When Ross Szabo began his freshman year at American University in Washington, D.C., in the fall of 1996, the former high school class president and varsity basketball player seemed destined for success.
He was doing well in his classes. He'd landed an impressive internship with a political organization. He was an emerging star on the freshman social scene, earning a reputation as a hard-core partier.
Unknown to his new college friends was how Szabo's life was careening toward a violent crash, and that he was helpless to do anything to stop it.
Just two months into the school year, Szabo had plunged into a “massive relapse” of a bi-polar disorder first diagnosed at 16.
“I was having a rough day and trying to tell people,” Szabo said, recalling what would be his last day on campus. “I was hearing voices, not sleeping, having anger outbursts.”
He arrived at his internship and spotted the telephone.
“We could call long distance,” Szabo explained, his voice channeling the fear and frustration of the desperate young man who was scrambling to save himself. “I called my father and said ‘you have to come get me. I have to go home.’”
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Szabo's cry for help may have represented the more extreme mental health distresses that can affect young people, but mental health professionals agree that young adulthood can be a time of extraordinary emotional and psychiatric vulnerability. Until very recently, however, misinformation and misconceptions cloaked the public discussion of mental illness in a shroud of social stigma.
A string of high profile student suicides in the mid-1990s, however, sparked a movement at universities across the country to try to better understand and manage the mental health of their students.
While serious mental conditions like the bi-polar disorder Szabo battled are relatively rare among the general student population, an ever-growing pile of research suggests that mood disorders such as depression and anxiety are increasingly common.
Research shows, in fact, that at any given time an alarming number of college students are engaged in some kind of mental crisis.
“This is not sudden, it’s been gradually coming to light for a decade or more,” said Martha Anne Kitzrow, Ph.D, a psychologist and professor at the University of Idaho Counseling and Testing Center and author of “The Mental Health Needs of Today’s College Students: Challenges and Recommendations,” a 2003 report published in the National Association of Student Personnel Administrators Journal. “If you look at the literature, we have been seeing this for some time,” she said.
“We know that psychiatric distress among college students is very high,” said Dr. Trisha Suppes, director of the Bipolar Disorder Research Program at the University of Texas Southwestern Medical Center in Dallas, where she also is a psychiatry professor. “It’s in the past five years that an effort for greater awareness has been made.”
It's estimated that as many as 20 percent of the general student population seeks counseling to help cope with psychological distress, according to Kitzrow and Suppes, who add that improved awareness and diagnosis contributes to higher reporting numbers.
“Students are more educated about seeking psychological help. It’s a positive thing that students are aware of services and are stepping into services when they need them,” Kitzrow said. “If you look at the students seeking counseling, the majority are not long-term. They get the help they need and move on,” she said.
Campus counselors who have been in the business for a while say that in recent years they've seen not only a dramatic increase in the number of students seeking mental health services, but in the severity of the illnesses diagnosed. Those numbers become even more troubling after figuring in an estimate of the number of students in crisis who never seek counseling.
According to the 2005 National Survey of Counseling Center Directors — which represents the responses of 366 college counseling centers across the country — 90.3 percent of directors reported a rise in the number of students with severe psychological problems, and 95 percent of directors reported an increase in the number of students coming to counseling who already are on psychiatric medication. Directors overall reported that more than 43 percent of their student clients have severe psychological problems.
"There is more pathology, more severity, not just more reporting," said Maggie Olona, a spokesperson for the Association of University and College Counseling Center Directors, and licensed psychologist and director of student counseling center services at Texas A&M University. Olona said that the mental health community was skeptical of some of the data being produced, and looked into whether they were simply seeing the results of improved awareness and reporting.
"Perception is reality. There is more pathology coming over our doorstep," Olona said.
In October, 2004, Olona said the counseling center she runs at Texas A&M experienced a 300-percent increase over the previous year in the number of students "presenting in crisis." In 2005, the center saw a 20 percent increase on top of that.
"These are not students who are homesick," Olona said. "These are students in real psychological distress with real problems," she said.
A June, 2006 study of Cornell and Princeton students found that nearly one in five students surveyed reported they engaged in some kind of physical self-abuse, usually in the form of self-inflicted cuts or burns. Wounding oneself is a disorder that stems from the need to use pain to help relieve stress, anxiety or emotional distress.
About as far away as you can get from the Ivy League, at the University of Texas at Brownsville — a commuter school near the Mexican border whose student body is largely Latino, low income, single mothers— cutting also is pervasive.
“Cutting is a big issue in the age range [19-23] we see,” said Charla Layne, a staff psychologist at Brownsville and the faculty advisor for UTB’s chapter of Active Minds, a national, student-run organization founded to raise awareness of mental health issues among college populations and help students find services.
Some other findings:
— In 2005, the American Psychiatric Association appointed a Presidential Task Force on Mental Health on College Campuses and reported that more students enter college already taking psychiatric medications, that more colleges are reporting increases in severe psychopathology in students, that campus mental health centers were prescribing more medications, and that suicide was the second leading cause of death among students.
— Eating disorders have their highest rate of incidence in college-aged women, according to the APA.
—In a 2004 report by the American College Health Association, 40 percent of college men and 50 percent of college women surveyed said they had experienced depression so severe at some point in time that they could “barely function;” 14.9 percent said they had been medically diagnosed with clinical depression. In this same survey, 60 percent of students reported “feeling things were hopeless” one or more times during the previous school year.
— The National Mental Health Association’s (NMHA) College Mental Health and Depression Pilot Initiative compiled data from a variety of studies, surveys and agencies and found that 30 percent of college freshman and 38 percent of college women reported feeling frequently overwhelmed.
— Suicide is the third leading cause of death among young people aged 15-24, but jumps to the second leading cause of death among the college population, according to the NMHA.
What's driving so many students to seek professional counseling?
In a nutshell: life.
Some experts point to greater student exposure to broken families, sexual abuse, media violence, an obsession with physical appearance and money, even divisive politics as a cause for psychological scarring.
Others point out that serious mental illnesses like bi-polar disorder, schizophrenia and serious depression typically surface during the late teens and early twenties. Students predisposed to these conditions often arrive on campus just as an illness emerges.
Shifting student demographics — more non-traditional students, older students, low-income students — also is thought to contribute to the increase in mental health disorders.
The common thread running through most of these factors appears to be that college now is more accessible, which creates a more diverse student body, including diversity of mental health issues.
For some, such as the low-income, minority, single mothers that comprise the majority of the student body at UT-Brownsville, diversity means the stresses caused by poverty, child-rearing, relationship issues, even domestic violence.
Combined with new environments, removal of familiar support systems, and the new pressures and responsibilities of independence and adulthood, and it's not surprising that many students begin college already heading for a crash.
“A lot of the students we see have been diagnosed previously or have a history,” Layne said. “They come in with disorders and the stress of school, the adjustment, is so overwhelming, they can’t function,” she said.
"I honestly do not know what the root cause is," Olona said. "You'd have to go so far back in their lives.
"The students who come in for counseling come in for so many reasons. There really isn't a one-size-fits-all answer. It's so individualized," she said.
College counseling centers are feeling the impact.
"I don't think students have more problems than young people not in college," Olona said. "We're just seeing more of what's out there. We're getting a better representative example of the general population on campus," she said.
Some students are under enormous pressure to succeed, both in school, and after graduation.
"They are very wanting to succeed," Olona said. "They feel the pressure to find a job in this economy. For all these reasons, students are anxious."
College life, itself — with late nights, poor nutrition, and alcohol or substance — can be a major culprit.
Sleep deprivation is cited repeatedly by experts as a root cause of anxiety, stress and depression. Excessive drinking can cause depression and trigger the onset of more serious illnesses, such as bi-polar disorder, especially in young people with a genetic vulnerability.
“We have to get rid of the destructive youth culture,” said Ross Szabo, recalling the anger outbursts, drinking binges and other outrageous behavior he exhibited during his relapse those first months of college. No one seemed to think there was anything unusual about his actions, he said.
“I had to have my stomach pumped [from drinking] my second week at school, and no one seemed to think anything about that,” he recalled. “It was hard to recognize that there was something wrong with me because everyone was living like that. It was more acceptable for me to drink and smoke and not sleep than to say that something was wrong with me,” he said.
“Different generations have tried to deal with things differently,” Layne said. “A whole generation tried to use drugs.”
This generation is steeped in a culture that, to a certain extent, encourages dangerous behaviors like eating disorders and cutting, she said.
“Media articles about celebrities doing it glamorize it,” Layne said. “They see web sites honoring movie stars who cut. The media can make it seem cool. As counselors, we have no way to fight that,” she said.
Colleges almost universally agree on the need to better accommodate the mental health needs of students. It's a challenge, however, that does not come without institutional dangers.
Liability — the legal exposure a college can face if it is found negligent or responsible when a student harms him or herself — is no small threat to a college's reputation and finances.
Patchwork policies — bans on alcohol and drug use, and firearms; minimum academic standards and behavior codes — can help ward off a lot of potentially destructive student behavior, as well as act to "flush" violators off campus. Administrators, in the process, have to be careful not to violate a student's civil rights since many mental illnesses are protected by the Americans with Disabilities Act.
"In reality, the Office of Civil Rights [within the department of higher education] has said that you cannot flush someone out who qualifies for a disability accommodation," Olona said.
Colleges, therefore, are left with with few options beyond increasing services and raising student awareness.
"We do alot of outreach," Layne said. "We're trying to do as much as we can to let people know services are available."
Student demand often outpaces the services college counseling centers can offer.
"I don't know any colleges out there who are just floating in money," Olona said. "Universities are making hard choices."
With students arrived on campus to begin the fall term, Texas A&M offered programs on stress and time management, and how to cope with the new challenge of college life.
"We've been filled to overflowing," Olona said.
To meet demand, universities have turned to creative solutions like 24-hour hotlines, student-run organizations like Active Minds, the student-run mental health organization Layne advises, Web sites providing information and resources, and a greater involvement of faculty and staff in spotting problems.
"I think most college counseling centers feel they are stretched thin," Kiztrow said. "We're trying to figure out unique ways to deliver services — groups, by telephone, self-help materials on Web sites. I think the whole concept of centers using Web sites as a point of entry is fairly new in the field."
At UT-Brownsville, counseling staff works with professors to encourage them to walk students over to counseling, Layne said. At Texas A&M, the teaching faculty are trained to spot warning signs and reach out to students who may be in crisis.
"We know students do talk to someone," Olona said. "They may not come to counseling, but a faculty member may be the one who sees it.
"The English 101 professor who sees the first two papers and can see that something might be wrong," she said.
Counselors agree that getting students into campus services is crucial.
"We know that if they come in, those students will stay and school and graduate," Olona said. "We know that if we can get them in here, chances are they will not commit suicide."
For Szabo, getting help made all the difference.
After a four-year hiatus from school, partially spent learning how to manage his condition, Szabo returned to American University and earned a bachelor's degree in psychology, graduating with honors. He now is the spokesperson for the Director of Youth Outreach for the National Mental Health Awareness Campaign, a nationwide nonpartisan public education initiative launched as part of the 1999 White House Conference on Mental Health organized by Tipper Gore. He said he has spoken publicly about his illness to an estimated half-million people.
"When I ask students how many people know someone having a mental crisis, they all raise their hands," Szabo said. "Drinking? They all raise their hands. Hurting themselves? They all raise their hands."
While Szabo is an example of how intervention can help a student successfully manage mental health issues, campus counselors agree that most students will never experience that degree of illness.
"If you look at the entire group of students seeking services at one time, it's a minority of students that need the more serious form of services," Kitzrow said.
"Some [of their problems] are just typical and normal for where students are in their lives. College students are very resilient and capable of making the changes they need to make," she said.