Telemental health (TH) resources – technology used to provide assessment and treatment for mental health conditions – are plentiful. But while we know college students can likely benefit from such services, we know little about their opinions on this particular type of resource. Tammy Toscos, Ph.D., Informatics Research Manager, Parkview Research Center, and team set out to examine students’ previous use of and willingness to use several types of TH. Here, she tells us more about their findings, and what they could mean for the future of mental health care in higher education.
Approximately 50,000 college students sought treatment at counseling centers in more than 400 U.S. universities during 2015-16.1 This represents a substantial uptick – 30% on average – in counseling center usage.1 During the same period, average enrollment increased only 5%, which has left many counseling centers challenged with balancing a stagnated budget with increased student needs.1
What our students are struggling with.
The top concerns of students who visited student counseling in 2015-16 were anxiety (61%), depression (49%) and stress (45.3%).1 Despite increases in counseling service utilization across campuses, substantial numbers of college students don’t seek treatment for their psychological distress.4-7 An oft-cited study on mental health help-seeking (MHHS) behaviors among college-age individuals found that fewer than 25% of those with any type of mental disorder had sought treatment within the past year.4 Moreover, only 36% of college students with depression only and 52% with anxiety only received treatment in the past year.6
Why aren’t they getting treatment?
Consistently across the literature, stigma has been cited as a significant barrier.9-14 Barriers also include distrust in mental health service providers, hesitance in self-disclosure, and perceived devaluation11,14 as well as lack of knowledge/familiarity with treatment14 and lack of clarity/urgency about whether one needs help.8,9,11 This may explain why college students with serious distress often choose to deal with their issue(s) themselves.11,15 Gender might also be a barrier to treatment. Women exhibit more depression, anxiety, and stress symptoms than men;16,17 however, women with mental health problems and suicidal ideation are more likely than men with these issues to seek treatment.7,8
Changing the model of care.
With both increased demand for care and low prevalence of MHHS, counseling centers must make tough budgeting decisions. Urgent and continual care for students at risk for suicide are constant areas of need.18 However, with high rates of mental health issues among the general college population,4 it is critical to reach those not already seeking treatment. As Eisenberg et al.5 proposed, “New strategies may prove to be especially important for changing the behavior of the large number of students who are not using services despite reporting positive attitudes and beliefs about treatment (p. 229).” These novel approaches could include web-based treatments and interactive software,19 which may be perceived as more confidential and less stigmatized methods of therapeutic support.20-22 As few college students engage with university resources23 and the majority prefer informal over formal resources9, these modern mechanisms might serve as a conduit for counseling centers to expand their reach and provide pathways to formal care.22
In recent years, there has been a surge in TH applications and websites24, many relying on traditional therapeutic approaches, like Cognitive Behavioral Therapy, to help with stress, mental health problems and/or suicidal behavior.19,25-31 College-age adults, who are prolific users of technology, the Internet, and social media,32,33 appear to be open to these online treatments.20,21,34 In fact, a recent study with 572 university students showed that students facing emotional problems were more likely to seek help online than face-to-face.34 As technology and TH resources become more accessible, it is important for counseling centers to continually reassess college students’ use of and willingness to engage with TH.
[THE BRIEF – PARKVIEW’S STUDY]
Goal of study.
Our aims were to assess college students’ preferences for, previous experience with, and willingness to use TH (including anonymous chat with a trained non-professional, online therapy, and self-help resources).
We worked with 662 students from two U.S. midwestern colleges.
We used an online survey in spring 2017, where we measured students’ depression, anxiety, stress and suicidal thoughts, preferences for care options during distress, and use and interest in anonymous chat with trained non-professionals, online therapy and self-help resources.
Overall, 10.1%-13.8% had experience with these TH resources; however, 24.6%-40.1% expressed willingness to try them. At-risk students, especially those higher in depression/anxiety scores, showed greater use of and willingness to use some applications.
Counseling centers might consider endorsing TH resources as potential pathways to care. TH resources might help broaden reach with minimal cost, reduce mental-health help seeking barriers, and provide support to at-risk populations.
Consistent with previous research,4 mental health problems were common in our sample of college students: 31% reported depressive symptoms and 9% had contemplated suicide in the past year. Additionally, 33% had seen a mental health provider. Although women reported significantly higher levels of depression, anxiety, and stress than men—a common finding across studies16,17— women and men were equally likely to have contemplated suicide. Thus, as other researchers have suggested, gender needs to be a consideration in delivering solutions for stress and/or mental health;17 however, suicide prevention strategies in college should target men and women equally.
Decisions about where to invest resources for the treatment of college students’ mental health problems must be driven by cost, need and potential reach. TH resources, such as self-help resources, online anonymous chat and online therapy, may provide pathways to care that fill current gaps in treatment and overcome major barriers in MHHS among college students. These technologies, especially self-help resources, might be particularly appealing to those in high-risk groups, such as those with moderate to high depression/anxiety scores, high stress levels and women.
- Pennsylvania State University Center for Collegiate Mental Health (CCMH) 2016 Annual Report. Publication No. STA 17-74. [serial online]. January 1, 2017;Available from: ERIC, Ipswich, MA. Accessed August 10, 2017.
- Gallagher, Robert P. National Survey of College Counseling Centers 2014. Project Report. The International Association of Counseling Services (IACS). Published 2015.
- Weissman J, Russell D, Jay M, Beasley J, Malaspina D, Pegus C. Disparities in health care utilization and functional limitations among adults with serious psychological distress, 2006-2014. Psychiatric Services (Washington, D.C.) [serial online]. July 1, 2017;68(7):653-659. Available from: MEDLINE, Ipswich, MA. Accessed August 10, 2017.
- Blanco C, Okuda M, Wright C, et al. Mental health of college students and their non-college-attending peers: results from the National Epidemiologic Study on Alcohol and Related Conditions. Arch Gen Psychiatry. 2008;65:1429.
- Eisenberg D, Hunt J, Speer N. Help seeking for mental health on college campuses: Review of evidence and next steps for research and practice. Harvard Review of Psychiatry (Taylor & Francis Ltd) [serial online]. July 2012;20(4):222-232. Available from: Academic Search Premier, Ipswich, MA. Accessed August 9, 2017.
- Eisenberg D, Golberstein E, Gollust SE. Help-seeking and access to mental health care in a university student population. Med Care. 2007;45:594–601.
- Hunt JB, Eisenberg D. Mental health problems and help-seeking behavior among college students. J Adolesc Health 2010;46:3–10.
- Eisenberg D, Hunt J, Speer N, Zivin K. Mental health service utilization among college students in the United States. Journal of Nervous and Mental Disease [serial online]. May 2011;199(5):301-308. Available from: PsycINFO, Ipswich, MA. Accessed August 9, 2017.
- Arria A, Winick E, O'Grady K, et al. Help seeking and mental health service utilization among college students with a history of suicide ideation. Psychiatric Services [serial online]. December 2011;62(12):1510-1513. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed August 9, 2017.
- Crosby Budinger M, Cwik MF, Riddle MA. Hotline utilization and attitudes questionnaire. Suicide and Life-Threatening Behavior. 2015;45:192-198.
- Downs MF, Eisenberg D. Help seeking and treatment use among suicidal college students. Journal of American College Health. 2012;60:104-114.
- Hinshaw SP, Stier A. Stigma as related to mental disorders. Annual Review of Clinical Psychology. 2008;4:367–393. http://dx.doi.org/10.1146/annurev.clinpsy.4.022007.141245.
- Talebi M, Matheson K, Anisman H. The stigma of seeking help for mental health issues: mediating roles of support and coping and the moderating role of symptom profile. Journal of Applied Social Psychology [serial online]. August 2016;46(8):470-482. Available from: Social Sciences Full Text (H.W. Wilson), Ipswich, MA. Accessed August 9, 2017.
- Topkaya N, Sahin E, Meydan B. The development, validity, and reliability of the barriers to seeking psychological help scale for college students. International Journal of Higher Education [serial online]. January 1, 2017;6(1):48-62. Available from: ERIC, Ipswich, MA. Accessed August 9, 2017.
- Kim J, Saw A, Zane N. The influence of psychological symptoms on mental health literacy of college students. American Journal of Orthopsychiatry [serial online]. November 2015;85(6):620-630. Available from: PsycARTICLES, Ipswich, MA. Accessed August 9, 2017.
- Bohon L, Cotter K, Kravitz R, Cello P, Fernandez y Garcia E. The Theory of Planned Behavior as it predicts potential intention to seek mental health services for depression among college students. Journal of American College Health [serial online]. November 2016;64(8):593-603. Available from: Education Full Text (H.W. Wilson), Ipswich, MA. Accessed August 9, 2017.
- Garett R, Liu S, Young S. A longitudinal analysis of stress among incoming college freshmen. Journal of American College Health [serial online]. July 2017;65(5):331-338. Available from: Academic Search Premier, Ipswich, MA. Accessed August 10, 2017.
- Roy N, Braider L. College students and mental illness: Strategies for optimal results. Psychiatric Times. 2016;33:1–4.
- Fallon Travers M, Benton SA. The acceptability of therapist-assisted, internet-delivered treatment for college students. Journal of College Student Psychotherapy. 2014;28(1):35-46. http://dx.doi.org/10.1080/87568225.2014.854676
- Kauer SD, Mangan C, Sanci L. Do online mental health services improve help-seeking for young people? A Systematic Review. Journal of Medical Internet Research. 2014;16(3):e66. doi:10.2196/jmir.3103.
- Palmer K. Undergraduate college students’ attitudes about Internet-based mental health interventions. Graduate Theses and Dissertations. http://scholarcommons.usf.edu/etd/575; 2015.
- Rickwood DJ, Mazzer KR, Telford NR.Social influences on seeking help from mental health services, in-person and online, during adolescence and young adulthood. BMC Psychiatry 15. http://dx.doi.org/10.1186/ s12888-015-0429-6, http://www.biomedcentral.com/content/pdf/s12888-015-0429-6.pdf. Published 2015. Accessed August 12, 2017.
- Goodwin J, Behan L, Kelly P, McCarthy K, Horgan A. Help-seeking behaviors and mental well-being of first year undergraduate university students. Psychiatry Research [serial online]. December 30, 2016;246:129-135. Available from: PsycINFO, Ipswich, MA. Accessed August 9, 2017.
- Farrer L, Gulliver A, Chan JY, Batterham PJ, Reynolds J, Calear A, Griffiths KM. Technology-based interventions for mental health in tertiary students: Systematic review. Journal of Medical Internet Research. 2013;15:35–48. doi:10.2196/jmir.2639.
- Christensen H, Griffiths KM, Korten A. Web-based cognitive behavior therapy: analysis of site usage and changes in depression and anxiety scores. Journal of Medical Internet Research. 2002;4(1):e3. doi:10.2196/jmir.4.1.e3.
- Crandall KJ, Steward K, Warf TM. A mobile app for reducing perceived stress in college students. American Journal of Health Studies. 2016;31:68-73.
- Day V, McGrath PJ, Wojtowicz M. Internet-based guided self-help for university students with anxiety, depression and stress: A randomized controlled clinical trial. Behaviour Research and Therapy. 2013;51:344-351. https://doi.org/10.1016/j.brat.2013.03.003.
- Mak,WW, Chio FH, Chan AT, Lui WW, Wu EK (2017). The efficacy of internet-based mindfulness training and cognitive-behavioral training with telephone support in the enhancement of mental health among college students and young working adults: Randomized controlled trial. Journal of Medical Internet Research. 2017;19:e84. doi:10.2196/jmir.6737.
- Vahabzadeh A, Sahin N, Kalali A. Digital suicide prevention: Can technology become a game-changer? Innovations in Clinical Neuroscience. 2016;13:16–20.
- Sharry J, Davidson R, McLoughlin O, Doherty G. A service-based evaluation of a therapist-supported online cognitive behavioral therapy program for depression. Journal of Medical Internet Research, 2013;15:e121. doi:10.2196/jmir.2248
- Topham P. The future is appy. Therapy Today. April 2012;23(3):1-10. Available from: Academic Search Premier, Ipswich, MA.
- Pew Research Center (2017a, January). Internet Use by Age. Retrieved from http://www.pewinternet.org/chart/internet-use-by-age/
- Pew Research Center (2017b, January). Social Media Fact Sheet. Retrieved from http://www.pewinternet.org/fact-sheet/social-media/
- Lungu A, Sun M. Time for a Change: College students' preference for technology-mediated versus face-to-face help for emotional distress. Telemedicine & E-Health [serial online]. December 2016;22(12):991-1000. Available from: Academic Search Premier, Ipswich, MA. Accessed August 9, 2017.
- Neal DM, Campbell AJ, Williams LY, Liu Y, Nussbaumer D. “I did not realize so many options are available”: Cognitive authority, emerging adults, and e-mental health. Library & Information Science Research (07408188). 2011;33, 25–33. doi:10.1016/j.lisr.2010.07.015
- HIPAA compliance at SurveyMonkey. SurveyMonkey. https://www.surveymonkey.com/mp/hipaa-compliance. Published 2017. Accessed August 8, 2017.
- Stress in America: Are teens adopting adults’ stress habits. American Psychological Association. http://www.apa.org/news/press/releases/stress/2013/stress-report.pdf. Published 2014. Accessed August 8, 2017.
- Kroenke K, Spitzer RL, Williams JB, Löwe B. An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics. 2009;50(6):613-21.
- Löwe B, Wahl I, Rose M, Spitzer C, Glaesmer H, Wingenfeld K, Brähler E. A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. Journal of affective disorders. 2010;122(1):86-95.
- Kroenke K, Spitzer RL, Williams JB, Löwe B. The patient health questionnaire somatic, anxiety, and depressive symptom scales: a systematic review. General hospital psychiatry. 2010;32(4):345-359.
- Khubchandani J, Brey R, Kotecki J, Kleinfelder J, Anderson J. The psychometric properties of PHQ-4 depression and anxiety screening scale among college students. Archives of psychiatric nursing. 2016;30(4):457-462.
- Youth Risk Behavior Surveillance System (YRBSS). Centers for Disease Control. https://www.cdc.gov/yrbss. Published 2016. Accessed August 8, 2017.
- May A, Klonsky ED. Validity of suicidality items from the Youth Risk Behavior Survey in a high school sample. Assessment. 2011;18(3), 379-381.
- Cooren F, Higham L, Huët R. Analyzing online suicide prevention chats: A communicative constitutive approach. Language & Dialogue. 2017;7:3-25. doi:10.1075/ld.7.1.02coo.
- Mokkenstorm JK, Eikelenboom M, Huisman A, Wiebenga J, Gilissen R, Kerkhof AM, Smit JH. Evaluation of the 113Online suicide prevention crisis chat service: Outcomes, helper behaviors and comparison to telephone hotlines. Suicide & Life-Threatening Behavior. 2017;47:282–296.