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The Rising Prominence of College and University Mental Health Issues
Jerald Kay
Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
1.1 Introduction
Throughout parts of the Western World, the increasing visibility of college and university mental health issues has been the result of both unfortunate and fortunate circumstances. In the former category, belong the tragedies of isolated students and the murder-suicides on two particular American campuses. Both of these are rare occurrences within the general population and equally so on the campuses of higher learning. However, within the recent past, a number of student suicides have received broad exposure in the media within the United States. Suicides at prominent universities [1,2] have highlighted the inadequacies of mental health services [3], institutional policies [4], and important ethical and legal concerns [5]. The mass shootings at Virginia Tech on April 16, 2007 [6] followed by the February 14, 2008 incident at Northern Illinois University [7] gripped the attention of the public. Fortunately, clinical and epidemiological research, accompanied by innovative programmatic development, has provided a more comprehensive appreciation of the scope of the issues. Scientific advances in the diagnosis and treatment of mental disorders have undoubtedly permitted some students, who heretofore would not have attended college, to do so. The development of more effective mental health care through advances in psychotherapy and psychopharmacology enables many teenagers to achieve a degree of emotional stability necessary for college and success in their studies and social-emotional development. Increasingly sophisticated college mental health services have ensured continuity of care for these students as well as providing assistance to a growing population of students presenting with new problems after matriculation.
1.2 How Prevalent are Emotional Disturbances and Mental Disorders?
Mental disorders, for the most part, are disorders of young people and many tend to be lifelong. (Figure 1.1 illustrates high-risk periods for psychopathology). More is now known about the vulnerability to and the onset of mood and anxiety disorders, for example, even within grade school children. College mental health clinicians know that the number of matriculating students with a history of mental health treatment and those who enter college on psychotropic medication and/or require ongoing psychotherapy has increased dramatically. One significant pressure on college mental health services therefore, can be attributed to this student population. However, the increased need for mental health services is much broader [8].
1.2.1 Student Surveys
Epidemiological studies of the prevalence of mental health issues among college students are becoming more scientifically rigorous Some of these will be briefly described shortly. (For an in depth discussion of surveys and research initiatives see Chapter 16.) However, much of the early and continuing indications of increasing college mental health problems have been elucidated by two significant survey mechanisms. The first survey is one conducted annually since 2000 by the American College Health Association (ACHA). Of the approximately18 million students enrolled in the US, the ACHA National College Health Assessment reported on nearly 95000 student responses during the year 2006 [10]. This survey indicated the percentage of students reporting the following conditions/disorders:
- Anorexia 1.8%
- Anxiety 13.4%
- Bulimia 2.2%
- Depression 18.4%
- 14.8% of students said they had been diagnosed with depression sometime in their lives
- 26% of those diagnosed with depression were receiving psychotherapy
- 36.6% of those diagnosed with depression were taking medication
- 1.3% made at least one suicide attempt
- 9.3% considered suicide within the last school year
- 17.8% experienced depression within the last school year
- Seasonal affective disorder 7.7%
- Substance abuse problems 4.0%.
To place these findings in perspective, only back pain, allergy problems, and sinus infection were reported more frequently than depression. These findings did not change substantially in the spring of 2008 report surveying 80 121 students [11]. This most recent report found that at least once in the past year, 63% of students felt hopeless, 93% felt overwhelmed, 91% felt exhausted(notfrom physical activity), 79% feltsad, and 45% feltso depressed it was difficult to function.
Figures 1.2–1.5 provide a graphic view of the changes in the numbers of students responding to questions about depression and treatment from 2000 to 2007.
The Healthy Minds Study group at the University of Michigan published a number of recent reports utilizing self-report measures such as the Patient Health Questionnaire (PHQ-9), a widely adopted depression screening tool in primary care medicine ([12] illustrated in Figure 1.6). A random sample of approximately 2800 students at a large state university, with demographic characteristics similar to the national student population, completed aweb-based survey that found a prevalence of any depressive(major depression/ dysthymia) or anxiety disorder (panic/generalized anxiety disorders) of 15.6% for undergraduates and 13% for graduate students [13]. Students were also queried about mental health service utilization within the previous year. Fifteen percent of respondents received psychotropic medication or psychotherapy (9% were prescribed medication). However, only 36% of those students with positive screens for major depression sought help. Asecond report [14] found that over 50% of students suffered from at least one mental health problem at baseline and that this persisted in 60% of this group 2 years later, yet only one half of this second group received mental health services during the 2-year period. Self-injurious behavior was reported by 7% of students over a previous 4-week period [15]; but, only one quarter received either psychotherapy or medication with in the previous 12months. Finally, the most recent report from this group [16] found that students with depression characterized by loss of interest and pleasure in activities were twice as likely to drop out of college. Those students with both depression and anxiety were noted as well to have significantly lower grade point average (GPA).
The College Screening Project at Emory University also utilized the PHQ-9 module for depression, accompanied by additional questions on anxiety, suicidal ideation, self-harm behavior, and past suicide attempts [17]. Of 729 respondents, 16.5% acknowledged a previous suicide attempt or self injurious episode, with 11.1% admitting suicidal ideation within the previous 4 weeks. Not surprisingly, those students with higher depression scores on the PHQ-9 reported more suicidal ideation. Of those with moderately severe to severe depression and those experiencing suicidal thoughts, more than 80% were receiving no treatment.
Lastly, 26 000 undergraduate and graduate students from 70 institutions, each with an average enrollment of nearly 18 000, responded to a web-based questionnaire from the National Research Consortium of Counseling Centers in Higher Education. The Survey of College Student Suicidality found6%percent of undergraduates and4%of graduate students seriously considered suicide in the previous 12 months [18]. For the majority of these students, suicidal thoughts were fleeting and lasted no longer than one day. However, of those who experienced a recent suicidal crisis, more than 50% sought no help. This study again supports the finding of low mental health utilization by struggling students.
1.2.2 Counseling Director Surveys
The second long-standing survey, The National Survey of Directors, has been conducted annually since 1981 by Dr Robert Gallagher. A limited number of Canadian and American administrative heads of colleges and universities participate in this survey.Some of the relevant findings [19] from the most recent report of 284 participants, representing 3 441 000 students, include:
- 9% of students (310 000) sought counseling in the past year
- 29.6% of students (about 1 million) were seen in other contexts such as workshops, orientations, class presentations
- 60% of campuses have psychiatric services but often with insufficient psychiatric consultation hours
- 16% of center patients are referred for psychiatric evaluation
- 26% of center patients are on psychotropic medication, an increase from 9% in 1994 and 20% in 2003
- 93% of directors reported an increased number of matriculants on medications
- 95% of directors acknowledge greater patient acuity leading to
- 64% reporting staff burnout
- 64% reporting shortages during peak times
- 62% reporting decreased focus on students with normal developmental concerns
- 33.5% reporting premature termination of treatment
- Directors report nearly 50% of patients have severe psychological problems
- 7.5% of students have serious impairment that requires leave or continuation only with extensive psychological/psychiatric treatment
- 53% of directors report an increase from the previous year in self injury
- 35.6% of directors noted an increase in students with eating disorders from the previous year
- 25.4% reported an increase in sexual assault cases compared to previous year
- 2075 students hospitalized (average of 8.2 students per school)
- 118 student suicides
- Other stresses reported by directors include
- 67% report increase in crisis counseling
- 66.5% report challenges in finding long-term treatment resources
- 59.5% report growing service demand without increase in resources
- 81% report significant increase of consultation requests from concerned faculty about troubled students.
1.2.3 Toward a More Rigorous Assessment of the Mental Health of College Students
Surveys have played an important role in identifying concerns about the mental health of college students. However, surveys have inherent limitations. In those recent studies relyingonscreeninginstrumentssuchasthePHQ-9,symptoms,even when measured with validated instruments, are not equivalent to establishing clinical diagnoses and may not consider contextual issues in the college and university settings [20]. For example, many students become symptomatic secondary to short-lived situational and developmental crises. As well, nearly all of the surveys ascertained only the presence of a limited number of disorders. Cross-sectional studies can provide only associational patterns and not causality. Some surveys may not be representative of the national college mental health picture since study participation by institutions was not random. Moreover, some colleges may join studies because of problems unique to their campuses. Lastly, no studies have included community samples or non-college attending comparison groups. Nevertheless, in reviewing numerous investigations, between 12% and 18% of college students appear to meet diagnostic criteria for mental disorders [21]. How accurate is this finding?
Some findings from a very recent report from the Center for the Study of Collegiate Mental Health [22] are summarized in Table 1.1. The report is a significant contribution since student patients, not the entire student population, provided responses.
Table 1.1 Selected data from the CSCMH Pilot Study
| 90% of patients had counseling before college, 18% during college and 15% both |
| 10% of patients prescribed medication before college, 14% during and 11% both |
| 5% of patient experienced psychiatric hospitalization before college, 14% during and 1% both |
| 7% of patients admitted to strong fears of losing control acting violently |
| 1% of patients acknowledging binge drinking did so 10 or more times in preceding 2 weeks |
At the end of 2008, an article appeared in the Archives of General Psychiatry, which reported on 12-month prevalence rates of psychiatric disorders and mental health utilization rates in college-aged individuals [23]. From the 43000 participants in the 2001–2002 National Epidemiological Survey on Alcohol and Related Conditions (NESARC), data was abstracted for a subsample of 5092 young adults between the ages of 19 and 25. A group of nearly 2200 college students (studying full-time or part-time within the previous year) was compared to a peer group of approximately 2900 not attending college [24]. What distinguishes this study from previously described ones is:
- Face-to-face interviews administered by trained non-clinicians
- UseofareliableandvalidstructuredclinicalinterviewbasedonDiagnosticandStatistical Manual-IV (DSM-IV) criteria
- Assessment for a broad range of psychopathology including:
- Substance abuse disorders (alcohol and drug abuse or dependence and nicotine dependence)
- Mood disorders (major depression, dysthymia, and bipolar disorder)
- Anxiety disorders (panic, social anxiety, generalized anxiety disorders and specific phobia)
- Lifetime history of conduct and selected personality disorders (paranoid, schizoid, antisocial, histrionic, obsessive-compulsive, dependent, and avoidant disorders)
- Assessments of stressful life events
- Specification of sociodemographic characteristics.
Stressful life events were assessed through the 12-item Social Readjustment Rating Scale that examined boyfriend or girlfriend relationship breakup, separation, divorce, and death of a spouse. Mental health service utilization was defined as receiving treatment within the past 12 months for a mood and or anxiety disorder either through hospitalization, emergency department visit, or medication. Substance abuse treatment included being seen by a professional or paraprofessional, inpatient or outpatient treatment (including detoxification, rehabilitation, methadone maintenance, emergency department/crisis center visit, or self help group). Table 1.2 summarizes some of the psychopathology and treatment findings from this study employing the National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule [25]. It is important to note that this report did not provide prevalence rates for borderline and narcissistic personality disorders, both of which are challenging treatment conditions in college mental health. However, two recent reports on the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions, which included 34 653 face-to-face structured interviews of adults using DSM criteria found a 6% lifetime prevalence rate (7.7% men versus 4.8% women) for narcissistic p...
