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Mental Health Services on College Campuses

Introduction

It is widely accepted and believed that the college years are an incredibly stressful and

formative time for those who experience them. As such, mental illnesses such as anxiety and

depression are incredibly prevalent among college students. Despite a demonstrated need for

preventative care and treatment to address the issue, mental health resources are remarkably

scarce on college campuses, which only exacerbates the crisis facing students today. The demand

for these services has increased significantly in recent years, yet the level at which they are

provided has remained relatively stagnant, rendering colleges and universities even more

incapable of addressing student needs. Not only does their incapacitation directly harm the

students which they are obligated to help, it results in a deadweight loss due to the economic

benefits that are unrealized owing to untreated mental illness among college students. To rectify

the problem, government intervention in the form of government financing is required to fully

address the economic failures that occur as a consequence of underproviding the good.

Problem Definition

Too many students do not have sufficient access to mental health resources while in

college, despite the overwhelming prevalence of mental illness among college students. An

estimated 73% of students experience a mental health crisis at some point during their four years

of college, illustrating a phenomenon that has only become more severe in the 21st century

(Winerman, 2017). However, students struggle to find the care they need on campus; a 2017

report by the National Council on Disability (NCD) found that only 35% of students who

experience mental illness receive treatment (National Council on Disability, 2017). In recent

years, demand for mental health services on campus has been steadily increasing. While college
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enrollment only increased by 5.8% between 2009 and 2015, demand for mental health services

on campus increased by about 30% (Reilly, 2018). Most colleges and universities have been

struggling to keep up with this unprecedented growth in demand, lacking the finances and

personnel necessary to combat the crisis on their campuses.

Mental illnesses such as anxiety, depression, and bipolar disorder typically onset around

age 20, but in college students it often occurs even earlier. College can have a drastic effect on

mental health; stress, newfound independence, and homesickness may trigger symptoms of

mental illness or exacerbate preexisting ones (Pedrelli, Nyer, Yeung, Zulauf, & Wilens, 2015).

Both academically and socially, college presents a significant challenge to psychological well-

being. Anxiety, depression, stress, eating disorders, and substance abuse are among the most

common concerns with regards to the mental health of college students (Winerman, 2017).

However, many students struggle to find adequate treatment for their mental health concerns due

to stigma and lack of accessibility. Recently, mental health problems among college students

have become increasingly prevalent, with 88% of counseling center directors reporting an

increase in “severe” psychological problems in the past five years (Pedrelli et al., 2015)

Yet this increase in demand has not triggered an increase in mental health personnel on

college campuses. The International Association of Counseling Services recommends that every

college have at minimum one trained professional for every 1,000 to 1,500 students; however,

the average university has only one trained professional for every 1,737 students (Reilly, 2018).

97% of schools who responded to a 2017 survey reported long waitlists when seeking treatment,

with wait times ranging anywhere from a few days to more than a month. Even if students are

lucky enough to get an appointment, only 24% of campus mental health services offer assistance

outside of regular business hours, making them unreachable for students in emergencies
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(National Council on Disability, 2017). Furthermore, more than half of colleges and universities

have a maximum number of sessions before referring students to off-campus treatment (National

Council on Disability, 2017). However, off-campus treatment is even more inaccessible due to

financial and transportation constraints, and some college towns are so small that there are no

existing psychological services close by.

Many colleges have made an effort in recent years to improve access to mental health

resources on campus, but most schools struggle with budget limitations and can do very little to

improve the overall quality of treatment. In a survey, the NCD found that the most commonly

reported obstacle to providing inadequate mental healthcare on campus was a lack of federal,

state, and college funding (National Council on Disability, 2017). In an attempt to solve the

problem, a number of schools have diverted more resources to rapid-access services, which are

typically more short-term services such as walk-in appointments and crisis treatment. However,

long-term services consequently decreased when more resources were devoted to short-term

treatment, which prevents students from receiving ongoing care to ensure that their mental health

stays in check.

When left untreated, students’ symptoms of anxiety, depression, and bipolar disorder

only worsen. As a result, students who are mentally ill experience lower GPAs and higher

dropout rates than their peers, making them less unsuccessful in the long run. Colleges

experience a loss of revenue when students drop out, and similarly, the earning potential of

society declines as well. Depression and anxiety can be overwhelming; many students report

having trouble functioning, which only hinders their academic success. Four of the top five

“substantial obstacles to academic success,” as reported by students, are sleep difficulties, stress,

anxiety, and depression (Douce & Keeling, 2014). These symptoms can lead to destructive
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behaviors such as substance abuse, eating disorders, and self-harm, all of which are problems of

their own on college campuses. More urgently, suicide is the second leading cause of death

among college students, and is especially common among those who do not receive treatment for

mental illness. According to a 2018 study, one in every five college students becomes stressed to

the point of considering suicide (Reinberg, 2018). If schools continue to underprovide mental

health services to their students, this phenomenon will continue to persist into the future, which

will have severe implications for society. When left untreated, crippling mental health disabilities

cause a tremendous decline in potential earnings, labeled in economic terms as a deadweight

loss.

In California, a coalition of county governments known as the California Mental Health

Services Authority (CalMHSA), has taken steps to improve mental health services on college

campuses. Funding for CalMHSA was voted on and passed by county constituents in the Mental

Health Services Act. According to their estimates, the net societal benefit to California from

higher graduation rates could be as much as $56 million, of which the state government would

receive $8.5 million in tax revenue (Stein et al., 2016). Furthermore, for every dollar invested in

student mental health programs, society would receive a net benefit of $6.49. Successful

initiatives – such as those of CalMHSA – can serve as a model for governments who are

interested in investing in the betterment of mental health care on college campuses. These data

show that providing an adequate level of mental healthcare to students can provide immense

benefit to society; likewise, not doing so fails to realize these gains, creating a deadweight loss.

Goals

College campuses have an obligation to meet objective standards of care for their

students. This includes preventative programs and diagnostic treatment, both short-term and
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long-term, that are comprehensive and easily accessible. In order to do so, colleges and

universities must have enough funding and personnel to meet student demand. As such, schools

should look for ways in which mental health services might be underprovided on their campuses.

Identifying the problem and taking steps to rectify it is the only way to truly address the

inefficiency and inequity caused by the college mental health epidemic.

Ultimately, achieving academic equity between mentally ill students and their peers is

desirable. Furthermore, restoring efficiency in the market for mental health services on campus is

also a priority. There is much to be gained from ensuring that all college students have access to

comprehensive mental health care, given the inherent stressors of early adulthood and higher

education. Ideally, mental health services on campus will be easily identifiable and accessible by

all students, and only weakly (if at all) affected by time or personnel constraints. In addition, on-

campus services will provide students with the tools they need to manage symptoms associated

with mental illness to ensure their academic success. To combat the onset of mental illness

during early adulthood, colleges will also enact prevention initiatives, such as those targeted

towards substance abuse and sexual assault, that at the very least outline practices that students

can undertake to cope with stressors before they become overwhelming.

Role for Government

Economically, the mental health epidemic poses a threat to universities and society as a

whole. As stated previously, mental illness can affect student productivity, often causing lower

GPAs and higher dropout rates than their peers. In turn, higher dropout rates among students

who struggle with mental health problems result in lost revenue and lower earning potential. The

unrealized gains from market transactions create a deadweight loss for both the university and
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society more generally. The Pareto inefficiency of the market and the inequity between the

mentally ill and their peers illustrates a need for government intervention.

Intervening in the market

for student mental health services

is in the interest of universities

and governments alike.

Governments should enact

policies to increase funding for

campus mental health services to

increase student retention and

lifetime earnings, as well as

university and income tax

revenue. Government funding

would provide universities with

the finances they need to meet the

growing demand for mental health

services, allowing them to hire

more personnel and offer long-term care to their students. On average, if a counseling center

treats 500 students, 30 drop-outs can be avoided, resulting in gains of $1.2 million in tuition and

$3 million in lifetime earnings. In comparison, the cost of providing such care would total

$500,000 (Eisenberg, Golberstein, & Hunt, 2009). The figure to the left illustrates the economic

and social value of campus mental health services.

Criteria and Alternatives

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To ameliorate the inequities and inefficiencies caused by the underprovision of mental

health services on college campuses, state and federal governments alike must take action to

better provide the public good. Ultimately, colleges and universities lack the financial and

personnel resources necessary to sufficiently provide this good to their students, illustrating a

clear need for government funds.

There are a number of existing policies that pertain to the provision and funding of

mental health services. The implementation of such policies fall under the authority of the

Substance Abuse and Mental Health Services Administration (SAMHSA), a division of the U.S.

Department of Health and Human Services. In 2004, Congress passed the Garrett Lee Smith

Memorial Act (GLSMA) with the goal of raising awareness about suicide prevention in college.

GLSMA allocates funds to a number of states and college campuses to establish suicide

awareness and prevention programs. However, the purview of GLSMA is relatively small and

has not been adjusted to accommodate the rising demand for college mental health services.

Similarly, the 21st Century Cures Act, passed in 2016, outlines reforms to mental health

infrastructure and provides financial assistance to programs around the country (Carroll, 2016).

Unfortunately, the Trump administration has proposed significant reductions to HHS funding in

the federal budget, which would undercut SAMHSA’s ability to financially support the

expansion of mental health infrastructure nationwide (Office of Budget (OB), 2017).

Policy tools to address the lack of campus mental health resources include government

financing, taxes and subsidies, and regulation. The alternatives can be evaluated according to a

number of criteria, including but not limited to effectiveness, equity, and political feasibility.

Government Financing
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Since healthcare can often be classified as a public good, it is imperative that the

government intervene to ensure that it is provided efficiently. Given that the government

maintains a monopoly on violence, it is the only body that possesses the authority to enforce

laws and regulations. It is clear that allowing individual colleges and universities to provide

mental health services has been unsuccessful, so it is up to the government to bear the burden of

financing these services. Although the government has already assumed some of this

responsibility through policies such as GLSMA and the 21st Century Cures Act, these policies do

not finance the good at the level necessary to address rising demand. Expanding these policies is

essential for providing colleges and universities with the necessary assistance to adequately

provide these services to their students.

The 21st Century Cures Act allows for the allocation of grant funds to institutions of

higher education to be used for a number of purposes, including the hiring of personnel,

prevention and treatment services, and education programs (National Council on Disability,

2017). Section 9031 of the law authorizes $7 million to be appropriated each fiscal year for such

purposes (Bonamici, 2016). Respectfully, it is absurd to conclude that $7 million is enough to

address the college mental health crisis. Given the extent of the problem, a much higher

appropriation is necessary to make a real difference. Thus, Congress should reauthorize the act to

fully finance Section 9031 to assist institutions of higher education in addressing student demand

for mental health services.

The prevalence of suicide among college students is alarming and requires immediate

attention, and, as such, Congress should also increase funding for GLSMA and its affiliated

campus suicide prevention program. The Garrett Lee Smith Campus Suicide Prevention grant

program provides grants to improve campus services and implement awareness and prevention
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programs for suicide and mental health disorders. Despite the passage of GLSMA in 2004 and its

subsequent reauthorization in the years since, suicide rates among college students have only

continued to increase, indicating that GLSMA has not been as effective as some might have

hoped.

In order to maximize the effectiveness of government financing, the progress of GLSMA

and the 21st Century Cures Act under the supervision of SAMHSA must be transparent and

easily observable. Both GLSMA and the 21st Century Cures Act ought to include some

mechanism for observing their effectiveness to ensure that they have the intended effect,

something that they both currently lack.

Furthermore, the distribution of funds under GLSMA and the 21st Century Cures Act

must be equitable, accounting for disparities in the socioeconomic statuses of colleges and their

students. The financial status of colleges and universities varies due to factors such as location

and classification (i.e. public vs private). As such, the financial status of their students varies as

well. Any financial assistance that the government provides must take into account these

differences, specifically targeting schools who, comparatively, lack financial capital and

represent a relatively poorer student body.

Taxes and Subsidies

Taxes and subsidies can be particularly effective in adjusting the market for mental health

services. The government ought to subsidize awareness and prevention programs on campus in

order to realize the full social benefit of improved mental healthcare. Currently, financial

assistance from the government is contingent upon colleges and universities establishing

substance abuse programs on campus. This requirement should be similarly applied to mental

health programs so as to incentivize colleges to provide adequate treatment to their students.

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Furthermore, the 21st Century Cures Act subsidizes education and training programs for

mental health-related careers to address the nationwide personnel shortage (Carroll, 2016). These

grants provide accredited institutions with an incentive to build up their programs and increase

the output of trained mental health professionals in the workforce. This provision has the

necessary implication of producing more labor in the mental health sector to hopefully allow

colleges and universities to meet student needs. However, this solution is not as equitable

because it fails to address the financial barriers that prevent less privileged students from

attending schools that offer such programs. Even if the number of schools who provide these

programs were to increase, there would still be a significant efficiency gap given the inevitable

number of individuals who might want to pursue the program, but simply cannot afford to do so.

Though taxes might be especially useful for generating revenue to fund college mental

health programs, they are less politically feasible given their unattractiveness to the general

population. Similarly, the government cannot provide subsidies if it does not have the revenue to

fund them. Unfortunately, voters would likely object to any tax increase, making it potentially

toxic for any politician to vote in support of them.

Regulation

Regulating campus mental health infrastructure can improve services for students. To

address the lack of mental health professionals on college campuses, SAMHSA should issue a

regulation requiring college campuses to meet the APA’s recommendation of, at minimum, one

trained mental health professional for every 1,500 students. If implemented, this regulation could

increase the supply of mental health services by ensuring that campus health center have enough

staff to accommodate student needs. However, this regulation would need to be easily observed

and enforced in order to be completely effective. If the regulation lacks an enforcement

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mechanism, schools could shirk their responsibility to fully staff their programs knowing that

they would not be punished for doing so.

In addition, SAMHSA ought to require colleges and universities who apply for grants to

outline in detail the programs and policies they intend to implement if they were to receive the

funds. Priority should be given to those with a demonstrated ability to understand and address the

needs of their students (i.e., those with some preexisting mental health infrastructure). These

requirements will induce some degree of competitiveness in the market, ensuring that those who

do receive grants have pure intentions and will use the funds effectively.

Regulation can also alleviate the inequities caused by mental health disorders in college

students. Many students who struggle with substance abuse or other mental health disorders are

forced to take a lighter course load in order to maintain their psychological well-being, which

can result in the loss of financial aid for lower-income students. The Department of Education

should adjust financial aid requirements to allow for course underloading under psychological

circumstances. Additionally, disability-related expenses are not taken into account when

determining financial aid status under the FAFSA (National Council on Disability, 2017). This

means that they are not receiving enough financial assistance to adequately offset the cost of

seeking mental healthcare and being a full-time student, placing them at a disadvantage relative

to their wealthier counterparts. The FAFSA must be modified in order to rectify these inequities

and provide sufficient financial assistance to low-income students with mental health disabilities.

Despite the fact that regulation is incredibly effective, it is perhaps the least politically

feasible of all possible alternatives. “Hard” regulation is seen by many as a government

overreach and infringement of individual liberty, and one would be hard-pressed to find a

legislature that would support it. Furthermore, the degree to which regulation would have to be
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softened in order for it to be politically feasible is such that doing so would significantly harm its

effectiveness – so much so that it would no longer be a viable alternative.

Recommendations and Conclusions

When evaluating the three alternatives under the criteria of effectiveness, equity, and

political feasibility, it becomes easier to identify which alternative to undertake. The table below

outlines the possible alternatives and indicates the degree to which they satisfy the given criteria.

Effectiveness Equity Political Feasibility

Government High Medium High
Financing
Taxes and Subsidies Medium Low Medium

Regulation High High Low

To decide which alternative is best, one can also look to places where one or more of

these alternatives have been successful. California is a good example of a state who has enacted

policies to address the issue of underprovided mental health services on college campuses

(National Council on Disability, 2017). In addition to the creation of CalMHSA, the California

legislature passed a law that requires college campuses to meet APA recommendations for

mental health personnel (Mello, 2018). Furthermore, California has increased funds for

community colleges, whose mental health resources tend to be especially lacking, often because

they are located in rural areas where healthcare providers are few and far between. California

also has a robust source of funding for the state and local provision of mental healthcare, given

the 1 percent tax on incomes of more than $1 million a year that was approved by voters in 2004

(Mello, 2018). Given the success of government financing in California, it seems likely that such

an approach would have similar success if it were implemented elsewhere.

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Ultimately, government financing will likely be the most effective alternative for solving

the problem. Government financing is more politically feasible than taxing and regulation, which

tend to evoke more hostile attitudes from voters and politicians. There is clear justification for

government intervention in the market for campus mental health services given the inefficiencies

and inequities caused by the underprovision of the good.

It is clear that the mental health epidemic among college students is concerning,

especially given the rising demand for mental health services in recent years. Financial and

personnel constraints have rendered colleges unable to respond to the needs of their students,

which has created a number of inequities and inefficiencies for students and society as a whole.

Government intervention is necessary in order to rectify the severe underprovision of mental

healthcare to college students and allow the market to equilibrate once more.
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References

Bonamici, S. (2016, December 13). H.R.34 - 114th Congress (2015-2016): 21st Century Cures

Act [webpage]. Retrieved November 18, 2018, from

https://www.congress.gov/bill/114th-congress/house-bill/34

Carroll, H. (2016, December). 21st Century Cures Act. Retrieved November 18, 2018, from

https://www.treatmentadvocacycenter.org/fixing-the-system/21st-century-cures-act

Douce, L. A., & Keeling, R. P. (2014, October). A Strategic Primer on College Mental Health.

American Psychological Association. Retrieved from

http://www.apa.org/news/press/releases/2014/10/college-mental-health.aspx

Eisenberg, D., Golberstein, E., & Hunt, J. (2009). Mental Health and Academic Success in

College. B.E. Journal of Economic Analysis and Policy, 9(1).

Mello, F. (2018, April 25). A push for mental health care at colleges: Depression and anxiety

“really eat up our kids.” Retrieved November 19, 2018, from

https://calmatters.org/articles/a-push-for-mental-health-care-at-colleges-depression-and-

anxiety-really-eat-up-our-kids/

National Council on Disability. (2017). Mental Health on College Campuses: Investments,

Accommodations Needed to Address Student Needs (pp. 1–132). Washington, D.C.

Retrieved from https://ncd.gov/publications/2017/mental-health-college-campuses-

investments-accommodations-needed-address-student

Office of Budget (OB), A. S. for F. R. (ASFR). (2017, May 19). FY 2018 Budget in Brief -

SAMHSA [Text]. Retrieved November 18, 2018, from

https://www.hhs.gov/about/budget/fy2018/budget-in-brief/samhsa/index.html
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Pedrelli, P., Nyer, M., Yeung, A., Zulauf, C., & Wilens, T. (2015). College Students: Mental

Health Problems and Treatment Considerations. Academic Psychiatry : The Journal of

the American Association of Directors of Psychiatric Residency Training and the

Association for Academic Psychiatry, 39(5), 503–511. https://doi.org/10.1007/s40596-

014-0205-9

Reilly, K. (2018, March 19). Anxiety and Depression: More College Students Seeking Help |

Time. Retrieved October 6, 2018, from http://time.com/5190291/anxiety-depression-

college-university-students/

Reinberg, S. (2018, September 10). 1 in 5 college students so stressed they consider suicide.

Retrieved October 8, 2018, from https://www.cbsnews.com/news/1-in-5-college-

students-so-stressed-they-consider-suicide/

Stein, B. D., Sontag-Padilla, L., Ashwood, J. S., Woodbridge, M. W., Eberhart, N. K., May, L.,

… Burnam, M. A. (2016). Campus Climate Matters (Product Page). RAND Corporation.

Retrieved from https://www.rand.org/pubs/research_briefs/RB9904.html

Winerman, L. (2017, September). By the numbers: Stress on campus. Retrieved October 6, 2018,

from http://www.apa.org/monitor/2017/09/numbers.aspx