a
History of a diagnosed mental disorder 779 (28.0) 176 (19.7) 589 (31.6) 14 (56.0)
Receiving mental health treatment/supporta 252 (8.5) 40 (4.1) 206 (10.4) 6 (24.0)
Type of treatment receiving
Pharmacological (medication) 91 (36.1) 17 (42.5) 70 (34.0) 4 (66.7)
Psychological (counselling) 63 (25.0) 13 (32.5) 49 (23.8) 1 (16.7)
Both pharmacological and psychological 98 (38.9) 10 (25.0) 87 (42.2) 1 (16.7)
a
Anxiety symptoms (GADS-7)
Minimal/none (0-4) 1034 (37.8) 434 (49.9) 599 (32.4) 1 (4.8)
Mild (5-9) 815 (29.8) 259 (29.8) 547 (29.6) 9 (42.9)
Moderate (10-14) 506 (18.5) 121 (13.9) 377 (20.4) 8 (38.1)
Severe (15-21) 383 (14.0) 56 (6.4) 324 (17.5) 3 (14.3)
Clinically significant anxiety (GADS ≥10) a
889 (32.5) 177 (20.3) 701 (38.0) 11 (52.4)
Associated functional impairment, yesa 414 (46.8) 70 (39.8) 339 (48.6) 5 (45.5)
a
Depression symptoms (PHQ-9)
Minimal/none (0-4) 1156 (42.4) 460 (53.2) 694 (37.7) 2 (10.0)
Mild (5-9) 819 (30.0) 236 (27.3) 576 (31.3) 7 (35.0)
Moderate (10-14) 418 (15.3) 102 (11.8) 312 (17.0) 4 (20.0)
Moderately severe (15-19) 207 (7.6) 51 (5.9) 151 (8.2) 5 (25.0)
Severe (20-27) 126 (4.6) 16 (1.9) 108 (5.9) 2 (10.0)
Clinically significant depression (PHQ ≥10)a 751 (27.6) 169 (19.5) 571 (31.0) 11 (55.0)
Associated functional impairment, yesa 338 (45.1) 68 (40.5) 263 (46.1) 7 (63.6)
Clinically significant Insomnia (SCI ≤16)a 480 (17.7) 103 (11.9) 368 (20.1) 9 (42.9)
Suicide and self-harm; have you ever…
Wished you were dead or would not wake upa 929 (34.1) 216 (24.9) 698 (37.9) 15 (71.4)
a
Had thoughts about ending your life 792 (29.0) 203 (23.4) 575 (31.3) 14 (66.7)
Self-harmed without intent to end your lifea 479 (17.6) 73 (8.4) 395 (21.5) 11 (52.4)
a
Attempted to end your life 166 (6.1) 30 (3.5) 129 (7.0) 7 (33.3)

Note: Missing responses ≤10% for full sample.

a
Chi-square test comparing males and females was statistically significant (P < .05).

(n = 3029) were compared to all first year students (n = 5242) eligible “other identity”), with differences examined using chi-square tests for
to take part. We described the indicators of mental illness and symp- independence. Among those who self-reported a lifetime diagnosis
toms of common mental disorders, as well as physical health both and those meeting clinical symptom cut-offs on screening scales, we
overall, and stratified by self-identified gender (“male”, “female”, estimated the percentage of those students who reported that they
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290 KING ET AL.

TABLE 3 Description of substance use in the past month, overall and by gender

Full sample (n = 3029) Male (n = 978) Female (n = 2012) Other (n = 25)

n (%) n (%) n (%) n (%)

Substance use, at least once a week
Anya 891 (32.7) 360 (41.5) 524 (28.5) 7 (33.3)
a
Binge drinking 667 (24.5) 282 (32.5) 383 (20.9) 2 (9.5)
Cannabisa 302 (11.3) 146 (17.3) 152 (8.4) 4 (19.1)
Non-prescribed sleeping pills or stimulants 155 (5.7) 55 (6.4) 96 (5.2) 4 (19.1)
Pain killers or opiates 58 (2.2) 22 (2.6) 34 (1.9) 2 (9.5)
a
Illicit drugs (psychedelics, cocaine, ecstasy) 36 (1.3) 22 (2.6) 13 (0.7) 1 (4.8)
Binge drinkinga
None 1011 (37.1) 276 (31.8) 721 (39.3) 14 (66.7)
Once 396 (14.6) 125 (14.4) 270 (14.7) 1 (4.8)
2-3 times 648 (23.8) 184 (21.2) 460 (25.1) 4 (19.1)
4 or more times 667 (24.5) 282 (32.5) 383 (20.9) 2 (9.5)
Cannabisa
Never 1972 (73.8) 565 (67.0) 1391 (76.9) 16 (76.2)
Less than once a week 399 (14.9) 132 (15.7) 266 (14.7) 1 (4.8)
Once a week 158 (5.9) 68 (8.1) 88 (4.9) 2 (9.5)
More than once a week 144 (5.4) 78 (9.3) 64 (3.5) 2 (9.5)

Note: Missing or prefer not to say on one or more item = 421 (13.9%) of full sample; All categories describe use in the past month.
a
Chi-square test comparing males and females was statistically significant (P < .05).

were not currently receiving treatment or support. Analyses were strati-
fied first by gender, then by age group (<18 years, 18-19, 20 years or
older), and domestic or international status. A series of crude and
adjusted log-binomial regression models were used to estimate the likeli-
hood of receiving no treatment or support among those diagnosed or
symptomatic of any mental disorder. Based upon our realized sample
size and prevalence of non-treatment, these analyses were 80%
powered to detect relative risks of 1.05 to 1.24 (alpha = 0.05, 2-sided).
3 | RESULTS
3.1 | Sample
The 3029 study participants represented a 58% response rate of all
first year students. Respondents were most commonly 18-19 years of
age, female, of white or Asian ethnic backgrounds, domestic students
from the province of Ontario, and from families with high levels of
formal education (Table 1). When compared with the 5242 eligible
first year students, survey participants were significantly more likely
to be female (66% vs 58%; χ , P < .01), slightly younger (mean 18.2 vs
2
18.5 years, P < .01), and domestic Canadian students (90.1% vs
87.3%; χ 2, P < .01), with similar distributions by province of residence
(domestic students only) and programme of study.
Table 2 describes self-reported physical and mental health indica-
tors in the full sample and stratified by gender. Twenty-eight per cent
of the sample had a history of one or more diagnosed mental
disorders, and 14% rated their current mental health as below average
(ie, “poor or very poor”). Only 8.5% of the full sample indicated that
they were currently receiving any form of mental health treatment.
Females were significantly more likely than males to report having
been diagnosed with a mental disorder and be receiving treatment.
Over one-third of the sample reported clinically significant anxiety
symptoms, 28% reported clinically significant depressive symptoms
and 18% reported significant sleep problems. Over 25% of students
reported having had thoughts about ending their life and 6% having
made a prior suicide attempt. Clinically significant symptoms and sui-
cide ideation/attempts were significantly more common in females
than males, and descriptively were the most common in the “other”
self-identified gender group.
Of those students who screened positively for anxiety symptoms,
40% (70/176) of males, 49% (339/700) of females and 46% (5/11)
other gender reported associated functional impairment with 89%
(81% to 96%), 76% (71% to 80%) and 40% (5% to 85%) not currently
receiving treatment, respectively. Of those who screened positive for
depressive symptoms, 41% (68/168) of males, 46% (263/570) of
females and 64% (7/11) of other gender reported associated func-
tional impairment, with 87% (79% to 95%), 76% (71% to 81%) and
57% (21% to 94%) not currently receiving treatment.
The prevalence of self-reported substance use is described in
Table 3. Substantial proportions of the students reported engaging in
weekly use of substances, with significantly higher levels (absolute dif-
ferences of 1.9-13%; P < .001) reported among males than females
(ie, overall, and for binge drinking, cannabis and illicit drugs use).

KING ET AL.
F I G U R E 1 Proportion of male and
female students reporting a history of
diagnosed mental disorders (A), physical
health conditions (B), and a family history
of mental disorders (C), by gender
Specific student lifetime diagnoses and family history of mental
disorders are more fully described in Figure 1. Females were more
likely to report a lifetime mental disorder or physical illness or family
history of illness than males. The most common reported diagnoses
were anxiety disorders, learning disabilities, and mood disorders. The
most common reported physical health conditions were allergies, lung
or breathing problems, ear, nose or throat problems, and chronic pain.
Forty-three per cent of the students reported one or more learning
disabilities or mental disorders in their first-degree (siblings, parents)
family members.
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291
Among those students who reported a lifetime mental disorder or
who met clinical cut-off scores on symptom rating scales, a significant
proportion (81% of males, 67% of females and 57% of other gender)
indicated that they were not receiving any form of treatment (medica-
tion and/or supportive counselling or psychotherapy) (Table 4). Symp-
tomatic males without a formal diagnosis were least likely to be
receiving any treatment or support (94%; CI: 92.1-96.0%).
The log-binominal regression analyses (Table 5) suggested that
age, domestic vs international status, programme of study, and level
of parental education had little impact on whether or not someone
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292 KING ET AL.

TABLE 4 Percentage of first year students with specific mental health disorders, and current receipt of treatment or support, by gender

Diagnosed with a mental disorder Clinically significant symptomsa

No treatment/support No treatment/support

Gender: mental disorder N (total) N (%) % (95% CI) N (total) N (%) % (95% CI)
Males
Any disorder 894 176 (19.7) 81.3 (75.5 to 87.0) 873 571 (65.4) 94.1 (92.1 to 96.0)
Anxiety disorder 894 79 (8.8) 77.2 (68.0 to 86.5) 870 177 (20.3) 91.0 (86.7 to 95.2)
Mood disorder 894 49 (5.5) 71.4 (58.8 to 84.1) 865 169 (19.5) 89.9 (85.4 to 94.5)
Sleep disorder 894 18 (2.0) 88.9 (74.4 to 100) 863 103 (11.9) 88.4 (82.2 to 94.6)
Substance use disorder 894 4 (0.5) 100 (40.0 to 100) 867 360 (41.5) 96.4 (94.5 to 98.3)
Eating disorder 894 6 (0.7) 83.3 (53.5 to 100) – – – –
Learning disability 894 73 (8.2) 84.9 (76.7 to 93.1) – – – –
Suicidal ideation/attempt 894 18 (2.0) 88.9 (74.4 to 100) 866 209 (24.1) 89.5 (85.3 to 93.6)
Other disorder 894 9 (1.0) 66.7 (35.9 to 97.5) – – – –
Females
Any disorder 1861 589 (31.7) 67.1 (63.3 to 70.9) 1849 1244 (67.3) 86.4 (84.5 to 88.3)
Anxiety disorder 1861 414 (22.3) 59.7 (54.9 to 64.4) 1846 700 (37.9) 81.3 (78.4 to 84.2)
Mood disorder 1861 263 (14.1) 54.4 (48.4 to 60.4) 1840 571 (31.0) 82.1 (79.0 to 85.3)
Sleep disorder 1861 83 (4.5) 63.9 (53.5 to 74.2) 1832 368 (20.1) 77.2 (72.9 to 81.5)
Substance use disorder 1861 15 (0.8) 46.7 (21.4 to 71.9) 1836 524 (28.5) 86.3 (83.3 to 89.2)
Eating disorder 1861 110 (5.9) 69.1 (60.5 to 77.7) – – – –
Learning disability 1861 125 (6.7) 69.6 (61.5 to 77.7) – – – –
Suicidal ideation/attempt 1861 97 (5.2) 48.5 (38.5 to 58.4) 1840 582 (31.6) 79.7 (76.5 to 83.0)
Other disorder 1861 18 (1.0) 66.7 (44.9 to 88.4) – – – –
Other identity
Any disorder 25 14 (56.0) 57.1 (31.2 to 83.1) 21 19 (90.5) 68.4 (47.5 to 89.3)
Anxiety disorder 25 11 (44.0) 45.5 (16.0 to 74.9) 21 11 (52.4) 54.6 (25.1 to 84.0)
Mood disorder 25 8 (32.0) 37.5 (4.0 to 71.1) 20 11 (55.0) 54.6 (25.1 to 84.0)
Sleep disorder 25 2 (8.0) 50.0 (0.0 to 100) 21 9 (42.9) 66.7 (35.9 to 97.5)
Substance use disorder 25 3 (12.0) 33.3 (0.0 to 86.7) 21 7 (33.3) 57.1 (20.5 to 93.8)
Eating disorder 25 1 (4.0) 0.0 – – – – –
Learning disability 25 5 (20.0) 80.0 (44.9 to 100) – – – –
Suicidal ideation/attempt 25 5 (20.0) 40.0 (0.0 to 82.9) 21 14 (66.7) 57.1 (31.2 to 83.1)
Other disorder 25 3 (12.0) 66.7 (13.3 to 100) – – – –
a
Symptomatic if score greater than or equal to (clinical) cut-off for disorder; substance use disorder was defined as engaging in at least one of the following
behaviours, once per week or more in the past month: binge drinking, use of non-prescribed sleep or wake-up pills, cannabis use, use of pain killers or
opiates, and illicit drug use; suicidal ideation/attempt was indicated if students responded that they had ever had any thoughts about ending their life, or
ever made an attempt to end their life.

was receiving treatment or support. Those reporting more mental
health disorders (ie, higher comorbidity) were more likely to receive
treatment or support.
4 | DISCUSSION
In this large representative sample of students entering a major Cana-
dian university we found high rates of self-reported lifetime mental
disorders and learning disabilities. We also documented a high
prevalence of students who screened positively for current symptoms
of common mental illness, often with associated functional impair-
ment. This pattern was consistent across age, gender, ethnicity,
domestic vs international status and study programme. The extent to
which the prevalence of these disorders and significant symptoms
exceeded levels of current clinical treatment or support was striking,
especially for males. These findings support the need for development
of accessible, developmentally appropriate and evidence-based pre-
vention and early intervention mental health services on campus and
partnerships to early intervention clinical services in the community.
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KING ET AL. 293

TABLE 5 Relative risk of not receiving treatment or support for a mental disorder (diagnosed or symptomatic) by socio-demographic factors

Relative risk (RR) of receiving no treatment or

support
Diagnosed or symptomatic of any mental
disorder Crude Adjusteda

N (% untreated) RR (95% CI) RR (95% CI)

Age group—years
Less than 18 359 (88.6) Ref 1.00 Ref 1.00
18 to 19 1419 (87.7) 0.99 (0.95 to 1.03) 1.00 (0.95 to 1.05)
20 or more 108 (79.6) 0.90 (0.81 to 1.00) 0.92 (0.79 to 1.07)
Gender
Male 572 (93.7) Ref 1.00 Ref 1.00
Female 1295 (84.9) 0.91 (0.88 to 0.94) 0.97 (0.93 to 1.01)
Other identity 19 (68.4) 0.73 (0.54 to 0.99) 0.91 (0.72 to 1.15)
Status
Domestic—Ontario 1432 (85.7) Ref 1.00 Ref 1.00
Domestic—rest of Canada 297 (92.3) 1.08 (1.04 to 1.12) 1.03 (0.98 to 1.08)
International 157 (94.3) 1.10 (1.05 to 1.15) 1.04 (0.96 to 1.12)
Programme of study
Arts, humanities and social Sciences 708 (81.9) Ref 1.00 Ref 1.00
Life and physical sciences 502 (89.0) 1.09 (1.04 to 1.14) 1.02 (0.98 to 1.07)
Engineering and applied sciences 297 (93.3) 1.14 (1.09 to 1.19) 1.04 (0.98 to 1.10)
Business 213 (93.9) 1.15 (1.09 to 1.20) 1.04 (0.98 to 1.10)
Computing 61 (88.5) 1.08 (0.98 to 1.19) 1.00 (0.90 to 1.12)
Nursing 36 (88.9) 1.09 (0.96 to 1.22) 1.01 (0.89 to 1.15)
Medicine 31 (77.4) 0.95 (0.78 to 1.15) 1.04 (0.85 to 1.27)
Law 38 (92.1) 1.12 (1.02 to 1.24) 1.15 (0.87 to 1.54)
Parental education level
Degree in professional school or doctorate 439 (87.0) Ref 1.00 Ref 1.00
Master's degree 466 (88.8) 1.02 (0.97 to 1.07) 1.01 (0.96 to 1.06)
Bachelor's degree or trades/apprenticeship 736 (87.0) 1.00 (0.95 to 1.05) 1.01 (0.96 to 1.06)
Completed high school or less 245 (86.9) 1.00 (0.94 to 1.06) 1.01 (0.95 to 1.08)
Number of mental disorders
1 755 (96.2) Ref 1.00 Ref 1.00
2 401 (90.8) 0.94 (0.91 to 0.98) 0.97 (0.93 to 1.01)
3 353 (86.1) 0.90 (0.86 to 0.94) 0.95 (0.90 to 0.99)
4+ 377 (67.6) 0.70 (0.66 to 0.76) 0.85 (0.80 to 0.90)
a
Adjusted for all other variables in the table.

As discussed recently in Lancet Psychiatry (Duffy et al., 2019), a coor-
dinated system of care should start with engaging clinical triage at
point of first contact integrated with a stepped care model of service
delivery. The aim would be to provide the appropriate level of inter-
vention at the earliest possible time with facilitated transitions to
more specialized community-based services as needed. Mental health
is strongly associated with academic performance and successful
higher education is a major social determinant of individual and socie-
tal prosperity and development (Patton et al., 2016).
Our primary findings are consistent with data from recent
Canadian university annual reports and white papers concerning
student mental health (Colleges Ontario and the Council of
Ontario Universities, 2017; Coordinating Committee of Vice Presi-
dents Students, 2015). To our knowledge, the only systematically
collected data describing rates of mental illness in Canadian uni-
versity students comes from the semi-regular National College
Health Assessment (NCHA) cross-sectional survey, which reported
similar rates of mental illness. Historically, NCHA findings must be
interpreted cautiously due to low response rates (under 20%) lim-
iting generalizability (American College Health Association, 2016).
Our study provides Canadian specific data and expands on the
NCHA surveys by using validated symptom rating scales and

294
achieving nearly triple the response rate (58% of all first year
students).
Beyond Canada, as we hypothesized, our findings are in line with
those reported in the international WHO-WMHS study of mental dis-
orders among 18-22 year olds in which the 12-month prevalence of
mental disorders was 25% in high-income countries, with only 16% of
diagnosed students receiving minimally adequate treatment (Auerbach
et al., 2016). Moreover, rates of common mental disorders were com-
parable to those in our study in terms of reported 12-month estimates
of anxiety (11.7%), mood disorders (6.0%), and substance use disor-
ders (4.5%). A subsequent WHO-ICS study used a similar web-based
survey format to our own, with application of validated screening
scales among first year college students. The WHO-ICS study esti-
mated lifetime and 12-month prevalence of any mental disorder of
35% and 31%, respectively, comparable to general population rates of
severe mental disorders (Auerbach et al., 2018).
The findings of our study highlight the mental health needs of
students transitioning to a major Canadian university. However, they
do not provide an explanation of the origin of such conditions or
explain why mental illness has emerged as one of the leading health
issues facing this generation of young people, including those who
attend university. Systematic research employing both quantitative
and qualitative approaches, and incorporating a longitudinal design is
required to understand contributing factors to student mental health
outcomes and the impact on academic success. However, evidence
from this study, although preliminary, points to specific prevention
and early intervention targets including alcohol and drug use,
impairing anxiety and mood symptoms/disorders. The implications of
our findings are clear—although valuable, a focus only on health pro-
motion, in the absence of a proactive system providing accessible
assessment and when indicated care, is unlikely to address the sub-
stantial mental health needs of the university student population.
The strengths of this study include: a large cohort representing
58% of potential student respondents, measures with good psycho-
metric properties that represent multiple domains of interest in this
population, and addressing a gap in information about university stu-
dents in the Canadian context. However, there are some limitations
that should be discussed. First, comparisons with the sampling base
suggest that our findings more fully represent the experiences of
younger, female, domestic students. The greater response rate for
females is common for online, student-based surveys (Sax, Gilmartin,
Lee, & Hagedorn, 2008). The clinical cut-off scores used for symptom
screening measures employed represent a balance between sensitivity
and specificity and do not equate to a clinical diagnosis. Screening
positive indicates a need for further assessment, rather than con-
firming the presence or absence of illness. However, for the purposes
of identifying students appropriate for prevention and early interven-
tion, psychopathology at the symptom level is appropriate. The survey
data are self-reported in nature and were not confirmed by direct
assessment. Finally, as this survey was conducted early in the school
year, and the majority of students entering Queen's University have a
permanent residence that is not local, this places limits on the per-
centage expected to be currently under care for mental health
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KING ET AL.
conditions. It may also indicate the lack of resources or engagement in
resources in the students' home communities.
5 | CONC LU SION
In this initial report from the U-Flourish Study, we document the life-
time prevalence of self-reported mental disorders and learning disabil-
ities at entry to university and the prevalence of significant symptoms
associated with common forms of mental illness. A notable finding was
the substantial percentage of students who were diagnosed or symp-
tomatic of a mental disorder and not receiving any form of support or
care and the immense potential burden this places on the university
and the students themselves. The occurrence of mental disorders and
symptoms was ubiquitous across the study body, although there was a
gendered pattern to rates of disorders and symptoms, as well as receiv-
ing care. Academic success is a major driver of societal development,
and depends upon mental health and well-being (Patton et al., 2016).
Therefore, these findings strongly support the need to augment invest-
ment in mental health prevention initiatives and clinical services that
are evidence-based, developmentally appropriate and tailored to the
student population (Duffy et al., 2019). Although the responsibility for
provision of student mental health care rests with many agencies and
stakeholders, it is our view that the university must take a lead role in
developing evidence-informed resources and advocating for facilitated
care pathways to effective campus and community services forming an
integrated system to ensure students have timely access assessment
and the appropriate level of care when needed.
AUTHOR CONTRIBU TIONS
A.D. designed and was responsible for conducting the study and over-
seeing data collection. D.R. led student engagement, and S.C. and
M.M. developed the online survey in collaboration with all authors.
A.D., N.K., W.P. and C.R.B. planned the analysis and N.K. took the lead
with data cleaning and analysis. A.D., W.P. and N.K. led the writing of
the manuscript and all authors contributed to revisions of the manu-
script. All authors approved the final version of this manuscript.
DATA AVAILABILITY STAT EMEN T
Access to de-identified data from this study considered upon request
to the corresponding author.
OR CID
Chris R. Bowie https://orcid.org/0000-0002-1983-8861
Anne Duffy https://orcid.org/0000-0002-5895-075X
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How to cite this article: King N, Pickett W, McNevin SH, et al.
Mental health need of students at entry to university: Baseline
findings from the U-Flourish Student Well-Being and
Academic Success Study. Early Intervention in Psychiatry. 2021;
15:286–295. https://doi.org/10.1111/eip.12939