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Digital Interventions to Improve College and University Student Mental Health

      See Related Articles on p.157
      I am writing this editorial during a particular busy time in the collegiate calendar: the last 2 weeks of the spring semester. In a “typical” (e.g., pre COVID-19) academic year, my undergraduate students would be pulled in many directions while they finished projects and internships, took finals, and for some, prepared for graduation and postcollege life. As those of us who work with, advise, and clinically care for college-aged adolescents can attest, the past 2 years have been anything but “typical” for these young people. COVID-19 has introduced considerable instability into their lives, including how they learn, how and where they can live, if and what they can eat, and how and with whom they have fun [
      • Gruber J.
      • Prinstein M.J.
      • Clark L.A.
      • et al.
      Mental health and clinical psychological science in the time of COVID-19: Challenges, opportunities, and a call to action.
      ].
      Although most of my students are hopeful that they will soon return to a more “normal” college life, all of them will tell you that this ongoing volatility has had adverse impacts on their health and well-being [
      • Pagoto S.L.
      • Conroy D.E.
      Revitalizing adolescent health Behavior after the COVID-19 pandemic.
      ], particularly their mental health. A growing body of evidence now clearly supports the link between pandemic-related stressors and mental health concerns, including depression, loneliness, and anxiety, of university-aged adolescents around the world [
      • Wang C.
      • Wen W.
      • Zhang H.
      • et al.
      Anxiety, depression, and stress prevalence among college students during the COVID-19 pandemic: A systematic review and meta-analysis.
      ]. Most of this literature underscores the same theme: while this population desperately needs access to mental health services, substantial barriers exist to connecting students to the supports they need [
      • Elharake J.A.
      • Akbar F.
      • Malik A.A.
      • et al.
      Mental health impact of COVID-19 among Children and college students: A systematic review.
      ]. For example, many students have had difficulty to access in-person services, either because the private and on-campus clinical demand exceeds the resources available [
      • Lederer A.M.
      • Hoban M.T.
      • Lipson S.K.
      • et al.
      More than inconvenienced: The unique needs of US college students during the COVID-19 pandemic.
      ], or because they relocated to a place without mental health providers [
      • Lee J.
      • Jeong H.J.
      • Kim S.
      Stress, anxiety, and depression among undergraduate students during the COVID-19 pandemic and their Use of mental health services.
      ]. Marginalized student communities, including racial/ethnic minorities, gender and sexual minorities, students from low-income families, and first-generation college students, experience additionally heightened barriers to accessing and engaging mental health services [
      • Frazier P.
      • Liu Y.
      • Asplund A.
      • et al.
      US college student mental health and COVID-19: Comparing pre-pandemic and pandemic timepoints.
      ].
      Many calls have now been made for researchers and clinicians to devise innovative programing that can effectively increase care access to college students in need [
      • Liu C.H.
      • Pinder-Amaker S.
      • Hahm H.C.
      • Chen J.A.
      Priorities for addressing the impact of the COVID-19 pandemic on college student mental health.
      ]. The work of Rackoff et al. [
      • Rackoff G.N.
      • Fitsimmons-Craft E.E.
      • Tyalor C.B.
      • et al.
      A randomized controlled Tiral of internet-based self-help for stress during the COVID-19 pandemic.
      ] in this month’s issue of Journal of Adolescent Health contributes much needed knowledge in this area, examining the efficacy of an online, randomized controlled trial self-help program for college students facing stress during the pandemic. Participants in the self-help condition completed modules designed to build resilience (e.g., promoting a positive sense of self or making connections with others) and to build space from COVID-19 (e.g., including promoting healthy sleep, coping with pandemic-related stress, or developing mindfulness). Participants in the control arm were provided information about available counseling services. The authors found that the self-help group experienced a larger reduction in stress and depression—but not anxiety—as compared to the control group, both 1 month and 3 months postprogram.
      Rackoff et al.’s work [
      • Rackoff G.N.
      • Fitsimmons-Craft E.E.
      • Tyalor C.B.
      • et al.
      A randomized controlled Tiral of internet-based self-help for stress during the COVID-19 pandemic.
      ] is exciting proof-of-concept about the possibility of delivering mental health interventions to the young people at greatest need for them. The idea of digital platforms for mental health support is not a new concept [
      • Borghouts J.
      • Eikey E.
      • Mark G.
      • et al.
      Barriers to and Facilitators of user engagement with digital mental health interventions: Systematic review.
      ]; however, the current study has several features that are particularly appealing in times of current (or future) crisis. First, intervention content can be consumed independently and “on-demand” at the convenience of the participant. Such features are important to reducing typical barriers experienced with both care delivery (e.g., clinician availability) and care seeking (e.g., stigma or cost) [
      • Himle J.A.
      • Weaver A.
      • Zhang A.
      • Xiang X.
      Digital mental health interventions for depression.
      ]. Second, the intervention included both skill-based and trauma-informed curriculum. Such provision could be important for supporting both shorter (e.g., managing immediate COVID disruption) and longer term (e.g., managing daily life in the context of ongoing COVID) [
      • Wasil A.R.
      • Taylor M.E.
      • Franzen R.E.
      • et al.
      Promoting graduate student mental health during COVID-19: Acceptability, Feasibility, and Perceived Utility of an online Single-Session intervention. Original research.
      ]. Third, the intervention was effective for multiple mental health concerns, making it an efficient approach for people who need support for more than one condition. Fourth, the flexibility and customizability provide an interesting potential for the development of just-in-time adaptive mental health interventions [
      • Nahum-Shani I.
      • Smith S.N.
      • Spring B.J.
      • et al.
      Just-in-Time adaptive interventions (JITAIs) in mobile health: Key components and Design Principles for ongoing health Behavior support.
      ].
      An important issue addressed neither in Rackoff et al. [
      • Rackoff G.N.
      • Fitsimmons-Craft E.E.
      • Tyalor C.B.
      • et al.
      A randomized controlled Tiral of internet-based self-help for stress during the COVID-19 pandemic.
      ] nor more broadly in the extant literature: while these models offer more accessible mental health care, how do we engage (and retain) young people in programs who lack computer/mobile devices or reliable internet, young people with hearing or vision challenges, or young people experience language barriers? [
      • Himle J.A.
      • Weaver A.
      • Zhang A.
      • Xiang X.
      Digital mental health interventions for depression.
      ] More research needs to be conducted on the adaptation of intervention approaches to reduce access in these populations. In addition, many individuals—including college students—are burned out on technology after spending 2+ years working, going to school, and connecting with others over web-based platforms. Digital interventions efficacy could be challenged when key components of user engagement—namely, regular and attentive access—induce more stress than they solve. Ultimately, addressing the unique mental health needs of college-aged adolescents means continually adapting existing solutions to meet these young people where they are.

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