An increasing number of students in Higher Education Institutions (HEIs) are experiencing mental distress and mental health conditions in the UK. In 2015 the Higher Education Statistics Agency (HESA) reported that a total of over eighty thousand students requested counselling from their HEI’S, compared to sixty thousand in 2013, a rise of over 27% . YouGov’s 2016 national survey found that one in four students suffer with mental health issues, with 77% experiencing depression-related symptoms and 74% experiencing anxiety-related symptoms . More recently, the World Health Organisation (WHO) World Mental Health International College Student Initiative reported that one in three first year university students experience symptoms of a mental health condition . Furthermore, the WHO contributed to a study at Ulster University in Northern Ireland to monitor student wellbeing using the WHO World Mental Health Composite International Diagnostic Interview (WMH-CIDI). Results showed high baseline prevalence rates of both short-term and long-term mental health and substance disorders, Attention-Deficit/Hyperactivity Disorder (ADHD) and suicidality, with more than 50% of new undergraduate students reporting a lifetime disorder. Alarmingly, co-morbidity was common with 19.1% of students experiencing three or more disorders at a given time .
In 2014 HESA surveyed 2843 students and found that the prevalence of depression and anxiety was 15.6% among undergraduate students (13% for graduate students) ; whilst internationally a meta-analysis involving 24 studies conducted in the USA, UK, EU, and other nations identified a weighted mean depression prevalence of 30.6% , although these studies all used validated self-report measures rather than diagnostic interview methods.
Anxiety and depression symptoms are the most commonly reported by HE students ; with over 77% of students reporting depression-related symptoms, 74% reporting anxiety-related symptoms, and a 74% co-incidence rate . The Royal College of Psychiatrists (RCP) found that students are more likely to experience mental health difficulties or symptoms compared to age-matched peers outside of HE . Worryingly, these findings may underestimate the true scope of the issue due to the social stigma surrounding mental health difficulties or due to such difficulties being undetected or unreported . Indeed, studies have shown that although student support services are frequently advertised by HEI’s, many students are reluctant to seek support [9, 11] or avoid doing so . A national survey conducted in 2013 on behalf of the National Union of Students (NUS) reported that 8% of students identified themselves as “having a mental health problem but not seeking diagnosis”  with 10% reporting having been diagnosed but not actively seeking treatment. Within the United States, a recent study found using the 12-item general health questionnaire  that 32% of doctoral students are at risk of having or developing a common psychiatric disorder, with the most common being depression .
The effects of mental distress and untreated mental health conditions can be debilitating, and has been highlighted in HE students in the form of decreased levels of academic performance . Study skill problems and poor psychological wellbeing, independently and in conjunction have been found to negatively impact academic potential, decrease levels of engagement, lower graduation rates, and increase academic dropout rates [2, 17]. HESA has reported substantial numbers of students experiencing study skill difficulties i.e. over 90% of students reported issues with exam stress and deadline stress . Another recent study found that 92% of students attending university counselling sessions were having problems completing their academic work . For international students, other study skill difficulties may present themselves. For example, a big challenge for international students concerns studying in a non-native tongue. Although there is a minimum language requirement for HE course entry, even when students do meet the entry criteria they may not be familiar with technical terminology for a specialist subject area. This has been found to be problematic for some international students at the initial stages of a course and during an already pressured time .
Student support services
HEIs often provide on-site student support services which may include academic services, such as essay writing courses, employment services, such as Curriculum Vitae (CV) workshops, and on site counselling. Data requested under the Freedom of Information Act shows that between 2011 and 2016 there was an 84% increase in the number of students contacting the counselling support service at their HEI . A 94% increase was found by the Institute for Public Policy Research (IPRR) . Moreover, 67% of HEIs were found not to be able to provide students access to NHS mental health specialists who can deliver interventions onsite and 23% not to work closely with NHS secondary mental health services . Financial pressures placed on HE students due to government funding decreases in particular courses, such as nursing, as well as high student to lecturer ratios have led to an increased demand for study support needs. For example, the National Student Loans Company provisional data for the academic year of 2016/17 showed a decrease of almost £0.6 billion or 36% was awarded based on the previous year . Early data shows that for 2017/18 a further fall of £0.55 billion is to be expected . Other possible explanations for the increased numbers in HE students experiencing mental health difficulties are the removal of protective factors, for example, larger class sizes compared to those in high school can make it more difficult to socialise for some, and increased demands on academic staff can result in less individual support for students. Another explanation for increased demand could be the 2016 British government Widening Access Scheme, which aimed to encourage students from wider backgrounds to apply for HE and indeed resulted in a steady 2% increase in university applications between 2015/16 and 2016/17 .
In 2011 the RCP reported that access to mental health services on the NHS has progressively narrowed down to focus on high-intensity treatments and severe illnesses, resulting in the clear majority of students presenting with mild to moderate symptoms not fitting the criteria for NHS Primary Mental Health Care . This narrowing of focus is the result of an influx of self-referrals for primary mental health care services from the general population to the NHS  due to increased accessibility and awareness. The effect of this increasing demand on HEIs’ student counselling services has been substantial. Students are often left without adequate support as student to counsellor ratios are typically less than favourable . Students frequently report response times to their initial enquiries at up to 2-weeks  and up to 9 weeks from referral to assessment . Research suggests that long waiting times can result in poorer mental health outcomes, such as more days in inpatient care and longer recovery times .
Another limitation of student support services is the lack of continuity of care that students may face when using them . For example, many students now study away from home and internationally, leaving them without support outside of term time. It is therefore imperative that a flexible solution is found.
The RCP  suggests self-help programmes and guides such as web-based interactive cognitive behavioural therapy (CBT) for non-emergency situations, leaving face-to-face counselling prioritized for those with a severity of distress, disabilities and academic difficulties. The use of these tools will likely increase the number of those seeking diagnosis and treatment  as well as improve standards of treatment [31, 32] and continuity of care and reduce dropout rates in HEI’s and possibly improve academic grades .
There is substantial evidence that supports the effectiveness of computer-based programmes when compared to face-to-face CBT [31, 34, 35]. In addition to this, groups that may be hard to contact on a face-to-face basis, such as those with anxiety disorders and depression, may particularly benefit from online CBT . Computerised programmes and application-based CBT also enable the user to maintain anonymity and privacy, avoid being subjected to long waiting lists and removing the stigma that surrounds appointments with a counsellor . Recent studies have shown great progress with the use of online support systems as interactive interventions, demonstrating their positive impact on accessibility and their flexibility [38, 39]. Furthermore, effects have been shown to be longitudinal, with self-reported symptoms significantly reduced 12 months post participation [40, 41].
In recent years, several web-based systems have started to offer psychological support, advice, and information to the public, for example NHS Silvercloud and PLUS . However, most of these systems focus on the general population and only a few address the study skill issues that HE students face. The few systems that target HE students, for example, “CALM” (Computer Aided Lifestyle Management) and “Students Against Depression”, have yet to be tested for their feasibility or effectiveness and unfortunately do not address study skills . Moreover, these systems offer pre-made, non-tailored packages for specific conditions.
The present paper will investigate the feasibility and acceptability of the contents, design, and functionalities of MePlusMe, an online support system designed specifically for HE students who are facing mild to moderate psychological and/or study skill difficulties, or for students who just simply want to take care of their psychological wellbeing and improve their academic competence. MePlusMe is the only system that currently offers personalised interventions in video format for HE students by addressing depression and anxiety symptoms and study skill difficulties. Unlike these, the packages offered by MePlusMe can vary each time depending on the user’s present difficulties, thus facilitating multiple uses from the same user, resulting in an increased likelihood of recurrent and long-term engagement.
iConcipio has designed a web-based solution under the name MePlusMe . It is designed to help students with mild to moderate mental health and/or study skills difficulties, as well as students who do not present with any specific difficulties but who desire to learn how to take care of their psychological wellbeing and improve their study skills. MePlusMe can be used as a stand-alone tool or alongside traditional face-to-face services.
Several filters throughout the system, including a “panic button”, refer students with severe difficulties to other services for more intensive support. The rest of the students can easily use the system by following one of the two available routes. The first is a symptoms-based assessment (Questionnaire route) that invites users to identify the symptoms they experience, and the second is a technique-driven approach (Library route) whereby users select directly their preferred techniques. Both routes lead to a customised package of psychological wellbeing and/or study skill techniques presented in 2D animated video format.
The screening questionnaire has been adapted from the following established tools and clinical questionnaires: the Hospital Anxiety and Depression Scale [HADS] ; the Generalized Anxiety Disorder Scale [GAD-7] ; the Patient Health Questionnaire [PHQ-9] ; and the Mini International Neuropsychiatric Interview [M.I.N.I.] . The HADS, GAD-7, and M.I.N.I. formed the choice of anxiety symptom-based questions. The HADS, PHQ-9, and M.I.N.I. formed the choice of depression symptom-based questions.
The design of the questionnaire addresses symptoms, instead of conditions/diagnoses and the system automatically links clusters of symptoms with specific video techniques. As a result, each package represents the best-fit solution for students tailored to address the specific difficulties they face each time. The library route leads to the package of techniques that students themselves see as best-fit to address their challenges. This route allows students the flexibility to edit their packages at any point by adding the techniques that they prefer or by deleting unsuitable techniques.
All the techniques that are provided are evidence-based. The psychological techniques derive from current treatment models such as Cognitive Behavioural Therapy (CBT) and Mindfulness [48,49,50] and the study skills techniques include strategies such as how to stay motivated and manage time effectively. The use of multimedia has been suggested to facilitate the active process of learning , which is why the techniques are presented in a relatable animated audio-visual format accompanied by downloadable printouts. The package of techniques that are to be practiced by the user is stored on the user’s “MyPlace”. Students can login and watch the videos anytime and from anywhere they wish. A reminder option that users are encouraged to make use of and which sends emails prompting them to return and practise their techniques within a period of 8 weeks, is also available.
Users are also asked to report how well they are doing over time, starting on the day they undertake the Questionnaire or Library route and then after 2, 4, and 8 weeks. This self-monitoring progress is shown in the form of a motivational graph. When a package is not relevant anymore, students can archive it for later use. Moreover, they can quickly access and restore past packages any time they wish in order to use them again. MePlusMe further offers an integrated, monitored online peer support network. Student engagement is encouraged in this social section of the site, called “Thoughtwall”, a space where students can post their thoughts under their chosen nickname, “like” the shared thoughts of other users, and share their progress graph after completion of a package. They can also share their thoughts and graphs to other sites outside MePlusMe. Finally, students can personalise their profile by uploading pictures of their preference on their “Wall”.
Preliminary market research conducted via the use of semi-structured interviews with counsellors and psychologists working in student support services within four UK HEIs (London School of Economics, King’s College London, University College London, and Kingston University) revealed current challenges and positive responses to the enquiry about an online solution (Tzotzoli, personal communication, 2011). This step enabled researchers to gather an understanding of current support services, the challenges they are facing, and whether an online system could fit into the market. An online survey was subsequently conducted which helped to identify difficulties faced by students at university, opinions on online support systems and what features students may want the system to include, or what may look appealing on the site . Findings demonstrated a demand and space in the market for an online system, and they further highlighted student needs and system requirements. iConcipio was awarded a Proof of Concept Grant (Smart Award) which allowed a beta version of MePlusMe to be constructed to demonstrate the system during a proof-of-concept study . With the help of a cohort of 873 students from five UK HEI (King’s College London, University of Warwick, University of Edinburgh, Bournemouth University, and University of Roehampton) the proof-of-concept study confirmed the conceptual and practical value (suitability) of MePlusMe. Feedback was collected from students about the main aspects of the proposed design, system contents, aesthetics, and the process of delivery. The results from this study were then used for system refinement. Members of an Academic Advisory Board and a Research Advisory Board, consisting of clinical psychologists and academics have further ensured that MePlusMe’s design and contents adhere to best psychological practice and supervised this work.
Scope of the present study
To date, iConcipio has developed the contents of MePlusMe, namely the design and all the initial video techniques and certain functionalities of the platform, with the exception of some automatized ones. The present study aims to collect qualitative data on the feasibility and acceptability of the MePlusMe’s contents in order to further develop the system. Furthermore, data gained from participants will contain user feedback on how engaging they found the media elements of MePlusMe (the video techniques). It will introduce this material offline to UK HEI students who will be administered one of the routes (Questionnaire or Library) and who will then receive their own customised package of techniques. Students will answer questions regarding the system’s design, functionalities, and video contents. They will then be advised to use their suggested techniques on an as and when needed basis. The students will be approached again to answer questions regarding their interaction and satisfaction with the video techniques on weeks 4 and 8 of the study. It is expected that students will enjoy MePlusMe’s personalized, friendly, and easy-to-use design, as well as the multimedia instructional videos alongside their supporting documents. We expect to see sufficient engagement with MePlusMe’s techniques as well as positive feedback about MePlusMe’s design and contents.