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The online edition of the magazine published by The Johns Hopkins University, Zanvyl Krieger School of Arts and Sciences


College Level Coping

As national statistics show a startling mental health trend at colleges and universities, Johns Hopkins reaches out to help students battle depression, anxiety, and more.

When Jamie Williams* began her freshman year on the Homewood campus four years ago, everything in her new life seemed to fall right into place. Her first day of orientation, she met a guy who would soon become her boyfriend. Her first semester, she made the dean’s list. Her second semester, she pledged a sorority, and she even managed to find time to go out dancing. “I was having fun, and life was pretty great,” she remembers.

The medication most frequently prescribed on college campuses isn’t the Pill.

It’s Prozac.

But toward the end of her sophomore year, Williams’ life “just started happening,” as she puts it. A cousin attempted suicide. Over the summer, her best friend’s father succumbed to cancer. At the beginning of her junior year, she began to have trouble getting along with the women with whom she shared a Charles Village apartment. Somewhere in there, her dog died. And then she and her boyfriend broke up.

Williams tried to cope with one heartbreak after another while taking 19 credits. Finally, she began to shut down. She stopped hanging out with her friends, preferring to isolate herself yet still feeling lonely. When she started struggling in the classroom, she sometimes had to ask her professors for extensions just to complete her assignments. “I was sleeping a lot more, I wasn’t social, I was very stressed, and I was unhappy all the time,” she says.

Anyone who pays any attention at all to the media these days can probably figure out that Williams was suffering from depression. Anyone who pays a little more attention knows that as a college student, she’s part of a national trend, an increase in the number of college students who suffer from mental health problems. It’s a situation so widespread and with such serious potential consequences it has been deemed a crisis.

Consider this: According to Psychology Today, the medication most frequently prescribed on college campuses isn’t the Pill. It’s Prozac.

That fact is not only a result of the upswing in mentally ill students on campus; it’s also a reason behind it. Because of the advent of mood stabilizers and antidepressants such as Prozac, kids with serious illnesses including depression, anxiety disorders, and bipolar illness who could not have coped with college 20 years ago are entering colleges and universities today, already medicated. But that’s only part of the story. The rest is about a response to academic and financial pressures that are greater than ever. When disrupted sleep patterns, poor eating habits, drug and alcohol experimentation, and normal developmental issues compound those stressors, the result is an environment pretty conducive to triggering or exacerbating psychiatric problems.

In a 2004 National Survey of Counseling Center Directors, 86 percent of directors said they’d seen an increase in students with severe psychological problems in recent years. In an American College Health Assessment (ACHA) last year, 40 percent of male college students and 50 percent of female college students reported feeling “so depressed it was difficult to function.”

With serious emotional problems on the rise, more and more students are seeking out campus counseling and psychiatric services, and colleges and universities all over the country are struggling to meet the demand. At Johns Hopkins, the university is working hard to create an environment that supports the mental and emotional health of its students. By increasing counseling staff, creating systems to monitor those at risk for suicide, and devising an integrated approach to serving students, Johns Hopkins is providing help to students who ask for it and reaching out to those who need it but never ask.


More Students, More Serious Problems

On the third floor of Garland Hall on the leafy Homewood campus, Michael Mond is keeping track. Mond is the director of the Johns Hopkins University Counseling Center. The Counseling Center, whose 14 professional staff members and four interns provide individual therapy, group therapy, and psychiatric care to students in the Krieger School of Arts and Sciences, the Peabody Institute, the Whiting School of Engineering, and the School of Nursing, serves as a kind of barometer of campus mental health, and Mond has the data to prove it.

Scrawled on a whiteboard affixed to the wall of Mond’s office is an extended tic-tac-toe grid of numbers so crowded that the numbers bump into the black lines: a week-by-week tally of such things as the number of new clients, emergencies, client hours, and so forth. On his desk is the center’s annual report, 38 number-laden pages depicting the center’s activity for the 2004-05 academic year.

That year, the center provided individual counseling to 1,083 of the 7,000 students who can access it. That’s up 18 percent from the previous year and 82 percent from a decade ago. Also last year, the center hospitalized 16 students and sent home 49 who couldn’t function in school or had decided college wasn’t the right place for them.

All of this for what’s technically a short-term outpatient clinic that isn’t capable of providing long-term care (beyond 12 counseling sessions) or treating chronic conditions.

“Most counseling centers are expected to use brief therapy models and help students matriculate through school, and yet there’s an expectation and desire for us to handle people who have more severe stress, which might require longer-term treatment, as well as people in crisis,” says Jaquie Resnick, president of the Association for University and College Counseling Center Directors.

Part of the increase in the Counseling Center’s caseload, Mond says, simply corresponds to an overall increase in the size of the student body. Part of it reflects a diminished stigma surrounding mental health treatment and a nationwide increase in diagnoses of depression and other problems. And part of it is simply a Build-It-And-They-Will-Come response: The center is there, and it’s free.

Mond emphasizes that most students who come to the center do not have serious psychiatric problems. “They’re struggling with life situations or growing situations, developmental issues,” he says, issues such as roommate conflicts, trouble learning how to meet people, and relationship problems. It’s the remaining students, about 20 percent, who have a serious disorder or are coping with a very traumatic experience.

College students are at an age when many mental health problems first manifest themselves. The onset of many mood disorders occurs during late adolescence and early adulthood, and suicide claims the lives of more 15- to 24-year-olds than anything but accidents and assault, according to the Centers for Disease Control and Prevention.

Among students, Mond says, “I think the severity [of problems] has increased, at least in my observation. There are kids with severe eating disorders, suicidal ideation, bipolar disorders, deep depressions. There have always been kids like that, but it just seems like there’s more of that now.”

Nationally, it’s the same story. “That’s definitely the buzz and has been what we’ve been talking about for the last five years or longer,” says Resnick.

The 2004 ACHA survey showed that 10 percent of college students have seriously contemplated suicide. Fifteen percent of students say they’ve actually been diagnosed with depression, up 4.6 percentage points from 2000. Students are also suffering from sleeping and eating disorders, substance abuse, and anxiety.

So what’s driving this collegiate mental health crisis?


Millennial Pressures

The most obvious factor is the increase in incoming students who are already on psychiatric medication. Ninety-two percent of college counseling center directors (including Hopkins’ Mond) say they have more of these students on their campuses than just a few years ago. At Hopkins, families of these students sometimes approach the Counseling Center before the student arrives to begin classes. Larry David, a staff psychologist and associate director at the center, met with one such student and her family last fall. “Her parents called me, and we arranged to meet to talk about what might be going on with her. This was someone who had made a suicide attempt the year before,” he says. Thanks to the student’s involvement with the Counseling Center, says David, “she did okay, and I believe the counseling helped her.”

There has also been a ramping up of societal—and economic—pressures or stressors for college students. Today, the financial burden alone can be overwhelming. Tuition increases have outpaced both inflation and salaries over the last decade. Even with financial aid, many students still graduate thousands of dollars in debt and with the pressure to land a job good enough to pay it off. And the more college costs, the more pressure many students feel to get a return on their investment. Many students increase their course load so they can graduate early and lower their bills.

Competition can be fierce, especially at elite schools like Johns Hopkins, which attract students used to doing well. Just ask Randy Morris*, a pre-med student who graduated last May. In high school, Morris was captain of his football and baseball teams, and academic success came easily to him. “I think I fell asleep in every class for all four years of high school,” he recalls. “So when I came to Hopkins, I wasn’t used to having to do work to do well, and then all of a sudden I wasn’t doing well, and I didn’t understand why.”

As Jamie Williams* puts it, there’s more to know and learn than there used to be: “My dad says I have it so much harder academically than he did. Tests are harder. I’m studying stuff that they had no clue about when he was in college.”

At the same time students face more pressure, many of them are less prepared to deal with it. “Most of our students didn’t have much time that wasn’t structured or scheduled [in high school],” says Susan Boswell, dean of student life. “They did after-school activities that for many of them went well into the evening. And now there’s not this imposed structure. They have to impose it themselves, and that’s hard.”

These are the “Babies-on-Board” of the Reagan years and the “Have You Hugged Your Child Today?” kids of the Clinton years, note authors Neil Howe and William Strauss in Millennials Rising, a book about this generation. Well-intentioned parents shuttled and mini-vanned Millennial kids from preschool to soccer practice, from day camp to ballet lessons. But higher education is often an independent experience, and the kid who never learned to work alone or manage his own time before going to college can find himself at sea.

“The state of the world today… it really is like a terror, a hazy fog over everything that makes everything so much worse.”

These are also the students who were grade-schoolers when Timothy McVeigh blew up the federal building in Oklahoma City and teenagers when terrorists attacked the World Trade Center on September 11. For them, the world has never seemed like a safe place. “The state of the world today… it really is like a terror, a hazy fog over everything that makes everything so much worse,” Williams says.

Williams did not seek out the Counseling Center the year she was depressed. She says she didn’t realize how depressed she was. She was lucky, she says in hindsight, to get out of her roommate situation and muscle her way through her pain. She didn’t take medication, either, but she knows plenty of people who do. “I have friends who’ll say, ‘I’m on this or that drug’ and then another will say, ‘Oh, yeah, I’ve been on that one for three years,’” she says. “Stuff like that happens a lot.”


Prescription Therapy

Indeed, the use of medication has seen an upswing among college students in recent years. Consider: In 1992, 16 percent of students who went to the Hopkins’ Counseling Center sought psychiatric care. By the 2004-05 school year, that percentage had doubled, to 32 percent. Most students who see a psychiatrist decide to take medication, Mond says. The most commonly prescribed drugs are selective serotonin reuptake inhibitors, a widely used class of antidepressants that includes Prozac, Paxil, and Zoloft.

Randy Morris* started taking Paxil his senior year because of a problem he was having in a romantic relationship. Looking back, he thinks that having someone to talk to at the Counseling Center was helpful, but that the drug was unnecessary. All the Paxil did, he says, was make him tired. “Now, my opinion is that I was not depressed, but that I needed to grow up and just get my life squared away,” he says. “I think at the time I was just too immature to actually do that.”

That’s the kind of anecdote that causes some critics to argue that psychiatric medications are overprescribed generally and that such problems as depression and anxiety (which frequently accompanies depression) are overdiagnosed.

Tell that to Richard Kadison, chief of the Mental Health Services at Harvard University and author of College of the Overwhelmed: The Campus Mental Health Crisis and What To Do About It, and his response is quick: “It’s actually underprescribed in colleges,” he says, pointing to the ACHA suicide and depression statistics. “Those are really scary numbers. Not all of them need meds, but it’s affecting their functioning and they need some help.”

Kay Redfield Jamison, a much-respected Hopkins psychiatrist, agrees: “It doesn’t mean there aren’t instances of overdiagnosis and overtreatment, but the major public health issue is that depression is underdiagnosed and underprescribed in general.”

According to Claude Smith, a psychiatrist at the Counseling Center, the center is very measured about prescribing drugs, first educating the client about the risks and benefits and always presenting medication as one treatment option. Despite the rise in the center’s number of cases and, since 1992, the increase in the number of students taking psychotropic drugs, the percentage (30 percent) of student clients prescribed medication has remained steady for the last five years. Many students coming to the center often are hesitant about taking them. “I don’t think students come in here thinking about [medication] lightly,” Smith says. “I’ve had instances of talking for an hour with a student, and then I ask them how they want to proceed. And their response may be, ‘It’s a good thought but I want to wait a bit.’”

But there are students who come in knowing exactly what they want—the type of drug and sometimes the therapy. “I had a guy come in the other day who said ‘I have social anxiety disorder and I want cognitive behavioral therapy,’” says David. “And he was right.”


‘Don’t Be Afraid to Get Help’

The good news is that for the most part, the university has dealt successfully with many of these problems. Two-thirds of students report feeling better after counseling, according to surveys the center conducts. The center estimates that in 2004-05, staffers prevented 140 students from dropping out of school and 112 from hurting themselves or others.

The center has also devised a tracking system for students who seem especially at risk for suicide. These students receive intensive treatment, which may include more frequent counseling sessions and psychiatric consultations. Every week, the Counseling Center’s staff spends time as a group reviewing cases to figure out the best way to help each student. According to surveys, most students who express having thoughts of suicide stop having them after just one or two sessions. Just having someone to talk to can make all the difference.

To offer all these services, the center has had to keep pace with the demand. When Mond started the center 13 years ago, there were four psychologists, 2.5 social workers, and a part-time substance abuse counselor. Today, there are nine psychologists; one half-time social worker; four predoctoral psychology interns; and four part-time consulting psychiatrists, with rotating shifts so that one psychiatrist is at the center every day.

Success isn’t just limited to the Counseling Center. The university is working on an integrated, coordinated approach to student mental health that includes everyone connected to the school. Every year, faculty and staff receive packets of information about how to recognize a distressed student. Resident advisers receive training on how to spot a student in trouble and how to approach them. Boswell says her office also actively encourages parents to call if they’re concerned. “There’s not a week that goes by that I don’t hear from somebody who’s worried about somebody,” she says. Sometimes she refers him or her to the Counseling Center. Sometimes Boswell spends her own time one-on-one with students, helping them with everything from difficulties with classes and friends to telling their parents they want to change majors. “Sometimes we get a student who has always wanted to be an engineer and all of sudden they’re interested in the Writing Seminars. They need to convince their parents that that’s going to be valuable,” she says. “Sometimes it’s helpful to role-play that.”

During times of crisis, the university expands its efforts. The center has a 24-hour emergency on-call system; staff members rotate carrying a pager, so that if an emergency occurs after hours, students can call Security and be put through to the staff member on-call. Boswell estimates that she talked to 250 students in relation to three student deaths that have occurred since the spring of 2004. During that time, the Counseling Center also accepted walk-ins with no appointment. “For any given death there could be 75 people who need extra assistance,” she says. “It may be talking to them once or they may need to leave school.”

Students who need some help coping but aren’t ready for the Counseling Center can also try A Place to Talk (APTT), a peer counseling program mostly run and used by undergraduates but also open to graduate students. APTT is located in a former library on the first floor of the AMR1 dorm. Students can vent their problems to a peer counselor known as a “listener,” whose function is to provide a safe outlet for students to express their problems.

To create a direct dialogue between students and the university about the emotional well being of students, Mond created a student advisory board (SAB) last year that serves as a liaison between the student body and the center. One of the first things the board did was convey via e-mail a message to fellow students about the warning signs for mental and emotional illness. They plan to send a letter to parents with similar information. Last spring, the SAB sponsored a contest to solicit ideas to create a better sense of community on campus. The university plans to review ideas from the contest this fall.

Mond continues to look at his numbers. He says he’d like to add more staff, especially for psychiatry services, because he knows that today’s clients expect it be part of their treatment. As long as the need increases, the university will be working on a response. Psychologist David sums up the expansion this way: “Our staff has grown; the number of people coming here has grown. It’s a growth industry.”

Williams, meanwhile, graduated in May, having recovered from her depression, but not before stress over graduate school applications caused her to start having panic attacks. This time, she went to the Counseling Center and asked for help. Now she knows how to recognize when she has a problem that needs addressing, she says. Her advice for other students with these issues is simply this: “Don’t be afraid to get help. It’s not that big a deal. Just go take care of it.”

Kristi Birch is a writer/editor at the Bloomberg School of Public Health.


* At their request, students' names and some identifying details have been changed to protect their privacy.



College-Level Coping
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