Up Against The Ivy Wall

Mental health issues now concern the highest offices of higher education

The hottest place on college campuses these days is not the local brewpub, the athletics center or the famous-architect-designed student union. It's the campus counseling center. Through its doors are likely to march at least 10% of the student body in any given year.

The vast majority of the nation's college counseling centers report they are under siege, trying to meet the demands of unprecedented numbers of students with a range of serious psychological problems. From major and manic depression to eating disorders to self-harm to substance abuse, campus mental health centers are increasingly dealing with conditions that have life and death consequences. Shedding their reputation as the Rodney Dangerfield of college services, counseling centers are now seen as critical to the core mission of the university--relieving the mental burdens that impede students from learning and creating a civil society.

As a result, the issues that campus counseling centers face reach into the highest offices of higher education. There isn't a meeting of college presidents where the subject of student mental health doesn't come up, observes Steven Hyman, as provost the second highest officer of Harvard University and a psychiatrist who was formerly director of the National Institute of Mental Health. "It's an important, nationwide problem in higher education," he says. Adds Kevin Kruger, assistant executive director of the National Association of Student Personnel Administrators:"It's one of the top five critical issues on campuses." The rising demand for clinical services by a new "psychologically diverse" student body is hitting a wall of finite, if not shrinking, resources. "By the eleventh week of a semester," says Russ Federman, the University of Virginia's head of counseling,"all appointments are filled. But students don't stop coming."

Their services overtaxed, schools are responding by triaging cases, rationing counseling and, some say, over-relying on medications to get kids through what may, in the end, prove to be an unusually difficult (but not necessarily permanent) transition to adulthood. "Counseling centers are struggling with brief crisis stabilization versus addressing fundamental issues to effect change," says Federman.

Schools literally can't afford to have anyone fall through the cracks; student suicide presents huge liability issues and is highly disruptive to a campus. At the same time, parents are pressing colleges to take on even more responsibility for student safety, well-being and success.

No one's sure when the demand for counseling and more intensive psychiatric services will level off. Or where, or how, to draw a line between academic and therapeutic community. But lots of students today have needs beyond traditional adjustment and developmental issues.

"Through 1996," reports Kansas State's Sherry Benton, Ph.D.assistant director of counseling, "the most common problem students came in with were relationship issues. That is developmentally appropriate." But in 1996 anxiety overtook it and has remained the top problem. Relationship problems may have leveled off but their severity has escalated. Colleges report ever more cases of obsessive pursuit, otherwise known as stalking, leading to violence, even death.

Fact: 14% of college students filling out prematriculation health forms indicate they are actively being treated for clinical depression. That's before they get to campus. Many more are diagnosed on campus. A depression screening day at 134 colleges processed 12,999 students; 5,199 were referred for treatment.

Fact: Campus counseling center directors report that 41% of their clients have severe psychological problems; 12.2% receive a psychiatric evaluation and 20% take psychiatric medication.

Fact: Anorexia and bulimia in florid or subclinical form afflict 40% of women at some time during their college career.

Fact: Hospitalization for psychological reasons is increasingly common on campus;333 counseling centers hospitalized a total of 2,136 students in 2003.

Fact: With suicide the third leading cause of death among those aged 15 to 24 and second among college-age students, schools can expect 1,100 student suicides this year. Two thirds of the students do not seek help beforehand.

Medication issues are huge. Even those students who come to college already diagnosed and well-treated can get into trouble. "The hottest cases for me," says Bruce Nelson, director of Elon College (N.C) counseling center, are bipolar disorder. "It's so hard to manage. They don't want help when they're manic." Under the best of conditions bipolar disorder is a challenge; on campus it's daunting.

Students are a long distance from their doctors and put in a disorganizing environment of more drinking, less structure, more stress and many reasons to forego sleep. Sleeplessness alone can precipitate mania. which has it's appeal when there's always studying to be done or distractions to enjoy. The illness impairs insight and encourages denial. "No one is managing the medication," says Nelson.

Then there are the students who think everything is going to be OK now that they're out of their home environment. "We always see a number of bipolar patients in crisis who've stopped their medication," reports Bradford King, Ph.D., head of counseling at the University of Southern California.

Add in the enterprising students who go off their meds but still fill their prescriptions--so they can peddle the pills to others. Many colleges unwittingly host an informal black market in medications.

Schools are struggling to find the right mix of educational, residential and therapeutic solutions. Catching students one by one in counseling will never suffice. Says Hyman: "Once a week all year is not financially viable, nor is it the right approach to depression, which responds to time-limited cognitive-based therapy."

Colleges are forced to maximize the resources they do have. On many campuses, academic faculty, athletic staff and residence advisors are now front-line defense and get basic training in behavioral warning signs--say, a student hasn't been seen in two days. They take seriously conversations overheard in locker rooms and bathrooms in the hopes of identifying students who might be self-injurious. It takes an effort to coax them out of their separate silos but an across-university case-conference approach to individual students is taking hold.

The problems now taxing resources may be just the tip of the proverbial iceberg. Students themselves point to an underground of anguish. "In the atmosphere that is established at a competitive university," says one student--a graduate of one competitive university now a master's candidate at another-- "it is often difficult to express personal vulnerability." Indeed, observes the former peer counselor, "many students see others effortlessly finding success and happiness at college. They feel they're the only ones who are unhappy. The dorm community of a competitive university is not a 'safe' place to expose personal weaknesses." The climate is too adversarial. Students go to great lengths to keep their problems private. "They suffer in silence."

Still, not everyone's sure that the new student is a more disturbed person than in past generations. "If you think about the etiology of the concerns students bring to us, the first thing that strikes you is they are 18," says Ted W. Grace, M.D., head of the student health service at Ohio State. He cites the experience of his own daughter. As a freshman, she encountered "the usual problems of adolescence such as loneliness and independence," and developed panic attacks.

"Late adolescents represent a unique subpopulation in transition between youth and adulthood marked by newfound freedoms, participation in high-risk behaviors and exposure to many stressors such as examinations, public speaking, interpersonal relationships and transition from structured home environments to independent living conditions."

His daughter was given an SSRI. Was she being treated for disease, Grace asks, or "being temporarily helped through a difficult transitional period before her avoidance behaviors had an opportunity to become established?" Such "pharmaceutical support to help ease them through adolescence" is producing "an increasing number of students being more successful than ever before."

Psychology Today's Blues Buster

March 2004