Mental health on campus: Reshaping higher education to help students thrive

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00:04 Will Heininger: I had been hiding this from everybody for months and we got into August. And august is when we go from workouts in shorts and t-shirts and weightlifting and that stuff, to actual football and putting on pads and you're allowed to have practice. And so, during August, you live with your teammates pretty much 24/7 and there's not much of hiding anything. And so, I made it like, I don't know, two or three days in and we're at the end of practice and coach was saying a couple of words, everybody gathers around. Everyone puts their hand in and get a break down and we head out, and that was when I broke down. I just felt so exhausted from hiding it for so long, I felt like I didn't care anymore. I felt the tears coming on. Like I said, I was just drained. At that point, I hadn't been sleeping, I was barely being able to eat 'cause chewing and swallowing food just took so long. Things that were very foreign to me as a big guy who likes to eat.

01:03 WH: And so, luckily, at that time it was 2008, my athletic trainer had some mental health education which now is much more common. They see us every day, right? We joke like, they know what our feet smell like 'cause they do, they tape us every day. But he luckily had some mental health education, some awareness and he must have seen me in distress. He walked over, his name is Lenny Navitskis, and put his arm around me, and he said, "Will, come with me. You're gonna be okay, we'll take care of you." And he walked me into Schembechler Hall, and into Barb Henson's office, and I really believe that she among with other people helped save my life.

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01:44 Tracy Carson: You just heard former Michigan football stand-out, Will Heininger, describe the day that changed his life forever. Will's story helps us introduce a complex topic, mental health, and in particular, mental health of college students. Just like our physical health, it's really important to prioritize and nurture our mental health. Today, data from the University of Michigan shows us that around 40% of college students in the United States are struggling with or are diagnosed with a mental health disorder, myself included. Hi, I'm Tracy Carson. I'm a PhD student at the University of Michigan, School of Public Health in the department of Epidemiology. I'll be your special guest host for this episode of Population Healthy, a podcast from the University of Michigan School of Public Health. Join us as we dig into important Public Health topics, stuff that affects the health of all of us at the population level. From the microscopic to the macroeconomic, the social to the environmental. From neighborhoods to cities, states to countries and all around the world.

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02:44 TC: So for me, mental health isn't just something I study, it's a big part of my story and has been a big part of my life. I've struggled with both anxiety and an eating disorder that really came out freshman year of college for me and so, ever since then, I still am challenged with mental health every single day, seek treatment and really prioritize my mental health and wellness every day. And these experiences have really led me to where I am with my current research work. Right now, I study eating disorders and other mental health disorders in collegiate female runners, and I also am really interested in how things like eating disorders affect both physical and psychological health in the long term for these female athletes.

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03:28 TC: Improving mental health on college campuses starts with understanding how students view it, and putting that information into the hands of the institutions that can use it. The University of Michigan School of Public Health Professor Daniel Eisenberg has dedicated his academic career to student mental health. He leads the Healthy Minds study at the University of Michigan, an initiative that gathers data on student mental health issues at institutions across the nation, and provides that data to help colleges better serve their students. I chatted with Professor Eisenberg about the specific mental health issues affecting college students and the attitudes they have about mental health stigma and treatment.

04:01 TC: If you could speak to some of the trends over the past several years and the most common mental health disorders that you're seeing and the data that you're collecting, and maybe also how that's has changed over time.

04:12 Professor Daniel Eisenberg: Our Healthy Minds Study shows that depression, anxiety, and disordered eating and body image are the three most common mental health concerns, and you could also count self-harm, suicidal thoughts. Each of these issues, depending on what cut-off you're talking about or what level of severity, is present among more than 10% of students at any given point in time, or above some at least moderately concerning level. And in fact, each of these concerns do appear to be rising over the last several years. In our data and also the National College Health Assessment, it seems like around 2012, 2013 before maybe there was a slight steady increase, then it really became more of a substantial year to year increase since these last now six years or so. That same trend is present in general adolescent national samples that other researchers have looked at in the United States. And so, that has led some researchers to conclude that it has to do with digital media and social media, because 2013 was around when the smartphone became pervasive. The vast majority of young people started having them, as well as adults of course, but I think the case is far from closed as far as what's going on and what's driving these increases. And personally, I'm persuaded by some of the evidence related to sleep.

05:35 TC: What are the reasons that students are reporting for, maybe, barriers to treatment seeking and maybe how do they differ from what is perceived to be the barriers for treatment seeking?

05:45 PE: Yeah, yeah. Yeah, actually our results do surprise people sometimes. We ask a question on our survey: Why have you not received mental health services? Or: Why have you received fewer services than you might have otherwise? The most common responses are, "I don't have enough time." "I don't think my problems are serious enough." "I think stress is normal in college or graduate school." "I think my problems get better on their own." "I get support from other sources." So, notably absent from that top list is like, "I'm concerned about privacy," or, "I'm concerned about what others might think." That is on the list and certainly some students do report that as a concern, but stigma is lower in this cohort of students. And the way that we've interpreted it's those these top most common responses, it's a lack of problem recognition or a lack of problem urgency. We ask another question: Do you think you've needed help in the past year for your mental or emotional health? A lot of students say yes or, "I somewhat agree at least with that statement," but then they also say, "I don't think my problems are serious enough," or, "I don't have enough time."

06:53 PE: So it's, on one level, they sort of recognize, "Yeah, my mental health has been struggling but on the other hand, it's not serious enough or urgent enough, critical enough to actually do something about it." So that goes back to the idea that, I think, a lot of these young people are open to the idea of seeking help and receiving treatment, but they're not necessarily being proactive about it. They're not taking that first step to get in and to just find out what it's all about, like, "What is therapy like? What is taking an antidepressant like?" And actually, I think it it makes sense from a Public Health standpoint because we think about other like diet and exercise, even substance use, there's a lot of health behaviors where people know what's healthy, moral...

07:37 PE: There's a pretty good knowledge in the population and even the attitudes are not necessarily getting in the way. There's not a stigma really around eating well or exercising, but it's more just that people have other priorities and we also tend to be very present-oriented as human beings. Sometimes even people have talked about theoretically we have a present-self and a future-self, and they're in competition with each other. The present-self usually wins, so that implies, well, maybe can we get people to focus a little bit more on their future-self or make the present-self benefit a little bit more, [chuckle] or make the benefits to the present-self a little more obvious. Do you have any thoughts on that? I'm curious.

08:15 TC: Yeah, especially two of the barriers you mentioned coming out of the study which is, "I don't have the time," and then this idea that it's not serious enough or what is really common in the eating disorder literature, the idea of, "I'm not sick enough to need or deserve treatment." Those are two barriers that I personally experience but are also really common within the peer groups that I'm in. The time that it takes to acknowledge what's really going on and the awareness to understand that you may need help, but then the time to research and seek out treatment, figure out if your health insurance covers it, if that therapist you're interested in takes health insurance, and so all those barriers. But then actually implementing that time block in your week, if it's every week, every other week, to go to see your therapist and sit in there and do the work.

09:07 TC: So that's something I hear really commonly is time. And then that second point being that it's not serious enough or, "Everybody's stressed out so it must be okay to feel this way and so, I don't need help because this is very common," and I think the nuance there is stress versus anxiety. For instance, if we're talking about anxiety, those common everyday stressors are present in our lives but then when somebody probably could benefit from treatment and help-seeking is when it's no longer little anxieties throughout the day or throughout a week or a month, but that constant overbearing stress or anxiety. And I think a lot of people are still unaware of what it feels like to have these clinical mental health disorders because we don't grow up really understanding what they look like or what they mean. It's not a broken arm that you can really see and understand and X-ray to know that like, "Yes, this is wrong, this is bad. I deserve treatment for this broken arm because my bone is broken."

10:05 PE: On the topic of stigma, I'm curious what you're seeing in student populations or just with your research as well because in our survey data, the way they answer our survey questions indicates a very low prevalence of stigma. I know stigmas is this complex concept which has many dimensions so I'm curious, what aspects of stigma do you think are still most problematic among young people?

10:30 TC: Yeah, I think that's such an interesting question to reflect on and thinking through even generationally how different mental health stigma is. Looking at my parents' age group, where my parents still don't really have the language to talk about mental health or express their own thoughts about mental health, and then I think my generation. Being an undergrad, nobody really talks about mental health. There started to be services available, there were some resources, but it wasn't something that came up in conversation, whereas I hear now students even in my Public Health 200 course that I'm GSI-ing, every week essentially we talk about mental health in some way, shape or form. And some students do talk about openly going to therapy and I think that's amazing.

11:13 TC: So I've seen a lot of improvements even since my time in college, which wasn't that long ago but long enough ago. I think some issues that still exist for college students, it's that initial opening up about mental health struggles and getting that first access to treatment or that first appointment with a therapist, or going to see your doctor that first time to talk about anxiety or depression or anything else they may be struggling with. And I see issues in access to getting that first point of contact. So when students have to wait four weeks to get that initial appointment with counseling services or at a university health service provider, I see that as being a big barrier to treatment and just getting that first foot in the door to then proceed with a course that is best suited for them.

12:02 PE: Yeah, that's consistent with how we've been thinking about some of our intervention strategies because for a lot of young people, it might not require that much convincing or it wouldn't necessarily require a heavy handed or intensive intervention to change people's attitudes or give them all kinds of knowledge. It's more just a nudge or a little reframing of their choices or, as you're alluding to, if they didn't have to wait a few weeks, that could make the difference even though it doesn't seem like a huge thing, especially in today's culture of immediate gratification. These small changes could actually lead to big differences for young people.

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12:46 PE: One of our new projects is trying to understand what's the impact of offering online therapy. We're doing a large randomized trial involving 20 campuses where we're screening tens of thousands of students and then those who have elevated risk for depression, anxiety or eating disorders are being offered, or randomized to being offered online therapy. It's a self-guided program, so it's less intensive. It's not like a tele-therapy, it's not that you're with a live therapist. It's that you're actually reading through and looking at videos, but there are coaches in the background who contact participants and try to help them move along if they're having trouble or they're getting stuck. The point of this study is just to understand, well, how beneficial is it? How many students are even using it? Are they replacing traditional therapy? Are they using it in addition to it? Is it actually increasing their use of additional therapy? And we don't know exactly how it's gonna play out in this population scale but that's another promising trend, I think.

13:38 TC: Yeah, that's really interesting to hear. Some students in the course that I work with, we had a discussion section on how can we improve mental health access to undergrads, and a lot of them did say they would love an option to have some kind of online sessions or some way to contact a professional in times of need, or even crisis, when they're given a four-week wait time at psychological services on campus. And so, I think that that could offer a lot of potential in the future and even decrease those barriers to help-seeking.

14:11 PE: Yeah. I always like to bring the conversation back sometimes because I think sometimes we get too swept up in what's new and what's rising. New problems, digital media, digital media solutions, but mental health, I think, mostly is determined by very basic things that have always been present and always been true like social contact, social support, in-person relationships, physical activity, getting exercise, sleep, diet. A lot of the basic staples of Public Health. They remain as important as ever. One of my favorite articles that I've read in Public Health or mental health, it's about the concept of nurturing environments and that the idea is, what's a unifying kind of thread that we can think if and when we want to improve mental health for young people? Because we tend to compartmentalize our approach. We talk about substance abuse, we talk about juvenile justice and delinquent behavior, and then we talk about depression, anxiety. So we have like 15 different compartments and approaches that each correspond to those, spreading out all the efforts and all the organizations and all the infrastructure.

15:15 PE: So what if we focus on just one thing, nurturing environments? And they define what that means and it's basically avoiding toxic exposures, both biological as well as environmental, promoting pro-social behaviors, like social and emotional and interpersonal skills. They also talk about psychological flexibility, but it's really fundamentally, it's what you think it would be. A nurturing environment's a supportive, warm relationship from parents, from teachers, from mentors. While it might seem simplistic, I think that is a useful way, maybe, to think about even campus environments for young adults, is what if we thought about some core principles of creating nurturing environments. I think that has legs. I think that has a lot of potential to bring together some of the efforts that are sometimes getting fragmented across a lot of different issues, understandably, 'cause these issues do have their important differences but I think we lose sight, sometimes, of the common thread that is relevant to them all.

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16:26 TC: Sara Abelson is a PhD student at the university of Michigan School of Public Health, and a co-investigator and lead for diversity, equity, inclusion projects with the Healthy Minds Study. Her research has a particular focus on how universities can improve structurally to better serve all students' mental health, and she's a part of initiatives both on and off campus working to integrate mental health into the fabric of educational institutions.

16:49 Sarah Abelson: Really broadly, my research focuses on the mental health of young people and better understanding how schools influence mental health and may be harnessed to better support mental health and mental health equity. More specifically, I'm dedicated to helping college leaders and educators understand the mental health needs of vulnerable student populations and identify how they may intervene to improve mental health and mental health equity through changing policies, structures and practices. Working with campuses and institutional leaders across the country in my role as Vice President for Student Health and Wellness at Active Minds, I saw that there was strong and increasing documentation regarding the scope of mental health problems on college campuses but not enough data and evidence on potential solutions. And I saw that without data, schools often struggled to understand the influence of their policies as well as what their opportunities were to intervene. And I also saw that without the needed data and evidence, that institutional leaders and efforts often tended to blame students or system failings outside of higher education and to neglect vulnerable student populations.

17:56 SA: And so, that work really led me back to higher education myself, I mean, to pursuing a PhD. I work closely with the Healthy Minds Study which provides really valuable population level data and helps us understand what's happening with mental health on students on diverse campuses all across the country. And the beauty of that type of population level data that has been collected over time on many campuses from many students, is that we can dive in deeper to understand what's happening with specific populations. So for example, some of my research has focused on better understanding mental health among transgender and gender minority students, and that population has often been really under-studied because data doesn't always collect information on gender identity and expression. Or it's a small data set and there may be only a small number of transgender and gender minority students represented in that data.

18:46 SA: We know that structures and policies in higher education shapes the climate at the institution at the school and we know that that has a big impact on student mental health so there's a lot of research showing that school climate has an impact on sense of belonging. It has an impact on mental health, it's really important to mental health, and it also has an impact on academic outcomes and success as well. When we say climate, we're talking about the norms and behaviors and expectations around how student needs and how people are treated at the institution. Sometimes we look at climate as an individual level so we would ask a student, "What's your perception of this campus climate? Is it a hostile environment? Is it a welcoming environment?

19:27 TC: In her work, Sara's been able to confirm one key idea, that mental health is experienced differently by different populations. And that's something we need to keep in mind when we're pushing for institutional change.

19:37 SA: Tons and tons of data show that racism, discrimination and bias are bad for everyone's mental health. I've been really actually just reading some research from college campuses showing that hostile racial climate is not only bad for the mental health of students of color, but also for white students. We also know that on campuses that racism and discrimination and bias hinder sense of belonging, which is important for mental health and academic success. There's data to show that discrimination and bias can lead to imposter syndrome and stereotype threat which negatively impacts, again, mental health and academics. And we also know that discrimination and bias, and our history of racism and current ongoing racism in this country, shape systems in ways that builds unnecessary structural barriers that can really harm specific populations and take a toll on mental health.

20:26 SA: Another thing that we know is that actually in many states and on many campuses, gender minority students aren't actually protected from discrimination, so many campuses have made an effort to add gender identity and expression to their non-discrimination policies. But that's not the case federally and that's not the case in every state and on every campus. Without those protections, that really leaves many students at risk. I think there's so much that institutions can be doing to better support the mental health of gender and sexual minority students on campus. I think they can be doing a lot to focus, as we've talked previously about the campus climate and making sure that there's appropriate and supportive policies in place, making sure that there's programs in place to support those students and to foster their well-being and social support and connectedness. I think there's also lots of opportunities to really focus on the healthcare that's provided and making sure that it's gender affirming and that providers are educated about sexual and gender minorities.

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21:26 SA: We need equity-minded leaders who are thinking about and focusing on understanding mental health, and specifically focused on better understanding and addressing mental health inequities. If we focus only on those broadest population approaches, we're gonna miss people and we're not gonna effectively help everyone get better. The broadest population approaches can sometimes lead to ongoing inequities and leave behind the folks that have often been left behind previously, vulnerable populations. And so, I think, really in terms of next steps for higher education, connecting the dots between some of these different issues on campus and connecting the dots between our efforts to address diversity, equity, inclusion and our concern about student mental health and making sure we're taking an equity-minded approach. Students are going to struggle with mental health at institutions. Suicide is currently the second leading cause of death on campuses, and institutions really need to be thinking about how are they supporting students after a tragedy like that occurs on campus. What are they doing for students that take a leave of absence to go take care of their mental health?

22:26 SA: How are they helping those students as they come back? How is the system set up to help guide them through their higher education experience? Campuses are also thinking proactively, how do we include mental health in orientation and in the their first year curriculum and in seminars and in training? How do we do proactive outreach at stressful points? So when freshmen maybe take their first set of exams or receive their first set of grades, what kind of mental health campaign do we have going on to reach out to them to that point? Campuses are doing some work with campus advisers, making sure that they're educated about student mental health, that they know how to recognize and respond and refer students in distress and that they really are recognizing and educating students about the link between mental health and academic success.

23:08 SA: And then thinking too about, "Alright, how are we transitioning students to the workplace?" So not only while they're at our institution, we're seeing workplaces more and more recognize and grapple with mental health. And it's really impacting the bottom line of companies. It's impacting the workplace and so they care about mental health. They wanna hire students that know how to take care of their mental health. And so, institutions are thinking about that as well as they prepare students to graduate and to transition to the real world, making sure, again, that mental knowledge and skills are built into that process as well.

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23:47 TC: Thanks for listening to this episode of Population Healthy from the University of Michigan School of Public Health.

23:51 Speaker 5: We're glad you decided to join us and we hope you learned something that will help improve your own health or make the world a healthier place. If you enjoyed this show, please subscribe or follow this podcast on iTunes, Apple Podcast, Google Play, Stitcher, Spotify or wherever you listen to podcasts. Be sure to follow us at umichsph on Twitter, Instagram, and Facebook so you can share your perspectives on the issues we discuss, learn more from Michigan Public Health experts and share episodes of the podcast with your friends on social media. You can also check out the show notes on our website, publichealth.umich.edu/podcast for more resources about the topics discussed in today's episode. If you want to stay up to date with the latest research and expertise from Michigan Public Health, subscribe to our Population Healthy newsletter at publichealth.umich.edu/news/newsletter. We hope you join us for next week's episode where we'll dig further into Public Health topics that affect all of us at a population level.