National Mental Health and Treatment Trends in ... - APA PsycNET

Psychological Services 2017, Vol. 14, No. 4, 407– 415

© 2017 American Psychological Association 1541-1559/17/$12.00 http://dx.doi.org/10.1037/ser0000130

Are We in Crisis? National Mental Health and Treatment Trends in College Counseling Centers Henry Xiao, Dever M. Carney, Soo Jeong Youn, Rebecca A. Janis, Louis G. Castonguay, Jeffrey A. Hayes, and Benjamin D. Locke

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Pennsylvania State University The current state of college student mental health is frequently labeled a “crisis,” as the demand for services and severity of symptomatology have appeared to increase in recent decades. Nationally representative findings are presented from the Center for Collegiate Mental Health, a practice research network based in the United States, composed of more than 340 university and college counseling centers, in an effort to illuminate trends in symptom severity and patterns in treatment utilization for the campus treatment seeking population. Clinical data collected over 5 academic years (2010 –2015) showed small but significantly increasing trends for self-reported distress in generalized anxiety, depression, social anxiety, family distress, and academic distress, with the largest effect sizes observed for generalized anxiety, depression, and social anxiety. On the other hand, a significantly decreasing trend was observed for substance use. No significant changes were observed for eating concerns and hostility. Utilization data over 6 years indicated a gradual yet steady increase in the number of students seeking services (beyond the rate expected with increasing institutional enrollment), as well as increases in the number of appointments scheduled and attended, with great variation between centers. Within the context of changing national trends, we conclude that it is advisable to consider the specific needs of local centers to best accommodate distinct student bodies. Keywords: college mental health, counseling centers, national trends, practice research network, treatment utilization

from the American College Health Association-National College Health Assessment, the prevalence of lifetime depression diagnoses grew approximately 10% to 20% from 2000 to 2015 (American College Health Association, 2001, 2014). Additionally, an increasing number of students are entering college with a history of mental health treatment (Haas, Hendin, & Mann, 2003). There is also evidence to suggest that clients’ presenting concerns in counseling centers (CCs) are more complex and severe than two decades ago. One study at a large university found increasing trends across decades in the following problem areas: developmental, depression, academic skills, grief, medication use, relationships, stress/anxiety, family issues, physical problems, personality disorders, suicidal thoughts, and sexual assault (Benton, Robertson, Tseng, Newton, & Benton, 2003). These changes have not gone unnoticed by CC leadership. A 2012 survey by the Association for University and College Counseling Center Directors (Mistler, Reetz, Krylowicz, & Barr, 2012) found that 96% of college CC directors believed that the number of students with significant psychological problems was a growing concern on their campus. In the 2014 National Survey of College Counseling Centers, 94% of 275 directors surveyed also believed that the number of students with severe psychological disorders had increased in the past year, creating a higher demand for mental health services (Gallagher, 2014). If students today frequently present with more complex and/or severe problems, they may also require more resources to support them. However, despite the increasing demand, college CCs have not seen an equivalent increase in resources for campus clinics. In a 2007 survey, professional members from the American College

With approximately 66% of high school graduates enrolling in postsecondary education (U.S. Department of Education, 2015), nearly 20 million students are in a position to seek mental health services while attending college or a university. According to data from the World Health Organization, mental and behavioral disorders are the primary leading causes of disability for young adults, and the majority of lifetime mental disorders have early ages of onset (Hunt & Eisenberg, 2010; Institute for Health Metrics & Evaluation, 2015; Kessler et al., 2005). Not only are college students a growing population, they represent a demographic with apparent heightened risk for developing mental health problems. Indeed, recent reports have also raised the concern that college mental health problems seem to be increasing in both number and severity of symptoms. Birth cohort comparison studies show that over the past several decades, college students have scored increasingly higher on clinical scales of psychopathic deviation, paranoia, schizophrenia, hypomania, hypochondriasis, depression, and hysteria (Twenge et al., 2010). In national surveys of college students

Henry Xiao, Dever M. Carney, Soo Jeong Youn, Rebecca A. Janis, and Louis G. Castonguay, Department of Psychology, Pennsylvania State University; Jeffrey A. Hayes, Department of Educational Psychology, Counseling, and Special Education, Pennsylvania State University; Benjamin D. Locke, Center for Counseling and Psychological Services, Pennsylvania State University. Correspondence concerning this article should be addressed to Henry Xiao, Department of Psychology, Pennsylvania State University, 346 Moore Building, University Park, PA 16802. E-mail: [email protected] 407


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Counseling Association were asked about the increasing demand for services, and only 4% replied that caseload was not a problem (Smith et al., 2007). For the other 96%, the most common response was that the CC needed more employees (26%). Because of these strained resources, centers have often needed to adopt strategies to cope with the clinical pressure, such as waitlists, implementing clinic-wide session limits, or referring students to external sites (Benton et al., 2003; Gallagher, 2011; Smith et al., 2007). Nearly half of 228 centers in one survey reported having had to adopt waitlists, and nearly 90% of their directors raised concerns that clients may not be getting treatment when it is most needed (Gallagher, 2011). This combination of growing college population, seemingly increasing distress among students, and strained resources in CCs to meet the clinical needs, has led many, including major media outlets, psychologists, and CC directors, to dub the current climate of collegiate mental health a “crisis” (Gabriel, 2010; Hoffman, 2015; Holterman, 2015; Kadison, 2004; Kadison & DiGeronimo, 2004; PBS News Hour, 2015; Sood & Martel, 2015; Zimmerman, 2015). However, it could be argued that this conclusion is premature. Although a study by Benton et al. (2003) identified increases in several problem areas, they also found no significant changes in substance abuse, eating disorders, legal problems, or chronic mental disorders. Schwartz (2015) examined longitudinal client selfreport measures and found a stable proportion of people meeting Axis-I diagnoses, no change in overall severity of symptoms, and a decline in suicidality. Furthermore, a recent study by KetchenLipson et al. (2015) examined presenting mental health symptoms and treatment utilization trends in a large sample of randomly selected students in schools across the country. Results showed that symptoms and demand for services were fluctuating, and that not all schools reported increasing or worsening of symptoms equally. Although the existing literature offers insight to issues faced by CCs, to conclude that collegiate mental health is in “crisis” appears to describe the present climate too broadly. These heterogeneous findings may highlight the difficulty in conducting research at this resource-starved setting. Much of the available empirical data are limited in generalizability as a result of reliance on one-time assessments or single-site studies. Even larger multisite studies may suffer from challenges such as disconnected research teams, time constraints, and restrictive data sets (Locke et al., 2012). Past research has also often relied on CC director and clinician recollection of trends to assess severity over a certain period instead of documented numbers (Gallagher, 2014; O’Malley et al., 1990; Robbins et al., 1985). To accurately describe the dynamic and changing state of collegiate mental health, large and representative data sets are needed. The development of such a dataset can be difficult, but not impossible; such data sets reflect and require the integration of science and practice as in practice-oriented research (POR). POR is a bottom-up approach to gathering and using scientific knowledge, where clinicians are directly engaged with research dedicated to improving clinical practice (Castonguay, Barkham, Lutz, & McAleavey, 2013). Practice research networks (PRN) can provide an optimal infrastructure for this type of synergistic relationship between science and practice. This is because practitioners have the opportunity to be involved in all aspects of data collec-

tion, which in turn is seamlessly integrated into their clinical work (Castonguay et al., 2013; Castonguay, Youn, Xiao, Muran, & Barber, 2015). The Center for Collegiate Mental Health (CCMH; ccmh.psu.edu) is an example of such a PRN. It was established as a collaborative and multidisciplinary collaboration to systematically address the growing and changing needs experienced specifically by college CCs across the United States (Castonguay, Locke, & Hayes, 2011; Hayes, Locke, & Castonguay, 2011; McAleavey, Lockard, Castonguay, Hayes, & Locke, 2015). The CCMH comprises over 340 member CCs across the United States and internationally, each using the same standardized demographic questionnaire and empirically valid multidimensional assessment tool. Participating CCs contribute data and, in return, receive results that can be used to inform their clinical practice. This study will explore two issues related to college mental health in CCs. First, mental health trends regarding the presenting mental health concerns of treatment-seeking clients will be evaluated. Second, utilization of treatment at CCs will be assessed to further understand the use and availability of resources. Because of its large and diverse membership, data gathered through the CCMH are demographically and geographically representative, and thus can begin to more accurately capture the current state of collegiate mental health and better inform decision-making related to institution/center policy, funding, staffing, resource allocation, and future research in this area.

Method Procedure The current study used standardized data collected by CCMH members via two instruments described below. All CCMH member centers secure and maintain their own Institutional Review Board approval. Once per year, all member centers contribute local de-identified data (from the same two instruments) to the CCMH’s centralized data repository (McAleavey et al., 2015). For the purpose of this study, a utilization of service survey was sent to CCMH member institutions via an e-mail sent to the CCMHmember only Listserv.

Measures Standardized data set. The standardized data set (SDS) is a set of standardized questions utilized by CCs, and includes client demographic and mental health history questions. The SDS is typically administered pretreatment, depending on each center’s policy. Based on clinical needs, a substantial format alternation was implemented at the beginning of the 2012 academic year to the SDS. Instead of only inquiring about lifetime prevalence of mental health difficulties, the SDS questions and the answer choices were modified to assess both recency (“The last time”) and frequency (“How many times”). Items affected by the aforementioned format change are denoted with a cross (†) in the list below. To best examine 5-year trends among college students in treatment, SDS items that serve as key mental health indicators were selected for this study, and answer choices were coded to a dichotomous “Yes” or “No” response.


NATIONAL TRENDS IN COUNSELING CENTERS

The key SDS items selected for the current study were grouped into theoretically derived, clinically relevant sections. Items related to treatment history included: “Attended counseling for mental health concerns,” “Taken a medication for mental health concerns,” and “Been hospitalized for mental health concerns†.” Items related to suicidality and self-harm included: “Purposely injured yourself without suicidal intent (e.g. cutting, hitting, burning, hair pulling, etc.)†,” “Seriously considered attempting suicide†,” “Seriously considered attempting suicide†” [within the last month], and “Made a suicide attempt†.” Items related to harming others included: “Considered seriously hurting another person†” and “Intentionally caused seriously injury to another person†.” Items related to traumatic events included: “Had unwanted sexual contact(s) or experience(s)†,” “Experienced harassing, controlling, and/or abusive behavior from another person (e.g. friend, family member, partner, authority figure, etc.)†,” and “Experienced a traumatic event that cause you to feel intense fear, helplessness, or horror†.” Items related to alcohol or drug use included: “Felt the need to reduce your alcohol or drug use†,” “Others have expressed concern about your alcohol or drug use†,” and “Received treatment for alcohol or drug use†.” Counseling Center Assessment of Psychological Symptoms. The Counseling Center Assessment of Psychological Symptoms (CCAPS) is a multidimensional measure of psychological symptoms designed specifically to assess college mental health difficulties, and it is administered pre-, during, and posttreatment, depending on each center’s policy. The CCAPS-62 includes 62 items, each asking the student to rate how well the items describe them in the past two weeks on a five-point Likert scale ranging from 0 (not at all like me) to 4 (extremely like me). The assessment has eight factor-analytically derived subscales including Depression, Generalized Anxiety, Social Anxiety, Eating Concerns, Substance Use, Family Distress, Academic Distress, and Hostility (Locke et al., 2011). It also includes a general measure of distress, the Distress Index (DI), which is composed of 20 items from across the various subscales (Nordberg et al., 2015). The CCAPS-62 has demonstrated strong convergent validity with other established measured of related domain-specific distress, and appropriately low correlations with unrelated domains (Locke et al., 2011; McAleavey, Nordberg, Hayes, et al., 2012). It has also been shown to have acceptable 1- and 2-week test–retest reliability in nonclinical samples, ranging from 0.76 for Academic Distress to 0.92 for Depression (McAleavey et al., 2012). Utilization of Counseling Centers Survey. This survey asked centers to provide the following utilization of counseling center resources data for each of the six academic years between 2009 and 2015: (a) the total number of client appointments scheduled at the counseling center, regardless of attendance, (b) the total number of attended client appointments, (c) the total number of clients seeking services at the CC, and (d) the total number of students enrolled in the university/college during the Fall semester of each of the academic years of interest. Items 1 through 3 were accessed through the centers’ electronic medical record software. Members were given a week to respond to this survey and provide their institution’s data.

Participants Mental health trends. Data to examine mental health trends were collected across five academic years, from 2010 to 2015. The

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combined data set includes a nationally representative sample of students seeking mental health services across 161 CCs in the United States, with a total sample of 476,388 students meeting eligibility criteria for inclusion in this study. The total sample represents the number of unique client intakes across the five academic years. In other words, clients are represented once in every year that they received treatment, and consequently, clients may be included in multiple years of data. If a client presented for multiple intakes within a given year, only their first intake was retained. The current study’s 5-year data set reflects the clinical reality that students often come back for multiple courses of therapy across various years, as they need services. To be included in the present study, clients must have provided a response to at least one of the SDS questions or had completed a valid pretreatment CCAPS-62. CCAPS-62 administrations are considered valid and scored if more than 50% of the total items were completed, at least 33% of the items on each subscale were completed, and not all the item values are the same (e.g., all 1s). The average client age was 22.64 years (SD ⫽ 5.37). The sample contained a majority of females (62.83%), followed by males (36.38%), transgender (0.28%), and less than 1% choosing to self-identify or not respond. The majority of the sample identified as White (70.28%), followed by African American (8.91%), Hispanic (7.32%), Asian American (6.36%), and multiracial (4.16%), with less than 3% reporting as Native American, Arab American, Hawaiian/Pacific Islander, other ethnicity, preferred to self-identify, or preferred not to answer. The majority of the sample described themselves as heterosexual (86.66%), followed by bisexual (4.37%), gay or lesbian (4.25%), questioning (1.81%), and 2.83% self-identified or chose not to answer this question. Regarding student status: 19.66% identified as freshman, 20.03% as sophomores, 22.58% as juniors, 21.93% as seniors, and 15.81% as other. Utilization of counseling centers. In total, 334 CCMH member institutions were contacted about the supplemental survey, and 119 institutions participated. From these, 33 centers with incomplete data across the six years were removed from the sample and thus, data from 86 centers was used for final analyses for this study.

Data Analyses Mental health trends. A multiple logistic regression was conducted to assess the significance of individual SDS item prevalence changes, where prevalence was regressed on year of data. From the logistic regression odds ratios and p values are reported. A multivariate regression analysis was conducted to test the overall trends in all nine CCAPS subscales across five years, followed by univariate analyses testing the trend in each subscale individually. From the multivariate regression models unstandardized coefficients and p values are reported. To prevent alpha inflation, we applied a Bonferroni correction for multiple comparisons. This resulted in required p values of .003 for SDS items and .006 for CCAPS subscales for significance. Utilization of counseling centers. Percent changes from year to year were calculated for each school for the number of appointments scheduled and attended, the number of clients seeking services, institutional enrollment, and utilization ratio, as assessed by the number of clients seeking services over the total institu-

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tional student body. The mean percentage change is reported for each academic year, as well as for the 5-year change from 2010 to 2015.

Results


Mental Health Trends Lifetime prevalence trends on SDS items related to treatment history, suicidality and self-harm, harming others, traumatic events, and alcohol or drug use, are respectively presented in Figures 1 through 5. Regression results indicated a significant change in annual prevalence for all examined SDS items (p ⬍ .001) except for one question, “Experienced a traumatic event that caused you to feel intense fear, helplessness, or horror.” Most of the significant changes indicated increasing 5-year trends, best interpreted through reported odds ratios. For example, for the item “Attended counseling for mental health concerns” (OR ⫽ 1.030), on average, each progressive year of data was associated with an average 1.03 times increase in the odds that a student would report “yes” for lifetime prevalence. The largest changes in odds for reporting “yes” were observed for the following items: “Been hospitalized for mental health concerns” (10.46% increase in odds per year), “Seriously considered attempting suicide” (11.52% increase), “Considered seriously hurting another person” (10.08% increase), “Intentionally caused serious injury to another person” (9.01% increase), and “Seriously considered attempting suicide in the last month” (7.67% increase). The SDS items that showed significant decreasing trends were “Others have expressed concern about your alcohol or

Figure 1. Treatment history SDS item prevalence by academic year. Prior Counseling ⫽ Attended counseling for mental health concerns. OR ⫽ 1.03; SE ⫽ .002; p ⬍ .001. Prior Medication ⫽ Taken a prescribed medication for mental health concerns. OR ⫽ 1.02; SE ⫽ .002; p ⬍ .001. Prior Hospital ⫽ Been hospitalized for mental health concerns. OR ⫽ 1.11; SE ⫽ .004; p ⬍ .001. ⴱ Item significant at Bonferroni adjusted p ⬍ .003. † Item received question format alteration between 2011 and 2012.

Figure 2. Suicidality and self-harm SDS item prevalence by academic year. Self-harm/Injury ⫽ Purposely injured yourself without suicidal intent (e.g., cutting, hitting, burning, etc.). OR ⫽ 1.03; SE ⫽ .0025; p ⬍ .001. Considered Suicide ⫽ Seriously considered attempting suicide. OR ⫽ 1.12; SE ⫽ .002; p ⬍ .001. Suicide Attempt ⫽ Made a suicide attempt. OR ⫽ 1.05; SE ⫽ .004; p ⬍ .001. Considering Suicide ⫽ Considered suicide within the last month. OR ⫽ 1.08; SE ⫽ .003; p ⬍ .001. ⴱ Item significant at Bonferroni adjusted p ⬍ .003. † Item received question format alteration between 2011 and 2012. a Item calculated for years 2012–2014 only, due to format change introduced in 2011– 2012.

drug use” (⫺5.29% decrease in odds per year), “Experienced harassing, controlling, and/or abusive behavior from another person” (⫺4.13%), “Had unwanted sexual contact(s) or experience(s)” (⫺2.51%), and “Felt the need to reduce your alcohol or drug use” (⫺1.08%). To explore whether student self-reported distress changed over time, the average CCAPS-62 subscale scores for five years are presented in Figure 6. Overall, there was a statistically significant upward trend across the five years across all subscales, although the effect size was small, Wilkes’ ⌳ ⫽ .994, F(9, 349220) ⫽ 215.15, p ⬍ .001, partial ␩2 ⫽ .006. Univariate tests (see Table 1) for specific subscales indicated that Eating Concerns and Hostility did not show a statistically significant trend, while the Distress Index, Depression, Generalized Anxiety, Social Anxiety, Family Distress, and Academic Distress subscales all had a statistically significant upward trend. The Substance Use subscale demonstrated a statistically significant downward trend. The largest effect sizes were observed for Depression (partial ␩2 ⫽ .003), Generalized Anxiety (partial ␩2 ⫽ .002), and Social Anxiety (partial ␩2 ⫽ .002).



Figure 3. Harming others SDS item prevalence by academic year. Cons. Harm Other ⫽ Considered seriously hurting another person. OR ⫽ 1.11; SE ⫽ .004; p ⬍ .001. Harmed other ⫽ Intentionally caused serious injury to another person. OR ⫽ 1.09; SE ⫽ .006; p ⬍ .001. ⴱ Item significant at Bonferroni adjusted p ⬍ .003. † Item received question format alteration between 2011 and 2012.

Utilization of Counseling Centers The results showed that across CCs over six academic years, the average annual enrollment at participating institutions was 18,836.32 (SD ⫽ 13,050.74) students. The average annual number of scheduled appointments was 8,779.72 (SD ⫽ 6,844.91), whereas the average number of attended appointments was 6,621.35 (SD ⫽ 5,275.45). The average annual number of clients seeking services at CCs was 1,340.53 (SD ⫽ 949.36). This resulted in an average of 8.95% (SD ⫽ 7.37) of the student body utilizing CC services each year. Table 2 includes the CCMH survey results of treatment utilization changes across the six academic years, from 2009 to 2014. The results indicate a steady growth in institutional enrollment and all reported aspects of CC utilization, including the number of scheduled appointments, attended appointments, and clients seeking services. On average, the growth in number of students seeking services at CCs (28.9%) was more than 4⫻ the rate of institutional enrollment (6.3%). The growth in CC appointments (39.1%) was found to be more than 6⫻ the rate of institutional enrollment. Seventy-six out of the 86 center respondents (88.37%) reported some increase in the total percentage of students seeking treatment over five years. 20 (76.74%) centers reported some increase in institutional enrollment.

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history, harm to others, traumatic events, and alcohol/drug use across the five years of data. That is, although there is indeed a significant change in prevalence from academic year to year, the change between years is comparatively small, and thus, difficult to deem as some kind of aggravated “crisis” for these mental health domains. On the other hand, there is a significant upward trend for suicide and self-harm–related issues. With suicide being the second leading cause of death for college students (Schwartz, 2006), this presents a specific and meaningful area of concern. Indeed, for each consecutive academic year of data, a larger percentage of students reported past incidences of self-harm, suicidal ideation, and suicide attempts. Perhaps even more clinically concerning and immediately relevant, the results from the SDS trend analyses also show an increase in clients presenting with suicidal ideation within two weeks of their intake appointment at CCs. When looking at the data for the most recent academic year, one fourth of students seeking services reported having self-harmed, nearly one third had considered suicide, and nearly one tenth had attempted suicide or recently endorsed suicidal ideation. This heterogeneity in trends is also reflected in changes in the clients’ self-reported presenting symptomatology. For example, the Academic Distress, Eating Concerns, Family Distress, Hostility and Substance Use CCAPS subscale scores appear to have relatively stable trends across the past 5 years, with very small to no increases or decreases. In fact, Substance Use was significantly decreasing over the past five years; this may reflect the efforts of more mainstream alcohol abuse psychoeducation, or more negatively, perhaps a normalization of alcohol use on college campuses. On the other hand, Depression, Generalized Anxiety, Social

Discussion Although some have expressed concern about the “crisis” in collegiate mental health, there has been limited nationally representative trend data available for clients seeking treatment in CCs to be able to draw any firm conclusions. The current study used five years of large, representative naturalistic data to provide a more comprehensive depiction of changes in presenting client symptomatology and utilization of CCs across the United States. The results show that there is heterogeneity and complexity in the changes across multiple mental health domains. For example, 5-year trends in prevalence of client demographic variables show that these are not uniformly increasing. There appears to be a relatively small increase in prevalence rate for mental health

Figure 4. Traumatic events SDS item prevalence by academic year. Unwanted Sex ⫽ Had unwanted sexual contact(s) or experience(s). OR ⫽ 0.98; SE ⫽ .003. p ⬍ .001. Harassed/Abused ⫽ Experienced harassing, controlling, and/or abusive behavior from another person. OR ⫽ .96; SE ⫽ .002; p ⬍ .001. Traumatic Event ⫽ Experienced a traumatic event that caused you to feel intense fear, helplessness, or horror. OR ⫽ 1.00; SE ⫽ .002; p ⫽ .025. ⴱ Item significant at Bonferroni adjusted p ⬍ .003. † Item received question format alteration between 2011 and 2012.

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Table 1 Univariate Regressions on CCAPS Subscales Predicted by Year Subscale

B

SE B

t

p

Partial ␩2

Eating Hostility Distress index Depression Generalized anxiety Social anxiety Family distress Academic distress Substance use

.003 ⫺.002 .026 .029 .035 .032 .008 .01 ⫺.008

.001 .001 .001 .001 .001 .001 .001 .001 .001

2.37 ⫺2.36 25.37 25.03 30.66 27.24 7.15 7.92 ⫺7.74

.018 .019 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001

⬍.001 ⬍.001 .002 .002 .003 .002 ⬍.001 ⬍.001 ⬍.001

Note.

Figure 5. Alcohol or drug use SDS item prevalence by academic year. Self Concern Alc. ⫽ Felt the need to reduce your alcohol or drug use. OR ⫽ .99; SE ⫽ .002; p ⬍ .001. Other Concern Alc. ⫽ Others have expressed concern about your alcohol or drug use. OR ⫽ .99; SE ⫽ .002; p ⬍ .001. Alcohol Treatment ⫽ Received treatment for alcohol or drug use. OR ⫽ 1.05; SE ⫽ .005; p ⫽ ⬍ .001. ⴱ Item significant at Bonferroni adjusted p ⬍ .003. † Item received question format alteration between 2011 and 2012.

Anxiety, and the Distress Index scores appear to be increasing over time. This specificity of change points to the same area of concern as the self-harm/suicidal ideation SDS items. With prior research linking anxiety disorders with suicidal ideation, especially when comorbid with mood disorders (Sareen et al., 2005), the increase of anxiety and depression related presenting concerns may be indicative of a trend toward increases of these more clinically complicated and resource-intensive clients. Furthermore, findings from the most recent CCMH annual report (CCMH, 2016) also report that clients who endorsed any of these items attended 25% more sessions compared to those who did not (respectively, roughly 10 sessions scheduled compared with 8), indicating that these items may represent particularly resource-intensive factors for an already resource-starved treatment setting.

Results reported at a Bonferroni adjusted .006 level of significance.

Overall, there seems to be an average national increase in a particular subset of the college student demographic. The upward trending self-harm and suicide SDS items and increase in presenting severity for CCAPS Depression and Anxiety subscales may be reflective of a subset of clients that are concerning not only for clinical reasons, but also require and use more clinical resources. This may be particularly concerning because treatment utilization has also changed across the past five years. Every year, the mean numbers of appointments and students seeking services has increased. From 2009 to 2014, the average CC saw nearly a 30% increase in number of students seeking treatment, compared to an average 6% institutional enrollment increase. In other words, on average, demand for CCs has increased more than 4⫻ faster than the general student body, which could indicate that CCs which receive funding based on student body size might indeed be underfunded. This compounds the problem of mental health treatment delivery- not only are more students seeking treatment than would be predicted from historical utilization rates, these students are coming with clinically concerning, high-risk, and resourceintensive concerns related to suicide and self-harm. These dual trends (increases in demand and potential risk to self) seem likely to be contributors to the notion that college student mental health is in a state of “crisis.” On the other hand, when viewed from a suicide prevention perspective, these same trends can also be viewed as appropriate outcomes. The Garret Lee Smith Memorial Act (GLSMA) was passed by the United States Congress in 2004 for the purpose of

Figure 6. CCAPS-62 mean subscale scores by academic year. adjusted p ⬍ .006.

ⴱ

Subscale change significant at Bonferroni


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Table 2 Mean % Changes in CC Utilization and Institutional Enrollment Between Academic Years, and Five-Year Changes From 2009 –2014

2009 to 2010 2010 to 2011 2011 to 2012 2012 to 2013 2013 to 2014

Mean % change (SD) 2009 –2014

7.36 (13.88) 7.29 (14.39) 8.71 (10.92) 2.42 (3.84)

6.96 (12.41) 9.37 (15.05) 4.24 (9.22) .84 (2.98)

5.68 (14.12) 5.68 (14.77) 3.05 (10.84) .82 (3.36)

6.19 (13.07) 6.28 (13.42) 3.17 (8.38) .71 (3.14)

7.78 (12.31) 8.44 (11.93) 7.56 (8.99) 1.09 (3.05)

39.08 (48.59) 42.24 (46.11) 28.91 (24.82) 6.27 (10.67)

⫺32.14 ⫺30.93 ⫺15.86 ⫺22.22

383.09 363.51 164.86 37.08

6.23 (10.95)

3.42 (9.23)

2.26 (10.64)

2.46 (7.84)

6.48 (9.28)

21.67 (20.83)

⫺20.40

101.56

Mean % change (SD) Variable


Number of appointments Attended appointments Students seeking services Institutional enrollment Utilization (% of student body served in the CC)

reducing college student suicide (GLSMA, 2004). Administered by the Substance Abuse and Mental Health Services Administration (www.samhsa.gov), the GLSMA injected (2005–2015) more than $60 million into colleges and universities (with some incidental overlap with CCMH members) to decrease mental health stigma, increase help-seeking, prevent suicide, and train college communities to identify and refer at-risk students to treatment (U.S. Department of Health & Human Services, 2015). In addition, during the last decade more than $275 million of GLSMA funding has been distributed to states to support youth suicide prevention efforts. In this context, the dual trend of increasing demand for service and student-clients reporting “threat to self” characteristics may be linked to a decade of intensive and well-funded suicide prevention efforts. That is, the efforts to increase awareness and decrease stigma of mental health issues, particularly for at-risk students, may play a role in the apparent increase in “prevalence” of these concerns: these students are more appropriately seeking services. The “crisis” experienced in college student mental health may not be solely dependent on changes in student presenting concerns, but rather a lack of commensurate resources available to CCs, systems that may struggle in proactively expanding to meet demand prompted by prevention efforts.

Clinical Applications Given the complexity of college student mental health at the treatment level, the practical application of findings in this study may require a more nuanced local approach. Just as there is a range in how and why mental health domains are changing, there also appears to be heterogeneity in how individual institutions and counseling centers are changing. Similar to the findings by Ketchen-Lipson and colleagues (2015), there is variability in the type of mental health problems and help-seeking behaviors across higher education sites. For example, although the results show an approximate 30% average increase in the number of treatmentseeking clients across five years, centers ranged from ⫺15% to 165%. Indeed, we found 10 centers (11.62%) reporting a decrease in the total percentage of students seeking treatment over five years. However, although 20 (23.26%) centers reported decreases in institutional enrollment, only three of them also reported decreases in percentage of students seeking treatment. That is, even for those centers institutions experiencing a decline in overall enrollment, a majority still experienced a growth in demand for mental health services.

Minimum Maximum % change % change 2009 –2014 2009 –2014

Without more specific information regarding individual CCs and institutions, it is impossible to accurately explain these findings, but it can be speculated that funding, staff size, and treatment model may play a role in these center differences. For example, an underfunded counseling center with much higher demand than capacity may also have long delays in delivering treatment or rely on referring clients out, perhaps lessening student willingness to seek treatment on-campus. On the other hand, it could also be that universities differ in their usage of outreach programs, mental health awareness, or openness and acceptance of mental health concerns, which may increase the demand for mental health services. Indeed, such variation between centers can be considered strong argument for the examination of center-specific effects on multiple levels. If the largest changes in counseling centers are increased rates of utilization by clients with somewhat higher risk to themselves, then further research would do well to examine these areas in a more focused manner. Fruitful client factors research might examine returning veterans, or those particularly affected by economic struggles. More research on the strengths and weaknesses of various referral strategies and the balance between outreach/suicide prevention programs and overloading counseling center capacity would also increase the efficiency of delivery for centers. In any case, these complex findings highlight the importance of examining national trends at the local level to determine needs and solutions for individual centers.

Limitations The results of the current study are not without limitations. It is important to note that a change in the question and answer format for several of the SDS items was implemented at the beginning of the 2012 academic year. Therefore, it is difficult to attribute the changes seen in some of the SDS items between the 2011 and 2012 academic years as being attributable to this format change, or to actual changes in the prevalence rates in these mental health domains. However, it could be argued that the change to a more clinically relevant question and answer format more accurately captured the existing prevalence rates for these issues.

Conclusion Despite these limitations, an argument can be made that institutions should address the challenge of college student mental health by increasing their awareness of counseling center utilization trends (historically and nationally) to thoughtfully evaluate

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local funding decisions systematically through the careful analysis of data describing observed local demand (e.g., the number of students seeking services). Just as it is important to be able to quantify what is meant by the national “crisis” in regards to collegiate mental health, it is also worthwhile to understand how the current state of presenting concerns and treatment utilization are reflected in individual CCs. There appears to be a nationally increasing trend in the prevalence of self-harm and suicide related issues, anxiety and depression related presenting concerns, and overall utilization of CC services, but heterogeneity of these domains between centers appears to warrant a nuanced approach that focuses on local demand and service availability. Arming counseling centers and institutions with data on both national and local prevalence data will enable them to advocate for the specific resources needed to create the optimal campus environment for fostering improved mental health, and to provide students with effective clinical care that is available when needed.

References American College Health Association. (2001). American College Health Association–National College Health Assessment: Reference group data report. Baltimore, MD: Author. Retrieved from http://www.acha-ncha.org/ reports_ACHA-NCHAoriginal.html American College Health Association. (2014). American College Health Association–National College Health Assessment: Reference group data report. Baltimore, MD: Author. Retrieved from http://www.acha-ncha. org/reports_acha-nchaii.html Benton, S. A., Robertson, J. M., Tseng, W. C., Newton, F. B., & Benton, S. L. (2003). Changes in counseling center client problems across 13 years. Professional Psychology: Research and Practice, 34, 66 –72. http://dx.doi.org/10.1037/0735-7028.34.1.66 Castonguay, L. G., Barkham, M., Lutz, W., & McAleavey, A. A. (2013). Practice-oriented research: Approaches and application. In M. J. Lambert (Ed.), Bergin and Garfield’s Handbook of psychotherapy and behavior change (6th ed., pp. 85–133). New York, NY: Wiley. Castonguay, L. G., Locke, B. D., & Hayes, J. A. (2011). The Center for Collegiate Mental Health: An example of a practice-research network in university counseling centers. Journal of College Student Psychotherapy, 25, 105–119. http://dx.doi.org/10.1080/87568225.2011.556929 Castonguay, L. G., Youn, S. J., Xiao, H., Muran, J. C., & Barber, J. P. (2015). Building clinicians-researchers partnerships: Lessons from diverse natural settings and practice-oriented initiatives. Psychotherapy Research, 25, 166 –184. http://dx.doi.org/10.1080/10503307.2014 .973923 Center for Collegiate Mental Health. (2016, January). 2015 annual report. University Park, PA: Author. Gabriel, T. (2010, December 19). Mental health needs seen growing at colleges. The New York Times. Retrieved from http://www.nytimes .com/2010/12/20/health/20campus.html Gallagher, R. P. (2011). National Survey of Counseling Center Directors 2011. University of Pittsburgh, PA: International Association of Counseling Services, Inc. Retrieved from http://www.iacsinc.org/ 2011%20NSCCD.pdf Gallagher, R. P. (2014). National Survey of College Counseling Directors 2014. University of Pittsburg, PA: International Association of Counseling Services, Inc. Retrieved from http://www.collegecounseling.org/ wp-content/uploads/NCCCS2014_v2.pdf Garret Lee Smith Memorial Act, 108 U.S. C. § 2634 et seq. (2004). Retrieved from https://www.govtrack.us/congress/bills/108/s2634/text Haas, A. P., Hendin, H., & Mann, J. J. (2003). Suicide in college students. American Behavioral Scientist, 46, 1224 –1240. http://dx.doi.org/10 .1177/0002764202250666

Hayes, J. A., Locke, B. D., & Castonguay, L. G. (2011). The Center for Collegiate Mental Health: Practice and research working together. Journal of College Counseling, 14, 105–119. http://dx.doi.org/10.1002/j .2161-1882.2011.tb00266.x Hoffman, J. (2015, May 27). Anxious student strain mental health centers. The New York Times. Retrieved from http://well.blogs.nytimes.com/ 2015/05/27/anxious-students-strain-college-mental-health-centers/ Holterman, A. (2015, July 17). Mental health problems for college students are increasing. Healthline. Retrieved from http://www.healthline.com/ health-news/mental-health-problems-for-college-students-are-increasing071715 Hunt, J., & Eisenberg, D. (2010). Mental health problems and help-seeking behavior among college students. Journal of Adolescent Health, 46, 3–10. http://dx.doi.org/10.1016/j.jadohealth.2009.08.008 Institute for Health Metrics and Evaluation. (2015). The global burden of disease: Generating evidence, guiding policy. Seattle, WA: University of Washington. Retrieved from http://www.healthdata.org/sites/default/ files/files/policy_report/2013/GBD_GeneratingEvidence/IHME_ GBD_GeneratingEvidence_FullReport.pdf Kadison, R. (2004, December 10). The mental-health crisis: What colleges must do. The Chronicle of Higher Education. Retrieved from http:// chronicle.com/article/The-Mental-Health-Crisis-What/1712 Kadison, R., & DiGeronimo, T. F. (2004). College of the overwhelmed: The Campus mental health crisis and what to do about it. San Francisco, CA: Jossey-Bass. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM–IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593– 602. http://dx.doi.org/10.1001/ archpsyc.62.6.593 Ketchen Lipson, S., Gaddis, S. M., Heinze, J., Beck, K., & Eisenberg, D. (2015). Variations in student mental health and treatment utilization across US colleges and universities. Journal of American College Health, 63, 388 –396. http://dx.doi.org/10.1080/07448481.2015 .1040411 Locke, B. D., Buzolitz, J. S., Lei, P. W., Boswell, J. F., McAleavey, A. A., Sevig, T. D., . . . Hayes, J. A. (2011). Development of the Counseling Center Assessment of Psychological Symptoms-62 (CCAPS-62). Journal of Counseling Psychology, 58, 97–109. http://dx.doi.org/10.1037/ a0021282 Locke, B. D., McAleavey, A. A., Zhao, Y., Lei, P. W., Hayes, J. A., Castonguay, L. G., . . . Lin, Y. C. (2012). Development and initial validation of the Counseling Center Assessment of Psychological Symptoms-34 (CCAPS-34). Measurement and Evaluation in Counseling and Development, 45, 151–169. http://dx.doi.org/10.1177/ 0748175611432642 McAleavey, A. A., Lockard, A. J., Castonguay, L. G., Hayes, J. A., & Locke, B. D. (2015). Building a practice research network: Obstacles faced and lessons learned at the Center for Collegiate Mental Health. Psychotherapy Research, 25, 134 –151. http://dx.doi.org/10.1080/ 10503307.2014.883652 McAleavey, A. A., Nordberg, S. S., Hayes, J. A., Castonguay, L. G., Locke, B. D., & Lockard, A. J. (2012). Clinical validity of the counseling center assessment of psychological symptoms-62 (CCAPS-62): Further evaluation and clinical applications. Journal of Counseling Psychology, 59, 575–590. http://dx.doi.org/10.1037/a0029855 Mistler, B., Reetz, D. R., Krylowicz, B., & Barr, V. (2012). The association for university and college counseling center directors annual survey. Retrieved from http://www.aucccd.org/director-surveys-public Nordberg, S. S., McAleavey, A. A., Duszak, E., Locke, B. D., Hayes, J. A., & Castonguay, L. G. (2015). Better fit, same meaning: Hierarchical models of general distress on the CCAPS-34. Manuscript submitted for publication.


NATIONAL TRENDS IN COUNSELING CENTERS O’Malley, K., Wheeler, I., Murphey, J., O’Connell, J., & Waldo, M. (1990). Changes in levels of psychopathology being treated at college and university counseling centers. Journal of College Student Development, 31, 464 – 465. PBS News Hour. (2015, September 2). More stress, less stigma drives college students to mental health services. PBS. Retrieved from http:// www.pbs.org/newshour/bb/stress-less-stigma-drives-college-studentsmental-health-services/ Robbins, S. B., May, T. M., & Corazzini, J. G. (1985). Perceptions of client needs and counseling center staff roles and functions. Journal of Counseling Psychology, 32, 641– 644. http://dx.doi.org/10.1037/0022-0167 .32.4.641 Sareen, J., Cox, B. J., Afifi, T. O., de Graaf, R., Asmundson, G. J., ten Have, M., & Stein, M. B. (2005). Anxiety disorders and risk for suicidal ideation and suicide attempts: A population-based longitudinal study of adults. Archives of General Psychiatry, 62, 1249 –1257. http://dx.doi .org/10.1001/archpsyc.62.11.1249 Schwartz, A. J. (2006). College student suicide in the United States: 1990 –1991 through 2003–2004. Journal of American College Health, 54, 341–352. http://dx.doi.org/10.3200/JACH.54.6.341-352 Schwartz, A. J. (2015). Is student pathology really increasing? Seven measures of the acuity of counseling center clients, 1992–2007. Journal of College Student Psychotherapy, 29, 257–270. http://dx.doi.org/10 .1080/87568225.2015.1074017 Smith, T. B., Dean, B., Floyd, S., Silva, C., Yamashita, M., Durtschi, J., & Heaps, R. A. (2007). Pressing issues in college counseling: A survey of American College Counseling Association members. Journal of College

415

Counseling, 10, 64 –78. http://dx.doi.org/10.1002/j.2161-1882.2007 .tb00007.x Sood, B., & Martel, A. (2015). Failures in campus mental health systems: Lessons from Virginia Tech. In A. B. Sood & R. Cohen (Eds.), The Virginia Tech massacre: Strategies and challenges for improving mental health policy on campus and beyond (pp. 65–92). New York, NY: Oxford University Press. Twenge, J. M., Gentile, B., DeWall, C. N., Ma, D., Lacefield, K., & Schurtz, D. R. (2010). Birth cohort increases in psychopathology among young Americans, 1938 –2007: A cross-temporal meta-analysis of the MMPI. Clinical Psychology Review, 30, 145–154. http://dx.doi.org/10 .1016/j.cpr.2009.10.005 U.S. Department of Education. (2015). The condition of education. Washington, DC: Author. Retrieved from http://nces.ed.gov/pubs2015/ 2015144.pdf U.S. Department of Health and Human Services. (2015). Budget and performance. Retrieved January 26, 2016, from https://archive-it.org/ collections/3920 Zimmerman, R. (2015, September 8). Stressed out undergrads and the college mental health crisis. WBUR: Boston’s NPR News station. Retrieved from http://commonhealth.wbur.org/2015/09/stressed-outundergrads

Received April 14, 2016 Revision received October 23, 2016 Accepted November 3, 2016 䡲