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Mental health issues have long held stigmas, despite the fact that one-in-five US adults will suffer from a mental health condition during his or her lifetime, and countless family members and friends will be affected in the process. [1] Whether you suffer from mild depression or anxiety, or you're helping a loved one cope with a more serious condition such as schizophrenia or bipolar disorder, you probably realize that it is not only the condition that's difficult to live with, but also the social isolation.
This is why it's so important to raise awareness about mental health, and do all you can to assist patients and loved ones who are trying to deal with mental health conditions. The month of May is dedicated to mental health awareness, but you can become informed and help spread awareness year-round. Here are a few things you should know to get started.

Mental Health Snapshot

According to the 2016 National Vital Statistics Reports issued by the Centers for Disease Control and Prevention (CDC), nearly 43,000 deaths each year are determined to be suicides. [2] This number increased 24 percent between 1999 and 2014, with rates growing in both female and male populations between the ages of ten and seventy-four. Suicide is now among the ten most common causes of death. This takes into account decreasing mortality rates in other areas while suicides rates concurrently increase. [3]

A contributing factor to suicide can often be serious psychological distress, which is defined as "mental health problems severe enough to cause moderate-to-serious impairment in social, occupational, or school functioning and to require treatment." Serious psychological distress has also been linked to higher instances of heart disease and other disorders among adults. It has been reported that over 27 percent of adults over age 65 with psychological distress suffer from impairments to daily living. In addition, women of all ages were found to be more likely than men to suffer from serious psychological distress. [4]
Mental illness can derail a person's life, and in addition, impact the lives of loved ones. At the very least, mental health issues affect the ability to live life to the fullest. At the worst, it may lead to fatal outcomes, either due to increased physical health risks or suicide.

In some cases, physical activity interventions can help with both the mental and physical obstacles associated with mental health disorders. However, mental health nurses and other health care workers must have proper support and resources to administer such plans for individual patients. [5]

Mental Health Conditions

Some of the most serious types of mental illness in the US include:

● Anxiety (affecting 42 million adults)
● Depression (impacting 16 million adults)
● Bipolar Disorder (with some 6.1 million adult sufferers)
● Schizophrenia (affecting 2.4 million adults) [6]
● Autism Spectrum Disorder (ASD) (currently affecting about 3 million, including one in 42 boys and one in 189 girls, with roughly 100 new cases diagnosed daily) [7]

Unfortunately, many conditions remain untreated. Approximately 50 percent of youths age eight to fifteen, and 60 percent of adults with mental illness, report they didn't receive mental health services in the previous year. [6] This may be caused by the social stigma that is sometimes attached to asking for help, to lack of access to mental health services, to lack of insurance, or to any number of other factors.

Benefits of Mental Health Awareness Month

As instances of mental illness increase, so too does awareness. Recognition and education are important to removing the stigma that is often associated with mental health concerns. Mental Health Awareness Month not only helps people realize the many ways in which mental illness touches their own lives, but also helps them learn about available services, and discover ways to advocate for increased support.

Sadly, many Americans suffering from mental illness still lack access to care. States with the lowest workforce populations have, on average, only one mental health professional per 1,000 individuals. However, access to insurance that covers mental health issues is on the rise. Access to actual treatment has also grown. [8] This change can be attributed to access expansion under the Affordable Care Act (ACA) that covers mental health and substance abuse services, along with rehabilitative and other services for those with behavioral health issues. Preventive services like behavioral assessments and screening for depression are often covered, as well. [9]

Fundraising and Participation

Mental Health Awareness Month provides an ideal opportunity for fundraising, community outreach, and holding awareness events. Groups like the National Mental Health Association, the American Mental Health Counselors Association, the Federation of Families for Children's Mental Health, and many other similar organizations work tirelessly to advocate, education, and fundraise on behalf of those with mental health concerns. Proceeds are used, in part, to fund events like National Anxiety Disorders Screening Day, and National Mental Health Counseling Week, to cite just a few examples. [10]
In addition to organizations, citizens themselves can become involved in the cause of mental health. They can fundraise, stage or participate in events, and work to raise awareness within their own communities. This involvement may occur not just during Mental Health Awareness Month, but throughout the calendar year. [11]

Dedicated individuals may even go so far as to pursue careers such as nursing or health administration. In these roles, they will have the opportunity to raise awareness and offer support on a larger scale. A psychiatric-mental health nurse practitioner (PMHNP), for example, is trained and qualified to offer a full range of psychiatric services, including:

● Health promotion and protection, disease prevention, and treatment
● Diagnosis of health status
● Care plan and treatment implementation
● Nurse practitioner services
● Teaching/coaching functions
● Monitoring and ensuring quality of health care
● Providing culturally diverse care [12]

With the proper education, you can help change the conversation around mental illness and its health care. In the proper role, you can focus on fostering or delivering preventive measures, help patients and loved ones find better ways to cope with mental health issues-and even one day be part of the workforce that helps mental illness shed its stigma and gain more powerful treatments.

Note from Regis College Professor Shari Harding

"PMHNPs are important advocates for individuals receiving mental health services and that one of the best parts of my job is teaching people about recovery and helping them in their recovery journey." - Shari Harding, PMHNP, CARN-AP, CPRP Assistant Professor, Nursing PMHNP Program Director.

Learn More

Psychiatric Mental Health nurse practitioners play a significant role in the modern health care system. Our online Master of Science in Nursing Psychiatric Mental Health program can help you develop your communication and therapeutic skills so you can assess, diagnose, manage, and treat mental illness in a variety of populations. It also prepares RNs to sit for the ANCC PMH-ANP exam upon graduation to immediately pursue a proactive and rewarding career as a psychiatric mental health Nurse Practitioner.

Recommended Readings:
How Psychiatric Nursing is Fighting the Mental Health Stigma
Best Practices to Promote Cultural Awareness
How Nurse Practitioners Can Become Community Advocates
Sources:

[1] National Alliance on Mental Illness
[2] Centers for Disease Control and Prevention - Mental Health
[3] Centers for Disease Control and Prevention - Increase in Suicide in the United States, 1999-2014
[4] Centers for Disease Control and Prevention - Data Briefs
[5] PubMed
[6] Mental Health Facts in America
[7] Talk About Curing Autism
[8] Mental Health in America
[9] U.S. Department of Health & Human Services
[10] FundRaisers.com
[11] National Alliance on Mental Illness
[12] Psychiatric-Mental Health NP Competencies

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The State of Mental Health in the U.S. - Improving Awareness

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Mental health issues have long held stigmas, despite the fact that one-in-five US adults will suffer from a mental health condition during his or her lifetime, and countless family members and friends will be affected in the process.

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Are you looking for tools to raise awareness about mental health in your community? You can use these free education and outreach materials to spread the word. NIMH encourages you to use the hashtag #ShareNIMH in your social media posts to connect with people and organizations with similar goals. Using the hashtag helps NIMH evaluate which resources and topics are most useful. Check back often for new topics and resources and sign up to receive the Discover NIMH enewsletter to learn about new materials, including tools you can share during upcoming health observances.

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Let us know what types of resources or topics would better help you connect with and educate your community. Email your suggestions to NIMHOutreach@mail.nih.gov.

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Are you looking for tools to raise awareness about mental health in your community? You can use these free education and outreach materials to spread the word. NIMH encourages you to use the hashtag #ShareNIMH in your social media posts to connect with people and organizations with similar goals.

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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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offer internet-based interventions in addition to the services already offered by student mental health and counselling centers.

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As screening mental disorders on college campuses becomes more commonplace, early identification will increase and prevent

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Leave a comment about either what you learned from this padlet or your opinions about this topic.

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Leave a comment about either what you learned from this padlet or your opinions about this topic.

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- 35% of the 13,984 respondents in the main sample reported at least one of the lifetime mental disorders assessed in the survey
- Lifetime and 12-month prevalence estimates ranged from a high of 48.3–43.3% in Australia to a low of 22.4–19.1% in Belgium
- The vast majority (89.0%) of respondents with a lifetime disorder had 12-month prevalence, from a high of 94.2% in Northern Ireland to a low of 83.3% in Spain.
- Motivated students and students with lower high school rankings had elevated odds of mental disorders.

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I chose an article about the distribution and prevalence of Mental Disorders in college students. With me being a college student myself, anything dealing with college students intrigues me. What really piqued my interest was what of the 13,984 students assessed. 35% of those screened positive for at least one of the common lifetime disorders assessed and 31% screened positive for at least one 12-month disorder.

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Abstract

Increasingly, colleges across the world are contending with rising rates of mental disorders, and in many cases, the demand for services on campus far exceeds the available resources. The present study reports initial results from the first stage of the WHO World Mental Health International College Student project, in which a series of surveys in 19 colleges across eight countries (Australia, Belgium, Germany, Mexico, Northern-Ireland, South-Africa, Spain, United States) were carried out with the aim of estimating prevalence and basic socio-demographic correlates of common mental disorders among first-year college students. Web-based self-report questionnaires administered to incoming first-year students (45.5% pooled response rate) screened for six common lifetime and 12-month DSM-IV mental disorders: major depression, mania/hypomania, generalized anxiety disorder, panic disorder, alcohol use disorder, and substance use disorder. We focus on the 13,984 respondents who were full-time students: 35% of whom screened positive for at least one of the common lifetime disorders assessed and 31% screened positive for at least one 12-month disorder. Syndromes typically had onsets in early-middle adolescence and persisted into the year of the survey. Although relatively modest, the strongest correlates of screening positive were older age, female sex, unmarried-deceased parents, no religious affiliation, non-heterosexual identification and behavior, low secondary school ranking, and extrinsic motivation for college enrollment. The weakness of these associations means that the syndromes considered are widely distributed with respect to these variables in the student population. Although the extent to which cost-effective treatment would reduce these risks is unclear, the high level of need for mental health services implied by these results represents a major challenge to institutions of higher education and governments.

Keywords: College, Mental Disorders, Lifetime Prevalence, 12-Month Prevalence

General Scientific Summary

Roughly one-third of first-year students in 19 colleges across 8 countries who participated in a self-report survey screened positive for at least one common DSM-IV anxiety, mood, or substance disorder (35.3% lifetime, 31.4% 12 months). Basic socio-demographic correlates were modest, showing that the syndromes were widely-distributed rather than concentrated in one small segment of the student population.

Introduction

College students are a key population segment for determining the economic growth and success of a country. Until recently, little attention was paid to identifying mental disorders among college students other than in the United States ( Blanco et al., 2008; Cho et al., 2015; Eisenberg, Golberstein, & Gollust, 2007; Kendler, Myers, & Dick, 2015; Mojtabai et al., 2015). However, given that the college years are a peak period for onset of many common mental disorders, particularly mood, anxiety, and substance use disorders ( de Girolamo, Dagani, Purcell, Cocchi, & McGorry, 2012; Kessler et al., 2007), it is not surprising that epidemiological studies consistently find high prevalence of these disorders among college students ( Hunt & Eisenberg, 2010; Ibrahim, Kelly, Adams, & Glazebrook, 2013; Pedrelli, Nyer, Yeung, Zulauf, & Wilens, 2015). This high prevalence is significant not only for the distress it causes at a time of major life transition, but also because it is associated with substantial impairment in academic performance ( Auerbach et al., 2016; Bruffaerts et al., 2018) as well as suicidal thoughts and behaviors ( Mortier et al., in press). While timely and effective treatment is important, the number of students in need of treatment for these disorders far exceeds the resources of most counseling centers, resulting in substantial unmet need for treatment of mental disorders among college students ( Auerbach, et al., 2016; Beiter et al., 2015; Storrie, Ahern, & Tuckett, 2010; Xiao et al., 2017).

Emerging adulthood-which includes the college years-represents a distinct period of development straddling the adolescent and young adulthood life stages. While emerging adulthood (ages 18-29 years) shares many features with these earlier and later periods, it is defined by increased autonomy from parents (e.g., leaving the home), marked shifts in social roles, and relational instability ( Arnett, 2000; Sussman & Arnett, 2014). In contrast to adolescents, emerging adults have reached sexual maturity and often pursue a range of educational and occupational opportunities (e.g., tertiary education, full-time work, combination of education and work). However, in comparison to adults, emerging adults have not yet established a stable life structure (e.g., long-term romantic relationship, stable job). More broadly, Sussman and Arnett (2014) differentiate emerging adulthood from other life stages across five dimensions: (i) identity exploration, (ii) feeling in-between, (iii) entertaining possibilities, (iv) self-focus; and (v) instability. While these dimensions are developmentally normative among college students, each has potential mental health implications, especially during a period when there is a high likelihood of disengaging from treatment (see Auerbach et al., 2016; Stroud, Mainero, & Olson, 2013). For example, although identity exploration is developmentally appropriate, within collegiate environments in which students can reinvent themselves, it is not without its challenges, particularly if students feel they have made the wrong choices. Similarly, college is characterized by substantial instability-changes in romantic status (including sexual orientation), peer groups, course selection (i.e., major, concentration), and career choices. This instability may contribute to reduced social support and increased stress, which are known contributors to mental disorders ( Slavich & Auerbach, 2018). Thus, while there is doubtlessly overlap with other life stages, the college years represent a distinct period in which there is a critical need to improve early identification and treatment for debilitating mental disorders.

It is a challenge for universities to determine whether and, if so, how to identify college students for outreach and treatment of existing mental disorders or for preventive interventions when at high risk of mental disorders and, once identified, how to offer services to the very large proportion of students likely to profit from either treatment or preventive interventions. Internet-based cognitive behavior therapy (CBT), which has been shown to have effects equivalent to those of face-to-face CBT ( Andersson, Cuijpers, Carlbring, Riper, & Hedman, 2014), is an attractive option for addressing the latter challenges based on its low cost and ease of implementation. However, little is known about the disorders for which such interventions are most needed or the effectiveness of internet-based CBT among college students. The WHO World Mental Health (WMH) International College Student (WMH-ICS) project was launched in an effort to address this critical knowledge gap. The first stage of the WMH-ICS is administering web-based mental health needs assessment surveys to convenience samples of entering first-year students in colleges and universities throughout the world and then following these students over their college careers to examine patterns and baseline predictors of onset and persistence of common mental disorders and impairments in academic performance associated with those disorders. As part of this initiative, a number of surveys also embed pragmatic clinical trials that screen for mood and anxiety disorders and then randomize screened positives either to internet-based CBT or usual care. Baseline survey data are then being used in the latter samples to develop precision medicine treatment models aimed at guiding the subsequent targeting of internet-based interventions to the students most likely to be helped by them.

The current report presents data from the first year of baseline WMH-ICS surveys among first-year college students from 8 countries. In carrying out these surveys, we aimed to determine the feasibility of successfully implementing large-scale cross-national surveys of first-year college students across a number of institutions using a web-based screening assessment of common mental disorders. We also aimed to determine whether such surveys would yield similarly high prevalence estimates of common DMS-IV disorders and low estimates of treatment as in previous college surveys and in the representative sample of 1,572 college students across 21 countries surveyed in two-hour face-to-face interviews as part of the larger WMH surveys ( Auerbach, et al., 2016). The WHO Composite International Diagnostic Interview (CIDI; Kessler & Ustun, 2004), a validated fully-structured diagnostic interview that generates diagnoses according to the definitions and criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( American Psychiatric Association, 1994), was used in the WMH surveys. One-fifth of college students in those surveys had 12-month DSM-IV/CIDI disorders, with anxiety and mood disorders the most common class of disorders. Only 16.4% of all 12-month cases received any treatment for these disorders. One of our aims in the current report is to determine whether comparable estimates of prevalence and treatment are found in the web-based WMH-ICS surveys. We also aimed in the WMH-ICS surveys to determine if the socio-demographic correlates of 12-month mental disorders in the WMH-ICS surveys would be the same as in previous surveys of college student mental health. These associations have typically been found to be small, but with women having higher rates of anxiety and mood disorders than men, men having higher rates of substance use disorders than women, and socio-economic background being inversely related to prevalence of all disorders ( Chen & Jacobson, 2012; Eisenberg, Hunt, & Speer, 2013).

Methods

Samples

The initial round of WMH-ICS surveys was administered in a convenience sample of 19 colleges and universities (henceforth referred to as "colleges") in eight mostly high-income countries (Australia, Belgium, Germany, Mexico, Northern Ireland, South Africa, Spain, and the United States). Each institution received ethics approval to participate in the project and all participants provided consent. Web-based self-report questionnaires were administered to all incoming first-year students in each participating school (7 private, 12 public) between October 2014 and February 2017. A total of 14,371 questionnaires were completed, with sample sizes ranging from a low of 633 in Australia to a high of 4,580 in Belgium. The response rates were quite variable across countries, from a low of 7.0% in Australia to a high of 79.3% in Mexico. The weighted (by achieved sample size) mean response rate across all surveys was 45.5%. summarizes the sample design in each participating country.

Table 1:

Country

Number of participating universities

Total size of the universities

Number of incoming freshmen eligible

Number of incoming freshmen participated

Response Rate

Survey Field Dates

Sampling & procedures

Procedures

Before initiating data collection, the country-specific Institutional Review Boards provided approval for a project entitled, Survey on College Adjustment (Australia: HR65/2016; Belgium: S54803(ML8724); Germany: 193_16 B; Mexico: CEI/C/032/2016; Northern Ireland: REC/15/0004; South Africa: N13/10/149; Spain: 2013/5252/I; United States: 2015P002664). All incoming first-year students in the participating schools were invited to participate in a web-based self-report health survey. Mode of contact varied widely across schools but in all cases other than in Mexico consisted of an approach that attempted to recruit 100% of incoming first-year students either as part of a health evaluation, as part of the registration process, or in a stand-alone survey administered to students via their student email addresses. Attempts were then made to convert initial non-respondents through a series of personalized reminder emails. Incentives were used in the final stages of recruitment (e.g., a raffle for store credit coupons, movie passes) in 10 schools. In addition, one country (Spain) used an "end-game" strategy consisting of a random sample of non-respondents at the end of the normal recruitment period that was offered incentives for participation. The sampling scheme was quite different in Mexico, where 100% of entering first-year students were invited to participate in conjunction with mandatory activities that varied from school to school (e.g., student health evaluations; tutoring sessions) and time was set aside for completing the survey during those activities. No follow-up of non-respondents was carried out in Mexico because it was assumed that students who failed to complete the survey even though time was set aside for it during mandatory activities were firm non-respondents. Informed consent was obtained before administering the survey in all countries. The text statement used to obtain informed consent varied across schools and was approved by the institutional review boards of the organizations coordinating the surveys in each country.

Measures

The self-report questionnaire was developed in English and translated into local languages using a translation, back-translation, and harmonization protocol that expanded on the standard WHO protocol in ways developed by survey methodologists to maximize cross-national equivalence of meaning and consistency of measurement ( Harkness et al., 2008).

Mental disorders.

The questionnaire included short validated self-report screening scales for lifetime and 12-month prevalence of six common DSM-IV mood (major depressive disorder, mania/hypomania), anxiety (generalized anxiety disorder, panic disorder), and substance (alcohol abuse or dependence [AUD], drug abuse or dependence, involving either cannabis, cocaine, any other street drug, or a prescription drug either used without a prescription or used more than prescribed to get high, buzzed, or numbed out). This is a larger set of disorders than used in most previous college mental health surveys, some of which focused only on depression (for review see Ibrahim, et al., 2013) or screening scales of current anxious and depressive symptoms ( Mahmoud, Staten, Hall, & Lennie, 2012). Although a larger set of disorders is used in the face-to-face WMH surveys ( Scott, de Jonge, Stein, & Kessler, in press), participating colleges were unwilling to administer student surveys that would be long enough to include all those disorders. The six disorders in the core WMH-ICS surveys were a compromise that included the disorders associated with the highest levels of role impairment among college students in the WMH surveys. As an indication that these disorders capture the vast majority of students with seriously impairment psychopathology, 83% of the college students in the WMH surveys who reported suicidal ideation in the 12 months before interview met criteria for one or more of these six disorders during that same 12-month time period ( Mortier et al., 2018).

The assessments of five of the six disorders were based on the Composite International Diagnostic Interview Screening Scales (CIDI-SC; Kessler et al., 2013; Kessler & Ustun, 2004). The exception was the screen for AUD, which was based on the Alcohol Use Disorders Identification Test (AUDIT; Saunders, Aasland, Babor, de la Fuente, & Grant, 1993). The CIDI-SC scales have been shown to have good concordance with blinded clinical diagnoses based on the Structured Clinical interview for DSM-IV (SCID; First, Spitzer, Gibbon, & Williams, 1994), with AUC in the range 0.70-0.78 ( Kessler et al., 2013a; Kessler et al., 2013b). However, these validation studies have not yet been carried out in samples of college students. The version of the AUDIT we used, which defined alcohol use disorder as either a total score of 8+ or a score of 4+ on the AUDIT dependence questions ( Babor, Higgins-Biddle, Saunders, & Monteiro, 2001), has been shown to have concordance with clinical diagnoses in the range AUC = 0.78-0.91 ( Reinert & Allen, 2002). Additional items taken from the CIDI ( Kessler & Ustun, 2004) were used to assess age-of-onset of each disorder and number of lifetime years with symptoms.

Socio-demographic correlates.

Only a handful of basic socio-demographic variables were included in the survey. Gender was assessed by asking respondents whether they identified themselves as male, female, transgender (male-to-female, female-to-male), or "other." Respondent age was divided into three categories (18 years, 19 year, 20 or more years old). Parental educational level was assessed for father and mother separately (none, elementary, secondary, some post-secondary, college graduate, doctoral degree), and was categorized into high (college graduate or more), medium (some post-secondary education), and low (secondary school or less) based on the highest-of-both parents' educational level. Parental marital status was dichotomized into "parents not married or parent(s) deceased" versus "parents married and both alive." Respondents were asked about the urbanicity of the place they were raised (small city, large city, town or village, suburbs, rural area), and their religious background (categorized into Christian, Other religion, No religion). Sexual orientation was classified into heterosexual, gay or lesbian, bisexual, asexual, not sure, and other. Additional questions were asked about the extent to which respondents were attracted to men and women and the gender(s) of people they had sex with (if any) in the past 5 years. Respondents were categorized into the following categories: heterosexual with no same-sex attraction, heterosexual with same-sex attraction, non-heterosexual without same-sex sexual intercourse, and non-heterosexual with same-sex sexual intercourse.

College-related correlates.

Respondents were asked where they ranked academically compared to other students at the time of their high school graduation (from top 5% to bottom 10%; categorized into quartiles) and what their most important reason was to go to university. Based on the results of a tetrachoric factor analysis (see Supplemental Table 1) the most important reason to go to university was categorized into extrinsic reasons (i.e., family wanted me to, my friends were going, teachers advised me to, did not want to get a job right away) versus intrinsic reasons (to achieve a degree, I enjoy learning and studying, to study a subject that really interests me, to improve job prospects generally, to train for specific type of job). Respondents were also asked where they were living during the first semester of the academic year (parents', other relative's, or own home, college hall of residence, shared house, apartment, or flat/private hall of residence, other), and if they expect to work during the school year.

Analysis methods

Weighting:

We noted above that one Spanish survey used an "end-game" strategy in which a random sample of non-respondents at the end of the normal recruitment period was offered incentives for participation. Respondents in this end-phase were given a weight equal to 1/p, where p represented the proportion of non-respondents at the end of the normal recruitment period that was included in the end-game, to adjust for the under-sampling of these hard-to-recruit respondents. In addition, in an effort to make increase the representativeness of the WMH-ICS sample in each college with respect to known population characteristics, a post-stratification weight was applied to the survey data to adjust for differences between survey respondents and non-respondents on socio-demographic information made available about the student body by college officials. Standard methods for post-stratification weighting were used for this purpose ( Groves & Couper, 1998). In the case of the Spanish survey, this meant that the data were doubly-weighted: once to include the end-game weight and then with the post-stratification weight applied to those weighted data.

Item-level missing data in the completed surveys were imputed using the method of multiple imputation (MI) by chained equations ( van Buuren, 2012). Four kinds of item-missing data were imputed simultaneously in this way. The first was a 50% random subsampling of the drug use section in Belgium, which was done to reduce interview length. The second was the complete absence of the panic disorder section in Mexico, Northern Ireland, and South Africa due to a skip logic error. The third was the complete absence of some socio-demographic variables in Australia, Belgium, and Spain because of a decision by school administrators not to assess those variables (sexual orientation, current living situation, expected student job, and most important reason for going to college in all these countries; parent education and marital status in Australia and Belgium; religion in Australia; self-reported high school ranking in Belgium). The fourth were invalid responses to individual questions made by some respondents in each country, although this fourth category was uncommon: less than 0.1% for lifetime disorders, 0.0-2.3% for 12-month disorders other than AUD, and in the range 3.0-9.3% (3.8-7.0% inter-quartile range) for AUD, 0.0-12.0% (inter-quartile range 1.9-2.7%) for disorder age-of-onset, 0.0-24.6% (inter-quartile range 2.4-8.8%) for disorder persistence, 1.8-25.4% (inter-quartile range 8.8-24.1%) for most important reasons for attending college, 1.0-10.8% (inter-quartile range 3.0-3.4%) for high school ranking, and 0.0-7.0% for the other socio-demographic and college-related variables.

Prevalence estimates are reported as weighted within-country proportions, with associated MI-adjusted standard errors obtained through the Taylor series linearization method. Estimates of age of onset and proportional persistence (i.e., the percentage of lifetime years with symptoms of each disorder from the age-of-onset to the age when survey was completed) are reported as median values with associated inter-quartile ranges. To obtain pooled estimates of prevalence, age of onset, and proportional persistence across countries, each country was given an equal sum of weights.

Substantive analyses:

All substantive analyses were conducted with SAS version 9.4 ( SAS Institute Inc, 2010), and weighted data were used in all data analytic procedures. Logistic regression analyses were used to identify correlates of lifetime and 12-month mental disorders in the total sample and 12-month disorders among lifetime cases. Logistic regression coefficients and their 95% confidence intervals (CIs; +/− 1.96 times their MI-based standard errors) were exponentiated to create odds ratios (OR) and associated 95% CIs. Negative binomial regression was used to identify correlates of number of years with symptoms among lifetime cases. These regression coefficients and their 95% CIs were exponentiated to create persistence rate ratios (RR) and their associated 95% CIs. Estimates were pooled across countries to examine both main effects and all possible two-way interactions among correlates, with risk for Type I error adjusted for using the false discovery rate method (Q=0.05) ( Benjamini & Hochberg, 1995). We then examined between-country variation in associations by including correlate-by-country interactions and an adjusted interaction dummy coding scheme that kept the product of all country-specific ORs and RRs equal to one. The latter method allowed us to detect significant between-country variation by evaluating the statistical significance of deviation of within-country coefficients from the median 1.0 value. Statistical significance in all analyses was evaluated using two-sided MI-based tests with significance level α set at 0.05.

Results

Preliminary Analyses

Although there were 14,371 respondents in the total sample, 35 respondents were excluded because of missing information on gender or full-time status, which we required as anchor variables for purposes of imputing other missing values. An additional 302 respondents were excluded because they were part-time students. Most of these students came from the Australian sample and were older, full-time employed people who would normally be expected to access mental health services, if they were needed, through their employer or employer-sponsored health insurance rather than through their college. In addition, preliminary analyses reported below showed that the majority of the 50 remaining students who identified either as transgender or "other" rather than as male or female endorsed a number of mental disorders and experienced considerable impairment, leading us to focus on them in a separate report. The analyses reported here are based on the remaining 13,984 respondents.

Prevalence of Common Mental Disorders

Thirty-five percent of the 13,984 respondents in the main sample reported at least one of the lifetime mental disorders assessed in the survey (). Prevalence was similar for the additional respondents excluded because of missing information on gender or full-time student status (35.9%) and because of being part-time (41.2%), whereas the students who self-identified as either transgender or "other" had much higher lifetime prevalence of any disorder (76.5%). Twelve-month prevalence of any of the disorders considered in the main sample was 31%. Lifetime and 12-month prevalence estimates ranged from a high of 48.3-43.3% in Australia to a low of 22.4-19.1% in Belgium. Median age-of-onset was 14.2 years of age, from a high of 14.6 in Spain to a low of 13.6 in the U.S. Median proportional annual persistence (i.e., the proportion of years in episode between age-of-onset and age at interview) was 65.0%, from a high of 72.2% in the U.S. to a low of 50.3% in Mexico. The vast majority (89.0%) of respondents with a lifetime disorder had 12-month prevalence, from a high of 94.2% in Northern Ireland to a low of 83.3% in Spain.

Table 2.

Major depressive disorder (MDD) was the most common of the disorders examined across all countries combined (21.2% lifetime prevalence; 18.5% 12-month prevalence) followed by generalized anxiety disorder (18.6-16.7%) (). The other disorders had comparatively much lower prevalence, from a high of 6.8-6.3% for AUD to a low of 3.5-3.1% for broadly-defined bipolar disorder. Median ages-of-onset of individual disorders were in the range 14.3 (major depressive disorder) to 16.2 (drug use disorder). Proportional annual persistence was considerably lower for drug use disorder (45.9%) than other disorders (62.4-73.3%). Twelve-month prevalence among lifetime cases also was considerably lower for drug use disorder (59.8%) than the other disorders (87.1-92.8%).

Table 3.

Socio-Demographic and College-Related Correlates of Mental Disorders

Female gender and older age (i.e., aged 19 and 20+ years) emerged as significant positive correlates of both lifetime and 12-month prevalence (). Parental education was unrelated to the disorders assessed, but students with unmarried parents or a parent who was deceased had significantly elevated odds of both lifetime and 12-month disorders. Respondents who endorsed no religious affiliation had a greater likelihood of reporting the presence of lifetime and 12-month mental disorders than those identifying as Christian. Relative to students reporting heterosexual identification with no same-sex attraction (72.6%), students identifying as heterosexual with some same-sex attraction (14.1%), non-heterosexual without same-sex intercourse (8.0%), or non-heterosexual with same-sex intercourse (5.4%) had two- to three-fold elevated odds of lifetime and 12-month disorders. Finally, extrinsically motivated (as compared to intrinsically motivated) students and students with lower high school rankings (relative to students with higher high school rankings) had elevated odds of mental disorders. Importantly, these associations were quite stable across countries, with only 6.3% of country-specific odds-ratios differing significantly from the cross-national average ().

Table 4.

Table 5.

Discussion

The present study reports initial results from the WHO WMH-ICS project administered to first-year college students-a series of surveys in 19 colleges across eight countries (Australia, Belgium, Germany, Mexico, Northern-Ireland, South-Africa, Spain, United States). At least one-third of the college students that participated in the surveys reported a history of one or more of the mental disorders examined in the survey. This finding is broadly consistent with earlier college student surveys in documenting high recent prevalence of common mental disorders ( Blanco et al., 2008; Cho et al., 2015; Eisenberg et al., 2007; Kendler et al., 2015); although most earlier surveys were carried out in the U.S. and assessed only current disorders ( Merikangas et al., 2010). Direct comparisons of prevalence estimates are not possible, as the measures, time frames (12-month and lifetime in the current surveys versus current prevalence in most other surveys) and populations represented differed across surveys. It is noteworthy in the latter regard that the colleges in the WMH-ICS project were not selected to be representative of all colleges in their countries but were instead a convenience sample of the colleges in which WMH collaborators worked or had close contacts. It is also noteworthy that the response rates in the college surveys were quite variable and were lower overall than in the nationally representative face-to-face community household surveys in the WMH initiative. An earlier WMH report based on face-to-face interviews with the subset of WMH household survey respondents in 21 countries who were college students found somewhat lower lifetime (29.3%) and 12-month (25.2%) prevalence estimates of any disorder in mostly high-income countries, but this result was based on a wider range of DSM-IV disorders and on most in-depth assessments of these disorders than in the WMH-ICS surveys ( Auerbach et al 2016).

It is impossible to tell the extent to which these differences reflect the fact that the colleges included in the WMH-ICS surveys were atypical of all colleges in their countries, that the 8 countries considered in the WMH-ICS surveys were different from the 21 included in the WMH surveys, that the mode of data collection was different in the two sets of surveys (self-administration in the WMH-ICS surveys versus face-to-face in the WMH surveys, with self-administration known to be associated with increased rates of reporting embarrassing behaviors; ( Gnambs & Kaspar, 2015), that the diagnostic measures were different, or some combination of these factors. It is noteworthy, though, that both sets of surveys documented that most lifetime mental disorders among college students started prior to college entrance and that persistence of these disorders was very high, suggesting that clinical interventions early in the college career might be warranted. Given the limited mental health resources that exist on most college campuses relative to the scope of the problem, there is also a need to consider cost-effective approaches to reduce the treatment gap for this important segment of the population (e.g., group psychotherapy, internet-based psychotherapy).

We found a number of socio-demographic and college-related variables that had statistically significant but substantively modest associations (OR=1.4-1.5) with overall disorder prevalence: being female, having parents who were not married or deceased, having no religious affiliation, graduating in the bottom 70% of their high school class, and having primarily extrinsic reasons for going to college. Odds-ratios of this size are equivalent to values of Cohen's d indicative of small effect sizes, whereas the 27% of students who reported either a non-heterosexual orientation or some same-sex attraction had relative-odds of disorder (OR=2.0-3.4) equivalent to values of Cohen's d in the small to medium range, and the roughly 0.4% of respondents who reported themselves to be either transsexual or "other" had a relative-odds of disorder (OR=5.6) equivalent to a Cohen's d in the large range ( Hasselblad & Hedges, 1995). The small effects for basic socio-demographic and college-related factors are in line with prior research (mostly conducted in the United States; e.g., Eisenberg et al., 2013; Pedrelli et al., 2016), and similarly, the elevated odds of disorder among students with non-heterosexual orientations are consistent with previous studies of the association between sexual orientation and mental health among college students ( Kerr, Santurri, & Peters, 2013; Kisch, Leino, & Silverman, 2005; Oswalt & Wyatt, 2011; Przedworski et al., 2015).

While our results show a median age-of-onset in early to middle adolescence, these findings are not easy to reconcile with prior epidemiological research that has assessed individuals across a much broader age range (~18-65 years; e.g., National Comorbidity Replication [NCS-R], National Epidemiologic Survey on Alcoholism and Related Conditions [NESARC]). Moreover, even among studies that stratify the prevalence of disorders across age groups, there is no delineation among students and non-students, which has important implications ( Auerbach et al., 2016). Of note, the majority of WMH-ICS respondents were aged 18-19 years, and this necessarily impacts the interpretation of age-of-onset. For example, in both NCS-R and NESEARC, median age-of-onset for major depression ( Hasin et al., 2005) and mood disorders ( Kessler et al., 2005) was ~30 years compared to ~14 years within the WMH-ICS sample. Similarly, age-of-onset for substance use disorders also is older (~20 years) in the NCS-R sample relative to the WMH-ICS (~14-16 years). These differences most likely reflect the age ranges of the samples as opposed to methodological differences (e.g., survey versus face-to-face interviews). That said, relative to the NCS-R, the WMH-ICS shows an older age-of-onset for anxiety disorders (~11 years vs. ~14 years); potentially indicating subtle differences in reporting accuracy (and potential recall biases) across instruments or across retrospective recall periods in samples where respondents are either mostly young (WMH-ICS) or have an unrestricted age range (NCS-R).

Trajectory of Mental Disorders and Associated Outcomes

The WMH-ICS was designed to follow first-year students though their college years to address key questions about illness onset, course, and consequences. Of particular importance, we want to determine if the syndromes detected in this baseline survey predict a range of key outcomes that are the focus of considerable concern on college campuses, including academic functioning (e.g., grades, attrition), sexual assault, and suicidal thoughts and behaviors. There is some precedent for expecting associations with these outcomes to be found. For example, in a prospective study of college students implemented as a forerunner to the WMH-ICS surveys, reports obtained during students' first year identified students with persistent suicidal thoughts and behaviors during subsequent college years ( Mortier et al., 2017). If similar prospective associations are obtained between the richer set of baseline symptoms probed in the current survey and a wider range of outcomes, such results could be important in targeting cost-effective interventions.

There also is strong reason to believe that rates of disorders, particularly externalizing disorders (e.g., substance use disorder) and serious mental illness (e.g., bipolar disorder, thought disorders), will show higher prevalence during later college years. Indeed, substance use disorders, bipolar disorder, and thought disorders typically emerge in the early-to-mid 20s, and the typical college lifestyle-irregular sleep, increased interpersonal stress, experimental substance use-may confer increased risk of disorder onset ( Arnett, 2005; Sussman & Arnett, 2014). Additionally, although our results show that female gender is a meaningful correlate of increased lifetime and 12-month disorder prevalence of the disorders considered, it also may be that (a) our assessment reflects an imbalanced assessment of internalizing versus externalizing disorders but (b) perhaps more critically, the assessment of these disorders is conducted before their peak period of onset. As first-year students are being followed throughout their collegiate career, the WMH-ICS project has a unique opportunity to identify factors that may be present before the unfolding of symptoms, which again, will ultimately afford institutions an opportunity to identify high-risk students who might benefit from preventative-intervention efforts.

Improving Access to Care

The finding that one-third of students from a range of countries in the WMH-ICS screened positive for at least one of the six12-month mental disorders assessed represents a key global mental health issue and raises questions about appropriate screening and intervention. As noted earlier, precise population prevalence estimates cannot be obtained because our surveys are not nationally representative and survey response rates are generally low, but it is nonetheless clear from our results, in conjunction with the larger literature, that a substantial proportion of college students meet criteria for common mental disorders. Furthermore, as symptoms of mental disorders range from sub-clinical through to severe, it is likely that more than one-third of our respondents suffered from significant distress and that fewer than the one-third suffered from a serious mental disorder. Fortunately, colleges often have a range of resources, and in recent years have developed programs to reduce stigma and increase mental health literacy, to screen and link students to mental health services, and to train key gatekeepers about mental disorders and treatment ( Eisenberg, Hunt, & Speer, 2012).

As screening mental disorders on college campuses becomes more commonplace, early identification will increase. However, one-third of students have one or more of the 12-month disorders considered here and other disorders that we did not consider are likely to be present among a substantial number of other students. It is unlikely in light of this that college campuses will have sufficient resources to support student needs for mental health services, exacerbating the problems that already exist in the mental health treatment system of escalating financial expenses and long waitlists ( Andersson & Titov, 2014; Webb, Rosso, & Rauch, 2017). As noted in the earlier, one practical response would be to offer internet-based interventions in addition to the services already offered by student mental health and counselling centers. A number of internet-based interventions exist for a broad range of psychiatric disorders (e.g., depression, anxiety, eating disorders) and associated problems (e.g., sleep, stress) and have been shown to be effective for both prevention and treatment of these conditions (e.g., Ebert et al., 2015; Josephine, Josefine, Philipp, David, & Harald, 2017; Olthuis, Watt, Bailey, Hayden, & Stewart, 2015; Riper et al., 2014; Rosso et al., 2017; van Straten, Cuijpers, & Smits, 2008); particularly guided internet-based CBT interventions (e.g., Baumeister, Reichler, Munzinger, & Lin, 2014; Palmqvist, Carlbring, & Andersson, 2007; V. Spek et al., 2007). In addition to their low cost, these interventions address a number of other important barriers to treatment, most notably stigma and inconvenience. Internet-based interventions could be especially useful if they are used in campus mental health counseling centers to triage care, with students experiencing less severe symptoms receiving these interventions. Importantly, sub-threshold cases are known to have substantial impairment ( Cuijpers, de Graaf, & van Dorsselaer, 2004; Fergusson, Horwood, Ridder, & Beautrais, 2005) and to benefit from internet-based interventions ( Andersson & Cuijpers, 2009; Spek et al., 2008); potentially reducing the incidence of threshold cases ( Buntrock et al., 2016).

Limitations and Summary

Our findings should be considered in light of several limitations. First, the cross-national prevalence estimates are based on a convenience sample of colleges with relatively low and quite variable response rates, limiting generalizability of results. Second, only six common mental disorders were assessed in the surveys. The omission of attention-deficit/hyperactivity disorder, eating disorders, phobias, post-traumatic stress disorder, conduct disorder, oppositional-defiant disorder, and intermittent explosive disorder are especially noteworthy because of their comparatively high prevalence in the WMH surveys ( Auerbach et al., 2016), and therefore, the true prevalence of mental disorders among college students is likely to be a good deal higher than reported in the current study; particularly as we are only including first-years students who are not yet through the high-risk periods for many common disorders. Although it would have been desirable to include a more comprehensive assessment, this was rejected by the administrations of participating schools. However, as an alternative we developed screening scales for omitted disorders, and we are experimenting with a design in which subsets of these screening scales are rotated in future iterations of the surveys at random to provide partial information about prevalence and correlates of a wider range of disorders. This approach, which is referred to in the survey methodology literature as matrix sampling ( Merkouris, 2015), is becoming an increasingly popular approach to reduce respondent burden when the number of questions of interest in a survey exceeds the number that causes respondent burden ( Hughes, Beaghen, & Asiala, 2015; Thomas, Raghunathan, Schenker, Katzoff, & Johnson, 2006). Third, our results indicated that female gender emerged as a positive correlate of both lifetime and 12-month mental disorder prevalence. While this is not unexpected, it also important to note that this difference may be driven by an imbalance in our assessment of number of internalizing (4) disorders, which are known to be more common among women, and externalizing (2) disorders, which are known to be more common among men. Last, although the surveys used well-validated screening scales calibrated to yield unbiased prevalence estimates in general population samples, calibration studies have not yet been carried out in samples of college students. Nor do we know if calibration studies in separate countries would show that concordance of the structured questions in our diagnostic screens are equally valid in all countries. Fourth, lifetime prevalence and age-of-onset were assessed retrospectively, which may contribute to downward biases given recall errors.

Despite these limitations, our study clearly underscores the fact that mental disorders are common among college students. In line with the precision medicine initiative approach ( Insel, 2014), the next step in this work will be to begin constructing personalized approaches that both identify each student's risk profile and then, provide access to intervention resources designed to ameliorate the negative effects of mental disorders on this important segment of the population.

Acknowledgements

Funding to support this project was received from the National Institute of Mental Health (NIMH) R56MH109566 (RPA), and the content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or NIMH; the Belgian Fund for Scientific Research (11N0514N/11N0516N/ 1114717N) (PM), the King Baudouin Foundation (2014-J2140150-102905) (RB), and Eli Lilly (IIT-H6U-BX-I002) (RB, PM); BARMER, a health care insurance company, for project StudiCare (DDE); ZonMw (Netherlands Organisation for Health Research and Development; grant number 636110005) and the PFGV (PFGV; Protestants Fonds voor de Geestelijke Volksgezondheid) in support of the student survey project (PC); South African Medical Research Council (DJS); Fondo de Investigación Sanitaria, Instituto de Salud Carlos III - FEDER (PI13/00343), ISCIII (Río Hortega, CM14/00125), ISCIII (Sara Borrell, CD12/00440); European Union Regional Development Fund (ERDF) EU Sustainable Competitiveness Programme for Northern Ireland, Northern Ireland Public Health Agency (HSC R&D), and Ulster University (TB); Ministerio de Sanidad, Servicios Sociales e Igualdad, PNSD (Exp. 2015I015); DIUE Generalitat de Catalunya (2017 SGR 452; 2014 SGR 748), FPU (FPU15/05728) (JA); The World Mental Health International College Student project is carried out as part of the WHO World Mental Health (WMH) Survey Initiative. The WMH survey is supported by the National Institute of Mental Health NIMH R01MH070884, the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty International Center (FIRCA R03-TW006481), the Pan American Health Organization, Eli Lilly and Company, Ortho-McNeil Pharmaceutical, GlaxoSmithKline, and Bristol-Myers Squibb (RK). None of the funders had any role in the design, analysis, interpretation of results, or preparation of this paper.

We thank the staff of the WMH Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork, and consultation on data analysis. A complete list of all within-country and cross-national WMH publications can be found at: http://www.hcp.med.harvard.edu/wmh/.

WHO WMH-ICS Collaborators. Australia: Mark Boyes, School of Psychology & Speech Pathology, Curtin University; Glenn Kiekens, School of Psychology & Speech Pathology, Curtin University and RG Adult Psychiatry KU Leuven, Belgium; Germany: Harald Baumeister, University of Ulm; Fanny Kaehlke, Matthias Berking, Friedrich-Alexander University Erlangen Nuremberg; Mexico: Adrián Abrego Ramírez, Universidad Politécnica de Aguascalientes; Guilherme Borges, Instituto Nacional de Psiquiatría Ramón de la Fuente; Anabell Covarrubias Díaz, Universidad La Salle Noroeste; Ma. Socorro Durán, Universidad De La Salle Bajío; Rogaciano González González, Universidad De La Salle Bajío, campus Salamanca; Raúl A. Gutiérrez-García, Universidad De La Salle Bajío, campus Salamanca & Universidad Politécnica de Aguascalientes; Alicia Edith Hermosillo de la Torre, Universidad Autónoma de Aguascalientes; Kalina Isela Martinez Martínez, Universidad Autónoma de Aguascalientes, Departamento de Psicología, Centro Ciencias Sociales y Humanidades; María Elena Medina-Mora, Instituto Nacional de Psiquiatría Ramón de la Fuente; Humberto Mejía Zarazúa, Universidad La Salle Pachuca; Gustavo Pérez Tarango, Universidad De La Salle Bajío; María Alicia Zavala Berbena, Universidad De La Salle Bajío; Northern Ireland: Siobhan O'Neill, Psychology Research Institute, Ulster University; Tony Bjourson, School of Biomedial Sciences, Ulster University; South Africa: Christine Lochner, Janine Roos and Lian Taljaard, MRC Unit on Risk & Resilience in Mental Disorders, Department of Psychiatry, Stellenbosch University; Jason Bantjes and Wylene Saal, Department of Psychology, Stellenbosch University; Spain: The UNIVERSAL study group also includes Itxaso Alayo, Pompeu Fabra University; José Almenara, Cadiz University; Laura Ballester, IMIM (Hospital del Mar Medical Research Institute); Gabriela Barbaglia, Pompeu Fabra University;, Maria Jesús Blasco, Pompeu Fabra University; Pere Castellví, IMIM (Hospital del Mar Medical Research Institute); Ana Isabel Cebrià, Parc Taulí Hospital Universitari; Enrique Echeburúa, Basque Country University; Andrea Gabilondo, Osakidetza-Basque Health Service; Carlos García-Forero, Pompeu Fabra University; Álvaro Iruin, Hospital Universitario Donostia- Osakidetza; Carolina Lagares, Cadiz University; Andrea Miranda-Mendizábal, Pompeu Fabra University; Oleguer Parès-Badell, Pompeu Fabra University; María Teresa Pérez-Vázquez, Miguel Hernández University; José Antonio Piqueras, Miguel Hernández University; Miquel Roca, Illes Balears University; Jesús Rodríguez-Marín, Miguel Hernández University; Margalida Gili, Illes Balears University; Victoria Soto-Sanz, Miguel Hernández University and Margarida Vives, Illes Balears University.

Footnotes

Declarations of Interest

In the past 3 years, Dr. Kessler received support for his epidemiological studies from Sanofi Aventis; was a consultant for Johnson & Johnson Wellness and Prevention, Shire, Takeda; and served on an advisory board for the Johnson & Johnson Services Inc. Lake Nona Life Project. Kessler is a co-owner of DataStat, Inc., a market research firm that carries out healthcare research.

Dr. Ebert has received consultant fees and served on the scientific advisory board for several companies, including MindDistrict, Lantern, Schoen Kliniken, and German health insurance companies (BARMER, Techniker Krankenkasse). He also is a stakeholder in the institute for health training online (GET.ON), which aims to implement scientific findings related to digital health interventions into routine care.

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# data[].attributes.attachment_link.title
The WHO World Mental Health Surveys International College Student Project: Prevalence and Distribution of Mental Disorders

# data[].attributes.attachment_link.description
Increasingly, colleges across the world are contending with rising rates of mental disorders, and in many cases, the demand for services on campus far exceeds the available resources. The present study reports initial results from the first stage of the ...