School mental health: a necessary component of youth mental health policy and plans
Authors: Stanley Kutcher, Yifeng Wei
Journal: World Psychiatry (2020)

Approximately 70% of cases of mental disorder have their onset prior to 25 years of age. Thus, effective mental health interventions should be applied in youth for life-long benefits. Globally, most young people spend much of their day in schools, and they can be more easily reached there than through any other single public health or clinic-based intervention. Resultingly, effectively addressing mental health and early onset of mental disorders in schools must be an essential component of youth-focused men­tal health policy. The realization that school mental health is an important aspect of promotion, early intervention and treatment is not new. The World Health Organization report in 19941 was an early foray into this territory, and recent years have seen many school mental health activities across the globe2. A substantial corpus of work has now been published, allowing us to critically consider what components of school mental health interventions are both essential and can be systematically and frugally applied with success. These are: mental health literacy for both students and educators; training for both in-service and pre-service teachers; and school site provision of integrated mental health care to youth who require it. Mental health literacy has been defined as knowledge and competencies that encompass four separate but intertwined domains: understanding how to obtain and maintain good mental health; understanding mental disorders and their treatments; decreasing stigma; enhancing help seeking efficacy (knowing when and where to seek help, and learning skills to apply in the help seeking interaction)3. Mental health literacy has been considered to be the foundation for mental health promotion, prevention, early identification, and intervention and ongoing care3. In the school setting, it is essential that mental health literacy interventions are evidence-based, developmentally appropriate, integrated into curriculum, applied by appropriately trained teachers, frugal and easily accessible. While a few different approaches have been promoted globally, school and other educational institutions in many countries have been applying two evidence-based and freely accessible mental health literacy resources: the Mental Health & High School Curriculum Guide4 for students aged 12-18, and the Transitions5 resource for first-year college students. The Guide features classroom-based modules that are easily embedded in the school curriculum, and has been adapted and extensively studied using robust research designs in various countries, demonstrating similar outcomes in significantly, substan­tively and sustainably improving all aspects of mental health lit­eracy for youth4-6. Transitions blends mental health into a life skill resource to help first-year college students' transition into post-secondary settings. Freely accessible, it addresses mental health in a de­stigmatizing manner, with evidence supporting its international application5. Currently, there is a substantial gap in addressing mental health literacy at the elementary school level, highlighting the pressing need for relevant resources among this age cohort. It is essential that, in addition to applying best available evidence-based mental health literacy curriculum resources, teachers be well trained in understanding pertinent aspects of student mental health. Teachers do not usually receive substantial education in this domain in teacher's college, nor do they receive substantive professional development when in practice, despite their concerns about needing to improve student mental health7. Fundamentally, teacher training should not only explore in depth all the aspects of mental health literacy, but also provide practical classroom strategies, and further focus on early identification of mental disorders and how to link students in need with appropriate services within and outside the school community. Moreover, teacher training should consider guiding teachers to learn how to care for their own mental health. Recognizing the lack of progress in this area to date, Canadian educators have begun to address this issue. For example, informed by inputs from more than 30 faculties of education in Canada, a freely available online learning platform has been created that can be applied in both undergraduate or postgraduate teacher education as well as for self-study professional development (www.teachmentalhealth.org). This is now being used in many faculties of education across Canada and globally by interested stakeholders. Robust research evaluating the effectiveness of this intervention is underway, but has yet to be published. Lastly, school-based health centers, which comprise full health/human services embedded into schools, may be the most parsi­monious approach to addressing student's mental health care needs, while concurrently supporting their other health care needs and social service requirements. Some of their advantages are that: a) they provide the greatest ease of access for the largest number of young people; b) they are designed to be youth friendly; c) they can provide a full range of health/mental health interventions (from promotion to prevention to care); d) they can be seamlessly linked to primary health care providers; e) they are relatively inexpensive to establish (i.e., require limited new infrastructure costs); f) they provide an easily accessible site for additional human health services; g) they can be enhanced by adding human resources such as mental health clinicians, h) they have a reasonable evidence base of pos­itive results, that include better and more equitable academic, health and social outcomes8. When properly implemented, such centers can provide both site-based integration of services and horizontal integration into primary health care and social services. However, governance can be a challenge (who "owns" and who funds). They are not likely to be "branded" and so may not be good at raising funds from non-government sources. While well established in some developed countries, they are not well known in other countries; and full services sites may not be economically feasible in very small schools. Taken together, the above three components constitute the es­sential core elements of school mental health, and have a reasonable body of research that demonstrates their positive impact. They can be integrated into existing education and health infrastructure and are ready for scale-out in both low- and high-income settings9. Globally, governments should consider applying these school mental health interventions into their youth mental health policies, plans and programs.