There are many psychosocial and economic factors impacting upon students’ mental health (Royal College of Psychiatrists, 2011). Students coming from more non-traditional backgrounds may be more vulnerable to developing depression; this is important given these students make up a significant proportion of the student body. Akin to the general population, indices of lower socioeconomic status (SES) have been associated with students’ depressive symptomology and other mental health outcomes. In a cross- cultural study involving university students from twenty-three countries, lower family wealth was associated with increased likelihood of screening for elevated depressive symptoms (Steptoe, Wardle, Tsuda, & Tanaka, 2007). Within seven of the participating countries, lower level of parental education was also associated with increased likelihood of elevated symptoms. This association was also found in the British student cohort: higher maternal level of education and higher family affluence were associated with lower likelihood of depressive symptoms (Ibrahim, Kelly, & Glazebrook, 2013). It may be that higher SES parents are more able to financially and practically support their child whilst at university.
Coming to university and coping with many new transitions and changes is naturally bound to affect students’ physical and mental health. These changes and challenges include adapting to higher
9 education, academic demands and assessments, changes in lifestyle, relocation and independent living, managing finances and employment, loss of established social networks and formation of new ones, and transition into adulthood and increased independence (Cleary, Walter, & Jackson, 2011; Denovan & Macaskill, 2013; Julal, 2012). Being in the higher education environment also means top- achieving students are now faced with others of similar ability; this, combined with the new level of education, means students may not achieve as highly, and experience many losses or perceived failures early in university (Enns, Cox, Sareen, & Freeman, 2001). Uncertainty in the graduate job market may also mean students place themselves under great pressure to achieve highly to stand out, and increased financial costs and availability of student loans has added further financial pressures (Bewick, et al., 2010). These stressors also affect students’ adjustment to university, academic performance and progression, and their decision to remain at university (Julal, 2012)
Students’ abilities to cope with these new demands and situations are also important, and the transitional period into university might make students more vulnerable and sensitive to stressors (Denovan & Macaskill, 2013). Sense of control (SoC) appears to be an important factor. In two student samples, lower SoC has been associated with screening for elevated depressive symptoms, and SoC may mediate the relationship between SES and depressive symptomology (Ibrahim, Kelly, & Glazebrook, 2013; Steptoe, et al.,
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2007). Prior to university, students are likely to have been in a secure family environment, where social support was more accessible. The shift in environment and social support may affect their coping skills at university. Problem-focused coping and social support aid students’ positive adaptation to university life (Denovan & Macaskill, 2013). In a cohort of psychology undergraduates (N=131), use of reflective coping styles (i.e. approach-orientated problem resolution) was significantly associated with seeking out student support services for personal problems (Julal, 2012).
Some personality traits influence the risk of developing depression: it is associated with neuroticism and has a negative association with extraversion (Kotov, Gamez, Schmidt, & Watson, 2010). Some personality traits aligned with high academic achievement and performance are also associated with increased risk for developing depression. Perfectionism is a multifaceted personality trait which has beneficial (‘adaptive’) and harmful (‘maladaptive’) forms (Dickinson & Dickinson, 2014). It has been conceptualised as representing three separate personality traits reflecting perfectionism about oneself (‘self-orientated’ perfectionism), about others (‘other-orientated’), and perception from other people (‘socially-prescribed’) (Sherry, Hewitt, Flett, & Harvey, 2003). Perfectionism can influence students’ attitudes, cognitions, motivation and behaviours relating to their academic performance and mental health. Adaptive perfectionism can be beneficial in helping goal achievement and motivation to reach positive
11 outcomes. Maladaptive perfectionism is characterised by personal expectation to achieve highly and flawlessly, unrealistic goals and expectations, chronic self-criticism and blame, and all-or-nothing thinking (Pirbaglou et al., 2013), and many of these characteristics resonate with depressive symptomology. Maladaptive perfectionism is a risk factor for depression, anxiety and eating disorders (Pirbaglou, et al., 2013). There has been increased focus upon university students’ perfectionism and its relationship with mental health, with medical students being a sub-group of focus (Enns, et al., 2001).
1.2.3 Diagnosing depression in university students and the risk of medicalisation
Assessing whether depressive symptoms are a normal reaction within daily life or whether they indicate a clinically significant case is difficult in young adults for several reasons. University students typically fall within the 18-24 age range, meaning they are emerging out of adolescence. Numerous psychosocial, physiological and cognitive developmental changes occur during adolescence, in which rapid changes in mood and behaviours are common (McDermott et al., 2010). Coping with various demands and life events can affect adolescents’ moods and thinking styles, and subsequently impair their quality of life and functioning (McDermott, et al., 2010). These natural mood fluctuations affect the ability to accurately recognise depressive symptoms.
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The social and cultural context in which depressive symptoms occur must be considered. Adolescence can influence lay recognition, with moods being labelled as being “grumpy”, instead of “sad” (McDermott, et al., 2010). Compared to older adults, in young people depressive symptoms may be more likely to present alongside anxiety, low self-esteem, and somatic symptoms (Carlson, 2000; McDermott, et al., 2010). Declining academic performance is also a strong indicator of young people’s impaired concentration and decision making (Carlson, 2000). Depression presentation in university students tends to be more cognitive, such as impaired concentration, pessimism, lethargy, self-blame and loathing (Khawaja & Bryden, 2006). University also challenges students’ abilities to cope with losses and they may grieve in response, resulting in feelings of sadness; these are typical human responses to such events (Horwitz & Wakefield, 2007). Some diagnostic symptoms of depression (e.g. sleeping problems, changes in appetite) may be less relevant for assessing student depression as university life itself can cause these symptoms to occur (Khawaja & Bryden, 2006).
It is important to contemplate the risk of over-diagnosis and medicalisation in perceiving symptoms as indicative of clinically- significant depression. Medicalisation refers to describing any problem in ‘medical terms’ and/or being treatable through medical intervention (Davis et al., 2008). For mental health, this involves perceiving and defining normal everyday emotions as medical
13 conditions, and thereby being manageable and treatable. Medical classification manuals have helped achieve some stability and reliability in identifying and treating mental disorders (McPherson & Armstrong, 2006). However, diagnostic criteria can also be applied to many experiences and emotions in those who are not experiencing clinical depression (Mulder, 2008). Normal unpleasant emotions are felt by everyone to some degree throughout their lives. Likewise some personality traits overlap with depressive symptomology but do not necessarily indicate a diagnosable disorder (Chodoff, 2002).
The boundary where mental health problems are clearly diagnosable mental disorders is less concrete than physical illnesses, partly due to more heterogeneous presentations and limited objective markers (Chodoff, 2002). Depressive symptomology is associated with some physical conditions (e.g. hypothyroidism), in which case ‘medicalisation’ through relevant screening is valid. The concept of labelling may be more important for mental health conditions, as correct recognition of symptomology is important for recognising and initiating the help-seeking process (Wright, Jorm, & Mackinnon, 2011). However, labelling can also lead to stigmatisation, illness behaviours and feelings of medicalization and victimisation, and potentially resulting in the perception that the person can only be helped by a professional (Mulder, 2008). Likewise, labelling can additionally encourage the unwarranted use of treatments (Dowrick & Frances, 2013).
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1.2.4 Deciphering clinically-significant symptoms of