Gaps in mental health care for college students

Eleanor Lott, a junior studying genetics at North Carolina State University, jumped at the chance to serve on the institution’s mental health task force this past academic year when a friend asked her to participate. Lott was already involved in student government wellness initiatives and had one urgent goal for the task force: “Getting student suicide numbers down as fast as possible—just seeing if there were any go items that we could act on in that moment.”

Collegiate mental health is widely considered to be a crisis, but N.C. State became the epicenter of the problem this year amid a rising number of student deaths: 14 total, seven of them by suicide and two from overdoses. In November, the university convened an emergency task force to understand and improve student mental health outcomes. The group finished its work in February. Shorter-term recommendations include hiring and retaining more clinicians and case managers and embedding them in academic and other student spaces across campus. Longer-term recommendations involve scaling up additional resources and putting them in closer proximity to students, various other policy changes, and creating an overarching “culture of care.”

Barriers and challenges to student mental health include “an inability to meet basic needs (food, housing, transportation, and finances), rigid coursework expectations, a perceived lack of empathy and flexibility from faculty, limited access to resources, a lack of a sense of belonging,” and other policies, the task force wrote in its report. “The entire campus community, faculty, staff, and administrators must take responsibility for our students’ mental health and wellness.”

Responses to the newest Student Voice survey by Inside Higher Ed and College Pulse in many ways support the task force’s conclusions, as well as other expert recommendations for addressing collegiate mental health. In the nationally representative survey of 3,000 undergraduates at 158 two- and four-year institutions, students answered questions about chronic and acute stress, physical health and wellness, and mental health. Their responses to questions about mental health, in particular, are detailed below. But here are five major mental health findings, up front:

  1. Half of students rate their mental health as excellent or good, and half rate it as fair or poor. 
  2. Half of students with a mental health condition haven’t used any campus counseling services. 
  3. Among students who have accessed campus counseling services, appointment availability is both the top feature that works well and the top feature that needs improvement, suggesting wide discrepancies in student experiences with seeking timely care. 
  4. Just two-thirds of students agree that they know where to turn on campus if they or a friend is experiencing a mental health crisis.  
  5. Nearly half of students say professors are responsible for helping students struggling with their mental health, and many students also see advisers, administrators, residential life staff and peers as playing a role. 

Sarah Ketchen Lipson, assistant professor of health law policy and management at Boston University and principal investigator of the Healthy Minds Network, has found that 60 percent of college students with an apparent need for mental health resources and services haven’t received any type of help within the last year. The treatment gap widens among certain already-underserved student populations, she says.

The reasons for this gap in care are layered and complex. Among them: typical onset age for many mental health issues is adolescence through early adulthood, college involves fundamental transitions, students juggling new responsibilities and stressors face barriers to getting care, and demand for care outstrips current institutional capacities. In the most recent Healthy Minds study, for example, a quarter of respondents said they received fewer mental health services than optimal because they lacked the time.

Possible solutions to the collegiate mental health crisis recall the N.C. State task force’s recommended culture of care.

Lipson puts it this way: “It’s really about expanding the menu of options, meaning creating more opportunities to reach students and to reach them earlier on.” Increasing traditional counseling capacity to better meet student need is an important goal, Lipson continues, but no institution can feasibly one-on-one counsel its way out of the problem.

“We need to instead be bringing mental health education, awareness, resources and prevention into the daily default routines of students”—this means classroom environments, residence halls, peer-based programs and more—“making it so that if a student is just kind of walking straight forward with blinders on, they’re going to come smack straight into mental health resources and information—just by virtue of being a part of our campus community.”

How Students Rate Their Mental Health

Asked to rate their own mental health, 15 percent of Student Voice respondents over all say it is excellent and 35 percent say good. A third say fair. Sixteen percent say poor. For comparison, in the March 2022 Student Voice survey, students were over twice as likely to rate their overall mental health as poor (22 percent) than excellent (9 percent), with 56 percent responding “fair” or “poor.”

In the most recent survey, fielded in April through early this month, differences emerge across a number of dimensions. These include gender, sexual orientation and financial aid status:

  • Two in five women (n=1,997) rate their mental health as excellent or good, compared to three in five men (n=747).
  • Fewer than four in 10 LGBTQIA+ students (n=829) rate their mental health as excellent or good, versus 54 percent of straight students.
  • Not quite half of students receiving some form of financial aid (n=1,826) rate their mental health as excellent or good, as do 56 percent of students with no financial aid (n=791).

Mental health self-ratings are relatively consistent by institution type (two-year or four-year and public or private), and among white, Asian, Black and Hispanic students in the Student Voice survey, although Lipson and others have found discrepancies in flourishing by race. Republican-leaning students also tend to rate their mental health better than Independents and Democrats in the Student Voice survey.

Tiffany Robinson, a junior at Louisiana State University at Shreveport studying business, says these differences track with her work as president of her campus’s Active Minds chapter for mental health advocacy.

“Students who struggle more are the more nontraditional students,” she says. “It can be hard for people of color or people in the LGBTQIA+ community to feel like they belong. They may come in with impostor syndrome.”

Lipson says such differences in experience derive from system-level factors and point to possible sites for mental health interventions. If students on financial aid and under financial stress report poorer mental health outcomes, for example, financial aid officers might be trained to help these students. This doesn’t mean that financial aid officers or any other nonclinicians should become counselors, Lipson underscores. Rather, it means that they’re part of broader campus conversations and efforts to improve student mental health.

Internal data collection is necessary for planning and targeting interventions, and students should be involved in these efforts, Lipson adds.

Accessing Resources (or Not)

Asked if they’ve used various campus-based mental health resources, a quarter of Student Voice respondents say they’ve accessed on-campus counseling. Twelve percent have used telecounseling, either from a campus counselor or arranged by their college. Nearly one in 10 students has gotten a referral to an off-campus therapist, and 6 percent of students each have used a mental health hot line and urgent or time-sensitive counseling.

The largest share of respondents—nearly two-thirds—have not used any of these resources. A more telling statistic, which suggests a major gap in care, is the share of students with a mental health condition (n=1,079) who haven’t accessed any mental health services: 50 percent. Some 49 percent of students who rate their mental health as poor (n=477) haven’t accessed any of these services, either.

There appear to be difference service-usage rates by major, with relatively fewer arts and humanities students (n=362) reporting they did not use services, at 55 percent. That’s compared to 61 percent of social sciences students (n=1,265) and 65 percent of natural sciences students (n=1,408).

Women and men seem to be accessing care at the same rates, even though women report having worse mental health. By contrast, LGBTQIA+ students report seeking care at elevated rates (53 percent have not accessed services, compared to 68 percent of straight peers), which corresponds somewhat with their lower self-ratings for mental health.

Campus Care: What’s Working and
What Isn’t

For students who’ve used counseling services at their institutions (n=1,110), these are the top five aspects that went well (of 10 listed choices):

  1. Appointment availability (47 percent of students say this went well)
  2. Quality of care (41 percent)
  3. Follow-up care (29 percent)
  4. Ability to schedule with a counselor I could relate to (24 percent)
  5. Referrals to off-campus providers (14 percent)

Fifteen percent of students say none of the listed options went well, in their experience.

Asked what needs improvement in counseling care, students who’ve accessed services say:

  1. Appointment availability (35 percent of students say this needs improvement)
  2. Follow-up care (32 percent)
  3. Quality of care (31 percent)
  4. Ability to schedule with a counselor I could relate to (28 percent)
  5. Medication or prescription management (18 percent)

Robinson, at LSU Shreveport, says that a counseling appointment was immediately available for her when she needed it in her second year. At the time, she was struggling with family dynamics and with making big choices about her future. She liked her therapist so much that she still sees her, although the provider has since moved to a practice off campus.

“I just really felt supported,” Robinson says her experience asking for help. “It just seemed like one moment I was considering it, and the next moment, I already had an appointment.”

Yet as the conflicting Student Voice data about appointment availability, quality of care and follow-up care demonstrate, not all students have such positive interactions with campus mental health services. Markie Pasternak, senior manager of education at Active Minds’ national office, says that even when students overcome barriers to ask for help, two- to five-week wait times for a counseling appointment are the norm on many campuses.

“A lot of universities just don’t have the infrastructure to support every single student’s mental health in a therapeutic capacity,” Pasternak says, echoing Lipson. At the same time, institutions “can do things to proactively promote student well-being.”

For Pasternak, these include having wellness centers and strong campus recreation centers, making financial aid offices accessible, and investing in welcoming academic and living spaces. Pasternak also suggests peer-to-peer counseling, mental health learning communities, group therapy and wellness group offerings.

A student struggling with mental health might who is also struggling with alcohol and drug use might join support group for students with similar concerns, for example, she says. Bigger picture, Pasternak endorses the notion of stepped care, in which the most effective, least resource-intensive forms of treatment are delivered first, and in which interventions can be stepped up or stepped down as necessary.

Pasternak describes counseling centers as responsible for mental illness treatment and “reactive” care for mental health issues, but, she says, “Everyone else is responsible for the proactive piece.”

Expectations About Who Should Help Struggling Students

Students already seem to feel strongly that professors and other noncounselors have a role to play in student mental health. Excluding campus counselors, many students believe other campus groups—especially professors, advisers and administrators—are responsible for helping struggling students. This is relatively consistent across institution types and student demographics.

Lott of N.C. State says that professors play a particularly pivotal role in student mental health, and that she emphasized the idea of faculty empathy for struggling students during her work on the task force.

“Most professors are kind and empathetic and love the students and would do anything to help them,” she says. “But then there are some professors that don’t want students to go to their grandparent’s funeral if it means missing an exam.”

Knowledge of Crisis Care

What about crisis care? Just 27 percent of Student Voice respondents strongly agree with the statement “I know where I can seek help on campus if I or a friend is experiencing a mental health crisis.”

Perhaps concerningly, students with excellent or good mental health are much more likely than those with lower mental health self-ratings to say they know where to turn in case of a mental health crisis: 71 percent versus 61 percent, respectively.

Numbers like these highlight the need for ongoing and accessible mental health education and interventions, comments Lipson of Boston University.

“Students get a lot of this information right when they arrive on campus and during orientation at a lot of schools, but that can’t be the only way that we deliver it.”

What are you doing to promote mental health on your campus? What challenges are you facing? What do you want to hear more about from this survey? Tell us here.

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