Introduction

A multitude of adolescents around the globe are suffering from mental problems [1]. As shown in the Global Adolescent Health Report issued by the World Health Organization (WHO) in 2014, mental health problem of teenagers has become increasingly prominent [2]. According to the latest data from the WHO in 2019, 20% of adolescents worldwide are confronted with psychological problems. Results of relevant study on Chinese show that, the lifetime morbidity of mental disorders (which can even result into suicidal tendency) in teenager’s ranges from 13.2% to 17.5% [3,4]. Adolescents are undergoing a transition from childhood to adulthood where their cognitive and emotional development is dynamic [5]. Their psychological problems can be attributed to family factors (such as educational methods and defective family structure), social reasons (such as social circumstances and professional considerations), personal elements (such as heredity and personality), etc.

In China, 42.9% of the citizens hold that psychological counseling will disgrace them and 61.4% admit the agony before visiting a psychologist; among the middle school students with mental problems, only 32.9% of those desiring help will take action [6].

As the Internet has become an indispensable part of daily life, online psychological counseling is suggested in certain circumstances thanks to its convenience and anonymity. Online psychological counseling refers to the practice of professional counseling and information provision when the consultant communicates online with the help seeker who is at a different place or far away [7]. Confidentiality, privacy, security, equality and affordability allow juveniles to seek the service more actively. Studies have proved that online counseling is acceptable and effective and the treatment based on the Internet can effectively supplement or integrate psychotherapy [8]. According to the studies respectively led by Day and Rassau, cognitive behavior therapy provided via the long-distance transmission of images and voice can achieve a similar effect to offline consulting [9,10]. According to a Chinese preliminary study on college students, emerging online psychological counseling is quite promising [11].

In this paper, the psychological demands of contemporary students as well as the upsides and downsides of both online and offline consulting will be identified and analyzed based on a survey on the students in Shanghai. Our results showed it is concluded that online mode has the advantages which the other lacks and can enrich the consulting environment for those respondents.

Method

Study design and setting

From October to December 2017, a survey was conducted on the students of Grade 6-12 in a municipal middle school of Shanghai.

Study methods

Questionnaire method was adopted. The questionnaire was self-designed by the investigators based on research needs. The questionnaire was anonymous. In addition, the survey was conducted online and offline at the same time. The questionnaire covers the profile of the students (gender and grade), degree of their pressure and anxiety as well as corresponding causes, ways of pressure alleviation, degree of online consulting acceptance, etc.

Statistical analysis

Statistical analysis Data collection and its statistical analysis was carried out using the SPSS software system (SPSS, Version 23.0). Based on logistic regression, the investigators analyzed the relationship between grade and gender, as well as stress and anxiety.

Results

Basic information

A total of 111 valid samples were collected. Among them, boys and girls respectively accounted for 34.2% and 65.9%; those from Grade 6, Grade 7, Grade 8, Grade 9, Grade 10, Grade 11 and Grade 12 each occupied 2.7%, 1.8%, 9.9%, 4.5%, 57.7%, 17.1% and 6.3%. (See Table 1 for details) Among the students with mental stress or anxiety, 12 of them willing to participate in the online consulting trial were selected randomly, and one was excluded because he/she rejected follow-up visits. Therefore, a total of 11 effective questionnaires were collected, including the feedbacks from 7 girls and 4 boys.

Due to the small sample size for Grades 6 and 7, the corresponding data was not deemed as universal and thus excluded during the grade-related cross analysis.

Basic psychological problems of students in different grades

The survey respondents needed to answer whether they feel mental stress or anxiety. After the exclusion of the samples of Grades 6 and 7, it was found that more than 50% of the students in other grades felt stressed or anxious. Higher-grade students experienced more pressure and anxiety, and the coefficient changes represented a linear trend. From the perspective of gender, female students were often under great pressure (OR = 0.717) compared with the males, who would feel more anxiety (OR = 1.057) (Figures 1 and 2).

Causes of anxiety for students of different grades

According to the analysis on what causes anxiety, psychological problems brought by academic pressure (94.3%) topped the list, respectively followed by those related to relationship with classmates (50.9%) and family members (37.7%). Among the students of Grade 10, 95.3% (61/64) believed school work would trigger dysphoric mood, 51.5% (33/64) linked anxiety to classmate relationships and 35.9% (23/64) thought family relationship was also one of the problems (Figure 3). High school students needed to deal with intense study and live up to high expectations from their parents, which might be the reason why such group suffers from mental problems such as anxiety. Given this, those of Grade 10 had prominent mental issues while corresponding proportion decreased after they moved to Grade 11 as shown in Figure 1.

Based on the results, students have great mental stress and suffer from mental problems like mood disorder, anxiety is the most common.

The psychological counseling methods adopted by students and their attitudes on offline consulting

61.3% of the students admitted that communication could help to alleviate mental problems. When feeling mental stress, 57.7% sometimes choose to talk with their parents, classmates or teachers, 56.8% vent out negative emotions by immersing themselves in hobbies, and 46.9% occasionally keep their thought bottled up. Among the students who choose to share their thoughts with parents and classmates, those deeming professional communication (with psychiatrists and teachers) more effective are 9 times more than those giving preference to non-professional talk (with parents and teachers). But only 11.7% will seek for psychological counseling (including psychology instructors and professional consultants) to cope with mental problems (Figure 4).

Only 14.4% of the respondents expressed their professional counseling experience. Among those, 62.5% said that their needs had been solved and their mindset had been improved. In this study, 80.2% of the students stated that online consulting was better than the offline mode, so we further investigated the reasons why this group preferred online therapy. The main factors include unwillingness to share their views (37.1%), reluctance to show their face (19.1%) and psychological burden during consulting (19.1%) (Figure 5). We also investigated why some students accepted psychological counseling but failed to take action. 23.4% of the students regarded the lack of parents’ understanding as main obstacle, 14.4% feared differential treatment by their classmates and 9.9% mentioned the limited attention from their teachers.

Although most respondents recognized the effectiveness of psychological counseling, the minority had ever received such service. Their concerns about current offline counseling mirror the shortcomings in timeliness and privacy. This indicates that face-to-face counseling cannot meet all of the needs of students.

Discussion

The psychological problems of adolescents are the focus of public health. A Chinese study shows that in recent years, both initial and further psychological consulting for teenagers has increased year by year and increasingly younger people have suffered from mental illness [12]. This study reveals that middle school and high students generally feel great mental stress and suffer from different degrees of psychological problems like mood disorder. More than half of teenagers are living in the shadow of excessive stress and anxiety, which become stronger as they move to higher grades. In addition, females are more prone to stress while males are more easily attacked by anxiety. This indicates the different genders vary in psychological problems, which is consistent with other studies at home and abroad [13,14]. The data shows that teenagers are generally troubled with psychological problems and the prompt solution is required. 10% of children and adolescents experience psychological problems in certain periods. However, less than one-third seek treatment [15]. which may be caused by limited understanding of mental diseases and uneven distribution and underutilization of mental health service system [16].

Study results show that 80.2% of students with psychological problems are more willing to choose online counseling, which is consistent with the results of overseas studies. Horgan A et al. found that 72.4% of the 922 youngsters surfed the Internet every day, and 30.8% of them had searched for mental health information, mainly about depression [17]. In a study in Australia, 72% of adolescents with mental health problems choose online consulting, and 31.9% prefer online treatment to traditional face-to-face support [18]. Teenagers are more willing to accept online support and guidance and their proportion even outtakes that of college students [17,18]. Thus, it can be seen that young people would rather get mental health information and psychological support on the Internet, which may be related to concerns about social prejudice and subsequent stigma after words about their offline counseling spread out. In China, psychological counseling seekers are often regarded as patients with mental illness. Such prejudice-caused stigma prevents common population from revealing their intrapsychic conflicts and seeking professional psychological intervention. Middle school students and high school students are still psychologically immature and lack the stable personality traits for adulthood. Therefore, a strong sense of shame significantly weakens their willingness to ask for help [19]. According to the study, parents are the main source of the sense of shame, and the actions adopted by adults to keep it secret can only backfire, making their children feel stronger stigma [15].

In addition, privacy is which teenagers care about most [20]. To put it another way, privacy matters a lot for those who need psychological counseling, especially for adolescents. Based on the survey on the help seekers of “One Psychology”, the platform takes into full account the opinions of the adolescents about whether to include their parents in the therapy, unless the seekers have illnesses such as depression and split personality. Non face-to-face consulting and absence of parents can effectively protect the privacy of the young, and mental diseases can be detected early by professionals after students confide in them. Thanks to this, intervention and treatment can be conducted as early as possible. The instant and effective psychological intervention and treatment online is available for those who originally resist help [21].

Although online consulting means convenience, timeliness and low barrier, it has just started in recent years and cannot fully replace the offline mode. On top of that, it needs to be improved in multiple aspects [22]. The online mode can only target limited service seekers because of the network layout. In addition, the online service is provided without a scene where they can communicate face-to-face with the consultant. So, the visitors will feel less trust in the advice giver, which is detrimental to favorable consulting relationship. It is worth noting that in despite of higher-level privacy, compromised confidentiality and security of the Internet remain an inevitable problem. Due to the defects of laws and regulations, high-caliber and unreliable online psychological consulting platforms mix up and the professionalism of the consultant is questionable. However, with the popularization of mental health knowledge, the research on and practice of online counseling will be more creative and challenging in the days to come. It is necessary for psychological counseling authorities, software development agencies, professional consultants, and other parties concerned to team up with each other. Relevant laws and regulations need to be established and improved, and more resources should be invested in the implementation strategy, security, confidentiality and other aspects of online consulting procedures [18,23].

Due to limitations in time and personnel, only 111 questionnaires were collected and the samples of each grade were distributed unevenly, which may lead to deviation of the analysis result. Meanwhile, as the survey did not cover the whole city, most samples were the students of the Shanghai Foreign Language School, which indicates the limitation of the results. We will further expand the sample size and distribute questionnaires to junior and senior high schools across the country to make results more universal and seek a more reliable way of intervention for the adolescents with mental problems.

Funding Sources

None.

Conflicts of Interest

None declared.

Zhao Xinyi contributed to research design, data analysis and writing, and other authors all participated in the design and implementation of the research.

Acknowledgement

We thank ‘Wenjuanxing’ for providing technical support.

Figure 1: Students of different grades and their stress degrees.

Figure 2: Students of different grades and their anxiety degrees.

Figure 3: Causes of anxiety among the students of different grades.

Figure 4: The counseling methods adopted by students to address psychological problems.

Figure 5: Reasons for the reluctance to seek offline consulting.

References

1. Patel V, Flisher AJ, Hetrick S, McGorry P (2007) Mental health of young people: a global public-health challenge. The Lancet 369: 1302-1313.
2. Hilario CT, Oliffe JL, Wong JP, Browne AJ, Johnson JL (2015) Migration and young people's mental health in Canada: A scoping review. J Ment Health 24: 414-422.
3. Huang Y, Wang Y, Wang H, Zhaorui Liu, Xin Yu, et al. (2019) Prevalence of mental disorders in China: a cross-sectional epidemiological study. The Lancet Psychiatry 6: 211-224.
4. Bo Bi, Tong J, Liu L, Shengnan Wei, Haiyan Li, et al. (2010) Comparison of patients with and without mental disorders treated for suicide attempts in the emergency departments of four general hospitals in Shenyang, China. Gen Hosp Psychiatry 32: 549-555.
5. Kristin A. Kullgren P, Sarah K. Sullivan, BA, Terrill Bravender, MD, MPH (2018) Understanding the Unique Needs of Hospitalized Adolescents and Young Adults Referred for Psychology Consults. Clinical Pediatrics 57: 1286-1293.
6. Minmin S (2016) Analysis of Outpatient Situations of Children and Adolescents' Psychological Consultation Clinic in a Hospital of Wuhan. Medicine and Society 29: 99-101. (in chinese).
7. National Board for Certified Counselor. NBCC’S The Practice of Internet Counseling [EB/OL]. (2011-7-6) [2016-05-20].
8. M Hautzinger, K Fuhr (2017) Kann die Online-Therapie die Psychotherapie sinnvoll ergänzen? Pro. Pro und Kontra.
9. (2002) Psychotherapy using distance technology: a comparison of face -to –face, video and audio treatment. Journal of Counseling Psychology 49: 499-503.
10. Rassau A, Arco L (2003) Effects of chat - based on - line cognitive behavior therapy on study related behavior and anxiety. Behavioural and Cognitive Psychotherapy 31: 377-381.
11. Dan Z (2010) Empirical study on effect of online-counseling in college students. China Journal of Health Psychology 4: 501-503.
12. Xue Yunyun XY, Hang F, Suwei Y, Yao Y, Jinjin C, et al. (2019) The status quo of child and adolescent mantal health in china and uts improvementbased on the survey results of three Hospitals in Shanghai. China Health Policy Research 12: 65-69. (in Chinese).
13. Nguyen H RJ, Flora DB (2011) Risk and protective predictors of trajectories of depressive symptoms among adolescents from immigrant backgrounds. J Youth Adolesc 40: 1544-1558.
14. Jianliang T (2008) Analysis of the Current Situation of Adolescent Psychological Problems. Journal of Clinical Psychosomatic Diseases 14: 263-264.
15. Kaushik A, Kostaki E, Kyriakopoulos M (2016) The stigma of mental illness in children and adolescents: A systematic review. Psychiatry Research 243: 469-494.
16. Coles ME, Ravid A, Gibb B, George-Denn D, Bronstein LR, McLeod S (2016) Adolescent Mental Health Literacy: Young People's Knowledge of Depression and Social Anxiety Disorder. J Adolesc Health 58: 57-62.
17. Horgan A, Sweeney J (2010) Young students' use of the Internet for mental health information and support. J Psychiatr Ment Health Nurs 17: 117-123.
18. Sweeney GM, Donovan CL, March S, Forbes Y (2019) Logging into therapy: Adolescent perceptions of online therapies for mental health problems. Internet Interv 15: 93-99.
19. Soto CJ, John OP, Gosling SD, Potter J (2011) Age differences in personality traits from 10 to 65: big five domains and facets in a large cross-sectional sample. J Pers Soc Psychol 100: 330-348.
20. Banfield M, McGorm K, Sargent G (2015) Health promotion in schools: a mul- ti-method evaluation of an Australian school youth health nurse program. BMC Nurs 14: 21.
21. Orman J, O'Dea B (2018) e-Therapy in primary care mental health. Aust J Gen Pract 47: 168-172.
22. Qiu Xuping LG, Xiaohong G (2018) Practice and problems of online psychological consultation. Modern Medicine and Health Research 2: 169-170. (in Chinese).
23. Sun B, Kang W, Zhang R, Zhiqi Fang, Xinguo Xu, et al. (2010) PsyCare: A novel framework for online psychological counseling. 5^th International Conference on Pervasive Computing and Applications.