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When do College Students Seek Mental Health Services?
Hanifah1
Asteria Devy Kumalasari1
Nadhira Meindy1
Authors Info & Affiliations
Abstract
Background:
As mental health problems have become more prevalent among college students, mental health services utilization needs to improve.
Objective:
This study aims to explore in what state of mental health problems students start to seek professional help by registering for a mental health service and explore the types of problems that trigger their help-seeking behavior.
Methods:
This study is a cross-sectional study. A total of 801 students registered as clients at the college's mental health service (649 women and 152 men) filled out the Beck Depression Inventory (BDI-II) questionnaire to measure students’ levels of depression. The severity of mental health symptoms was assessed from their level of depression. Data were analyzed using descriptive statistics, t-tests, and ANOVA tests.
Results:
The findings demonstrated that most college students registering at the mental health service had moderate (31.2%) and severe (32.5%) levels of depression symptoms. The most common causes of their problems were emotional (35.8%), followed by academic (12.4%), negative thinking (11.2%), and relationship problems (10.4%). No differences were found in severity level between the male and female students [t(799)=0.841, p=0.4].
Conclusion:
This study reports that college students tend to delay seeking psychological help through mental health services until they have moderate to severe mental health symptoms.
1. INTRODUCTION
Considering mental health, college students are one of the vulnerable groups as they often experience mental health problems [1]. The data from National College Health Assessment by American College Health Association reported that in the United States, the prevalence of mental health problems in college students has significantly risen in the last few years. The depression rate has increased by 34%, while anxiety has risen by 24% from 2011-2018 [2]. This phenomenon occurs worldwide as other countries, such as South Africa [3], Norway [4], Canada [5], and China [6], also report similar findings. Furthermore, the COVID-19 pandemic also contributes to the increase in mental health problems among college students [7-9]. The high prevalence of mental health problems is also evident in Indonesia. Previous research found that 76.9% of college students were indicated to have mental health problems [10]. Another research further reported that the most common mental health problems experienced by college students are anxiety (95.4%) and depression (88%) [11]. From 2016 and 2019 in South Africa, the prevalence of “moderate-severe depression” increased year over year, from 14.44% to 31.66% [3]. Among British college students, depression was detected in up to 37.2% of girls and 16.7% of males [12]. It has been determined that 28.4% of Chinese college students experience depression [13]. A study that combined research from 20 low- and middle-income nations discovered that 24.4% of college students exhibited depressive symptoms [14]. Depression has been recognized as one of the most common mental health problems in college students and is also associated with many aspects of college students’ life, such as academic performance, risk of college dropout, anxiety, physical illness, addiction, and risk of suicide [15]. Thus, the measurement of depression symptoms could represent the state of mental health problems that are endured by college students, as used in various prior studies [16, 17].
The increasing mental health problems need to be addressed by proper mental health services utilization. Seeking professional help through mental health services is an important step toward proper assessment, diagnosis, and undergoing intervention for mental health problems [18]. However, some studies suggest that only 8-38% of students experiencing a significant mental health problem seek professional help [19]. Most college students tried to solve their problems by consulting people considered to have experienced the same issues and dealt with them successfully [11]. For instance, they talk to their peers [20], partners, or families [21]. The students experiencing mental health problems also tried to solve their problems independently by researching them online, suppressing them or forgetting their problems [11, 21].
The experience of higher symptoms of mental health problems correlates with the intention to seek help from mental health services [19]. Some studies further suggest that a more severe and longer duration of mental health problems is related to a lower intention to seek help from mental health services [6]. Considering the different results of previous studies, we would like to explore the condition of college students’ mental health problems and their relationship to the intention to seek help from mental health services, especially in Indonesia. We hypothesize that college students will only seek psychological help from mental health services when experiencing severe mental health symptoms, given their propensity to manage their own problems or ask those around them for aid. Therefore, the aims of this study are 1) to explore in what state of mental health problems students started to seek professional help by registering for mental health services and 2) to explore the types of problems behind their help-seeking behavior through mental health services.
2. MATERIALS AND METHODS
2.1. Participants
This study was a cross-sectional study. This study has been approved by the Ethics Committee of Universitas Padjadjaran with registration number 985/UN6.KEP/EC/2021. Participants in this study were students registered at the Mental Health Service of a public university in Indonesia. The willingness to participate in the study was asked when the potential participants filled out registration forms to schedule counseling meetings. The participants in this study were students aged 18 years old or above, who filled out the consent forms and the online questionnaires. A total of 831 students were recruited to participate in the survey, but only 801 students filled out the survey completely.
2.2. Procedures
The online survey of 801 participants was conducted from March to May, 2021. An existing and validated scale to measure the depression level of the students was employed in this study. The screening process was conducted by using a questionnaire distributed during the registration process. An explanation of the survey procedure, risks, and benefits was given to the participants before deciding to participate in the study. The participants willing to participate in the survey provided their consent online on the informed consent page of the survey and then were directed to complete a socio-demographic form and a self-administered questionnaire written on Google Forms.
2.3. Survey Instrument
A standard socio-demographic form was used to collect self-report data on gender, faculty, and school year. The Beck Depression Inventory-II (BDI-II), developed in 1996 by Dr. Aaron T. Beck, is a 21-item multiple-choice self-report inventory used to measure the severity of depression [22]. The 21-item self-administered questionnaire is scored on a scale of 0-3 in a list of four statements arranged in increasing severity about a particular symptom of depression. The Indonesian version of BDI-II showed good construct validity and internal consistency. The test-retest reliability was acceptable [23]. Based on this study, the receiver operating characteristic (ROC) curve indicated that the cut-off point of the Indonesian BDI-II for a mild severity of depression in the Indonesian population should be 17. A total score of 0–10 is considered minimal range, 11-16 is mild, 17-20 is a cut-off score for clinical depression, 21–30 is moderate, 31–40 is severe, and above 40 is extreme depression. Higher scores indicated higher depression levels in the participants. Some questions regarding the types of problems were also asked.
2.4. Data Analysis
Data were analyzed using SPSS (Statistical Package for the Social Sciences) version 24 (IBM Corp, 2018). Descriptive statistics were used to describe the demographic characteristics of the participants and the BDI-II scores. The total score of BDI-II was categorized into six categories, namely ‘The Ups and Downs Considered Normal’, ‘Mild Mood Disturbance’, ‘Borderline Clinical Depression’, ‘Moderate Depression’, ‘Severe Depression’, and ‘Extreme Depression’. Associations between demographic variables and the BDI-II scores were analyzed by the t-tests for the categorical variables, namely gender and type of problems reported by students. To investigate the difference in BDI-II scores among different sociodemographic factors, the depression level among the participants was compared using a t-test and one-way analysis of variance (ANOVA). A p-value of < 0.05 in the statistical analysis was considered statistically significant.
Table 1.
| Depression Level | Mean (SD) | Frequency | Percentage |
|---|---|---|---|
| The Ups and Downs Considered Normal | 5.95 (2.6) | 22 | 2.7% |
| Mild Mood Disturbance | 13.8 (1.75) | 60 | 7.5% |
| Borderline Clinical Depression | 18.5 (1.12) | 68 | 8.5% |
| Moderate Depression | 25.6 (2.92) | 250 | 31.2% |
| Severe Depression | 35.15 (2.84) | 260 | 32.5% |
| Extreme Depression | 46.95 (11.02) | 141 | 17.6% |
| Type of Problems | Frequency | Percentage |
|---|---|---|
| Emotional problem | 287 | 35.8% |
| Academic problem | 99 | 12.4% |
| Negative thinking | 90 | 11.2% |
| Relationship problem | 83 | 10.4% |
| Suicidal thinking/self-injury | 77 | 9.6% |
| Physical symptoms | 66 | 8.2% |
| Sleeping problem | 42 | 5.2% |
| Stress | 35 | 4.4% |
| Others | 22 | 2.7% |
3. RESULTS
3.1. Demographic Characteristics
A total of 801 students (649 female and 152 male) completed the survey. Most participants (50.7%) were 20 years old (M = 20.3, SD = 1.9). All of the participants were undergraduate students.
3.2. Students’ Depression Levels
The average level of depression of the students was 30.45, with the lowest score of 1 and the highest score of 62. The average score of 30.45 indicates that the level of depression was severe. Based on Table 1, the majority of students were at the level of severe depression (32.5%), followed by moderate levels of depression (31.2%).
3.3. Types of Problems
Table 2 shows the students’ common concerns encouraging them to visit the university’s mental health service. The top three problems that urge students to seek help from mental health services are emotional problems (35.8%), academic problems (12.4%), and negative thinking (11.2%). The emotional problems include difficulty in controlling emotions, feeling sad, angry, empty, anxious, depressed, and easily worried. Procrastination, difficulty in working on the final project, demotivation towards academic matters, and confusion about choosing a future career are categorized into academic problems. Problems related to negative thinking are overthinking, rumination, and being unmotivated. Relationship problems are conflict with family, difficulty establishing friendships, and issues with boyfriend or girlfriend. Suicidal thoughts, suicide attempts, self-harm, and the desire to end life are categorized into the suicidal thinking/self-injury category. Physical symptoms experienced by students were headache, fatigue, nausea, and palpitations. Students also reported difficulty initiating sleep, waking up during sleep, and difficulty falling back asleep. Some of them stated they were stressed out.
3.4. Students’ Depression Levels Based on Gender and Type of Problems
This study found no significant difference between male and female students’ BDI scores [t(799) = 0.841, p = 0.4]. The study also found no difference in depression scores based on the types of problems reported by students seeking psychological assistance at the university’s mental health service [F(8,792) = 1.182, p = 0.307].
4. DISCUSSION
This study aimed to explore in what state of mental health problems students started to seek psychological help by registering for mental health services. Consistent with the previous studies, the findings showed that most college students start seeking psychological help through mental health services when they are at moderate to severe levels of depression. College students seeking help from mental health services reported significantly high symptoms of depression, longer and more episodes of depression, higher symptoms of anxiety, and high levels of total stress [19, 24-26], while lower severity of psychological symptoms tended to be addressed with informal help and self-help strategies. As the severity rises, the intention to find informal help tends to decrease [27]. The notion also relates to the tendency to seek online mental health services, where college students who have sought help through online mental health services reported higher psychological distress [28]. Higher levels of distress were found to be related to a lower relationship between help-seeking stigma and help-seeking behavior. Higher levels of distress lead college students to perceive help-seeking behavior as a more personal experience and lower their stigma of seeking help from mental health services [29]. The study also found that students usually consider seeking help through mental health services as the “final step.” College students with depressive symptoms would try to cope privately, and if their coping strategies have been perceived as ineffective, they will try to seek help from mental health services [30]. Besides, college students usually delay seeking psychological help until they perceive severe symptoms, which impact their studies [31]. The decision to seek help through mental health services could also correlate with students’ ability to recognize their problems. A previous study found that mental health or depression literacy could enhance problem recognition. Once college students recognize the problems and symptoms of mental problems, they would evaluate strategies that could help them, including mental health services utilization [32]. Higher literacy about mental health problems decreases the probability of seeking informal help [26], while lack of mental health literacy and perceived benefits of therapy could be one of the factors influencing delay in seeking psychological help [27, 33].
This study finds no differences in levels of depression symptoms between men and women, but the result might be influenced by the fact that more women registered for mental health services than men. This result is different from several previous studies reporting that women have a higher level of psychological symptoms than men [19, 28]. Nevertheless, the fact that more female students registered at the mental health service may indicate that women tend to be more willing to seek psychological help. Whereas men tend to be more reluctant to seek psychological help, including through mental health services [34].
This study also aimed to explore the types of problems behind students’ help-seeking behavior through mental health services. This study demonstrated that most college students seek help from mental health services with emotional problems as the main concern, followed by academic problems, negative thinking, and relationship problems. The first three categories are related to college students’ relationships within themselves or intrapersonal problems, and the fourth category is relationships with people around them or interpersonal problems. This result confirmed the findings of a previous study suggesting intrapersonal and interpersonal problems as the key variables impacting a wide range of mental health symptoms in college students [19]. This result is also consistent with the findings of another study in Indonesia, which found that more than 90% of college students have problems related to their daily academic and relationship challenges, as well as problems with emotional and stress management [11]. This study found that emotional problems are the most common category experienced by college students who seek help from mental health services. This category relates to difficulties regarding emotion and emotion regulation. Research has found that lower emotional competence is related to low intentions to seek help from professionals [35]. As the main problem experienced by college students, it is possible that college students tend to delay seeking help through mental health services because of their lack of emotional competence.
This study found that college students tend to seek psychological help through the university’s mental health service when they are at moderate to severe levels of depression. Mental health literacy or mental health promotion on a university scale should be conducted to help college students identify and recognize their problems. Mental health services and professional psychological benefits could also be promoted to encourage college students to examine the benefits of psychological help. An initiative from universities to conduct a wide-scale screening could also identify college students that might need help but have not sought psychological help early.
Furthermore, the WHO’s model of formal and informal help from Brown (2018) suggests that both formal and informal help are helpful for students. Based on their adapted model, students with low to moderate levels of mental health problems could get benefits from informal but structured help. University’s mental health services could help students to do self-help, build peer support, and coordinate with lecturers or faculty to build the university’s support [36]. This model of college mental health service tends to be effective since college students can initially seek informal help when they face a mental health problem [11]. This model also helps mental health services to give service effectively and avoid overcapacity. University’s mental health services should make sure that their students can utilize informal help and access formal help whenever necessary.
The findings of this study provide us insight into the mental health condition of college students’ tendency to seek help from mental health services. There are several limitations to this study. First, the data collected in this study was part of the screening tools of the mental health service. Therefore, they tend to provide limited factors contributing to more exploration of college students’ help-seeking behavior, such as barriers to treatment and whether they have sought help from a professional before. Second, this study only included college students who registered themselves with the mental health service. Therefore, this study cannot provide a comparison between college students who seek and do not seek help from mental health services. A follow-up study should be conducted to explore more about other factors, such as perceived benefits, perceived barriers, and cues to registering at the mental health service, which can endorse psychological help-seeking other than symptom severity. Moreover, further study could also explore the coping strategies that college students apply, and individuals consulted for informal help before seeking formal help by registering at mental health services.
CONCLUSION
This study concluded that college students registering at the mental health service are in moderate to severe levels of depression symptoms. The main problems that lead them to seek help from mental health services are problems related to intrapersonal and interpersonal problems, such as academic problems, emotional problems, negative thinking, and relationship with others. This study found no differences in severity levels between male and female college students. This study suggested that the mental health literacy of college students should be improved to increase awareness of students’ mental health conditions and encourage students to seek psychological help as soon as possible. The university should conduct wide-scale screening to identify college students that would need help and organize a holistic system to help college students’ mental health.
LIST OF ABBREVIATIONS
| ROC | = Receiver Operating Characteristic |
| ANOVA | = One-way Analysis Of Variance |
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
This study has been approved by the Ethics Committee of Universitas Padjadjaran with registration number 985/UN6.KEP/EC/2021.
HUMAN AND ANIMAL RIGHTS
No animals were used in the studies that are the basis of this research. All human procedures followed were in accordance with the guidelines of the Helsinki Declaration of 1975.
CONSENT FOR PUBLICATION
Informed consent has been obtained from all participants.
AVAILABILITY OF DATA AND MATERIALS
All the data and supportive information are provided within the article.
STANDARDS OF REPORTING
STROBE guidelines were followed.
FUNDING
None.
CONFLICT OF INTEREST
The authors declare no conflict of interest, financial or otherwise.
ACKNOWLEDGEMENTS
The authors would like to thank the Board of Mental Health Service at Universitas Padjadjaran for their help in the data-collecting process.
