We are the Association for Child and Adolescent Mental Health or ACAMH for short. Hello. Welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health or ACAMH for short. I'm Mark Dadds. I've worked in mental health for the last 25 years, including 15 years as a commissioner of mental health services. In this series, we speak to authors of papers published in one of ACAMH's three journals. These are the Journal of Child Psychology and Psychiatry, commonly known as JCPP. The Child and Adolescent Mental Health, known as CAMH and JCPP Advances. Today, I'm delighted to be with our three guests. Assistant professor Helena Tuomainen of the University of Warwick Medical School. Christina Dennison, junior doctor working in Cumbria and Warwick University graduate. And Olivia Ellard, junior doctor working in London, and also Warwick University graduate. They're the co-authors of the review paper, Interventions Addressing Loneliness Amongst University Students, a Systematic Review, recently published in the Child and Adolescent Mental Health journal. If you're a fan of our Papers Podcast series, please subscribe on your preferred streaming platform. Let us know how we did with the rating review and do share with friends and colleagues. Helena, Christina, and Olivia, can we start with an introduction. Helen, if we could start with you, and then we'll ask Olivia and Christina to introduce themselves. Thank you, Mark. I'm Helena and assistant professor of youth mental health at Warwick Medical School. In position since January 2020. Before that, I was the scientific research manager and senior research fellow on an EU funded project focusing on improving care, the transition boundary between child and adult mental health services. The project was called Milestone. And we managed to recruit over 1,000 young people from eight countries into the study we were conducting. And many of these ended up being university students. My name is Olivia. I'm a first-year junior doctor working at Hamad Hospital in London. First year out of University, first year working as a doctor. I've got a particular interest in psychiatry and mental health and would love to pursue a career in psychiatry in future. Hi, Mark. Thank you so much for having us on the podcast. I'm Christina. I started studying psychology for three years at Durham University. And then I went on to study medicine for four years at Warwick University, graduating last July. Since then, I've been working as a junior doctor at Cumberland Infirmary in Carlisle, as well as an interest in psychiatry. I'm also interested in emergency health care. Thank you. Let's turn to the paper, Interventions Addressing Loneliness Amongst University Students, a Systematic Review recently published in the CAMH Journal. Can you give us a brief overview of the paper sentencing? Well, I'd like to first say that I recognize the need for this review prior to the COVID-19 lockdowns in the UK. And the idea for focusing on students stemmed from our Milestone project, as most of the project advisors and study participants went to university. Then a colleague came up to me with an idea for an intervention at university that would address loneliness. And from there, I wanted to know about other interventions that have helped university students. So in the review, we've identified all intervention studies published today that have addressed student loneliness. And we evaluated the quality of these studies, and also the effectiveness of the interventions, which we grouped into different types. And one of the key findings was that 2/3 of interventions that were delivered in group settings were considered effective in reducing loneliness irrespective of intervention type. Thank you. That's very interesting, Helena. You touched on the methodology there, Christina. Could you just tell us a little bit more about how you carried out the systematic review? Sure. So we first began collecting our data at the start of 2020. We started with quite a wide net. So we searched four of the largest databases for mental health research. And we used quite broad search terms. So for example, we included isolation as a keyword, as well as loneliness. Studies across all time periods and from all countries were included just so we could capture the full picture of the interventions out there. The initial search returned about 7,000 articles, which we were really excited about at the time. We then managed to screen those articles. And we removed any that didn't investigate interventions, loneliness on students. And we were left with 28 for our final review. The next step was to assess the quality of the papers. So for that, we use the Cochrane Risk of Bias tool. This is just a tool that determines how likely each paper is to be subject to bias. The articles with the highest score were deemed to be less reliable. So two of those articles were removed for that reason. Finally, we could extract the data that we were interested in from the articles that remained. And we looked at the types of interventions that were tested. For example, whether the interventions involved grouped activities, whether the activities involved a form of reflective practice or some form of teaching, for example. We looked at sample sizes for each intervention and whether it was targeted towards a specific subgroup of students. For example, some of the articles sampled only female students. Some sampled only neurodivergent students. Once we had the information collected, we can then comment on the patterns within the research like which types of interventions were the most successful. Then we compared what we'd found to other reviews looking at interventions for loneliness as well. Excellent. Thank you. That's really comprehensive. From that methodology, what were the key findings, the things that really stood out for you in the review? What we found was actually really interesting. So a lot of the interventions used are very similar techniques. So much so that we were able to create four categories to group the interventions. The most common type of intervention was psychoeducation. So this included those that used some form of teaching to help students overcome loneliness. For example, one of our studies assessed a 16-week positive psychology course. The second most common intervention site was reflection. So this included any intervention that utilized reflective exercises like writing in a journal or meditation. The third most common was social interaction. So these provided an opportunity for students to interact with each other. For example, some with through playing sport. Some with through creative exercises. One of the studies even recruited a dog for students to interact with together. And the least common type of intervention was social support. So this included interventions in which students could discuss problems or worries in a support group setting. The interventions that we found most likely to be successful seem to be those performed in groups, particularly those in the social interaction category. So one theory that we had for this is that students might lose any identity with the friendship group when they move away from home. So these types of interventions provide an opportunity to regain that place in a group. The least affective category seemed to be psychoeducation with about half been successful. Interestingly, the articles that studied specific subgroups showed equal efficacy. However, we did conclude that more research is needed across these subgroups. Thank you. Could you just expand on that a little? The paper seemed to suggest that some university students appear to be more vulnerable to feelings of loneliness, and, therefore, the additional risk of mental health problems. Could you just unpack that a little bit more for us, Olivia? Yes, absolutely. So we had a look at the demographics of students who took part in the intervention so that we could start to understand the way that marginalized groups experience loneliness at university. A particular message stood out to us. Often, neurodivergent students have a different experience at university compared to their neurotypical counterparts. From our research, we've seen that some neurodivergent students experience barriers to social opportunities that we do not see as commonly in neurotypicals, such as unwelcoming sensory environments, which can deter them from traditional routes of friendship forming. Masking is also a common strategy adopted by neurodivergent students in order to fit in with peers. And this in itself can be extremely mentally draining leading to ungenuine connections, which, unfortunately, initiates feelings of being alone. In addition to this, we have seen that a lot of the resources for those identifying as neurodivergent are aimed at assisting children or parents of children who are neurodivergent. Unfortunately, that leads to a catch-22 situation where neurodivergent teens and young adults are unable to access resources that they desperately need to help them feel happier around this big transition period. Thank you. There are several references in the paper to the impact that COVID restrictions have had on loneliness in recent times. For example, young people now and over the next few years have had fewer chances of interacting with peers. Can you tell us a little bit more about the impact of COVID on your findings? We believe that university students have suffered significantly throughout the COVID pandemic. Closure of campuses, restriction of face-to-face teaching and canceling sports and society events has taken a massive toll on student being. We know that many students were confined to their accommodation where some universities have actually taken extreme measures to put up barriers to prevent students from leaving. This really had flipped their lives upside down. Attending Freshies' Fair, joining a sports club, and meeting similar minded people like yourselves from all over the globe is all part of the university experience, which is arguably just as important as an education aspect. So this experience has been taken away from a cohort of young adults, which undoubtedly led to rising feelings of loneliness reported during and post-pandemic. Both myself and Christina can also relate on a personal level. We're both recent graduates from University. So we understand first-hand experiences at students report. We understand how lonely it can be been taken from the environment where we get to see our friends regularly and some adults in social settings to a new world where all teaching is delivered online. It really does have an impact on your mental well-being. Thank you. You identified that universities have the power to tackle loneliness. How can they best do this? And what would you recommend they do? Loneliness is such a huge risk factor for development of mental health conditions, especially in this vulnerable population. We think universities have a duty to students to minimize, well, I would say eradicate this risk. We feel that the preventative strategy to combat loneliness is a solution for the rise in demand for mental health services that we've seen over the past few years. And we think there are a couple of ways that universities can start to do this. First of all, by offering social events, which are accessible to all. I briefly mentioned earlier about specific needs of specific students. We've seen from our research that offering societies, which, for example, mirror cultural backgrounds of students can generate cultural connection between students, and, therefore, improve well-being in a broader remit. Inclusivity at university is so, so important. Generating inclusive spaces fosters an environment where students feel safe, respected, and supported, which are the building blocks of generating meaningful relationships. Secondly, we believe universities should offer a virtual space for connection. The COVID pandemic has transformed our society, which is fast forward a lot of technological advancement. Providing a space for students to connect and build friendships from the comfort of their own home is another way that we feel that universities can start to tackle social isolation of their students. We know that a great number of CAMH professionals are under extreme pressure with the increase in the number of people needing services. What advice would you give to university mental health practitioners to assist with prevention? For example, Christina, what type of interventions would you suggest the most effective? So I think as we touched on earlier, the research showed that bringing students together does seem to reduce loneliness, which then, in turn, can reduce other mental health problems as well. This was especially true where a student was to partake in group activities. A helpful starting point might just be to encourage students to participate in sports clubs, creative clubs, even charity work or volunteering. I think it's important for universities to offer a large variety of options just so students can find groups that suit their needs. And, again, this might be particularly important for some of the subgroups that we've mentioned already as well. It could even be helpful to allocate time away from lectures and away from studies to allow for these types of activities. However, we are aware that there are some barriers that would prevent students from joining group activities. For example, we understand that it could be too overwhelming for some to be new to a group of strangers. It might also be quite difficult for universities to facilitate group activities given restraints on time and on resources as well. One way that this might be addressed is just to encourage the use of more virtual platforms. Some of the interventions that we found to be successful were facilitated via smartphone apps or online groups. This could help to overcome some of the barriers. And it can also be used in conjunction with face-to-face interventions as well. Thank you. For the young people themselves, what would you be recommending that were feeling lonely? I think one of the most salient messages that we took from our research and from our own experience is how important it is to connect with others. Students often learn through this that other students were in a very similar position to themselves. If young people do find that they are suffering with loneliness, it's important to reach out as soon as possible. I think we just recommend doing some research into what your university already has available and see what things you'd like to be involved with. Yeah. That's so important. It's so easy to feel like it's just you and that increases that sense of isolation and loneliness. Both of my children are at university. So I wondered whether there was anything from the research that would be a good message for parents or carers. I think it would be really good if parents or carers do not put too much pressure on their child regarding academic achievement, especially in the first year, when they're trying to find their way at uni. It would be good if the students feel they've got time to take part in some of the social groups available at university, whether it's choir, or sports group, or any other activity. These are golden opportunities to meet like-minded people and to make lifelong friends. But if your child doesn't make any close friends at uni, being a part of a group can boost their self-esteem, and alleviate feelings of loneliness. And if they have existing depression or anxiety, then the feeling of being socially connected to others via group activity may actually help reduce their symptoms and prevent loneliness. So parents need to keep in mind that being part of social groups and investing them can translate into better academic performance, and also better employment prospects in the future. The message is to the CAMH professionals themselves. Is there any advice that you would give? Much more needs to be done in this area. And university mental health services or CAMH services can work with universities to solve the problem. Many clinicians and GPs struggle with this patient group students because they're no longer at home. And they're at uni at a different GP practice and often getting help to students who are struggling with their mental health is difficult. And student support services in universities is high demand for their support. But what this paper is about is prevention. And that if you can support students with loneliness, and prevent that from becoming more severe or prevented from happening altogether, then there's scope to prevent other mental health problems. If we can prevent loneliness in students, we can most likely reduce the development of risky behaviors, such as alcohol and drug abuse or internet addiction. Also, certain groups of students are likely to suffer more from loneliness than others. These students with disabilities or autism might need greater focus and more support than other students. Mental health services should be working with universities and the young people to develop prevention strategies. Students themselves will have good ideas of what might help them. So they should be involved from the start, when planning any intervention. Our review indicates that group-based interventions seem to be more likely to reduce feelings of loneliness than interventions that involve just the individual. The good news is that the group activities can be varied and don't have to focus on student support, or have to be specifically aimed at or labeled as reducing loneliness. So more attention needs to be paid on what time the group activities take place. Not all students can make evening activities. Connecting online might be helpful for some students. Some students may also benefit from interventions that address maladaptive cognition, which refers to having negative thoughts about self-worth and how other people perceive you. This may be more relevant for students who have anxiety or who are already struggling with feelings of loneliness. Some more targeted interventions may be appropriate in this group. There are digital apps that can help with this. And Australian team have already developed an app for students. And it showed some promising findings in some of the preliminary research that they made. Is there anything that you think needs to change at that kind of policy level that would help loneliness in university students? Personally, I would actually remove university rankings, like, I would remove Ofsted inspections in schools to reduce pressure and high levels of stress. However, I guess that won't happen. On the other hand, these types of inspections and rankings should take on board student well-being. And perhaps, then more focus will be placed on the promotion of mental well-being, including the prevention of loneliness. Usually, ranking exercises focus on things like teaching, research quality, academic support, or student satisfaction. But student satisfaction isn't the same as student well-being. There's a connection between well-being and academic achievement. So perhaps, more should be invested in creating environments and opportunities that promote well-being and enable connecting with others. This links up with mentally healthy universities or the whole organization approach to mental health. In this approach, all aspects of university life can contribute to better mental health. Apart from providing safe and pleasant spaces for socializing, universities should review the curriculum to ensure there is time for non-academic activities and clubs that can take place during the day. If there are too many assessments and exams, students won't feel they have time for anything but to study and revise. Are you planning some follow-up research? Or is there anything else in the pipeline that you'd like to share with us? Clearly, more high-quality research is needed in this area, as most of the studies in our review were carried out in the United States or elsewhere. And many of the studies were of relatively poor quality. There's scope for doing some basic research linked to loneliness among university students in this country, but also for developing interventions. Finally, is there a take home message for our listeners? We don't often associate university students with loneliness. We think they are social beings. And they interact on campuses. But loneliness is real among students. Students are one of the population groups with highest rates of loneliness. Being among lots of people of the same age doesn't mean that you are immune to loneliness. Participation in non-academic group activities should be high on the agenda for students. And parents and professionals should not forget the importance of these for student well-being. Universities are not only about academic qualifications. It's an opportunity to make friends for life. These friends are among the ones we'll turn to later on in life when going through difficult times. They are the ones who will help us feel less lonely. Research shows that existing close friendships become more important with age. And that interactions with friends reduce loneliness to a greater extent than interactions with close relatives or family members. Thank you so much, Helena, Olivia, and Christina. For more details on our guests, please visit the ACAMH website, www.acamh.org, and Twitter, @acamh. ACAMH is spelled A-C-A-M-H. Don't forget to follow us on your preferred streaming platform. Let us know if you enjoy the podcast with a rating or review. And do share with friends and colleagues. 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