Addressing student mental health and suicide concerns: are we there yet?

The mental health and suicide rates of further education (FE) and higher education (HE) students have been generating international concern in many countries, including the United States of America (USA), United Kingdom (UK), Canada, Australia, and Ireland. Several charters and national frameworks have emerged to support and inform whole institution provision. There is evidence of sector engagement and investment to support implementation in HE and to a lesser extent, FE, particularly from the USA and UK, although effectiveness evidence is currently lacking. Barriers affecting help seeking and early identification of difficulties, delays in accessing appropriate support, and lack of continuity of care from campus supports into specialist Mental Health services, remain key challenges. This editorial discusses the current position and the next stage of development in student mental health support and suicide prevention. Overall, the transformation of FE and HE provision to address student mental health and suicide concerns still has a considerable way to go.

Academic and non-academic predictors of common mental health difficulties among university students during the COVID-19 pandemic.

Introduction: Public concern for the mental health of university students has been rising over recent years. Newly arising stressors associated with the COVID-19 pandemic could contribute to further mental health burden for students. This study aimed to understand the mental health status of university students at an early stage in the pandemic and to identify academic, non-academic, and COVID-19-related predictors of common mental health difficulties at this time. Methods: This study examined how academic and non-academic predictors relate to common mental health difficulties using a cross-sectional sample of university students (n = 3817). Results: There were high levels of depression and anxiety during the pandemic, with more than 50% experiencing levels above the clinical cut offs. Academic stress, social isolation, intolerance of uncertainty, and more negative attitudes towards remote teaching and learning predicted higher levels of depression and anxiety. University identification predicted lower levels of depression whereas receiving a diagnosis of COVID-19 was associated with higher levels of depression. Discussion: This study identified COVID-19-related factors that uniquely contributed to students' distress during the pandemic, over and above social connectivity variables. As COVID-19 factors, such as the uncertainty surrounding the pandemic, may have driven an increase in distress levels among students, these findings provide insights that could help universities and policymakers develop targeted interventions to support the mental health and well-being of university students during future crises.

A Rapid Review of Mental Health Training Programs for School Nurses.

There is an urgent need for improved school-based mental health services to address students' increasing mental health needs. School nurses are often at the frontlines of youth mental health, but report feeling unprepared to manage student needs due to limited training. We conducted a rapid review to identify evidence-based mental health educational interventions for school nurses and evaluate program characteristics. Eleven studies met the inclusion criteria. While the literature evaluating mental health training programs for school nurses is limited, it suggests that training may improve school nurse knowledge, confidence, and preparedness to address student mental health needs and improve the management of student mental health. Additionally, it highlighted the importance of support, resources, and policies that foster mental health promotion. Future research should focus on obtaining a current assessment of school nurse mental health education needs, evaluating existing interventions, and developing more evidence-based mental health training programs for school nurses.

Long-Term Effects of Internet-Based Cognitive Behavioral Therapy on Depression Prevention Among University Students: Randomized Controlled Factorial Trial.

Background: Internet-based cognitive behavioral therapy (iCBT) shows promise in the prevention of depression. However, the specific iCBT components that contribute to its effectiveness remain unclear. Objective: We aim to evaluate the effects of iCBT components in preventing depression among university students. Methods: Using a smartphone cognitive behavioral therapy (CBT) app, we randomly allocated university students to the presence or absence of 5 different iCBT components: self-monitoring, behavioral activation, cognitive restructuring, assertiveness training, and problem-solving. The active intervention lasted 8 weeks but the app remained accessible through the follow-up. The primary outcome was the onset of a major depressive episode (MDE) between baseline and the follow-up after 52 weeks, as assessed with the computerized World Health Organization Composite International Diagnostic Interview. Secondary outcomes included changes in the 9-item Patient Health Questionnaire, 7-item General Anxiety Disorder, and CBT Skills Scale. Results: During the 12-month follow-up, 133 of 1301 (10.22%) participants reported the onset of an MDE. There were no significant differences in the incidence of MDEs between the groups with or without each component (hazard ratios ranged from 0.85, 95% CI 0.60-1.20, for assertiveness training to 1.26, 95% CI 0.88-1.79, for self-monitoring). Furthermore, there were no significant differences in the changes on the 9-item Patient Health Questionnaire, 7-item General Anxiety Disorder, or for CBT Skills Scale between component allocation groups. However, significant reductions in depression and anxiety symptoms were observed among all participants at the 52-week follow-up. Conclusions: In this study, we could not identify any specific iCBT components that were effective in preventing depression or the acquisition of CBT skills over the 12-month follow-up period, but all participants with and without intervention of each iCBT component demonstrated significant improvements in depressive and anxiety symptoms. Further research is needed to explore the potential impact of frequency of psychological assessments, nonspecific intervention effects, natural change in the mental state, and the baseline depression level.

Student mental health outcomes of a clustered SMART for developing an adaptive implementation strategy to support school-based CBT delivery.

PURPOSE: Most youth experiencing anxiety/depression lack access to evidence-based mental health practices (EBPs). School-delivered care improves access, and various support can help school professionals (SPs; school social workers, counselors) deliver EBPs, like Cognitive Behavioral Therapy (CBT). Understanding implementation strategies' impact on downstream mental health outcomes is crucial to scaling up EBPs to address the treatment gap, but it has rarely been assessed. METHODS: This paper compares implementation strategies' impact on change in student outcomes, collected as exploratory outcomes from a type III hybrid implementation-effectiveness trial. A clustered, sequential, multiple-assignment randomized trial design was used, which embedded four implementation supports that differentially sequence three implementation strategies, Replicating Effective Programs (REP), Coaching, and Facilitation. Prior to the first randomization, N = 169 SPs from 94 Michigan high schools each identified up to 10 students whom they believed could benefit from CBT and facilitated student survey completion. Changes in students' depression (Patient Health Questionnaire-9, modified for teens) and anxiety symptoms (Generalized Anxiety Disorder-7) over 10 months were compared across the four sequences of implementation support using a generalization of a marginal, weighted least squares approach developed for a clustered SMARTs. RESULTS: Small, non-clinically significant reductions in symptoms over the study period were found. Pairwise comparisons found no significant differences in symptom change across the four implementation strategies. The difference in the estimated mean PHQ-9T/GAD-7 scores between the least and the most intensive strategies (REP vs. REP+Coaching+Facilitation) was 1.04 (95%CI = -0.95, 3.04) for depression and 0.82 (95%CI = -0.89, 2.52) for anxiety. DISCUSSION: No difference in symptom change was found across the four implementation strategies. Multiple forms of implementation support may be useful for improving student mental health outcomes. TRIAL REGISTRATION: NCT03541317-Registered on 29 May 2018 on ClinicalTrials.gov PRS.

"A Liability to the University"-Addressing Student Mental Health Needs on Campus.

Students at colleges and universities report high rates of mental disorders, including depression and anxiety, and frequent suicidal ideation. School policies toward such students, however, often have appeared punitive or aimed primarily at reducing the institution's potential liability. A recent lawsuit against Yale University highlighted allegations of practices that violated several federal statutes by failing to provide reasonable accommodations for students with psychiatric disabilities. The resolution of those claims in a sweeping settlement agreement can provide a model for the many other universities that need to align their policies with federal disability law.

Can an Online Course, Life101: Mental and Physical Self-Care, Improve the Well-Being of College Students?

Unlabelled: The COVID-19 pandemic has had a significant impact on the mental health of college students worldwide. As colleges shifted to online instruction, students faced disruptions and increased stressors, leading to a decline in mental health that appears to continue in the postpandemic era. To alleviate this problem, academic institutions have implemented various interventions to address mental health issues; however, many of these interventions focus on a single approach and lack diverse delivery methods. This viewpoint introduces the concept of a multimodal self-care online course, Life101: Mental and Physical Self-Care, and discusses the potential effectiveness of such an intervention in improving students' well-being. The course combines evidence-based interventions and incorporates interactive lectures, workshops, and guest speakers. Pre- and postcourse surveys were conducted over a span of 4 academic terms to evaluate the impact of this course on the well-being and self-care practices of students. The survey data suggest positive outcomes in students taking Life101, including the adoption of healthier habits, reduced stress levels, and increased knowledge and practice of self-care techniques. Life101 represents a novel multimodality intervention to address the epidemic of mental health issues faced by students today. By implementing similar evidence-based multimodal didactic curricula across campuses, academic institutions may be able to better equip students to navigate challenges and promote their overall well-being.

Predicting Suicidal Ideation, Planning, and Attempts among the Adolescent Population of the United States.

Suicide is the second leading cause of death among individuals aged 5 to 24 in the United States (US). However, the precursors to suicide often do not surface, making suicide prevention challenging. This study aims to develop a machine learning model for predicting suicide ideation (SI), suicide planning (SP), and suicide attempts (SA) among adolescents in the US during the coronavirus pandemic. We used the 2021 Adolescent Behaviors and Experiences Survey Data. Class imbalance was addressed using the proposed data augmentation method tailored for binary variables, Modified Synthetic Minority Over-Sampling Technique. Five different ML models were trained and compared. SHapley Additive exPlanations analysis was conducted for explainability. The Logistic Regression model, identified as the most effective, showed superior performance across all targets, achieving high scores in recall: 0.82, accuracy: 0.80, and area under the Receiver Operating Characteristic curve: 0.88. Variables such as sad feelings, hopelessness, sexual behavior, and being overweight were noted as the most important predictors. Our model holds promise in helping health policymakers design effective public health interventions. By identifying vulnerable sub-groups within regions, our model can guide the implementation of tailored interventions that facilitate early identification and referral to medical treatment.

University students' access to mental health services: A qualitative study of the experiences of health service professionals through the lens of candidacy in England.

OBJECTIVES: In order to develop a better understanding of students' access to mental health services, we explored the experiences of health care professionals interacting with university students with mental health problems. METHODS: We interviewed 23 professionals working across university advice and counselling services, NHS general practice, crisis, and psychological services in North and East London between June 2022 and January 2023. Our approach drew on reflexive thematic analysis and the principles of abductive analysis. The notion of candidacy - that is, how different needs are deemed deserving of health service attention - was particularly helpful to our understanding of the ongoing phenomenon of interest in the data. RESULTS: Each student's access to mental health support was highly contingent on the student's dynamic social context and the pressures and organisation of the local health system. Professionals described how different students viewed different needs as deserving of health service attention. Which students reached the professional's service depended on the resources and relationships a student could draw upon, and the service's relative permeability. Once there, what action professionals took was strongly influenced by the professional's service expertise, resource constraints, the relationships the professional's service had with other organisations, the students' wishes, and whether students regarded treatment offers as acceptable. CONCLUSIONS: Candidacy offers a useful lens to view university students' access to mental health support. Access appears to be an increasingly intricate task for students, given the fragmented service landscape, surging demand for mental health care and challenges of emerging adulthood. Our findings suggest that policy goals to increase use of mental health services are unlikely to improve outcomes for students without policy makers and health systems giving holistic consideration of inter-service relationships and available resources.

The Moderating Impact of Student Mental Health, Sports Passion, and Athlete Role Model on Students Game Performance: A Survey of Twenty Colleges in Iraq / El impacto moderador de la salud mental de los estudiantes, la pasión por los deportes y el modelo a seguir de los atletas en el rendimiento de los estudiantes en los juegos: una encuesta realizada en veinte universidades de Irak

The objective of this study was to assess the influence of students' mental health, sports passion, and athlete role models on the connection between sports education and their game performance. This research aims to address the inconsistencies identified in the existing body of knowledge through previous studies. Twenty colleges in Iraq collected the data set, which included a total of 184 people. A questionnaire using a Likert scale was chosen to collect data through a simple random sampling method. The research findings were analysed using Statistical Packages for Social Sciences (SPSS) 21. Various statistical tests, including descriptive findings, Pearson's correlation, model summary, Analysis of Variance (ANOVA), and coefficients, were employed to examine the data. The study revealed that students' mental health, passion for sports, and the presence of athlete role models play a crucial role in influencing the relationship between their sports education and game performance. This study aims to address the existing gaps in knowledge that have led to inconsistencies in the literature. Policymakers in Iraq must prioritise the sports education of students, considering their enthusiasm for sports and mental well-being, while also providing them with positive role models.(AU)

The Negative Effects of Travel on Student Athletes Through Sleep and Circadian Disruption.

Collegiate athletes must satisfy the academic obligations common to all undergraduates, but they have the additional structural and social stressors of extensive practice time, competition schedules, and frequent travel away from their home campus. Clearly such stressors can have negative impacts on both their academic and athletic performances as well as on their health. These concerns are made more acute by recent proposals and decisions to reorganize major collegiate athletic conferences. These rearrangements will require more multi-day travel that interferes with the academic work and personal schedules of athletes. Of particular concern is additional east-west travel that results in circadian rhythm disruptions commonly called jet lag that contribute to the loss of amount as well as quality of sleep. Circadian misalignment and sleep deprivation and/or sleep disturbances have profound effects on physical and mental health and performance. We, as concerned scientists and physicians with relevant expertise, developed this white paper to raise awareness of these challenges to the wellbeing of our student-athletes and their co-travelers. We also offer practical steps to mitigate the negative consequences of collegiate travel schedules. We discuss the importance of bedtime protocols, the availability of early afternoon naps, and adherence to scheduled lighting exposure protocols before, during, and after travel, with support from wearables and apps. We call upon departments of athletics to engage with sleep and circadian experts to advise and help design tailored implementation of these mitigating practices that could contribute to the current and long-term health and wellbeing of their students and their staff members.

It's very difficult to set the boundaries, it's human nature to want to respond: exploring health professions educators' responses to student mental health difficulties through a positioning theory lens.

By virtue of their teaching role and contact with students, health professions (HP) educators are often the first point of connection for students who are experiencing mental health difficulties. Educators are increasingly expected to include some form of pastoral care in their role. Mental health-related interactions with students may have a negative emotional impact on educators, particularly when roles and expectations are not clearly defined and where boundaries are not managed effectively. Using positioning theory as a lens, this study explored how educators experienced such interactions and how this manifested in positions, storylines, and speech acts. Interviews were conducted with 27 HP educators at a faculty of medicine and health sciences. Reflexive thematic analysis using inductive coding identified themes corresponding to the nearing, weighted, ambivalent, and distancing positions participants adopted in relation to students with mental health difficulties. There was fluidity in and between positions, and more than one position could be occupied simultaneously; participants each moved through different positions in response to different relational situations. Multiple storylines informed these positions, representing how moral- and care-informed responsibility intersected with responsiveness to make certain actions possible or impossible. Normative and personal value narratives were evident in storylines, in many cases underscored by care or justice ethics. The value of positioning theory in facilitating reflective faculty development initiatives for educators engaged in these interactions is discussed.

A multisite, longitudinal study assessing prevalence of depression in student pharmacists.

OBJECTIVE: Conduct a multisite, survey-based study assessing rates of self-reported depressive symptoms among student pharmacists enrolled in the first 3 years (P1-P3) of 4-year Doctor of Pharmacy (PharmD) curricula. METHODS: This study followed a cross-sectional observational design conducted at Washington State University, College of Pharmacy and Pharmaceutical Sciences, and the University of Arkansas for Medical Sciences, College of Pharmacy. Student pharmacists in the first 3 years of pharmacy school (P1-P3) of the PharmD curricula were invited to voluntarily complete the Center for Epidemiologic Studies Depression Scale (CES-D) to collect self-reported measures of depression. The CES-D is a validated 20-item instrument using a 4-point Likert scale. RESULTS: A total of 1795 surveys were evaluated from P1-P3 students at Washington State University, College of Pharmacy and Pharmaceutical Sciences and University of Arkansas for Medical Sciences, College of Pharmacy over a 4-year period (2019-2022). Overall, 1150 (64.1%) surveys indicated the presence of depressive symptoms on CES-D. The highest rate of reported depressive symptoms was recorded in 2021 (71.4%), notably during the coronavirus disease 2019 pandemic, whereas the lowest rate was prepandemic in 2019 (57.8%). The P1 cohort had the highest depression rate in 2020 and 2021, whereas the P2 cohort was highest in 2019 and 2022. The P3 cohort screening positive for depression increased from 52.6% to 69.3% over the 4-year period. CONCLUSION: This multisite, longitudinal study confirms that self-reported depressive symptoms in student pharmacists are significantly higher than what is reported in undergraduate students. Opportunities exist for pharmacy educators and university wellness services to better identify and serve student pharmacists experiencing depression or depressive episodes.

Intention to use digital mental health solutions: A cross-sectional survey of university students attitudes and perceptions toward online therapy, mental health apps, and chatbots.

Background: Globally, the high prevalence of mental disorders among university students is a growing public health problem, yet a small minority of students with mental health problems receive treatment. Digital mental health solutions could bridge treatment gaps and overcome many barriers students face accessing treatment. However, there is scant evidence, especially in South Africa (SA), relating to university students' use of and intention to use digital mental health solutions or their attitudes towards these technologies. We aim to explore university 2students attitudes towards and perceptions of digital mental health solutions, and the factors associated with their intention to use them. Methods: University students from four SA universities (n = 17 838) completed an online survey to assess experience with, attitudes and perceptions of, and intentions to use, digital mental health solutions. We conducted an exploratory factor analysis to identify factors underlying attitudes and perceptions, and then used multivariate ordinal regression analysis was used to investigate the factors' association with students' intention to use digital mental health solutions. Results: Intention to use digital mental health solutions was high, and attitudes towards and perceptions of digital mental health solutions were largely positive. Importantly, our analysis also shows that 12.6% of users were willing to utilise some form of digital mental health solutions but were unwilling to utilise traditional face-to-face therapies. The greatest proportion of variance was explained by the factor 'Attitudes towards digital technologies' utility to improve student counselling services, provided they are safe'. Conclusion: SA university students are already engaging with digital mental health solutions, and their intention to do so is high. Certain attitudes and perceptions, particularly concerning the utility, effectiveness, and safety, underlie willingness to engage with these solutions, providing potential targets for interventions to increase uptake.

Educational agents and institutions called into action in suicide prevention, intervention, and postvention.

Introduction: Suicide is the second leading cause of death in the 15 to 29 age group worldwide, and is a severe public health problem. Adolescent and young adult individuals attend educational institutions which can play an essential role in detecting and preventing suicide. For this reason, the purpose of this research is to identify what educational institutions and agents are called into action in suicide prevention, intervention, and postvention. Methods: The method of systematic review of the literature based on the PRISMA protocol was used. The review protocol was registered in PROSPERO (PROSPERO 2020 CRD42020189127). The systematic review yielded 66 articles published between 1990 and February 2023. Results: The results show that a wide variety of educational stakeholders are required to intervene for suicide prevention, interventions and postvention between primary education and college. The study describes the different programs that have been provided, the countries in which they have been implemented and the agents who have been targeted. It also identifies gaps in the research on suicide in the educational field. Discussion: Overall, educational suicide initiatives report positive effects on participants' understanding, attitudes, and beliefs regarding suicide and suicide prevention, although some studies have expressed some caution.

Sociodemographic characteristics, social support, and family history as factors of depression, anxiety, and stress among young adult senior high school students in metro Manila, Philippines, during the COVID-19 pandemic.

Introduction: Academic institutions must consider the students at risk for developing poor mental health and the factors influencing them. With the scarcity of literature concerning student mental health in the Philippines, this study determined the factors influencing the risk of anxiety, depression, and stress among senior high school students in metro Manila. Methods: This cross-sectional study explored the influence of sociodemographic characteristics, social support, and family history on depression, anxiety, and stress among young adult senior high school students using the Depression, Anxiety, and Stress Scale-21 (DASS-21) and the Multidimensional Scale of Perceived Social Support (MSPSS). After describing the data, regression analyses were performed. Results: A total of 187 participants were recruited. Three out of five participants have a significant risk for depression. Four out of five participants were at significant risk for anxiety. One out of four participants was at risk for significant stress. Social support from a significant other and one's family may be protective factors for significant depression among the participants. Having female sex may be a risk factor for significant anxiety. In addition, having female sex and a family history of mental disorders may be risk factors for significant stress. Discussion: Social support should be strengthened among senior high school students to improve their mental well-being. Students at risk for poor mental health, including females and those with a family history of mental disorders, may need additional support in school mental health programs. Finally, further research is recommended to fully understand mental health among Filipino students.

Cultivating Voice and Solidarity in Times of Crisis: Ethnographic Online Journaling as a Pedagogical Tool.

Ethnographic journaling can provide students with powerful opportunities to recognize and value their individual and collective perspectives as both observers and analysts of the world around them, especially in times of crisis. In this Perspectives essay, we share our experiences of using the Pandemic Journaling Project platform as a teaching resource in the first years of the COVID-19 pandemic and beyond. We consider various aspects of online ethnographic journaling, including creative teaching strategies, journaling's therapeutic potential, and student perspectives on the opportunity to document their own experiences as a forward-looking form of "archival activism." We also discuss how journaling can create robust ethnographic learning opportunities while at the same time providing a valuable space for connection and social support, especially when classroom dynamics are constrained by crisis conditions. Ethnographic journaling can help students appreciate what it means for ethnographers to bring their whole selves into their qualitative work in ways that can challenge mainstream misconceptions and contribute concrete forms of data and ethnographic insight. Overall, the essay explores how ethnographic journaling can create meaningful and creative opportunities for curricular innovation; generate durable forms of ethnographic insight; and also bring student experiences into the classroom in ways that can help them cultivate their voice, build a sense of solidarity, and potentially ease student distress.

An Online Mindfulness Intervention for International Students: A Randomized Controlled Feasibility Trial.

Background: Student mobility across borders poses challenges to health systems at the university and country levels. International students suffer from stress more than their local peers, however, do not seek help or underutilize existing help offers. Some barriers to help-seeking among international students are insufficient information regarding the health offers, stigma, and language, which might be overcome via culturally adapted internet and mobile-based interventions (IMI). Method: A randomized controlled feasibility trial with a parallel design assessed the feasibility and potential efficacy of an online mindfulness intervention adapted for international university students. Participants were randomized into either an adapted online mindfulness intervention (StudiCareM-E) (IG, n = 20) or a waitlist control group (WL, n = 20). Participants were assessed at baseline (t0) and eight-week post-randomization (t1). The feasibility of StudiCareM-E was evaluated regarding intervention adherence, client satisfaction, and potential negative effects. The potential efficacy of StudiCareM-E was measured by means of the level of mindfulness, perceived stress, depression, anxiety, presenteeism, and wellbeing. Efficacy outcomes were evaluated with regression models on the intention-to-treat (ITT) sample (n = 40), adjusting for the baseline values. Results: Participants' formative feedback suggested improvements in the content of the IMI. There were no crucial negative effects compared to WL. Assessment dropout was 35% (IG: 50%: WL: 20%), and intervention dropout was 60%. StudiCareM-E yielded significant improvements in mindfulness (ß = .34), well-being (ß = .37), and anxiety (ß = -.42) compared to WL. Conclusion: StudiCareM-E might be used among culturally diverse international student populations to improve their well-being. Future studies might carefully inspect the extent of the adaptation needs of their target group and design their interventions accordingly.

A Novel and Integrated Digitally Supported System of Care for Depression and Anxiety: Findings From an Open Trial.

BACKGROUND: The global burden of anxiety and depression has created an urgent need for scalable approaches to increase access to evidence-based mental health care. The Screening and Treatment for Anxiety and Depression (STAND) system of care was developed to meet this need through the use of internet-connected devices for assessment and provision of treatment. STAND triages to level of care (monitoring only, digital therapy with coaches, digital therapy assisted by clinicians in training, and clinical care) and then continuously monitors symptoms to adapt level of care. Triaging and adaptation are based on symptom severity and suicide risk scores obtained from computerized adaptive testing administered remotely. OBJECTIVE: This article discusses how the STAND system of care improves upon current clinical paradigms, and presents preliminary data on feasibility, acceptability, and effectiveness of STAND in a sample of US-based university students. METHODS: US-based university students were recruited and enrolled in an open trial of the STAND system of care. Participants were triaged based on initial symptom severity derived from a computerized adaptive test and monitored over 40 weeks on anxiety, depression, and suicide risk to inform treatment adaptation and evaluate preliminary effectiveness. RESULTS: Nearly 5000 students were screened and 516 received care. Depression and anxiety severity scores improved across all tiers (P<.001 in all cases). Suicide risk severity improved in the highest tier (ie, clinical care; P<.001). Acceptability and feasibility were demonstrated. CONCLUSIONS: STAND is a feasible and acceptable model of care that can reach large numbers of individuals. STAND showed preliminary effectiveness on all primary outcome measures. Current directions to improve STAND are described.

Referring students for professional psychological help: A qualitative study of teachers' experience in Hong Kong.

Teachers have frequent interaction with students and are well positioned to refer students for mental health assistance when needed. Twelve secondary schoolteachers in Hong Kong were interviewed about their experience referring students to mental health professionals (MHPs). Using consensual qualitative research, multiple factors were found to influence teachers' referral decisions, including problem severity, students' willingness, stigma of help-seeking, parent/guardian's beliefs, teacher-parent/guardian relationship, MHPs' effectiveness and availability, quality of interaction with MHPs, and teachers' self-efficacy in handling student issues. Based on the findings, we propose a conceptual model of factors influencing teachers' referral decisions. Implications for research, practice, and training are discussed.