Ann Arbor, Mich—The scenario is becoming all too common across college campuses today. Students face not only the time-honored ritual of leaving family and longtime friends, but a host of other pressures. New relationships can send students on an emotional roller coaster, while parents in the throes of divorce may add to the anxiety. The pressure to succeed academically perhaps has never been higher, and at the first sign of falling grades, even students who excelled in high school may wonder if they are really college material. And as college costs continue to climb, students approaching gradation with substantial loans to be repaid face the gloomiest job market in the past decade.
Grahic Jump Location
Against this backdrop, growing numbers of students are seeking help for depression and other psychiatric disorders. But student health services and campus counseling centers often have not kept pace with the increased demand for treatment.
At many student health centers, "the pattern still tends to be not to ask about family history, not to put this in a plural context, not to pursue what might be going on and get an early start on it," said John Greden, MD, executive director of the University of Michigan Depression Center and Rachel Upjohn professor of psychiatry and clinical neurosciences in the university's medical school.
That means thousands of students with depression go undiagnosed and untreated at a time when they face some of life's most important junctures.
Greden noted that the peak onset of symptoms in the general population occurs between the ages of 15 and 19 years. But for most students, a diagnosis will not be made until many years later. The average age at diagnosis for unipolar depression is 27 years and 21 years for biopolar disorder, according to the Depression and Bipolar Support Alliance, a national mood disorders advocacy group.
Because campus services can offer a crucial point of entry to diagnosis and treatment, officials at the University of Michigan recently hosted the inaugural "Depression on College Campuses" conference in March not only to boost awareness of the problem, but to discuss implementation of best practices in student mental health services.
Several surveys conducted during the past decade suggest that the prevalence of depression among college students is growing, and that it eclipses the rate in the general public. Richard Kadison, MD, chief of the Mental Health Service at Harvard's University Health Services in Boston, Mass, offered what he called some "scary" statistics.
Citing a 2000 survey by the American College Health Association, Kadison said that within the last school year, 61% of college students reported feeling hopeless, 45% said they felt so depressed they could barely function, and 9% felt suicidal. The National Mental Health Association's College Student and Depression Pilot Initiative lists suicide as the second leading cause of death among college students.
Another survey by researchers at Kansas State University in Manhattan has shown that from 1988-1992 to 1996-2001, the proportion of students who came to its counseling center with depression increased from 21% to 41%. A 1999 survey by researchers at the University of California, Los Angeles, reported that 30% of college freshman felt overwhelmed by the transition to campus life, compared with only 16% in 1985. The US Surgeon General's report on mental health in 1999 indicated that about 20% of US adults will experience depression at some time in their lives.
In preparation for the conference, Todd Sevig, PhD, director of the University of Michigan Counseling and Psychological Services, examined 1992-2002 utilization data from counseling centers at the 11 universities that comprise the Big Ten Conference. "There has been roughly a 42% increase in the number of students seen at these counseling centers," he said.
Massachusetts Institute of Technology (MIT), in Boston, also has recorded an increase in the number of students seeking counseling. Kristine Girard, MD, chief of Mental Health Services, said that from 1995 to 2000, the proportion of the student body seeking counseling increased from 8% to 12%.
"That figure continues to rise at about 1% per year, and it taxes our services," said Girard.
At a time when public and private universities face worsening budget crises, how can campus mental health professionals expand existing programs or launch new ones to help their students face emotional crises? Kadison said it is a "no good deed goes unpunished" scenario.
"If we get the education out there, and get people to recognize that depression is very much a problem, where are we going to find the resources to take care of people?" he asked.
Recognizing that students with depression need immediate attention, Kadison said, Harvard has borrowed a triage system implemented nearby at the University of Massachusetts. Students who call Harvard's Mental Health Service often can get an appointment the same day.
"Getting students into care in a day or two is crucial," he said.
An even greater challenge is determining how much care individual students really need. Distinguishing developmental issues from clinical depression often is difficult at best, said Kadison. He noted that some individuals need a disproportionate amount of care.
"Most counseling services find that 10% or 20% of students use 60% or 70% of the resources," he noted. Girard agreed, noting that, increasingly, students who seek mental health services at MIT require ongoing, continuous care.
"We're seeing growing numbers of students who need psychiatric hospitalization and growing numbers of medical leaves for reasons of mental health," she said.
Because resources are scarce, campus mental health professionals walk a fine line in determining whether to emphasize prevention or dedicate funds for intensive care for students with the greatest need.
Kadison, for example, questioned whether treatment sessions should be limited, and asked how universities can find alternatives to community resources that are drying up because of shrinking budgets. This can mean using creative strategies to help students get needed treatment; Kadison noted that sometimes he meets pharmaceutical representatives at an off-campus coffee shop. "They're not allowed on university property, so [by leaving the campus] I can get prescription samples and drop them off at the pharmacy so students can use them."
MIT contacts all incoming freshmen before they arrive on campus with information about campus medical services and a questionnaire about their own personal health, including a mental health history, said Girard. The practice is an effective screening tool, and it "normalizes" mental health issues for students by placing them in the overall context of general health, she noted.
Improving communication among campus departments is another key to optimal student care, said Rachel Glick, MD, former director of the University of Michigan's Psychiatric Emergency Services and now associate dean for student programs and clinical associate professor of psychiatry at the university's medical school. Universities "are very complex places with lots of different ‘silos' where people can get help, but we don't talk to each other," she noted.
At the University of Michigan, students can block the release of personal information, including family contact information, explained Glick. If a student who has prohibited the release of that information comes to the hospital with a psychiatric emergency, physicians may have no way to determine if a previous psychiatric diagnosis has been made, or if the student is receiving treatment away from the campus.
Sharing information in a way that preserves confidentiality is essential, said Glick.
"As an institute of higher education, we need to figure out ways to be part of the same team so we can share information between the emergency room and the counseling service, between the registrar's office and the emergency room," she noted. "That will really improve the services we provide for individual students."
Researchers from the Big Ten Conference and the US Department of Education have estimated that nearly 1100 suicides occur on college campuses each year. The Jed Foundation, a nonprofit group formed by the parents of a 20-year-old university student who committed suicide, and the National Mental Health Association offer the following checklist for universities to help safeguard against student suicides.
Is a screening program in place; are on-site mental health services available?
Is transitional support available for families of incoming students who already have been diagnosed as having a mental illness?
Have faculty, staff, coaches, clergy, and student or resident advisors received training to identify suicidal behaviors?
Are students educated to identify their own at-risk behaviors and those of their fellow students?
Are campus health care providers trained to handle suicidal clients? If not, is training available?
Have working relationships been established with community mental health providers to ensure appropriate, off-site referrals?
Is a crisis management plan in place if a suicide or other traumatic event occurs on campus?
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
Instructions
Comments are moderated and will appear on the site at the discretion of the Journal of American Medical Association editors. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest* Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more
Subscribe for full-text access to content from 1998 forward and a host of useful features
Activate your current subscription (AMA members and current subscribers)
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Customize your page view by dragging & repositioning the boxes below.
and access these and other features:
Register Now
Enter your username and email address. We'll send you a reminder to the email address on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.