Years ago, college counseling centers were pleasant little side
channels of the mental health system, helping students cope with roommate
conflict and adjustment to college. No more.
Today they are the newest front line in the war against mental
illness, struggling to manage swarms of students with serious depression
and anxiety disorders. And generally facing a growing demand for their
services in a world of shrinking resources.
The middle of the night may find a SWAT team of counselors calming
down a dorm wing after having crisis-managed an acute manic episode or
yet another incident of self-mutilation. Morning will certainly find the
staff administering psychotherapy to students struggling to overcome
histories of trauma such as childhood sexual abuse, relationship problems
including date violence, and that dormitory staple, eating
Did we mention substance abuse? Attention deficit disorders and
learning disabilities? At one elite institution, 10% of students report
problems with binge drinking.
Rare is the college that has not experienced a student suicide. A
10,000-student campus can expect one student suicide a year. That doesn't
count all the highly disturbing attempts.
Hospitalization, a court of last resort, is commonplace.
Eighty-nine percent of counseling centers hospitalized at least one
student in 2001; one hospitalized 80. On one 5,000-student campus where
most students are commuters, three to six students are typically
hospitalized a semester, primarily for suicidal gestures and first
In 2001, 85% of North America's student counseling centers reported
an increase in "students with severe psychological problems" over the
past five years. Thirty percent of them had a student suicide; 60% of
them dealt with obsessive pursuit cases (50 persons injured, five
"Every director of every college counseling center is reporting
more hospitalizations, more serious problems, and taking care of sicker
students," says Richard Kadison, M.D., a psychiatrist who heads Harvard
University Health Services and its counseling center. The severity of
students' mental health problems has been rising since 1988, reports
psychologist Robert Gallagher, Ph.D., of the University of Pittsburgh,
who each year surveys directors of college counseling centers.
"The world isn't getting crazier," observes Pamela L. Graesser,
M.Ed., director of counseling at Rivier College, a small Catholic college
in New Hampshire whose students are primarily from blue-collar families.
"College is just getting more like the real world around it." College is
simply available to more people than it used to be. The problems Graesser
saw 12 years ago when she worked in a psychiatric hospital "are the same
ones I now see on campus."
"We are probably seeing the true prevalence of mental disorders,"
observes psychiatrist Morton Silverman, M.D., head of counseling services
at the University of Chicago. "There is not as much surveillance in the
Then too, he says, "we are the beneficiaries of our own
Call it the Prozac payoff. Colleges are reeling from the number of
students arriving already on antidepressant and other medication and
requiring psychiatric monitoring. A decade of improved drugs has
encouraged earlier diagnosis.
Early treatment of depression—along with institutional
accommodation of disability—has enabled students to stay in the
academic system who in other eras might not have made it to college, or
would have dropped out after a semester or drifted into community
colleges. Today they are attending the nation's elite institutions, where
academic, living and developmental demands sometimes overwhelm the coping
skills they have yet to acquire.
"Many who wouldn't have gotten to an elite college before are
getting here because they were treated when younger," observes Harvard's
Dr. Kadison. "They need ongoing, intensive care," which not every school
has the resources to supply. Many students fall apart given the looser
environment, erratic sleeping patterns and added stresses of
Many others experience their first onset of disorder. There is the
indisputable fact that age 18 to 25 is prime time for eruption of mental
illness, making college, with its concentration of 18- to 25-year-olds,
the prime place. Increasingly, mental health professionals recognize that
depression, anxiety disorders, bipolar illness, personality disorders and
schizophrenia are conditions that first arise in young adulthood.
Catching them quickly is critical, as early management strongly
influences how they play out over adulthood.
And so it is that increasingly, colleges are the first best hope
for rescuing the minds of America's future. But what no one ever imagined
is that colleges would also find themselves the last best hope of mental
health care in America.
April is the cruelest month. College counseling centers really feel
Students who put off counseling suddenly realize they're going home
soon. "They're going back to the situation that made them crazy in the
first place, or back to the abuser," reports Rivier's Graesser. Seniors
flock in with anxieties about confronting the real world.
And there's a whole new rite of spring. It starts just after
college acceptance letters go out. Parents call the counseling centers at
the schools where their offspring have been accepted. "They say 'my son
or daughter has a serious eating disorder' or 'has been hospitalized for
depression; what can you do to support them?'" reports Mark H. Reed,
M.D., counseling director at Dartmouth. They're footing the bill; access
to mental health care is now one of the factors they weigh before writing
In addition to handling more cases of depression diagnosed
pre-college, counselors find that they are picking up many more new cases
of depression in college. "There are increases in both undergraduate and
graduate students carrying a diagnosis," reports Chicago's Dr.
"More students are coming to college predisposed to developing
depression," he observes. There are more students with a family history
of the disorder. And there are many more students with prior sexual and
physical abuse, both of which increase the risk for depression. "The
incidence of sexual and physical abuse was on the rise 10 years ago," he
says, "and that generation is now coming to college."
Some students come in knowing that their concentration is off and
that they are withdrawn. "Still, they don't put the cluster together and
recognize that they have depression," says Harvard's Dr. Kadison. And
half of those students presenting with depression have moderate to severe
illness, reports psychologist Joseph M. Behan, Ph.D., head of counseling
services at the School of the Art Institute of Chicago.
However, students are increasingly willing to talk about depression
once they get on campus. And the general destigmatization of mental
illness encourages them to seek help. Many have looked forward to college
as a place where they could be free to get the help their families
discouraged—or made necessary in the first place.
Remnants of stigmatization drive problems, too. Although many
students come to college openly declaring experience with depression or
bipolar disorder, large numbers do not make it known—until a crisis
erupts. Dartmouth's Dr. Reed worries "most about the students we don't
Cases of moderate to severe depression are rising also because
depression often co-occurs with other problems—alcohol and drug abuse;
personality, eating and anxiety disorders. "We're seeing more depression
because more other disorders are arriving and present as depression,"
explains Dr. Silverman.
Most college counseling directors confess to being surprised by the
number of students turning out to have bipolar disorder. It typically
presents dramatically, with an acute manic episode. "We are seeing more
first episodes of mania every year," Dr. Silverman reports. "It's very
disruptive. It generally means hospitalization for the student. The
number of hospitalizations is going up each year, and the percentage
attributable to bipolar disorder has risen."
The boom in bipolar disorder may in part be the outgrowth of wanton
diagnosis of attention deficit disorder in schoolchildren. "It's
difficult to tell the difference between ADD and BPD in kids," says Dr.
Reed. "Lots of ADD turns out to be bipolar disorder."
The trouble is, the kinds of stimulants that work for ADD, not to
mention caffeine, are precisely wrong for bipolar illness and can trigger
a manic episode. "The first manic episode is related to a stressor, such
as sleep deprivation," Dr. Reed explains. "Almost always some substance
is also on board." He believes it is often an attempt by a student at
Since depression is the single biggest risk factor for suicide, and
since the severity of mental problems on campus is increasing, it might
be expected that the number of campus suicides would be skyrocketing. But
that is not the case, although a few highly publicized incidents at
Harvard and MIT have fostered a general perception that ivory towers are
It is more likely that the social structure of college protects
people in some way and that colleges are doing a good job of keeping
suicide attempts from being successful. The suicide rate is actually
lower on campus than among same-age people outside.
"Suicide is not a good marker for the rise in mental disorders in
colleges," insists Dr. Silverman. "Every suicide is a personal tragedy.
But it's not a reflection on university policies or procedures."
Every suicide is also enormously disruptive to an entire campus. So
counseling centers make a big effort to prevent problems by reaching out
to students with programs of information. "We're no longer just mental
health professionals," says Dr. Kadison. "We're marketing directors,
trying to figure out how to connect with students who might need our
The only problem is, outreach programs, such as after 9/11, work
too well. Where Harvard's mental health service was seeing 240 new cases
a week in January 2001, it was up to 280 a week in January 2002.
MIT is still reeling from a suicide when a young woman a month from
her baccalaureate and entering a graduate program leapt to her death from
a campus dorm. Her family is suing the university, on the grounds that
parents should be notified if a student is suicidal.
"We can't do that," says Dr. Kadison. The trust that help-seeking
will be kept confidential, often particularly from their families, is
what encourages students to come in in the first place. "The students are
adults at age 18. We are all seeing suicidal students. We'd just be a
switchboard calling families all the time."