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NCCP | Adolescent Mental Health in the United States

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Mental health and social and emotional wellbeing are key components of any strategy to promote adolescents' healthy development. This fact sheet presents basic facts about adolescent mental health, outlines barriers to ensuring adolescents are mentally healthy, and makes recommendations for eliminating these barriers going forward.

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In 2011, researchers at the University of Missouri looked at whether teachers understood the 10 evidence-based mental-health interventions or resources their schools employed. The results were disheartening, to say the least. While two-thirds of the surveyed teachers held graduate degrees, and the remaining third had earned undergraduate degrees, more than 80 percent had never heard of some of the interventions or strategies their own school utilized. Half of the teachers surveyed did not know if their schools provided functional behavioral assessment or intervention planning at all. Given that the response rate for this study was only 50 percent—and it’s likely that teachers with a heightened interest in student mental health would be more likely to respond to the survey—these results probably overstate teachers’ understanding of the tools their own school districts use to support students’ mental and emotional health.

Dr. Michael Hollander, Assistant Professor in Psychology at Harvard Medical School and director of Training and Consultations on the 3East Dialectical Behavioral Therapy program at McLean Hospital in Belmont, Massachusetts, urges teachers to use caution when intervening in students’ mental-health crises. “In my experience, teacher response tends to be bi-modal; either they get solicitous, over-involved, and in over their head, or they mistake mental health issues for behavioral problems that require in-class discipline.”

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As an increasing number of schools roll out evidence-based mental-health programs such as Positive Behavioral Interventions and Supports (PBIS), teaching that promotes appropriate student behavior by proactively defining, teaching, and supporting positive student conduct, and Trauma-Sensitive Schools, programs aimed at reducing the effects of trauma on children's emotional and academic well-being, educators need to be at least minimally conversant in the terminology, methods, and thinking behind these strategies. These programs provide strategies that can be highly effective, but only if the teachers tasked with implementing them are sufficiently trained in the basics of mental-health interventions and treatment.

Teachers routinely receive first-aid training in CPR, EpiPen use, and safe body fluid cleanup, but it's rare for schools to offer training in mental health, said Todd Giszack, Academic Dean of Fork Union Military Academy in Fork Union, Virginia. Recognizing that schools are responsible for their students' mental, as well as physical health, Fork Union Military Academy designed and implemented its own curriculum with the help of two mental-health professionals, and now offers eight-hour certification programs in Mental Health First Aid. "It has taken two years, but nearly all of our faculty and staff has become certified in Mental Health First Aid. This has allowed our school community to become familiar with trends and warning signs associated with adolescent emotional and mental health" Giszack said.

Dr. Michael Hollander, Assistant Professor in Psychology at Harvard Medical School and director of Training and Consultations on the 3East Dialectical Behavioral Therapy program at McLean Hospital in Belmont, Massachusetts, urges teachers to use caution when intervening in students' mental-health crises. "In my experience, teacher response tends to be bi-modal; either they get solicitous, over-involved, and in over their head, or they mistake mental health issues for behavioral problems that require in-class discipline."

Programs such as NAMI's Parents and Teachers as Allies presentation are beneficial, Dr. Hollander said, because they help teachers understand both the benefits and limitations of in-class interventions. Despite his worries about teacher-facilitated mental health interventions, he's grateful for the trend toward a greater understanding of students' mental health. "We have arrived at a place where we finally understand that teaching is not just about educating someone's rational mind, but also educating their heart," he said.

Children with untreated mental-health issues can get by. They can limp along toward adulthood until an inevitable, eventual mental-health crisis lands them in the hospital, in jail, or even at an inpatient drug and alcohol rehabilitation facility for adolescents, where I teach. But by then, a lot of damage has been done to their young minds and hearts-damage that could have been prevented if they had received support when their symptoms first appeared.

As I read their essays about crippling childhood anxiety, alcoholic parents, and/or domestic violence, I can't help but mourn for all the lost opportunities and squandered potential that was wasted on the way.

We want to hear what you think about this article. Submit a letter to the editor or write to letters@theatlantic.com.

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Teacher Training Is Failing Students' Mental Health

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As an increasing number of schools roll out evidence-based mental-health programs such as Positive Behavioral Interventions and Supports (PBIS), teaching that promotes appropriate student behavior by proactively defining, teaching, and supporting positive student conduct, and Trauma-Sensitive Schools, programs aimed at reducing the effects of trauma on children's emotional and academic well-being, educators need to be at least minimally conversant in the terminology, methods, and thinking behind these strategies.

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80 percent of the nation's school-based health centers employ mental health professionals, but only 19 percent are PhD-level clinical or counseling psychologists --- most are clinical social workers.

“It’s a huge issue,” said Amanda Nickerson, director of the Alberti Center for Bullying Abuse Prevention at the University at Buffalo Graduate School of Education, who is attending the annual convention in Chicago of the National Association of School Psychologists. “We do not have enough mental health professionals to meet the increasingly complex needs of the students that are walking through the door.”

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Think earaches, sore throats or runny noses top the list of reasons children visit the nation's 1,700 school-based health centers? Try depression, anxiety and trauma.

In fact, mental health services are the fastest-growing component of school-based health care. In the last 10 years, the number of school-based health centers with mental health professionals on staff has more than doubled.

"You will hear people say at school-based health care meetings that if there has to be a choice between a full-time nurse practitioner and a full-time mental health provider, that they'll take the mental health provider because the unmet need is that great," says Julia Lear, PhD, of George Washington University's Center for Health and Health Care in Schools.

School-based health centers are also increasingly popular among parents, teachers and school administrators because they deliver low- or no-cost health and mental health care. A 2003 survey conducted by Lear's center found that 83 percent of parents support health-care delivery in schools. A 2007 survey by the W.K. Kellogg Foundation found that two-thirds of voters support them.

Such centers are also growing in number: 152 opened between 2001 and 2005, and Congress is considering two bills that would expand that number.

Yet some school mental health experts say that school-based health centers are an inefficient use of public funds, especially in urban areas that have untapped community mental health services. School clinics, they maintain, aren't always cost-effective for long-term mental health disorders and can become a low priority if funding dries up.

"Education is the mission of schools, and school policymakers are quick to point this out when asked to do more, especially with respect to mental health," says Howard Adelman, PhD, of UCLA's Center for Mental Health in Schools. Meanwhile, funding is also a major concern of those working to keep such programs afloat.

"You constantly have to prove your worth," says school health center veteran Beth Warner, PhD, of the University of Maryland, College Park. "Every year you have to re-apply for funding and you wait on the edge of your seat to see what will happen."
Care right there
Many of today's school-based health centers offer services far beyond the part-time nurse with no back-up model. They offer immunizations, physicals, dental care, nutrition counseling, reproductive health care, and asthma and diabetes management.

On the mental health front, they may offer individual, group and family therapy, crisis counseling, mental health screenings, assessment and substance abuse counseling and prevention.

Demand for these centers is up in part because research suggests they work. A 2007 study in Pediatrics (Vol. 120, No. 4) found that low-income and uninsured adolescents who used school-based health centers were more likely to have had regular checkups, flu and tetanus shots and less likely to visit emergency rooms than adolescents who were tapped community clinics. A 2006 study in the American Journal of Public Health (Vol. 96, No. 9) found that teen pregnancy rates dropped significantly among black adolescents attending high schools with school-based health clinics. And a 2003 study in the Journal of Adolescent Health (Vol. 32, No. 6) found that students were 21 times more likely to make mental health-related visits to school-based health centers than to community health clinics.

Psychologists on the front lines in these centers agree that setting up shop on school grounds is the best way to reach children.

"Not only can you observe them in their social context, you are setting up an environment where they feel they are on their own terms and on their own turf," says Laura Hurwitz, who directs school mental health programs at the National Assembly on School-Based Health Care.

Plus, today's time-strapped parents often have trouble getting children to after-school appointments at offsite clinics.

"You reduce two barriers by being in the school," says Hurwitz. "You reduce the stigma of the traditional mental health setting and the barrier of having to get there."

Being in schools also enables mental health professionals to guide teachers on ways to follow up on a child's therapy in the classroom. Psychology practitioner Christine Cheng, PhD, for example, recently worked with a first-grade teacher whose student was so attached to him, he worried the boy wouldn't come to school the week he'd be on vacation. Cheng, who works at the Montefiore Medical Center School Health Clinic at P.S. 105 in the Bronx, told the teacher to give the boy something of his to keep all week. The boy not only made it through the week with few tears, he gained confidence in the classroom.

"He's doing better academically, he's speaking up more ... he even went on stage for a school performance," says Cheng.

School-based health centers are also an additional mental health resource for teachers who are faced with challenging student behaviors or who may struggle with job-related stress, says psychologist Gary Blau, PhD, who worked in school-based health centers and now runs the Child, Adolescent and Family branch of the Center for Mental Health Services at SAMHSA.

"If a teacher has trouble managing a child, extra consultation may be readily available to them," says Blau. "It's also an opportunity to educate teachers and administrators about how their mental health impacts their ability to teach and function."
Bang for the buck?
While Cheng works full time at P.S. 105, not every clinic has a 40-hour-per-week mental health professional. Many psychologists work in these centers part time or are split across several schools. Education backgrounds also vary: Although 80 percent of the nation's school-based health centers employ mental health professionals, only 19 percent are PhD-level clinical or counseling psychologists; most are clinical social workers.

Funding for the centers is often tenuous. The centers receive limited federal funding; the money to pay for them generally comes from state grants, partnerships with local hospitals or public health departments, or grants from nonprofits, such as the W.K. Kellogg Foundation and the Robert Wood Johnson Foundation, which has funded more than 80 centers.

A lack of steady funding is one reason these centers haven't caught on in Boston, says Boston College's Mary Walsh, PhD, who conducts research on mental health delivery in schools. She recommends that schools tap community mental health services, especially in urban areas.

"It doesn't make sense for schools to try to duplicate services in resource-rich areas," she says. "It does make sense to try to make effective links."

That instability can also create too much competition for resources within schools that must keep student achievement at the fore, adds UCLA's Adelman.

"Prevailing school accountability pressures increasingly have concentrated on instructional practices-to the detriment of all matters not seen as directly related to raising achievement test scores," he says. Adelman and his colleagues at the Center for Mental Health in Schools at UCLA pursue research and advocacy on the best ways to enhance mental health in schools by working within the schools' education missions and creating mental health interventions and promotion programs that "braid together the resources of schools and communities," he says.

School-based health centers can also be highly controversial in some communities, especially in high schools, where some view them as pregnancy clinics that push the use of birth control. But contraception is dispensed in fewer than a quarter of the centers, according to NASBHC, and pregnancy screening and abstinence counseling represent only a small slice of the health services such centers offer.
Coming soon
Yet more school-based centers may soon be on their way. Congress is considering the School-Based Health Clinic Establishment Act (S. 600) and the School-Based Health Clinic Act of 2007 (H.R. 4230), to expand federal funding for school-based health care, including mental health. APA supports the bills, noting that the centers connect underserved children with health and mental health care and boost schools by promoting health and reducing absenteeism, says Annie Toro, JD, associate executive director of APA's Public Interest Government Relations Office.

APA's Practice Directorate is working with NASBHC to expand psychology's role in school-based health centers, such as through supervisory roles and part-time roles at centers that can't fund full-time psychologists.

Meanwhile, other facets of psychology are looking for ways to fine-tune mental health screening at school-based health centers. Mark Weist, PhD, and Sharon Hoover Stephan, PhD, of the University of Maryland's Center for School Mental Health, trained professionals from 19 school-based health centers on how medical and mental health staff can collaborate more closely on diagnoses and treatments. They then surveyed the trainees and found a significant increase in the number of mental health screenings and assessments at their sites and a more team-oriented approach.

The findings are encouraging to Stephan, who saw firsthand how much these centers offer children during the two years she worked in Baltimore's school health centers.

"Far more children actually get the services they need where there is a center on site, especially one that includes mental health services," says Stephan. "And we're constantly hearing, 'How can we get more of these centers?'"

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Think earaches, sore throats or runny noses top the list of reasons children visit the nation's 1,700 school-based health centers? Try depression, anxiety and trauma. In fact, mental health services are the fastest-growing component of school-based health care. In the last 10 years, the number of school-based health centers with mental health professionals on staff has more than doubled.

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Schools need to find more ways to provide students with more mental health professionals. These specialists not only provide medical insight but also emotional stability for the students, since these practitioners come from outside of the school “bubble,” away from the regular school faculty,  whom students feel uncomfortable revealing mental distress to. While teachers should be educated in mental health as well, an increased number of mental health counselors should administer students’ mental health needs through one-on-one therapy and screening.

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Over 1.7 million youth with major depressive episodes did not receive treatment (rates of severe youth depression have increased within the last 5 years from 5.9% to 8.2%)

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Mental Health America (MHA) is committed to promoting mental health as a critical part of overall wellness. We advocate for prevention services for all, early identification and intervention for those at risk, integrated services, care and treatment for those who need them, and recovery as the goal.

We believe that gathering and providing up-to-date data and information about disparities faced by individuals with mental health problems is a tool for change.

Due to methodological and societal changes caused by the COVID-19 pandemic between 2019-2020, SAMHSA has announced that the 2019-2020 data from the National Survey on Drug Use and Health (NSDUH) survey may be misleading. Twelve of the 15 indicators used to rank the states in the 2023 State of Mental Health in America report were calculated using the 2019-2020 NSDUH data. We report this as a caution regarding interpretation of this year's report and a reminder that the 2023 State of Mental Health in America report cannot be compared to previous or future reports. For more information, see SAMHSA's statement here.
FILL OUT THE FORM BELOW TO DOWNLOAD THE PRINTABLE VERSION OF THE REPORT.
2023Key Findings

In 2019-2020, 20.78% of adults were experiencing a mental illness. That is equivalent to over 50 million Americans.

The vast majority of individuals with a substance use disorder in the U.S. are not receiving treatment. 15.35% of adults had a substance use disorder in the past year. Of them, 93.5% did not receive any form of treatment.

Millions of adults in the U.S. experience serious thoughts of suicide, with the highest rate among multiracial individuals. The percentage of adults reporting serious thoughts of suicide is 4.84%, totaling over 12.1 million individuals. 11% of adults who identified with two or more races reported serious thoughts of suicide in 2020 - 6% higher than the average among all adults.

Over 1 in 10 youth in the U.S. are experiencing depression that is severely impairing their ability to function at school or work, at home, with family, or in their social life. 16.39% of youth (age 12-17) report suffering from at least one major depressive episode (MDE) in the past year. 11.5% of youth (over 2.7 million youth) are experiencing severe major depression.

Over half (54.7%) of adults with a mental illness do not receive treatment, totaling over 28 million individuals. Even in Montana (ranked #1), over 4 in 10 adults with a mental illness did not receive care.

Almost a third (28.2%) of all adults with a mental illness reported that they were not able to receive the treatment they needed. 42% of adults with AMI reported they were unable to receive necessary care because they could not afford it.

10.8% (over 5.5 million) of adults with a mental illness are uninsured. Hispanic adults with AMI were least likely to have health insurance, with 19% reporting they were not covered by insurance.

6.34% of youth in the U.S. reported a substance use disorder in the past year. That is equivalent to over 1.5 million youth in the U.S. who meet the criteria for an illicit drug or alcohol use disorder.

22.87% of adults who report experiencing 14 or more mentally unhealthy days each month were not able to see a doctor due to costs. In Georgia (ranked 51), over one-third of adults experiencing frequent mental distress are unable to afford a doctor's visit.

59.8% of youth with major depression do not receive any mental health treatment. Asian youth with major depression were least likely to receive specialty mental health care, with 78% reporting they did not receive mental health services in the past year. In South Carolina, the lowest ranking state, nearly 8 in 10 youth with depression do not receive care.

Nationally, only 28% of youth with severe depression receive some consistent treatment (7-25+ visits in a year). Most (57.3%) youth with severe depression do not receive any care.

Nationally, 1 in 10 youth who are covered under private insurance do not have coverage for mental or emotional difficulties - totaling over 1.2 million youth. In Arkansas (ranked 51), nearly one-quarter of youth with private insurance do not have coverage for mental health care.

Only .718 percent of students are identified with emotional disturbance for an individualized education program (IEP). IEPs, with sufficient resources for schools and teachers, are critical for ensuring that youth with disabilities can receive the individualized services, supports, and accommodations to succeed in a school setting.

In the U.S., there are an estimated 350 individuals for every one mental health provider. However, these figures may actually be an overestimate of active mental health professionals, as it may include providers who are no longer practicing or accepting new patients..

Explore the web-based report using the links provided on the left or download the printable report In the above links you will find a Collection of Data across all 50 states and the District of Columbia answering the following questions:
The State of Mental Health in America
Our Goal:

How many adults and youth have mental health issues?

How many adults and youth have substance use issues?

How many adults and youth have access to insurance?

How many adults and youth have access to adequate insurance?

How many adults and youth have access to mental health care?

Which states have higher barriers to accessing mental health care?

Why Gather this Information?

To provide a snapshot of mental health status among youth and adults for policy and program planning, analysis, and evaluation;

To track changes in the prevalence of mental health issues and access to mental health care;

To understand how changes in national data reflect the impact of legislation and policies; and.

To increase dialogue and improve outcomes for individuals and families with mental health needs

This publication was made possible by the generous support of Alkermes and Otsuka America Pharmaceutical Companies.

Using national survey data allows us to measure a community's mental health needs, access to care, and outcomes regardless of the differences between the states and their varied mental health policies.

Rankings explore which states are more effective at addressing issues related to mental health and substance use.

Analysis may reveal similarities and differences among states in order to begin assessing how federal and state mental health policies result in more or less access to care.

The content of this webpage is the property of Mental Health America. MHA grants a limited license to use the webpage, or portions thereof, only if, whenever the webpage is used in written or electronic form, it is clearly stated that the website was created by and is the property of Mental Health America and a link is provided to www.mhanational.org. Under no circumstances may the website be used for any commercial purpose without the express written permission of Mental Health America. For permission to use the content of this webpage, please contact info@mhanational.org.

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Mental Health America's annual State of Mental Health Report ranks all 50 states and the District of Columbia based on several mental health and access measures.

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Trend in the shortage of counselors

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The international center of counseling services recommends that the counselor ratio should be 1 for every 1 to 1,600 students, since students’ mental disorders and poor mental health has increased, waiting list will decrease, liability risks to the school and counselors decrease, and opportunities to treat students with severe mental disorders increase.

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Read the Statement about Recommended Staff to Student Ratios

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The International Association of Counseling Services offers a statement regarding the recommended staff to student ratio. Read it in full on this page.

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Provider Perspectives on School-Based Mental Health for Urban Minority Youth: Access and ServicesAuthor(s): Gamble, Brandon E. Lambros, Katina M.Entry Date: 2014

"School-based mental health plays a key role in the provision of direct and indirect intervention services to support life skills and social emotional development."

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"School counselors are well-positioned resources"
with the small student to counselor ratio, there is "Burnout in counselors" & somewhat of a disorganization in students' case loads
also: " ... contemporary school counselors
need support in receiving robust training and preparation in professional identity and competencies, resolving
administrative and systemic issues, and obtaining efficient supervision to guide the course of the counseling
profession in the school system"

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LACK OF MENTAL HEALTH EDUCATION IN TRAINING

1. http://content.ebscohost.com/ContentServer.asp?EbscoContent=dGJyMNLe80Sep7Q4v%2BvlOLCmr1Cep7NSr6e4TLGWxWXS&ContentCustomer=dGJyMPGsr1C0p65PuePfgeyx43zx1%2B6B&T=P&P=AN&S=R&D=eue&K=97611446
2. http://content.ebscohost.com/ContentServer.asp?EbscoContent=dGJyMNLe80Sep7Q4v%2BvlOLCmr1Cep7NSr6u4SbKWxWXS&ContentCustomer=dGJyMPGsr1C0p65PuePfgeyx43zx1%2B6B&T=P&P=AN&S=R&D=eue&K=117173786

how to expand their training:
https://wtvr.com/2017/06/07/law-requires-mental-health-training-for-school-counselors/

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"... the young people in this study did not want counselling from their teachers, as they preferred this form of support from mental health practitioners outside of school. This was because they did not want to stand out from the crowd, ..."
" ... this 15-year-old female participant declared: ... I don't want them to look at me differently."

Tania Hart's How do teenage school children, experiencing significant mental health difficulties, perceive they can be better supported at school?

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STIGMA of Counselors; society needs to "help the helper"
Help for the Helper: Mental Health Concerns, Supports, and Stigma in School Counselors. Authors: Crowe, Allison Mullen, Patrick R. Avent Harris, Janeé R. Publication Date: 2017

how to deter that stigma:

1.The university has embedded two counselors in dorms since 2016 and is considering adding more after freshmen said it was a helpful service they would not have sought out on their own.
http://time.com/5190291/anxiety-depression-college-university-students/

2.https://www.wsj.com/articles/schools-look-to-ease-stigma-of-counseling-1499631858

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Between 2009 and 2015, the number of students visiting counseling centers increased by about 30% on average, while enrollment grew by less than 6%, the Center for Collegiate Mental Health found in a 2015 report.

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COST & how to deter that cost: https://www.ocde.us/HealthyMinds/Documents/Landing%20Page/Return_On_Investment_Mental%20Health%20Kognito_WhitePaper.pdf

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Disorganized collaboration of Mental Health services

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Mental Health in Schools and Public Health

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THE COUNSELORS THEMSELVES

1. The Role of School Counselors in Meeting Students' Mental Health Needs: Examining Issues of Professional Identity Authors: DeKruyf Lorraine Auger Richard W.Trice-Black Shannon Publication Year: 2013
2. “Compassion fatigue” & “burnout” http://go.galegroup.com/ps/retrieve.do?tabID=T002&resultListType=RESULT_LIST&searchResultsType=SingleTab&searchType=BasicSearchForm&currentPosition=9&docId=GALE%7CA355938649&docType=Article&sort=Relevance&contentSegment=&prodId=HRCA&contentSet=GALE%7CA355938649&searchId=R15&userGroupName=tel_k_smes&inPS=true

counter-argument: These "burnouts" and counselors' fatigue stem from the heavy case load and many patients; an increased counselor presence would create more stability for the students but also for the professionals.

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Not long after Nelly Spigner arrived at the University of Richmond in 2014 as a Division I soccer player and aspiring surgeon, college began to feel like a pressure cooker. Overwhelmed by her busy soccer schedule and heavy course load, she found herself fixating on how each grade would bring her closer to medical school. "I was running myself so thin trying to be the best college student," she says. "It almost seems like they're setting you up to fail because of the sheer amount of work and amount of classes you have to take at the same time, and how you're also expected to do so much."

At first, Spigner hesitated to seek help at the university's counseling center, which was conspicuously located in the psychology building, separate from the health center. "No one wanted to be seen going up to that office," she says. But she began to experience intense mood swings. At times, she found herself crying uncontrollably, unable to leave her room, only to feel normal again in 30 minutes. She started skipping classes and meals, avoiding friends and professors, and holing up in her dorm. In the spring of her freshman year, she saw a psychiatrist on campus, who diagnosed her with bipolar disorder, and her symptoms worsened. The soccer team wouldn't allow her to play after she missed too many practices, so she left the team. In October of her sophomore year, she withdrew from school on medical leave, feeling defeated. "When you're going through that and you're looking around on campus, it doesn't seem like anyone else is going through what you're going through," she says. "It was probably the loneliest experience."

Spigner is one of a rapidly growing number of college students seeking mental health treatment on campuses facing an unprecedented demand for counseling services. Between 2009 and 2015, the number of students visiting counseling centers increased by about 30% on average, while enrollment grew by less than 6%, the Center for Collegiate Mental Health found in a 2015 report. Students seeking help are increasingly likely to have attempted suicide or engaged in self-harm, the center found. In spring 2017, nearly 40% of college students said they had felt so depressed in the prior year that it was difficult for them to function, and 61% of students said they had "felt overwhelming anxiety" in the same time period, according to an American College Health Association survey of more than 63,000 students at 92 schools.

As midterms begin in March, students' workload intensifies, the wait time for treatment at counseling centers grows longer, and students who are still struggling to adjust to college consider not returning after the spring or summer breaks. To prevent students from burning out and dropping out, colleges across the country - where health centers might once have left meaningful care to outside providers - are experimenting with new measures. For the first time last fall, UCLA offered all incoming students a free online screening for depression. More than 2,700 students have opted in, and counselors have followed up with more than 250 who were identified as being at risk for severe depression, exhibiting manic behavior or having suicidal thoughts.

Virginia Tech University has opened several satellite counseling clinics to reach students where they already spend time, stationing one above a local Starbucks and embedding others in the athletic department and graduate student center. Ohio State University added a dozen mental health clinicians during the 2016-17 academic year and has also launched a counseling mobile app that allows students to make an appointment, access breathing exercises, listen to a playlist designed to cheer them up, and contact the clinic in case of an emergency. Pennsylvania State University allocated roughly $700,000 in additional funding for counseling and psychological services in 2017, citing a "dramatic increase" in the demand for care over the past 10 years. And student government leaders at several schools have enacted new student fees that direct more funding to counseling centers.

But most counseling centers are working with limited resources. The average university has one professional counselor for every 1,737 students - fewer than the minimum of one therapist for every 1,000 to 1,500 students recommended by the International Association of Counseling Services. Some counselors say they are experiencing "battle fatigue" and are overwhelmed by the increase in students asking for help. "It's a very different job than it was 10 years ago," says Lisa Adams Somerlot, president of the American College Counseling Association and director of counseling at the University of West Georgia.

As colleges try to meet the growing demand, some students are slipping through the cracks due to long waits for treatment and a lasting stigma associated with mental health issues. Even if students ask for and receive help, not all cases can be treated on campus. Many private-sector treatment programs are stepping in to fill that gap, at least for families who can afford steep fees that may rise above $10,000 and may not be covered by health insurance. But especially in rural areas, where options for off-campus care are limited, universities are feeling pressure to do more.

'I needed something the university wasn't offering'

At the start of every school year, Anne Marie Albano, director of the Columbia University Clinic for Anxiety and Related Disorders (CUCARD), says she's inundated with texts and phone calls from students who struggle with the transition to college life. "Elementary and high school is so much about right or wrong," she says. "You get the right answer or you don't, and there's lots of rules and lots of structure. Now that [life is] more free-floating, there's anxiety."

That's perhaps why, for many students, mental health issues creep up for the first time when they start college. (The average age of onset for many mental health issues, including depression and bipolar disorder, is the early 20s.)

Dana Hashmonay was a freshman at Rensselaer Polytechnic Institute in Troy, New York in 2014 when she began having anxiety attacks before every class and crew practice, focusing on uncertainties about the future and comparing herself to seemingly well-adjusted classmates. "At that point, I didn't even know I had anxiety. I didn't have a name for it. It was just me freaking out about everything, big or small," she says. When she tried to make an appointment with the counseling center, she was put on a two-week waitlist. When she finally met with a therapist, she wasn't able to set up a consistent weekly appointment because the center was overbooked. "I felt like they were more concerned with, 'Let's get you better and out of here,'" she says, "instead of listening to me. It wasn't what I was looking for at all."

Instead, she started meeting weekly with an off-campus therapist, who her parents helped find and pay for. She later took a leave of absence midway through her sophomore year to get additional help. Hashmonay thinks the university could have done more, but she notes that the school seemed to be facing a lack of resources as more students sought help. "I think I needed something that the university just wasn't offering," she says.

A spokesperson for Rensselaer says the university's counseling center launched a triage model last year in an effort to eliminate long wait times caused by rising demand, assigning a clinician to provide same-day care to students presenting signs of distress and coordinate appropriate follow-up treatment based on the student's needs.

Some students delay seeing a counselor because they question whether their situation is serious enough to warrant it. Emmanuel Mennesson says he was initially too proud to get help when he started to experience symptoms of anxiety and depression after arriving at McGill University in Montreal in 2013 with plans to study engineering. He became overwhelmed by the workload and felt lost in classes where he was one student out of hundreds, and began ignoring assignments and skipping classes. "I was totally ashamed of what happened. I didn't want to let my parents down, so I retreated inward," he says. During his second semester, he didn't attend a single class, and he withdrew from school that April.

For many students, mental health struggles predated college, but are exacerbated by the pressures of college life. Albano says some of her patients assume their problems were specific to high school. Optimistic that they can leave their issues behind, they stop seeing a therapist or taking antidepressants. "They think that this high school was too big or too competitive and college is going to be different," Albano says. But that's often not the case. "If anxiety was there," she says, "nothing changes with a high school diploma."

Counselors point out that college students tend to have better access to mental health care than the average adult because counseling centers are close to where they live, and appointments are available at little to no cost. But without enough funding to meet the rising demand, many students are still left without the treatment they need, says Ben Locke, Penn State's counseling director and head of the Center for Collegiate Mental Health.

The center's 2016 report found that, on average, universities have increased resources devoted to rapid-access services - including walk-in appointments and crisis treatment for students demonstrating signs of distress - since 2010 in response to rising demand from students. But long-term treatment services, including recurring appointments and specialized counseling, decreased on average during that time period.

"That means that students will be able to get that first appointment when they're in high distress, but they may not be able to get ongoing treatment after the fact," Locke says. "And that is a problem."

'We're busier than we've ever been'

In response to a growing demand for mental health help, some colleges have allocated more money for counseling programs and are experimenting with new ways of monitoring and treating students. More than 40% of college counseling centers hired more staff members during the 2015-16 school year, according to the most recent annual survey by the Association for University and College Counseling Center Directors.

"A lot of schools charge $68,000 a year," says Dori Hutchinson, director of services at Boston University's Center for Psychiatric Rehabilitation, referring to the cost of tuition and room and board at some of the most expensive private schools in the country. "We should be able to figure out how to attend to their whole personhood for that kind of money."

At the University of Iowa, Counseling Director Barry Schreier increased his staff by nearly 50% during the 2017-18 academic year. Still, he says, even with the increase in counseling service offerings, they can't keep up with the number of students coming in for help. There is typically a weeklong wait for appointments, which can reach two weeks by mid-semester. "We just added seven full-time staff and we're busier than we've ever been. We're seeing more students," Schreier says. "But is there less wait for service? No."

The university has embedded two counselors in dorms since 2016 and is considering adding more after freshmen said it was a helpful service they would not have sought out on their own. Schreier also added six questions about mental health to a freshman survey that the university sends out several weeks into the fall semester. The counseling center follows up with students who might need help based on their responses to questions about how they'd rate their stress level, whether they've previously struggled with mental health symptoms that negatively impacted their academics, and whether they've ever had symptoms of depression or anxiety. He says early intervention is a priority because mental health is the number one reason why students take formal leave from the university.

As colleges scramble to meet this demand, off-campus clinics are developing innovative, if expensive, treatment programs that offer a personalized support system and teach students to prioritize mental wellbeing in high-pressure academic settings. Dozens of programs now specialize in preparing high school students for college and college students for adulthood, pairing mental health treatment with life skills classes - offering a hint at the treatments that could be used on campus in the future.

When Spigner took a medical leave from the University of Richmond, she enrolled in College Re-Entry, a 14-week program in New York that costs $10,000 and aims to provide a bridge back to college for students who have withdrawn due to mental health issues. She learned note-taking and time management skills in between classes on healthy cooking and fitness, as well as sessions of yoga and meditation.

Mennesson, the former McGill engineering student, is now studying at Westchester Community College in New York with the goal of becoming a math teacher. During his leave from school, he enrolled in a program called Onward Transitions in Portland, Maine that promises to "get 18- to 20-somethings unstuck and living independently" at a cost of over $20,000 for three months, where he learned to manage his anxiety and depression.

Another treatment model can be found at CUCARD in Manhattan, where patients in their teens and early 20s can slip on a virtual reality headset and come face-to-face with a variety of anxiety-inducing simulations - from a professor unwilling to budge on a deadline to a roommate who has littered their dorm room with stacks of empty pizza boxes and piles of dirty clothes. Virtual reality takes the common treatment of exposure therapy a step further by allowing patients to interact with realistic situations and overcome their anxiety. The center charges $150 per group-therapy session for students who enroll in the four-to-six-week college readiness program but hopes to make the virtual reality simulations available in campus counseling centers or on students' cell phones in the future.

Hashmonay, who has used the virtual reality software at the center, says the scenarios can be challenging to confront, "but the minute it's over, it's like, 'Wow, OK, I can handle this.'" She still goes weekly to therapy at CUCARD, and she briefly enrolled in a Spanish course at Montclair State University in New Jersey in January. But she withdrew after a few classes, deciding to get a job and focus on her health instead of forcing a return to school before she is ready. "I'm trying to live life right now and see where it takes me," she says.

Back at the University of Richmond for her senior year, Spigner says the attitude toward mental health on campus seems to have changed dramatically since she was a freshman. Back then, she knew no one else in therapy, but most of her friends now regularly visit the counseling center, which has boosted outreach efforts, started offering group therapy and mindfulness sessions, and moved into a more private space. "It's not weird to hear someone say, 'I'm going to a counseling appointment,' anymore," she says.

She attended an open mic event on Richmond's campus earlier this semester, where students publicly shared stories and advice about their struggles with mental health. Spigner, who meets weekly with a counselor on campus, has become a resource to many of her friends because she openly discusses her own mental health, encouraging others not to be ashamed to get help.

"I'm kind of the go-to now for it, to be honest," she says. "They'll ask me, 'Do you think I should go see counseling?'" Her answer is always yes.

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Record Numbers of College Students Are Seeking Treatment for Depression and Anxiety

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Not long after Nelly Spigner arrived at the University of Richmond in 2014 as a Division I soccer player and aspiring surgeon, college began to feel like a pressure cooker. Overwhelmed by her busy soccer schedule and heavy course load, she found herself fixating on how each grade would bring her closer to medical school.

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Behavioral health has become a public health crisis. No other public health crises are as widespread or contribute as much to the burden of illness in the U.S. as do behavioral health disorders. By 2020, mental and substance use disorders will surpass all physical diseases worldwide as major causes of disability.

Around the world we are gradually winning public health battle after public health battle. The CDC list of "Ten Great Public Health Achievements, 2001-2010" includes significant improvements globally with respect to infant mortality, vaccine-preventable diseases, access to safe water & sanitation, malaria, HIV, tuberculosis, tropical diseases, tobacco, road safety, and response to pandemics.

Meanwhile, developed nations are leading the world with respect to a new generation of public health crises relating to physical health (chronic diseases, such as heart disease and diabetes) and behavioral health (mental illness & substance abuse). As noted above, by 2020, "mental and substance use disorders will surpass all physical diseases worldwide as major causes of disability."

The perspective of the public health establishment is that the behavioral health crisis must be met with increased funding for "public behavioral health services." From their perspective, we need massive new investments in treatment centers, counselors, therapists, psychologists and psychiatrists, community interventions, etc.

The Hippocratic Oath exhorted doctors to "first do no harm." In order to scale back the accelerating public health crisis stemming from mental health and substance abuse issues, I propose that public health officials first reflect on the role of government-managed secondary education in causing our epidemic of mental illness and substance abuse.

Stated so bluntly, my thesis is controversial. But it is not controversial that lifelong substance abuse (see here, here, and here) and mental illness typically start in adolescence. As the National Institute of Mental Health notes, "Mental disorders are really the chronic diseases of the young." The appropriateness of focusing on adolescent years is not controversial.

There are those who regard behavioral health as strictly a matter of genetics. That said, the Center for Disease Control has firmly stated the role of "school connectedness" in preventing adolescent dysfunction:
School connectedness was found to be the strongest protective factor for both boys and girls to decrease substance use, school absenteeism, early sexual initiation, violence, and risk of unintentional injury (e.g., drinking and driving, not wearing seat belts). In this same study, school connectedness was second in importance, after family connectedness, as a protective factor against emotional distress, disordered eating, and suicidal ideation and attempts.

The data above is taken from a study of 36,000 teens.

Researchers are only now discovering just how deeply these connections go. For instance, a 2007 article in the Journal of Adolescent Health discovered a direct connection between early teen experiences and mental health. They surveyed a cohort of almost 3,000 teens at grade 8, grade 10, and one year after graduation:

Overall, young people's experiences of early secondary school and their relationships at school continue to predict their moods, their substance use in later years, and their likelihood of completing secondary school. Students with good school and good social connectedness are less likely to experience subsequent mental health issues and be involved in health risk behaviors, and are more likely to have good educational outcomes.

In a world in which an estimated one third of teens are on prescription medication, and almost half of those are on psychiatric drugs ( ADHD, anti-depressent, anti-psychotics, and anti-anxiety), it is important for more parents to realize that school may be a causal factor with respect to their child's depression.

Another cohort study of 2,000 teens states bluntly in its report title: " School Connectedness Is an Underemphasized Parameter in Adolescent Mental Health."It explicitly suggests that a lack of school connectedness is a causal factor in mental health issues.

School connectedness also predicted depressive symptoms 1 year later for both boys and girls, anxiety symptoms for girls, and general functioning for boys, even after controlling for prior symptoms. . . . Results suggest a stronger than previously reported association with school connectedness and adolescent depressive symptoms in particular and a predictive link from school connectedness to future mental health problems.

Pharmaceutical companies invest significant marketing dollars into persuading parents and health care practitioners that depression is a biochemical disorder to be corrected by pharmaceuticals. But what if a significant portion of adolescent dysfunction and mental illness is actively caused by a child's feeling of disconnection from the school community?

A recent dissertation on schools and depression summarizes the scale of the issue:

Depression is a debilitating condition that is increasingly recognized among youth, especially adolescents. Nearly a third of adolescents experience a depressive episode by age 19 and an increasing number of youth experience depressed mood, subsyndromal symptoms, and minor depression. The prevalence of depression is particularly high among female, racial minority and sexual minority youth. . . . major depression and subthreshold depressive symptoms often first appear during the adolescent years. Rates of depression steadily increase from ages 12 to 15. Based on retrospective studies of depressed adults and prospective studies of youth, major depression is most likely to emerge during the mid-adolescent years (ages 13-15). Prospective studies that follow the same children over time reveal a dramatic increase in the prevalence of major depressive episodes after age 11 and again after age 15, with a flattening of rates in young adulthood.

Moreover, the importance of school connectedness extends to suicide as well:

The protective associations of higher school connectedness for suicidality in adolescents after accounting for the presence of depressive symptoms suggests that enhancing school connectedness may be a useful universal strategy for preventing suicidal behaviours in adolescents.

There is growing mainstream recognition that "school connectedness" is a significant risk factor for adolescent dysfunction, including substance abuse, mental illness, and suicide. Certainly "family connectedness" is also important. But as Judith Rich Harris showed twenty years ago, for adolescents peers are much more important an influence on behavior than are parents. In prominent surveys, "School connectedness" includes

I feel close to people at this school.

I am happy to be at this school.

I feel like I am part of this school.

The teachers at this school treat students fairly.

I feel safe in my school.

Clearly relationships to peers and educators are key variables here. Guess what? Human relationships are important to adolescents.

Meanwhile, a Gallup poll finds that only 44 percent of high school students feel engaged at school. Beyond a "smoking gun," this is an obvious catastrophe. For decades pop culture has been celebrating teen loathing of school: Alice Cooper, "School's Out," Pink Floyd, "Another Brick in the Wall," or as Rolling Stone describes Mogwai's "I Love You, I'm Going to Blow Up Your School,"

And what better way to show that special someone how much you care? For seven minutes the Scottish noise-rock monks of Mogwai ride a slow fuse from somber restraint to explosive chaos, adding their own unique contribution to rock's rich canon of school-as-murderous-hellhole songs - from Hüsker Dü's "Guns At My School" to the Dead Milkman's "Violent School" to the Boomtown Rats' school-shooting lament "I Don't Like Mondays."

Sometimes I wonder what planet public health researchers live on. Haven't they noticed that school is hell?

Here we find the key problem: Academic research is generated by individuals who underwent a self-selection process. Those who found school tolerable are more likely to continue formal education. Some eventually become degreed experts with the authority to dictate to others what education should look like. Meanwhile, most who find school a living hell leave and never look back.

Although I was a straight A student who got into Harvard, to this day I regard my secondary school years as the most boring and cruel years of my life. I was completely sympathetic then and now to those who hate school - many of whom self-medicated to address the boredom and cruelty (often thereby starting on the path to substance abuse) and/or were horribly depressed.

What if the institution of school itself is only appropriate for a fraction of our population? Perhaps those 44% who are engaged according to Gallup? What if school was actively harmful for most of the rest? Not just, "bummer" harmful, but contributing to lifelong substance abuse and mental illness harmful?

In Mind, Modernity, and Madness, Liah Greenfeld argues that reforming education is the only real solution we have to addressing the mental health epidemic. While she acknowledges there are genetic and familial factors that may predispose one to mental illness, the fact that rates of mental illness increase as nations transition from traditional cultures to modern cultures, and continue to increase with prosperity, is evidence that a cultural variable is essential to explain the growing prevalence of mental illness. Because some believe that the increased prevalence of mental illness may be a reporting artifact, note the increased prevalence of teen suicide in the modern world: rates in the U.S. are up about 3x since 1950. An astute student of Durkheim, she recommends greater urgency in addressing the growing anomie in the modern world that has resulted in higher rates of suicide, substance abuse, and mental illness.

What does "school connectedness" and "identity formation" have to do with public schools "causing" mental illness? By and large, there is little evidence that private schools are much better. Indeed, while Catholic students at Catholic schools are at a lower risk of suicide than the population as a whole, non-Catholic students at Catholic schools faced a 2-4 x higher risk of suicide. Private religious schools might actually be more dangerous if there is a mismatch.

Is it possible to create better schools, or should we simply accept that a growing percentage of our population will be depressed, try to counsel alienated teens from suicide and substance abuse, and accept the associated health care costs anticipated by the public health establishment?

I've spent most of my life creating small private and charter schools where teens who were previously miserable become happy and well. I've worked with dozens of teens who had been depressed, suicidal, and medicated with various pharmaceuticals become happy and well without "medication." Let's hear from a teen who was suicidal but is no longer thanks to a change in school environment,

I walk through the hallways of the public middle school on my way to the bathroom. I stop in the center of hallway staring ahead at the overwhelming endless hallway, no one in sight. clenching my fists I look around panicky around the solid brick white wall. No sign of anyone or anything living anywhere. I scratch my fingernails hard on the plastered wall. not making a dent. I do this several times until the tips of my fingers look like the tops of roses. I then start hitting my head then slamming my body against the wall still hitting my head trying to get out . . .

A backpack of melancholy weighs down on my shoulders so I free the questions inside with my thoughts: Why did I have to be depressed?, Why couldn't I learn like everyone else?, Why did I have to be scared? . . . I figured something was wrong with me. Just an idiot with issues, too stupid to learn and too ungrateful to be happy. All I could ever do was make my parents and the people around me worry. I was angry at myself, I was angry that I couldn't learn or be happy. If all I could do was make my parents worried I was just a waste of time to them. I didn't deserve to live I wanted to hurt myself. . . .

I stayed up all night in bed fearing the next day of school. I eventually did start talking to the school counselor about my problems. At first I would come in calmly and just talk to her. Then I started coming in every single day crying and more depressed than the day before. Sometimes I just came in asking to call my mom. I never told anyone that I wanted to commit suicide. Until the day I told my mom.

I fiddle with lock and push open the steel door to the inside of my small house. Immediately I drop my school bag near the the front door. Mom is still at work. Slowly walking to the kitchen I stare at the sharp kitchen knife tucked into the knife block. Slowly still walking toward it I carefully take out the knife and feel the blade across my finger. I endeavor to conceive how much it would hurt if I were to stab it into my chest. I pose the knife back in its place. i'm too afraid too and cowardly of the pain. I think of less brutal ways but all thoughts fail. . . .

There is nothing abstract about these issues for me. Sure we could add more counselors and medication. But simply changing schools, from a one-size-fits-all public school to one at which she was allowed to learn at her own pace in her own way, in a warm, supportive peer culture, eliminated the misery.

But our system creates unreasonable obstacles to the creation of such schools. Because of my experience creating small, personalized schools, I am intimately familiar with the obstacles to creating them. For instance, my current school, The Academy of Thought and Industry, with campuses in San Francisco, New York, and Austin is working to persuade accrediting organizations that students should be allowed to take advanced academic courses whenever they want rather than follow grade-level curricula. Even in the world of private schools, mainstream accreditation agencies tend to force mainstream expectations on schools.

Because I know it is possible to create schools that integrate emotional well-being with academic performance, if it was not so challenging to create such schools the demand would be great for them. If parents could choose schools at which their children were happy and well, they would do so. Indeed, in light of the high stakes associated with school connectedness, as recognized as the CDC, I go ballistic when I read about education researchers insulting the judgment of parents who choose to leave public schools, such as this summary of a famous 2006 paper by Judy Jackson May:

"Many parents base their school choice decision on factors that have nothing to do with the quality of education" (May, 2006, p. 28). In her study, parents reflected on positive feelings, which translated into smaller class sizes, teacher familiarity, one-on-one attention, and a sense of belonging. May refers to this construct as "the perception gap" - the positive expressions parents charter schools that are consistent more with their feelings rather than with achievement results, but are ultimately defined as "academic satisfaction."

She calls parents' decision to put their children in a school with " smaller class sizes, teacher familiarity, one-on-one attention, and a sense of belonging" a "perception gap"? I perceive I don't want my child to kill herself, and you call that a "perception gap" that has "nothing to do with the quality of education"? WTF?

I used to be optimistic about the charter school movement. Indeed, I co-created a charter school in rural New Mexico that was ranked the 36th best public high school in the U.S. (and ranked the best public high school in NM by K12.Niche.com in 2016). But federal control restricts charter school autonomy too much to address our public health crisis. In order to create fundamentally new kinds of schools, educators need freedom from all existing curricular constraints, licensing constraints, and testing constraints. As long as opportunities for "innovation" in education are constrained by the same constraints faced by public schools, innovators only have small parameters within which to innovate.

In order to develop robustly healthy personal identities in a world of anomie and constant change, adolescents will need to be embedded in new subcultures which have not yet been developed. Thus rather than new technology, new pedagogies, new evaluations, and so forth, the educational project of the future is the creation of new, deliberately developed teen subcultures that will support lifelong happiness and well-being.

Thus it is not so much that public schools per se are causing mental illness. But their existence and dominance are preventing the evolution of a better system much as the existence and dominance of the Soviet Union prevented the evolution of an innovative technology sector. We need an innovative humanities sector to address the behavioral health crisis coming our way. It must be based on radical freedom to create new systems of education and new subcultures of well-being.

What will they look like? We don't know. But if you'd like to explore ten school designs that are "eye-poppingly liberating to the pedagogical imagination" (in the words of the poet Fred Turner), please do so. And improve upon them. And allow them. Let's get started now.

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Are Public Schools Causing an Epidemic of Mental Illness?

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Behavioral health has become a public health crisis. No other public health crises are as widespread or contribute as much to the burden of illness in the U.S. as do behavioral health disorders. By 2020, mental and substance use disorders will surpass all physical diseases worldwide as major causes of disability.