Beginning the Conversation

Beginning the Conversation

Too few college students get help for depression. Blake Wagner is seeking to change that.

“Have you ever felt trapped?”

Blake Wagner III poses this question five seconds into a short video from his inkblots series. He is a young man with a messenger bag stepping onto an elevator, pushing the button to floor two. Coffee in hand, he might be going to school or work. The elevator begins its ascent, then stops suddenly.

In voiceover, Wagner begins to list a series of recent events in his life: the worsening of his grandfather’s dementia, a spinal cord injury, a breakup with his girlfriend, the death of his mother. Images of beloved people and places intertwine with images of Wagner—drinking, crying, and lying in bed alone.

Two minutes and ten seconds into the film, he states flatly, “I felt at times like ending my life, so that I could end my suffering.”

Sitting now, several years later, in the Glass House Café at the University of Michigan School of Public Health, sunlight streaming through the windows, Wagner pauses, trying to string together the exact sequence of events leading up to his diagnosis of depression: “That’s such a blurry time,” he explains. In many respects, the Wagner sitting in the café seems far removed from the young man in his video “Trapped.” Currently a research assistant at SPH, Wagner works as part of a research team developing a series of videos collectively known as inkblots.

To date, he has completed videos on topics as varied as self-esteem, interpersonal relationships, and academic stress. His goal with the series is to encourage a more open conversation among college students about mental health.

As a young boy growing up in Mansfield, Ohio, Wagner enjoyed spending time with his parents and two younger brothers, camping on the weekends and taking a yearly trip to Cape Cod. He was 19 and attending college when his mother was diagnosed with cancer. During her illness, Wagner struggled with his emotions. “It was hard to disentangle depression from grieving,” he says. “It’s just something that persisted and intensified. It was very physiological for me. I felt completely hollow and numb, and I couldn’t find pleasure in anything that I used to find pleasure in.”

While he was close with his parents, he found it difficult to talk about his feelings of hopelessness. Speaking about his father, he says, “I worried what he might think, and I didn’t want to add to his plate.”

Wagner’s experience with a mental health disorder is not uncommon. In high-income countries such as the U.S., mental disorders account for almost half of the total burden of disease for adolescents and young adults. These conditions are connected with school dropout, suicide, violence, and substance abuse. Among college students in particular, suicide is a leading cause of death. Fortunately, effective treatments are available. A study in the November 2006 issue of the American Journal of Psychiatry reported that 67 percent of adults with major depressive disorder experienced full remission through medication and/or therapy. Health professionals maintain that for adolescents and young adults, successful outcomes may be even higher.

John Greden, MD, executive director of the U-M Comprehensive Depression Center, states that peak ages of onset for depressive and bipolar illnesses are between the ages of 15 and 24. He believes that screening for and treating these disorders during the adolescent years is “vitally important” because “the earlier that these illnesses are found, the more treatable they are.” He explains that “untreated, they just get episodic, recurrent, and progressively worse.”

Greden argues against the practice of watchful waiting: postponing treatment to see whether a person’s symptoms go away over time. Instead, he advocates for an early and vigorous approach. “Almost always, major illnesses are best treated in their early stages,” he explains. He cites diabetes as an example where early intervention can mitigate a disease’s potential long-term effects.

But despite the benefits of early intervention, many college students with mental illness do not receive treatment, according to findings by Daniel Eisenberg, associate professor of health management and policy. In 2005, Eisenberg initiated the Healthy Minds Study, a web-based survey of college student mental health. The first survey, distributed to a random sample of U-M students, screened for depressive and anxiety disorders. Remarkably, of students with positive screens, the proportion who did not receive services ranged from 37 to 84 percent, depending on the disorder.

“Since then, we’ve found that the numbers for U-M are generally in the middle of the range when compared with other colleges and universities,” says Eisenberg, citing data from his ongoing survey work, which expanded nationally in 2007 and has reached over one hundred colleges and universities across the country.

Eisenberg’s study has identified a range of reasons for students’ not using services. In the initial report on U-M students, the most frequently identified reason was “stress is normal in college/graduate school.” Other reasons included the belief that the problem would get better without treatment, lack of time, and concern about what others might think.

Wagner mentions some of these findings when explaining his own reluctance to get help: “I prefer to deal with things on my own. I don’t feel like my symptoms are severe enough. Oh—” Wagner leans forward: “Not having enough time was a big one.” He elaborates: “It’s a really important piece. If you’re depressed, everything becomes more difficult,” including figuring out how to balance therapy with other obligations.

The inkblots series aims to address some of these concerns by engaging students who might benefit from mental health services.

Eisenberg is the principal investigator for the grant-funded inkblots project with Wagner acting as a co-investigator, leading the development and production of the videos. Rebecca Lindsay, MPH ’11, serves as study coordinator. Their team is multidisciplinary, employing researchers with expertise in areas such as mental health, information sciences, and social media.

At the heart of the inkblots project is sharing stories. As Wagner knows, part of depression is having a story to tell, a powerful one—and fearing the telling of it.

Two minutes and sixteen seconds into “Trapped,” we are introduced to Wagner’s roommate “Joe,” who finds Wagner unconscious in the bathroom. The images are not pretty. Joe crouches, lifting his roommate, moving him to the bedroom. Wagner lies in bed and Joe offers him food, his hand hovering above a half-empty bottle of liquor on the nightstand. Though Joe has only known Wagner a couple of months, he recognizes the signs of depression and encourages Wagner to get help.

In conversation today, Wagner explains that his roommate sensed something was wrong and expressed his concerns. “I’m here for you if you want to talk,” he told Wagner, adding that he had himself sought help from a therapist in the past. This conversation persuaded Wagner to do the same: “If he could do it, then I could do it.”

After rebounding from what he describes as “that dark place,” Wagner began sharing his story in conversations with others. He was amazed by how many people then came forward with their own struggles. They often expressed feelings of isolation, “as if they were the only ones in the world” experiencing the symptoms of anxiety and depression. Speaking about young adults in particular, Wagner says, “We need to start the conversation on mental health because I don’t see or hear it.”

After his mother’s death in 2011, Wagner was diagnosed with depression and prescribed an antidepressant, which took “about seven or eight weeks to kick in,” he remembers. Therapy helped, too. “There’s just no question.” Although he worried that his father would respond negatively to the news, Wagner shared his diagnosis with his father, a clinical psychologist at Ohio State, Mansfield. But his father seemed proud of his son for seeking help. Wagner was so surprised by this response that he initially found himself wondering, “You really don’t think I’m a weak person? You’re not concerned?”

Wagner and his father, Blake Wagner Jr., had already worked together on mental-health related videos prior to his mother’s illness. In 2011, they teamed up again, conducting student focus groups at several colleges. The goal was to determine what kind of mental health information students most want. Five characteristics emerged. Students want material that is engaging, relevant, convenient, confidential, and anonymous. Wagner acknowledges that there’s a lot of great self-help material out there in bookstores. Yet, for the younger generation—particularly busy students who already struggle to balance classes and jobs—the effort to find the right book can feel overwhelming. “We need answers, like now,” he says, paraphrasing the findings. With this in mind, Wagner set out to create online videos that meet the specific needs of college students.

In 2013, Wagner and his father submitted a proposal to give a presentation on their work at the Depression on College Campuses Conference, sponsored by the U-M Depression Center in partnership with U-M schools and colleges. Eisenberg, who helps organize the annual conference, wanted to promote intervention research, so he invited the Wagners to be part of the closing panel discussion. A couple of months later, Eisenberg asked Blake Wagner III to join the research staff of the Healthy Minds Network.

A unique aspect of the inkblots project is the ongoing use of student focus groups to evaluate the videos’ content, style, and length. Students comment positively on the videos’ goals and approach. “It’s fun because it’s creative,” said one student, adding that the films are informational but “not especially pedantic, which I like.” Another focus group member shared that she has been in recovery for addiction for over three years. Commenting on “Trapped,” she said, “I could just really relate to that on a personal level.” In particular, she appreciated how the videos seek to de-stigmatize asking for help. “It’s very un-American to ask for help,” she comments. “I certainly was raised that way with perfectionist tendencies.”

In addition to student endorsements, the inkblots team has garnered praise from outside experts, among them Harvard Medical School’s Paola Pedrelli, director of dual diagnoses research in the Depression Clinical Research Program, who says the videos deliver “self-help skills in a format that resonates greatly with young people” and may reduce stigma and lower barriers to treatment. The inkblots team has also received funding support from the U-M Depression Center, the Blue Cross Blue Shield of Michigan Foundation, the U-M Injury Center, and U-M’s Global Challenges for the Third Century Initiative, which supports nontraditional, multidisciplinary research projects that directly engage the community.

The project’s multidisciplinary approach is evidenced by the videos themselves, which are influenced not just by the latest health research, but also by the humanities. Early in the project, William Del Rosario was recruited as cinematographer. A graduate of the University of Southern California’s film school, he describes his approach: “It’s really about storytelling.” Many of the films employ metaphor: the closed elevator doors, fireflies, even Mr. Potato Head. (This last one comes from Wagner’s girlfriend, who explained that dating him was “like being in a relationship with Mr. Potato Head.”) Del Rosario suggests that unlike more traditional mental health materials, the films’ creative qualities engage viewers’ emotions, which can encourage self-reflection.

The videos are also informed by relevant scholarly literature. The coping skills and constructs like radical acceptance have an evidence base behind them, largely drawn from the field of cognitive behavioral therapy, or CBT, which combines cognitive strategies with behavioral changes and can be applied to the wide range of issues that students face­­­—including stress, interpersonal conflict, self-esteem, and perfectionism. Eisenberg notes that “CBT is one of the most evidence-based modes of talk therapy in mental health.”

When Wagner and Del Rosario describe their work, they speak with excitement, even playfulness. They often work on several scripts at once, and while “Trapped” has a decidedly serious tone, some of the other inkblots videos incorporate humor. This is reflected in their weekend to-do list for upcoming videos: Film a man driving down a country road in a dinosaur costume. Find and film a squirrel who will (somehow) teach a coping skill. Organize a mock Halloween party with kids wearing costumes and parents dressed in marathon gear. These images make heavier emotional issues seem approachable, even surmountable.

Towards the end of “Trapped,” after Wagner has begun therapy—after the elevator doors have re-opened—images of Wagner’s mother appear from old home movies. Twirling in a pink dress, she smiles as her eyes meet the camera. In voiceover, her son says, “My amazing mother, despite being riddled with cancer, was able to find joy in each day. She often reminded me and my brothers that the present is perfect, even if it doesn’t look or feel that way.” Wagner stands in a forest clearing, breathing deeply.

For all of their emphasis on speed and convenience, the inkblots videos stop short of promising a quick-fix for mental health issues. Therapy emerges as a recurring theme, and the coping skills depicted in the videos could be cultivated over a lifetime. Eisenberg notes that, “in general, we see the videos not just as stand-alone interventions but also as a kind of hook into something more.”

Wagner, too, continues to treat his depression. When he moved to Ann Arbor in early 2013, he found a new therapist. “You spill your guts out—again,” he says, laughing. Overall, though, he describes this transition as easier than he thought it would be.

Back in the Glass House Café, Wagner returns to the topic of his mother, whose character he has incorporated into several videos. “It’s really incredible to think that she’s continuing to affect people and have an impact,” he says, referring to her ability to embrace the present, even while facing death. He shakes his head. “It’s amazing, the birthing of this project, and how far we’ve come in such a short period of time—how many people we can potentially reach.”

Sara Talpos is a writer based in Ann Arbor. She holds an MFA in creative writing from U-M.

The Healthy Minds Network

An outgrowth of the Healthy Minds survey study, which began in 2005, the U-M–based Healthy Minds Network for Research on Adolescent and Young Adult Mental Health is devoted to improving the mental and emotional well-being of young people through multidisciplinary scholarship. The network now extends to over a hundred institutions nationwide and includes scholars in a range of disciplines, including public health, education, medicine, psychology, and information sciences. Many scholars are affiliates of the U-M Comprehensive Depression Center. The network serves as a resource for secondary and higher education administrators, researchers, clinicians, policymakers, and the public. Individual research projects include The Healthy Minds Study, The Healthy Bodies Study, and inkblots.

By the Numbers: The Healthy Minds Study

  • 10 Percentage of college students who screen positive for major depression
  • 15 Percentage of college students who screen positive for eating disorders
  • 26 Percentage of college students who received mental health services in the past year
  • 33 Percentage of college students with an apparent mental health problem (depression, anxiety, suicidal ideation, self-injury)
  • 62 Percentage of college students who screen positive for eating disorders who are not receiving treatment

Healthy Minds: This Generation and the Next

SPH graduates Sara Abelson, Sheila Krishnan, and Stephanie Salazar have all worked with Associate Professor Daniel Eisenberg and the Healthy Minds Network and are now furthering that work through public health careers in mental health. An update:

Sara Abelson, MPH ’08
Senior Director of Programs,
Active Minds

Sara Abelson, senior director of programs at the national nonprofit Active Minds, develops strategies and partnerships aimed at transforming the way college campuses support student mental health. Active Minds’ peer-to-peer programming is based on data from the U-M Healthy Minds Network showing that distressed students turn to each other before turning to professionals or parents. “We work to ensure that students are educated about the signs and symptoms of mental health disorders and empowered to promote help-seeking without shame or stigma,” Abelson says, noting that today’s students are also “the teachers, parents, policymakers and presidents of tomorrow.” Abelson oversees a network of more than 400 student-led chapters across the U.S.and a dozen nationally acclaimed programs, including:

  • Send Silence Packing (a traveling suicide-prevention exhibit)
  • National Day Without Stigma (an awareness campaign)
  • The Active Minds Speakers Bureau (first-hand stories of resilience and recovery from young adults)

For more: Active Minds

Sheila Krishnan, MPH ’08
Campus Prevention Specialist,
Suicide Prevention Resource Center

Funded by the Substance Abuse and Mental Health Services Administration of the Department of Health and Human Services, the nationwide Suicide Prevention Resource Center promotes “a public health approach to suicide prevention.” As one of the organization’s campus prevention specialists, Sheila Krishnan works primarily with colleges and universities to develop and implement programs to heighten student awareness of mental health issues, boost coping skills, and ultimately prevent suicide. Some of the most common strategies used by campuses she’s worked with include:

  • Implementation of screening programs (on-campus or online)
  • Gatekeeper training (to educate faculty, staff, student leaders, and others on the warning signs and risk and protective factors for suicide, and how to approach at-risk students and refer them for help)
  • Communications and social media campaigns
  • Programs designed to promote connectedness and positive personal relationships

For more:

Stephanie Salazar, MPH ’08
Program Coordinator for Outreach
and Education, 2008–present
U-M Comprehensive Depression Center

As program coordinator for outreach and education at U-M’s Comprehensive Depression Center, Stephanie Salazar has helped develop and run a Peer-to-Peer Program in nine public high schools in Washtenaw County, education and support groups on the U-M campus, a quarterly Bright Nights Community Forum held in local libraries, and an annual Depression on College Campuses conference. These and other initiatives all have a similar aim: to deepen young people’s understanding of depression and related illnesses, foster education and support groups, and impart the skills young adults need to lower stress and anxiety and reduce depression. Evaluations show that students participating in these programs have a better understanding of depression and feel more comfortable recognizing and reaching out to peers who may need help. Salazar and her colleagues are now disseminating their programs to other U.S. colleges and high schools.

For more: UM Depression Center: Education & Outreach

Four Top Reasons College Students Don’t Seek Help for Mental Health Problems

  • I prefer to deal with issues on my own.
  • I question how serious my needs are.
  • Stress is normal in college/graduate school.
  • I don’t have time.