Depression on College Campuses — The Downside of Higher Education
By Jennifer Sisk, MA
Social Work Today
Vol. 6 No. 5 P. 17

Campus life is not all new friends, parties, and pizza. Many students struggling with major stressors in an unfamiliar environment succumb to depression.

A lawsuit is filed against the Massachusetts Institute of Technology and some of its staff by the parents of a student who committed suicide. George Washington University suspends a student and bans him from campus after he seeks medical help for depression and suicidal thoughts. Many colleges may require students seeking help at counseling centers to sign waivers that would allow confidential medical information to be shared with administrators.

Recent headlines reflect the increasing prevalence of depression among college students and the importance of on-campus support services. Social workers, psychologists, and other mental health professionals who work with college students are responding to the growing mental health needs of this population.

Staggering Statistics
College-aged students are more likely to experience depression than other age groups, according to published studies, statistics from mental health organizations, and observations by social workers and other professionals working with the college population. The 2005 National College Health Assessment (NCHA), a survey of nearly 17,000 college students conducted by the American College Health Association, revealed that 25% reported they “felt so depressed it was difficult to function” three to eight times during the past year and 21% reported they “seriously considered suicide” one or more times during the past year. In the NCHA survey, students also ranked depression as one of the top 10 impediments to academic performance.

“Depression has always been the No. 1 problem here,” says Tom Morson, LMSW, MSW, ACSW, in counseling and psychological services at the University of Michigan. At the university counseling center, approximately 67% of students showed symptoms of depression, according to recently collected data from intake forms on which students rank their reasons for seeking counseling.

Depression is the second major reason students visit the counseling office at Bentley College, a small Massachusetts business school, according to Angela Guerrero, MSW, LICSW, a counselor and minority liaison. “Once the newness of college wears off in the first year, depression often occurs in the second year,” she observes.

Mary Anne Knapp, MSW, LCSW, senior staff therapist at Penn State University’s (PSU) Center for Counseling & Psychological Services, reports that roughly one third of students who visit the center each year have a depression diagnosis beyond that associated with adjustment issues. A 2003 PSU Health Services student survey found that 42% of students said they were depressed at least once during the past year and 10% reported seriously considering suicide. Knapp also observes that while individual students’ symptoms of depression remain similar from year to year, more students each year come to the counseling center for depression treatment.

Prentiss Price, PhD, staff counseling psychologist in the Counseling and Career Development Center at Georgia Southern University, says, “Depression ranks third after academics and anxiety as one of the major problems students indicate on our intake information forms.”

She cited a recently published study conducted at a large Midwestern college counseling center that reported the number of students seen with depression doubled from 1989 to 2001 and the number seen with suicidal ideation or intentions tripled (Benton et al., 2003). “The depression and suicide statistics are staggering,” she says.

The 2005 National Survey of Counseling Center Directors (Gallagher et al., 2005) revealed that 27% of the responding schools had at least one student commit suicide during the 2004-2005 academic year. The National Mental Health Association lists suicide as the second-leading cause of death among college students.

Common Causes
Depression and suicide are more common in the college population, in part, because college brings new stresses, including increased academic demands, challenges of living independently for the first time, financial responsibilities, changes in social and sexual identity, and different types of peer pressure. For new students, more difficult college academics can be a primary factor in depression. Guerrero notes that many new students encounter academic failure for the first time in college, which can contribute to depression. Price says, “A confluence of factors may underlie depression in the typical college student.” In addition to academics, she cites problems with friends and family, academics, a crisis event (eg, sexual assault), and/or a specific situation (eg, social isolation) as typical causative factors.

Guerrero believes separation from family for the first time can contribute to depression for many students. Morson agrees: “Transitioning from home environment to college life—and for international students, from home country—creates stress and anxiety that can result in depression.”

According to Guerrero, at Bentley College, where approximately 10% of the students are from outside the United States, the transition from home to college is especially stressful and “culture shock” may contribute to depression. “International students have different stresses—they may have difficulties with American food, the climate, religion, politics, and society. These cultural differences, in combination with being so very far from their home and family, can lead to depression,” she says. Guerrero adds that multiethnic American students may have to confront similar challenges if they attend an institution with a primarily Caucasian population. “Having a campus multicultural center for supporting multiethnic students may be pivotal for their success,” she notes.

In her 20-plus years as a college social worker, Knapp has observed that while depression in students often is related to new external pressures and stresses associated with college life, “internal factors,” or biological and emotional conditions, also play a role. When counseling students at PSU, she evaluates the interaction between these external triggers and internal factors. “For students with a genetic predisposition to depression or bipolar disorder, symptoms may emerge for the first time during the college years,” Knapp says. In some cases, self-esteem or sexual identity issues, or another condition, such as an eating disorder, can predispose a student to developing depression.

“The majority of our student visits to the counseling office result from relationship issues,” Guerrero notes. “Students are trying to figure out where they fit in socially in the new college environment.”

Unrealistic expectations of students and their parents can also lead to depression. “I think this emphasis on self-perfection that our society has really contributes to depression in college students,” says Morson. “Many students have an ‘all-or-nothing’ mentality, not only about academics but also physical attractiveness and wealth,” he adds. Such perfectionistic thinking, coupled with high expectations from parents, adds to the stress of college life.

When expectations do not mesh with reality, students feel stressed, and many are unable to cope with stress that can quickly become overwhelming. “Many students lack the coping skills to handle the new demands of college life,” says Guerrero. Such overwhelming stress, when not managed appropriately, can ultimately lead to depression, according to Knapp and Price. It is the job of the psychologist or social worker to help students manage stress and identify depression. “A student may not even know he or she is depressed,” Price has observed.

Guerrero recently helped one senior student, a working mother, recognize that she was depressed by helping her distinguish symptoms of depression, which the student had been attributing to her busy family, work, and school lives.

Drinking and drug use—common at many college parties—are often a response to stress and can also confuse the diagnosis of depression. “Drug and alcohol abuse can mask depression in many students,” Guerrero says. Some students respond to stress and depression by using and abusing alcohol and drugs—self-medication. However, such behavior is often overlooked as a symptom or consequence of depression because it is viewed simply as partying, a typical college behavior. “When we assess a student, we must distinguish clinical depression from acute stress,” Price says. Acute stress caused, for example, by impending academic tests, may dissipate after the tests are taken, and the student may return to a stable emotional state. Students with clinical depression, on the other hand, often report vague somatic or emotional problems, sleeping problems, loss of appetite, and substance abuse problems.

Multifaceted Student Services
Because every student is unique and the roots of depression vary, counseling services must be multifaceted and the service providers must be multidisciplinary. Knapp, who refers to herself and other social workers and therapists in her center as “mental health generalists,” says, “We really act as a multifaceted resource for students, with duties that range from counseling to service brokering to advocating with parents, insurance companies, or the university.” At PSU, four social workers along with several psychologists and counselors provide counseling and support for 42,000 students. The multidisciplinary staff performs initial assessment, crisis assessment and intervention, individual and couples counseling, and group therapy.

For a student with depression, a typical intervention is preceded by an assessment of contributing factors, discussion of treatment options, and ruling out any physical causes, Knapp says. Once the depression is diagnosed and clarified, she says, the best intervention strategy for the student is planned and may include short-term individual therapy or longer-term group therapy at the counseling center. This therapy may involve helping students understand and work through the impact of trauma as well as focusing on cognitive behavioral strategies and interpersonal interventions. “We also act as gatekeepers to psychiatric services,” says Knapp. At PSU, students requiring evaluation for psychiatric medications such as antidepressants can be referred to a general physician in the health center, to one of two counseling center psychiatric providers, or to private or community agency psychiatrists, especially if they require long-term intervention.

Guerrero, the only social worker on a team of five professional providers, primarily serves as a counselor, helping students find solutions to problems and providing support. “Depending on students’ needs, I may help them with social skills, listen to and explore feelings, and provide encouragement,” Guerrero says. For some students who come to counseling with feelings of depression, simply acknowledging that they are homesick and lonely can lead to an improvement. In such cases, Guerrero encourages students to become more “connected” with the college community, rather than with friends from home, and helps them identify and join campus activities of interest.

Morson works in a multidisciplinary department that includes social workers, psychologists, and psychiatrists. He was a speaker at the University of Michigan’s 2006 Depression on College Campuses Conference, which focused on critical incidents and crises as they present on college campuses. While there is always a relatively high level of depression among students, he says, just within the past few years, depression following a reaction to community violence and tragedy, such as September 11 and Hurricane Katrina, has increased, he believes. Last year, he and his colleagues provided support for many transfer students relocated from New Orleans in the aftermath of Hurricane Katrina. “Their counseling needs were much different from those of other students, given the recent tragedy they experienced,” says Morson.

The Freshman Depression
The many stresses of college life and the emergence of biologically predisposed mental health conditions do result in newly diagnosed depression during the college years. However, many students will also bring a diagnosis of depression with them when they start their freshman year. Knapp notes, “We are really seeing more freshmen entering college already with a diagnosis of depression.” Morson estimates that 30% to 40% of students seen at the University of Michigan counseling center are already taking antidepressant medications. He attributes this to an overall greater acceptance of antidepressant medication use in society today, in part, due to the increased prominence of the pharmaceutical industry.

Interestingly, Guerrero says, college can actually be positive for some students who previously have been depressed. “College offers an opportunity to redefine self-image, become involved in new activities, and make new friends, leaving negative factors from the home and high school environments behind them,” she says. However, for students with clinical depression, this response is rare, and campus counseling services must be able to handle incoming students with diagnosed clinical depression so their treatment is not interrupted.

A report by the University of Michigan Mental Health Work Group concluded that “colleges and universities have experienced increasing enrollment of students with pre-existing mental illness, and concurrently, the number of students with more complex and severe mental health problems has increased.” Guerrero has also observed that medications may allow adolescents who may never have been able to attend college before to do so now. “With the advent of psychiatric medications, we now have more kids with mental illnesses and on medication on campus than in the past,” says Guerrero.

This increased need for depression treatment monitoring has led to many centers “beefing up” the level of psychiatric services provided on campus. According to Guerrero, due to the number of students requiring psychiatric intervention for depression and other mental health issues, Bentley College recently had to increase the frequency of psychiatric services. It now has a psychiatrist on site once weekly, allowing medication services to be offered at the counseling office. “Weekly on-site psychiatric services, along with our policy of unlimited counseling visits, really makes a difference in treatment and medication compliance for the students,” Guerrero notes.

Morson has also noticed this trend in changes to counseling center services since he was hired as the first campus social worker in 1978. “We aren’t just about intervention and response to diagnosis. Now, we have to be able to diagnose and treat, and we’ve had to add psychiatrists to our staff,” he says.

However, even though on-campus services have grown, counseling centers are limited in the extent of services that support students with depression, especially at larger universities. At PSU, even though staffing has increased over the years, Knapp notes, “there are still limits to the amount of services that can realistically be provided to any one student.”

Many, if not most, universities have session limits and refer students to private or community providers if they need long-term care, she says. It’s not possible with the available resources to see every student who may need weekly or twice weekly sessions throughout his or her college career. Caseloads would be full and it would be impossible to absorb new students in crisis. Often, this means that for students who have preexisting conditions and access to insurance and/or parental involvement, the best plan involves crisis stabilization and helping the student find a good match in a private psychiatrist and therapist rather than beginning services on campus, Knapp explains.

Guerrero has also noticed an increased need for more interaction between parents and counseling center staff compared with past years. “Parents have more contact now with us than ever before. Many parents even refer their kids to counseling. In fact, now, the parents may visit our office or meet a counselor first before we even see their child,” she says.

At the University of Michigan, social workers now run parent orientation programs, according to Morson. “Because more students are entering college already with depression, and perhaps even suicidal ideation, we now have parent orientation programs about counseling services available,” he says.

Efforts to increase student awareness of depression have also occurred. At Georgia Southern University, Price and her colleagues have organized campus outreach programs for depression, including a depression screening day every October, online mental health screening tests, and screening opportunities in the college’s student union building. “To avoid the negative association with the word depression that may prevent students from taking advantage of this screening, we call it an emotional awareness event,” Price explains. “Campus organizations can also request programs from us on depression, suicide prevention, and stress management,” she says.

According to Morson, the University of Michigan also has an online depression center with student self-assessments on substance abuse and depression.

Despite the increased number of individuals with depression and other mental health issues, there is still a stigma attached to such disorders, and college students may be afraid of reactions from friends and families if they admit to being depressed by seeking treatment. Guerrero says, “Many times students have told me during our first session that they did not come to me for help sooner because they felt it was proof that they were weak and unable to deal with their own problems.”

Now, based on the recent controversial response of some college administrations to depression and campus suicides, students may even be motivated to deny or hide symptoms of depression, fearing repercussions from college officials in addition to social rejection. Price says, “It is alarming that a large majority of students who commit suicide have never come into contact with their campus counseling services.”

Given the growing numbers of students entering college already diagnosed with depression or other mood disorders, the implementation of policies perceived as punishing students for seeking help is a disturbing trend in college administration. Such policies go against the “don’t be afraid to seek help” messages conveyed by campus counseling centers and their outreach programs and impede the important progress in depression awareness among college students that college social workers and psychologists have advocated over the past several years.

— Jennifer Sisk, MA, is a suburban Philadelphia-based freelance writer with 15 years of experience as a writer and a research analyst in the healthcare field. She has written on depression, attention-deficit/hyperactivity disorder, schizophrenia, mental wellness, and aging.

References
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Benton, S. A., Robertson, J. M., Tseng, W. C., Newton, F. B., & Benton, S. L. (2003). Changes in counseling center client problems across 13 years. Professional Psychology: Research and Practice, 34, 66-72.

Gallagher, R. P., Weaver-Graham, W., Taylor, R. (2005). National Survey of Counseling Center Directors, 2005. Alexandria, VA: International Association of Counseling Centers, Inc.

Guerrero, A. Depression—How Social Workers Help: Depression in the College Population. Retrieved from http://www.helpstartshere.com.

Voelker, R. (2003). Mounting Student Depression Taxing Campus Mental Health Services. JAMA, 289, 2055-2056.