On Campus Podcast – Mental Health and Student Health Services

Darren Gaddis: From CITI Program, I’m Darren Gaddis, and this is On Campus. Today, what are factors which contribute to student mental health, the role student health services plays in a student’s mental health, and how the COVID-19 pandemic has impacted healthcare and mental health.

I spoke with Sarah Lipson, an assistant professor at the Boston University School of Public Health and the Principal Investigator of the Healthy Minds Network. Her research focuses on understanding and addressing mental health in higher education, and has been funded by the National Institute of Mental Health and WT Grant Foundation, among others.

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Hi, Sarah. Thank you for joining me today.

Sarah Lipson: Thanks for having me.

Darren Gaddis: Sarah, to get us started today, when you think about student mental health, what are some factors that can contribute to the overall state of student mental health?

Sarah Lipson: Yeah, that’s a big question. There are so many things that mental health affects and is affected by. We like to talk about it as a bidirectional relationship. So what really motivates the work of my colleagues and I and so many others in studying mental health among college students, is just that it’s a really important predictor of pretty much every outcome that anyone could care about, from health to academic outcomes. And it is affected by so many things as well, so it’s a really complicated and important area of study and of practice.

A few of the factors that really contribute to the overall state of student mental health, from a public health perspective often talk about risk and protective factors. So a few key risk factors, these are things that negatively affect mental health in student populations. The first I would mention would be financial stress. That is arguably the most salient negative predictor of student mental health. Students who are low-income or experiencing financial stress in college on average have poorer mental health outcomes.

And I’ll actually, I’ll focus this answer I think on mutable factors. So another really important risk factor is … Discrimination is another really key risk factor. We could think about everything from microaggressions, all the way towards more violent forms of discrimination. That’s another really important risk factor for poor mental health among students. And there’s a lot of policy implications in terms of how do we reduce students’ experiences of discrimination.

I’ll mention a few protective factors, so these are factors that positively affect student mental health, are associated with flourishing, thriving in college. And so one is sense of belonging. And this is a bit of a difficult concept to measure, but it essentially means that a student feels like they belong on their campus. In our Healthy Minds data we measure it in a few different survey items. One is, “I see myself as a part of the campus community.” So students who see themselves as a part of the campus community on average have better mental health outcomes.

Another protective factor related, I think, to sense of belonging is peer relationships and connections. Having a sense of purpose, of course. I mean, that’s not something that’s unique to college student mental health, but in general it’s a really important protective factor for mental health. Another key protective factor is having an adult, in particular, a faculty member, who is really supportive of you. Who knows your name, who knows you as a person really. Not just a student in a classroom, but actually having a faculty member who cares about you as a person, that’s a really important protective factor for students.

I’m happy to go into some of the other risk and protective factors, but those are some of the key ones I wanted to mention and specifically wanted to highlight them because they’re all mutable. They’re all things that can be changed through policies, programs, and practices.

Darren Gaddis: And traditionally, what role could student health services on a campus play in student mental health?

Sarah Lipson: Yeah, that’s a great question. I think that the answer to this has really shifted in good ways in recent years and needs to continue to shift. Student health services is obviously the kind of what oversees the delivery of health services to students, and that often includes mental health services. There’s differences in terms of the integration of mental health services with health services across different institutions.

But really what the role of student health services is, I see as shifting. It used to be that they were almost the sole entity that was responsible for student mental health. Now, as we’ve talked about in the past, and as folks can see in our Healthy Minds data and in other sources of data, the prevalence rates of mental health problems in college student populations are just so high. Roughly 50 to 60% of students in our data are meeting criteria for one or more clinically significant mental health conditions.

And when we’re talking about proportions as high as half or more of student bodies, it’s very unrealistic to think that the health system is going to be the only unit on campus that’s going to be responsible for addressing this problem. We really need cross-campus collaborations from student health services, to residential life, financial aid, student activities, athletics, even some entities that are not often thought about in these conversations, like campus policing. And really think about student health services as being experts in the delivery of health services and maybe the starting point for a lot of the initiatives around student mental health, and certainly the place that students who need clinical treatment are accessing that at many campuses. But not the only entity on campus that is responsible for thinking about student mental health and for being involved in addressing these challenges.

Darren Gaddis: With this understanding, how does access to general health services support student mental health and their overall wellbeing?

Sarah Lipson: Yes. College is unique in the sense that it is a time when access to health services tends to be even better than it is in other settings or in other life stages. So that’s a really important opportunity. It’s one of the reasons that higher education presents a unique opportunity for addressing mental health, is that access is … It’s certainly still a barrier. And we could talk about community colleges, variations across institutions, but writ large, access to health services is better in college settings than it is in many non-college settings.

So having that access is a really important gateway. We know that health services on campus can often help to identify students who are experiencing mental health problems, connect them to services that can be helpful for them. It’s also an increasing awareness of things that … I don’t tend to like the term “wellness.” I think it’s maybe a little bit overused and now maybe overly commercialized.

But when we think about initiatives like mindfulness and meditation and exercise and sleep habits and eating and nutrition, oftentimes those health behaviors are under the purview of health services. And of course, those health behaviors really change a lot as students transition into college. There’s a lot of newfound autonomy that students have and new opportunities for them to make decisions about. “When am I going to sleep? What am I eating?” Exposure to new substances that they could potentially use. And so health services is a really key place for education and for the delivery of services.

Darren Gaddis: If a campus has limited student health services, how could this potentially impact a student’s mental health?

Sarah Lipson: Yes. Certainly there’s a lot of variation across institutional types in terms of the breadth of health services that are available at an institution. And at some institutions, there really is very limited health services. This could impact screening initiatives or other initiatives that are made at a population level to identify students who are struggling. If we’re not identifying students, then we’re limited in our ability to connect them to resources that could be helpful. Not just treatment, but prevention resources as well. We know that physical and mental health, of course, are inextricably linked, and so for students to not be able to access health services, physical health services at their institution, may also affect not only their physical health, but also their mental health.

I also want to make sure that I highlight that even campuses that have very limited student health services, we can think about community colleges as just one example, are still many of them are really innovating in the space of providing mental health resources to students. Thinking about structural changes at an institutional level. Again, getting back to those risk and protective factors.

We could think about mental health initiatives as also encompassing things like policy changes, protective policies, things like name-change policies for trans and non-binary students. That is likely to have a really positive impact on trans and non-binary students to be able to change their name and indicate their preferred pronouns, and the impact of that on their wellbeing. So that’s not dependent on having a health services in order to actually influence mental health outcomes for students.

But certainly, for campuses that don’t have student health services, it’s really important that there be partnerships with local community health centers. There’s a number of different resources that can be leveraged in local communities, and even nationally and web-based or mobile mental health apps that can be delivered, regardless of whether there’s a student health service on campus.

Darren Gaddis: How have the impacts of COVID-19 and other changes to healthcare impacted student mental health?

Sarah Lipson: Certainly in terms of access to mental health services, at the beginning of the pandemic, so in spring of 2020, we saw a lot of restrictions. And some of that was due to students leaving a state where they were a student, and traveling back to maybe their home state and not being able to continue to access mental health services because of different state policies. A lot of that was smoothed out and has somewhat become obsolete as Telemental Health has continued to be a part of the campus mental health menu of options.

The impacts of COVID, like I said, were initially making some new challenges in terms of accessing mental health services. Starting in the 2020/2021 academic year we saw a lot of those barriers overcome, and we saw the levels of service utilization return to roughly what they were in 2019. However, at the same time, we were seeing even more of an increase in prevalence. So the pace of increase in terms of symptom prevalence has far outpaced the increase in service utilization [inaudible 00:12:42], particularly throughout the pandemic, as needs have continued to rise among students.

But we really have seen a lot of innovation in terms of the delivery of services via Telemental health. Utilizing virtual mental health care not as the only option, but as again, a part of a menu of options that can be leveraged to provide care to students.

Darren Gaddis: Sarah, what else should we know about student health services and student mental health?

Sarah Lipson: I think one of the most important things for folks to be aware of is the barriers that do exist in terms of why students are not accessing mental health services. I think this surprises some people who aren’t in this field.

Some of the key barriers, the reasons that students report not accessing mental health services when they’re struggling, I think that that’s a really interesting area that some folks might not be aware of. The most common reasons that students report are, “I question how serious my needs are.” “I don’t have time.” “I prefer to deal with issues on my own,” and, “The problems will get better on their own.” So those reasons really require a shift in our thinking in terms of how do we promote help-seeking for a student who has a positive screen for major depression, but says these problems are going to get better on their own or, “I don’t have time.”

And the fields of behavioral economics is one we can look to for potential answers in this regard. Behavioral economics is really about thinking about the cognitive biases that people hold. And it seems that there’s really a lack of urgency or a lack of inertia that surrounds the help-seeking process. A simplified way of thinking about it might even be to think about it as a form of procrastination, that students are … They’re so busy, and it’s really hard to say, “Today’s the day I’m going to prioritize my mental health. I’m going to go and access services today in my very, very busy life.”

But behavioral economics would say that we really need to shift the default. We need to bring mental health services into students’ daily lives, into their routine default experiences. And in higher education we know that classroom learning environments, that is the place where we have the ability to reach every single student on campus. So if we can bring mental health resources, training, screening, awareness prevention efforts, into classroom environments, that is a really important way that we might be able to address the most common barriers that students report in terms of why they’re not accessing services.

Darren Gaddis: Sarah, thank you for joining me today.

Sarah Lipson: Yes, absolutely. Thanks for having me.

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