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QUESTION OF THE WEEK PODCAST

How Is the Conversation around Mental Health Changing among College Students?

Sarah Lipson discusses new insights and numbers behind the ever-changing mental health landscape in higher education.

A version of this article originally appeared in BU Today. It was produced and engineered by Andrew Hallock.

As awareness of its importance rises, mental health has become a topic of much discussion in higher education, especially in the wake of the COVID-19 pandemic. Sarah Lipson, assistant professor of health law, policy & management, investigates mental health impacts among young people, primarily students. In this episode Sophie Yarin and Lipson discuss new insights and numbers behind the ever-changing mental health landscape in higher education

Have a question or topic idea for a future episode? Send an email to today@bu.edu. Bonus points if you attach a voice memo with your question.

Takeaways

• Lipson’s research primarily measures symptoms of five mental health outcomes: depression, anxiety, eating disorders, nonsuicidal self-injury, and suicidal ideation. In spring 2022, more than 50 percent of students met criteria for one or more of those conditions. Trends have shown an increase in incidence since 2015. 
• In recent years universities are developing a higher level of knowledge about a public health approach to mental health on campus. Traditional crisis services and treatment for students at a clinically significant symptom level are small parts of a larger protocol. Resources, support, and prevention programs to reach the entire college population are as important. 
• Despite the increasing frequency of mental health problems in recent years, roughly one third of students in Healthy Minds data are flourishing at any given time, experiencing positive mental health. Additionally, the social emotional learning they experience in K through 12 is beneficial to them as college students. It is important to remember that mental health is dynamic, and will be throughout an individual’s youth and college experience. 

Transcript

Sophie Yarin: This Question of the Week from BU Today. I’m Sophie Yarin, writer at BU Today.

For quite a while now, the conversation around mental health and the conversation around adolescent and post-adolescent development has kind of almost been one and the same. And the urgency of this issue just seems to be on the increase for individuals, families, and educators.

Our guest today is Sarah Lipson, an assistant professor of health law, policy, and management at BU’s School of Public Health. Sarah has dedicated her research to mental health impacts among young people, primarily students. She is also a principal investigator at the Healthy Minds Network, which administers the largest higher ed survey on mental health in the country, the Healthy Mind Survey, and she’s been at SPH since 2018. We’ve invited Sarah to come on the podcast today to discuss how the conversation around mental health is changing, and how students are shaping it. Sarah, thank you so much for joining us today.

Sarah Lipson: Thanks so much, Sophie. Happy to be here.

Yarin: Happy to have you. We wanted to ask you our question of the week. How is the conversation around mental health changing among college students?

Lipson: Yeah, so I think there’s a lot of different ways to think about this. I’ll share a few thoughts about kind of shifting conversations around mental health in higher education.

So one is, we see in our Healthy Minds data, our national survey data, a significant increase in the prevalence of mental health problems in college student populations.

At the same time, there’s also decreasing levels of stigma around mental health. Meaning that many students are more open to talking about mental health, to thinking about the resources that might be available for them. So there’s two pieces together of increasing prevalence, which is, of course, [it’s] a problem, and then decrease in stigma, which is, from a public health perspective, a really important advancement. I spend a lot of time [on these pieces], and this is something that I really enjoy, and I’m really glad to have the opportunity to do so.

I spend a lot of time talking to campus leaders, so college presidents and boards of trustees. And I would say that the conversation there has shifted in a number of ways in recent years. So in general, we’re all just much more comfortable with public health language and understanding really what is a public health approach to a health problem, what that actually looks like.

And so I have certainly seen in my conversations with college presidents a much higher level of knowledge in recent years about what is a public health approach to mental health on campus. It’s not just crisis services or treatment for students who are at a clinically significant symptom level, but it’s actually having resources and support and prevention programs that can reach the entire college population. So that, I think, has been a really important shift in terms of campus leaders and the conversation around mental health. And then lastly, really trying to bring together conversations around equity in higher education, and conversations around mental health.

This is somewhere where I feel hopeful that those two conversations will really come together even more so moving forward. And I’ll just kind of share a little bit about why there’s such urgency around that, or why there’s such an opportunity to advance equity in both domains. So we know that certain students on average are less likely to graduate from college, and that includes first-gen, low-income, and students of color.

And those same students on average are the least likely to be able to access mental health services when they’re in college, or are least likely to have access to services that actually meet their needs and preferences. And we also know that mental health is a really significant predictor of students’ persistence and retention.

Untreated depression is associated with a twofold increase in the likelihood of dropping out or stepping out of college. So there’s a really important economic case here for investing in mental health services and a real opportunity to try to advance equity, both for college outcomes, as well as student mental health.

Yarin: Thanks. So when you were mentioning talking with campus leaders and school presidents, in how many of these conversations do you see Gen Z sort of leading the information aspect of the discussion?

Lipson: Yeah, I’m really glad that you asked that, because I think it’s a key starting point to any decision-making or investments that colleges and universities are making related to mental health.

It has to really be tied to what students’ needs are. So another aspect of a public health approach to mental health involves data collection. And I obviously come from the perspective of someone who collects large-scale data, so it’s not a far stretch for me to push this as a priority.

But it also really aligns with accessing what are students’ needs—I mean, we don’t know that unless we ask. And so having population-level data from students, regardless of their treatment history, regardless of their identities, that’s really key for informing decision-making on campus. Also, of course, having students that are a part of committees and task forces that are put together to make decisions about mental health on campus.

There’s a national organization called Active Minds, which runs chapters or sort of student clubs at hundreds and hundreds of campuses across the country. And it’s really about student mental health advocacy and students being at the forefront of advocating for what their needs are and what their preferences are, and working directly with administrators.

So that’s really exciting and it’s an essential piece if we’re going to make progress, and this is listening to the voices of students.

Yarin: Would you be able to sort of pinpoint when students were starting to become more vocal and destigmatizing? Would you say it’s a Gen Z thing, a millennial thing, or is it a different framework?

Lipson: Yeah, it’s interesting. We’ve seen decreasing levels of stigma overall at a population level for at least the last 10 years in our Healthy Minds data. Right around 2015, 2016, so students who are starting college right around that time, it seems to be a really pivotal point in our data in terms of both decreasing levels of stigma, as well as increasing prevalence rates.

The trends are really quite powerful around that time in terms of worsening mental health outcomes for students. So yeah, I think that that conversation with today’s college students, we can approach it with, so many students have a language around mental health. Many students are arriving at college already having engaged in mental health services at some point in their lives.

So yeah, there’s a starting point for that conversation already with students in a way that there wasn’t when I was in college. I didn’t even know the term mental health, I didn’t know about anything related to mental health at my university. So I think that there’s a big shift in that regard over the last 20 years, in particular over the last 6 or 7 years.

Yarin: And from the diagnostic end, how is the diagnosis changing for different age groups? Is there an increasing or a decreasing trend in what you’re seeing clinically?

Lipson: So yeah, I guess there’s two different ways to look at prevalence trends, and one is in terms of diagnosis, so people who’ve actually gone and received a diagnosis from a mental health professional. And we have seen increasing prevalence of folks who have a diagnosed mental health condition. 

What I focus on more so is prevalence of symptoms. So regardless of diagnosis and regardless of treatment, what are the symptom levels? And we’ve seen increases both among undergraduate students as well as graduate students. We measure symptoms of depression, anxiety, eating disorders, nonsuicidal self-injury, and suicidal ideation. Those five mental health outcomes are kind of the ones that we look at most closely from our Healthy Minds data. And if you combine all of those together, so a positive screen for one or more of those, in spring 2022, more than 50 percent of students met criteria for one or more of those conditions. And we’ve seen significant increases since about 2015, 2016 in particular.

Yarin: So when you look at things symptom-wise as opposed to diagnostically, for lack of a better term, do we wind up seeing different treatment models for, let’s say, somebody who has depressive symptoms versus treating major depressive disorder, and same thing with anxiety? Is there a difference sort of in looking at something situationally versus something purely via the DSM [Diagnostic and Statistical Manual of Mental Disorders]?

Lipson: Yeah, I mean, mental health is dynamic, right? I mean, I think back to my own time in college, and I think there are times when I would have met a threshold for flourishing, which is positive mental health, thriving.

About a third of students in our data are flourishing at any given time. And there also certainly would have been times in my college career when I would have screened positive for anxiety and possibly also depression. So just remembering that mental health is dynamic and mental health will be dynamic throughout someone’s college experience.

But to the question of, I think, how we are responding to clinical levels of need among students versus more, as you said, situational or maybe transient symptoms, I think that points, again, to this need for a public health approach. So there are daily stressors or common experiences that students face, whether it’s social things related to relationships or student athletes facing different stressors.

So there’s sort of things that we would put into the category of normal college life. And I use the word normal very hesitantly. But we don’t want to pathologize that, right? We don’t want to think that every student who is experiencing symptoms of depression or anxiety necessarily needs one-on-one counseling or therapy.

And in fact, if that’s the only approach that we have for a student who’s struggling in that moment with symptoms, we’re going to continue to overtax the campus mental health system. It’s not necessarily going to be what students need. And that’s why having a broader array of resources and programs that meet students needs wherever they are on the mental health continuum throughout their entire college career is sort of the gold standard.

But the answer is essentially yes, there is a different approach needed, but it’s not [that] there’s an intervention for one group and there’s no intervention for the other group.

The difference is more around whether it’s a clinical intervention, which a group of students certainly would benefit from, versus there’s a lot of growing body of evidence around the effectiveness of peer interventions and peer counseling.

And again, we don’t want to think of that as trained mental health treatment. But we do want to think about that as a really potentially helpful resource for students who are going through, again, things that we would think of as being part of a normal college trajectory or stressors. And the last thing I’ll say about this is, in order to be able to differentiate which students might be going through an acutely stressful moment versus which are experiencing major depression [is] that’s going to require regular data collection and assessment of students needs—ongoing data to understand students. And maybe I’ll also just say one last thing, which is to your question around kind of the role of students in this. I think it’s not enough for institutions to simply be collecting data internally using that of students.

This generation of students is very used to seeing data on themselves. I mean, they carry a computer in their pocket at all times in the form of their cell phone. And so I’m really interested in ways that we can share mental health data back with students in a way that allows them to reflect on how they’re doing and to be part of thinking about the resources that they need.

Yarin: When you were talking about treatment and intervention going beyond sort of the clinical model and therapy, where does self-care come into play in all of this, and what do you think about self-care?

Lipson: It’s a problematic word in a lot of ways, and it looks different for everyone.

What that self-care really looks like for me is making sure that I spend time outside. I really love being in nature. That to me is probably the most effective form of self-care. I think we can do a lot of work to help students identify what are the environments where you’re really able to relax, what are the activities that really feel good to you, what do you need to recharge?

So self-care is certainly a part of an approach to mental health. I’ll take particularly [the] example of students who have experienced systemic racism or trauma—we don’t want to be thinking about self-care as an antidote to any of that. We want to be thinking about structural change that can prevent that in the first place.

So a lot of times in public health, we talk about these different levels in an ecological model. So you have an individual and what they can do, and that’s kind of where self-care comes in. And at the broadest level is the system and the structures, and that is part of what is shaping the individual’s mental health and well-being.

And we also think about upstream and downstream, and really, upstream things are changing. Things like systems and policies to protect student well-being, things like name change, policies for trans students, for example. So self-care is a piece of it.

It’s potentially more downstream and it’s more kind of at an individual level.

I will say that in my work with college students, something that I notice that is different in this generation of college students is sort of a selflessness in a way and not necessarily feeling comfortable investing time in yourself, and it’s a very overused phrase, but you can’t pour from a cup that’s empty, or, put your own oxygen mask on first.

I think faculty need to be reminded of that as well. So I think self-care is really important however you want to define that, but it certainly is not going be the solution to the rising mental health problems that we see. I’ll also mention, financial stress is probably the biggest negative predictor of poor mental health in student populations.

So thinking about financial stress, financial aid, all of that is also really inextricably linked to student well-being.

Yarin: So we all know that COVID is talked about as this watershed moment in mental health awareness, but in actuality, how much credit can the pandemic really take for this wave and how much was already in motion previously?

Lipson: So what we see in our Healthy Minds data, again from hundreds and thousands of students across the country, is that throughout the pandemic there was a continuation of a troubling trend. So there was a continuation of increases in symptoms of depression, anxiety, suicidality. But not a unique spike, so it wasn’t as if in 2019 the levels were really low and then suddenly in 2020 they jumped up.

Instead, they continue to climb throughout the pandemic out of population level. And again, like I said, it’s really around 2015, 2016 that we start to see the sharpest increases in prevalence. So in 2013, about 22 percent of students in our Healthy Minds data screened positive for symptoms of major depression, and in 2022, 39 percent.

So from 22 to 39 percent, over less than 10 years, similar increases for anxiety from 17 percent in 2013 to 33 percent in 2022 and the sharpest increases were around 2015, 2016 and a continuation throughout the pandemic. I will kind of also add to that, that’s at a population level. So there’s a real need to look at how the pandemic widened inequalities, and we did see that among first-gen, low-income, and students of color, the mental health treatment gap, or the access to mental health services among students who are struggling.

The inequalities widened there, for students of color, and for first-gen low-income students, so they’re even less likely to be accessing services in recent years.

Another really key outcome that we saw a unique change in throughout the pandemic was the proportion of students who say that their mental health has negatively affected their academic performance.

This probably won’t come as a surprise to faculty members and advisors, folks who’ve been working directly with students in recent years. About 80 percent of students in our Healthy Minds data say that on one or more days in the past month, their mental health has negatively affected their academics.

This again really points to bringing together these two national conversations around persistence and retention, higher ed and mental health, and higher ed and thinking about that connection between the two and the inequalities that exist in both.

Yarin: So if you could take a temperature of where we are at today, 2022, and based on these trajectories, where you think we might be in this conversation five years from now. How would that look?

Lipson: That’s a great question, and obviously [it’s] a tough one for a researcher to answer anything that’s kind of trying to predict the future, but it is an important question. I mean, some hopeful things: I’m very hopeful that there will be more explicit attention to the needs of underrepresented minorities on campus.

I’ve seen that conversation gaining a lot of momentum over recent years, so I am hopeful that there will be investment and innovation to meet the needs of underrepresented students on campus. I think there’s much more conversation right now as well around faculty and staff mental health. I anticipate over the next several years that there will be more, so what we think of as campus-wide approach to mental health, where for all students, all faculty, and all staff, there are resources and programs and data collection.

I think we’ll continue to see stigma decreasing and knowledge around mental health being relatively high. In terms of prevalence levels, symptoms, essentially what we have seen in our in our data is that every semester for the past five years has been 1 to 2 percentage points higher than the semester before.

So that trend has really been quite consistent in our data. So my first instinct is to assume that that trend will continue. But I hope that with more and more schools adopting public health best practices, population level approaches to address mental health and higher ed, we will begin to see the prevalence levels decreasing, and it’s also not isolated just to higher education.

We need to think about what’s going on in K through 12. I’m really hopeful about the emphasis on social emotional learning in K through 12 and coping skills and resilience that so many young people are receiving formal education around. And those young students will someday hopefully be in college, and I think there’s a lot of reasons to be hopeful about their skills, and their coping skills, and their social and emotional intelligence.

Yarin: All right. Well, thank you so much, Sarah, for joining us on this episode of Question of the Week.

Lipson: Thanks so much for having me.

Yarin: To learn more about mental health and find other educational resources, check out the links in the show notes. This episode was produced and engineered by Andy Hallock and hosted by me, Sophie Yarin.

Thank you for listening and we’ll see you in two weeks.