Cover Story

Nicole Stearman remembers the morning well. Around 10:30 a.m., just as her research methods class at Eastern Washington University was finishing up, she felt an abrupt sense of terror and shortness of breath. It was the start of a panic attack — not the first she'd experienced — and she knew she needed immediate help. Stearman headed straight to the university's counseling and psychological services center.

When she arrived, she learned there were no counselors available, so she left and found a corner of the building to ride out the rest of the attack. "I can't really time my panic attacks to hit only on weekdays during the center's 11 a.m.- 4 p.m. counselor walk-in hours," says Stearman, who'd been diagnosed with depression and social phobia/social anxiety disorder in high school. "While the counseling center is a great resource, it could be a lot better."

Stearman is one of an increasing number of students who struggle with getting treatment for their mental health issues in college. About one-third of U.S. college students had difficulty functioning in the last 12 months due to depression, and almost half said they felt overwhelming anxiety in the last year, according to the 2013 National College Health Assessment, which examined data from 125,000 students from more than 150 colleges and universities.

Other statistics are even more alarming: More than 30 percent of students who seek services for mental health issues report that they have seriously considered attempting suicide at some point in their lives, up from about 24 percent in 2010, says Pennsylvania State University psychologist Ben Locke, PhD, who directs the Center for Collegiate Mental Health (CCMH), an organization that gathers college mental health data from more than 263 college and university counseling or mental health centers.

"Those who have worked in counseling centers for the last decade have been consistently ringing a bell saying something is wrong, things are getting worse with regard to college student mental health," Locke says. "With this year's report, we're now able to say, ‘Yes, you're right.' These are really clear and concerning trends."

Psychologists are stepping in to help address these trends in several ways. Researchers are examining the effect of mental health on how prepared students are for learning and exploring innovative ways to expand services and work with faculty to embed mental wellness messages in the classroom, says Louise Douce, PhD, special assistant to the vice president of student life at Ohio State University.

"For students to be able to learn at their peak capacity, they need to be physically, emotionally, intellectually and spiritually well," says Douce. "Students who struggle are more likely to drop out of school, but by providing services for their anxiety, depression and relationship issues, we can help them manage these issues, focus on their academics and learn new ways to be in the world."

College and university mental health trends by school year among students already receiving services at counseling centers

More students, more need

One of the biggest reasons why college and university counseling services are seeing an increase in the number of people requesting help and in the severity of their cases is simply that more people are now attending college. Enrollment in degree-granting institutions increased by 11 percent from 1991 to 2001 and another 32 percent from 2001 to 2011, according to the National Center for Education Statistics.

"One of the things that seems to be going on for colleges and universities is that as access to colleges and universities continues to grow, the population of colleges and universities is moving towards the general population, especially if you combine community colleges as part of that equation. So the level of need for access and the severity of concerns is growing — just like it has been in the general population," Locke says.

In addition, students who may not have attended college previously due to mental health issues, such as depression or schizophrenia, or behavioral or developmental concerns, such as attention-deficit hyperactivity disorder or autism, are now able to attend thanks to better treatment approaches and new medications. Access to wraparound services and individualized education plans in primary and secondary education have also helped more students graduate high school and qualify to attend college.

But when these young people go to college, such specialized services and accommodations rarely exist. The result is more students seeking help at counseling centers. Over the last three school years, the CCMH reports a nearly 8 percent increase in the number of students seeking mental health services. And college counseling centers report that 32 percent of centers report having a waiting list at some point during the school year, according to the 2013 Association for University and College Counseling Center Directors (AUCCCD) survey.

Unfortunately, even as students want more services, many center budgets remain unchanged or have increased only slightly from years past, the same survey finds. AUCCCD survey data suggest that larger institutions have struggled to attain pre-2008 recession budget levels, reflected in fewer counseling clinicians proportionate to the student body, compared with smaller institutions. The result can be seen in lower utilization rates and large waiting lists. In fact, the AUCCCD survey finds that from 2010 to 2012, the average maximum number of students on a waiting list for institutions with more than 25,000 students nearly doubled, from 35 students to 62 students.

Percentage of students who presented with depression, anxiety or a relationship problem as their main reason for seeking help at a counseling center.

Healthy minds and the bottom line

One way that counseling centers are trying to get more support for mental health services is by focusing on a factor administrators understand: a return on investment.

Research led by University of Michigan economist Daniel Eisenberg, PhD, for example, suggests that investing in mental health services for college students can help keep them from dropping out (B.E. Journal of Economic Analysis & Policy, 2009). That's good news for schools since they want to retain tuition revenue, but more important, it helps secure significantly higher lifetime earnings for the students, Eisenberg says.

"Every college and university cares a lot about its retention rate," he says. "It's one of the primary indicators of operating a successful institution — that people want to stay and that people are succeeding there."

Eisenberg has replicated these findings with samples from other colleges and universities, and in 2013, posted a formula to help counseling centers develop their own return on investment spreadsheet to present to university administrators when advocating for additional funding. Users can plug in their school's population size, departure/retention rate, and prevalence of depression to calculate the economic case for student mental health services.

"This economic case doesn't even count the most direct benefits of mental health services and programs — the boost in student well-being and the relief of suffering," Eisenberg says. Students who participate in counseling report improvements in their satisfaction with their quality of life — often a better predictor of student retention than grade point average.

Innovative treatment models

The insufficient funding for college mental health services also means inadequate access to care and treatment. Colleges and universities are addressing this challenge by developing quick screening tools and brief consultations to rapidly determine the needs of each new student who visits the counseling center. The University of Texas at Austin's Counseling and Mental Health Center, for example, created a Brief Assessment and Referral Team (BART), which replaces a lengthy initial consultation with a brief assessment with a trained counselor, who then refers the student to the appropriate level of care.

"For some students, a single session with a mental health professional is all they need, perhaps to help them problem-solve a situation or talk about a personal concern," says Chris Brownson, PhD, associate vice president for student affairs and director of UT-Austin's Counseling Center. "Other students are in need of more intermediate or even extended care. This is a way of getting students in front of a counselor more quickly and then ultimately getting them connected to the type of treatment that they need in a much faster way."

In another effort to connect students with mental health services faster, the University of Florida's Counseling and Wellness Center launched its Therapist Assisted Online (TAO) program to deliver therapy to students with anxiety disorders — all over a computer or smartphone screen. The seven-week program consists of several modules that teach students to observe their anxiety, live one day at a time and face fears. Students also have weekly 10- to 12-minute video conferences with counselors, as well as homework that they do via an app. They even get text message reminders to prompt them to complete their assignments, says Sherry Benton, PhD, the former director of the UF counseling center who led TAO's development.

The idea for TAO emerged after the center got funding to hire three more counselors, which Benton thought would help them eliminate their waiting list. Instead, it only bought them two weeks without a waiting list.

"It just seemed like every time we got an increase in funding and got more staff, we just had more students who wanted services," she recalls. The realization forced her to rethink how the center delivered care. TAO's success has been beyond Benton's expectations: When she compared the outcomes of the center's traditional face-to-face services with TAO's outcomes, the online clients' improvement in well-being and anxiety symptoms was significantly better than those receiving face-to-face therapy.

"It was phenomenal," says Benton, whose study on the results was submitted for journal publication in June. She thinks the program's success is due to how it's integrated into each student's life via smartphones — the technology allows students to do their therapy homework easily, and their counselors can monitor what students do during the week.

"Let's face it, we would all floss our teeth more often if our dentist could check up on us every few days and see if we were flossing," says Benton. She is now working with the school's office of technology and licensing to develop TAO into a commercial product and is investigating a similar prototype to treat substance abuse and depression among college students.

Education and awareness

Counseling centers are also reaching out beyond the therapist's walls in another way: working with faculty to include wellness awareness in their interactions with students.

"Certainly the bread and butter of what counseling centers do is seeing and treating individuals, but there's a significant amount of campus policy, faculty and staff training, consultation, outreach/prevention, and crisis work they provide as well," Douce says.

Data from the AUCCCD survey confirm that counseling centers are getting involved in more and more aspects of the university, says David Reetz, PhD, director of counseling services at Aurora University in the suburbs of Chicago, and one of the survey's lead authors.

The association's data show that a typical counseling center staffer spends about 65 percent of his or her time in direct clinical service, and another 20 percent to 25 percent of time on outreach initiatives, such as training students, faculty and other staff in mental health issues, as well as offering suicide, sexual violence, and drug and alcohol prevention programs, Reetz says.

At Aurora University, for example, in addition to delivering presentations to faculty on ways to detect early signs of student distress, strategies to intervene and techniques for referring them to the appropriate mental health services, Reetz instructs faculty on the best ways to increase student motivation, pulling in concepts from the psychological literature on resilience, growth mindsets and grit. "We're taking psychological concepts that we … have been using in one form or another in the clinical setting and helping faculty think about how they can … infuse these concepts into their curriculum or into creating their classroom climate," Reetz says.

Some counseling centers are beefing up their efforts to help all students understand the importance of mental health. That's essential, since 78 percent of students with mental health problems first receive counseling or support from friends, family or other nonprofessionals, suggests a 2011 study led by Eisenberg (Journal of Nervous and Mental Disease).

One popular alliance among counseling centers and students is Active Minds. The organization's more than 400 student-run chapters throughout the United States support efforts to remove the stigma around mental health issues. For example, the Active Minds' "Send Silence Packing" is a traveling exhibition of 1,100 donated backpacks that represent the number of college students who die by suicide each year. "The backpacks are spread out in a high-traffic area on campus, like the quad, and it's impossible to walk by without taking notice," says Sara Abelson, senior director of programs at Active Minds. "It helps students recognize the need to pay attention, because we all have a role to play in preventing suicide."

Abelson says the organization is also dedicated to championing the idea that student mental health and well-being are central to the mission, purpose and outcomes of every school — and that they need to be a priority.

"I think we're beginning to see more and more universities recognizing that creating a healthy climate and an open dialogue about mental health needs to be a priority," she says. "They're also realizing that it can't just be the responsibility of the counseling center, but that this is relevant across the university, and that everyone from the students to the administration needs to be playing a role."

Amy Novotney is a journalist in Chicago.