In my previous blog, I detailed the evidence for the current college student mental health crisis (CSMHC). As reported, college students are showing greater levels of stress, anxiety, depression, eating disorders, and poor sleep patterns than any time in our nation’s history, and the current trend lines suggest that it will continue to get worse. Given this reality, the next question that follows is: What might be causing the CSMHC? This blog surveys the landscape of possible explanations. These explanations overlap and are, of course, not mutually exclusive. Indeed, something as large and complex as the CSMHC will almost certainly not be reduced to a single cause, but instead likely is a “wicked problem” meaning that it has many causes, correlations, and interrelated feedback loops.
I have divided the possible explanations into three general categories. The first has to do with the broadest level considerations, examining trends and issues in society as a whole. Indeed, there is good evidence that a mental health crisis exists at the level of society (i.e., it is not just a crisis facing college students). The next has to do with generational considerations, and the third category has to do with the unique setting of college students. For the record, I am not explicitly endorsing any particular causes, nor do the numbers mean rank of importance. My objective here is to start a catalogue of factors that might be contributing. Much more advanced study will be needed to begin to sort out what actually is going on. For a couple of books on this topic, I recommend College of the Overwhelmed and Within Our Reach: Ending the Mental Health Crisis.
I. Broad Societal Considerations
1. We live in the “Age of Anxiety” (and Depression).
To consider the possible source of the CSMHC, we need to ask whether there are societal trends in toward greater levels of mental illness because, if so, then the CSMHC might simply be a result of a larger social trend. And, indeed, there are, in fact, very clear trends for increases in the levels of anxiety and depression. Indeed, the trend is so significant that some have called it “The Age of Anxiety.” One estimate found an increase in the prevalence of reported anxiety disorders of more than 1,200 percent since 1980!
The rates for depression show similar rise. To quote one source: Statistical trends related to depression are hard to come by, but most experts agree that depression rates in the United States and worldwide are increasing. Studies show that rates of depression for Americans have risen dramatically in the past 50 years. Research published in The American Journal of Psychiatry found that major depression rates for American adults increased from 3.33 percent to 7.06 percent from 1991 through 2002.
One of the most important empirical findings I have made in my career speaks directly to this issue. From 1999-2003, I worked with A. T. Beck on examining an intervention for people who recently attempted suicide. One day while I was cleaning out some old rooms, I found a fascinating data set from the 1970s. During that time, Beck's lab had screened hundreds of people who had recently attempted suicide with very similar measures to what we were doing and someone had also tracked them and recorded the frequency of subsequent attempts. Thus, I had what researchers call a ‘cohort’ comparison…I could compare the levels of psychopathology and subsequent rates of suicide attempts between two groups in the same general vicinity 30 years apart. What did I find? To quote from the abstract: “Present-day suicide attempters were found to exhibit greater levels of depression (p = 0.031), hopelessness (p = 0.008), suicide intent (p < 0.001), and had much higher rates of illicit drug use (p < 0.001). Almost twice as many of the present-day suicide attempters had histories of four or more suicide attempts (p < 0.001), and the present-day suicide attempters made subsequent suicide attempts at close to four times the rate in the year following the index attempt (p < 0.001). CONCLUSIONS: The present-day suicide attempters exhibited greater levels of psychopathology on every major variable assessed.”
The bottom line here is that the data suggest that we may not be looking at a college student mental health crisis per se but a much more global phenomenon. Of course, this finding raises the question what is causing the deterioration of mental health in our society. Below are some possible explanations.
2. The Rapid Evolution of Technology, Information Overload, and Environmental Mismatch
The last few decades have seen the rapid acceleration of technology and social change. The emergence of the internet, smart phones, Facebook, Twitter and other social media technologies have fundamentally altered the social fabric and the ways we relate. In the words of Tom Friedman, the world is flat and hyper-connected. While the hyper-connected, flat world creates many opportunities, it also potentially creates chaos, flux and danger, which is a recipe for stress. There are several ways to think about how this might broadly impact mental health. One is that the new media might create opportunities for the emergence of forces that drive broad psychological processes in a problematic way. A fictional but useful example of this is seen in Michael Crichton’s State of Fear, where he suggests, albeit via a fictional character but it is clear he is trying to make a genuine point, that the “Political-Legal-Media” conglomerate is driving us toward a constant stream of phantom worries, which feeds on itself and becomes self-perpetuating.
Another possible issue is that the hyper-connected world gives us ever more access to an endless array of choices and information that overwhelms and confuses us. Psychological research on choices shows that in many cases, more choices lead to more anxiety. In addition, we now have endless access to information that might be psychologically disturbing, either via constant news of troubling stories (e.g., Newtown or Syria), or possible threats (e.g., Global Warming). And there is also constant exposure to extremely attractive, wealthy individuals who command attention and create problematic downward social comparisons (think Brad Pitt or Jennifer Lawrence).
One general way to think about how the evolution of technology might be creating mental health problems is to be thinking in terms of the growing “mismatch” between the world we live in (e.g., sitting at a computer screen and interfacing over technology) and world we evolved to live in (i.e., close-knit hunter gather communities). An argument can be made that the greater the mismatch, the greater the likelihood that we will create an environment that will cause stress and not meet fundamental needs. I am thinking here in terms of things like our diet, our potential lack of group bonding, and our lack of spending lots of time in the natural world.
3. Existential Confusion and the Loss of a Grand Narrative
In his fascinating book, The Battle for Human Nature, Barry Schwartz detailed how the emergence of science dethroned religion from its central place in society, and while that had many good consequences, one potentially very troubling consequence was the lack of a clear moral compass and existential purpose.
Instead of a moral compass, people have been given enormous freedom to construct their own lives and make their own moral decisions. Although this outcome has had many positive elements, it also has resulted in large numbers of people, at least in America, who are fundamentally unsure when it comes to their philosophy of life. In Schwartz's words, "They don't seem to know where they belong. They don't seem to know that they are doing the right things with their lives. They don't seem to know what the right things are." Another consequence has been a focus on hedonism and materialism, which many psychological analyses have shown to be associated with lower levels of well-being. All of this may be particularly relevant for the CSMHC because a sociological analysis of emerging adults drives home Schwartz's analysis regarding the loss of a moral compass and paints an even bleaker picture of the capacity of today's young adults to ground their perspective in a moral perspective. Based on hundreds of detailed interviews, the book Lost in Transition explores the darker side of emerging adulthood, and one consequence they emphasize is a shallow, confused existential position, which creates deep-seated vulnerabilities for anxiety, depression, and other mental ailments. In addition, it is clear that more and more students are going to college for the long term financial gain, rather than for developing a meaningful philosophy of life.
4. Economic and Financial Pressures
Our economic world has seen much obvious upheaval since 2008. However, the trend lines for folks on the lower ends of the economic spectrum have not been good for much longer. Currently, we have a significant jobs and unemployment crisis, where huge numbers of people have either dropped out of the employment sector or are underemployed. In addition, there is a crisis of inequality (see this video to get a handle on it), and there are good reasons to believe that massive inequality would cause mental health problems for both the well-off and the disadvantaged. Especially, relevant to the CSMHC is that the financial squeeze on this population has been very tough. More students must work to pay for their college education, tuition, and other costs are much greater thus there are greater levels of debt, and the jobs prospects are worse for emerging adults than they have been for a long time.
5. A Troubled, Ineffective Health Care System
It is well-known that the American health care system is troubled, and our mental health care delivery is fragmented and poorly organized. Indeed, there is evidence that we spend much more than any other nation and get poorer outcomes. And most agree that our mental health delivery is uneven and chaotic and many populations, especially underserved, do not have good access to evidence-based care.
6. Problematic Attitudes Toward Mental Illness
Although mental illness is far more publicized now than in the past, it remains the case that mental illness is not easy to talk about and, in many circles, comes with a lot of stigma. Thus, people often avoid discussing the problem, both those who have the problem and those around them. These are general issues of education, awareness, access to care, and a system that fosters approaching rather than avoiding these problems. There has been some progress made on these fronts, but it remains the case that mental illness often stays in the shadows. In terms of specifically applying to CSMHC, a college counseling director I spoke with characterized the growing mental health problems as a “shadow” issue. From a basic public relations perspective, it is the natural response of a university to emphasis the educational and personal growth opportunities and down play mental health struggles. Thus, education about mental illness, accessibility, and stigma all play general roles. Of course, these dynamics have always been present, so they are not really best conceptualized as a direct “cause” of the CSMHC but rather can be considered part of the causal matrix.
7. Psychopharmacology and the Rise of the Disease-Pill Model of Mental Illness
There has been a radical medicalization of suffering and problems in living over the past five decades or so. The debate about the nature of this “medicalization” was on stark display as the new DSM-V was rolled out. To see it clearly, consider, as one example, this report on America’s State of Mind. It is a report by Medco on psychotropic medication use! (As you might have guessed, it reports that the use of meds to manage psychological symptoms has sky-rocketed over the past few decades). The fact that a report on "America’s State of Mind" is in fact an inventory of pill use says volumes. Indeed, one very real possibility is that the disease-pill model of mental illness might be having catastrophic implications for societal mental health. The book An Anatomy of an Epidemic, by fellow PT blogger Robert Whitaker makes a great case for why this might be.
8. A Breakdown in the Traditional Family Structure and Confusion of Roles
It is a conservative cliché to point to the breakdown in the family as one of the great ailments of society. Although many progressives point to the many positives that are associated with the diversity of today’s “modern families,” it also is the case that much evidence points to problems that stem from the lack of a stable family structure from which children can build a secure base. The significant rise of divorce rates and the breakdown of the traditional family structure certainly must be considered as a possible contributor to the emerging mental health crisis. My take is that traditional family should not be defined as a man and a woman with two and a half kids. But what is absolutely needed is a stable, loving, secure, predictable structure that kids can call home. Modern families are not providing this to the extent that they need to.
II. Generational Considerations
9. A Failure of the Education/Socialization System
There is much evidence that our society’s education system is seriously flawed, which is reflected in our trending downward on many measures of academic success. In addition to failing at the level of academic achievement, many also argue that the structure of today’s schooling, the obsession with assessment, and content/curriculum learning creates a massively unhealthy environment for socializing today’s youth. Fellow PT blogger Peter Gray points to the dramatic decreases in free play and argues cogently for the incredible value of that kind of experience in fostering adaptive development. Indeed, he is so critical of the current educational system that he is part of the “unschooling movement” and he points to rise in our mental health problems as being a function of our approach to early childhood development.
10. Self-Esteem Nation/Nation of Wimps
There is good evidence that there has been a fundamental shift in the approach to parenting that is misguided, over-indulgent, and overprotective. PT Editor Hara Estroff Marano described us as being a nation of wimps, and as I document here in a blog I called “Self-Esteem Nation,” there has emerged over the last 20 to 30 years cultural belief that we must, as parents, friends, coaches, therapists, and educators, work hard to protect and enhance the self-esteem of our children. So we have “helicopter” and “snowplow” parents, teachers giving stickers and cupcakes for normal appropriate behavior, coaches giving trophies for kids showing up and all sorts of other well-meaning but deeply misguided attempts to protect children from negative feelings and experiences. Unfortunately, as a consequence of excessive coddling, kids then don’t learn how to cope with disappointment, adjust to tough feedback or develop general resiliency skills.
11. Generation Me and the Narcissistic Epidemic
Likely related to Self-Esteem Nation and the shift in how we socialize our children, fellow PT blogger Jean Twenge has made a very convincing case that the current generation of young people are experiencing an “epidemic of narcissism.” There is much evidence that the current generation has both higher levels of assertiveness and confidence in some ways, but also are lacking in coping skills and empathy and demonstrate a sense of entitlement. There are many possible causes (see above), and it can easily be considered to be part of a self-fulfilling cycle. As therapists know, narcissists are often not “value added” to social systems. A generation of them is going to create serious mental health consequences.
12. The Emergence of Emerging Adulthood
Although now clearly part of our lexicon, the term emerging adulthood did not even exist when I was in graduate school in the mid-1990s. It was coined by Jeffrey Arnett in 2000, and represented a documented developmental shift…such that now we must consider a whole additional period of development, in between adolescence and young (but full) adults. This developmental period can be argued to arise out of the incredible opportunity and complexity of modern society, such that, in order to function independently, humans need a longer and longer period of development. While this might not be directly tied to mental health issues, it is included here as a nod to just how much is different with regard to the human experience than was the case even 30 years ago.
III. Considerations Specific to College and University Life
13. A Dramatic Transition
Going off to college is extremely stressful, especially for individuals who might have been overprotected, have difficulty coping and rely heavily on adults for support. It is, in many ways, a rite of passage, but with that comes much adjustment difficulty. This has always been somewhat the case, so I don’t see this as a “new” cause per se, but it must be noted as part of the process.
14. Intense Academic Pressures to Succeed
I have already mentioned that the financial stress on this group of college students is likely greater than in previous generations. Several have argued that the academic pressure to succeed is also greater. There has been massive grade inflation, especially at the high school level. That, combined with overprotective parenting, seems likely to have the result of creating in students the expectation that they will continue to get virtually all As. Yet doing so is difficult in college and the failure to meet expectations, and to struggle relative to peers is experienced by many students to be enormously stressful.
15. Massively Increased Accessibility to College
Several decades ago, college was attended by a much more select group of individuals. Massive strides have been made to make college more accessible to a much broader swath of the population. Thus colleges have much more diversity, individuals with medical and mental health difficulties now have access to accommodations and support. Of course, by definition these individuals are struggling with stressful life issues; as such, one possible reason for the increase in the level and severity of difficulties seen on the college campus is that more folks have access to college today and in the past they never would have had the chance to attend
16. Shifting Gender Ratios
Although I believe that, looking overall, males and females have similar mental health profiles, it nevertheless is the case that the profiles of the kind of mental health issues they have is different. Males tend to have more externalizing problems related to violence and substance use. Women have more problems related to stress, anxiety, and depression. They also tend to be more open about their problems. There has been a major shift in the gender ratios of students in the past three decades, thus it follows that a portion of the increase in reported levels of depression and anxiety is a function of there being more women in college, who report higher levels of problems in these domains.
17. Poor Handling of (Some) Mental Health Issues on College Campuses
College counseling centers are overloaded with demand, and many have wondered if they are effectively geared toward handling the sea change in mental health needs. In addition, in this age of litigation, there is an increasing chorus of voices that many universities are beginning to respond to the mental health challenges in a defensive and problematic way. This, of course, is almost certainly not a primary cause of CSMHC, but given that college counseling centers must be part of the solution, it is worth noting the emerging problems.
As I noted above, my goal here is an attempt to catalogue the various contributing factors to both the current general trend toward mental illness in our society and in college students in particular. I welcome additional critiques, thoughts, and suggestions.