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Psychiatric Times: The Crisis in College and University Mental Health

In the past few years, college mental health issues have received increasing attention by the mental health community, the public, administrators, and legislators. Events such as the death of MIT student Elizabeth Shin and the subsequent legal battle, and the series of suicides at NYU a few years ago received prominent media coverage. In the aftermath of the tragic murders/suicides at Virginia Tech and Northern Illinois University, college student mental health issues and campus safety have become pressing public health and policy concerns.

Psychiatrists have historically played a peripheral role in most college mental health services and, thus, have not been well informed about the mental health challenges encountered on campus.

The scope of the problem
While the tragedies at Virginia Tech and Northern Illinois University riveted the nation’s attention, professionals within the college mental health world had been discussing the mental health crisis for years before these horrific events. Research in college mental health issues has not been well funded, and epidemiological information is scarce. The American College Health Association undertakes a yearly self-report survey of college students (nearly 95,000 respondents last year), which gathers general information about students’ health and mental health. Dr Robert Gallagher of the University of Pittsburgh surveys college counseling center directors yearly. The University of Michigan is al-so in the early stages of a multiyear study of the mental health of university students.

What have these reports shown? There are currently approximately 17.5 million university students in the United States. Gallagher reported that in 2006, 8.5% of students sought counseling through their school service; another 29% were seen by college-based counselors in other settings. Voelker noted that visits to university counseling centers rose 42% between 1992 and 2002 at 11 large Midwestern universities.

For the past 10 years, Gallagher has consistently reported that about 90% of counseling center directors believe they are treating increasing numbers of students with severe pathology. In 1994, 9% of students seen at counseling centers were taking psychiatric medications. By 2006, this number had risen to 23.3%, and 7.5% of students had such serious impairments that they could not function in college settings or without extensive psychiatric/psychological support.

Students’ self-reports seem no more reassuring. According to the most recent American College Health Association survey, about 13% of students reported having symptoms of anxiety, and more than 18% reported depression symptoms. Almost 15% had received a diagnosis of depression sometime in their lives; 25% reported problems with their studies as a result of sleep problems; 33% acknowledged stress-related problems; 43% said they felt so depressed at some point in the academic year that it was difficult to function; 10% had seriously considered suicide; and 1.9% had attempted suicide.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has gathered data on alcohol use in colleges. The news is dire on this front as well: 31% of the surveyed students met criteria for alcohol abuse. Moreover, there were 1.3 million yearly alcohol-related injuries or assaults among college students. While there are estimated to be about 1100 suicides each year on college campuses, 1700 deaths are attributed to alcohol-related accidents and unintentional injuries. Large numbers of students acknowledged that they had unsafe sex while intoxicated or did something they later regretted. Rates of assault and sexual assault related to alcohol and drug use are also alarmingly high. In 2005, 83% of campus arrests were alcohol-related. Students who abused painkillers during the previous month increased from under 1% in 1993 to 3.1% in 2005. During the same period, daily marijuana use more than doubled from 1.9% to 4%; the use of illegal drugs other than marijuana, such as heroin and cocaine, increased from 5.4% to 8.2%.

The clinical crisis
When most college clinicians discuss the crisis in college mental health, they emphasize that the demands on services have dramatically outpaced the capacity and rate of growth of available mental health care systems. Most college counseling services provide free, short-term care for students and are usually funded by student services fees. Historically, the counseling centers were conceptualized as settings where students could be helped through a specific developmental challenge or adjustment problem (eg, homesickness, failure to establish a social network). The centers are frequently staffed by psychologists (more often counseling psychologists rather than clinical psychologists) and, until recently, often had little if any psychiatric staff. Because many students have limited or no insurance coverage and many communities have limited options for low-fee care, colleges find themselves providing services for larger numbers of seriously ill students for longer periods. With the availability of effective treatment options, students with serious mental illness are now able to attend college. The need for clinicians equipped to care for these students has grown simultaneously. Colleges must decide whether to spend money hiring lower-salaried therapists (social workers and nurse practitioners) or psychiatrists. Colleges are not in the business of providing health and mental health care. While the schools recognize the need to provide ample services, this is often done somewhat grudgingly and often after a crisis (such as a campus suicide).

The policy crisis
Colleges have a complicated relationship with their students. Most students are legal adults and entitled to privacy and autonomy. However, colleges have some responsibility to oversee their students’ conduct and to provide in some general way for their safety and well-being. Parents expect to be part of the discussion if their child is having difficulties. College administrators, policy makers, legislators, and judges have all struggled to strike a balance between these values of privacy/autonomy and oversight/safety/ parental involvement.

The concerns around this conflict of values have been acutely heightened by the tragedies at Virginia Tech and Northern Illinois University. There have been calls from many corners to increase oversight of students, curtail their privacy and autonomy, and lower current legal thresholds for parental contact and mandatory leaves of absence. These concerns have placed new pressures on college mental health services to keep campuses safe but sometimes without appropriate strategic planning. While there may be circumstances in which sharing clinical information or mandated medical leaves might be appropriate, these pressures have increased the challenge and conflict experienced by campus clinicians to keep patient care the primary goal of the clinical interaction. Lowering the threshold for communication is likely to erode the often fragile trust between a troubled student and the campus mental health systems and/or university administrators.

Role of psychiatry
Currently, fewer than 1% of college counseling centers are directed by psychiatrists, and only 63% of schools provide psychiatric services on campus. The average weekly number of consultation hours is 17 per 100,000 students.

In 2004, Michelle Riba (2004 American Psychiatric Association [APA] president) convened a Presidential Task Force on College Mental Health to increase awareness and promote advocacy for college mental health in the psychiatric community. This group, now an APA committee, has become a “meeting place” (both real and virtual) for psychiatrists who work in college mental health settings. Many of these psychiatrists experience professional isolation.

College mental health services play an important role in promoting healthy and safe college communities and campuses. Having robust services available improves student retention and, thus, good services make good economic sense. With increasingly severe psychopathology of students, psychiatric services must be enhanced. Clinicians who support and treat the most troubled students and who can assess and manage psychiatric emergencies are needed. If an on-site psychiatrist is not economically feasible, referrals to accessible and affordable psychiatric services off-campus need to be provided.

Residency training and fellowship electives at college mental health services provide wonderful opportunities for residents to learn about college mental health issues (and to learn about short-term therapies and combined and split treatment). Experts in college mental health have begun to be invited to address grand rounds and professional meetings. The APA has established a college mental health area on its website and there are a growing number of other websites devoted to college mental health and substance abuse. While there are some efforts at careful epidemiological work, much more needs to be done to continue to understand and explain the growing number of increasingly troubled students presenting to college services and the best approaches for their care. The stigma associated with mental health problems on campus needs to be addressed, and integrated models of mental health care need to be put into practice.

The best college mental health services, while scrupulously maintaining the privacy of their patients, also find ways to educate their college communities about mental health issues. Tragedies on college campuses are more likely to be prevented by establishing open lines of communication and a strong collaboration among students, faculty, and administrators. College mental health clinicians and administrators need to be well versed in the laws pertaining to college students but primarily should act in the “best interest of the student.” Relevant laws such as the Family Educational Rights and Privacy Act and the Americans with Disabilities Act provide a framework for decision making in complex cases. However, these laws do not, and should not, dictate case management in crisis situations; ultimately, clinicians should follow sound clinical judgment and appropriate consultation with colleagues in the decision-making process.

Despite all the problems and challenges that face college mental health services, work in this setting is generally quite rewarding. University students are usually intelligent, hard working, and resilient; and they often make substantial strides in treatment, however brief. Helping a student to remain in school, complete an education, and actualize his or her potential is a deeply gratifying professional experience.

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The World Health Organization defines “mental health” “as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” In using this definition, S2i recognizes that some mental health challenges reflect brain diseases that, like physical diseases, require appropriate stigma-free and patient-centered care and include both mental health and substance use disorders. Other mental health challenges stem from social conditions and marginalization and require different forms of interventions.