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A Study on the Relationship Between Academic Stress and Mental

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A Study on the Relationship Between Academic Stress and Mental

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Health Among High School Students in South Korea

The article "A Study on the Relationship Between Academic Stress and Mental Health" is a journal article that was issued in a peer-reviewed academic journal. The author of the work is Ji-Hye Chung. This adds to my understanding of the students' experience of stress, through empirical evidence showing that mental health, important for the development of effective strategies that manage stress between school and work commitments, may be adversely affected by academic stress.

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College Students: Mental Health Problems and Treatment Considerations

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College Students: Mental Health Problems and Treatment Considerations

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College Students: Mental Health Problems and Treatment Considerations" is an article in a peer-reviewed scholarly journal written by the author, Palola Pedrelli. The contribution this article makes toward my understanding of the stressor phenomena experienced by students is related to exploring specific mental health concerns faced by students and discussions regarding considerations for treatment; thus, the development of comprehensive strategies to cope with academic and work demands serves as evidence.

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Abstract

Attending college can be a stressful time for many students. In addition to coping with academic pressure, some students have to deal with the stressful tasks of separation and individuation from their family of origin while some may have to attend to numerous work and family responsibilities. In this context, many college students experience the first onset of mental health and substance use problems or an exacerbation of their symptoms. Given the uniqueness of college students, there is a need to outline critical issues to consider when working with this population. In this commentary, first, the prevalence of psychiatric and substance use problems in college students and the significance of assessing age of onset of current psychopathology are described. Then, the concerning persistent nature of mental health problems among college students and its implications are summarized. Finally, important aspects of treatment to consider when treating college students with mental health problems are outlined, such as the importance of including parents in the treatment, communicating with other providers, and employing of technology to increase adherence. It is concluded that, by becoming familiar with the unique problems characteristic of the developmental stage and environment college students are in, practitioners will be able to better serve them.

Keywords: College, Mental health, Treatment considerations

Mental health problems are very common among college students [ 1]. This may be due to the fact that attending college corresponds to a challenging time for many traditional and non-traditional undergraduate students. Traditional college students start college after completing high school, are typically younger, depend on parents for financial support, and do not work or work part-time [ 2]. Thus, in addition to stress related to academic load, these students may have to face the task of taking on more adult-like responsibilities without having yet mastered the skills and cognitive maturity of adulthood. For example, many traditional college students may face potentially stressful experiences for the first time including working, being in a significant relationship that may lead to marriage, or having housemates with cultures and belief systems different from their own [ 3]. Non-traditional college students are often employed full-time, older, and may have dependents other than their spouses [ 3]. Thus, this group of students may have to cope with meeting work and family demands in addition to academic requirements. In these contexts, many college students may experience the persistence, exacerbation, or first onset of mental health and substance use problems while possibly receiving no or inadequate treatment. With the increasing recognition of child mental health issues and the use of more psychotropic medications, the number of young adults with mental health problems entering college has significantly increased. For example, in a survey of 274 institutions, 88 % of counseling center directors reported an increase in "severe" psychological problems over the previous 5 years including learning disabilities, self-injury incidents, eating disorders, substance use, and sexual assaults [ 4]. Thus, there is an increase in demand for counseling and specialized services. However, the increase in demands has not always corresponded to an increase in staff [ 4]. In particular, counseling centers are in need of psychiatrists with expertise in treating traditional as well as non-traditional college students, two groups with specific age-related characteristics and challenges. In this commentary, the prevalence of psychiatric and substance use problems in college students, as well as their common onset, will be described. Next, the worrisome persistent nature of mental health problems among college students and its implication will be discussed. Finally, important treatment considerations for traditional and non-traditional college students will be outlined.

Prevalence of Mental Health Disorders

Most mental health disorders have their peak onset during young adulthood. Kessler et al. [ 5] observed that by the age of 25 years, 75% of those who will have a mental health disorder have had their first onset. Among traditional students, the significant disruptions associated with attending college may exacerbate current psychopathology that first manifested in childhood and/or trigger its first onset. Similarly, non-traditional students who may have to attend to the demands of their numerous roles (work and family) may experience an exacerbation of their symptoms or a relapse.

Anxiety disorders are the most prevalent psychiatric problems among college students, with approximately 11.9 % of college students suffering from an anxiety disorder [ 1]. Among the anxiety disorders, social phobia has an early age of onset (median age of onset between 7-14 years), while panic disorder, generalized anxiety disorders (GAD), and post-traumatic stress disorder (PTSD) have somewhat later onsets [ 6]. Giaconia et al. [ 7] found that in a community sample of adolescents the peak risk period for developing PTSD was between the ages of 16 to 17 years, with approximately one third of the sample developing the disorder by the age of 14 years [ 7]. Through a national mental health survey, Vaingankar et al. [ 8] examined 6,616 respondents and reported that the mean age of onset for obsessive-compulsive disorder (OCD) was 19 years of age and 20 years of age for GAD. Thus, many traditional students with PTSD may have experienced symptoms before college, whereas those with GAD and OCD may start experiencing symptoms while in college.

Another common mental health problem among college students is depression, with prevalence rates in college students of 7 to 9 % [ 1, 9]. Zisook et al. [ 10] found that over half of all cases of depression had a first onset during childhood, adolescence, or young adulthood. Similarly, others have shown an elevated risk for mood disorders beginning in the early teens increasing with age in a linear fashion. In the National Comorbidity Survey-Replication study, Kessler et al. [ 6] reported that one out of every five individuals with depression had their first episode by the age of 25 years. The onset of bipolar disorder (BAD) appears to follow a similar trend. Approximately 3.2 % of college students meet the criteria for BAD [ 1]. An emerging literature has shown that the majority of adults with BAD have the onset of their disorder in child and adolescent years, with at least a third of adults with BAD having their onset before the age of 12 years [ 11].

Suicide, although not a specific diagnosis, is the third leading cause of death among young adults and is a significant problem among college students [ 12]. A large survey reported that among 8,155 students, 6.7 % reported suicidal ideation, 1.6 % reported having a suicide plan, and 0.5 % reported making a suicide attempt in the past year [ 13]. Given that many students with suicidal ideation do not seek treatment, it is critical to implement screening strategies to identify them and engage them in treatment [ 14, 15]. Among the major risk factors for suicide in this age group are depression [ 16], hopelessness [ 17, 18], and substance use [ 19, 20].

Eating disorders such as bulimia, anorexia, and binge eating are common and often have their onset during adolescence with a rapid increase in risk during early adulthood [ 21]. For instance, a survey of 2,822 college students reported that 9.5% of students screened positive for an eating disorder with a greater proportion of females relative to males (13.5 vs. 3.6 %, respectively) [ 22]. Stice et al. [ 23] found that peak periods of risk for onset was between 17 and 18 years of age for bulimia nervosa and binge-eating disorder, and was between 18 and 20 years for purging behavior (feeding or eating disorder not elsewhere classified). They also found that sub-threshold eating disorders are even more common than full criteria-eating disorders, with both full and subthreshold disorders associated with significant impairment [ 23].

Attention-deficit/hyperactivity disorder (ADHD) onsets during childhood and persists into adulthood in approximately one half of cases and negatively affects many critical areas in young adults. Between 2 and 8 % of college students suffer from ADHD and approximately one fourth of students receiving disability services have ADHD [ 24]. ADHD is associated with poor academic performance [ 25], social difficulties, and an increased risk for alcohol and drug use [ 26] that further exacerbate difficulties in college.

There is a paucity of literature regarding the prevalence of schizophrenia among college students; however, it appears that symptoms in the psychotic spectrum are not uncommon among college students. Studies have described the course of schizophrenia as having its beginning in early adolescence and persisting into young adulthood. Sham et al. [ 27] studied 270 schizophrenic probands in an older Swedish study and found that for both males and females there was a rapid increase in the onset of schizophrenia in late teens and early twenties followed by a lower risk of onset in the late twenties. Similar results were found by Hafner et al. [ 28], who studied 267 patients with schizophrenia and found that the initial onset of the disorder showed an early and steep increase in young adulthood until the age of 25 years. Furthermore, they found that 47% of females and 62% of males in the sample had their first symptoms of schizophrenia before the age of 25 years. Thus, young adults in college may experience the prodromal or early manifestation of a first onset of a psychotic disorder.

Autism spectrum disorders (ASDs) include a group of related complex and chronic neurodevelopment disorders, which are generally characterized by a variable presentation of problems with socialization, communication, and behavior [ 29]. Although ASDs are typically considered very disabling, a number of young people with ASDs do not have co-occurring intellectual impairment or language speech impairment (i.e., high functioning autism spectrum disorder and Asperger's disorder) and are able to attend college. Interestingly, a sample of 667 college students at a single university was used to diagnostically and dimensionally assess the rate of high functioning ASD in college populations. The study found that depending upon the ascertainment method between 0.7 and 1.9 % of college students could meet the criteria for high-functioning ASD [ 30]. Although the severity of ASD may decline during the adult period, individuals continue to have poor social functioning and often continue to require services [ 31- 34]. Thus, to enable people with ASD to succeed in college, providers should ensure that specific accommodations regarding academics, independent living, and social and vocational counseling are implemented [ 35].

Substance Use Among Young Adults in College

The use of alcohol and illicit drugs peaks during young adulthood and slowly declines with age [ 36]. Therefore, it is not surprising that the most prevalent problem among college students is the presence of substance use disorders. Approximately one in five college students meet the criteria for alcohol use disorder (AUD) in the previous year (12.5 % alcohol dependence and 7.8 % alcohol abuse) [ 37]. Another hazardous behavior common among college students is binge drinking, defined as consuming four standard drinks for women and five for men in a 2-h period [ 38]. Nearly half (44 %) of college students binge drink, and one in five engages in this behavior frequently [ 39, 40]. Binge drinking is considered the number one public health hazard and the primary source of preventable morbidity and mortality for college students in the USA. Among college students, alcohol consumption is associated with motor vehicle accidents, another leading cause of death in this age group [ 41], accidental injuries, unsafe sex, sexual assaults, and poor classroom performance, as well as impairments in prefrontal cortex functions such as memory and attention [ 39, 40, 42, 43]. Furthermore, many college students who are heavy drinkers continue to exhibit substance use-related problems after college [ 44, 45] and later develop an AUD [ 46]. Nicotine use is also very common, with 22-40 % of adolescent and young adult smokers meeting the criteria for dependence [ 47- 49]. Drug use disorders are less common, with approximately 1 in 20 students meeting the criteria (4.2 % drug abuse and 1.4 % drug dependence) [ 1]. Marijuana use is very prevalent in this population. A study by Suerken et al. [ 50] found that 30 % of those entering college admitted to using marijuana before college entry. Furthermore, according to the most recent 2012 data from the National Survey on Drug Use and Health [ 36], approximately 23.5 % of male full-time college students and 16.1 % of female full-time college students are current marijuana users. Cannabis use has been shown to negatively influence cognitive performance, memory, and achievement motivation, all of which can deleteriously impact educational achievement and lead to higher risk of school dropout, lower occupational attainment, and workforce failure [ 51- 53]. Among college students, binge drinking and cannabis use often co-occur. College students who drink heavily are approximately ten times more likely to use marijuana than those that are light drinkers [ 54]. Data from the National College Health Risk Behavior Survey shows that binge drinking students are nine times more likely to report lifetime use of marijuana than their non-binge drinking peers [ 55]. The increased risk for using illicit substances among binge drinkers has serious implications, given that alcohol use in combination with drug use is known to increase substance-related negative consequences [ 56], even when controlling for level of drinking [ 57].

In addition to substance use and hazardous alcohol use, college students often engage in non-medical use (or misuse) of prescription medications, namely taking prescription medications without a prescription or taking more than prescribed. Although in the past 2 years, the rates of non-medical use of pain relievers among young adults have decreased, they continue to be high [ 58]. According to the National Survey on Drug Use and Health, approximately one in ten young adults reported non-medical use of pain relievers in the past year [ 59]. Data suggest that the most commonly misused medications among college students include opioids, benzodiazepines (sedative/hypnotics), and amphetamine/methylphenidates (stimulants), with 5-35 % of college students having misused stimulants [ 60]. In a nationwide representative sample of 10,904 college students, McCabe et al. [ 61] found that the rates of non-medical use of prescription stimulants were highest among Caucasians, males, members of fraternities and sororities, and those who have lower grade point averages. In a study by Garnier-Dykstra et al. [ 62], assessing 1,253 college students, they found that by year four 61.8 % of students were offered prescription stimulants at least once and approximately one third had used them non-medically. They found that subjects endorsed friends as the most common source of prescription stimulants and the most common reason for use was to study [ 62]. Of concern is that over the past 20 years the rates of overdoses involving prescription drugs in the USA have reached epidemic proportions, with increased risk of overdosing for those using opioid analgesics or benzodiazepines and who have multiple prescriptions [ 63]. Nonmedical use of prescription medications often co-occur with heavy alcohol use [ 64], a worrisome occurrence given that alcohol taken in combination with analgesic opioids may further inhibit activity in the central nervous system, increasing the risk of oversedation, respiratory depression, and death. Regrettably, college students do not appear to view prescription drug abuse as problematic [ 64]. Practitioners should communicate with college students about the ethical, medical, psychological, addictive, and legal issues of prescription drug abuse. College students should be advised to take their medications as prescribed and not give or sell their medications to others. Safe storage of controlled substances such as benzodiazepines or stimulants is important.

Implications of Age of Onset on Trajectory of Psychopathology

When assessing college students, it is critical to determine the age of onset of current psychopathology. Specifically, early age of onset of any mental health disorder is associated with poorer outcome and may be associated with a different presentation from that of later onset. For example, several studies have found that early-onset anxiety disorders are associated with greater severity and chronicity than adult-onset [ 65]. Childhood onset anxiety appears to increase the likelihood for the development of other subsequent psychiatric comorbidity [ 66, 67]. Early age of onset of obsessive-compulsive disorder is associated with more symptomatology [ 68], higher rates of comorbid tic disorders [ 69], and higher frequency of tic-like compulsions [ 70]. Multiple studies have shown that childhood onset mood disorders are linked to longer episode duration, a higher number of depressive episodes among women, increased suicidality and need for hospitalization, and increased risk for other co-occurring mental health problems in adulthood [ 71- 73]. Similarly, an earlier onset of bipolar disorder is more problematic as it is associated with higher risk for co-occurring psychiatric and substance use disorders, less lithium responsiveness, more mixed presentations, and increased illness burden [ 74- 79]. Likewise, studies suggest that the onset of schizophrenia before the age of 18 years may correspond to a more chronic form of the disorder [ 80- 82] with studies reporting an overall lower psychosocial functioning and poorer long-term outcome related to early-onset schizophrenia [ 81, 83, 84]. Finally, among college students, age of first alcohol use is associated with heavier use and worse alcohol-related problems [ 85].

In summary, mental health problems are prevalent in college students, with substance use, anxiety, and mood disorders being the most common. Traditional college students are in a transitional age, young adulthood, which is associated with numerous stressors and during which many mental health problems often first occur. Non-traditional college students also face numerous stressors associated with having multiple roles, demands, and financial obligations. College students who have their first onset of mental illness or initiate substance use during childhood or adolescence appear to have a more pernicious trajectory and course of illness. Early identification of college students with mental health problems and thorough assessments are critical in order to provide adequate services and to ensure better outcomes, such as graduation.

Significance of Early Identification of Mental Health Problems and Outreach Strategies

Among college students, mental health problems not only are common, but they often persist for several years. Zivin et al. [ 86], through longitudinal data on 763 students, observed that 60 % of those who had a mental health problem at baseline continued to report at least one mental health problem 2 years later. The rate of persistence differed among disorders. For example, eating disorders were reported as most persistent, with 59 % of those reporting an eating disorder at baseline still having it at follow-up. Of the students with depression at baseline, 27 % continued to have it 2 years later. Self-injury behavior and suicidal thoughts also persisted. Approximately 40 % of students continued to report self-injury behavior and 35 % continued to report suicidal thoughts 2 years after baseline [ 86].

Lack of identification or acknowledgement (denial) of mental health symptoms and/or lack of or inadequate treatment are common problems among college students and may contribute to the persistence of mental health problems in this population. For instance, in a study by Zivin et al. [ 86], less than half of the college students with mental health problems persisting over 2 years received mental health treatment during that time period [ 86]. Other studies have also shown that the rates of treatment in college students are very low. For example, in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a national survey on adults including 2,188 college students, data showed that only 18 % of students with past year mental health diagnoses had received treatment in the previous year [ 1]. Specifically, 34 % of stder, 15 % of students with a diagnosis of anxiety disorder, and only 5 % of those with an alcohol or drug disorder received treatment. Similarly, the Healthy Minds study, a large online survey of college mental health, found that only 36 % of students who screened positive for a mental health problem including depression, panic disorder, GAD, suicidal ideation, or self-injury received treatment in the previous year [ 87]. A few reasons have been proposed for the low rates of help seeking in this population including fear of personal stigma, not perceiving treatment as urgent or essential, and lack of time [ 88, 89]. The Healthy Minds study also showed that more women receive treatment than men (39 vs. 30 %) [ 87]. It is concerning that even when students receive treatment it appears that often it is inadequate. Eisenberg et al. [ 87], on the basis of the Healthy Minds study, outlined that approximately only half of the students with depression received adequate care, defined as receiving 2 months of an antidepressant medication or at least eight sessions of counseling or therapy.

The early identification and treatment of psychopathology and substance use disorders impact the ultimate trajectory and sequelae of the disorder(s). With regard to bipolar disorder, it has been shown that the recurrence of episodes is associated with progressive loss of brain volume, that with the progression of the disease patients respond less to both pharmacotherapy and psychotherapy and that early intervention may be neuroprotective [ 90]. It has, therefore, been suggested to implement an "energetic broad-based treatment" during the first onset of bipolar disorder to change its trajectory [ 90]. Similarly, the Treatment and Intervention in Psychosis (TIPS) project showed that early detection and delivery of standard treatment for psychosis including antipsychotic medication, individual psychosocial treatment, and psychoeducational multifamily groups had positive effects on long-term functional outcome [ 91]. Moreover, it was shown that the duration of untreated psychosis has long-term negative effects on the course of the illness [ 91]. The presence of psychiatric and substance use problems during college is associated with a wide range of negative outcomes from unemployment, serious social and educational impairment [ 46, 92, 93], and obesity [ 94]. Together these studies underline the importance of prompt and adequate treatment of psychopathology to prevent neurocognitive and functional decline.

The problem of low treatment seeking in college students may be addressed by the use of technology. As noted previously, traditional as well as non-traditional students report that they do not seek help because of limited time or because they worry about what others may think [ 87, 95]. Technology-based programs for screening as well as for treatment would have the advantage of providing anonymity and could be available at any time and may be cost-effective. Escoffery et al. [ 96] found that 74 % of the students acknowledged having ever received health information online, and more than 40 % reported that they frequently searched the Internet for health information, suggesting that college students regularly use the Internet as a health resource. Several studies explored the use of Web-based surveys of depression and anxiety to screen for mood problems among college students [ 97]. Hass et al. [ 98] tested a Web-based method to perform screening for depression and other suicide risk factors, and respondents were provided personalized assessment and online communication with a clinical counselor. They reported that such an approach increased the rate of help-seeking behavior among at-risk students. Our team at the Massachusetts General Hospital Depression Clinical and Research Program showed that the use of emails and social networking sites, such as Facebook, is feasible and cost-effective for reaching out to college students and for depression screening [ 99]. Taken together, these studies support using Web-based programs with college students as a strategy to enhance treatment seeking. Moreover, it may be advisable to offer computer-based treatments to students who may be afraid of stigma or have limited time. For example, numerous Internet-based cognitive-behavioral therapy approaches are available that have been found effective for treating a range of mental health problems [ 100- 102].

Many students who present at college health centers have mental health problems [ 103]. Thus, a collaborative relationship between university health centers and behavioral health services may lead to an increase in identification and referrals for behavioral health treatments of students with mental health problems. A collaborative relationship between university health centers and behavioral health services can be categorized in several ways [ 104]. In the integrated model, medical and behavioral health services are delivered in an integrated manner as part of a team program. In this model, the team members have a treatment plan that includes medical as well as behavioral aspects [ 104]. Alternatively, medical and behavioral health services can be co-located, and services are coordinated as a result of medical and behavioral health staff sharing resources and being in the same location. Finally, when medical and behavioral health services are delivered at different locations, the services can be coordinated. In this model, information between health centers and behavioral health centers are exchanged in a formalized and established way [ 104]. In the last two models, the clinicians delivering medical care and those delivering behavioral health services are not part of the same team. An important aspect of coordination of services is the use of electronic medical records (EMRs). Specifically, the adoption of the use of EMRs may be associated with better care for college students because its use may enhance communication between providers, coordination, measurement, and decision support [ 105].

Treatment Considerations

Upon completion of thorough evaluation, evidence-based practice (EBP) interventions should be employed for the treatment of this population. Given that numerous resources are available outlining EBP for mental health problems, this commentary will not review them. The American Psychiatric Association (APA) provides evidence-based recommendations for the assessment and treatment of psychiatric disorders online ( http://psychiatryonline.org/guidelines.aspx), and the Substance Abuse and Mental Health Services Administration (SAMHSA) has a National Registry of EBP available online as well ( http://www.samhsa.gov/ebpWebguide/). The latter also provides links to other resources including the National Guideline Clearinghouse™ (NGC) ( http://www.guideline.gov/index.aspx), which is a comprehensive database of evidence-based clinical practice guidelines and related documents maintained by the Department of Health and Human Services. Clinicians may also consult several books, including A Guide To Treatment That Works [ 106]. Given that low adherence is a common problem among college students, providers may opt to enhance EBP with Motivational Interviewing (MI) [ 107]. MI has been shown to enhance engagement and adherence to psychosocial as well pharmacological treatments [ 108, 109], and thus, it could be useful to address these problems with college students. When treating college students, several issues ought to be considered related to the developmental stage as well as the context college students are in. Some considerations are relevant for the treatment of both traditional and non-traditional students and some are specific to each group. When treating traditional students, it is important to consider that most of them are still dependent on their parents, thus parental involvement in treatment is advisable. Parents could be invited to attend some of the treatment meetings with their children to address problems involving them or to be enlisted as a support source to facilitate improvement. When communicating with parents, it is important to educate them on what to expect during the early stages of symptom abatement and recovery, enhancing their ability to support the college student in coping with the cycles of both partial and full remissions and relapses over time. Allowing feedback and providing access in a proactive, mutually agreeable manner will not only enhance safety, but also facilitate support and treatment of the college student. Moreover, given the negative effect that parents' mental health problems have on children [ 110, 111], providers may consider offering referrals for mental health services to the parents who may need them. Services can be offered to parents even if their offspring are not willing to engage in the treatment. For example, the Community Reinforcement and Family Training (CRAFT) has been shown to help parents facilitate seeking treatment of family members who are substance users [ 112]. With regard to prevention interventions, Turrisi et al. [ 113, 114] have developed a parent-based intervention (PIB) that has been shown to be associated with reduction of binge drinking in the children of those who received it. Parents' involvement can be beneficial even when they live away from where the students are currently attending college as they could provide, even if remotely, critical information about the patient's history or they could ensure/facilitate continuity of care during school breaks. While the involvement of the parents can be beneficial, given that most young adults in college are over 18 years of age, the patient's consent is required. When conducting mental health evaluations of young adults in college, providers should routinely discuss the pros and cons of parental involvement and encourage it. Ideally, parents could be involved at a minimum as a resource for information and to ensure continuity of care.

Issues to consider with non-traditional college students relate to the fact that most of them have to juggle academic responsibilities as well as work and/or family commitments and demands. Thus, to ensure that these students receive adequate services, providers should have extended and flexible hours and even child care options. These students may need additional and different types of services than traditional students such as case management to deal with financial, housing, relational, and child rearing issues. Moreover, to address their family needs, they may be more likely to need couple counseling or family therapy.

One important issue to consider for all college students relates to the problem of continuity of care during school breaks. Providers should ensure continuity of care by establishing services during school breaks or by identifying strategies for maintaining mental health during this period. Care for college students may occur in different ways, and college providers must examine each situation carefully to ensure continuity of care. Some students may have a primary provider where they reside with their parents, may be followed remotely, and may need intermittent support while in college. In this case, the college providers should communicate with the provider at home to be aware of whether the student may be at risk for safety and their needs. Vice-versa, some students may have a primary provider at their college and may need a provider for either medication management or psychotherapy during breaks. In this scenario, the college's providers should ensure that the student will continue to receive adequate care while away. Not having insurance coverage may be a barrier to continuity of care. However, with the new healthcare reform, allowing US patients up to 26 years to be covered by their parent's insurance, college students may be able to have more options for care during breaks. In addition to ensuring continuous care, college providers may have to pay special attention to students whose needs cannot be addressed by the services provided on campus. Therefore, health centers or counseling centers should develop an extensive referral system easily accessible to their students with severe mental illness or in need of higher level of care. Lastly, some students may receive services from providers at their college as well as from outside their institution; therefore, it is critical that all providers coordinate care.

Conclusion

In this commentary, we aimed at illustrating critical issues to consider when treating college students with mental health problems. This commentary did not aim to be exhaustive and it includes a selected number of references. Therefore, the conclusions drawn are not the results of a systematic assessment. Moreover, our illustration refers to issues typical of undergraduate students, and we have not discussed problems present among graduate or medical students. The latter differ from undergraduate students in a number of important ways including academic responsibilities, campus life, and relationships with academic advisors. These limitations withstanding, we believe that mental health providers working in college campuses should enhance their training and knowledge by becoming familiar with the topics reviewed here.

In summary, mental health problems are common among college students. Academic pressure together with stressors typical of starting and attending college may precipitate the first onset of mental health and substance use problems or an exacerbation of symptoms. Often the nature of psychopathology is chronic due to low rate of treatment seeking and low adherence to treatment. Thus, it is critical to employ outreach programs and implement strategies to ensure treatment retention. Given that many traditional students continue to depend on their family while in college, parental involvement in treatment is important. Finally, given the effect that the academic calendar may have on continuity of care, it is critical for clinicians to ensure that college students receive treatment throughout the year and to coordinate with other clinicians that may be involved in the students' care. Thus, expertise in developmental psychopathology, family dynamics, specific college issues, and systems of care is critical to conduct clinical treatment to college students.

​

Mental health problems are prevalent among college students with substance use, anxiety, and depression being the most common.

It is critical for mental health providers to develop an extensive knowledge of the prevalence and range of mental health problems occurring among college students and of the various needs of traditional as well as non-traditional college students.

College students may receive services from mental health providers inside and outside the campus and the need for communication is critical.

Strategies to enhance treatment seeking and engagement among college students should be implemented.

Acknowledgments

This research was supported by NIH K24 DA016264 to Timothy Wilens and in part by NIAAA K23AA020064-012 to Paola Pedrelli. Timothy Wilens receives/d research support from or is/has been on the advisory board for the following Pharmaceutical Companies: National Institute on Drug Abuse (NIDA), Euthymics, Shire, Theravance, and TRIS. Dr. Timothy Wilens is or has been a consultant for Euthymics, Major League Baseball, Minor League Baseball, the National Football League, and Shire. Dr. Timothy Wilens has a published book with Guilford Press: Straight Talk About Psychiatric Medications for Kids.

Footnotes

Disclosure Drs. Pedrelli, Nyer, and Yeung as well as Ms. Zulauf have no conflicts of interest to report.

Contributor Information

Paola Pedrelli, Massachusetts General Hospital, Boston, MA, USA.

Maren Nyer, Massachusetts General Hospital, Boston, MA, USA.

Albert Yeung, Massachusetts General Hospital, Boston, MA, USA.

Courtney Zulauf, Massachusetts General Hospital, Boston, MA, USA.

Timothy Wilens, Massachusetts General Hospital, Boston, MA, USA.

References

8. Vaingankar JA, et al. Age of onset of life-time mental disorders and treatment contact. Soc Psychiatry Psychiatr Epidemiol. 2012 [[ PubMed] Google Scholar]

29. Joshi G, et al. Psychiatric Comorbidity and Functioning in a Clinically Referred Population of Adults with Autism Spectrum Disorders: A Comparative Study. J Autism Dev Disord. 2012 [[ PubMed] Google Scholar]

38. Alcoholism, N.I.o.A.A.a. Moderate & Binge Drinking. 2013 [ Google Scholar]

50. Suerken CK, et al. Prevalence of Marijuana Use at College Entry and Risk Factors for Initiation During Freshman Year. Addictive Behaviors. 2013 [[ PMC free article] [ PubMed] Google Scholar]

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College Students: Mental Health Problems and Treatment Considerations

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Attending college can be a stressful time for many students. In addition to coping with academic pressure, some students have to deal with the stressful tasks of separation and individuation from their family of origin while some may have to attend to ...

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The work–study relationship: experiences of full‐time university students undertaking part‐time employment

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The work–study relationship: experiences of full‐time university students undertaking part‐time employment

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The article "Perceived Organizational Support and Work Status: A Comparison of the Employment Relationships of Part-Time and Full-Time Employees Attending University Classes" is a journal article from a peer reviewed academic journal. The authors are Anika Gakvoic, and Lois E. Tetrick. This article adds to my knowledge about student stress by discussing the perceived organizational support for part-time and full-time student employees and indicates how important it is to have workplace support in reducing the stress of balancing work and academic life.

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J Organ Behavior - 2003 - Gakovic - Perceived organizational support and work status  a comparison of the employment

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Take Control of Your Schedule: How to Balance School, Work, and Life as a Student

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Take Control of Your Schedule: How to Balance School, Work, and Life as a Student

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"Take Control of Your Schedule: How to Balance School, Work, and Life as a Student" is a video uploaded on YouTube, prepared by Dr. Andre Pinesett. It gives practical tips that deal with time management and stress management in such a way as to balance school and work and thereby help students cope with the demands of school and work.

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Dr. Andre Pinesett: The Premed Productivity Expert

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Take Control of Your Schedule: How to Balance School, Work, and Life as a Student

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The video "How to Manage Stress as a Student" is posted on YouTube by Med School Insider. The video discusses how to handle stress caused by mental health challenges among people who have to balance work with academic life.

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Should You Work While You’re In College?

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Should You Work While You’re In College?

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"Should You Work While You're In College?" a youtube video by Shane Hummus is a video published on the site, which gives an actual insight into what students go through to balance their working and academic schedules, stressing how stressors would impact academic performance and life in general.

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Should You Work While You’re In College?

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Why is School so Stressful? Exploring Causes and Solutions

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Why is School so Stressful? Exploring Causes and Solutions

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"Why is School so Stressful? Exploring Causes and Solutions" is an online article published on the Healium platform by the author Sarah Hill. The article outlines several causes for stress in school and possible solutions, assisting me with how stressors affect a student's academic performance and mental well-being.

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Student anxiety encompasses a range of emotional responses and physiological reactions triggered by the pressures and demands students face during their educational journey.

This stress manifests in various ways, impacting students both mentally and physically. Common manifestations include:

* Persistent worry and fear about academic performance

* Heightened anxiety, especially during tests

* Difficulty concentrating

* Overwhelming or racing thoughts

From a neurological standpoint, excess academic stress sends the brain's beta brainwaves into overdrive, causing the heightened "fight or flight" state . This heightened state leads to difficulties in focusing, decreased cognitive performance, and an overall sense of restlessness.

Numerous studies and research have shed additional light on the detrimental effects of academic pressure on students' mental health, especially as it relates to feeling depressed or overwhelmed.

According to a study conducted by the American Psychological Association (APA) , during the school year, teenagers reported stress levels went well beyond what is deemed healthy, even surpassing the average reported stress levels of adults.

Additionally, 31 percent of teenagers disclosed feeling overwhelmed, while 30 percent admitted experiencing feelings of depression or sadness due to stress. An alarming 36 percent of teens reported feeling tired and nearly a quarter of them (23 percent) revealed that they had skipped meals as a consequence of stress.

The Anxiety and Depression Association of America 's data appears to validate those figures, with 80% of U.S. students report feeling stressed sometimes or often, while 34% felt depression.

The Main Factors That Make School so Stressful

1. Immense academic pressure placed upon students to excel in their studies. The pursuit of high grades and the fear of failure can create a formidable burden on young minds, leading to feelings of inadequacy and self-doubt.

2. The workload imposed on students can be overwhelming, leaving them juggling multiple assignments, projects, and extracurricular activities. This constant sense of urgency to manage competing responsibilities elevates stress levels.

3. High expectations from parents, teachers, and peers further intensifies student anxiety. The desire to meet others' standards and fear of disappointing loved ones creates a significant source of stress and pressure.

4. Social factors within the school environment can also contribute to student anxiety. Issues like peer competition, bullying, social isolation, and the fear of not fitting in can significantly impact students' emotional well-being.

Navigating Academic Pressure: The Burden on Modern Day Students

Students face intense pressure from a number of sources that creates a sense of mounting stress, damaging students' mental well-being and overall educational experience.

* Competitive Nature of Modern Education: Modern education systems have become highly competitive, fostering a culture of comparison and rivalry among students. This competitive atmosphere creates feelings of inadequacy and intensifies the pressure to outperform peers.

* Implications of Grades and Academic Achievements: Grades and academic achievements hold significant weight in shaping students' future opportunities. Colleges, universities, and employers often use academic records as a primary metric for evaluation. Consequently, students face tremendous pressure to maintain exceptional grades, fearing that a single setback could jeopardize their desired academic or professional paths.

A Look at High Homework Workload

Homework is undoubtedly a significant source of stress for students, particularly when the workload becomes overwhelming and time-consuming.

Homework and workload related stressors were among the most frequent responses from students when asked about their stress levels, according to statistics presented on Research.com . Finals and midterms was the top response from 31% of U.S. students, followed closely by class workload and homework.

We've written more extensively on this subject in our blog "Does Homework Cause Stress? Exploring the Impact on Students' Mental Health".

High Expectations from Parents and Teachers

The desire for students to meet these expectations often becomes a driving force in their academic pursuits, but it can also lead to adverse effects on their mental well-being.

Social Factors within the School Environment

Students navigate a complex web of interactions, and these social dynamics can play a pivotal role in contributing to their anxiety levels.

Peer competition, often fueled by academic pressures and extracurricular achievements, can create a constant sense of comparison and inadequacy. Moreover, the prevalence of bullying and the fear of not fitting in can lead to emotional distress, affecting students' overall well-being. Social isolation can be a silent yet significant stressor as well, as it leaves students feeling disconnected and unsupported.

How to Handle Stress from School: Coping Strategies and Support

When it comes to managing academic stress and reducing student anxiety, a proactive approach can make all the difference. Here are some tips to help students cope with the pressures of school life:

* Learn Stress-Relief Techniques: Breathing exercises, meditation, and mindfulness practices can calm the mind and promote relaxation.

* Time Management: Create a structured schedule that allocates time for studying, relaxation, and extracurricular activities. This helps prevent last-minute cramming and reduces the feeling of being overwhelmed.

* Seek Support from Teachers and Counselors: You don't have to navigate stress alone. Reach out to teachers and school counselors for academic and emotional support.

* Connect with Friends and Family: Strong social support systems act as buffers against stress.

* Avoid Overcommitment: Strike a balance between school, extracurriculars, and personal time. Learning to say no when feeling overwhelmed is crucial.

* Practice Positive Self-Talk: Challenge negative thoughts and replace them with positive affirmations. This fosters a healthy mindset and boosts confidence.

* Know When to Seek Professional Help: If stress becomes unmanageable and starts to interfere with daily life, seek guidance from mental health professionals.

Alleviating Academic Stress: How Healium Provides Solutions

Healium is a mental fitness tool that combines VR guided meditation experiences with data-driven biofeedback equipping students with essential tools to self-regulate their stress, anxiety, and mental well-being.

Our hope is that Healium paves the way for a more focused and productive learning experience, especially for students experiencing severe academic stress. As stress dissipates, students can engage more actively in class discussions and participate confidently in academic endeavors.

By empowering students with emotional resilience and providing a platform for inner peace, Healium not only enables them to overcome academic stress but also equips them with invaluable life skills.
To learn more about how to use Healium, watch our video below!

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Why is School so Stressful? Exploring Causes and Solutions - Healium

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Learn what makes school so stressful & the solutions that empower students to navigate academic pressures.

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Stress in College Students: What to Know

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Stress in College Students: What to Know

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"Stress among College Students: What to Know" is a news article in U.S. News & World Report written by Emma Kerr. The article provides an overview of the prevalence and sources of stress among college students, therefore helping me understand how this condition can affect academic performance and overall wellness.

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From paying for school and taking exams to filling out internship applications, college students can face overwhelming pressure and demands. Some stress can be healthy and even motivating under the proper circumstances, but often stress is overwhelming and can lead to other issues.

"Stress is there for a reason. It's there to help mobilize you to meet the demands of your day, but you're also supposed to have times where you do shut down and relax and repair and restore," says Emma K. Adam, professor of human development and social policy at Northwestern University in Illinois.

Chronic and unhealthy levels of stress is at its worst among college-age students and young adults, some research shows. According to the American Psychological Association's 2022 "Stress in America" report, 46% of adults ages 18 to 35 reported that "most days they are so stressed they can't function."

In a Gallup poll that surveyed more than 2,400 college students in March 2023, 66% of reported experiencing stress and 51% reported feelings of worry "during a lot of the day." And emotional stress was among the top reasons students considered dropping out of college in the fall 2022 semester, according to findings in the State of Higher Education 2023 report, based on a study conducted in 2022 by Gallup and the Lumina Foundation.

As students are navigating a new environment and often living independently for the first time, they encounter numerous opportunities, responsibilities and life changes on top of academic responsibilities. It can be sensory overload for some, experts say.

"Going to college has always been a significant time of transition developmentally with adulthood, but you add to it everything that comes along with that transition and then you put onto it a youth mental health crisis, it's just compounded in a very different way," says Jessica Gomez, a clinical psychologist and executive director of Momentous Institute, a researched-based organization that provides mental health services and educational programming to children and families.

Experts say college students have experienced heightened stress since the COVID-19 pandemic, a trend likely to continue for the foreseeable future.

"What some of our research at Gallup has shown is that we had a rising tide of negative emotions, not just in the U.S. but globally, in the eight to 10 years leading up to the pandemic, and of course it got worse during the pandemic," says Stephanie Marken, senior partner of the education research division at Gallup who conducted the 2023 study. "For currently enrolled college students, there's so many contributing factors."

Adam notes that multiple factors combine to contribute to heightened stress among younger adults, including the nation's racial and political controversies, as well as anxiety regarding their futures fueled by climate change, global unrest and economic uncertainty. Female students reported higher levels of stress than males in the Gallup poll, which Marken says could be attributed to several factors like increased internal academic pressure, caregiving responsibilities and the recent uncertainty regarding abortion rights following the reversal of Roe v. Wade.

All of this, plus the residual effects of pandemic learning, has contributed to rising stress for college students, Marken says.

"We need to give them a lot of credit," she says. "They had the most challenge in remote learning of all the learners that have come before them. Many of them had to graduate high school and study remotely, or were a first-year college student during the pandemic, and that was incredibly difficult."

The challenges that came with that learning environment will likely affect students throughout college, she says, as well as typical stressors like discrimination, harassment and academic challenges.

"Those will always be present on college campuses," she says. "The question is, how do we create a student who overcomes those challenges effectively?"

Experts suggest a range of specific actions and positive shifts that can help ease stress in college students:

Notice the symptoms of heightened stress.

Build and maintain social connections.

Sleep, eat well and exercise.

Notice the Symptoms of Heightened Stress

College students can start by learning to identify when normal stress increases to become unhealthy. Stress will appear differently in each student, says Lindsey Giller, a clinical psychologist with the Child Mind Institute, a nonprofit focused on helping children and young adults with mental health and learning disorders.

"Students prone to anxiety may avoid assignments as well as skip classes due to experiencing shame for being behind or missing things," she says. "For some, they may also start sleeping in more, eating at more random times, foregoing self-care, or look to distraction or escape mechanisms, like substances, to fill time and further avoid the reality of workload assignments."

Changes in diet and sleeping are also telling, as well as increased social isolation and pulling away from activities that once brought you pleasure is also a red flag, Gomez says.

She warns students to watch for signs of irritability, a classic indicator of increased stress that can often compound issues, especially within interpersonal relationships.

"Your body speaks to you, so be in tune with your body," she says.

Build and Maintain Social Connections

Socializing can help humans release stress. Experts say having fun and finding joy in life keep stress levels manageable, and socializing is particularly important developmentally for young adults. In the 2023 Gallup poll, 76% of students reported feeling enjoyment the previous day, which Marken says was an encouraging sign.

But 39% reported experiencing feelings of loneliness and 36% reported feeling sad. "We are in the midst of an epidemic of loneliness in our country, where we are noticing people don't have the skills to build friendships," Gomez says.

Talking about feelings of stress can help college students cope, which is why the amount of students feeling lonely is concerning, Marken says. If students don't feel like they belong or have a social network to call on when feeling stressed, negative emotions are compounded.

"I think we're more connected, and yet we're more isolated than ever," she says. "It feels counterintuitive. How can you be more connected to your network and campus than ever, yet feel this lonely? Just because they have a device to connect with each other in a transactional way doesn't mean it's a meaningful relationship. I think that's what we're missing on a lot of college campuses is students creating meaningful connections about a shared experience."

Setting boundaries on social media use is crucial, Gomez says, as is getting plugged in with people and organizations that will be enriching. For example, Gomez says she joined a Latina sorority to be in community with others who shared some of her life experiences and interests.

Sleep, Eat Well and Exercise

Maintaining healthy habits can help college students better manage stressors that arise.

"Prioritizing sleep, moving your body, getting organized, and leaning on your support network all help college students prevent or manage stress," John MacPhee, CEO of The Jed Foundation, a nonprofit that aims to protect emotional health and prevent suicide among teens and young adults, wrote in an email. "In the inevitable moments of high stress, mindful breathing, short brain breaks, and relaxation techniques can really help."

Experts suggest creating a routine and sticking to it. That includes getting between eight and 10 hours of sleep each night and avoiding staying up late, Gomez says. A nutrient-rich diet can also go a long way in maintaining good physical and mental health, she says.

Getting outdoors and being active can also help students limit their screen time and use of social media.

"Walking to campus, maybe taking that longer walk, because your body needs that to heal," Gomez says. "It's going to help buffer you. So if that's the only thing you do, try to do that."

Colleges typically offer mental health resources such as counseling and support groups for struggling students.

Students dealing with chronic and unhealthy stress should contact their college and reach out to friends and family for support. Reaching out to parents, friends or mentors can be beneficial for students when feelings of stress come up, especially in heightened states around midterm and final exams.

Accessing student supports and counseling early can prevent a cascading effect that results in serious mental health challenges or unhealthy coping mechanisms like problem drinking and drug abuse, experts say.

"Know there are lots of resources on campus from academic services to counseling centers to get structured, professional support to lower your workload, improve coping skills, and have a safe space to process anxiety, worry, and stress," MacPhee says.

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Stress in College Students: What to Know

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Strong social connections and positive habits can help ease high levels of stress among college-age adults.

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Academic stress and mental wellbeing in college students: Associations, vulnerable groups and the COVID-19

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Academic stress and mental wellbeing in college students: Associations, vulnerable groups and the COVID-19

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The journal article "Academic stress and mental wellbeing in college students: Associations, vulnerable groups and the COVID-19" published by the author Georgia Barbayannis in Frontiers in Psychology, explores associations such as academic stress and mental health, focusing on the challenges that each of the students faces during the COVID-19 pandemic and the correlates of the responses to outcomes of mental health.

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Department of Neurology, Rutgers New Jersey Medical School, Newark, NJ, United States

Rutgers New Jersey Medical School, Newark, NJ, United States

Office for Diversity and Community Engagement, Rutgers New Jersey Medical School, Newark, NJ, United States

Department of Biology, The College of New Jersey, Ewing, NJ, United States

Academic stress may be the single most dominant stress factor that affects the mental well-being of college students. Some groups of students may experience more stress than others, and the coronavirus disease 19 (COVID-19) pandemic could further complicate the stress response. We surveyed 843 college students and evaluated whether academic stress levels affected their mental health, and if so, whether there were specific vulnerable groups by gender, race/ethnicity, year of study, and reaction to the pandemic. Using a combination of scores from the Perception of Academic Stress Scale (PAS) and the Short Warwick-Edinburgh Mental Well-Being Scale (SWEMWBS), we found a significant correlation between worse academic stress and poor mental well-being in all the students, who also reported an exacerbation of stress in response to the pandemic. In addition, SWEMWBS scores revealed the lowest mental health and highest academic stress in non-binary individuals, and the opposite trend was observed for both the measures in men. Furthermore, women and non-binary students reported higher academic stress than men, as indicated by PAS scores. The same pattern held as a reaction to COVID-19-related stress. PAS scores and responses to the pandemic varied by the year of study, but no obvious patterns emerged. These results indicate that academic stress in college is significantly correlated to psychological well-being in the students who responded to this survey. In addition, some groups of college students are more affected by stress than others, and additional resources and support should be provided to them.

Introduction

The overall aim of this study was to assess academic stress and mental well-being in a sample of college students. Within this umbrella, we had several goals. First, to determine whether a relationship exists between the two constructs of perceived academic stress, measured by the Perception of Academic Stress Scale (PAS), and mental well-being, measured by the Short Warwick-Edinburgh Mental Well-Being Scale (SWEMWBS), in college students. Second, to identify groups that could experience differential levels of academic stress and mental health. Third, to explore how the perception of the ongoing COVID-19 pandemic affected stress levels. We hypothesized that students who experienced more academic stress would have worse psychological well-being and that certain groups of students would be more impacted by academic- and COVID-19-related stress.

Materials and Methods

Survey Instrument

A survey was developed that included all questions from the Short Warwick-Edinburgh Mental Well-Being ( Tennant et al., 2007; Stewart-Brown and Janmohamed, 2008) and from the Perception of Academic Stress Scale ( Bedewy and Gabriel, 2015). The Short Warwick-Edinburgh Mental Well-Being Scale is a seven-item scale designed to measure mental well-being and positive mental health ( Tennant et al., 2007; Fung, 2019; Shah et al., 2021). The Perception of Academic Stress Scale is an 18-item scale designed to assess sources of academic stress perceived by individuals and measures three main academic stressors: academic expectations, workload and examinations, and academic self-perceptions of students ( Bedewy and Gabriel, 2015). These shorter scales were chosen to increase our response and study completion rates ( Kost and de Rosa, 2018). Both tools have been shown to be valid and reliable in college students with Likert scale responses ( Tennant et al., 2007; Bedewy and Gabriel, 2015; Ringdal et al., 2018; Fung, 2019; Koushede et al., 2019). Both the SWEMWBS and PAS scores are a summation of responses to the individual questions in the instruments. For the SWEMWBS questions, a higher score indicates better mental health, and scores range from 7 to 35. Similarly, the PAS questions are phrased such that a higher score indicates lower levels of stress, and scores range from 18 to 90. We augmented the survey with demographic questions (e.g., age, gender, and race/ethnicity) at the beginning of the survey and two yes/no questions and one Likert scale question about the impact of the COVID-19 pandemic at the end of our survey.

Sample

Participants for the study were self-reported college students between the ages of 18 and 30 years who resided in the United States, were fluent in English, and had Internet access. Participants were solicited through Prolific ( https://prolific.co) in October 2021. A total of 1,023 individuals enrolled in the survey. Three individuals did not agree to participate after beginning the survey. Two were not fluent in English. Thirteen individuals indicated that they were not college students. Two were not in the 18-30 age range, and one was located outside of the United States. Of the remaining individuals, 906 were full-time students and 96 were part-time students. Given the skew of the data and potential differences in these populations, we removed the part-time students. Of the 906 full-time students, 58 indicated that they were in their fifth year of college or higher. We understand that not every student completes their undergraduate studies in 4 years, but we did not want to have a mixture of undergraduate and graduate students with no way to differentiate them. Finally, one individual reported their age as a non-number, and four individuals did not answer a question about their response to the COVID-19 pandemic. This yielded a final sample of 843 college students.

Data Analyses

After reviewing the dataset, some variables were removed from consideration due to a lack of consistency (e.g., some students reported annual income for themselves and others reported family income) or heterogeneity that prevented easy categorization (e.g., field of study). We settled on four variables of interest: gender, race/ethnicity, year in school, and response to the COVID-19 pandemic ( Table 1). Gender was coded as female, male, or non-binary. Race/ethnicity was coded as white or Caucasian; Black or African American; East Asian; Hispanic, Latino, or of Spanish origin; or other. Other was used for groups that were not well-represented in the sample and included individuals who identified themselves as Middle Eastern, Native American or Alaskan Native, and South Asian, as well as individuals who chose "other" or "prefer not to answer" on the survey. The year of study was coded as one through four, and COVID-19 stress was coded as two groups, no change/neutral response/reduced stress or increased stress.

Our first goal was to determine whether there was a relationship between self-reported academic stress and mental health, and we found a significant correlation (see Results section). Given the positive correlation, a multivariate analysis of variance (MANOVA) with a model testing the main effects of gender, race/ethnicity, and year of study was run in SPSS v 26.0. A factorial MANOVA would have been ideal, but our data were drawn from a convenience sample, which did not give equal representation to all groupings, and some combinations of gender, race/ethnicity, and year of study were poorly represented (e.g., a single individual). As such, we determined that it would be better to have a lack of interaction terms as a limitation to the study than to provide potentially spurious results. Finally, we used chi-square analyses to assess the effect of potential differences in the perception of the COVID-19 pandemic on stress levels in general among the groups in each category (gender, race/ethnicity, and year of study).

Results

In terms of internal consistency, Cronbach's alpha was 0.82 for the SMEMWBS and 0.86 for the PAS. A variety of descriptors have been applied to Cronbach's alpha values. That said, 0.7 is often considered a threshold value in terms of acceptable internal consistency, and our values could be considered "high" or "good" ( Taber, 2018).

The participants in our study were primarily women (78.5% of respondents; Table 1). Participants were not equally distributed among races/ethnicities, with the majority of students selecting white or Caucasian (66.4% of responders; Table 1), or years of study, with fewer first-year students than other groups ( Table 1).

Students who reported higher academic stress also reported worse mental well-being in general, irrespective of age, gender, race/ethnicity, or year of study. PAS and SWEMWBS scores were significantly correlated ( r = 0.53, p < 0.001; Figure 1), indicating that a higher level of perceived academic stress is associated with worse mental well-being in college students within the United States.

Among the subgroups of students, women, non-binary students, and second-year students reported higher academic stress levels and worse mental well-being ( Table 2; Figures 2- 4). In addition, the combined measures differed significantly between the groups in each category ( Table 2). However, as measured by partial eta squared, the effect sizes were relatively small, given the convention of 0.01 = small, 0.06 = medium, and 0.14 = large differences ( Lakens, 2013). As such, there were only two instances in which Tukey's post-hoc tests revealed more than one statistical grouping ( Figures 2- 4). For SWEMWBS score by gender, women were intermediate between men (high) and non-binary individuals (low) and not significantly different from either group ( Figure 2). Second-year students had the lowest PAS scores for the year of study, and first-year students had the highest scores. Third- and fourth-year students were intermediate and not statistically different from the other two groups ( Figure 4). There were no pairwise differences in academic stress levels or mental well-being among racial/ethnic groups.

Figure 2. SWEMWBS and PAS scores according to gender (mean ± SEM). Different letters for SWEMWBS scores indicate different statistical groupings ( p < 0.05).

Figure 4. SWEMWBS and PAS scores according to year in college (mean ± SEM). Different letters for PAS scores indicate different statistical groupings ( p < 0.05).

The findings varied among categories in terms of stress responses due to the COVID-19 pandemic ( Table 3). For gender, men were less likely than women or non-binary individuals to report increased stress from COVID-19 (χ ²= 27.98, df = 2, p < 0.001). All racial/ethnic groups responded similarly to the pandemic (χ ²= 3.41, df = 4, p < 0.49). For the year of study, first-year students were less likely than other cohorts to report increased stress from COVID-19 (χ ²= 9.38, df = 3, p < 0.03).

Discussion

Our primary findings showed a positive correlation between perceived academic stress and mental well-being in United States college students, suggesting that academic stressors, including academic expectations, workload and grading, and students' academic self-perceptions, are equally important as psychological well-being. Overall, irrespective of gender, race/ethnicity, or year of study, students who reported higher academic stress levels experienced diminished mental well-being. The utilization of well-established scales and a large sample size are strengths of this study. Our results extend and contribute to the existing literature on stress by confirming findings from past studies that reported higher academic stress and lower psychological well-being in college students utilizing the same two scales ( Green et al., 2021; Syed, 2021). To our knowledge, the majority of other prior studies with similar findings examined different components of stress, studied negative mental health indicators, used different scales or methods, employed smaller sample sizes, or were conducted in different countries ( Li and Lin, 2003; American Psychological Association, 2020; Husky et al., 2020; Pascoe et al., 2020; Patsali et al., 2020; Clabaugh et al., 2021; Lee et al., 2021; Lopes and Nihei, 2021; Yang et al., 2021).

This study also demonstrated that college students are not uniformly impacted by academic stress or pandemic-related stress and that there are significant group-level differences in mental well-being. Specifically, non-binary individuals and second-year students were disproportionately impacted by academic stress. When considering the effects of gender, non-binary students, in comparison to gender-conforming students, reported the highest stress levels and worst psychological well-being. Although there is a paucity of research examining the impact of academic stress in non-binary college students, prior studies have indicated that non-binary adults face adverse mental health outcomes when compared to male and female-identifying individuals ( Thorne et al., 2018; Jones et al., 2019; Budge et al., 2020). Alarmingly, Lipson et al. (2019) found that gender non-conforming college students were two to four times more likely to experience mental health struggles than cisgender students ( Lipson et al., 2019). With a growing number of college students in the United States identifying as as non-binary, additional studies could offer invaluable insight into how academic stress affects this population ( Budge et al., 2020).

In addition, we found that second-year students reported the most academic-related distress and lowest psychological well-being relative to students in other years of study. We surmise this may be due to this group taking advanced courses, managing heavier academic workloads, and exploring different majors. Other studies support our findings and suggest higher stress levels could be attributed to increased studying and difficulties with time management, as well as having less well-established social support networks and coping mechanisms compared to upperclassmen ( Allen and Hiebert, 1991; Misra and McKean, 2000; Liu, X et al., 2019). Benefiting from their additional experience, upperclassmen may have developed more sophisticated studying skills, formed peer support groups, and identified approaches to better manage their academic stress ( Allen and Hiebert, 1991; Misra and McKean, 2000). Our findings suggest that colleges should consider offering tailored mental health resources, such as time management and study skill workshops, based on the year of study to improve students' stress levels and psychological well-being ( Liu, X et al., 2019).

Limitations

While our study has numerous strengths, including using standardized instruments and a large sample size, this study also has several limitations due to both the methodology and sample. First, the correlational study design precludes making any causal relationships ( Misra and McKean, 2000). Thereby, our findings should be taken in the context of academic stress and mental well-being, and recognize that mental health could be caused by other non-academic factors. Second, the PAS comprised only the perception of responses to academic stress, but stress is a multi-factorial response that encompasses both perceptions and coping mechanisms to different stressors, and the magnitude of stress varies with the perception of the degree of uncontrollability, unpredictability, or threat to self ( Miller, 1981; Hobfoll and Walfisch, 1984; Lazarus and Folkman, 1984; Wheaton, 1985; Perrewé and Zellars, 1999; Schneiderman et al., 2005; Bedewy and Gabriel, 2015; Schönfeld et al., 2016; Reddy et al., 2018; Freire et al., 2020; Karyotaki et al., 2020). Third, the SWEMSBS used in our study and the data only measured positive mental health. Mental health pathways are numerous and complex, and are composed of distinct and interdependent negative and positive indicators that should be considered together ( Margraf et al., 2020). Fourth, due to the small effect sizes and unequal representation for different combinations of variables, our analysis for both the PAS and SWEMSBS included only summed-up scales and did not examine group differences in response to the type of academic stressors or individual mental health questions.

An additional limitation is that the participants in our study were a convenience sample. The testing service we used, prolific.co, self-reports a sample bias toward young women of high levels of education (i.e., WEIRD bias) ( Team Prolific, 2018). The skew toward this population was observed in our data, as 80% of our participants were women. While we controlled for these factors, the possibility remains that the conclusions we draw for certain groups, such as nonbinary students, ethnic/racial minorities, and men, may not be as statistically powerful as they should be. Moreover, our pre-screening was designed to recruit undergraduate level, English-speaking, 18-30-year-olds who resided in the United States. This resulted in our participant demographics being skewed toward the WEIRD bias that was already inherent in the testing service we used. Future research will aim to be more inclusive of diverse races/ethnicities, sexual orientations, languages, educational backgrounds, socioeconomic backgrounds, and first-generation college students.

Another limitation of our study is the nature of satisficing. Satisficing is a response strategy in which a participant answers a question to satisfy its condition with little regard to the quality or accuracy of the answer ( Roberts et al., 2019). Anonymous participants are more likely to satisfice than respondents who answer the question face-to-face ( Krosnick et al., 2002). We sought to mitigate satisficing by offering financial incentives to increase response rates and decrease straight-lining, item skipping, total missing items, and non-completion ( Cole et al., 2015). Concerns of poor data quality due to surveys offering financial incentives found little evidence to support that claim and may do the opposite ( Cole et al., 2015). On the other hand, social desirability bias may have influenced the participant's self-reported responses, although our anonymous survey design aimed to reduce this bias ( Joinson, 1999; Kecojevic et al., 2020).

Future Studies

Future studies should replicate our study to validate our results, conduct longitudinal cohort studies to examine well-being and perceived academic stress over time, and aim for a more representative student sample that includes various groups, including diverse races/ethnicities, sexual orientations, socioeconomic backgrounds, languages, educational levels, and first-generation college students. Additionally, these studies should consider examining other non-academic stressors and students' coping mechanisms, both of which contribute to mental health and well-being ( Lazarus and Folkman, 1984; Freire et al., 2020). Further explorations of negative and other positive indicators of mental health may offer a broader perspective ( Margraf et al., 2020). Moreover, future research should consider extending our work by exploring group differences in relation to each factor in the PAS (i.e., academic expectations, workload and examinations, and self-perception of students) and SWEMBS to determine which aspects of academic stress and mental health were most affected and allow for the devising of targeted stress-reduction approaches. Ultimately, we hope our research spurs readers into advocating for greater academic support and access to group-specific mental health resources to reduce the stress levels of college students and improve their mental well-being.

Conclusion

Utilizing two well-established scales, our research found a statistically significant correlation between the perceived academic stress of university students and their mental well-being (i.e., the higher the stress, the worse the well-being). This relationship was most apparent among gender and grade levels. More specifically, non-binary and second-year students experienced greater academic burden and lower psychological well-being. Moreover, women, non-binary students, and upper-level students were disproportionately impacted by stress related to the COVID-19 pandemic.

Studies regarding broad concepts of stress and well-being using a questionnaire are limited, but our study adds value to the understanding of academic stress as a contributor to the overall well-being of college students during this specific point in time (i.e., the COVID-19 pandemic). Competition both for admission to college ( Bound et al., 2009) and during college ( Posselt and Lipson, 2016) has increased over time. Further, selective American colleges and universities draw applicants from a global pool. As such, it is important to document the dynamics of academic stress with renewed focus. We hope that our study sparks interest in both exploring and funding in-depth and well-designed psychological studies related to stress in colleges in the future.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Institutional Review Board at Rutgers University. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GB and MB contributed to conceptualization, study design, IRB application, manuscript drafting, and revision. XZ participated in the conceptualization and design of the questionnaires. HB participated in subject recruitment and questionnaire collection. KP contributed to data analysis, table and figure preparation, manuscript drafting, and revision. XM contributed to conceptualization, study design, IRB application, supervision of the project, manuscript drafting, and revision. All authors contributed to the article and approved the submitted version.

Funding

This study was made possible by a generous donation from the Knights of Columbus East Hanover Chapter in New Jersey.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

The authors wish to thank Shivani Mehta and Varsha Garla for their assistance with the study. We also thank all the participants for their efforts in the completion of the study.

References

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American Psychological Association. (2020). Stress in AmericaTM2020: A National Mental Health Crisis. Washington, DC: American Psychological Association.

Lally, M., and Valentine-French, S. (2019). Chapter 7: Emerging and Early Adulthood. Lifespan Development: A Psychological Perspective. 2nd Edn. p.246-306). [E-book] San Francisco: Creative Commons. Available online at: http://dept.clcillinois.edu/psy/LifespanDevelopment.pdf (accessed February 6, 2022).

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Frontiers | Academic Stress and Mental Well-Being in College Students: Correlations, Affected Groups, and COVID-19

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Academic stress may be the single most dominant stress factor that affects the mental well-being of college students. Some groups of students may experience ...