There are 4706 degree-granting institutions of higher education (IHE) in the US with 21 million students.1 Of these IHEs, 63% are traditional 4-year schools that typically provide mental health care for enrolled students. A much lower percentage of 2-year schools provide these services. These institutions are seen as a pathway to a better life by US students and close to 1 million international students.2 An increasingly diverse cohort of students is coming to campus with a wide array of mental health challenges and concerns. The nature of the setting and the types of students who are coming to campus are essential to understanding the context for this article.
Decades ago, students in these settings would seek care for developmental issues, relationships, and life direction. Medications were few and far between (eg, TCAs, diazepam, chlordiazepoxide, chlorpromazine), and many were problematic by today’s standards. Today more serious issues such as suicide, self-injury, eating disorders, substance abuse, and bipolar disorders are common concerns. The medications have become better, with greater efficacy and fewer adverse effects. College mental health today looks more like community mental health as students are matriculating with more significant mental health histories than in the past.
As evidence of the level of distress seen nowadays among university students, the American College Health Association’s survey based on 79,266 students at 140 IHEs in 2014 revealed that at some point in the previous 12 months, 33% of students reported feeling so depressed that it was difficult to function, 46% of students felt hopeless, 54% experienced overwhelming anxiety, 8% seriously considered suicide, and 1% attempted suicide.3 It is also noteworthy that nationwide the percentage of adults who have serious thoughts about suicide is highest among persons aged 18 to 25 (7.4%).4 The number of completed suicides among college students is half that of their non-student peers, largely thought to be because of restrictions on firearms on college campuses.5
There are several explanations for the growth in serious difficulties. The first is that medications are frequently started in middle school and high school but often without the benefit of counseling. Or only limited counseling is provided in school, which—with parental support—helps students graduate from high school. In college, symptoms increase when students encounter greater academic and psychosocial challenges.
Second, the Americans With Disabilities Act requires schools to provide reasonable accommodations for students with disabilities, and mental health issues fall under that category. Historically, students often hid their disability, but now they declare it and seek accommodations.
Finally, while infrequent on any given campus, recent high-profile acts of violence as well as the threat assessment movement have shaped the national dialogue and given college mental health a higher profile. Consequently, IHEs have developed an increased sense of responsibility for providing comprehensive mental health care to students, and many campuses have experienced an increase in staffing and programs for both outreach and treatment.
Mental health care on campus
Every day, counseling center directors are typically faced with balancing increased clinical demands, providing training to new professionals, overseeing outreach to the community, ensuring that electronic patient records systems are working appropriately, maintaining quality control, and keeping up staff morale. At the same time, they must wrestle with stable and sustainable models for funding these efforts.
Providing mental health care for students at today’s IHEs involves responding to expanding levels of complexity. It requires strong clinical skills and a willingness to participate in a highly interactive and interpersonally connected community. Psychiatrists who practice in these settings are usually part of agencies with a focus on the entire campus community, beyond the individual patients. This involves consultation with colleagues in the clinics where they work, such as therapists and primary care physicians, and in the academic world, such as deans, faculty members, and student affairs personnel. Many of the patients have recently become legal adults; however, their parents expect ongoing involvement in their care, and the students experience ambivalence about such involvement.
Dr Meilman is Director of Counseling and Psychiatric Services and Professor in the department of psychiatry at Georgetown University in Washington, DC; Dr Eells is Director of Counseling and Psychological Services and Associate Director of Gannett Health Services at Cornell University in Ithaca, NY; Dr Mendola is Assistant Director for Psychiatry, Counseling and Psychological Services at Cornell University; Dr Lillrank is Assistant Director for Psychiatry, Counseling and Psychiatric Services at Georgetown University. The authors report no conflicts of interest concerning the subject matter of this article.
1. National Center for Education Statistics. Fast Facts. 2015. https://nces.ed.gov/fastfacts/display.asp?id=84. Accessed October 24, 2015.
2. Institute of International Education. Open Doors 2014 Report. Open doors 2014: International students in the United States and study abroad by American students are at all-time high. http://www.iie.org/Who-We-Are/News-and-Events/Press-Center/Press-Releases/2014/2014-11-17-Open-Doors-Data. Accessed October 24, 2015.
3. American College Health Association National College Health Assessment II. Spring 2014 Reference Group Executive Summary. http://www.acha-ncha.org/docs/ACHA-NCHA-II_ReferenceGroup_ExecutiveSummary_Spring2014.pdf. Accessed October 24, 2015.
4. Substance Abuse and Mental Health Services Administration. Results From the 2013 National Survey on Drug Use and Health: Mental Health Findings. http://www.samhsa.gov/data/sites/default/files/NSDUHmhfr2013/NSDUHmhfr2013.pdf. Accessed October 24, 2015.
5. Drum DJ, Brownson C, Denmark AB, Smith SE. New data on the nature of suicidal crises in college students: shifting the paradigm. Profess Psychol. 2009;40:213-222.
6. Association for University and College Counseling Center Directors Annual Survey. Reporting period: September 1, 2013 through August 31, 2014. http://www.aucccd.org/assets/documents/2014%20aucccd%20monograph%20-%20public%20pdf.pdf. Accessed October 24, 2015.
7. Center for Collegiate Mental Health. 2014 Annual Report. http://ccmh.psu.edu/wp-content/uploads/sites/3058/2015/02/2014-CCMH-Annual-Report.pdf. Accessed October 24, 2015.
8. Boone M, Eells GT. Reaching students who won’t walk in: innovative outreach programs offer options. 2008. https://www.gannett.cornell.edu/cms/services/counseling/caps/talk/upload/Reaching-Students-Who-Won-t-Walk-In.pdf. Accessed October 24, 2015.
9. New J. A ‘chilly climate’ on campus. January 8, 2015. https://www.insidehighered.com/news/2015/01/08/report-details-microaggressions-campuses-students-color-and-women. Accessed October 24, 2015.