University students are at risk of depression – could peer-led interventions help, and if so, how?

Around 280 million people worldwide are living with depression. It can affect people of all ages and research has shown university students have high rates of mental health problems.

Depression can impact all aspects of a student’s life – from academic studies to work to relationships. It often occurs alongside other mental health problems, especially anxiety, and can also increase the risk of self-harm and suicide.

Yet, there is a lack of effective interventions to help young people.

“Existing university support systems are struggling to address the student mental health burden. This challenge is especially stark in low- and middle-income countries,” says Dr Daniel Michelson, a Clinical Senior Lecturer at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. 

“Without timely and effective support, students with depression are more likely to underachieve academically, dropout prematurely and suffer restricted life chances in the longer-term,” he continues.

Daniel is leading a research team that wants to close this research gap and find better ways to intervene early. To do so, they want to test components of existing effective mental health interventions and find out if and how they work, and why.

He’s working on a Wellcome-funded programme called METROPOLIS (Mechanistic Trial of Problem Solving and Behavioural Activation for Depression). It builds on a previous seven-year research project funded by Wellcome, called PRIDE (Premium for Adolescents), which developed and evaluated a suite of low-cost mental health interventions for adolescents in secondary schools in India.

PRIDE took a ‘stepped care’ approach, offering treatment in stages. In step one, the team delivered a problem-solving intervention to young people with a variety of mental health problems. Therapeutic modules were then made available in step two for participants who did not respond to the first step. Both steps were provided by lay counsellors, trained individuals without formal qualifications in counselling.

The results showed that step one alone was able to reduce the stressful problems experienced by adolescents and had long-term effects on mental health symptoms up to one year later.

Now, the research team behind METROPOLIS wants to extend this evidence for students in university.

“Most psychological interventions tend to package together several components that have the potential to drive clinical effect. This increases complexity and resource demands, without necessarily leading to better outcomes,” explains Daniel.

METROPOLIS will explore the effects of peer-delivered problem solving and behavioural activation – two strategies found to help improve symptoms of mental health problems – as standalone early interventions for young people with depression.

"By paring down interventions, we want to simplify delivery, reduce costs and minimise unnecessary burden for students who take part in the study,” says Daniel.

In a large randomised controlled trial, the team will test how problem solving and behavioural activation improve symptoms of depression. They will compare the two interventions against each other, as well as against a control group that receives support to improve their study skills. To assess the impact of the trial, the team will measure self-reported depression, anxiety and social functioning at six weeks, six months and one year.

The team will also use questionnaires and interviews with participants to better understand the processes through which the interventions actually drive change. Some potential drivers could be a person’s access to rewarding environmental activities, how they perceive and deal with stressful situations, and changes in hopefulness.

These findings can then inform how future interventions are developed, for example by suggesting ways to tailor support to an individual’s specific needs.

This research approach, which takes components of existing effective interventions and tests what makes them effective, is called ‘back translation’.

If proven to be effective, these interventions could help to address the unmet needs of students and strengthen mental health care on university campuses.

The METROPOLIS study will take place in India, home to one-fifth of the world’s population of young people, and host to the largest population of university students in the world. With plans to recruit over 700 undergraduates, it could be one of the largest youth mental health trials in any low- or middle-income country.

“In India, there is less than one mental health specialist for every 100,000 people and finding help if you are a young person is even more challenging, especially for students from socially marginalised groups,” explains Dr Pattie Gonsalves, co-investigator of the research.

That’s why it’s so important to move away from relying on mental health specialists. METROPOLIS will do this by training and supervising peers to deliver interventions.

Many studies have already shown peer-delivered mental health support to be effective.

“We know that young people experiencing depression may be reluctant to seek a formal support service, even when there is one available,” says Pattie.

“They are much more likely to disclose mental health problems to a peer or a friend. So, we want to train peers to support them." The team will recruit and train around 70 students or recent alumni to be peer counsellors.

Making sure these interventions align with the needs of students is a key priority.

To achieve this, METROPOLIS will collaborate with young people who have lived experience of mental health problems at every stage of the research – from co-design to delivery to evaluation. Recognising people’s lived experience as a source of expertise will ensure the study has a lasting impact.

Study co-investigator Hitesh Sanwal is a lived experience expert and founder and CEO of Youth for Mental Health Foundation in India. The youth-led organisation works with students from more than 50 campuses across the country. Its network of student mental health volunteers will help to raise awareness of the study and outreach through student-led groups.

The research team will work closely with a Young People’s Advisory Group to provide regular feedback on the project. They will help ensure the project is accessible to students from diverse backgrounds, including those who experience marginalisation due to their economic status, gender identity, sexuality, religion or caste.

“Traditional research models involve studies designed by mental health professionals and researchers. This can lead to some things being overlooked,” says Hitesh. “For a very long time, people with lived experience have been seen as receivers. Now is the time to change this and work together as equals.”

For Hitesh, joining the team was an easy decision.

“I first experienced mental health concerns when I was an undergraduate student,” he says. “At that time, there was not much support available. It took me more than a year to understand what it was I was experiencing and begin treatment."

METROPOLIS has the potential to close this treatment gap and speed up support for students.

"I really want young people to have access to what I could not access,” says Hitesh. “This project wants to do that, and being able to contribute to that is amazing.”

And the impacts of this study could go beyond university campuses in India.

“Effective, scalable interventions that fit with the priorities and preferences of the current generation of students in India could move the dial for youth mental health on a massive scale,” says Daniel.

Crucially, he adds: “Similar interventions could be adapted and shared with people across low-resource settings globally.”