Does Going to College Damage Our Kids' Mental Health?

There is considerable disquiet about what seems to be happening to university students' mental health. Reports have appeared in many parts of the media: for example, that university mental health programs are being swamped with clients, that the suicide rate in students is now the second most common cause of death (after road accidents), and that anxiety or depression are now the leading reasons why students seek help from health services, and that depression is at an all-time high for college students. One study puts it as high as 28 percent (this may be an over-estimate). Eating disorders are common, particularly in female students. This is not limited to students in the US—similar reports have appeared from other countries, including the UK. What is happening? Is it true? If so, why is it happening?

The short-term and later consequences of episodes of mental illness in young people are serious. Depression increases the risk for later episodes, and the risk for suicidality. There is a reduction in potential for employment. There is increased misuse of drugs, both prescription and illegal. Friendships and other relationships are imperilled. Educational achievements may be impaired. If the fact of going to University increases the risk for mental disorder, of whatever type, this needs urgent attention. It also might suggest screening of applicants to identify those at high risk of developing an adverse mental state. But before we jump to such conclusions, we need to examine the evidence.

Both in the USA and UK there has been a steady increase in the incidence of mental disorders in young people over the past several decades, irrespective of whether they go to University. Most of this is depression or anxiety, though eating disorders (e.g. anorexia) have also risen. So our first conclusion is that this increase, if it is true, is not limited to universities. There has also been a marked increase in the ability to recognise mental illness, and a willingness to seek help. Public attitudes in the USA and UK have changed; this is not true for all countries. For example, a recent study showed that Vietnamese tended to believe that individuals with mental illness were dangerous and needed to be kept out of the community, while Americans perceived mental illnesses as being the same as other illnesses. So at least some of the apparent increase may well be the result of improved recognition, rather than prevalence. The definition of mental illness (eg depression) has also changed over the years. For example, the most recent editions of DSM (Diagnostic and Statistical Manual) of the American Psychiatric Association and ICD (International Classification of Disease) have altered their definitions – and they do not entirely agree! The point here is that how a disease is defined will affect its apparent prevalence. So how much of the apparent increase is due to definition rather than true pathology? It is important to remember that definitions of mental disorders rely entirely on symptoms: there are no blood tests, X-rays, scans etc that are diagnostic, in contrast to most other areas of medicine (e.g. neurology). History shows that diagnosis that depends entirely on symptoms lacks accuracy. The precision of diagnosing heart disorders, for example, has been vastly improved by such techniques as ECG, angiograms and various blood tests; nothing like this is available to psychiatrists. So we might argue that at least some of the apparent increase in mental disorders results from changed, or even inaccurate, diagnosis. Are the goal-posts where they were 20 or more years ago? Arguing about what constitutes a mental illness is hardly new: it was a vigorous topic in the 1960s (remember R.D. Laing?).

Despite all this, there are valid reasons why going to University might well present a risk for mental disorders, or adverse reactions, is some students. Stress, particularly that which is perceived as a loss and as uncontrollable (so-called negative ‘life-event’) is a prequel to most first episodes of depression and eating disorder. It’s important to recognise that the reverse is not true: most people experiencing such events do not become depressed or anorexic. So individual vulnerability to stress is important. Students most commonly become depressed in their first year: when they are likely to experience being away from home for the first time, are exposed to a new and competitive environment (students compete not only intellectually but also socially), and are exposed to teaching methods very different from their school—often more demanding but also more impersonal - which may have detrimental effects on their self-esteem, self-liking and feelings of competence. Many Universities now recognise that students need social and personal support, particularly in their first year. Some Universities, such as Cambridge, use much small-group teaching (which is expensive); this not only increases personal contact with staff but also allows earlier recognition of problems which might not be otherwise volunteered. We are beginning to define environmental factors that may predispose to adverse mental reactions to stress. Interestingly, they are not always what one might expect: for example, a study in Syria showed that, whilst psychological disorders were very common in University students (as one might expect), surprisingly they were not related to the on-going war with all its horror, but rather to financial problems (often the result of the war).

We are getting better at identifying those who might be at higher risk: there are particular genetic variants which, together with early life experience (eg adversity or even abuse) and current social and educational contexts (levels of demand, ability to cope etc), and even physiological reactions, such as levels of the stress hormone cortisol, that may one day allow us to identify more precisely those whose time at University might be blighted by mental illness. So we could target support or other interventions. There have been a number of attempts set up intervention programs to try and head off mental disorders in University students. They have focussed mostly on online techniques for advice or guidance, or attempts to modify teaching methods. The results, so far, have not been very impressive. The bottom line is that we need to do everything we can to reduce the cost/benefit ratio of going to University. It ought to be a glorious and memorable time for any young person. It can be ruined by a bout of mental illness.