Postsecondary Mental Health Policy in Canada: A Scoping Review of the Grey Literature: Politique de santé mentale post-secondaire au Canada: un examen de la portée de la littérature grise

Abstract

Objective:

Concerns surrounding the mental health and well-being of Canadian postsecondary students have increased in recent years, with data suggesting increases in the prevalence of self-reported stress and psychological distress. Strategies to address postsecondary mental health have emerged at the national, provincial, and institutional levels. While reviews of the academic literature on the subject have been conducted, a detailed review of the grey literature has not. The objective of this study was to map the current state of grey literature related to current or recommended action supporting postsecondary mental health and well-being in Canada, with a focus on policy documents and guiding frameworks.

Methods:

We conducted a review following Arksey and O’Malley’s 5-step framework for scoping reviews, as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our search was restricted to documents with a primary focus on postsecondary mental health, a national or provincial scope, and publication date between 2000 and 2019.

Results:

While a national policy or guiding framework applicable to all postsecondary institutions across Canada does not yet exist, recommendations for policy at both the national and provincial levels were well aligned, emphasizing the need for a comprehensive approach to addressing mental health services through the use of a whole-campus approach that encompasses both upstream and downstream services.

Conclusion:

Postsecondary sector stakeholders should consider how existing policy documents and guiding frameworks can be used to inform evidence-based, institutionally specific action on postsecondary mental health. More work is required to align the fragmented action occurring across Canada and incentivize postsecondary institutions to create a sustainable, effective strategy to address the increasingly complex and unique mental health needs of their students, staff, and faculty.

Introduction

In recent years, the mental health and well-being of postsecondary students has escalated as a governmental and institutional priority. The majority of postsecondary students fall into an age group where the initial onset of mental illnesses is most common. Additionally, students face elevated levels of stress, financial difficulties, increased autonomy, and social pressures, and interact more frequently with social media and technology, which can hinder self-esteem and feelings of inclusion. ^{1 –4} Data suggest that the prevalence and complexity of mental health concerns self-reported by students are increasing. ^5,6 This is an important challenge faced by postsecondary institutions across the country, as mental health is foundational to academic success, employment outcomes, and the formation of personal relationships. ^1,7 Conversely, languishing mental health and the development of mental illnesses has been linked to absenteeism, dropout, substance misuse, declining academic performance, and suicide. ^8,9 The social and economic costs to society as a result of mental health challenges are immense, with mental illness costing the Canadian economy an estimated $50 billion per year in direct (i.e., treatment) and indirect (i.e., employee leave) costs. ^10,11 Promoting student mental health and resilience is therefore a long-term investment in student success, population health, and economic prosperity. To ensure timely, impactful adoption of skills that promote well-being and resilience, it is necessary for governments and institutions to form strong partnerships and provide comprehensive mental health supports to students in early childhood, throughout the advanced education system, and as they transition into the workforce. ^9,12

While there have been several initiatives and tools released by champion organizations over the past several years designed to address postsecondary mental health, there is currently no overarching national policy or guiding framework to steer action related to postsecondary mental health in Canada. For example, the National College Health Assessment II survey ⁵ and the Canadian Campus Wellbeing Survey ¹³ are designed to provide cross-sectional data on postsecondary students’ mental and physical health indicators, but not all institutions participate in these surveillance efforts. Similarly, initiatives such as Bell Let’s Talk Day ¹⁴ and mental health or wellness weeks to coincide with World Mental Health Day are being increasingly adopted on campuses across Canada, but with little consistency between institutions and with unknown effects. Tools such as From Surviving to Thriving: Developing Personal and Academic Resilience, ¹⁵ developed by Canada Life’s Centre for Workplace Mental Health, do not include policy recommendations, per se, but demonstrate a desire to contribute toward an overarching strategy for improving student mental health.

The National Standard on Psychological Health and Safety for Post-Secondary Students (“the Standard”) is currently in development, a collaborative effort between the Mental Health Commission of Canada, the Canadian Standards Association, Bell Canada, the Royal Bank of Canada, and the Rossy Family Foundation. The Standard, set to be released in 2020, will provide a flexible, detailed guiding framework to help Canadian postsecondary institutions better address and respond to mental health-related needs on campus. ¹⁶

Purpose of Study

The primary goal of this study was to map the current state of grey literature related to existing or recommended action supporting postsecondary mental health and well-being in Canada. A secondary goal was to evaluate whether there was a focus on upstream or downstream mental health services or the comprehensive delivery of both. Upstream mental health services refer to those delivered prior to the development of a mental illness (e.g., mental health promotion and mental illness prevention). Downstream mental health services are those provided after the onset of a mental illness or symptoms consistent with clinical levels of psychological distress (e.g., treatment and recovery). While detailed reviews of the academic literature pertaining to postsecondary mental health have been conducted, ¹⁷ grey literature, including literature published outside of traditional commercial publishing sources such as government or institutional reports, is often overlooked despite its wealth of relevant information. ¹⁸ To our knowledge, a comprehensive review of the grey literature on this topic has not yet been conducted.

We investigated grey literature with a primary focus on postsecondary mental health at both the national and provincial levels. First, we assessed all records with a national scope intended to guide the development of institutional approaches to postsecondary mental health in Canada. Secondly, we examined whether postsecondary-specific policies or guiding frameworks had been developed for each Canadian province and territory. Institutional records were excluded to restrict the scope of this review and because campus-specific mental health strategies have already been the focus of a thorough environmental scan. ¹⁹

Methods

A scoping review of both grey and academic literature on postsecondary student mental health and well-being in Canada was conducted as a component of a larger project in May 2017. ² The results of the grey literature search resulting from this study was augmented by a secondary search conducted in December 2019 to ensure that all new additions to the literature were captured to date. The methods of this study followed a 5-step framework for scoping reviews (described below), ^20,21 which were used to operationalize the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, which require an a priori rationale, research question, and search strategy. A PRISMA flow chart is included below (Figure 1). A more detailed description of the PRISMA protocol can be found elsewhere. ²²

Figure 1.

PRISMA flow diagram for recording screening and selection. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Identify the Research Question

A broad research question with a clearly articulated target population, outcome of interest, and scope of inquiry ²¹ was developed to ensure a comprehensive range of coverage ²⁰ : “What is the current state of grey literature related to policy-making and/or the development of guiding frameworks specific to Canadian postsecondary mental health and well-being?”

Identification of Relevant Studies and Selection

Four search strategies were used to obtain records: (1) official provincial and territorial government websites search; (2) Queen’s University’s online library government publication Google custom search; (3) search of relevant grey literature databases, including the Canadian Electronic Library, Public Policy: Key Government Resources Research Guide, the Public Health Agency of Canada, Health Canada, and the Centre for Innovation in Campus Mental Health; and (4) citation mining from included records.

The search strategy was undertaken in English and French using several key words (Table 1). To be included in the search, documents needed to meet the following inclusion criteria: primary focus on mental health at the postsecondary level; English or French language; and published between 2000 and 2019. These criteria were set to capture a manageable, yet comprehensive collection of records focused on relatively current action in Canada. Records with both national and provincial scopes were included to ensure a comprehensive understanding of existing postsecondary mental health policy and guiding frameworks. The broad term “postsecondary institution” was used in an effort to capture all institutions across Canada. However, we included records predominantly addressing publicly funded universities and colleges, excluding those from adult education centers, religious schools, online postsecondary platforms, and technical or agricultural colleges. Records were excluded if they lacked specificity to the postsecondary level (e.g., primary focus on youth); were published outside of Canada; were published at the municipal, regional, or institutional levels; or took the form of newsletters, news releases, or memorandums.

Table 1.

Sample Key Word Search Strategy.

Key words	“post-secondary” AND “mental health” AND (“policy” OR “framework”)
Limits	(date range = 2000 to 2019) AND (language = English OR French)

Note. Limits were applied manually as no limits function was available in the search engine.

Records were imported into Mendeley citation manager and screened for initial inclusion into the review by title, abstract, and/or executive summary. Records meeting the inclusion criteria were exported into a tracking document, where 2 reviewers (C.M. and B.L.) conducted a full-text screen of remaining records, with a third reviewer (H.S.) available to break ties. Figure 1 details the complete screening process. In total, n = 24 records were included in the review.

Data Extraction and Analysis

Records that met the inclusion criteria were sorted into groups with a national or provincial level scope. Data extracted from each record and charted in a tabular analysis included document title, author/organization, year of publication, the province or territory from which the record originated (where applicable), type of record (e.g., policy or guiding framework), and the mental health service level emphasized in the document (e.g., upstream, downstream, or both).

Results

National Review

Records that detailed recommendations for postsecondary mental health at a national level are presented in Table 2, accompanied by brief summaries. Records were categorized as either primarily policy documents or guiding frameworks. Those considered as policy documents explicitly provided recommendations for action with respect to improving and supporting postsecondary mental health, while those considered as guiding frameworks were designed to offer institutions a blueprint with which to develop an approach to campus mental health and well-being.

Table 2.

National Postsecondary Mental Health Records Summary, Reverse Chronologically by Publication Date.

Year	Document	Focus	Service level	Brief summary
2018	Breaking Down Barriers: Mental Health and Canadian Post-Secondary Students (Canadian Alliance of Student Associations)	Policy	Comprehensive	Highlights policy recommendations for federal action to support students’ mental health regarding academic accommodations, stigma reduction and mental health support services, and financial accessibility.
2015	Okanagan Charter: An International Charter for Health Promoting Universities and Colleges (International Conference on Health Promoting Universities and Colleges)	Framework	Upstream	A national guiding framework for postsecondary institutions, providing guidance on how to implement a “whole campus” approach to postsecondary mental health and well-being.
2014	A Roadmap for Federal Action on Student Mental Health (Canadian Alliance of Student Associations)	Policy	Comprehensive	Comprehensive report focusing on the role of the federal government regarding the development of mental health policy in postsecondary education.
2014	Policy Approaches to Post-Secondary Student Mental Health (OCAD U and Ryerson University)	Policy	Comprehensive	Details a scan of current institutional practices around student mental health across Canada and the United Kingdom to support institutional policy development.
2013	Post-Secondary Student Mental Health: Guide to a Systematic Approach (Canadian Association of College and University Student Services, Canadian Mental Health Association)	Framework	Comprehensive	Outlines a framework for addressing student mental health in postsecondary institutions. Includes a companion document, campus assessment, and planning inventory.
2011	Mental Health and Well-being in Post-Secondary Education Settings (Canadian Association of College and University Student Services)	Policy	Comprehensive	Literature scan outlining the current status of postsecondary student mental health. Recommends a system-wide approach that extends the focus from individualized care to a “whole campus approach.”
2009	Sustaining Student Health: Healthy Students, Healthy Campus Settings Report on the Outcomes and Recommendations from the National Policy Roundtable (Association of Canadian Community Colleges)	Policy	Comprehensive	Summary of outcomes from a policy roundtable of the young adults working group of the Canadian Council on Learning
2009	Towards a Comprehensive Mental Health Strategy: The Crucial Role of College and Universities as Partners (Ontario College Health Association)	Framework	Comprehensive	Outlines vital mental health services on campuses as well as important gaps, providing a number of recommendations for the development of comprehensive frameworks to support the health of postsecondary students.
2008	Report on Post-Secondary Institutions as Healthy Settings: The Pivotal Role of Student Services (Canadian Council on Learning and the Association of Canadian Community Colleges)	Framework	Upstream	Provides overview of the role student services play in making postsecondary institutions healthy settings, identifies related issues, and provides recommendations for addressing these.

Policy documents

Two national-level environmental scans were included in this review, providing background support for policy development. In 2011, MacKean conducted a review of the literature outlining the current state of postsecondary student mental health policies and service delivery, recommending a system-wide approach that extends the focus from individualized care to a holistic “whole campus approach” that encompasses the environment, organizational structure, policies and practices to support students, staff, faculty, and the broader community. ^1,12 Echoing this sentiment, Robinson and colleagues reviewed postsecondary institutional policies in Canada, concluding that most policies focused on individualized care, rather than a universal approach, with the majority falling into the realm of disability and accommodations. ²³ However, the authors noted that a growing number of institutions were attempting to integrate a mental health perspective into institutional policy review and development, applying an overall wellness promotion approach to support the needs of the campus as a whole. ²³ These scans underscored both upstream and downstream mental health services and were therefore considered to be comprehensive in their approach.

Three documents were considered to be primary policy documents, providing recommendations for action to support mental health at the postsecondary level. In 2018, the Canadian Alliance of Student Associations produced a report detailing policy recommendations for federal government action to support postsecondary students’ mental health in the areas of academic accommodations, stigma reduction, mental health support services, and financial accessibility. ⁷ Four years previously, the same organization released a report focusing on the role of the federal government regarding the development of mental health policy in postsecondary education. ²⁴ Both documents emphasized the need to take a comprehensive approach to supporting students’ mental health by bolstering both upstream and downstream mental health services and supports. This emphasis on a comprehensive approach is not new. In 2009, the Association of Canadian Community Colleges conducted a national policy roundtable examining how to develop healthy postsecondary settings and evaluate their impact on students’ academic success. ²⁵ Again, a comprehensive approach was taken, emphasizing the importance of taking an ecological approach to postsecondary mental health, promoting mental health through the creation of supportive campus environments, as well as reorienting downstream student wellness services and strengthening community action.

Guiding frameworks

In 2008, a report emphasizing the pivotal role of student services in creating healthy settings for postsecondary students was released by the Canadian Council on Learning and the Association of Canadian Community Colleges. ²⁶ Key issues that emerged from interviews with both students and staff included the need for better communication of existing mental health services to students as well as more financial resources to support student services. However, it was evident that students’ definition of mental health went well beyond downstream treatment services, encompassing a range of life and lifestyle issues (such as fitness, recreation, financial concerns, substance use, etc.), suggesting that increased focus on upstream services was warranted. The authors concluded that there was an increasing need to expand and reframe student health services through transitioning from a treatment model of illness to a more comprehensive model encompassing both upstream and downstream services. In keeping with this message, a report 1 year later by the Ontario College Health Association recommended a multipartner response to address current hazardous gaps in postsecondary mental health service delivery, including inconsistency, instability, underfunding, and fragmentation of services. The authors argued that government, health, and education stakeholders should invest in strong partnerships to support the development of a comprehensive postsecondary mental health strategy. ²⁷

Since the release of these reports, guiding frameworks designed to support the development of such comprehensive mental health strategies have emerged, including the Campus Assessment and Planning Inventory, and most recently, the Okanagan Charter. In 2013, the Canadian Association of College and University Student Services and the Canadian Mental Health Association produced a guide to a systemic approach designed to support postsecondary institutions with self-evaluation and the development of an action plan for systematically supporting mental health and well-being on campus. ¹² As a companion tool to this guide, the Campus Assessment and Planning Inventory was created, composed of seven key areas of focus: institutional structure, organization, planning and policy; supportive, inclusive campus climate and environment; mental health awareness; community capacity to respond to early indications of student concern; self-management competencies and coping skills; accessible mental health services; and crisis management.

Similarly, the Okanagan Charter provides broad transformative vision for supporting the development of healthy, holistic campus cultures. ²⁸ Postsecondary institutions that sign on to the charter aim to embed health into all aspects of campus cultures, across the administration, operations, and academic mandates. This includes creating supportive campus environments, generating thriving communities and a culture of well-being, supporting personal development of both students and staff, and creating or reorienting campus services to support equitable access to both upstream and downstream services. Furthermore, the charter encourages institutions to strive to lead health promotion action and collaboration locally and globally, by integrating health, well-being, and sustainability in multiple disciplines to develop change agents, advancing research, teaching, and training for health promotion knowledge and action, and leading and partnering toward local and global actions.

Provincial Review

Records that detailed recommendations for postsecondary mental health at a provincial level were organized by province and territory and are presented in Table 3. As with national records, we briefly summarized the content and identified each as either primarily policy documents or guiding frameworks. Policy documents varied in scope; some provided a broad summary of the state of postsecondary student mental health and comprehensive recommendations across the service levels, whereas others addressed a narrow component of the postsecondary mental-health system, such as supporting transitions or accommodations. We found that one province had a provincial policy dedicated to postsecondary mental health (Alberta), 2 had guiding frameworks (Alberta and British Columbia), and 4 had a shared framework in development (Prince Edward Island, New Brunswick, Nova Scotia, Newfoundland and Labrador). As there is currently no nationally recognized policy or framework regarding postsecondary mental health available in Canada, we compared records with a provincial scope to those with a national scope in terms of consistency and service level focus.

Table 3.

Provincial Postsecondary Mental Health Records Summary.

Province	Year	Document	Focus	Service level	Brief summary
NS. PEI, NB, NL	2018	Mental Health: Atlantic ministers to endorse a regional mental health approach in public and postsecondary education (Council of Atlantic Ministers of Education and Training)	Framework (IP)	Comprehensive	Describes an Atlantic Mental Health Framework in development to strengthen and promote mental health initiatives in public and postsecondary education across the Atlantic provinces
NS, PEI	2016	Creating a pathway through mental health care for postsecondary students (Stan Kutcher)	Framework (IP)	Comprehensive	A comprehensive mental health framework built upon proven youth mental health strategies to improve mental health literacy and on-campus mental health care, currently undergoing field testing in NS and PEI
NS	2016	From school to success: clearing the path; report of the transition task force (Province of Nova Scotia)	Policy	Upstream	Highlights recommendations formulated by a Transition Task Force for the Government of Nova Scotia to support students as they transition out of public school into college, university, apprenticeship, and the work force
AB	2018	Postsecondary institutions’ mandates for mental health care (Government of Alberta)	Framework	Downstream	Outlines the 3 major types of mental health care that fit within postsecondary institution’s mandates (screening, brief intervention, and referrals)
AB	2017	Advisory panel on postsecondary mental health: final recommendations report (Alberta Advanced Education)	Policy	Comprehensive	Presents strategic directions, areas for action, and recommendations for the Government of Alberta to build a long-term, province-wide system of support for postsecondary students
AB	2015	Alberta postsecondary mental health and addiction framework (Government of Alberta)	Framework	Comprehensive	Outlines Alberta’s provincial approach to address postsecondary mental health and addiction
BC	n.d.	BC healthy minds/healthy campuses: a community of practice to promote campus mental health (CMHA BC Division, Centre for Addictions Research of BC)	Framework	Upstream	Outlines the implementation of a Community of Practice model in which community members work collectively to improve mental health, reduce suicidal behavior, and reduce harms associated with substance use across BC campuses
ON	2017	With learning in mind; inquiry report on systemic barriers to academic accommodation for postsecondary students with mental health disabilities (Ontario Human Rights Commission)	Policy	Downstream	Describes the progress public colleges and universities in Ontario have made in 6 areas for action to reduce systemic barriers to postsecondary education faced by individuals with mental health disabilities recommended by the OHRC in 2016
ON	2017	In it together: taking action on student mental health (College Student Alliance, Ontario Undergraduate Student Alliance, Colleges Ontario, and the COU)	Policy	Comprehensive	Outlines an action plan on postsecondary student mental health in Ontario, providing guidance and recommendations to strengthen the delivery of mental health services.
ON	2017	Supporting the mental health of emerging adults in Ontario’s postsecondary system (Ontario University and College Health Association)	Policy	Upstream	Emphasizes the need to support emerging adults in postsecondary systems as they face transitional periods and new stressors and provides recommendations to build a comprehensive strategy for postsecondary institutions that is linked with the broader health-care system and aligned with provincial objectives.
ON	2015	White paper on postsecondary student mental health (Coordinating Committee of Vice Presidents Students of Colleges Ontario)	Policy	Comprehensive	Summarizes the current state of mental health services and provides 9 recommendations for action to meet the increasing mental health needs of college students across Ontario
ON	2015	Recommendations for documentation standards and guidelines for academic accommodations for postsecondary students in Ontario with mental health disabilities (Queen’s University, St. Lawrence College)	Policy	Downstream	Provides recommendations to develop province-wide documentation standards and guidelines for providing academic accommodations for students with mental health challenges and to develop consistent training for how to best accommodate students with mental health challenges.
ON	2012	Mental health in Ontario’s postsecondary education system (T. Popovic, College Student Alliance)	Policy	Comprehensive	Summarizes how mental health relates to postsecondary education and provides recommendations to improve the recognition of mental health issues on campus and to enhance support services.
ON	2012	Student health: bringing healthy change to Ontario’s universities (Ontario Undergraduate Student Alliance)	Policy	Downstream	Reports the provision of physical and mental health services on Ontario campuses, outlining a number of best practices in each of these areas.
ON	2010	COU submission to the ministry of health and long-term care- every door is the right door: toward a 10-year mental health and addictions strategy (Council of Ontario Universities)	Policy	Comprehensive	Provides postsecondary specific feedback and recommendations for the Ministry of Health and Long-Term Care regarding their mental health and addictions strategy

Note. AB = Alberta; BC = British Columbia; CMHA = Canadian Mental Health Association; COU = Council of Ontario Universities; OHRC = Ontario Human Rights Commision; NB = New Brunswick; n.d. = not determined; NL = Newfoundland and Labrador; NS = Nova Scotia; PEI = Prince Edward Island.

Postsecondary student mental health has traditionally fallen under provincial jurisdiction, and consequently, there is significant variability in its consideration across the provinces. Alberta and British Columbia are currently the only provinces to have developed an approach to comprehensively address mental health in postsecondary institutions. While Ontario has formally acknowledged the importance of addressing mental health on campuses by generating various services and policy reports, ^{6,29 –31} it has not established a province-wide framework or policy dedicated to postsecondary mental health. One such framework is currently in development for the Atlantic provinces as a result of a shared initiative between Prince Edward Island, Nova Scotia, New Brunswick, and Newfoundland and Labrador. This collaborative, regional approach will facilitate partnership and data sharing and may be a fitting strategy for the territories to adopt due to the scarcity of postsecondary institutions in Northern Canada. ³² Our search revealed that none of the remaining provinces and territories had a strategy to address postsecondary mental health. However, all but Nunavut and Quebec have a policy, framework, or action plan to address mental health in the general population. ^{33 –36} These provincial strategies broadly address mental health within their community, and although they often tailor components to vulnerable groups, most do not acknowledge postsecondary students as a unique and at-risk population.

Despite the variation in approaches to addressing postsecondary mental health across Canada, comprehensive policy reports were consistent in their recommendations. A comprehensive, whole community (or “whole campus”) approach with funding models that clearly highlight the respective roles of government, postsecondary institutions, student groups, health-care providers, and community organizations was emphasized. Ideally, strong collaboration between these partners will facilitate the development of seamless, integrated services and the sharing of best practices. A distinguished model for this approach is the Community of Practice model that has been implemented across British Columbia and Alberta as part of the Healthy Minds/Healthy Campuses and Healthy Campus Alberta initiative, respectively. ^9,37 It is based on horizontal communication, where local insights are combined with evidence-based practices to promote innovation at all levels of action, such as empowering the community, modifying environmental structures, promoting mental health literacy, and providing supportive services. ³⁸ This creates an inclusive environment rich in social supports and opportunities for personal development fostering the resilience, coping skills, and a sense of belonging needed to weather future challenges and reduce crises. ⁹

Although there is still a focus on student mental health, this whole campus approach underscores the interrelationship between community members, students, faculty, and staff and the importance of including all of these groups in their mental health strategies. ^9,19,37 Faculty and staff have historically been integrated into campus mental health initiatives through education and awareness campaigns for students’ benefit, however the number of faculty and staff experiencing mental illness is increasing. ¹⁹ Guidelines have gradually shifted to a holistic approach that supports student, staff, faculty, and overall community well-being through a public health and health promotion lens. However, many strategic plans currently fall short of this. ¹⁹

Policy recommendations underscored the importance of providing mental health services that are effective, equitable, timely, and flexible. ³⁹ To do so, systematic processes for data collection should be established to support ongoing quality assurance and evaluation. ^39,40 Policies should be reviewed to ensure they support the mental well-being of students, and those related to health information disclosure should be updated to facilitate seamless transitions between service providers on campus and more clinically intensive services offered within the broader community. ^39,40 Reports emphasized the importance of maintaining culturally sensitive, student-focused models and creating population-specific services for specialized groups, such as indigenous and/or racialized students, members of the LGBTQ2S + community, and other groups shown to be at increased risk for the development mental health problems. Students should be engaged in the development of social, economic, cultural, and medical supports to create an inclusive environment. ⁴⁰ Finally, relevant information should be communicated through sources students perceive to be both credible and relevant, such as social media channels or within faculty communications. ¹²

The need for a comprehensive, multilevel approach to address postsecondary mental health was frequently emphasized. Policy reports with a narrower scope primarily addressed downstream factors, providing detailed recommendations for supporting transitions into and out of postsecondary education, improving access to accommodations, identifying common practices for mental health training on campus, and clarifying roles across postsecondary mental health stakeholders. Reports with a broader scope included recommendations for both upstream and downstream service delivery approaches, though notable emphasis was placed on upstream factors. Mental health promotion, mental illness prevention, and anti-stigma initiatives were recommended to destigmatize mental health problems, improve mental health literacy, build resilience, and allow for early detection and intervention before students’ mental health problems reach clinical levels of distress. ^30,40,41 Evidence has demonstrated that upstream mental health services are imperative to improving student mental health, while concentrating resources on downstream treatment is an ineffective method for creating lasting improvements. ⁴² Increasingly, a shift in focus toward upstream strategies to address the broader determinants of students’ mental health has been emphasized to ease the burden presently overwhelming campus treatment services.

Discussion

Although there is currently no overarching policy or framework to guide action related to postsecondary mental health across Canada, we found that policy recommendations made at the national and provincial level were well aligned in their priorities. There was widespread recognition of the need for a holistic, whole campus approach that encompasses both upstream and downstream services, with the majority of policy documents recommending a comprehensive strategy. Other important recommendations reiterated at both levels included: (1) to improve collaboration and role clarification between postsecondary mental health stakeholders including government agencies, postsecondary institutions, student groups, health-care providers, and community organizations; (2) to reform institutional policies and structures to ensure student-centeredness and inclusive, equitable access to services; (3) to facilitate transitions between service providers on campus and in the community, and transitions into and out of the postsecondary environment; and (4) to enhance systems for data collection and surveillance that embed mental health-related indicators into routine care to support evidence-based planning and evaluation of initiatives.

The consistency in policy recommendations was not, however, mirrored in actions. There was a notable variation in the extent to which the provinces and territories approached mental health needs on campuses. This discordance in action is even more significant at the institutional level, and no institutional strategy has been systematically evaluated thus far. ⁴³ Release of the National Standard framework could help align institutional approaches and promote collaboration on the systematic evaluation of shared policies, as it identifies core guiding principles, best practices, and benchmarks for addressing mental health on campuses. ¹⁶ Consequently, development of the Standard to promote key components foundational to effectively supporting campus mental health may be an important step in solidifying the Canadian postsecondary mental health strategy. Designed to allow for flexibility in implementation, the Standard will be accompanied by tool kits and other resources to support institutions in adopting its guidelines, as postsecondary education varies widely across the nation. This is attributed to a number of factors, including education falling within provincial jurisdiction; differences in governance, financial models, and government regulation status across institutions; differences in student and community demographics; and differences in the type and concentration of institutions. ⁴⁴ As a result, despite the flexibility of the Standard, a “one size fits all” approach may not be feasible as one overarching framework may not be sufficient to address the unique institutional and regional contexts across Canada. For example, Ontario has a significant number of postsecondary institutions that range in size, focus, and organizational structure, including universities, colleges of arts and technology, agricultural colleges, the federally funded Royal Military College, hundreds of privately funded institutions, and many nondegree-granting institutions that do not have regulatory oversight. ⁴⁵ Provinces and territories with a limited number of postsecondary institutions and related resources may also benefit from a more regional approach, such as the shared framework recently adopted by the Atlantic Provinces. ³²

Identifying the appropriate balance of alignment with key strategies identified by broader national and provincial frameworks while allowing for regional adaptations to encompass each unique context is a complex task. While a national framework may act as a general guideline for action, its successful implementation is likely to be improved by each province, territory, and institution conducting a gap analysis to determine individual needs and areas for prioritization. A tendency toward this approach was demonstrated throughout the grey literature; comprehensive policy documents provided a broader set of recommendations, while particular areas of interest were selected to be the focus of a more intensive report that dove deeper into the logistics of implementation. This contextual adaptation of sweeping recommendations made at the national and provincial levels is also intended to occur within institutions; for example, the Post-Secondary Student Mental Health: Guide to a Systematic Approach has informed mental health strategies at the institutional level across Canada. ¹² Guidance on how to effectively assess regional needs and resources to apply recommendations at the provincial, territorial, or institutional levels was not consistently included in the foundational documents. This could be detailed in future companion documents to facilitate uptake; an approach that has been used to guide context-specific implementation of mental health frameworks internationally. For example, Universities UK has developed a self-assessment tool to facilitate adoption of their whole-campus strategy, the Stepchange framework. ⁴⁶ Similarly, the JED Foundation’s Campus Journey guide includes a Community Tool Box that begins with a campus baseline self-assessment to allow customized support built upon existing mental health action. ⁴⁷

The call to shift from a treatment-based model to a more comprehensive one that promotes resilient, healthy campus communities was consistent across the literature. This includes a holistic, community-based approach that encompasses both upstream and downstream services and embeds mental and physical health into all campus activities. Upstream services are designed to intervene prior to the development of mental illness or clinical levels of psychological distress. The literature consistently highlighted the importance of these services, including mental health promotion, anti-stigma programming, mental health awareness, and programs to foster mental health literacy and resilience. Placing more emphasis on these upstream services will contribute to a reduction in the number of students in need of downstream services, the source of the current bottleneck in an increasingly overburdened, treatment-oriented system. Some distinguished frameworks that promote these values cohesively are the widely endorsed Okanagan Charter, ²⁸ the Community of Practice model implemented in British Columbia and Alberta, ³⁸ the Healthy Campus approach adopted by institutions across the nation, ¹⁹ and the model of an integrated system of student mental health care created by Duffy and colleagues. ⁴³ The latter is a modified stepped-care approach that utilizes upstream (campus well-being resources) and downstream (on-campus and off-campus mental health services) strategies to support students as they transition throughout these different levels as clinically needed. Advocacy for a comprehensive, whole campus approach occurring at the national, provincial, and institutional scope demonstrates that efforts to create an integrated, inclusive, and collaborative culture of well-being permeate through all levels of action.

Implementation of such an approach is a long-term process that will require monumental cultural and structural change within institutions that have proven resistant to linear, top-down models of change. ⁴⁶ To encourage uptake of emerging guidelines, tools, resources, and incentives should accompany foundational mental health frameworks. For example, the United Kingdom’s Student Minds initiative will be releasing a Charter Award Scheme in 2020 to recognize and reward institutions with strong mental health strategies aligned with the University Mental Health Charter. ⁴⁸ Institutions across Canada could be similarly incentivized to adopt policies outlined in the Standard or other frameworks. Furthermore, since no Canadian postsecondary institution has conducted a systematic evaluation of their mental health strategy to date, adopting shared strategies from the Standard would create an opportunity to centralize resources to evaluate their effectiveness across the nation. Finally, it is worth critically assessing how transitions between mental health services at home, on campus, and in the community occur. Canadian literature has called for improved supports, however organizations in the United Kingdom, including the Institute for Public Policy Research and Universities UK, call for reinvention. They have proposed a student mental health team service model where students, health-care providers, and student services work closely together, as well as the piloting of a digital NHS Student Health Passports to support a seamless continuity of care where students have control over their own health data. ^46,49 Insight from international organizations further along the road to effectively addressing postsecondary mental health is worth more detailed consideration. However, it is important to note that postsecondary systems, policies, and funding structures vary significantly between countries.

Limitations

There are some limitations associated with this study. The scope of the review was restricted to records at the national and provincial levels, excluding those focused at the institutional level. While institutional policy plays a pivotal role in campus mental health and several excellent guiding frameworks surrounding postsecondary mental health are already being applied at the institutional level, ^50,51 a thorough review of these records has already been conducted. ¹⁹ It is possible that some insight into individualized postsecondary mental health approaches was missed, though this would have broadened the scope of our analysis beyond what was manageable. Literature published prior to 2000 was excluded to ensure a focus on more recent action, however it is possible that older documents contained unique and foundational insight that may have been lost. We also excluded documents that did not provide specific policy recommendations or guiding frameworks for action regarding postsecondary mental health (e.g., mental health strategies for the general population) and consequently may have missed some relevant contextual information. Literature produced outside of Canada was excluded from this review to ensure specificity to the Canadian postsecondary setting. Finally, to ensure that a broad overview of the literature was captured, a critical appraisal of the quality of every document included in the review was not conducted.

Conclusion

Stakeholders in postsecondary education are mobilizing across the nation to shift the current treatment-oriented approach to mental health toward a more holistic, comprehensive, and collaborative one. Mental health is a vital contributor to an individual’s ability to learn and flourish in the postsecondary setting. ^39,40 Successful, evidence-informed mental health strategies are likely to create lasting improvements in well-being that will propagate throughout students’ lives as they transition to the workforce and broader Canadian community.

The purpose of this review was to provide an overview of the current state of grey literature advancing national and provincial policy to support postsecondary student mental health. While we found that the national and provincial approaches were generally well aligned in their intentions, the immense diversity in postsecondary institutions across Canada was reflected in the diversity of action underway. The National Standard will support the long-term process of aligning efforts across the provinces and territories by providing a general framework for postsecondary mental health strategies that allows for flexibility in its implementation to accommodate the unique needs of each institution. ¹⁶ Future efforts should aim to develop tools, resources, and incentives to support institutions as they consider how existing policy documents and guiding frameworks can be adapted to implement evidence-based action. They should also address the lack of Canadian data related to postsecondary mental health by improving systems for data collection and surveillance that support ongoing quality assurance monitoring, systematic evaluation of activities, and identification of best practices.