Podcast: College Student Mental Health 101

Jeff talks to Dr. Sarah Ketchen Lipson about common mental health concerns for college students and they discuss tips for recognizing and addressing these challenges and the conditions they can lead to. Jeff also asks Sarah some audience questions about typical campus resources for students who are struggling.

Sarah Ketchen Lipson, PhD, EdM, is an associate professor in the Department of Health Law, Policy, and Management at the Boston University School of Public Health and Principal Investigator of the Healthy Minds Network. Her research focuses on mental health and service utilization in college populations.

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Jeff: Welcome, and thanks for joining us. My name is Jeff Bell, and on behalf of McLean Hospital, I’d like to pass along our sincere appreciation, for your interest in our educational webinar series.

Our topic today, college student mental health. And our goal is twofold. First, to explore the state of mental health in higher education, and second, to provide a roadmap for navigating the mental and emotional challenges of campus life.

We’ll look at common mental health concerns for college students, typical campus resources available to students who are struggling, and public health approaches to promoting mental health in higher education.

For help with all that, we are joined by a leading expert in this field, Dr. Sarah Ketchen Lipson is an associate professor in the Department of Health Law Policy and Management at the Boston University School of Public Health.

She’s also Principal Investigator of the Healthy Minds Network, which includes the Healthy Minds Study, a sweeping survey of mental health in higher education. Sarah, thanks so much for making time for this conversation today.

Sarah: Absolutely, thanks for having me.

Jeff: Well before we dive in too deeply, in the topic matter itself, I want to ask you a little bit about your background and specifically what brought you to this work, and maybe tell us a little bit more about Healthy Minds as well.

Sarah: Yes, so I was kind of on the path of being a higher education administrator and just was really just loved the world of kind of student life, student affairs. And so, while I was getting a master’s degree in higher education, I worked in the equivalent role of like a residence hall director.

And that experience of working in residence life, really opened my eyes to the prevalence of mental health problems in student populations, and just how much mental health was affecting really every aspect of students’ daily lives.

And I think also from that experience, I was able to really see a disconnect between the campus mental health system and the resources that were available to students and the ways that students were navigating their daily lives, and sort of how those were two separate things.

And it requires a lot of proactive outreach on the part of students at the time to access mental health services. So, I became really interested in student mental health, wondered if what I had seen at one institution had kind of been an outlier.

This was about 15 years ago, wondering if my experience had been an outlier or if the problems were prevalent across institutions. And then while I was doing my PhD, I started kind of looking into sources of data on student mental health.

And there was very limited data at the time. And so, my colleague Daniel Eisenberg and I, started the Healthy Minds Network, which as you said, includes the Healthy Minds Study. And that’s been going on for since about 2007.

And we’ve done this study, it’s an online survey and we’ve done the survey now at over 800 colleges and universities, including community colleges, minority-serving institutions. So, all types of institutions are open to enroll in the study.

It’s been really exciting to see a growing kind of diversity of the institutional sample as we’ve expanded. So, the Healthy Minds Study has been going strong for many years and we collect data every semester at colleges and universities across the country.

Jeff: It’s an amazing initiative. And I want to talk more about the research and some of your findings here, but first, let’s talk a little bit about the college experience and why it is such a critical time for the development of good mental health for college students.

Sarah: Yeah, I’m glad that we’re having this conversation at this time because the academic year is starting at a lot of colleges and universities right now. So even if this is not new information, what I’m about to say, I think it’s a good reminder at this moment in the academic year.

So, I’ll share some of the reasons why college populations are so important and kind of why there are unique opportunities to promote mental health in college populations. So, one, epidemiologically, it’s the age of onset for lifetime mental health problems. About 75% of lifetime mental health problems will first onset by around age 24 or age 25.

So, the traditional college years really coincide with that epidemiological vulnerability. And, which is not to say that there’s an increasing number of students coming to college with preexisting mental health problems, or who’ve already received mental health treatment in their lifetime.

But it’s also a time when a lot of new problems will onset. It’s also a time of newfound autonomy and independence, particularly if we’re thinking about students who are living away from home, many of them for the very first time.

And we can think about that transition to college as changing pretty much all of the key health behaviors. So, suddenly you’re responsible for when you eat, when you sleep, all of those health behaviors.

Your peer networks change, and that newfound autonomy presents an opportunity, for positive decision-making and good pattern-setting with the right resources, education, and support. Or it can be a really vulnerable time as well. So, yeah, go ahead.

Jeff: I was just going to say there are also some unique opportunities that the college campus experience affords students.

Sarah: Yeah, that’s exactly what I was going to say. So, depending on the definition that we’re using of kind of post-secondary education, it’s at least half of every birth cohort, is going into colleges and universities in the United States.

So, about half of all adolescents and young adults are going, so first of all, college provides access to a large proportion of all adolescents and young adults. And again, that’s a vulnerable time for the onset of mental health problems.

So, college settings provide access to a large proportion. College settings are also very unique in terms of the rich network of human resources that exist. There are of course peers, there’s staff, there’s faculty, there are so many units across campus that students are interacting with, and all of those pathways.

And I think we’ll talk about some of these, specific pathways on campus. We can think about athletics, there’s a lot of opportunities to identify someone, a student-athlete who’s struggling with their mental health through pathways of athletics, trainers, coaches, and teammates.

On the academic side, there are all these different ways to try to identify students who might be struggling—connect them to resources. And probably just as importantly, all of those pathways, all of those rich human resources and networks, provide opportunities to promote positive mental health and well-being as well.

So, it’s not just about reducing the problems or treating the crisis. It’s also about using this really unique environment where students have such rich academic lives and oftentimes really rich extracurricular lives to think about how well-being can be prioritized in all of those settings.

And then the last thing I’ll say is, and this is I think just for those of you who kind of appreciate, a more like sociological perspective on this, there’s a concept of a total institution, and it’s a place basically where every aspect of a person’s daily life would be encompassed within that institution that they’re affiliated with.

Prisons are commonly referred to as an example of a total institution. Obviously a very, very different setting than higher education, but maybe helpful for understanding the concept.

So, at colleges and universities, particularly students who are living on campus, it’s where they’re living, it’s where their jobs are as students, and oftentimes jobs that they’re getting paid for, it’s where their peer networks are, it’s where they’re oftentimes accessing health insurance and health services.

And all of those aspects of daily life are shaped by college policies and programs and investments. And again, mental health is increasingly a priority at that really structural level at the institution.

Jeff: Help us understand the scope of the problem. And I know you’re the right person to ask this question of, because you’ve been doing so much research over the years through Healthy Minds and through your own work.

What should we know about the prevalence of mental health challenges at colleges and universities?

Sarah: Yeah, I’ll say a bunch of things that I think are important to understand this, but just let me know if you have other, specific questions that you want me to touch on related to the state of mental health and kind of prevalence.

So, the short version is that we’ve seen significant increase in the prevalence of mental health symptoms. So, I’ll be talking about symptoms, not diagnoses, but symptoms based on screening tools.

So, in Healthy Minds, we have a nine-item screening tool for depression and a seven-item screening tool for anxiety, for example. And so, we’ve seen over the last five to 10 years, and particularly over the last seven or eight years, a really significant increase in the prevalence of mental health problems.

A lot of folks might think maybe the problems really spiked during the pandemic. And we can talk about a few indicators that did uniquely change during the pandemic. But when we talk about prevalence of symptoms, what we saw throughout the pandemic was really a continuation of a troubling trend as opposed to a unique spike in prevalence.

So, when we started doing Healthy Minds and really having, large-scale national data, because the first few years were a little bit smaller sample sizes. So, thinking to around 2010, 2011, and comparing that to about 2023, we’ve seen about 130% increase in the prevalence of depression, about 110% increase in the prevalence of anxiety.

A tiny bit of good news is that this past academic year, we actually saw a slight decrease in depression and anxiety relative to 2021, 2022. So, in the 2022, 2023 academic years, the most recent year of national survey data from Healthy Minds, 41% of students screened positive for clinically significant symptoms of major depression.

So just over four in 10 students on that patient health questionnaire, nine measure scoring 10 or above, so four out of 10 students for depression. And again, that’s a significant increase since about 2016, but a little bit lower, it was about 43% in 21, 22.

For anxiety, over a third of students this past academic year, 36% screened positive on the generalized anxiety disorder seven scale. Again, a score of 10 or more on that. One of the most concerning measures that we have relates to suicidal ideation. So, we ask students if they’ve seriously considered attempting suicide in the past year.

And when we first had that measure in our survey in 2007, in the very beginning, the very first year, 6% of students indicated that they’d seriously thought about attempting suicide in the past year, which still 6% is, you know, very worrisome.

In 22, 23, 14% of students reported seriously considering attempting suicide in the past year. So that’s, I think, one of the most worrisome indicators of mental health.

Two other quick things that I’ll say, because I think conversations about student mental health and just as I’ve answered this question, tend to, you know, focus on the challenges and the indicators that should really, raise the urgency and the need to try to address these problems.

There’s also a lot of students who are thriving, who are flourishing. We have an eight items screen in our Healthy Mind study, the flourishing scale. It has items like “I’m optimistic about my future,” “people respect me,” and there’s a cutoff for flourishing. And in this past academic year, about a third of students met that criteria for flourishing.

So that’s down from when we first added this measure about 10 years ago, but still, I think really important to recognize that there’s this group of students on campus who are flourishing.

And for me, one of the most important things to think about there is that there are students who come from backgrounds where we’re particularly worried about their mental health because of structural systemic inequalities that are burdening those groups.

So, we can think about trans and non-binary students. And so, when I talk about flourishing, I’m really also interested in the students, so, for example, trans and non-binary students who are flourishing because there are trans and non-binary students across the country who are flourishing in colleges and universities.

So, it presents an opportunity to try to think about what are the institutional level factors, programs, and investments that are associated with those students in particular that are flourishing.

And then the last thing that I will say is folks might be wondering how this compares, you know I said more than a 100% increase in less than 10 years in terms of prevalence of depression and anxiety. How does that compare to non-college populations?

And is this, when people talk about a “campus mental health crisis,” quote unquote, like, it’s not actually a crisis that is unique to college populations. These problems are being seen in adolescent and young adult and even full adult populations as well.

But again, there are unique opportunities through the college setting to address this and such a large proportion of adolescents and young adults in U.S. higher education.

Jeff: These numbers that you’ve shared are so sobering to be sure. When you share them with academia, when you share them with higher education officials, what is the response?

Is there a great surprise? Do they realize that these things are happening on college campuses?

Sarah: So that’s also something I think that’s really changed. It used to be that higher education leaders and policy makers really wanted and needed that thorough understanding of kind of what is the scope of the problem?

Are these problems, sort of similar to the questions that I asked when I worked in residence life. Like, is my campus, is my institution unique? Is this happening at other places?

And for sure those questions, are still on folks’ minds, but by and large college presidents, policymakers, they are well aware of the problem. I don’t think that takes away from the fact that, as you said, the data are very sobering. But I do think that many higher ed leaders are well aware of the high and rising prevalence.

Jeff: Sarah, one of our goals with these webinars is to weave in some audience questions and a couple are coming that I just want to get to you right away here, were there many students who scored high on both flourishing and mental health symptoms? Interesting question.

Sarah: Yeah, that is, and you’re absolutely right that they’re not mutually exclusive. And I also should have said at the beginning, mental health is dynamic.

And thinking about kind of the psychosocial development that’s going on for many students, and I’m leaning towards thinking about undergraduates in this case, like, mental health is, is a dynamic thing. It’s going to change, throughout a college experience.

So, I think your question kind of points to that. I will often say to my own students, there would’ve been times for me in college when I would’ve been flourishing, and there would’ve been times absolutely where I would’ve screened positive for anxiety or had other risk factors all throughout just my own college experience.

We haven’t looked in our most recent data at the proportion of students with a positive screen for depression who are flourishing. But there certainly are, there would be, they’re negatively correlated with one another as you might imagine.

So as depression scores go up, flourishing scores on average go down, but that doesn’t mean that there aren’t students who are both flourishing and experiencing symptoms of depression.

Jeff: Were you able to break out in your research, big schools versus small schools, elite schools versus less elite schools? Is there an equity gap of any kind in terms of the findings that you’re getting?

Sarah: Yeah, so there’s certainly variation in prevalence and in help-seeking behaviors, and access to resources across institutional characteristics. None of the patterns are perfect or point to this very strong conclusion like this exact type of institution falls on this side and this side.

There are outliers to all of the patterns that start to emerge. In terms of, I’ll start with the kind of academic, like most elite institutions, we have many of them in our Healthy Minds data. And I think oftentimes people assume the prevalence will be, significantly higher at some of the most elite or competitive institutions.

We actually don’t see that in our data. There are of course some self-selecting aspects of this. Like the students at those institutions, probably, they’ve maybe been exposed to academic stress before. Or there’s of course, there are of course, as I said, students who are starting at all different types of institutions who have histories of mental health problems.

And that is not necessarily, not by any means a weakness, but there is still, of course, a self-selection. So, at these most elite institutions, there are many students who have been thriving in academics.

And we could talk about how the relationship between academics and mental health. But to answer the question succinctly around kind of, the competitiveness of institutions, we actually don’t see a strong pattern there at all.

In terms of institutional size, this is a tricky one because of course that’s a factor that is not mutable. It’s not something that we can change. So, I hesitate because it’s not the most helpful. People will ask this a lot, but it’s just not the most helpful discussion to be having. Because small schools can’t become big and big schools really can’t become smaller.

Though, there are ways to think about living-learning communities within larger institutions that of course do create that smaller college feel within a large university. That said, we do see that students at small, highly residential colleges and universities are more likely to access mental health services when they’re struggling.

So, one of the indicators that our Healthy Minds team focuses on a lot is the mental health treatment gap. So, the proportion of students with a positive screen for depression, anxiety, and suicidality, among those students who have a positive screen, what proportion have not received any treatment in the past year?

So that’s the treatment gap, and the treatment gap is wider at large public institutions. There are more students who are not accessing services at those large institutions. Public institutions have a slight correlation with that as well as non-residential schools. It’s a little hard to take the conversation much further.

It is important to, I think, recognize that, but not easy to think about kind of the policy implications for that. I will say that I think a lot of colleges and universities, particularly like, large public institutions are working with peer institutions.

So other, large institutions try to think of ways to address this because there’s no one-size-fits-all approach, but there are certainly strategies that work better depending on different institutional characteristics.

Jeff: I have all kinds of questions for you about help-seeking, but before we get into those, talk a little bit about the impacts of mental health challenges that are unaddressed on campus. What are some of the repercussions of not tackling one’s mental health challenges?

Sarah: Yeah, well, I think the first thing that I will say is how mental health relates to students’ academic performance. And for many students, that is their primary goal. If they’re asked, what do you care about? What are your goals? What are the things that you really want to get out of college? Their goals will relate to their academic performance.

So, it is a top priority for students, but many of them don’t recognize how their mental health is affecting their academics. And so, we have data around that.

And I mentioned earlier that in the pandemic, we didn’t see a unique spike in prevalence of symptoms, but we actually did see a unique spike during the pandemic in terms of the proportion of students who said that their mental health was negatively affecting their academic performance.

So over 80% of students in our Healthy Minds data in recent years have said that their mental health has negatively affected their academics in the past month.

So, the vast majority of students, when I talk to faculty members and academic staff, that’s one of the statistics that I really try to underscore is that the vast majority of students are saying that their mental health is negatively affecting their academics.

Untreated mental health problems, and specifically untreated depression, we have looked longitudinally and gotten data from the registrar’s offices at campuses where we can see students’ grades in classes, what classes they’ve dropped, their grade point average, and their institutional status, whether they’re enrolled in the institution.

And then we got that data at multiple time points from the registrar’s office and then linked it with their survey-reported data over time as well. And that longitudinal analysis revealed that untreated depression is associated with a twofold increase in the likelihood of dropping out or stopping out of college without graduating.

For those of you who are in the higher ed space, or particularly in the higher ed persistence and retention space, you know that there are very few indicators that are that strongly associated with persistence and retention.

And many of those other indicators are in the models for persistence and retention and have been for so, so long and are really emphasized in discussions of persistence and retention and need to be and continue to be. But mental health is largely ignored in how we predict and try to reduce dropping out and stopping out of college.

For folks who are interested, we’ve built an economic case or, like, a return-on-investment calculator where institutions can plug in some basic information about your institutional characteristics.

Then, based on that return-on-investment analysis that I mentioned with the longitudinal data, it will tell you, what would be the return on investment in terms of tuition retained from additional resources invested in mental health for students.

Jeff: Sarah, before we move on from here, another question came in, which I think is very interesting. There’s a lot of talk about anxiety and depression with college students. Is there data regarding students with psychosis, first breaks, for example?

Sarah: Yes, just want to go back to the question right before this of how mental health, and as I said, the reason I became really interested in this topic was because I saw that mental health affected every aspect of students’ lives.

So, I led with academics, but we can talk about the role of mental health in social networks, in athletics, in career preparation. So, there are so many different angles we could take that. But in terms of, yeah, so we focused thus far in our discussion today around the most prevalent concerns, which are depression and anxiety in college populations.

We do have data on students with diagnosed psychotic disorders. It’s a very small proportion, but because we have so many years of data, I think Healthy Minds actually does present a unique opportunity to try to look at that population. It would require aggregating many years of the Healthy Minds data to get a good size.

But it’s because it’s less than 1% of students in our data who have a reported diagnosis of a psychotic disorder. But we don’t have measures of experiences of psychotic episodes or psychosis in the data. We only have that indicator of diagnoses.

Jeff: Let’s talk help seeking for a little bit, what does the data tell you about the patterns for average college students who are dealing with mental health challenges? When do they seek help? What keeps them from reaching out?

Sarah: Yeah, so this is one of those indicators, use of mental health services, that has a lot of things that we can talk about that are really positive. And then there’s a lot of challenges, namely kind of the supply demand imbalance that exists, particularly if we’re just thinking about resources as one-on-one counseling or therapy.

So, thinking about that indicator of have you received counseling or therapy in the past year or received psychotropic medication? We’ve seen both of those indicators among students with symptoms. Both of those indicators have been going up.

So, every year more and more students are accessing mental health services. That’s on at a simple level, that is good news. We want to narrow that treatment gap. However, the prevalence of problems has, the increasing prevalence has far outpaced the increases in help seeking.

So that treatment gap has actually just continued to widen over time, despite the fact that many students, more and more students are seeking help. So, in our most recent data, among students with a positive screen for depression or anxiety, 59% of them had received either therapy and or medication in the past year.

So about 60% of students with symptoms had received treatments that would be about a 40% treatment gap. In terms of barriers, this is a really interesting piece, like the reasons why students aren’t seeking help.

Consistently we see this in our Healthy Minds data, over many, many years and across all sorts of different student identities, we see these same barriers on average, being the most salient to students.

So, I’ll give a little cliffhanger, before I actually say what those barriers are, just to remind us that most of the efforts on campus right now from a public health, population level approach are really focused on barriers that relate to stigma and barriers that relate to knowledge.

So, trying to educate students, trying to reduce stigma, those are really common approaches that that would fall under quote unquote “help seeking interventions.” But in reality, knowledge and stigma do not appear to be the most salient barriers for students.

And in fact, most students with untreated mental health problems actually have positive attitudes. They think that treatment is effective. They report low stigma, and they report relatively high levels of knowledge, in general, levels of knowledge are high and rising in student populations in terms of mental health.

So, if those aren’t the reasons, they have positive attitudes, they know what to do. We’ve thought a lot about that situation and how it parallels to other situations where people have positive attitudes, know the healthy thing to do and just aren’t doing it.

And there’s so many examples of things like that, from diet and exercise to seeking help for mental health or addressing one’s mental health. So, the barriers that we see really reflect a lack of urgency or sort of an inertia that surrounds the help seeking process.

I think this is particularly important if we think about the fact that so many of these students are experiencing these signs and symptoms of mental health problems for the first time, or their mental health and well-being is changed in some way due to the transition to college.

And so, these problems in that case are new to them, and something that they’re trying to understand and think about, when do I go seek help? Is this really that big of a problem? So, students with untreated mental health problems report, “I question how serious my needs are,” “I prefer to deal with issues on my own,” and “I don’t have time.”

Those are the most common reasons, the most common barriers that students select, for why they haven’t received treatment. And our current public health approaches really aren’t addressing those barriers, that lack of urgency.

On the counseling center side, the clinical side, what many counseling centers are seeing is that students, when they do seek help, they’re doing so in a crisis or they’re doing so when they’re really in an acute level of need. And then of course more resources are needed to support that student.

There may be preventable things that might have been preventable, like academic challenges, had the student been able to connect to helpful mental health and well-being resources earlier on. But many students wait until they’re in a crisis.

And part of that relates, I think, to not recognizing that mental health is so important for academics, the thing that so many students are trying to prioritize.

And especially with the barrier of “I don’t have time,” That’s when I talk with my students about a lot that, you know, of course our time is really precious, but investing your time in prioritizing your well-being and mental health is actually going to help your other goals, academic or otherwise.

So, we could talk more if folks are interested about, what do we do in response to those barriers, “I prefer to deal with issues on my own,” “I question how serious my needs are,” “I don’t have time,” and those are even the most common barriers among students who report seriously considering suicide in the past year.

So, if folks want to get into more of a conversation about what would interventions look like that explicitly address those barriers, I’m happy to talk about that. But I think the question was just what are the barriers? So, the most common barriers are really that lack of urgency, that inertia.

Jeff: Well, when it comes to these intervention options, I’ve heard you discuss them as red light, yellow light, or green light interventions. Can you explain what you mean by that and kind of walk us through what those options might look like?

Sarah: Yeah, that’s more around kind of the evidence and categorizing the evidence of effectiveness. Like what do we know about what works? And so, there’s a category when we’ve reviewed all the public health interventions, we’re working to compile a repository of best practices and evidence. And we have done a lot of that work synthesizing the evidence so far.

And so, we can categorize interventions as that the simplest way to think about it would be like red light, meaning the evidence actually shows that these approaches are not effective. They’re not working. So, we’re doing them on college campuses, but the evidence is not saying that this is an effective approach.

Yellow light would be interventions where there’s maybe some promising evidence, but we really need more evidence in that category to be able to recommend it. And then green light would be interventions that have been evaluated and that have evidence that they are effective.

So that’s sort of the red light, yellow light, green light approach. And I’m happy to talk about kind of what we think falls into those. But I also wanted to just say, maybe something about kind of, a triaged model or like a stepped care model, from the perspective of identifying students.

A huge part of any public health approach to mental health is regular data collection. And many schools are doing that through Healthy Minds, but they’re also doing that through their own surveys, through the National College Health Assessment, through various other means.

And it’s just important to be collecting those data and then really trying to connect students to the resources that are going to be most useful and effective for them. And trying to kind of reserve the most resource-intensive services like one-on-one counseling or therapy for the students who most need that and also the ones who prefer that.

So, it’s a kind of a balancing act of trying to meet students’ preferences as well as their needs. But if the menu of options is just, if you’re struggling, go receive one-on-one counseling or therapy, that means you know that a student, that’s their only option.

So that’s what they would do if they did that. And they might not do that until they’re in a crisis. But a triage or a stepped care approach, particularly when coupled with regular data collection to assess students’ needs, means that you’re trying to connect students to different levels of resources.

Resources throughout a broader campus mental health system that has more than just the counseling or therapy option. Yeah, and then the red light, green light, yellow light is the evidence, the effectiveness evidence.

Jeff: So much to talk about. There is a term that I’ve seen you use in an interview called “no wrong door,” and I find this very fascinating in terms of peer support, and in terms of support from faculty and staff on a college campus.

Can you talk a little bit more about that concept and why you think it’s so important?

Sarah: Yes, and I don’t know the origins of that term, but I really like it because it points to the population-level approach and opportunities, and it’s something that our colleagues at the JED campus program are often talking about this “no wrong door” approach.

And so essentially what it means is that someone is struggling, a member of the college or university community—and we’ll start with a student because that’s the most obvious example.

So, a student is struggling and anyone they go to, whether that be their roommate, their residence hall advisor, a faculty member, an academic advisor, a coach, a trainer, that every single person would be in a position and have the basic skills and knowledge to support that student.

And so how we get there, it requires that every person at a college or university, student, faculty, and staff—and I’ll make this the best-case scenario—has regular ongoing opportunities, preferably mandatory or kind of just embedded within the routine.

So, it’s just something that automatically happens that we’re getting this training, it’s often referred to as gatekeeper training.

But one of the challenges in that, and we can talk about the evidence of effectiveness, is that gatekeeper training programs, which are programs designed to train laypeople, non-mental health professionals, to recognize the signs and symptoms of mental health problems, have a conversation, and make a referral to some type of resources for someone.

Those are the basic skills of a gatekeeper training program. But oftentimes, and the evidence comes from studies that are this way where they’re really not measuring outcomes in the target population.

So, gatekeeper trainings have really strong evidence that they’re effective for folks that have gone through a training, feeling more confident, and oftentimes the measures are taken immediately after the training. Like I think I’m prepared to intervene. I know what resources are available and that’s sort of it.

If we are going to, we talk about gatekeeper training as like, it’s not necessarily something that needs to be abandoned, but it needs to be drastically reshaped in terms of actually teaching skills and having opportunities for folks to practice skills.

It’s only a “no wrong door” approach if a student goes to someone, a peer, faculty, or staff, and that person is prepared to actually have that conversation, has language that they can call upon, and knows what the steps would be.

And that’s not to say, you can’t be looking something up while you’re supporting a student or finding someone else who might be able to help if you don’t know. But ideally as many as possible students, faculty, and staff to be trained in having those skills. That’s really where we get that “no wrong door” approach. And that’s really a cultural climate-level intervention.

Jeff: The question came in specifically about residential halls and those who help and advise students the RAs and so forth. Is that a critical frontline?

Sarah: Yes, absolutely, and a lot of the gatekeeper training literature focuses on training residence hall staff. So yes, that’s a very important avenue. Maybe I will talk a little bit about what do we do in response to these barriers of like, “I don’t have time,” “I’m going to deal with this on my own.”

The basic, the simple answer of what do we do in the face of those barriers is that we actually need to bring mental health into the default daily routines of students.

So rather than them having to proactively recognize that they might need help and then seek out services and then go and access those services, a more daily routine approach would involve bringing mental health into students’ routines, into the places that they’re already inhabiting at their institution.

And residence halls are absolutely one of those settings. And so that’s a place where there can be important education, there can be skills training, there can of course be embedded counselors in residence halls, and residence hall staff are very important gatekeepers as well.

Jeff: An audience member also asks about online resources for college students that might augment what they can get on campus.

Sarah: Yeah, so digital mental health interventions are absolutely proliferating and there’s a lot of good things, I think that’s by and large a good thing. Because the supply demand imbalance has been so out of whack, there have been far fewer counseling center staff than can meet the demand from students for mental health resources.

So, expanding into digital, mental health interventions obviously increases the capacity of the institution. There’s so much in, I mean, it’s all about the details, like how that is integrated within the campus mental health system, just what students’ experiences are, if they’re using those resources versus something that’s physically on campus.

But it can be done really well, and it can be done in a way that meets students’ needs. And the evidence shows that the clinical effectiveness, like looking at cognitive behavioral therapy, whether it’s delivered in person or whether it’s delivered, virtually, there’s equal effectiveness there.

So, a lot of students want in-person resources, but yeah, that’s certainly an increasing part of campus mental health systems is tele-mental health therapy or tele-counseling, and also these digital mental health interventions. So, there’s the piece of them that are about treatment.

So, in increasing the capacity of counselors, and sometimes that can be done in really important and intentional ways that can advance equity. So, I know of schools that have specifically increased their counseling services through digital mental health interventions.

Prioritizing providers that can, deliver services in non-English languages, because that’s very important for students for whom English is not their native language, or other dimensions and identities that might not be represented in the counseling center.

So, there are opportunities to kind of expand the breadth and the scope of services through tele-mental health and telemedicine like that. But also, digital mental health interventions also include kind of nonclinical things.

So, things that are other types of interventions that can be delivered in a digital format, like coping skills, like teaching coping skills, or mindfulness. All of these things are important. They require practice, they require opportunities to actually practice, but there might be a more didactic portion that could be delivered through a digital platform as well.

Jeff: You just touched on a couple of things in terms of risk reduction, I’d like to talk about that a little bit as well. What are some of the lifestyle changes that can be very effective for promoting mental well-being on campus?

And do you find that college campuses are embracing those at the administrative level? Are these programs that colleges and universities are getting behind?

Sarah: Yeah, I mean, I think, two things come to mind immediately in terms of like health behaviors, broadly defined. And that is like loneliness and sense of belonging. So those are not, they’re not like the opposites of one another.

They’re separate, they’re separate things, but very important for opportunities and ways to prioritize students actually connecting with one another. That’s another thing that I really emphasize when I talk to faculty, it is really important for students to know their peers in class.

And so, we’re starting this new academic year and I’m really explicit about that. Like, I want the students in my class to know one another and I talk about there’s so much loneliness and isolation that exists in society. This is again, another problem that’s not unique to college environments, but it is present here.

And so, there’s so much loneliness and isolation that exists and there’s a lot of academic stress that students are experiencing as well. And I want my classroom to be a place where students know each other, where that sense of belonging is being strengthened in some small way through our classroom environment.

Administrators, campus leaders, many, many folks, are thinking really brilliantly about how to promote sense of belonging through physical environments on campus. So, like, what is the layout of spaces that’s most conducive to students actually like knowing one another. There’s a lot of different efforts, at so many different levels to try to promote sense of belonging.

How that relates to kind of health behaviors, like for students individually to just to know that and maybe just be really mindful of like, “I’m going to prioritize meeting people at school,” “I’m going to prioritize building a community.”

I think that so often I think about the way we orient first year students, it’s like they’re running around doing a million things, have so many things that they’re checking off their lists and they’re trying to start this whole new, course schedule that they’re about to embrace.

And it’s very easy to skip over saying like, some of the most important ways you can be spending your time right now are like connecting with your peers. So, I think that’s just a good reminder for this time of year.

Other mutable risk factors, like things that can be changed, another key risk factor is discrimination. So, looking at the ways in which campus systems are protecting students against experiences of discrimination.

I mentioned I do some work around trans and non-binary students, so things like name change policies. So, if students aren’t allowed to change their name in a campus record, that means that every time they go into a new classroom, every time they go to the health center, they’re going to be deadnamed.

They’re going to be misgendered, they’re going to need to, encounter that at the very least, microaggression at a bigger level, oftentimes, overt discrimination. And so, system-level changes that allow students to change their name and pronouns help to prevent those experiences of discrimination that are such powerful drivers of poor mental health.

One other health behavior that I’ll mention is sleep. So that’s a big one. It’s one that for parents out there, I’m sure you’re, have kind of battled against that or maybe worried like, my kid’s going to go to school and I’m not going to be able to remind them to wake up at this time or go to bed at this time.

And that’s absolutely true. Sleep is a huge, huge, hugely important health behavior. It’s very predictive of mental health and oftentimes it changes dramatically in college.

And so, I try to take the approach of thinking of students as autonomous and gaining independence and reminding them of the importance of sleep. And many of them have had that type of health education in high school. So just the reminders.

Jeff: Important reminders. Here’s a question that’s right in your wheelhouse in terms of public health and policy. How might we address all this systemically, what can we do? Or is it even more possible for community health systems and public health systems to help campus health systems move forward?

Sarah: So, wait, can you read the last part? Like how can community health systems help?

Jeff: Is it possible for community health systems and public health systems to help campus health systems?

Sarah: Yeah, I mean, I guess it goes both ways. So, some of the things that I think are currently in practice are ways of integrating local mental health providers into, there used to be sort of this like rotating door where like maybe a student would call and go to their counseling center, which is oftentimes short-term counseling or therapy.

They’d have a few sessions and then they’re referred out and there it’s just a void. The school has no idea what has happened to that referral or whether the student followed up on it.

And then the revolving door would be that student comes back to the counseling center weeks or months later and is potentially struggling even more than they were when they initially presented.

So that problem is one that requires collaboration between kind of community partners, providers, and institutions. And there’s actually a lot of innovation happening in that space to try to increase the communication that happens between kind of local providers and campus environments.

There’s so much that can happen at a system level, like just within higher education, thinking about policies, the built environment really, it’s just about investing in public health. So, it’s thinking most of our investments are on the clinical, like kind of treatment side of things.

We invest very little across all types of settings in the public health population-level prevention approaches. So, I think community partners are probably well aware of that, as are colleges and universities.

But that’s really the “where do we go from here” answer for me, is we prioritize and put in place really, public health best practices, which again, begins with data collection, includes regular data collection and assessment, has a more, triaged or stepped care model, which takes into account that mental health exists along a continuum.

So, students might be thriving and flourishing and there are resources to continue to strengthen that for them to build life skills, to have them be even better peer supports and leaders on campus. And then that continuum extends to students who are in a real mental health crisis. So, I think that the public health approach is probably the main answer I would have to that.

Jeff: Let me squeeze in a couple more questions that we didn’t get to yet. Has the Healthy Minds research identified any correlation between learning differences and mental health conditions in college populations?

Sarah: We have done a little bit of work among students with disabilities and their mental health, and we did, I believe, disaggregate by like disability types, but I don’t recall the findings off the top of my head other than the findings for the overall disability and how that’s associated with mental health and prevalence.

So having a diagnosed disability, college students with a diagnosed disability on average are more likely to screen positive for one or more mental health problems. And then on the strength side of things, they’re also more likely to have accessed resources.

So, the treatment gap is a bit lower for students with a diagnosed disability. But it’s also a good time for me to maybe mention that we make all of our de-identified Healthy Minds data publicly available.

So, to the question earlier about students with psychosis or looking at flourishing and depression in our most recent data or looking at students with learning disabilities, we do ask students, do you have a diagnosed disability? And then if they say yes, it’s followed up with more information about what that disability is.

And so, we make our data available to researchers and others who want to do analyses, and we have a relatively small research team that couldn’t possibly do all of the important analyses that could happen from the data just on our own.

So, if anyone’s interested in accessing our Healthy Minds data, you can just go to HealthyMindsNetwork.org.

Jeff: What’s the frontier with all of this? Where would you like to see this research go, Sarah?

Sarah: I mean, I think there’s the practice, the “where are things going to go with practice?” And in that case, I hope it is really embracing public health best practices. Related to that, I think a big challenge is that there’s a lot that falls in, there’s a lot that’s being done right now, that falls under that red light category. Like it’s not actually working.

And there’s a lot that’s under that promising category. We’re not really sure about things like peer support programs. We need more evidence, we need more studies about peer support programs.

So, I think the next big advancement for the field from my perspective, from our Healthy Minds team would be to have this national repository of best practices to build a peer learning network around that so that campuses can talk to one another.

They could share and understand what’s working at another institution and what their own is doing and really share the best practices and the evidence there. And, we’ll continue to collect our Healthy Minds data every year.

Jeff: Excellent, I’m sorry for cutting you off there. The Healthy Minds website is a great resource. Are there other resources that you would point people to that are interested in learning more about this topic, whether that be books or videos or other online platforms?

Sarah: Yes, we have a section on our website of our partners, and there’s a number of those organizations like the JED campus program or Active Minds that folks might be interested in, or the Steve Fund, which focuses on mental health among students of color.

My colleague Sarah Abelson from Temple University led a comprehensive book chapter in “The Handbook of Higher Education Theory and Practice” that was published last year that synthesizes everything we know to date about the effectiveness of commonly used intervention paradigms in higher education.

So that book chapter is available. And then we also, because that’s a really long document, we also distilled that into a brief recently with the American Council on Education. So, if you wanted to search for the American Council on Education, what works for mental health in higher education, I think you should be able to find that PDF too, it’s about a five-page brief.

Jeff: I always like to wrap up these webinars on a positive note, and you have certainly infused into our conversation today a number of promising trends. What do you want to leave us with?

Sarah: Well, I mean, I did say, there’s a big proportion of students on campus who are thriving, who are flourishing. I want to underscore that again. I mentioned stigma is not being the most salient barrier, but also a piece of good news is that stigma has been declining.

So, we can really see that over time. And I think we can all kind of move forward with the assumption that today’s college students, by and large, are actually quite open to talking about mental health.

There are some different, some areas where we see somewhat higher levels of stigma, but overall, the levels are actually quite low. I think that’s very positive. Yeah, and I mean, I think that the public health attention on this topic, and particularly from campus leaders, college and university presidents, is a very good indicator of this being prioritized moving forward.

Jeff: Well, I think that the work that you’re doing, and Healthy Minds is doing is really making a difference, Sarah, so thank you so much for that work. Thank you for taking time to visit with us today and add to this important conversation. We really appreciate your time.

Sarah: Absolutely, thanks for having me. Thanks for everyone for being here.

Jeff: Yeah, to all of you who have joined us today, we want to thank you for your time and your interest, and we want to encourage you to check back on the McLean website for additional webinars coming up. We wish you a wonderful day.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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