Crisis on the Campus

Ten or so years ago, college counseling centers were pleasant little side channels of the mental health system, helping students cope with roommate conflict and adjustment to college. No more.

Today they are the newest front line in the war against mental illness, struggling to manage swarms of students with serious depression and anxiety disorders. And generally facing a growing demand for their services in a world of shrinking resources.

The middle of the night may find a SWAT team of counselors calming down a dorm wing after having crisis-managed an acute manic episode or yet another incident of self-mutilation. Morning will certainly find the staff administering psychotherapy to students struggling to overcome histories of trauma such as childhood sexual abuse, relationship problems including date violence, and that dormitory staple, eating disorders.

Did we mention substance abuse? Attention deficit disorders and learning disabilities? At one elite institution, 10% of students report problems with binge drinking.

Rare is the college that has not experienced a student suicide. A 10,000-student campus can expect one student suicide a year. That doesn't count all the highly disturbing attempts.

Hospitalization, a court of last resort, is commonplace. Eighty-nine percent of counseling centers hospitalized at least one student in 2001; one hospitalized 80. On one 5,000-student campus where most students are commuters, three to six students are typically hospitalized a semester, primarily for suicidal gestures and first psychotic breaks.

In 2001, 85% of North America's student counseling centers reported an increase in "students with severe psychological problems" over the past five years. Thirty percent of them had a student suicide; 60% of them dealt with obsessive pursuit cases (50 persons injured, five killed).

"Every director of every college counseling center is reporting more hospitalizations, more serious problems, and taking care of sicker students," says Richard Kadison, M.D., a psychiatrist who heads Harvard University Health Services and its counseling center. The severity of students' mental health problems has been rising since 1988, reports psychologist Robert Gallagher, Ph.D., of the University of Pittsburgh, who each year surveys directors of college counseling centers.

"The world isn't getting crazier," observes Pamela L. Graesser, M.Ed., director of counseling at Rivier College, a small Catholic college in New Hampshire whose students are primarily from blue-collar families. "College is just getting more like the real world around it." College is simply available to more people than it used to be. The problems Graesser saw 12 years ago when she worked in a psychiatric hospital "are the same ones I now see on campus."

"We are probably seeing the true prevalence of mental disorders," observes psychiatrist Morton Silverman, M.D., head of counseling services at the University of Chicago. "There is not as much surveillance in the outside world."

Then too, he says, "we are the beneficiaries of our own successes."

Call it the Prozac payoff. Colleges are reeling from the number of students arriving already on antidepressant and other medication and requiring psychiatric monitoring. A decade of improved drugs has encouraged earlier diagnosis.

Early treatment of depression—along with institutional accommodation of disability—has enabled students to stay in the academic system who in other eras might not have made it to college, or would have dropped out after a semester or drifted into community colleges. Today they are attending the nation's elite institutions, where academic, living and developmental demands sometimes overwhelm the coping skills they have yet to acquire.

"Many who wouldn't have gotten to an elite college before are getting here because they were treated when younger," observes Harvard's Dr. Kadison. "They need ongoing, intensive care," which not every school has the resources to supply. Many students fall apart given the looser environment, erratic sleeping patterns and added stresses of college.

Many others experience their first onset of disorder. There is the indisputable fact that age 18 to 25 is prime time for eruption of mental illness, making college, with its concentration of 18- to 25-year-olds, the prime place. Increasingly, mental health professionals recognize that depression, anxiety disorders, bipolar illness, personality disorders and schizophrenia are conditions that first arise in young adulthood. Catching them quickly is critical, as early management strongly influences how they play out over adulthood.

And so it is that increasingly, colleges are the first best hope for rescuing the minds of America's future. But what no one ever imagined is that colleges would also find themselves the last best hope of mental health care in America.

April is the cruelest month. College counseling centers really feel the crunch.

Students who put off counseling suddenly realize they're going home soon. "They're going back to the situation that made them crazy in the first place, or back to the abuser," reports Rivier's Graesser. Seniors flock in with anxieties about confronting the real world.

And there's a whole new rite of spring. It starts just after college acceptance letters go out. Parents call the counseling centers at the schools where their offspring have been accepted. "They say 'my son or daughter has a serious eating disorder' or 'has been hospitalized for depression; what can you do to support them?'" reports Mark H. Reed, M.D., counseling director at Dartmouth. They're footing the bill; access to mental health care is now one of the factors they weigh before writing a check.

In addition to handling more cases of depression diagnosed pre-college, counselors find that they are picking up many more new cases of depression in college. "There are increases in both undergraduate and graduate students carrying a diagnosis," reports Chicago's Dr. Silverman.

"More students are coming to college predisposed to developing depression," he observes. There are more students with a family history of the disorder. And there are many more students with prior sexual and physical abuse, both of which increase the risk for depression. "The incidence of sexual and physical abuse was on the rise 10 years ago," he says, "and that generation is now coming to college."

Some students come in knowing that their concentration is off and that they are withdrawn. "Still, they don't put the cluster together and recognize that they have depression," says Harvard's Dr. Kadison. And half of those students presenting with depression have moderate to severe illness, reports psychologist Joseph M. Behan, Ph.D., head of counseling services at the School of the Art Institute of Chicago.

However, students are increasingly willing to talk about depression once they get on campus. And the general destigmatization of mental illness encourages them to seek help. Many have looked forward to college as a place where they could be free to get the help their families discouraged—or made necessary in the first place.

Remnants of stigmatization drive problems, too. Although many students come to college openly declaring experience with depression or bipolar disorder, large numbers do not make it known—until a crisis erupts. Dartmouth's Dr. Reed worries "most about the students we don't see."

Cases of moderate to severe depression are rising also because depression often co-occurs with other problems—alcohol and drug abuse; personality, eating and anxiety disorders. "We're seeing more depression because more other disorders are arriving and present as depression," explains Dr. Silverman.

Most college counseling directors confess to being surprised by the number of students turning out to have bipolar disorder. It typically presents dramatically, with an acute manic episode. "We are seeing more first episodes of mania every year," Dr. Silverman reports. "It's very disruptive. It generally means hospitalization for the student. The number of hospitalizations is going up each year, and the percentage attributable to bipolar disorder has risen."

The boom in bipolar disorder may in part be the outgrowth of wanton diagnosis of attention deficit disorder in schoolchildren. "It's difficult to tell the difference between ADD and BPD in kids," says Dr. Reed. "Lots of ADD turns out to be bipolar disorder."

The trouble is, the kinds of stimulants that work for ADD, not to mention caffeine, are precisely wrong for bipolar illness and can trigger a manic episode. "The first manic episode is related to a stressor, such as sleep deprivation," Dr. Reed explains. "Almost always some substance is also on board." He believes it is often an attempt by a student at self-medication.

Since depression is the single biggest risk factor for suicide, and since the severity of mental problems on campus is increasing, it might be expected that the number of campus suicides would be skyrocketing. But that is not the case, although a few highly publicized incidents at Harvard and MIT have fostered a general perception that ivory towers are for jumping.

It is more likely that the social structure of college protects people in some way and that colleges are doing a good job of keeping suicide attempts from being successful. The suicide rate is actually lower on campus than among same-age people outside.

"Suicide is not a good marker for the rise in mental disorders in colleges," insists Dr. Silverman. "Every suicide is a personal tragedy. But it's not a reflection on university policies or procedures."

Every suicide is also enormously disruptive to an entire campus. So counseling centers make a big effort to prevent problems by reaching out to students with programs of information. "We're no longer just mental health professionals," says Dr. Kadison. "We're marketing directors, trying to figure out how to connect with students who might need our services."

The only problem is, outreach programs, such as after 9/11, work too well. Where Harvard's mental health service was seeing 240 new cases a week in January 2001, it was up to 280 a week in January 2002.

MIT is still reeling from a 2000 suicide when a young woman a month from her baccalaureate and entering a graduate program died by apparent self-immolation in a campus dorm. Her family is suing the university, on the grounds that parents should be notified if a student is suicidal.

"We can't do that," says Dr. Kadison. The trust that help-seeking will be kept confidential, often particularly from their families, is what encourages students to come in in the first place. "The students are adults at age 18. We are all seeing suicidal students. We'd just be a switchboard calling families all the time."