This letter was sent by APA members to the Chronicle of Higher Education in response to an article that expressed concern regarding the overmedication of young people.

Too Much at Stake: Let's Not Ignore or Dismiss Serious Mental Illness in Young People

We felt compelled to respond to a recent Chronicle "Observer" piece entitled "Let's Not Medicate Away Student Angst." Speaking respectively as a researcher who has done a great deal of work on the changes in counseling center client problems over the past decade and as Chair-elect of the College and University Counseling Centers section of the Society for Counseling Psychology, a division of the American Psychological Association, we believe that one must be mindful and understanding of the difference between "teenage angst" and the very real diagnosis of depression and other serious mental illness.

Some of the observations made by the author, Joli Jensen, a professor of communications at the University of Tulsa, do appear to make sense. Certainly, since the development of the Selective Serotonin Reuptake Inhibitors, a class of antidepressant medications with less side effects than older generations, the use of anti-depressants has risen. Many studies suggest that the numbers of students who are identified with anxiety and depression have risen as well. One possible explanation for these increases is that as mental health and health care professionals we have come to diagnose and recommend medication more than in the past. The other possible explanation is that rates of anxiety and depression have truly risen among college students. It is also possible that the truth lies in some combination of the two.

For example, a recently completed study at Kansas State University, which one of us co-authored, ("Changes in Counseling Center Client Problems Across 13 Years," Benton, Robertson, Tseng, Newton, & Benton, 2003) sheds some light on this issue. Our data indicated that over the 13 (now 14) years of the study, annual rates of anxiety and depression more than doubled. However, since our data came from the perspective of the therapist at the time of case termination, it is possible that we had become more in tune to diagnosing and simply over identified these disorders. Yet, not all mental health issues increased across time in our data. For example, even though we spent many hours in in-service training on substance abuse and eating disorders over the years of the study, these two problem areas did not increase at all over the 14 years. If we were over identifying problem areas generally, one would expect a consistent pattern across diagnostic categories. Since this was not the case, actual increases in problems was the more parsimonious explanation for the patterns we observed, particularly in the areas of anxiety, depression, and suicidal thought and intent. With that in mind, it is important to note that we have observed small increases in completed suicides over the past 8 years as well.

Thus, while it is quite possible that more physicians feel comfortable prescribing SSRI's than the old tricyclics, this does not explain many of the increases we are seeing in counseling services where the primary mode of treatment is psychotherapy rather than medication. Moreover, there is a marked lack of good epidemiological studies of mental health problems in college students over the past 20 years. As of now, NIMH has no funded grants to study college student mental health. In the absence of good epidemiological research, it is difficult to determine what might be happening among college students overall.

If one perceives the distress of college students as normal and developmental, it would make sense that medication would be overkill. Yet, in general, the college instructor sees only a limited sample of a student's behavior, while there can be a lot more going on behind the scenes. For example, the subdued behavior of the student used as an example in Jensen's article could be symptomatic of depression, rather than a possible side effect of the medication. And, while medication is sometimes overused, there is also a great risk that treatment (psychotherapy or medication) is actually underutilized. The side effects of that, which can include impaired performance, emotional disturbance, substance abuse and suicide attempts, can be quite severe.

Fortunately, many campuses do have centers that provide counseling and mental health services to students and do offer various forms of treatment. And, even though medication is an adjunct form of treatment at many universities, it is far from being the exclusive or even primary form of treatment at most. Individual therapy in different modalities, group therapy, support groups, peer counseling, and psychoeducational outreach, offer forms of treatment that do not rely on medication. By in large, counseling center staff are well trained and equipped to help students with their concerns. And, like a good education, these approaches challenge the students to question their assumptions and misperceptions in order to make sense of their lives.

So, what should be done to assist those centers on campus so they can better meet the very real needs of a growing pool of students who are seeking various levels of counseling and support? What can be done to reach out to those that may have need for mental health services, but for a variety of reasons have, not sought help?

The American Psychological Association has recommended that Congress and the Administration include a program in the upcoming reauthorization of the Higher Education Act that provides support to counseling centers on campus that provide mental health services to students. The federal government's role in addressing this problem is clear. Without the support and guidance provided by centers on campus that provide mental health services to students, many of these students will be at greater risk of school failure. A Chronicle story from last year reported that depression among freshmen has risen from 8.2% to 16. 3%. (February 1, 2002). Suicide is the third leading cause of death among 10-24 year olds. (NIMH Suicide Fact Sheet, 2000). In addition to treating student's mental illness, psychologists and other counselors on campus focus on the prevention and treatment of excessive drinking and other behavioral health problems that have an impact on college completion rates. According to the National Institute of Alcohol Abuse and Alcoholism (NIAAA) Fact Sheet on the Risks of College Drinking (2002), 1400 college students die each year from alcohol-related injuries. NIAAA also noted that college students who drink are more likely to assault, sexually abuse, and vandalize others. And finally, NIAA includes this fact, "About 25 percent of college students report academic consequences of their drinking including missing class, falling behind, doing poorly on exams or papers, and receiving lower grades overall (Engs et al., 1996; Presley et al., 1996a, 1996b; Wechsler et al., 2002)."

Clearly, mental and behavioral health issues are underlying factors related to a student's ability to succeed in and complete college. Consequently, in addition to efforts to encourage greater retention and better graduation rates, the federal government should support centers on campus that provide mental health services and identify needs of our nation's college students. This comparatively small investment would make a big difference in the lives of our children - the Nation's next generation.

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