The challenges and mental health issues of academic trainees

Introduction

In this review paper, we discuss the complex issues facing academic trainees and use many abbreviations summarized in Table 1 (references 1–14). Today, the pressure faced by university students at all levels may be greater than it has ever been in the past 25 years¹⁵. Increasing financial stressors since the 2007 recession are affecting undergraduates and graduates alike^15–18. Students are increasingly concerned with getting a high-status job and earning a high income, and are consequently taking their academics more seriously^15,19–21, resulting in increased feelings of academic pressure as early as high school^15,19. This increased cultural focus on academia is reflected by the fast-paced growth in the number of PhD trainees, which is now outpacing the growth rate of the academic employment market²². As their numbers increase, graduate students face greater competition for a tightening pool of academic jobs, funding resources and mentorship^16,23,24. These raised stakes underscore the pre-existing stresses and high competition inherent to academic culture²⁵, resulting in intensely stressful conditions²⁶. Thus, it is unsurprising that students have been repeatedly found to have worse overall mental health compared to the general population, characterized by elevated rates of depression, distress and other mental illnesses^27–31.

Several studies have posited that the prevalence and severity of university student psychological issues is on the rise according to counselling centres, self-reported mental health data and symptom severity scales^3,32,33, though the validity of these findings has been debated^34,35. Still, even though the exact trends in psychopathology are difficult to verify due to confounding factors, mental health is increasingly being recognized as an important issue. The Cooperative Institutional Research Program at Higher Education Research Institute (CIRP) of the University of California at Los Angeles found that, for incoming freshmen, “student self-rating of emotional health was at an all-time low and feeling overwhelmed in high school had been increasing” in 2011¹⁵. In tandem with recent social movements to reduce stigma around mental illness and promote awareness, many universities are now trying to incorporate wellness into the student experience. This review will discuss some of the literature relevant to a variety of student mental health issues and some of the proposed solutions therein. Abbreviations used in this review can be found in Table 1.

Are student mental health issues increasing in prevalence and complexity?

There is growing evidence suggesting that the prevalence and/or severity of university mental health issues has been increasing over the past half-century. Summarized in Table 2, this section will discuss some of this evidence, as well as its criticisms. Firstly, as discussed in the Introduction, the CIRP at the University of California, Los Angeles, asserted that freshman self-reported mental health is at an all-time low for the past 25 years, as a direct result of increasing economic pressures¹⁵. The study found that this deterioration in self-reported mental health coincides with an increase in student loan use and a decrease in financial independence due to decreasing job opportunities.

Twenge et al.³³ performed a cross-temporal meta-analysis of self-reported student mental health between 1938 and 2007. The authors chose to do a cross-temporal analysis to avoid the issue of response bias which results from people with depression not living as long as the average population. They also controlled for each generation’s propensity to lie and corrected their answers on psychopathology scales, adjusting for newer generations being more open to answering the survey honestly. Their assessment of mental health via the Minnesota Multiphasic Personality Inventory found that mental health worsened in each generation, including increased anxiety, depression, and dissatisfaction. These authors attribute this worsening to increased materialism and ambition. They comment that such ambition may be unrealistic, leading to eventual depression, and also that these goals may not be as fulfilling finding “meaning” in life and building interpersonal relationships.

Gallagher, in his National Survey of College Counselling Centers, reports that 94% of American college counselling centre directors agree that there is a continuously increasing number of students with severe psychological problems³⁶. Almost 90% of directors reported an increase in anxiety disorders over the past 5 years, while 58% reported an increase in clinical depression. It is also worth noting that 69% “reported an increase in crises requiring immediate response”, such as a student with a suicidal ideation.

It is entirely possible that this increase in students seeking counselling is due to the reduction of social stigma around mental health. Hunt and Eisenberg³⁵ explore this possibility and find that this increased prevalence in reported problems does coincide with increases in help-seeking behaviour, but that it is possible that mental illness severity is indeed increasing in tandem.

Benton et al.³ performed an analysis of the severity and frequency of the problems presented to campus therapists between 1988 and 2001, using the Case Descriptor List, a report filed by the therapist at the end of the client’s case. They found a threefold increase in suicidal tendencies, a twofold increase in depression, and a fourfold increase in issues stemming from sexual assault, concluding that not only the prevalence, but also the severity, of student mental health problems were on the rise. Until 1994, relationship issues were the most common reason for seeking counselling, but thereafter, depression and anxiety took its place. However, they acknowledged that several studies using client self-report data or “objective” measurement scales (i.e. not dependent on the report of the client or psychologist) consistently find no such increase. This raises the possibility that, for unknown reasons, therapists perceive an increase in student issues that is not reflected by self-reports or other attempts based on objective measurements.

In fact, based on this possibility, there is a body of work disputing the claim that student mental health issues are increasing at all. Sharkin disputes the validity of using counselling practitioners’ perceptions as evidence for an increase in mental health issues³⁷. He also offers a critique on the aforementioned Benton study, firstly on the basis of its methods of measuring distress, which he feels are too vague to produce conclusive results, and secondly on its potential sampling bias, since it only examined students already receiving counselling³⁴. However, it is important to note that Benton et al. did find a likely-genuine increase in students seeking counselling for career-planning issues. The authors believe this increase to be objectively genuine (rather than an artefact of therapists’ perceptions) because the number of students seeking vocational counselling decreased upon the establishment of a career-development centre at the studied university, but then increased again later³. This increase in career concerns is consistent with that described by the CIRP¹⁵, Twenge et al.³³, and Bishop¹⁹.

Costello and colleagues found no difference in depression levels for young persons over a 30-year span in a review of 26 studies, although cohorts were not specific to university students³⁸.

Strepparava and colleagues performed a 5-year study of Italian students receiving counselling, but they did not find an increase in mental health issue severity or prevalence³⁹. However, 5 years is a very short timeframe for assessing overarching trends in mental health issues³⁷.

Cornish et al.⁴⁰ studied university students over a 6–8 year span and found no significant increase in mental health problems, and Berger et al.⁴¹ and Franke et al.⁴², actually found a decrease in mental health issue severity over time. However, the latter two authors were both studying German students, and attribute the decrease to positive changes in academic conditions that are specific to Germany only (for example, massive reduction in tuition). Furr et al. also found that depression rates decreased from 81% to 53% between 1987 and 2001⁴³. Pledge et al. acknowledge a large body of works that have found increases in mental health issues up to the 1980s, but the authors themselves did not find any difference between 1989 and 1995. They hypothesize that mental health issues may have been increasing until the 1980s, but thereafter began to plateau⁴⁴. Finally, in a systematic review of 24 studies, Ibrahim and colleagues found no trend of increasing prevalence of mental health problems between 1990 and 2010²⁷.

Thus, the trend in student mental health issue prevalence is a controversial topic. While the above studies may not be reflective of a true increase in mental health issue prevalence among students, they reflect the importance of well-staffed and well-resourced university counselling centres and reveal that mental health and wellness are increasingly becoming important to students and universities.

Depression

Rates of depression reported among students vary greatly, depending on factors such as symptom scale, demographics and time period, as summarized in Table 3. This section will discuss various reports and contextualize their findings. The American College Health Association National College Health Assessment (ACHA NCHA) Fall 2018⁴⁵ reported that 17.3% of respondents (a mixed sample of about three quarters undergraduates and one quarter graduates) had accessed professional services for depression in the past 12 months.

Systematic literature reviews have found massive ranges of depression incidence among students: Ibrahim et al. found a global range of 10-84.5% among undergraduates²⁷ and Alfaris et al. found 8–70%⁴⁶ among Saudi Arabian health science students specifically. These ranges include the extremes of the most well-to-do universities in rich regions, to highly competitive conditions in impoverished regions. The weighted mean global rate of depression found by Ibrahim et al. was 30.6% ,which is closer to the following studies discussed in this review (though the mean for non-medical students only was slightly higher, 35.6%).

Independent studies surveying student symptoms using the PHQ-9 (Patient Health Questionnaire 9) for depression reported 13.8%⁴⁷, 17.3%¹⁷, 15.4%⁴⁸, and 7.9%⁴⁹ among American, and in the last case, Australian, students. A well-known 2007 study on Emory University undergraduate students found the highest depression rates among the PHQ-9 studies included in this paper; they reported that 29.6% of the respondents had mild depression, 30.6% had moderate depression and 6.6% had severe depression⁵⁰. A study using the CES-D (Centre for Epidemiologic Studies depression) scale found 14.5% for the rate of students with severe depression and an additional 19% with mild depression symptoms, totalling to 33.5% of students having any form of depression⁵¹. Using the DASS-42 (Depression, Anxiety and Stress) scale, Bayram and Bilgel found a rate of 27.1% for depression among Turkish university students⁵². When Goldberg’s Anxiety and Depression scale was used in a Spanish study, a much higher rate was found—55.6%⁵³. Boujut et al. report, in a review of French literature, depression rates of about 30%, with 6% of students suffering from a major depressive episode. In their own study on university freshmen, they reported that 18% scored as moderately-to-severely depressed using the BDI (Beck Depression Inventory)²⁰.

Many studies have also examined the prevalence of general feelings of depression or sadness among students, rather than depressive symptoms on a clinical scale. In a study on Australian first-year undergraduates, Hussain et al. found that 21.3% reported feeling “often/always unhappy”, and 9% often/always felt they had nothing to look forward to. However, this study also found that only 8% of first-year students had a diagnosis of either anxiety or depression⁵⁴. It is worth noting that this study was performed in a rural area, so perhaps such settings have lower rates of mental health diagnoses for a number of possible reasons, including lower access to mental health services. Similarly, a UK study reported that 32% of undergraduate students felt “often or always” down/depressed in the past 4 weeks⁵⁵. An American study found that 53% of students reported feelings of depression since having started college, but “depression” here was not given a standard definition by the authors but rather left up to the interpretation of the individual respondent. It is also worth noting that grades were the most common reason cited by students for their depressive feelings⁴³.

Anxiety

The ACHA NCHA Fall 2018 survey reports that 22.1% of a mixed student sample (about three quarters undergraduates and one quarter graduates) had been seen by a professional for diagnosed anxiety in the past 12 months⁴⁵. In total, 62.3% reported having felt “overwhelming anxiety” in the past year, with 29.5% having felt that way in the past 2 weeks alone. The lowest rates of anxiety discussed in this paper were found by Zivin and colleagues, using the PHQ-9 (GAD-7) diagnosis scale: they reported rates of approximately 4%⁵⁶, 9.8%¹⁷ and 5–7%⁴⁸. Interestingly, an Australian study using GAD-7, the extended and updated version of the PHQ-9, found a significantly higher rate of 17.5%. The authors explain that this rate may be higher than that found by papers such as Zivin et al’s because the extended and thorough nature of the GAD-7 makes it a more sensitive tool for detecting anxiety than the PHQ-9. Since this rate is much closer to that of students found to have been professionally diagnosed with anxiety by the AHCA NCHA, it is likely that the GAD-7 can identify students that the PHQ-9 would miss⁴⁹.

Higher rates were found using other scales: two papers, one using the Goldberg’s Anxiety and Depression scale and one using the DASS-42 scale, both found rates of 47%^52,53. Please see Table 4 for a summary of anxiety rates among students.

Other mental health concerns

Some literature does not specifically test for depression or anxiety but rather addresses the prevalence of general mental health concerns among subjects, as summarized in Table 5. In a selection of UK student surveys, 10–20% report having a mental health issue^55,57–59. In a 2010 study of Australian undergraduates, 19.2% qualified as at-risk for a serious mental illness according to the K10 (Kessler) scale, and a further 64.7% show sub syndromic symptoms that classify them as at-risk of a mild/moderate mental illness. In a comparative age-matched sample of the general population, only 3% classified as at-risk for a serious mental illness, supporting the conclusion that students have significantly higher rates of mental distress compared to the general population³¹.

Using the PHQ-9 and SCOFF eating disorder scale, Zivin et al. measured student mental health at the beginning and end of a two-year period. They found that, at either given time point, 35% of students had some probable mental health issue (depression, suicidal thoughts, self-harm, anxiety, or an eating disorder)⁴⁸. A very similar result was found by Bruffaerts et al., who measured freshman mental health with the WMH-ICS (World Mental Health International College Student) survey and found a prevalence rate of 34.9%⁶⁰.

Many other studies also examine the prevalence of elevated or clinically significant distress among students. A brief review by Marcotte and Lévesque reports a range of 21–31% among European literature²⁵. Two additional studies included in the present review have found rates that are in-line with this range using the GHQ-12 questionnaire: 19% among Hungarian health students⁶¹, and 30% among Canadian undergraduates²⁹. Much higher rates were reported by studies using measures other than the GHQ-12, except for one that used the DASS-42 scale and found a rate of 27%⁵². Bernaras and colleagues reported that 47.4–62.8% of students were above the clinical cut-off in various measures of distress using the CORE-OM (Clinical Outcomes in Routine Evaluation-Outcome Measure) scale⁵.

Rosenthal and Wilson reported an even higher prevalence of 83% for “moderate-to-severe” distress among undergraduates, using the Dysphoria Domain of the Trauma Symptom Inventory and Psychological Distress Scale, although only 9% of participants were classified as having clinically significant levels⁶². Finally, Hyun and colleagues reported that 44–45% of graduate students at University of California Berkeley self-reported a significant emotional or stress-related mental health concern^63,64.

Suicidality and self-Injury

Suicidality can be classified into consideration, ideation, plans and attempt. Table 6 provides an overview of the discussed studies. Some studies that have made an effort to distinguish serious thoughts from ideation include Eisenberg et al.’s¹⁷ and Garlow et al.’s⁵⁰, which reported 6.3% and about 10% of students had such thoughts within the year the study was performed. Furthermore, Garlow also found that 19.2% of the 10% group were currently suicidal at the time of the study. Overall, 16.5% of the entire student population reported either a suicide attempt or non-suicidal self-injury incident at any point in their lives. They found that 12% of participants had reported a suicidal ideation in the past 12 months⁴⁵, 4.2% reported ideation currently often or always⁵⁴, and 8.5% reported it since starting college⁴³.

According to the ACHA NCHA, 2% of undergraduates have attempted suicide in the past 12 months⁴⁵. Boujut et al. reported a range of 9–15% for suicidal ideation and 3–10% for suicide attempts among students²⁰. In total, 4.3% of French freshmen reported having suicide plans. Hussain and colleagues further reported that 3.7% of first years surveyed had thoughts of self-harm (often or always), and that the percentage of students who had attempted self-harm at some point in their lives were 17% female and 11% male⁵⁴. For undergraduates, the rate of self-harm was 8.5% and the rate of suicide attempts was 2% in the past 12 months⁴⁵. For pure-graduate groups, the non-suicidal self-injury (NSSI) rate was 7.3% in the past 4 weeks⁶⁶.

Graduate students and post-doctorate challenges

Graduate students face additional academic pressures, having to juggle a myriad of responsibilities, such as attending courses, managing their projects and writing papers. Many graduate students feel unsure about their future career paths and are afraid that they will not find a permanent position in academia⁶⁷. Surveys find that graduate students’ greatest concerns are their work-life balance, career security and success, financial security, and general uncertainty about their professional path^68,69.

As mentioned in the introduction, academic positions and funding are becoming increasingly more competitive^23,24. The Organization for Economic Co-operation and Development reported that in the last 20 years, the number of young PhDs has doubled and academic positions did not keep pace with this rapid growth^22,70–73. A 2014 report by the National Science Foundation found that employment across the science and engineering fields was the lowest in the past 15 years. For fields outside of science and engineering, employment was at the lowest in the past 20 years⁷³. An American study from 2014 estimated that, in engineering, there are only enough academic positions for 12.8% of PhD graduates⁷¹. Meanwhile, a Physics World article, using data from the Institute of Physics, estimated that just 1.7% of the UK postdocs in physics would go on to an academic position⁷⁴.

Graduate education is widely seen as a secure path to a high-status job, but in reality about a third of graduates do not even believe that their PhD significantly improves their job prospects⁶⁸. Many are afraid that they will not be able to find a job at the end of their studies, and this stress has been found to contribute to depressive feelings among graduate students⁷⁵.

This increasing competition is also affecting grant funding: a report in the magazine Nature found that funding has not been increasing in pace with the growing number of PhDs. Major grant providers, such as the NIH and the European Research Council, now award grants to less than 20% of applicants, most of whom will be older scientists with more established careers rather than young investigators.

American funding success rates have more than halved since 1980⁶⁷. A graduate student survey found that 50% of North American PhD trainees felt surprised by how difficult it was to secure funding⁶⁷. The increased scarcity of funding and research resources is likely contributing to trainee mental health issues^23,30.

This high competition is usually explained by academia’s emphasis on overwork. Especially in the sciences, academia has created a culture that venerates the idea of voluntary self-sacrifice for the collective advancement of humanity^76,77. As a result, there is a persistent expectation on graduate students and young researchers in general, to overwork themselves^{24,30,78–82}. Many academics “see suffering as a badge of honour”, as University of Derby Psychotherapist Gareth Hughes explains in an interview with Nature⁷⁸. For many graduate students and other early-career researchers, it is not out of the ordinary to work 60-80 hours a week^79,81,83, or at least be expected to^84,85. One study on graduate students of economics, natural sciences and engineering found that about 55% work 41-60 hours per week, and approximately another 25% work 61-80 hours per week. According to this study, the majority of graduate students work far past the 9-5 hours expected in most jobs⁸⁶. As Evans et al. put it “work-life balance is hard to attain in a culture where it is frowned upon to leave the laboratory before the sun goes down”³⁰. Meanwhile, many graduate students struggle to make ends meet on their stipends alone, despite their long work hours^69,87. The veneration of suffering in academia makes it difficult for graduate students to recognize their distress as a valid mental health issue rather than just the hardship expected in higher education⁸⁸.

Consequently, several studies report that graduate students experience elevated stress levels, even compared to undergraduate students. The Gradresources survey found that 37% of graduate students experienced “more stress than they can handle” as a direct result of their studies, with a total of 45% reporting more stress than they can handle in general. A 2015 University of Arizona study found that 73% of graduate students reported greater than average stress, with 23% describing their stress level as “tremendous”⁸⁹. In one survey of PhD students, 62% reported worrying about their work even when they were not currently working⁸⁶. The ACHA NCHA found that 61.4% of graduate students report greater than average stress, compared to 57% of undergraduates⁴⁵.

Studies comparing graduate student mental health to the general population’s found them to be at greater than two-to-six times the risk of depression and anxiety compared to the general population^23,30,86. Specifically, Evans and colleagues found, using the PHQ-9 and GAD-7 scales, that graduate students experienced depression and anxiety at rates of 41% and 39%, respectively. Comparatively, they reported rates of 6% for the general population in other GAD-7 studies³⁰. Of course, the comparison studies are chosen on the basis of using the same measurement scale as the primary study, even though they may have been performed under different conditions. For example, the Evans study has been criticized for using a German sample as comparison rather than an American survey⁸⁴. Levecque and colleagues²³ performed a thorough analysis of Flemish PhD student mental health as compared to control groups from other highly educated demographics (those in the general population, those who are employed, and those who are higher education students obtaining a degree other than PhD) using the 12-symptom scale General Health Questionnaire (GHQ-12). They found that PhD students were roughly 1.5-4 times at the risk of experiencing each of the 12 symptoms of anxiety/depression, compared to the three other groups. Further, 32% of PhD students reported four or more symptoms, which classifies them as being at serious risk of developing depression and other common mental illnesses.

Barreira et al. reported that 18% of graduate students in economics, natural sciences and engineering scored at or above 10 on the PHQ-9 scale for exhibiting symptoms of moderate-to-severe depression and anxiety. This score corresponds to severity to such a degree that the symptoms would likely garner a formal diagnosis from a professional, according to the authors. They compare these rates to those for the age-matched general population, which were found in other studies to be 5.6% for depression and about 3.5% for anxiety⁸⁶. Thus, graduate students were found to be 3–5 times more likely than the general population to experience moderate-to-severe depressive and anxious symptoms.

A brief review⁹⁰ of seven studies on graduate student mental health showed a range of 43-44.7% for experiencing emotional/stress-related problems, including symptoms of depression. The one exception to this rule was the Gloria & Steinhardt study⁹¹ which found a depression rate of only 29% but that 58% classified as “languishing”. One study featured in the review is a 2014 UC Berkeley study that employed the CES-D scale. It found that 47% of PhD students and 37% of Masters students scored within the clinical depression range⁷⁵. These are similar to the results found by Evans et al., and not significantly higher than the percent of students at risk of mental illness found by Levecque et al. This study also corroborates Levecque et al.’s finding that higher education students outside of PhD programs, including Masters students, have slightly lower rates of mental illness relative to PhDs.

Another particularly informative study was conducted by Garcia-Williams, Moffit, and Kaslow. It found that more than 50% of the graduate sample reported feelings of anxiety and 95.4% reported “feeling nervous or worrying a lot” within the past 4 weeks. Also, within the past 4 weeks, 34.4% scored moderate-or-higher levels of depression on the PHQ-9, and 44.4% felt hopeless. Most strikingly, 7.3% reported suicidal ideation, 2.3% reported forming suicide plans, and 1.7% had committed NSSI within the past 4 weeks⁶⁶. For comparison, the ACHA NCHA found an NSSI rate of 3.2% in the past 12 months among graduate students⁴⁵. Information from this section is gathered in Table 7.

Do graduate students struggle more than undergraduate students?

Despite the extra responsibilities and pressures faced by graduate students, there is evidence that their mental health is slightly-to-significantly better than that of undergraduates^66,92. For example, the ACHA NCHA found that graduates had slightly lower rates of diagnosed depression (14.8% vs 17.3% in undergraduates) and anxiety (19.5% vs 22.8% in undergraduates)⁴⁵. Also, the ACHA NCHA graduate reference group showed lower rates of feelings of depression (32.9% having felt “too depressed to function” in past 12 months, 28.4% “experienced depression” in past 12 months ), anxiety (60.5% having felt “overwhelming anxiety” in past 12 months, 16.6% in past 2 weeks), NSSI (3.3%), suicide attempts (0.3% in past 12 months) compared to those in the undergraduate reference group (42.8% and 32.9% for depression, 63% and 31% for anxiety, 8.5% for NSSI and 2% for suicide attempt, all in respective order)⁴⁵.

In contrast, the ACHA NCHA did find a slightly higher rate of suicidal ideation (past 12 months) among graduates (12.7% versus 12%), and other studies have also found that graduate students may have higher suicidality than undergraduates⁶⁶. Meanwhile, Eisenberg and colleagues also found slightly lower rates of mental health issues among graduate students; with a prevalence rate of 11.3%, they were 2.5 percentage points less likely to suffer from depression than undergraduates, and almost 10% less likely to suffer from anxiety (3.8% versus 4.1%)⁵⁶. In Gallagher and Taylor’s report, 80% of the 125 student suicides reported in 2014 were carried out by undergraduates⁹³. Most conclusively, Wyatt and Oswalt directly compared undergraduate and graduate mental health and found that undergraduates are significantly worse-off in that regard⁹².

These effects may be a result of the contradicting forces of increased pressure and of selection bias: graduate students face more adult responsibilities and higher academic pressure. However, in order to get into graduate school in the first place, students must be able to meet a high standard of academic functioning. It is likely that the slightly lower rates of mental illness among graduates reported by some studies are due to such selection bias. Students with severe mental health issues are less likely to be able to continue to graduate school.

Medical and health studies students

It has been suggested that medical students and other health science trainees have particularly high rates of mental distress^25,46,84. For example, a Swedish study using the MDI (Major Depression Inventory) found that medical students have a depression rate of 12.9%⁷⁶, more than 1.5x the prevalence they found in the general population (7.8%)⁹⁴. As a result, there is an abundance of mental health studies focussing on these disciplines specifically. A review of global literature, performed by Puthran et al., concluded that 28% of medical students worldwide could be classified as clinically depressed⁹⁵. Notably, this study did not find a significant difference in depression prevalence between medical and non-medical students. Meanwhile, a review on Saudi Arabian health science student mental health by Alfaris and colleagues found a weighted average of 47%, calculated from a range of results between 8–70%⁴⁶. However, this result may not be representative of those in North America. For example, the authors explain that the lowest end of the range (8%) was from an American study, whereas the highest end (70%) was from a Pakistani study. Finally, the global review of literature by Ibrahim and colleagues actually found a lower prevalence of depression in medical students: 25.6% (calculated from a range of 10.3–59%), compared with 35.6% for non-medical students (calculated from a range of 10–84.5%)²⁷. The authors note that this is contrary to expectation and suggest the explanation that medical students are perhaps better at recognizing their own mental health issues and reaching out for help. It is also possible that selection bias plays a role in this finding as well.

Turning to American studies, a study of Illinois pharmacy school students found that, on the PHQ-9 scale, 31.9% registered as having mild depression, 16.9% as having moderate depression, 2.4% as having moderate-severe depression, and 1.2% as having severe depression. The study also noted that pharmacy students were twice as likely as the general population to report experiencing a depressive symptom⁷⁹. Dyrbye et al. measured burnout among medical students and found a prevalence of 49.6–52.8% using the Maslach Burnout Inventory^96,97. More strikingly, the prevalence they found for suicidal ideation was 11.2% over the past 12 months, though they calculated that, if all non-respondents were assumed to experience no ideation, the lowest possible prevalence was 5.8%. When respondents were asked instead if they had ever considered suicide at any point in their lives, the prevalence rose to just over a quarter. Wallin and Runeson, in another Swedish study, found even higher rates of suicidal ideation: 33% and 44% for students in their first and final years, respectively⁹⁸.

Dyrbye and colleagues also compiled evidence for and against the claim that medical students experience elevated distress and rates of depression and anxiety compared to the general population. They conclude that the vast majority of studies with upper-year medical students found that they do indeed experience significantly poorer mental health than the general population²⁸. This is summarized in Table 8.

Who is most at risk?

Out of the studies included in this review, those that measured gender differences almost unanimously found that women are at higher risk for certain mental illnesses, such as major depression and anxiety, distress, self-harm, and/or suicidal ideation. One such study of the different trends between male and female undergraduate mental illness, Conley and colleagues speculate that males are more likely to avoid dealing with their emotions (avoidant coping), whereas females are more likely to try to acknowledge their feelings and try to deal with them. While avoidant coping is generally not considered healthy, it has not been conclusively linked to greater psychopathology in males and it could potentially be a better strategy for dealing with the stresses of university. The study suggests that female students’ tendency to focus on their feelings in an attempt to remedy them may actually be exacerbating their distress⁹⁹. Interestingly, this finding of increasing distress over time among females, but not males, was also found in a separate study on Canadian medical students. In this study, male students started the semester with elevated distress (one standard deviation above the general population average), whereas females started with average distress which increased to the elevated level (one standard deviation above the general population average) by the end of the semester¹⁰⁰.

This higher propensity for distress may be somehow correlated with the finding that females have higher financial strain and insecurity. The Wisconsin-HOPE Lab found that females were 9 percentage points more food-insecure compared to males¹⁰¹. Stallman’s study found that females were slightly more likely to report “frequent financial stress” and “constant financial stress”, and less likely to report “no financial stress” as compared to males³¹. However, the author does not comment upon whether these differences are statistically significant. More conclusively, a UK study by the National Union of Students reported that females are 1.5 times more likely to worry frequently about finances, compared to males¹⁰³.

Additionally, the Global Young Academy found that women had a slightly more pessimistic view of their career prospects, giving lower estimates of their chances to become a professor or land an academic or teaching position. Overall, women gave their career prospects an average rating of 0.1 lower than males, on a scale of 1-5. Also, women were more likely to report lack of support from superiors (50.6% versus 41.2%) and job rationalization (21.3% versus 13.1%), as well as gender discrimination (17.1% versus 4.6%), as obstacles to their career¹⁰⁴. However, the authors warn that an existing sampling bias due to overrepresentation of women in the survey was not corrected, so these values should not be viewed as conclusive.

While male students have lower psychological distress than female students, they comprise a much larger portion of student suicides³⁵. For example, in his 2014 survey of university counselling centres across America, Gallagher reported that 70% of that year’s student suicide victims were male¹⁰⁵. The UK Office for National Statistics reported that male higher-education students are almost three times as likely to commit suicide as females¹⁰⁶. This is consistent with the general population: while females are more likely to have suicidal ideation and/or attempt suicide, males are much more likely to actually end their lives¹⁰⁷. This could in part be due to differences in chosen method: males are twice as likely to use a firearm, whereas females are three times as likely to attempt to poison themselves¹⁰⁷. Also, Bernaras and colleagues found that men were at a higher risk of doing “actual harm” to either themselves or others⁵.

Besides sex differences in the preferred method of suicide, another reason for the higher suicide rate among males is that they are less likely to access mental health services or partake in wellness practices, perceiving a higher stigma around discussing personal problems and seeking professional help^27,108. Gallagher’s 2010 National Survey of University Counselling Centres found that just 35% of student-counselling clients are male¹⁰⁵. Bernaras and colleagues even cited this discomfort with disclosing personal issues as an explanation for the gender differences many studies have found in rates of psychological distress and related symptoms. Perhaps this gap is due in part to the fact that women are more likely to openly and honestly report their mental health issues and symptoms on surveys⁵. Also, Conley and colleagues reported that male students typically have less social support than females⁹⁹, which may be another factor that discourages them from reaching out to seek help. Finally, studies on undergraduates report that females are significantly more prone to eating disorders^54,99, whereas males are more prone to binge drinking^54,109.

Studies including a racial component also found that racial minority students are at higher risk of distress and other mental health issues. Smith et al. found that minority students exhibited worse mental health than white students, even at universities that had a high concentration of students from ethnic minorities¹⁰⁹. Eisenberg and colleagues found that white students were less likely to screen positive for major depression on the PHQ-9, compared to any other race, with students identifying as “other race” having the highest likelihood^17,47. They also found that students identifying as multi-racial were more likely to experience major depression, suicidal ideation, and NSSI¹⁷. This evidence points to the possibility that students who do not easily fall into a single socially defined racial category experience additional stress. Richardson et al. corroborated claims that minority students experience poorer mental health, but interestingly, they found white students to be at higher risk of alcohol dependence than black and Asian students¹¹⁰. Notably, Dyrbye et al.’s review of North American medical students revealed no link between ethnicity and mental health²⁸. It is possible that medical students have a higher socioeconomic status overall and therefore medical students from an ethnic minority do not experience more economic challenges than white medical students. Students of colour, especially black students, are less likely to seek mental health services compared to white students^62,111–113. Moreover, minority students may experience additional race-related stress, in the form of MEES (mundane extreme environmental stress, also called “microaggressions”), isolation, and stereotype threat^12,111.

According to the HOPE Lab, minority students were at a higher risk of food and housing insecurity compared to white students, with the exception of Asian students, who were at the lowest risk out of all the racial categories¹⁰¹. Native American students were at the highest risk for food insecurity (55%), housing insecurity (69%), and homelessness (19%), followed by black students (54%, 55%, and 13%, respectively), and “mixed/other” students (50%, 52%, and 17%). Hispanic students were at a slightly lower risk (47%, 51%, and 10%), followed by Middle Eastern/Arab students (43%, 49%, and 12%). White students had the second-lowest risks (37%, 42%, and 11%), followed by Asian students, who had the lowest risks across the board (36%, 37%, and 7%). Native American and “mixed/other” students experienced the highest prevalence of homelessness¹⁰¹. The elevated risk of homelessness for “mixed/other” students may correlate with their higher risk of psychological distress. In the same vein, the CIRP reports that in America, students at historically black colleges and universities report higher levels of financial insecurity, with one in five students unsure of whether they had the financial means to complete their degree¹⁵.

It is likely that the link between ethnicity and socioeconomic status plays some role in the increased prevalence of mental health issues among minority students. Socioeconomic status has been linked to worse mental health^35,114,115, reduced access to mental health services, and reduced wellness behaviour^35,108. Eisenberg and colleagues found that even growing up in a lower- socioeconomic-status household predicted worse mental health in students⁴⁷. In fact, a NUS Insight survey reports that 36% of students report that they worry about finances so much that it affects their mental health¹⁰³. A British study found that self-reported financial stress and debt were strongly correlated to worse overall mental health, including depression, anxiety, stress and alcohol abuse. Interestingly, though, this study did not find that family affluence could predict mental health issues, in contrast to the findings by Eisenberg et al.¹¹⁰. Cuéllar and Roberts, therefore, argue that studies exploring the link between racial identity and mental health should also control for the mediating effect of socioeconomic status. In their analysis of survey responses gathered from Latino students, they found that socioeconomic status plays a much more significant role in poor mental health compared to ethnic identity¹¹⁴.

Interestingly, in a study of 1,773 undergraduates across four socioeconomic status groups, Rosenthal and Wilson found no disparities in mental health service utilization between sexes, socioeconomic status groups, or ethnicities⁶². The authors note that this is contradictory to the prevailing assumptions about service use disparity, but they stress that there are no identifiable errors or statistical anomalies that could have erroneously led to these results.

As may be expected, LGBTQ+ students face additional challenges, unique to their identity. There is evidence that homosexual students experience poorer mental health and higher suicidality compared to heterosexual students^111,116 with bisexual students especially at risk. Kerr, Santurri & Peters found female bisexual students to be 3.1 times as likely to report a depression diagnosis, twice as likely to report anxious and depressive symptoms, and almost five times as likely to report suicidality and self-harm, compared to heterosexual female students. Lesbian students were twice as likely to report a depression diagnosis, five times as likely to report self-harm, and about four times more likely to report suicidality, compared to heterosexual female students. Bisexual women were overall significantly more likely to report depressive and anxious symptoms and suicidality compared to lesbian and heterosexual women¹¹⁶. Meanwhile, Liu and colleagues reported that bisexual students were 1.5 times more likely to report a mental health diagnosis or suicidality than homosexual students, and 3.9 times more likely compared to heterosexual students. Furthermore, they report that over half had experienced suicidal ideation and a quarter had made attempts on their lives¹¹¹. Eisenberg and colleagues also found that bisexual students were at particular risk of experiencing depression⁴⁷.

As before, this comes with a significantly increased risk of housing and food insecurity: homosexual students had greater risk than heterosexual students, and bisexual students had the highest risk of all. Bisexual students were about 10–15 percentage points more likely to report food and housing insecurity and homelessness compared to heterosexual students, and 5–7 percentage points more likely than homosexual students¹⁰¹.

Not just students from sexual-orientation minority experience additional distress and needs insecurity, but also students from a gender-identity minority as well. A study of transgender and non- binary students found that 85% reported a mental health issue, with 25% explicitly relating to the challenges of being a gender-identity minority to their poor mental health. Many trans/non-binary students are reluctant to access mental health services due to the risk of landing a transphobic or ignorant counsellor. Slightly more than 25% of respondents described their previous counselling experiences as ambivalent or non-affirming towards trans/non-binary issues¹¹⁷. The obstacles facing gender minorities who need to access mental health services are particularly concerning in light of the fact that they are at much higher risk for mental illness^30,111,117. Evans and colleagues found that transgender students were 12-21 percentage points more likely to report anxiety compared to cisgender males and females respectively, and 16-22 points more likely to report depression³⁰. Liu and colleagues reported that transgender students were 1.9-2.4 times as likely to report mental health issues and suicidality compared to cisgender students. They have a much higher rate of distress compared even to bisexual students, with two-thirds experiencing suicidal ideation and one-third having made an attempt¹¹¹. It is additionally concerning that some studies have reported an increase in the prevalence of transphobic bullying at universities¹¹⁸.

A report on LGBTQ+ scientists in the physical sciences may be indicative of some of the factors at play in LGBTQ+ students’ mental health challenges: 18% of LGBTQ+ scientists, and in particular, 32% of non-binary scientists, reported being the target of discriminatory behaviour at their workplace¹¹⁹.

What stops students from getting help?

While great progress has recently been made in dismantling the stigma around mental health issues, stigma is likely still a primary obstacle standing between many students and the help they need¹¹⁹. Hussain et al. interviewed some of the first-year subjects in their study and concluded that stigma is still a concern among students who are considering seeking help. Students mentioned feeling that seeking help might be embarrassing, as they would appear unable to handle academic and social stresses. The authors further suggest that students in rural/small-town settings may feel that there is a higher social risk to seeking help, due to the reduced privacy/anonymity of such settings⁵⁴.

Similarly, Eisenberg, Golberstein, and Gollust investigated the most common reasons that students who need help do not seek it. In total, 20% cited worrying about what others will think of them if they were in mental health treatment, 10% feared that it would somehow go onto their academic record and 9% feared that their parents would find out. Besides stigma, 32% reported simply lacking the time to seek help, and 8% lacked the finances. A total of 32% thought they would just get better by themselves over time, which may indicate a need for better awareness about the seriousness of mental health issues. It is also noteworthy that 51% said they felt that stress was just a regular part of school, though only 45% indicated that they felt they had no need for mental healthcare. A possible interpretation is that the 51% recognized they had more stress than they could handle, but thought it would be inappropriate to seek help for distressed caused by “normal/mundane” problems such as school¹¹³.

Interestingly, Eisenberg and colleagues also found that students’ own internalized stigma of mental illness is a bigger obstacle to seeking help than their perception of public stigma. In comparing students’ own internalized stigma with their perception of public stigma, Eisenberg found large disparities, pointing to the possibilities that students either have an inflated sense of public stigma or are under-reporting their own internalized stigma¹²⁰. The review by Storrie, Ahern, and Tuckett compiles evidence that the vast majority of students with emotional problems and/or severe distress are not receiving treatment and attributes stigma as a key reason¹²¹.

In Gallagher’s report, only 13% of people who had completed suicide had received counselling¹⁰⁵, though this may be a case of selection bias: students in treatment would be less likely to resort to suicide. In another study on the persistence of student mental health problems, less than half of the students who had a persistent mental health problem over the two-year span of the study received help within that duration⁴⁸. In Barreira et al.’s study of PhD students, only 27% of students with depression and 21% of students with anxiety were in treatment. Although this could simply reflect oversensitivity of the survey’s screening instruments, only 27% of students who self-reported suicidal thoughts were in treatment, which indicates that a majority of students with mood disorders are not receiving treatment⁸⁶. Similar numbers were reported by Garlow et al., who found that 84% of students with suicidal ideation and 85% of students who screened as moderately-severely-to-severely depressed on the PHQ-9 were also not receiving treatment⁵⁰. According to Hunt and Eisenberg³⁵, similar rates of treatment among mentally ill students (less than 25%) were also reported by Blanco et al.¹²², though they also noted that this low rate of treatment is not significantly different from the rate among non-students. There is evidence suggesting that men experience greater stigma around mental illness and are therefore particularly unlikely to seek help¹²³. This also seems to be case for Asian and Latino students¹²⁰.

Factors that could contribute to mental health concerns

Wellness

Wellness is a broad concept that endorses a holistic view of health, wherein physical mental, and emotional well-being are equally important. It embraces self-care, stress-relief and management, healthy emotional coping, mindfulness, and reaching out for help when necessary. As such, it emphatically promotes mental-health awareness and stigma reduction, and, more broadly, cultivation of good mental/emotional framework for coping with stress and grievances in a healthy manner¹⁴⁴. A key tenet of wellness is the value of prevention over treatment¹⁴⁵. Prevention is achieved by prioritizing an individual’s well-being, being aware of one’s health needs and adapting one’s lifestyle accordingly.

Focussing on staying healthy and being aware of signs of illness, whether physical or mental, is a more productive approach to health as opposed to waiting until after one is already sick. Physical wellness include exercising and eating well, emotional wellness can include building a social support group and implementing healthy coping strategies, and mental wellness can include mindfulness activities and counselling, if necessary. Wellness may have been considered unimportant, or even a distraction from work, in the past, but cultural attitudes are shifting, as evidence amasses showing that employee happiness is key to maximizing productivity^146,147.

Several studies have assessed the effectiveness of wellness practices such as meditation, mindfulness, counselling and mindful physical exercise. Conley, Durlak, and Dickson performed an analysis of 83 studies to assess the effectiveness of mental health promotion and prevention programs in higher education. Their review confirms the effectiveness of wellness programs in alleviating depressive and anxious symptoms and highlights cognitive behavioural therapy and mindfulness as the two most effective wellness strategies. The study further concluded that supervised, skill-oriented, class-format wellness programs are the most effective¹⁴⁸. In their own experiment with a wellness seminar for first- year students, Conley and colleagues once again found that attendance and engagement with the wellness program are key to seeing improvements. Participants who regularly attended wellness seminars and practiced the skills they were taught showed better psychosocial and academic adjustment and better stress management¹⁴⁹.

In another such review, Fernandez and colleagues examined the effectiveness of university mental health promotion and intervention programs, as well as the qualitative validity of the studies being analysed. The topic of the studies analysed varied greatly, so it is difficult to generalize their results here. However, their assessment of the program efficacy, combined with validity considerations, had an overall mixed tone. For example, a 1984 University of Illinois policy mandating students with suicidal ideation to receive four therapy sessions appeared to reduce suicides by 72%, but oddly, graduate/professional student suicides rose by 94.6% following this policy¹⁵⁰. A Chinese study on the impacts of a “youth development” wellness course reported that it was effective in increasing positive and hopeful feelings, but Fernandez and colleagues deemed the study to be of questionable credibility due to its lack of detail¹⁵¹. A third study found that subjecting medical students to a stress-management lecture reduced their stress by 46.7%, but again, it was deemed of low-credibility due to its lack of control group. Also, many other studies included did not find that such programs had any significant positive impacts. One repeated finding among studies in the review that did seem conclusive, however, was the impact of grading systems on student health: grading systems with fewer increments seemed to reduce stress, depression, and anxiety¹⁵¹.

Universities are trying a variety of approaches to improve student mental health. For example, a few studies have explored the possibility of using tai-chi to foster wellness among students. One such study found no significant effects on mental health¹⁵², but another study found that tai chi chuan significantly decreased anxiety and improved sleep quality among young adults¹⁵³. In fact, a systematic review of the impact of tai chi on higher-education student mental health concluded that it is an effective method of reducing anxious and depressive symptoms among students¹⁵⁴. As mentioned earlier, mindfulness has been a hot topic in student wellness discussions. Vidic & Cherup reported that mindfulness relaxation was so effective among a sample of college students, that the test group went from higher stress than the control group to lower stress¹⁵⁵.

In a review of empirical mindfulness studies, Keng, Smoski, & Robins analyse a growing body of credible evidence that general mindfulness practices have a positive impact of mental health¹⁵⁶.

However, the two university-sample studies in the review have conflicting findings: Bluth et al. found that mindfulness can uplift bad mood in students¹⁵⁷, whereas Kuehner, Huffziger & Liebsch did not find any significant impact^158,159. The authors explain that this may be due to differences in sample or in methodology¹⁵⁶. Cook recommends the usage of cognitive behavioural therapy and wellness courses to alleviate student mental distress, based on evidence supporting their effectiveness¹¹⁹. Cook references Brown & Schiraldi, who found cognitive behavioural therapy to be significantly more effective in stress-reduction than a conventional stress-management course among students. Similarly, Kitzrow compiles evidence on the positive impact of counselling on both student mental health and academic performance³².

Combining the wellness principles of mindfulness and exercise, Caldwell et al. studied the benefits of mindfulness established through movement-based courses for university students. They reported that that such courses were successful in reducing negative arousal and the prevalence of insomnia, but mood changes were only statistically significant through the mediating factor of mindfulness: students who showed an increase in mindfulness (via the Five Facet Mindfulness Questionnaire) also showed an increase in positive feelings, relaxation, self-regulatory efficacy, and sleep quality, and a decrease in perceived stress¹⁵⁴. Finally, this paper also includes recommendations from papers and articles on policy and attitude changes that can hopefully make academia a more welcoming and less stressful environment. For convenience, these are presented in Table 9.

Conclusions

As shown in this review, there is a plethora of studies covering various aspects of student mental health, using diverse measurement tools and consequently, finding a very broad range of prevalence. Even among two studies using the same measurement tool, the reported prevalence of mental illness may differ significantly, depending on what level of symptom severity the authors choose as the cut-off.

Continuing to refine and standardize measurement tools seems necessary. Given the numerous strains and concerns specific to students and trainees in academia, it would seem appropriate that studies should view student wellness within the context of these challenges and continue assessing student mental health in comparison to that of the general population. Such comparisons illustrate whether student-specific challenges contribute to poor mental health, and therefore direct the approach of student wellness initiatives. For example, student wellness initiatives can guide students to deal with student-specific challenges or recommend changes to mitigate these challenges at the institutional level, rather than simply directing students to mental health counselling. Of course, as indicated by even the lower end of the prevalence ranges in this review, ensuring that university mental health counselling is well-staffed, well-resourced and well-educated is paramount to student well-being. This review merely recommends that student mental health be viewed within the context of student-specific challenges and that institutions and institutionalized counselling focus on helping students to deal with these issues.

Data availability

No data is associated with this article.