ABSTRACT

OBJECTIVE

To present strategic options to support the adoption of mental health strengthening policies for university students in the field of health, to be implemented by university institutions.

METHODS

Rapid review, without period delimitation, with searches carried out from May to June 2020, in 21 sources of bibliographic data, including gray literature. The following keywords were used: mental health, students and university. The selection process prioritized systematic reviews of mental health interventions for university students in health care courses, and also considered other types of review and relevant primary studies.

RESULTS

Forty-five studies were included: 34 systematic reviews, an evidence synthesis, an overview, a scope review, three narrative reviews, three experience reports and two opinion articles. The evidence from these studies supported the development of four options: 1) to establish and support policies to strengthen the mental health of students in health care courses; 2) to integrate mental health care programs, expand their offer and facilitate access by students; 3) to promote educational programs and communication strategies related to contemporary psychic suffering and its confrontation, so that students can get to know the services and resources and identify strengthening practices; 4) to continuously monitor and assess the mental health needs of students in health care courses.

CONCLUSIONS

The options are challenging and require universities to establish institutional commissions to implement a policy to strengthen the mental health of university students in the health area, with the ability to recognize the different health needs, including manifestations of psychic suffering ; to integrate the university’s internal actions with each other and with the services of the Unified Health System; to implement and monitor the actions that make up the mental health policy.

Students, Health Occupations; Student Health Services; Mental Health; Review

INTRODUCTION

Mental health problems are a global concern and the complex phenomenon of suicide is considered a public health problem¹1. World Health Organization. Preventing suicide: a global imperative executive summary. Geneva (CH): WHO; 2014 [cited 2020 Oct 22]. Available from: https://www.who.int/mental_health/suicide-prevention/exe_summary_english.pdf?ua=1
https://www.who.int/mental_health/suicid... because it is the second leading cause of death among young people aged 15 to 29 years²2. World Health Organization. Mental health atlas 2017. Geneva (CH): WHO; 2018 [cited 2021 Nov 29]. Available from: https://www.who.int/publications/i/item/9789241514019
https://www.who.int/publications/i/item/... .

The object of this review is the mental suffering of university students, a group in which the phenomenon is associated with university sociability and family distancing³3. Souza M, Caldas T, De Antoni C. Fatores de adoecimento dos estudantes da área da saúde: uma revisão sistemática. Rev Psicol Saude Debate. 2017;3(1):99-126. https://doi.org/10.22289/2446-922X.V3N1A8
https://doi.org/10.22289/2446-922X.V3N1A... ,⁴4. Costa MC, Moreira YB. Saúde mental no contexto universitário. Semin Ensino Design. 2016;2(10):73-9. https://doi.org/10.5151/despro-sed2016-009
https://doi.org/10.5151/despro-sed2016-0... , as well as academic overload and an increasingly competitive environment generated by competition in the labor market⁵5. Gomes CFM, Pereira Junior RJ, Cardoso JV, Silva DA. Common mental disorders in university students: epidemiological approach about vulnerabilities. SMAD Rev Eletron Saude Ment Alcool Drogas. 2020;16(1):1-8 [cited 2021 Nov 29]. Available from: https://www.revistas.usp.br/smad/article/view/166992
https://www.revistas.usp.br/smad/article... . For graduate students, the probability of suffering from depression and anxiety is six times greater than for the general population⁹9. Evans TM, Bira L, Gastelum JB, Weiss LT, Vanderford NL. Evidence for a mental health crisis in graduate education: Nat Biotechnol. 2018;36(3):282-4. https://doi.org/10.1038/nbt.4089
https://doi.org/10.1038/nbt.4089... .

A study conducted by the World Health Organization among university students from eight countries found that 35% of students had positive screening for at least one of the common mental disorders evaluated, reasons for suffering and impaired academic performance¹⁰10. Auerbach RP, Mortier P, Bruffaerts R, Alonso J, Benjet C, Cuijpers P, et al; WHO WMH-ICS Collaborators. WHO World Mental Health Surveys International College Student Project: prevalence and distribution of mental disorders. J Abnorm Psychol. 2018;127(7):623-38. https://doi.org/10.1037/abn0000362
https://doi.org/10.1037/abn0000362... .

An integrative review of the Brazilian literature found a variation from 34% to 49% in the prevalence of psychological distress among university students¹¹11. Graner KM, Cerqueira ATAR. Revisão integrativa: sofrimento psíquico em estudantes universitários e fatores associados. Cienc Saude Coletiva. 2019;24(4):1327-46. https://doi.org/10.1590/1413-81232018244.09692017
https://doi.org/10.1590/1413-81232018244... . A survey conducted with 136,000 undergraduates, 14% of the total number of students from 53 Brazilian federal universities, found that 80% had emotional difficulties in the previous year, 58% related to anxiety, 45% to feelings of discouragement/lack of will, 32% to insomnia/sleep disorders, 23% to feeling helpless/hopeless, 21% to feelings of loneliness, 13% to eating problems and 11% to fear/panic. The results also identified 6% of responses related to the idea of death and 4% to suicidal thoughts, corresponding to almost 60,000 students who thought about death and 40,000 with suicidal ideation¹²12. Fórum Nacional de Pró-Reitores de Assuntos Comunitários e Estudantis. IV Pesquisa do perfil socioeconômico e cultural dos estudantes de graduação das instituições federais de ensino superior brasileiras - 2014. Uberlândia, MG: Fonaprace; 2016 [cited 2021 Nov 29]. Available from: https://www.andifes.org.br/wp-content/uploads/2017/11/Pesquisa-de-Perfil-dos-Graduanso-das-IFES_2014.pdf
https://www.andifes.org.br/wp-content/up... .

In Brazil, studies that focus on health and education policies aimed at attention to mental suffering in university students mainly focus on students from courses in the health area⁷7. Bleicher T, Oliveira RCN. Políticas de assistência estudantil em saúde nos institutos e universidades federais. Psicol Esc Educ. 2016;20(3):543-9. https://doi.org/10.1590/2175-3539201502031040
https://doi.org/10.1590/2175-35392015020... ,¹¹11. Graner KM, Cerqueira ATAR. Revisão integrativa: sofrimento psíquico em estudantes universitários e fatores associados. Cienc Saude Coletiva. 2019;24(4):1327-46. https://doi.org/10.1590/1413-81232018244.09692017
https://doi.org/10.1590/1413-81232018244... . The complexity of the health care object carries feelings that cause psychological distress¹³13. Cerchiari EAN, Caetano D, Faccenda O. Prevalência de transtornos mentais menores em estudantes universitários. Estud Psicol. 2005;10(3):413-20. https://doi.org/10.1590/S1413-294X2005000300010
https://doi.org/10.1590/S1413-294X200500... for students starting practical activities, due to insecurity and proximity to pain and death³3. Souza M, Caldas T, De Antoni C. Fatores de adoecimento dos estudantes da área da saúde: uma revisão sistemática. Rev Psicol Saude Debate. 2017;3(1):99-126. https://doi.org/10.22289/2446-922X.V3N1A8
https://doi.org/10.22289/2446-922X.V3N1A... ,¹¹11. Graner KM, Cerqueira ATAR. Revisão integrativa: sofrimento psíquico em estudantes universitários e fatores associados. Cienc Saude Coletiva. 2019;24(4):1327-46. https://doi.org/10.1590/1413-81232018244.09692017
https://doi.org/10.1590/1413-81232018244... ,¹⁴14. Fórum Nacional de Pró-Reitores de Assuntos Comunitários e Estudantis. IV Pesquisa do perfil socioeconômico e cultural dos estudantes de graduação das instituições federais de ensino superior brasileiras - 2014. Uberlândia, MG: Fonaprace; 2016 [cited 2021 Nov 29]. Available from: https://www.andifes.org.br/wp-content/uploads/2017/11/Pesquisa-de-Perfil-dos-Graduanso-das-IFES_2014.pdf
https://www.andifes.org.br/wp-content/up... ,¹⁵15. Rocha ES, Sassi AP. Transtornos mentais menores entre estudantes de medicina. Rev Bras Educ Med. 2013;37(2):210-6. http://www.scielo.br/pdf/rbem/v37n2/08.pdf
http://www.scielo.br/pdf/rbem/v37n2/08.p... . In nursing courses, exposure to stressful factors can occur during the initial adaptation period; throughout the course, due to insecurity and the complexity of care; in the end, due to the concern with entering the labor market and the demands of the profession¹⁶16. Esperidião E, Barbosa JA, Silva NS, Munari DB. A saúde mental do aluno de Enfermagem: revisão integrativa da literatura. SMAD Rev Eletron Saude Ment Alcool Drogas. 2013;9(3):144-53. https://doi.org/10.11606/issn.1806-6976.v9i3p144-153
https://doi.org/10.11606/issn.1806-6976.... , and the traditional evaluation processes¹⁷17. Silva ARS, Silva AL, Bezerra MPM, Mendes MLM, Santos IN. Estudo do estresse na graduação de enfermagem: revisão integrativa de literatura. Cad Grad Cienc Biol Saude. 2015 [cited 2021 Nov 29];2(3):75-86. Available from: https://periodicos.set.edu.br/facipesaude/article/view/3211
https://periodicos.set.edu.br/facipesaud... . Undergraduates in the health area are more susceptible to psychological and emotional distress, due to the link to environments with high emotional demand, such as contact with pathological processes, like communicable diseases that generate fear of acquiring diseases, in addition to the fear of making mistakes and the feeling of impotence in the face of some diseases and death³3. Souza M, Caldas T, De Antoni C. Fatores de adoecimento dos estudantes da área da saúde: uma revisão sistemática. Rev Psicol Saude Debate. 2017;3(1):99-126. https://doi.org/10.22289/2446-922X.V3N1A8
https://doi.org/10.22289/2446-922X.V3N1A... ,¹⁴14. Fórum Nacional de Pró-Reitores de Assuntos Comunitários e Estudantis. IV Pesquisa do perfil socioeconômico e cultural dos estudantes de graduação das instituições federais de ensino superior brasileiras - 2014. Uberlândia, MG: Fonaprace; 2016 [cited 2021 Nov 29]. Available from: https://www.andifes.org.br/wp-content/uploads/2017/11/Pesquisa-de-Perfil-dos-Graduanso-das-IFES_2014.pdf
https://www.andifes.org.br/wp-content/up... ,¹⁵15. Rocha ES, Sassi AP. Transtornos mentais menores entre estudantes de medicina. Rev Bras Educ Med. 2013;37(2):210-6. http://www.scielo.br/pdf/rbem/v37n2/08.pdf
http://www.scielo.br/pdf/rbem/v37n2/08.p... .

It is noteworthy that mental problems starting in the university period can also affect professional life, which reinforces the importance and need for the development of institutional coping strategies, with the university environment being considered fertile for the conduct of actions that promote mental health³3. Souza M, Caldas T, De Antoni C. Fatores de adoecimento dos estudantes da área da saúde: uma revisão sistemática. Rev Psicol Saude Debate. 2017;3(1):99-126. https://doi.org/10.22289/2446-922X.V3N1A8
https://doi.org/10.22289/2446-922X.V3N1A... , ⁴4. Costa MC, Moreira YB. Saúde mental no contexto universitário. Semin Ensino Design. 2016;2(10):73-9. https://doi.org/10.5151/despro-sed2016-009
https://doi.org/10.5151/despro-sed2016-0... ,¹⁴14. Fórum Nacional de Pró-Reitores de Assuntos Comunitários e Estudantis. IV Pesquisa do perfil socioeconômico e cultural dos estudantes de graduação das instituições federais de ensino superior brasileiras - 2014. Uberlândia, MG: Fonaprace; 2016 [cited 2021 Nov 29]. Available from: https://www.andifes.org.br/wp-content/uploads/2017/11/Pesquisa-de-Perfil-dos-Graduanso-das-IFES_2014.pdf
https://www.andifes.org.br/wp-content/up... ,¹⁸18. Cuijpers P, Auerbach RP, Benjet C, Bruffaerts R, Ebert D, Karyotaki E, Kessler RC. Introduction to the special issue: The WHO World Mental Health International College Student (WMH-ICS) initiative. Int J Methods Psychiatr Res. 2019;28(2):e1762. https://doi.org/10.1002/mpr.1762
https://doi.org/10.1002/mpr.1762... .

Based on these considerations, this study aimed to present strategic options to support the adoption of institutional policies to strengthen the mental health of university students in the field of health, to be implemented by university institutions.

METHODS

Study Design

It is a rapid review, recognized as a type of study capable of providing high-quality evidence in a timely manner to support decision-making and the improvement of health policies, as per the guide of the World Health Organization (WHO) (2017 )¹⁹19. Tricco AC, Langlois EV, Straus SE, editors. Rapid reviews to strengthen health policy and systems: a practical guide. Geneva (CH): World Health Organization; 2017 [cited 2021 Nov 29]. Licence: CC BY-NC-SA 3.0 IGO. Available from: https://apps.who.int/iris/bitstream/handle/10665/258698/9789241512763-eng.pdf
https://apps.who.int/iris/bitstream/hand... . The elaboration process is guided by the systematic review method, with adaptations, aiming to produce summaries of the best available evidence, in a timely manner, to meet specific demands¹⁹19. Tricco AC, Langlois EV, Straus SE, editors. Rapid reviews to strengthen health policy and systems: a practical guide. Geneva (CH): World Health Organization; 2017 [cited 2021 Nov 29]. Licence: CC BY-NC-SA 3.0 IGO. Available from: https://apps.who.int/iris/bitstream/handle/10665/258698/9789241512763-eng.pdf
https://apps.who.int/iris/bitstream/hand... . This review was carried out in 90 days, a modality of the McMaster Health Forum Rapid Response program^a, and developed in two stages. First, the problem was delimited through project team meetings and preliminary bibliographic surveys, which guided the stage of definition of search strategies and publications survey, to retrieve studies that presented or evaluated strengthening actions, programs and policies of mental health of university students, in order to compose a list of plausible interventions to be implemented by university institutions.

Eligibility Criteria

Priority was given to studies of mental health interventions for university students, from systematic reviews (SR), with or without meta-analyses, overviews, evidence syntheses, and other types of reviews, published in English, Spanish and Portuguese. There was no restriction regarding the year of publication of the studies.

Search and Selection of Studies

Searches were performed from May to June 2020, using the terms students, university and mental health in 21 data sources in the literature: PubMed, Health System Evidence, Social System Evidence, Epistemonikos, McMaster Plus, Health Evidence, Embase, ASSIA, Campbell, Cochrane, ERIC, JBI, CINAHL, Scopus, PsycInfo, LILACS, CAPES Theses and Dissertations Catalog, Sociological Abstract, OpenGrey, PEDro, Social Service Abstract. Search strategies were set out for each data source. Box 1 shows an example of the search strategy in PubMed.

Subsequently, publications indicated by researchers or identified in supplementary searches were integrated to synthesize evidence not dealt with in the included reviews. The selection process showed that the contingent of publications on individual therapeutic interventions, of the cognitive-behavioral type, was very numerous (48), which would require extra time for data extraction. In this case, an additional filter, more rigorous and specific in the selection, was established, excluding reviews that did not provide the countries where the primary studies were carried out or the search date, and those that did not present a meta-analysis.

Data Extraction and Assessment of the Methodological Quality of Included Studies

The extraction was performed in an Excel spreadsheet and included items such as author, year, study objective, intervention, results, limitations, proportion of studies from low- and middle- income countries, as classified by the World Bank²⁰20. The World Bank. World Bank Country and Lending Groups. Washington, DC; 2020 [cited 2021 Nov 29]. Available from: https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups
https://datahelpdesk.worldbank.org/knowl... . The SRs were assessed for methodological quality using the AMSTAR²¹21. Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 2007;7:10. https://doi.org/10.1186/1471-2288-7-10
https://doi.org/10.1186/1471-2288-7-10... tool and classified as low (score 0 to 3), moderate (4 to 7) or high (8 to 11) quality. Non-systematic reviews and primary studies were also assessed for methodological quality using specific instruments: JBI Critical Appraisal Checklist for Text and Opinion Papers²²22. McArthur A, Klugarova J, Yan H, Florescu S. Innovations in the systematic review of text and opinion. Int J Evid Based Healthc. 2015;13(3):188-95. https://doi.org/10.1097/XEB.0000000000000060
https://doi.org/10.1097/XEB.000000000000... ; Critical Appraisal of a Case Study²³23. Center for Evidence Based Management. Critical Appraisal of a Case Study. Leiden (NL): CEBMa; 2014 [cited 2021 Nov 29]. Available from: https://www.cebma.org/wp-content/uploads/Critical-Appraisal-Questions-for-a-Qualitative-Study.pdf
https://www.cebma.org/wp-content/uploads... ; Scale for the Quality Assessment of Narrative Review Articles (SANRA)²⁴24. Baethge C, Goldbeck-Wood S, Mertens S. SANRA - a scale for the quality assessment of narrative review articles. Res Integr Peer Rev. 2019;4:5. https://doi.org/10.1186/s41073-019-0064-8
https://doi.org/10.1186/s41073-019-0064-... ; JBI Critical Appraisal Checklist for Systematic Reviews and Research Synthesis²⁵25. Center for Evidence Based Management. Critical Appraisal of a Case Study. Leiden (NL): CEBMa; 2014 [cited 2021 Nov 29]. Available from: https://www.cebma.org/wp-content/uploads/Critical-Appraisal-Questions-for-a-Case-Study.pdf
https://www.cebma.org/wp-content/uploads... ; Criteria for Evaluation of Experience Report²⁶26. Universidade Federal de Juiz de Fora. Critérios para avaliação de relatos de experiência. Juiz de Fora, MG: UFJF; 2014 [cited 2020 Nov 1]. Available from: https://www.ufjf.br/edfinanceira/files/2014/03/Crit%c3%a9rio-de-Avalia%c3%a7%c3%a3o-do-trabalhos.pdf
https://www.ufjf.br/edfinanceira/files/2... and Evaluation of the Methodological Quality of Evidence Synthesis for Policy²⁷27. Ministério da Saúde (BR), Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos, Departamento de Ciência e Tecnologia. Diretriz metodológica: síntese de evidências para políticas. Brasília, DF; 2020 [cited 2020 Nov 1]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/diretriz_sintese_evidencias_politicas.pdf
https://bvsms.saude.gov.br/bvs/publicaco... . They were classified as low (up to 30%), moderate (30% to 60%) and high (60% to 100%) quality.

Shortcuts Used

Six reviewers (CBS; EMGG; FCAC; MCB; LC; TST) performed the stages of study eligibility, data extraction and methodological quality assessment; as indicated in rapid reviews, the study did not need a pair of reviewers. Selection questions were resolved by consensus and extraction was verified by a seventh reviewer (TY).

RESULTS

Search strategies retrieved 4,164 publications, 14 of which were duplicates and 4,047 were excluded in the steps of reading titles and abstracts. Of the 114 publications analyzed in full, 69 were excluded for not meeting the inclusion criteria, and finally 45 publications were included (Figure): 34 SR, one evidence synthesis, one overview, one scope review, three narrative reviews, three experience reports and two opinion articles.

The studies included (Tables 1 and 2) provided evidence for the formulation of four strategic options to respond to students’ mental health needs. Each option presents a set of key messages, which constitute plausible courses of action for implementation (Box 2) of these options. The evidence behind these key messages is presented below.

Key message 1. Based on the policy of the Federal University of São Carlos (UFSCar), which integrates the various actors in mental health, establishes a working group to define a common agenda and organizes a front to face suicide²⁹29. Bleicher T. Criação de Política de Saúde Mental da Universidade Federal de São Carlos. Trabalho apresentado na Conferência sobre a Criação de Política de Saúde Mental da Universidade de São Carlos; jun 2018; Manaus, AM [cited 2020 Nov 1]. Available from: https://www.researchgate.net/publication/325679239_CRIACAO_DE_POLITICA_DE_SAUDE_MENTAL_DA_UNIVERSIDADE_FEDERAL_DE_SAO_CARLOS
https://www.researchgate.net/publication... . To compose this policy, principles and actions to combat racism must be considered, adopting reforms of commitment to rights, justice, dignity, respect, participation and intersectoriality, which involves the public recognition of institutional responsibility in combating racism, and adoption of mechanisms to identify and fix problems and provide support for coping³⁰30. Metivier K. Envisioning higher education as antiracist. Inside Higher Ed (Washington, DC). 2020 Jul 2 [cited 2020 Sep 7]. Available from: https://www.insidehighered.com/views/2020/07/02/actions-higher-ed-institutions-should-take-help-eradicate-racism-opinion
https://www.insidehighered.com/views/202... . Multicomponent suicide prevention policies involved restricting the means to commit suicide and mandatory health assessment for those with suicidal behavior³¹31. Harrod CS, Goss CW, Stallones L, Diguiseppi C. Interventions for primary prevention of suicide in university and other post-secondary educational settings. Cochrane Database Syst Rev. 2014;10:CD009439. https://doi.org/10.1002/14651858.CD009439.pub2
https://doi.org/10.1002/14651858.CD00943... ,³²32. Fernandez A, Howse E, Rubio-Valera M, Thorncraft K, Noone J, Luu X, et al. Setting-based interventions to promote mental health at the university: a systematic review. Int J Public Health. 2016;61(7):797-807. https://doi.org/10.1007/s00038-016-0846-4
https://doi.org/10.1007/s00038-016-0846-... .

Key message 2. Based on evidence on the availability of resources and training to faculty to create a stigma-free university environment, and on encouraging the development of student bodies to support those with mental health problems³³33. Tamboly S, Gauvin FP. Issue brief: addressing student mental health needs at McMaster University. Hamilton (CA): McMaster Health Forum; 10 April 2013 [cited 2020 Oct 22]. Available from: https://macsphere.mcmaster.ca/bitstream/11375/14872/1/fulltext.pdf
https://macsphere.mcmaster.ca/bitstream/... ; interventions to reduce stigma through training students on the theme³⁴34. Livingston JD, Milne T, Fang ML, Amari E. The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review. Addiction. 2012;107(1):39-50. https://doi.org/10.1111/j.1360-0443.2011.03601.x
https://doi.org/10.1111/j.1360-0443.2011...

35. Giralt-Palou R, Prat-Vigué G, Tort-Nasarre G. Attitudes and stigma toward mental health in nursing students: a systematic review. Perspect Psychiatr Care 2019;56(2):243-55. https://doi.org/10.1111/ppc.12419
https://doi.org/10.1111/ppc.12419...

36. Yamaguchi S, Wu SI, Biswas M, Yate M, Aok Y, Barley EA, et al. Effects of short-term interventions to reduce mental health-related stigma in university or college students: a systematic review. J Nerv Ment Dis. 2013;201(6):490-503. https://doi.org/10.1097/NMD.0b013e31829480df
https://doi.org/10.1097/NMD.0b013e318294... -³⁷37. Heim E, Henderson C, Kohrt BA, Koschorke M, Milenova M, Thornicroft G. Reducing mental health-related stigma among medical and nursing students in low- and middle-income countries: a systematic review. Epidemiol Psychiatr Sci. 2019;29:e28. https://doi.org/10.1017/S2045796019000167
https://doi.org/10.1017/S204579601900016... and activities that promote cultural and social development and that favor well-being, such as theater, dance, nature walks³⁸38. Leckey J. The therapeutic effectiveness of creative activities on mental well-being: a systematic review of the literature. J Psychiatr Ment Health Nurs. 2011;18(6):501-9. https://doi.org/10.1111/j.1365-2850.2011.01693.x
https://doi.org/10.1111/j.1365-2850.2011...

39. Mansfield L, Kay T, Meads C, Grigsby-Duffy L, Lane J, Alistair J, et al. Sport and dance interventions for healthy young people (15-24 years) to promote subjective well-being: a systematic review. BMJ Open. 2018;8(7):e020959. https://doi.org/10.1136/bmjopen-2017-020959
https://doi.org/10.1136/bmjopen-2017-020... -⁴⁰40. Meredith GR, Rakow DA, Eldermire ERB, Madsen CG, Shelley SP, Sachs NA. Minimum time dose in nature to positively impact the mental health of college-aged students, and how to measure it: a scoping review. Front. Psychol. 2020;10:2942. https://doi.org/10.3389/fpsyg.2019.02942
https://doi.org/10.3389/fpsyg.2019.02942... and movies, for improvement patterns of rest and sleep⁴¹41. Labrague LJ, McEnroe-Petitte DM, Gloe D, Thomas L, Papathanasiou IV, Tsaras K. A literature review on stress and coping strategies in nursing students. J Ment Health. 2017;26(5):471-80. https://doi.org/10.1080/09638237.2016.1244721
https://doi.org/10.1080/09638237.2016.12... .

Key message 3. Based on: introduction of stress management programs into the medical curriculum, changes in duration, curriculum type, and pass/fail grading system⁴²42. Shiralkar MT, Harris TB, Eddins-Folensbee FF, Coverdale JH. A systematic review of stress-management programs for medical students. Acad Psychiatry. 2013;37(3):158-64 https://doi.org/10.1176/appi.ap.12010003
https://doi.org/10.1176/appi.ap.12010003... ; interprofessional discipline on contemporary youth problems, with emancipatory potential for university sociability⁴³43. Cordeiro L, Cavalcanti BSG, Campos CMS, Kehl TM, Soares CB, Martins VLS. Ensino sobre drogas psicoativas e redução de danos emancipatória: proposta de disciplina para graduação, na perspectiva da Saúde Coletiva. Rev Sociol Rede. 2016 [cited 2020 Sep 7];6(6):272-87. Available from: https://www.researchgate.net/publication/310572456_Ensino_sobre_drogas_psicoativas_e_reducao_de_danos_emancipatoria_proposta_de_disciplina_para_graduacao_na_perspectiva_da_Saude_Coletiva
https://www.researchgate.net/publication... ; curriculum changes implemented in early periods of courses to increase social skills and resources to address personal or academic problems⁴⁴44. Cromlish A. Reframing solutions to mental health in higher education. Essays Educ. 2020 [cited 2020 Sep 7];25:2. Available from: https://openriver.winona.edu/eie/vol25/iss1/2
https://openriver.winona.edu/eie/vol25/i... ; mandatory course on mental health in modern society and a course in mind-body medicine, taught to first-year medical students, as well as structural changes in the curriculum³²32. Fernandez A, Howse E, Rubio-Valera M, Thorncraft K, Noone J, Luu X, et al. Setting-based interventions to promote mental health at the university: a systematic review. Int J Public Health. 2016;61(7):797-807. https://doi.org/10.1007/s00038-016-0846-4
https://doi.org/10.1007/s00038-016-0846-... ; group stress management, training in relaxation skills and cognitive-behavioral techniques in the Nursing course to prevent course dropout⁴⁵45. Bakker EJM, Kox JHAM, Boot CRL, Francke AL, Beek AJ, Roelofs PDDM. Improving mental health of student and novice nurses to prevent dropout: a systematic review. J Adv Nurs. 2020:76(10):2494-509. https://doi.org/10.1111/jan.14453
https://doi.org/10.1111/jan.14453... ; structural, systemic and cultural changes that can impact medical education⁴⁶46. Witt K, Boland A, Lamblin M, McGorry PD, Veness B, Cipriani A, et al. Effectiveness of universal programmes for the prevention of suicidal ideation, behaviour and mental ill health in medical students: a systematic review and meta-analysis. Evid Based Ment Health. 2019;22(2):84-90. https://doi.org/10.1136/ebmental-2019-300082
https://doi.org/10.1136/ebmental-2019-30... . Although training programs in early mental health care are considered effective to improve knowledge in the area, few are the curricula that integrate them, being found in courses in the health area in only three countries⁴⁷47. El-Den S, Moles R, Choong HJ; O’Reilly C. Mental Health First Aid training and assessment among university students: a systematic review. J Am Pharm Assoc. 2020;60(5):E81-95. https://doi.org/10.1016/j.japh.2019.12.017
https://doi.org/10.1016/j.japh.2019.12.0... .

Key message 4. Supported by interventions to improve access to minority mental health services, such as crisis services information hotline, presentations of experts and family members and individuals with mental health problems³³33. Tamboly S, Gauvin FP. Issue brief: addressing student mental health needs at McMaster University. Hamilton (CA): McMaster Health Forum; 10 April 2013 [cited 2020 Oct 22]. Available from: https://macsphere.mcmaster.ca/bitstream/11375/14872/1/fulltext.pdf
https://macsphere.mcmaster.ca/bitstream/... . The organization of conferences on inclusion, equality and diversity in university education provided an opportunity to discuss homophobia for academics, students, LGBT activists and other Nigerian groups⁴⁷47. El-Den S, Moles R, Choong HJ; O’Reilly C. Mental Health First Aid training and assessment among university students: a systematic review. J Am Pharm Assoc. 2020;60(5):E81-95. https://doi.org/10.1016/j.japh.2019.12.017
https://doi.org/10.1016/j.japh.2019.12.0... . Institutional guidelines for situations of violence and discrimination based on gender and sexual orientation, and protection measures so that victims of violence are not harmed in their training, such as comprehensive care for victims, investigation and rapid responses to reported cases⁴⁸48. Okanlawon K. Homophobia in Nigerian schools and universities: victimization, mental health issues, resilience of the LGBT students and support from Straight Allies. a literature review. J LGBT Youth. 2021;18(4):327-59. https://doi.org/10.1080/19361653.2020.1749211
https://doi.org/10.1080/19361653.2020.17... .

Key message 5. Based on the concept of integration of services and resources offered by the university to those of the Brazilian Unified Health System (SUS), as integrated strategies can enhance the supply and access to services, preventing the university from taking responsibility alone for the care of students²⁹29. Bleicher T. Criação de Política de Saúde Mental da Universidade Federal de São Carlos. Trabalho apresentado na Conferência sobre a Criação de Política de Saúde Mental da Universidade de São Carlos; jun 2018; Manaus, AM [cited 2020 Nov 1]. Available from: https://www.researchgate.net/publication/325679239_CRIACAO_DE_POLITICA_DE_SAUDE_MENTAL_DA_UNIVERSIDADE_FEDERAL_DE_SAO_CARLOS
https://www.researchgate.net/publication... .

Key message 6. Supported by evidence on individual non-pharmacological treatments for stress, anxiety and other signs and symptoms of psychic suffering. Analysis of mindfulness intervention and other behavioral therapies showed satisfactory results⁴⁶46. Witt K, Boland A, Lamblin M, McGorry PD, Veness B, Cipriani A, et al. Effectiveness of universal programmes for the prevention of suicidal ideation, behaviour and mental ill health in medical students: a systematic review and meta-analysis. Evid Based Ment Health. 2019;22(2):84-90. https://doi.org/10.1136/ebmental-2019-300082
https://doi.org/10.1136/ebmental-2019-30... ,⁵⁰50. Regehr C, Glancy D, Pitts Al. Interventions to reduce stress in university students: a review and meta-analysis. J Affect Disord. 2013;148(1):1-11. https://doi.org/10.1016/j.jad.2012.11.026
https://doi.org/10.1016/j.jad.2012.11.02...

51. Bamber MD, Morpeth E. Effects of mindfulness meditation on college student anxiety: a meta-analysis. Mindfulness. 2019;10(2);203-14. https://doi.org/10.1007/s12671-018-0965-5
https://doi.org/10.1007/s12671-018-0965-...

52. Huang J, Nigatu YT, Smail-Crevier R, Zhang X, Wang J. Interventions for common mental health problems among university and college students: a systematic review and meta-analysis of randomized controlled trials. J Psychiatr Res. 2018:107:1-10. https://doi.org/10.1016/j.jpsychires.2018.09.018
https://doi.org/10.1016/j.jpsychires.201...

53. Winzer R, Lindberg L, Guldbrandsson K, Sidorchuk A. Effects of mental health interventions for students in higher education are sustainable over time: a systematic review and meta-analysis of randomized controlled trials. Peer J. 2018;6:e4598. https://doi.org/10.7717/peerj.4598
https://doi.org/10.7717/peerj.4598...

54. Chen D, Sun W, Liu N, Wang J, Guo P, Zhang X, et al. Effects of nonpharmacological interventions on depressive symptoms and depression among nursing students: a systematic review and meta-analysis. Complement Ther Clin Pract. 2019;34:217-28. https://doi.org/10.1016/j.ctcp.2018.12.011
https://doi.org/10.1016/j.ctcp.2018.12.0...

55. Dawson AF, Brown WW, Anderson J, Datta B, Donald JN, Hong K, et al. Mindfulness-based interventions for university students: a systematic review and meta-analysis of randomised controlled trials. Appl Psychol Health Well Being. 2020;12(2); 384-410. https://doi.org/10.1111/aphw.12188
https://doi.org/10.1111/aphw.12188... -⁵⁶56. González-Valero G, Zurita-Ortega F, Ubago-Jiménez JL, Puertas-Molero P. Use of meditation and cognitive behavioral therapies for the treatment of stress, depression and anxiety in students. a systematic review and meta-analysis. Int J Environ Res Public Health. 2019;16(22):4394. https://doi.org/10.3390/ijerph16224394
https://doi.org/10.3390/ijerph16224394... . For depression, psychological therapies were highlighted as the most effective⁵⁷57. Li C, Yin H, Zhao J, Shang B, Hu M, Zhang P, et al. Interventions to promote mental health in nursing students: a systematic review and meta-analysis of randomized controlled trials. J Adv Nurs. 2018;74 (12):2727-41. https://doi.org/10.1111/jan.13808
https://doi.org/10.1111/jan.13808... ,⁵⁸58. Fu Z, Zhou S, Burguer H, Bockting CLH, Williams AD. Psychological interventions for depression in Chinese university students: a systematic review and meta-analysis. J Affect Disord. 2020;262:440-50. https://doi.org/10.1016/j.jad.2019.11.058
https://doi.org/10.1016/j.jad.2019.11.05... . Mindfulness interventions and stress management programs were effective. Compared to pharmacological treatment, non-pharmacological interventions had moderate beneficial effects on depressive symptoms in nursing students. Short-term interventions moderately relieved depressive symptoms and depression⁵⁴54. Chen D, Sun W, Liu N, Wang J, Guo P, Zhang X, et al. Effects of nonpharmacological interventions on depressive symptoms and depression among nursing students: a systematic review and meta-analysis. Complement Ther Clin Pract. 2019;34:217-28. https://doi.org/10.1016/j.ctcp.2018.12.011
https://doi.org/10.1016/j.ctcp.2018.12.0... . Psychoeducational interventions produced significant effects in reducing symptoms of anxiety, stress, psychological distress, among others⁵⁹59. Conley CS, Durlak JA, Kirch AC. A meta-analysis of universal mental health prevention programs for higher education students. Prev Sci. 2015;16(4):487-507. https://doi.org/10.1007/s11121-015-0543-1
https://doi.org/10.1007/s11121-015-0543-... . Interventions with music, physical exercise, yoga, tai chi, among other activities, were effective in preventing common mental health problems, with medium-term programs having better effects than short-term ones⁵²52. Huang J, Nigatu YT, Smail-Crevier R, Zhang X, Wang J. Interventions for common mental health problems among university and college students: a systematic review and meta-analysis of randomized controlled trials. J Psychiatr Res. 2018:107:1-10. https://doi.org/10.1016/j.jpsychires.2018.09.018
https://doi.org/10.1016/j.jpsychires.201... . Counseling and mindfulness interventions contributed to stress management and reduction⁶⁰60. Ghilardi A, Buizza C, Carobbio EM, Lusenti R. Detecting and managing mental health issues within young adults. a systematic review on college counselling in Italy. Clin Pract Epidemiol Ment Health. 2017;13:61-70. https://doi.org/10.2174/1745017901713010061
https://doi.org/10.2174/1745017901713010...

61. Amanvermez Y, Rahmadiana M, KaryotakI E, Wit L, Ebert DD, Kessler RC, et al. Stress management interventions for college students: a systematic review and meta-analysis. Clin Psychol Sci [Early View] [posted 2020 May 22]. https://doi.org/10.1111/cpsp.12342
https://doi.org/10.1111/cpsp.12342... -⁶²62. Conley CS, Shapiro JB, Kirch AC, Durlak JA. A meta-analysis of indicated mental health prevention programs for at-risk higher education students. J Couns Psychol. 2017;64(2):121-40. https://doi.org/10.1037/cou0000190
https://doi.org/10.1037/cou0000190... . Brief interventions with individual focus of mindfulness were shown to be limited in reducing levels of anxiety, depression and stress in medical students with suicidal ideation; most of the evaluated interventions were offered during the pre-clinical years, and there is evidence that the problems become more expressive during the period of incursion into clinical practice⁴⁶46. Witt K, Boland A, Lamblin M, McGorry PD, Veness B, Cipriani A, et al. Effectiveness of universal programmes for the prevention of suicidal ideation, behaviour and mental ill health in medical students: a systematic review and meta-analysis. Evid Based Ment Health. 2019;22(2):84-90. https://doi.org/10.1136/ebmental-2019-300082
https://doi.org/10.1136/ebmental-2019-30... . Analyses of interventions to reduce alcohol consumption, such as face-to-face and internet programs, have shown the need for further research to identify more promising approaches⁶³63. Dietz P, Reichel JL, Edelmann D, Werner AM, Tibubos AN, Schäfer M, et al. A systematic umbrella review on the epidemiology of modifiable health influencing factors and on health promoting interventions among university students. Front Public Health. 2020;8:137. https://doi.org/10.3389/fpubh.2020.00137
https://doi.org/10.3389/fpubh.2020.00137... . Individual therapies aimed at changing behavior showed an effect in reducing alcohol consumption⁶⁴64. Reid AE, Carey KB. Interventions to reduce college student drinking: state of the evidence for mechanisms of behavior change. Clin Psychol Rev. 2015;40:213-24. https://doi.org/10.1016/j.cpr.2015.06.006
https://doi.org/10.1016/j.cpr.2015.06.00... ,⁶⁵65. Reavley N, Jorm AF. Prevention and early intervention to improve mental health in higher education students: a review. Early Interv Psychiatry. 2010;4(2):132-42. https://doi.org/10.1111/j.1751-7893.2010.00167.x
https://doi.org/10.1111/j.1751-7893.2010... . Satisfactory results were observed from the brief, single-session intervention for high alcohol consumption, but future research should examine what would be the effective duration of this intervention⁶⁶66. Samson JE, Tanner-Smith EE. Single-session alcohol interventions for heavy drinking college students: a systematic review and meta-analysis. J Stud Alcohol Drugs. 2015;76(4):530-43. https://doi.org/10.15288/jsad.2015.76.530
https://doi.org/10.15288/jsad.2015.76.53... . Regarding the improvement of eating habits, face-to-face interventions, media approaches and nutrition labeling were positive. Physical activity promotion interventions should carefully consider personalized interventions. In the case of sleep, cognitive behavioral therapy showed greater effects compared to hygiene interventions⁶³63. Dietz P, Reichel JL, Edelmann D, Werner AM, Tibubos AN, Schäfer M, et al. A systematic umbrella review on the epidemiology of modifiable health influencing factors and on health promoting interventions among university students. Front Public Health. 2020;8:137. https://doi.org/10.3389/fpubh.2020.00137
https://doi.org/10.3389/fpubh.2020.00137... .

Key message 7. Based on e-health type interventions. A small effect on academic performance, depression and anxiety was reported in the analysis of interventions such as: web platform, with optional use of a mobile application; program with personalized feedback; opportunities for personal training integrated into the university’s online course platform; intervention with thematic modules such as goal setting, personal strengths and career plan; integration of knowledge about oneself with meaningful goals; intervention based on acceptance and commitment therapy; computerized expressive writing intervention to report academic fears⁶⁷67. Bolinski F, Boumparis N, Kleiboer A, Cuijpers P, Ebert DD, Ripper H. The effect of e-mental health interventions on academic performance in university and college students: a meta-analysis of randomized controlled trials. Internet Interv. 2020;20:100321. https://doi.org/10.1016/j.invent.2020.100321
https://doi.org/10.1016/j.invent.2020.10... . Multidirectional intervention, with feedback through a computer program, showed a positive result on the intention to smoke cigarettes, but not marijuana. Brief web-based or computer-based personalized feedback programs were not effective in reducing or preventing marijuana use⁶⁸68. Gulliver A, Farrer L, Chan JKY, Tait RJ, Bennett K, Calear A, et al. Technology-based interventions for tobacco and other drug use in university and college students: a systematic review and meta-analysis. Addict Sci Clin Pract. 2015;10:5. https://doi.org/10.1186/s13722-015-0027-4
https://doi.org/10.1186/s13722-015-0027-... . Virtual interventions such as feedback to assess current levels of alcohol consumption and interactive games have shown potential to help reduce alcohol consumption⁶⁹69. Khadjesari Z, Murray E, Hewitt C, Hartley S, Godfrey C. Can stand-alone computer-based interventions reduce alcohol consumption? A systematic review. Addiction. 2011;106(2):267-82. https://doi.org/10.1111/j.1360-0443.2010.03214.x
https://doi.org/10.1111/j.1360-0443.2010... . Indicated interventions (with pre-existing problems) were advantageous over universal interventions (without pre-existing problems) for outcomes such as depression, anxiety, stress, social and emotional skills⁷⁰70. Conley CS, Durlak JA, Shapiro JB, Kirsch AC, Zahniser E. A meta-analysis of the impact of universal and indicated preventive technology-delivered interventions for higher education students. Prev Sci. 2016;17(6):659-78. https://doi.org/10.1007/s11121-016-0662-3
https://doi.org/10.1007/s11121-016-0662-... . Internet interventions to improve mental health, well-being, and social and academic functioning showed small positive effects for depression, anxiety and stress symptoms, and moderate positive effects for eating disorder symptoms and social and academic functioning⁷¹71. Harrer M, Adam SH, Baumeister H, Cuijpers P, Karyotaki E, Auerbach RP, et al. Internet interventions for mental health in university students: a systematic review and meta-analysis. Int J Methods Psychiatr Res. 2019;28:e1759. https://doi.org/10.1002/mpr.1759
https://doi.org/10.1002/mpr.1759... .

Key message 8. Considered strategies such as: articulation between mental health services inside and outside the university; presentation of these services to students; access to resource information materials available in print and online; mental health campaigns; sending e mail to students; and teacher training to address mental health issues, including referrals to appropriate services³³33. Tamboly S, Gauvin FP. Issue brief: addressing student mental health needs at McMaster University. Hamilton (CA): McMaster Health Forum; 10 April 2013 [cited 2020 Oct 22]. Available from: https://macsphere.mcmaster.ca/bitstream/11375/14872/1/fulltext.pdf
https://macsphere.mcmaster.ca/bitstream/... Evidence was also integrated about the use of the app to inform about the services offered in health and reception units at the university, and about well-being. The information was considered convenient and reliable by the students, being effective in reducing anxiety and depression symptoms; risk identification for mental disorders; reduction of alcohol and tobacco consumption and cessation of tobacco consumption⁷¹71. Harrer M, Adam SH, Baumeister H, Cuijpers P, Karyotaki E, Auerbach RP, et al. Internet interventions for mental health in university students: a systematic review and meta-analysis. Int J Methods Psychiatr Res. 2019;28:e1759. https://doi.org/10.1002/mpr.1759
https://doi.org/10.1002/mpr.1759... . Educational program and gatekeeper training with the objective that colleagues, teachers and employees recognize and respond to the warning signs of emotional crises and suicide risk were considered effective, with an increase in short-term knowledge and self-efficacy in suicide prevention³¹31. Harrod CS, Goss CW, Stallones L, Diguiseppi C. Interventions for primary prevention of suicide in university and other post-secondary educational settings. Cochrane Database Syst Rev. 2014;10:CD009439. https://doi.org/10.1002/14651858.CD009439.pub2
https://doi.org/10.1002/14651858.CD00943... .

Key message 9. Formulated based on an intervention at the University of Mexico, which created reception and support services for students, and sought to understand the situation of the university community, offer courses on gender for teachers and advocate for the training of university surveillance workers⁴⁹49. Maito DC, Panúncio-Pinto MP, Severi FC, Vieira EM. Construção de diretrizes para orientar ações institucionais em casos de violência de gênero na universidade. Interface (Botucatu). 2019;23:e180653. https://doi.org/10.1590/interface.180653
https://doi.org/10.1590/interface.180653... .

Key message 10. Based on the monitoring model of the University of Dentistry of São Paulo (FOUSP), conducted through longitudinal research of a cohort composed of freshmen, emphasizing the burnout syndrome. Another strategy involving application of research with feedback and follow-up of undergraduate and graduate students is used to improve mental health and culture at the university, since professors and other workers monitor the results (available anonymously). The feedback involves time management, better study and metacognitive skills, as well as preparation for the specific difficulties of the programs⁴⁴44. Cromlish A. Reframing solutions to mental health in higher education. Essays Educ. 2020 [cited 2020 Sep 7];25:2. Available from: https://openriver.winona.edu/eie/vol25/iss1/2
https://openriver.winona.edu/eie/vol25/i... . UFSCar develops longitudinal research following the university community and created an extension program involving the academic departments of courses in the health area, the University Hospital, among other entities, having as its axis the institutional diagnosis, the profile of mental health in the university community and articulation with the municipality’s psychosocial care network²⁹29. Bleicher T. Criação de Política de Saúde Mental da Universidade Federal de São Carlos. Trabalho apresentado na Conferência sobre a Criação de Política de Saúde Mental da Universidade de São Carlos; jun 2018; Manaus, AM [cited 2020 Nov 1]. Available from: https://www.researchgate.net/publication/325679239_CRIACAO_DE_POLITICA_DE_SAUDE_MENTAL_DA_UNIVERSIDADE_FEDERAL_DE_SAO_CARLOS
https://www.researchgate.net/publication... .

Key message 11. Based on experience with the development of tutoring programs in two units of the University of São Paulo (USP): FOUSP, which provides resources such as a website, tutor guide with basic guidelines for teachers, annual training for tutors with mental health professionals and semiannual follow-up reports, with 20 professors, a psychologist and two social workers supporting undergraduate students⁷³73. Faculdade de Odontologia da Universidade de São Paulo. Grupo de Apoio ao Estudante. São Paulo; 2020 [cited 2020 Nov 22]. Available from: http://www.fo.usp.br/?page_id=13852
http://www.fo.usp.br/?page_id=13852... ; the School of Nursing, which develops an academic tutoring project, with four professors from the Bachelor’s Degree Commission, with one being a reference for each undergraduate year, for monitoring academic difficulties, listening to suffering and strain related to mental health and referrals⁷⁴74. Leonello VM, Campos CMS, Sigaud CHS, Toriyama ATM, Nogueira PC. Acompanhamento dos estudantes pela Comissão Coordenadora do Curso de Enfermagem da Universidade de São Paulo. Rev Grad USP. 2018;3(2):119-21. https://doi.org/10.11606/issn.2525-376X.v3i2p119-121
https://doi.org/10.11606/issn.2525-376X.... . McMaster University student housing workers and members of student unions collaborate with first-year undergraduates who struggle to transition to university; in addition, professors are encouraged to offer students, in the disciplines, availability to discuss mental health problems, such as stress and anxiety; other groups also provide support to students³³33. Tamboly S, Gauvin FP. Issue brief: addressing student mental health needs at McMaster University. Hamilton (CA): McMaster Health Forum; 10 April 2013 [cited 2020 Oct 22]. Available from: https://macsphere.mcmaster.ca/bitstream/11375/14872/1/fulltext.pdf
https://macsphere.mcmaster.ca/bitstream/... .

DISCUSSION

The options formulated from the literature to respond to the mental health needs of university students are challenging and require universities to establish institutional commissions capable of implementing a policy in the area.

The first option summons managers of healthcare courses and universities to action and decision-making, showing the need to establish institutional policies, in contrast to specific actions and isolated initiatives. This decision requires the constitution of a working group that: prepares a plan for implementation, with clear and objectively delineated purposes and goals; provide the development and monitoring of the results of projects and implemented actions; and offer permanent support to students and managers, for the effectiveness and continuity of the process. These actions must not lose sight of the confrontation of the stigma intrinsic to the theme of mental suffering, nor the perspective of dealing with the theme of mental health across the curriculum, in order to enable the student to develop critical analysis and the understanding of the roots of problems faced. The studies point to the need to include teachers and other workers in the discussion process, improving the debate and favoring proposals for joint confrontation, with institutional commitment to sensitive issues that cause suffering, such as racism, prejudices against LGBTI and quota holders, and other forms of discrimination⁴⁸48. Okanlawon K. Homophobia in Nigerian schools and universities: victimization, mental health issues, resilience of the LGBT students and support from Straight Allies. a literature review. J LGBT Youth. 2021;18(4):327-59. https://doi.org/10.1080/19361653.2020.1749211
https://doi.org/10.1080/19361653.2020.17... ,⁷⁵75. Williams DR, Lawrence JA, Davis BA. Racism and health: evidence and needed research. Annu Rev Public Health. 2019;40:105-25. https://doi.org/10.1146/annurev-publhealth-040218-043750
https://doi.org/10.1146/annurev-publheal... . This first option requires deep structural, paradigm and practice changes from the institutions, and its implementation in the medium/long term demands dedication of time and effort from those involved.

As a second option, in the short term, universities and courses in the health area can make an effort to identify existing actions and available services, in order to integrate them and formally offer the university community information and access to this care network. Institutional protagonism is essential, organizing programs and actions linked to the university’s internal care network and SUS (Brazilian Unified Health System), to the detriment of isolated actions. The need to expand the offer of these services is included, pointing out two paths: expansion of therapeutic activities so that they are not restricted to pharmacological interventions, and inclusion of information and communication technologies to assess suffering, then guiding and directing students to appropriate services. Telehealth is a useful tool to increase access, and mental health is a pioneer in the use of these technologies⁶⁷67. Bolinski F, Boumparis N, Kleiboer A, Cuijpers P, Ebert DD, Ripper H. The effect of e-mental health interventions on academic performance in university and college students: a meta-analysis of randomized controlled trials. Internet Interv. 2020;20:100321. https://doi.org/10.1016/j.invent.2020.100321
https://doi.org/10.1016/j.invent.2020.10... ,⁷¹71. Harrer M, Adam SH, Baumeister H, Cuijpers P, Karyotaki E, Auerbach RP, et al. Internet interventions for mental health in university students: a systematic review and meta-analysis. Int J Methods Psychiatr Res. 2019;28:e1759. https://doi.org/10.1002/mpr.1759
https://doi.org/10.1002/mpr.1759... ,⁷²72. Johnson kF, Kalkbrenner MT. The utilization of technological innovations to support college student mental health: Mobile Health Communication. J Technol Hum Serv. 2017;35(4):314-39. https://doi.org/10.1080/15228835.2017.1368428
https://doi.org/10.1080/15228835.2017.13... . The university, which often researches these innovations, has a duty to incorporate them into the care routine of its community¹⁶16. Esperidião E, Barbosa JA, Silva NS, Munari DB. A saúde mental do aluno de Enfermagem: revisão integrativa da literatura. SMAD Rev Eletron Saude Ment Alcool Drogas. 2013;9(3):144-53. https://doi.org/10.11606/issn.1806-6976.v9i3p144-153
https://doi.org/10.11606/issn.1806-6976.... ,¹⁷17. Silva ARS, Silva AL, Bezerra MPM, Mendes MLM, Santos IN. Estudo do estresse na graduação de enfermagem: revisão integrativa de literatura. Cad Grad Cienc Biol Saude. 2015 [cited 2021 Nov 29];2(3):75-86. Available from: https://periodicos.set.edu.br/facipesaude/article/view/3211
https://periodicos.set.edu.br/facipesaud... .

Option 3 focuses on the need for institutional development of educational strategies that illuminate contemporary mental problems, with emphasis on those arising from prejudice and attitudes of discrimination, and the ways in which they are faced. The implementation of educational strategies and debates with the entire academic community should focus on issues related to forms of discrimination and their relationship with psychic suffering. This debate can bring up demands and strengthen the intra-institutional support network³¹31. Harrod CS, Goss CW, Stallones L, Diguiseppi C. Interventions for primary prevention of suicide in university and other post-secondary educational settings. Cochrane Database Syst Rev. 2014;10:CD009439. https://doi.org/10.1002/14651858.CD009439.pub2
https://doi.org/10.1002/14651858.CD00943... ,³³33. Tamboly S, Gauvin FP. Issue brief: addressing student mental health needs at McMaster University. Hamilton (CA): McMaster Health Forum; 10 April 2013 [cited 2020 Oct 22]. Available from: https://macsphere.mcmaster.ca/bitstream/11375/14872/1/fulltext.pdf
https://macsphere.mcmaster.ca/bitstream/... .

Option 4 shows that coping with psychic suffering requires permanent monitoring of mental health actions, as well as their inclusion in the institutional agenda, with the creation of support networks for students and the involvement of the entire academic community. In this option, tutoring programs and monitoring of cases of mental suffering among students are identified, within the units, which demand coping and welcoming strategies, joint reflection on the identified problems and possible referrals, follow-up and monitoring of the processes²⁸28. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med. 2009;6(7):e1000097. https://doi.org/10.1371/journal.pmed.1000097
https://doi.org/10.1371/journal.pmed.100... ,⁴³43. Cordeiro L, Cavalcanti BSG, Campos CMS, Kehl TM, Soares CB, Martins VLS. Ensino sobre drogas psicoativas e redução de danos emancipatória: proposta de disciplina para graduação, na perspectiva da Saúde Coletiva. Rev Sociol Rede. 2016 [cited 2020 Sep 7];6(6):272-87. Available from: https://www.researchgate.net/publication/310572456_Ensino_sobre_drogas_psicoativas_e_reducao_de_danos_emancipatoria_proposta_de_disciplina_para_graduacao_na_perspectiva_da_Saude_Coletiva
https://www.researchgate.net/publication... ,⁷³73. Faculdade de Odontologia da Universidade de São Paulo. Grupo de Apoio ao Estudante. São Paulo; 2020 [cited 2020 Nov 22]. Available from: http://www.fo.usp.br/?page_id=13852
http://www.fo.usp.br/?page_id=13852... . The institution can create integrated work mechanisms with health services, family and professors, to facilitate the student’s therapeutic process, given that the university environment is excellent for the implementation and monitoring of actions to promote mental health⁴4. Costa MC, Moreira YB. Saúde mental no contexto universitário. Semin Ensino Design. 2016;2(10):73-9. https://doi.org/10.5151/despro-sed2016-009
https://doi.org/10.5151/despro-sed2016-0... ,¹⁹19. Tricco AC, Langlois EV, Straus SE, editors. Rapid reviews to strengthen health policy and systems: a practical guide. Geneva (CH): World Health Organization; 2017 [cited 2021 Nov 29]. Licence: CC BY-NC-SA 3.0 IGO. Available from: https://apps.who.int/iris/bitstream/handle/10665/258698/9789241512763-eng.pdf
https://apps.who.int/iris/bitstream/hand... .

Mental health needs are shaped by the forms of work and life inherent to the class inclusion of students and their families⁷⁸78. Campos CMS, Dias VFG, Otrenti E, Pascon DM, Meireles E, Mira VL. A study on the social reproduction conditions of nursing undergraduates of two universities in São Paulo. Rev Esc Enferm USP. 2020;54:e03570. https://doi.org/10.1590/s1980-220x2018052103570
https://doi.org/10.1590/s1980-220x201805... . A university policy to strengthen university students in the health area, which takes into account the strategic options shown in the literature, must recognize the social differences and the different manifestations of students’ psychological suffering, in the implementation of collective monitoring mechanisms.

In health courses, the conditions for admission and permanence, as well as the occurrence of mental health problems, are unequal. An analysis of the occurrence of depressive symptoms among students from different courses shows a higher prevalence of these symptoms in nursing courses, followed by dentistry and medicine courses⁷⁹79. Lima SO, Lima AMS, Barros ES, Varjão RL, Santos VF, Varjão LL, et al. Prevalência da depressão nos acadêmicos da área de saúde. Psicol Cienc Prof. 2019;39:e187530. https://doi.org/10.1590/1982-3703003187530
https://doi.org/10.1590/1982-37030031875... . These courses are attended by graduates from heterogeneous groups from the point of view of class insertion, considering social indicators such as the level of education of father and mother and type of institution (public/private) where the student attended high school⁸⁰80. Maas LWD. Análise comparativa da base social da Medicina e Enfermagem no Brasil entre os anos de 2000 e 2010. Cad Saude Publica. 2018;34(3):e00199116. https://doi.org/10.1590/0102-311x00199116
https://doi.org/10.1590/0102-311x0019911... .

Recognizing that the university environment can be, in part, the cause of mental suffering is a fundamental step in transforming the university into a healthier environment.

To cope with psychological suffering, UFSCar constituted a commission that proposed a mental health policy^b that provides for the integration between SUS services and the services and resources offered by the university, in order to develop actions aimed at: improving mental health; prevention of injuries; the provision of care to consequences of these possible injuries, such as suicide attempts; and the reduction of harm caused by the problematic use of psychoactive substances. It also provides for actions to collect, analyze and manage data to generate indicators and monitor the phenomena of psychological distress and evaluate the actions taken. It also indicates the establishment of mechanisms to understand the relationship between the teaching/learning processes and psychic suffering, as well as the development of the UFSCar Code of Ethics, and protocols for preventive actions and for the care of situations of violence⁸¹81. Universidade Federal de São Carlos. Relatório da Comissão para Estudo de Política de Saúde Mental para a UFSCar. São Carlos, SP: UFSCar; 2020..

The options presented here, for coping with the psychic suffering of students, require the involvement of the entire academic community, with a marked commitment from the faculty, which, however, is under intense pressure and psychological burden⁸²82. Bernardo MH. Produtivismo e precariedade subjetiva na universidade pública: o desgaste mental dos docentes. Psicol Soc. 2014;26 Nº Espec:129-39. https://doi.org/10.1590/S0102-71822014000500014
https://doi.org/10.1590/S0102-7182201400... . In the Brazilian context, this is compounded by scientific productivity demands to professors linked to graduate programs, which generate suffering and illness⁸³83. Teixeira TSC, Marqueze EC, Moreno CRC. Academic productivism: when job demand exceeds working time. Rev Saude Publica. 2020;54:117. https://doi.org/10.11606/s1518-8787.2020054002288
https://doi.org/10.11606/s1518-8787.2020... .

The subjective precariousness felt by the university professor, who is permanently concerned with responding to the high productivity demands, translates into a feeling of isolation and abandonment⁸⁴84. Linhart D. Modernisation et précarisation de la vie au travail. Papeles CEIC. 2009 [cited 2020 Nov 22];1(43):1-19. Available from: https://www.researchgate.net/publication/26597371_Modernisation_et_precarisation_de_la_vie_au_travail
https://www.researchgate.net/publication... . This precariousness operates less objectively as compared to that which affects workers from outsourced companies and temporary professors, as they are subjected to informal work and the loss of fundamental, social, labor and social security rights. Therefore, they see their security concretely shaken.

Graduate students have also been the object of studies related to stress in mental health⁹9. Evans TM, Bira L, Gastelum JB, Weiss LT, Vanderford NL. Evidence for a mental health crisis in graduate education: Nat Biotechnol. 2018;36(3):282-4. https://doi.org/10.1038/nbt.4089
https://doi.org/10.1038/nbt.4089... ,⁸⁵85. Woolston C. PhD poll reveals fear and joy, contentment and anguish. Nature. 2019 [cited 2020 Nov 22];575:403-6. Available from: https://media.nature.com/original/magazine-assets/d41586-019-03459-7/d41586-019-03459-7.pdf
https://media.nature.com/original/magazi... ,⁸⁶86. Costa EG, Nebel L. O quanto vale a dor? Estudo sobre a saúde mental de estudantes de pós-graduação no Brasil. Polis (Santiago). 2018;17(50):207-27. https://doi.org/10.4067/S0718-65682018000200207
https://doi.org/10.4067/S0718-6568201800... , as a consequence of pressure. There are pressures caused by the obligation to fulfill academic demands; by the difficulty in maintaining a balance between academic and personal life; by uncertainties about the future⁸⁵85. Woolston C. PhD poll reveals fear and joy, contentment and anguish. Nature. 2019 [cited 2020 Nov 22];575:403-6. Available from: https://media.nature.com/original/magazine-assets/d41586-019-03459-7/d41586-019-03459-7.pdf
https://media.nature.com/original/magazi... ; and by the need to achieve the academic productivity goals required by research development agencies⁸⁶86. Costa EG, Nebel L. O quanto vale a dor? Estudo sobre a saúde mental de estudantes de pós-graduação no Brasil. Polis (Santiago). 2018;17(50):207-27. https://doi.org/10.4067/S0718-65682018000200207
https://doi.org/10.4067/S0718-6568201800... .

Therefore, the implementation of responses to mental health needs within universities finds the context of pressure for productivism, which imposes on professors, students and the entire set of workers the achievement of institutional goals based on quantitative international standards of academic excellence. The deepening and amplification of neoliberalism in higher education needs to be made explicit and recognized as a process that responds to the aggressive global capitalist expansion, shaped by the market logic⁸⁷87. Canaan JE. Resisting the English neoliberalising university: what critical pedagogy can offer? J Crit Educ Policy Stud. 2013 [cited 2020 Dec 22];11(2):16-56. Disponivel em: http://www.jceps.com/wp-content/uploads/PDFs/11-2-02.pdf
http://www.jceps.com/wp-content/uploads/... ,⁸⁸88. Asher G. Working in, against and beyond the neoliberal university. Paper for SCUTREA 2015 [cited 2020 Nov 1]. Available from: https://www.academia.edu/13925922/Working_in_against_and_beyond_the_neoliberal_university
https://www.academia.edu/13925922/Workin... . In the Brazilian case, the quality of knowledge production is questioned in the face of the current competition for excellence⁸⁹89. Santos LRCS, Sampaio RJ. Crise social das instituições de ensino superior e a formação em saúde para o mercado. Saude Debate. 2017;41 Nº Espec 3:277-87. https://doi.org/10.1590/0103-11042017s321
https://doi.org/10.1590/0103-11042017s32... .

It is urgent that universities make commitments to the public cause, genuinely democratic, for and with society. Since neoliberalism is ideologically pedagogical, in the sense of teaching consent and reproducing domination, the answer, also of a pedagogical nature, must radically oppose it, constituting a transformative pedagogy, whose purpose is freedom and emancipation⁹⁰90. Andrade KRC, Pereira MG. Tradução do conhecimento na realidade da saúde pública brasileira. Rev Saude Publica. 2020;54:72. https://doi.org/10.11606/s1518-8787.2020054002073
https://doi.org/10.11606/s1518-8787.2020... .

This study has some limitations: it did not survey evidence of harm reduction, an approach increasingly adopted by institutions, in the area of harmful drug use among university students; it included some non-systematic reviews and primary studies, due to the need to address the collective and organizational dimensions and other related objects that were not addressed in systematic reviews.

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