Psychiatric Symptoms and Diagnoses Among U.S. College Students: A Comparison by Race and Ethnicity
Abstract
Objective:
The mental health challenges of college students are a critical public health concern, and they may be exacerbated among racial and ethnic minority groups. Unfortunately, there is a lack of recent large-scale research on this topic. This study provides an update on the mental health experiences of U.S. college students from minority backgrounds.
Methods:
This is a retrospective analysis of cross-sectional data from the spring 2015 administration of the American College Health Association–National College Health Assessment (ACHA-NCHA IIB). Survey results from 67,308 undergraduates at 108 colleges were analyzed.
Results:
Past-year rates of self-reported psychiatric symptoms and diagnoses were high, regardless of race or ethnicity. Students from minority groups generally reported lower rates of both symptoms and diagnoses compared with whites, with notable exceptions. Despite reporting generally lower rates of psychiatric diagnoses compared with whites, students who identified as multiracial (N=7,473) or Asian/Pacific Islander (N=7,166) were more likely to endorse having felt hopeless, so depressed that it was difficult to function, or overwhelmed by anger and were more likely to have considered or attempted suicide. Compared with whites, blacks and Hispanics endorsed lower rates of psychiatric diagnoses but had similar rates of past-year suicide attempts.
Conclusions:
Lower rates of formally diagnosed psychiatric illnesses may obscure significant mental health burden among minority students, especially with regard to suicidal thoughts and attempts among Asian/Pacific Islander and multiracial students. Students from racial and ethnic minority backgrounds may have undetected psychiatric problems and, therefore, represent a particularly at-risk group on campus.
HIGHLIGHTS
•
Racial-ethnic minority students may be at high risk of undetected mental illnesses and their sequelae.
•
Despite generally lower rates of diagnosed psychiatric illness, Asian/Pacific Islander and multiracial students appear to have significantly elevated rates of concerning mental health symptoms, including suicidal ideation and suicide attempts, compared with their white peers.
•
Given the increasing diversity among U.S. college students, there is an urgent need for universities to develop and implement proactive and culturally informed programs designed to increase mental health awareness and improve support for students, especially those from minority backgrounds.
College students in the United States are facing a mental health crisis (1, 2). Over the past two decades, university counseling centers have reported a steady increase in the number of students with psychiatric illness, with rates of depression, anxiety, substance misuse, and suicidal behaviors reaching record levels (3–5). High-profile cases, such as the tragic murders and suicide at Virginia Tech in 2007, have spurred media attention and calls for intervention from policy makers and the public (6). Some researchers have observed that concerns about college students’ psychological health are more pressing than concerns about their physical health (7).
Although stressors in multiple domains are inevitable during this developmental period, the burden of stigma that accompanies mental illness and a perceived or real lack of support services may overwhelm college students’ capacity to cope. This may be especially true for students from racial and ethnic minority backgrounds, for whom specific stressors—such as discrimination and impostor syndrome—can contribute to increased rates of mental health problems (8–10). Meanwhile, multiple factors may contribute to racial and ethnic disparities in psychiatric service utilization, including differences in illness beliefs, stigma toward seeking psychological help, limited availability of cross-culturally trained mental health clinicians, and implicit or overt discrimination by providers or health systems (11–13). Given the persistence of mental health problems on campus, untreated symptoms could lead to worse outcomes (14).
Despite these concerns, few studies have specifically examined differences in psychiatric symptoms and diagnoses among college students from various racial and ethnic backgrounds. Eisenberg and colleagues (15, 16) have carried out the most significant work in this area with the Healthy Minds study, an annual Web-based survey. In 2015 they published a report on racial-ethnic disparities in mental health care utilization that was based on data from the 2005 and 2007 waves of this survey (N=32,133). The report showed that Hispanic, Asian, and multiracial students exhibited more severe depressive symptoms than whites, as measured by scores on the Patient Health Questionnaire–9 (PHQ-9), but had generally lower rates of mental health service utilization (12). The study was limited to 26 campuses and focused on disparities in health care utilization rather than on differences in psychiatric symptoms or diagnoses.
Prior research also found elevated rates of suicidal thoughts and attempts among students who identified as Asian/Pacific Islander (17). Other than these examples, both a recent systematic review on depression among university students published in 2013 (18) and our own literature review did not yield many studies specifically examining rates of psychiatric symptoms or diagnoses by race and ethnicity. Over the years, the available data have presented a mixed picture, including reports of both higher (16) and lower (19) rates of psychiatric symptoms and diagnoses among racial-ethnic minority groups compared with whites and of variation (20) or no variation (21, 22) in psychiatric symptoms and diagnoses among different racial-ethnic groups.
The generalizability of most survey data is limited by the variability of the data collected, including variations by campus setting (e.g., single versus multiple campuses), method of assessing mental health (e.g., single item versus standardized screening), and symptoms assessed (e.g., depression only). Given the increasing diversity among U.S. university students (23, 24), the lack of recent large-scale data describing the mental health experiences of college students from racial-ethnic minority backgrounds represents a significant gap in the literature.
The goal of this study was to address this gap by performing an updated large-scale analysis of the mental health experience of college students from racial-ethnic minority groups. We used the American College Health Association–National College Health Assessment (ACHA-NCHA), a nationwide research survey that captures a wide range of health data, including health habits, behaviors, and self-reported psychiatric diagnoses. Data from the spring 2015 survey were used to assess and compare the rates of psychiatric diagnoses, suicidal behaviors, and concerning symptoms of mental illness among white, black, Hispanic, Asian/Pacific Islander, American Indian/Native Alaskan/Native Hawaiian (AI/NA/NH), and multiracial undergraduate students. The study is significantly different from other studies in this area, which did not stratify data at the symptom level by race.
Methods
Data Source and Sample
Data were obtained from the spring 2015 administration of the ACHA-NCHA IIB, which collected cross-sectional data from 93,034 students attending one of 108 colleges or universities in the United States. Institutions that self-selected to participate administered the survey to a random sample of enrolled students who were at least 18 years of age. Schools overall had an 18% response rate for the Web-based survey and an 83% response rate for the paper survey, and each institution determined the survey format provided to students. This analysis was deemed exempt from review by the Committee on Clinical Investigations Institutional Review Board for the Beth Israel Deaconess Medical Center.
Measures
Symptoms of mental illness.
Symptoms of mental illness were assessed by questions about 11 mental health–related feelings and behaviors, for which participants selected one of five options to indicate frequency (“No, never”; “No, not in the past 12 months”; “Yes, in the past 2 weeks”; “Yes, in the past 30 days”; and “Yes, in the past 12 months”). Because the options were not mutually exclusive, responses were recoded into two categories (“No, not in the past 12 months” [which also included “No, never”] and “Yes, in the past 12 months” [which included all three “yes” options]). Eight of the 11 questions were related to mood (“felt things were hopeless,” “felt overwhelmed by all you had to do,” “felt exhausted [not from physical activity],” “felt very lonely,” “felt very sad,” “felt so depressed that it was difficult to function,” “felt overwhelming anxiety,” and “felt overwhelming anger”). Three items assessed self-harm and suicidality (“intentionally cut, burned, bruised, or otherwise injured yourself”; “seriously considered suicide”; and “attempted suicide”).
Psychiatric diagnoses.
Psychiatric diagnoses were assessed by participants’ self-report of having been diagnosed or treated by a professional within the past 12 months for 15 different diagnoses. Therefore, in contrast to the symptoms described above, this category required that students had previously interfaced with a psychiatric or medical care provider. Diagnoses included anorexia, anxiety, attention-deficit hyperactivity disorder, bipolar disorder, bulimia, depression, insomnia, other sleep disorders, obsessive-compulsive disorder, panic attacks, phobia, schizophrenia, substance abuse or addiction, other addiction (e.g., gambling, Internet, sexual), and other mental health condition. We focused on diagnoses for depression and anxiety and collapsed the remaining nine disorders into one category, yielding four mutually exclusive psychiatric diagnosis categories (depression, anxiety, comorbid depression and anxiety, and other mental health conditions).
Sociodemographic characteristics.
Our analyses were stratified by race and ethnicity. Other sociodemographic characteristics were included as covariates on the basis of previously reported associations with mental health outcomes in college samples. These included age (18–24 versus ≥25) (25), gender (16), sexual orientation (26), institution type (public or private) (27), year in school (28), transfer student status (29), and international student status (30).
Race-ethnicity was assessed by the query, “How do you usually describe yourself? (Mark all that apply)” and seven options (white, black, Hispanic or Latino/a, Asian or Pacific Islander, AI/NA/NH, biracial or multiracial, and other). Because respondents could select multiple options, responses were recoded to produce mutually exclusive categories. Participants who selected only one response were coded with that identity. Those who selected more than one option were combined with those who selected biracial or multiracial. We refer to this broader group as multiracial. For example, a student who selected black and Hispanic would be coded as multiracial, as would a student who selected Asian, other, and black. Participants who selected only the option of other were excluded.
All other sociodemographic variables were included by using self-selected categories. Only degree-seeking undergraduates were included.
Data analysis.
Consistent with other studies (31, 32), respondents were retained only if they reported a realistic height of between 120 cm (3 feet, 9 inches) and 210 cm (6 feet, 9 inches), a weight between 35 kg (77.2 pounds) and 180 kg (396.8 pounds), and a body mass index between 16 and 65. Participants were excluded if any question about the 11 symptoms presented was unanswered or any responses to the diagnosis questions were missing. This resulted in a sample of 67,308 students for analysis.
For the logistic regression analysis, binary outcomes were used for each of the 11 symptoms of mental illness and four psychiatric diagnoses. Given the large sample size and the large number of comparisons, a conservative level of significance was set at p<0.01, and 99% confidence intervals are reported. This approach was chosen over others, e.g., the Bonferroni correction, to balance the risk of type I versus type II errors.
Results
Table 1 presents sociodemographic statistics for the sample, and Table 2 presents proportions of students endorsing various mental health outcomes, each stratified by race-ethnicity. Past-year rates of psychiatric diagnoses were high, with 16,726 (24.9% of the total sample) endorsing one of the four mutually exclusive self-reported psychiatric diagnosis categories. Across the entire sample, past-year rates of the 11 symptoms ranged from 1.5% (ever attempted suicide) to 87.3% (“ever felt overwhelmed by all you had to do”). Approximately one in 10 reported seriously considering suicide in the past year (range 8.7%−12.6% across racial-ethnic groups), and one in 14 reported self-injurious behaviors (range 4.4%−8.7%).
| Total (N=67,308) | White (N=43,330) | Hispanic (N=5,980) | Black (N=3,002) | Asian/Pacific Islander (N=7,166) | AI/NA/NHa (N=357) | Multiracial (N=7,473) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Characteristic | N | % | N | % | N | % | N | % | N | % | N | % | N | % |
| Age (years) | ||||||||||||||
| 18–24 | 61,422 | 91.3 | 39,660 | 91.5 | 5,328 | 89.1 | 2,604 | 86.7 | 6,694 | 93.4 | 281 | 78.7 | 6,855 | 91.7 |
| ≥25 | 5,886 | 8.7 | 3,670 | 8.5 | 652 | 10.9 | 398 | 13.3 | 472 | 6.6 | 76 | 21.3 | 618 | 8.3 |
| Gender | ||||||||||||||
| Male | 21,159 | 31.4 | 13,841 | 31.9 | 1,678 | 28.1 | 783 | 26.1 | 2,350 | 32.8 | 113 | 31.7 | 2,394 | 32.0 |
| Female | 45,848 | 68.1 | 29,308 | 67.6 | 4,291 | 71.8 | 2,207 | 73.5 | 4,790 | 66.8 | 243 | 68.1 | 5,009 | 67.0 |
| Transgender | 301 | .4 | 181 | .4 | 11 | .2 | 12 | .4 | 26 | .4 | 1 | .3 | 70 | .9 |
| Sexual orientation | ||||||||||||||
| Heterosexual | 59,536 | 88.5 | 38,572 | 89.0 | 5,320 | 89.0 | 2,672 | 89.0 | 6,429 | 89.7 | 307 | 86.0 | 6,236 | 83.4 |
| Gay/lesbian | 2,017 | 3.0 | 1,228 | 2.8 | 224 | 3.7 | 95 | 3.2 | 172 | 2.4 | 12 | 3.4 | 286 | 3.8 |
| Bisexual | 3,777 | 5.6 | 2,423 | 5.6 | 286 | 4.8 | 155 | 5.2 | 270 | 3.8 | 25 | 7.0 | 618 | 8.3 |
| Unsure | 1,978 | 2.9 | 1,107 | 2.6 | 150 | 2.5 | 80 | 2.7 | 295 | 4.1 | 13 | 3.6 | 333 | 4.5 |
| Institution type | ||||||||||||||
| Public | 46,940 | 69.7 | 30,004 | 69.2 | 4,971 | 83.1 | 2,157 | 71.9 | 4,342 | 60.6 | 298 | 83.5 | 5,168 | 69.2 |
| Private | 20,368 | 30.3 | 13,326 | 30.8 | 1,009 | 16.9 | 845 | 28.1 | 2,824 | 39.4 | 59 | 16.5 | 2,305 | 30.8 |
| Year in school | ||||||||||||||
| 1st | 18,228 | 27.1 | 11,409 | 26.3 | 1,724 | 28.8 | 748 | 24.9 | 2,106 | 29.4 | 106 | 29.7 | 2,135 | 28.6 |
| 2nd | 15,034 | 22.3 | 9,840 | 22.7 | 1,233 | 20.6 | 637 | 21.2 | 1,602 | 22.4 | 69 | 19.3 | 1,653 | 22.1 |
| 3rd | 16,305 | 24.2 | 10,533 | 24.4 | 1,453 | 24.3 | 785 | 26.1 | 1,689 | 23.6 | 88 | 24.6 | 1,737 | 23.2 |
| 4th | 13,251 | 19.7 | 8,791 | 20.3 | 1,050 | 17.6 | 614 | 20.5 | 1,340 | 18.7 | 56 | 15.7 | 1,400 | 18.7 |
| ≥5th | 4,490 | 6.7 | 2,737 | 6.3 | 520 | 8.7 | 218 | 7.3 | 429 | 6.0 | 38 | 10.6 | 548 | 7.3 |
| Transfer | ||||||||||||||
| No | 56,176 | 83.5 | 36,485 | 84.2 | 4,815 | 80.5 | 2,440 | 81.3 | 6,017 | 84.0 | 289 | 81.0 | 6,130 | 82.0 |
| Yes | 11,132 | 16.5 | 6,845 | 15.8 | 1,165 | 19.5 | 562 | 18.7 | 1,149 | 16.0 | 68 | 19.0 | 1,343 | 18.0 |
| International | ||||||||||||||
| No | 63,944 | 95.0 | 42,193 | 97.4 | 5,744 | 96.1 | 2,817 | 93.8 | 5,782 | 80.7 | 343 | 96.1 | 7,065 | 94.5 |
| Yes | 3,364 | 5.0 | 1,137 | 2.6 | 236 | 3.9 | 185 | 6.2 | 1,384 | 19.3 | 14 | 3.9 | 408 | 5.5 |
a
AI/NA/NH, American Indian/Native Alaskan/Native Hawaiian.
| Total (N=67,308) | White (N=43,330) | Hispanic (N=5,980) | Black (N=3,002) | Asian/Pacific Islander (N=7,166) | AI/NA/NH (N=357)b | Multiracial (N=7,473) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Symptom and diagnosis | N | % | N | % | N | % | N | % | N | % | N | % | N | % |
| Symptom | ||||||||||||||
| Ever felt things were hopeless | 33,508 | 49.8 | 20,737 | 47.9 | 3,093 | 51.7 | 1,463 | 48.7 | 3,900 | 54.4 | 157 | 44.0 | 4,158 | 55.6 |
| Ever felt overwhelmed by all you had to do | 58,737 | 87.3 | 38,517 | 88.9 | 5,067 | 84.7 | 2,471 | 82.3 | 5,775 | 80.6 | 279 | 78.2 | 6,628 | 88.7 |
| Ever felt exhausted (not from physical activity) | 55,794 | 82.9 | 36,478 | 84.2 | 4,745 | 79.3 | 2,336 | 77.8 | 5,554 | 77.5 | 264 | 73.9 | 6,417 | 85.9 |
| Ever felt very lonely | 40,974 | 60.9 | 26,482 | 61.1 | 3,325 | 55.6 | 1,725 | 57.5 | 4,332 | 60.5 | 170 | 47.6 | 4,940 | 66.1 |
| Ever felt very sad | 44,074 | 65.5 | 28,466 | 65.7 | 3,719 | 62.2 | 1,837 | 61.2 | 4,556 | 63.6 | 198 | 55.5 | 5,298 | 70.9 |
| Ever felt so depressed that it was difficult to function | 23,843 | 35.4 | 14,764 | 34.1 | 2,097 | 35.1 | 1,013 | 33.7 | 2,754 | 38.4 | 106 | 29.7 | 3,109 | 41.6 |
| Ever felt overwhelming anxiety | 39,139 | 58.1 | 25,638 | 59.2 | 3,289 | 55.0 | 1,519 | 50.6 | 3,873 | 54.0 | 185 | 51.8 | 4,635 | 62.0 |
| Ever felt overwhelming anger | 26,560 | 39.5 | 16,383 | 37.8 | 2,446 | 40.9 | 1,239 | 41.3 | 2,907 | 40.6 | 138 | 38.7 | 3,447 | 46.1 |
| Ever intentionally cut, burned, bruised, or otherwise injured yourself | 4,766 | 7.1 | 3,158 | 7.3 | 344 | 5.8 | 131 | 4.4 | 458 | 6.4 | 25 | 7.0 | 650 | 8.7 |
| Ever seriously considered suicide | 6,621 | 9.8 | 4,109 | 9.5 | 518 | 8.7 | 275 | 9.2 | 743 | 10.4 | 38 | 10.6 | 938 | 12.6 |
| Ever attempted suicide | 995 | 1.5 | 551 | 1.3 | 99 | 1.7 | 52 | 1.7 | 125 | 1.7 | 10 | 2.8 | 158 | 2.1 |
| Diagnosis | ||||||||||||||
| Depression only | 2,283 | 3.4 | 1,544 | 3.6 | 175 | 2.9 | 84 | 2.8 | 182 | 2.5 | 13 | 3.6 | 285 | 3.8 |
| Anxiety only | 4,083 | 6.1 | 3,019 | 7.0 | 271 | 4.5 | 105 | 3.5 | 204 | 2.8 | 23 | 6.4 | 461 | 6.2 |
| Depression and anxiety | 6,734 | 10.0 | 5,010 | 11.6 | 376 | 6.3 | 148 | 4.9 | 361 | 5.0 | 32 | 9.0 | 807 | 10.8 |
| Other | 3,662 | 5.4 | 2,566 | 6.0 | 231 | 3.9 | 128 | 4.3 | 253 | 3.5 | 27 | 7.6 | 457 | 6.1 |
a
Results are from spring 2015.
b
AI/NA/NH, American Indian/Native Alaskan/Native Hawaiian.
Table 3 presents unadjusted odds ratios for mental health outcomes when race-ethnicity was entered as a predictor. Table 4 presents the same comparisons, with odds ratios adjusted to control for the full set of sociodemographic characteristics. Given the similarity in patterns across both models, we report below only adjusted odds ratios (AORs).
| Hispanic | Black | Asian/Pacific Islander | AI/NA/NHb | Multiracial | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Symptom and diagnosis | OR | 95% CI | OR | 95% CI | OR | 95% CI | OR | 95% CI | OR | 95% CI |
| Symptom | ||||||||||
| Ever felt things were hopeless | 1.17** | 1.09–1.25 | 1.04 | .94–1.14 | 1.30** | 1.22–1.39 | .86 | .65–1.13 | 1.37** | 1.28–1.46 |
| Ever felt overwhelmed by all you had to do | .69** | .63–.77 | .58** | .51–.66 | .52** | .48–.57 | .45** | .32–.62 | .98 | .89–1.09 |
| Ever felt exhausted (not from physical activity) | .72** | .66–.79 | .66** | .59–.74 | .65** | .60–.70 | .53** | .39–.73 | 1.14** | 1.04–1.25 |
| Ever felt very lonely | .80** | .74–.86 | .86** | .78–.95 | .97 | .91–1.04 | .58** | .44–.76 | 1.24** | 1.16–1.33 |
| Ever felt very sad | .86** | .80–.92 | .82** | .75–.91 | .91** | .85–.98 | .65** | .49–.86 | 1.27** | 1.19–1.37 |
| Ever felt so depressed that it was difficult to function | 1.05 | .97–1.13 | .99 | .89–1.09 | 1.21** | 1.13–1.29 | .82 | .61–1.10 | 1.38** | 1.29–1.47 |
| Ever felt overwhelming anxiety | .84** | .79–.91 | .71** | .64–.78 | .81** | .76–.87 | .74* | .56–.98 | 1.13** | 1.06–1.20 |
| Ever felt overwhelming anger | 1.14** | 1.06–1.22 | 1.16** | 1.05–1.28 | 1.12** | 1.05–1.20 | 1.04 | .78–1.37 | 1.41** | 1.32–1.50 |
| Ever intentionally cut, burned, bruised, or otherwise injured yourself | .78** | .67–.90 | .58** | .46–.73 | .87* | .76–.99 | .96 | .56–1.64 | 1.21* | 1.08–1.36 |
| Ever seriously considered suicide | .91† | .80–1.03 | .96 | .81–1.14 | 1.10† | .99–1.23 | 1.14 | .73–1.77 | 1.37** | 1.24–1.51 |
| Ever attempted suicide | 1.31† | .92–1.74 | 1.37† | .94–2.00 | 1.38* | 1.07–1.78 | 2.24† | .97–5.15 | 1.68** | 1.33–2.12 |
| Diagnosis | ||||||||||
| Depression only | .72** | .58–.88 | .67** | .50–.90 | .60** | .49–.73 | 1.00 | .48–2.09 | 1.05 | .89–1.25 |
| Anxiety only | .57** | .48–.67 | .43** | .33–.56 | .34** | .28–.41 | .91 | .52–1.59 | .87* | .76–1.00 |
| Depression and anxiety | .48** | .41–.55 | .36** | .29–.45 | .36** | .32–.42 | .76 | .47–1.23 | .92† | .83–1.02 |
| Other | .57** | .48–.68 | .61** | .48–.78 | .50** | .42–.59 | 1.25 | .74–2.11 | 1.02 | .89–1.17 |
a
Results are from the spring 2015 American College Health Association–National College Health Assessment IIB. Whites are the reference group.
b
AI/NA/NH, American Indian/Native Alaskan/Native Hawaiian.
*
p<.01, **p<.001.
†
p<.05
| Hispanic | Black | Asian/Pacific Islander | AI/NA/NHb | Multiracial | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Symptom and diagnosis | OR | 95% CI | OR | 95% CI | OR | 95% CI | OR | 95% CI | OR | 95% CI |
| Symptom | ||||||||||
| Ever felt things were hopeless | 1.17** | 1.09–1.26 | 1.04 | .94–1.14 | 1.32** | 1.24–1.42 | .87 | .66–1.16 | 1.31** | 1.23–1.40 |
| Ever felt overwhelmed by all you had to do | .68** | .61–.75 | .56** | .49–.63 | .56** | .51–.61** | .46** | .33–.65 | .98 | .88–1.08 |
| Ever felt exhausted (not from physical activity) | .71** | .65–.78 | .64** | .56–.72 | .68** | .63–.74 | .54** | .40–.75 | 1.13* | 1.03–1.24 |
| Ever felt very lonely | .81** | .75–.87 | .87** | .79–.96 | .96 | .89–1.03 | .61** | .46–.80 | 1.19** | 1.11–1.28 |
| Ever felt very sad | .86** | .80–.93 | .81** | .73–.90 | .91** | .84–.98 | .67** | .51–.89 | .66** | .61-.72 |
| Ever felt so depressed that it was difficult to function | 1.05 | .97–1.13 | .97 | .88–1.08 | 1.21** | 1.13–1.30 | .80 | .59–1.08 | 1.30** | 1.22–1.40 |
| Ever felt overwhelming anxiety | .83** | .77–.89 | .68** | .61–.75 | .84** | .79–.90 | .74* | .56–.97 | 1.09* | 1.02–1.17 |
| Ever felt overwhelming anger | 1.12** | 1.05–1.21 | 1.15** | 1.04–1.27 | 1.16** | 1.08–1.24 | 1.02 | .76–1.35 | 1.37** | 1.28–1.46 |
| Ever intentionally cut, burned, bruised, or otherwise injured yourself | .80** | .68–.93 | .58** | .45–.73 | .87 | .76–1.00 | .98 | .57–1.71 | 1.09 | .96–1.23 |
| Ever seriously considered suicide | .92 | .81–1.04 | .98 | .82–1.16 | 1.15* | 1.02–1.29 | 1.11 | .71–1.75 | 1.25** | 1.13–1.38 |
| Ever attempted suicide | 1.28† | .96–1.71 | 1.38† | .94–2.01 | 1.32* | 1.01–1.73 | 2.10† | .91–4.88 | 1.47** | 1.16–1.86 |
| Diagnosis | ||||||||||
| Depression only | .69** | .56–.86 | .62** | .46–.83 | .59** | .48–.73 | .91 | .43–1.90 | .98 | .83–1.17 |
| Anxiety only | .55** | .47–.66 | .39** | .30–.51 | .34** | .28–.41 | .87 | .49–1.54 | .84* | .74-.97 |
| Depression and anxiety | .46** | .40–.53 | .32** | .26–.40 | .37* | .32–.43 | .70† | .42–1.15 | .84** | .75-.93 |
| Other | .56** | .46–.67 | .59** | .47–.76 | .50** | .42–.60 | 1.15 | .68–1.95 | .98 | .86–1.13 |
a
Results are from the spring 2015 American College Health Association–National College Health Assessment IIB. Whites are the reference group. Adjusted for age, gender, sexual orientation, institution type, relationship status, year in school, transfer student status, and international student status.
b
AI/NA/NH, American Indian/Native Alaskan/Native Hawaiian.
*
p<.01, **p<.001.
†
p<.05.
Hispanic, black, and Asian/Pacific Islander students were less likely to report any past-year psychiatric diagnosis compared with whites (AOR range .32–.69). AI/AN/NH students, whose sample sizes were much smaller, did not show statistically significant differences in rates of any of the four disorder categories compared with whites.
Members of racial-ethnic minority groups were generally less likely or no more likely than whites to report most past-year symptoms, but there were notable exceptions. Multiracial students showed a significantly elevated likelihood of experiencing eight of the 11 mental health indicators compared with students identifying as white (AOR range 1.09–1.47). Asian/Pacific Islander students showed a mixed pattern, with reduced likelihood of endorsing some mental health indicators (e.g., feeling overwhelming anxiety, very sad, or overwhelmed by all you had to do) but elevated likelihood of feeling so depressed it was difficult to function (AOR=1.21), overwhelming anger (AOR=1.16), seriously considering suicide (AOR=1.15), and attempting suicide (AOR=1.32).
Discussion
Main Findings
These data depict a somewhat complex relationship between racial-ethnic minority status, symptoms of mental illness, and psychiatric diagnoses. Compared with white students, we found that black, Hispanic, and Asian/Pacific Islander students had uniformly lower rates of self-reported past-year psychiatric diagnoses and lower rates of symptoms of mental illness, with notable exceptions.
Specifically, compared with white students, Asian/Pacific Islander students were significantly more likely to endorse having felt hopeless, having felt so depressed that it was difficult to function, and having felt overwhelmed by anger, and they were also significantly more likely to have seriously considered or attempted suicide, all in the past year. Black and Hispanic students were less likely than whites to have a self-reported psychiatric diagnosis or to endorse most symptoms of mental illness, but their rates of past-year suicide attempts were statistically indistinguishable from white students at a conservative significance level of p<0.01. When a less conservative p level was used (p<0.05), past-year suicide attempts among black and Hispanic students were significantly elevated compared with white students (AOR=1.38 and 1.28, respectively).
Compared with whites, multiracial students endorsed similar or lower rates of psychiatric diagnoses but almost uniformly higher rates of past-year symptoms of mental illness, including feeling hopeless, exhausted, very lonely, depressed to the point of having difficulty functioning, and overwhelmed by anxiety and anger. Compared with whites, multiracial students also had higher odds of intentional self-injury, seriously considering suicide, and attempting suicide.
In comparing AI/AN/NH and white students, there appeared to be a trend for AI/NA/NH students to have strikingly higher rates of attempted suicide (OR=2.10). However, this comparison reached statistical significance only at the p<.05 level, likely because of the small size of this group (N=357) compared with the overall sample.
These results are consistent with the Healthy Minds study data from 2005 and 2007, which found that compared with whites, students classified as Asian, Hispanic, multiethnic or multiracial, or other race-ethnicity exhibited depressive symptoms of greater severity, as measured by PHQ-9 scores, but generally had lower rates of psychiatric service utilization, although the study did not report psychiatric diagnoses (12).
The fact that rates of self-reported psychiatric diagnoses in this sample were lower among most minority groups than among whites could represent a true difference in prevalence, a conclusion supported by other epidemiologic studies reporting similar or lower rates of symptoms of mental illness among blacks, Hispanics, and Asian Americans compared with whites (33–35). Alternatively, this finding could reflect a disparity in access to clinicians who can provide a diagnosis to students from minority groups, whether due to student-related factors, provider- or health system–related factors, or a combination. For example, students from racial-ethnic minority groups may conceptualize and express symptoms differently than their white peers or may be reluctant to seek help because of stigma or unawareness of services (13). Additionally, systemic bias may result in poor accessibility of mental health services for students from racial-ethnic minority groups, limited availability of clinicians who are well equipped to sensitively work with students from different racial-ethnic backgrounds, and minimization or misinterpretation of students’ description of symptoms (12).
This latter hypothesis—that the lower rates of diagnoses among students from racial-ethnic minority groups may reflect a disparity as opposed to a true difference in prevalence—is supported by elevated rates of concerning symptoms among participants from certain minority groups in this study. Our findings are consistent with prior publications utilizing ACHA-NCHA data showing that Asian/Pacific Islander college students were more likely than whites to have suicidal ideation or attempts (17), strongly suggesting underdetection of psychiatric problems in this group. This possible underdetection also accords with prior research suggesting that depressed students from racial-ethnic minority groups are less likely to receive minimally adequate care (36).
Implications
Our study has direct implications for universities. Because Asian/Pacific Islander and multiracial students are likely to experience concerning psychiatric symptoms and behaviors in the absence of a diagnosis, universities should consider implementing early, proactive, and culturally informed education and prevention programs designed to increase mental health awareness and engagement, especially among students from these minority backgrounds. In other words, simply providing care for those already aware of their diagnosis is likely not enough. This recommendation is especially pressing considering the rapid growth in the percentage of Americans who identify as multiracial (37). Further, the possibility remains that underdetection of mental health problems contributed to lower rates of psychiatric diagnoses through a similar mechanism for all of the racial-ethnic groups, even though Asian/Pacific Islander and multiracial students demonstrated a different pattern of psychiatric symptoms and diagnoses than the other groups. As an example, black and Hispanic students attempted suicide at similar rates as whites, despite having much lower rates of psychiatric diagnosis.
These results also suggest that educational institutions must prioritize and strengthen their efforts to be inclusive. Psychiatric illness affects all students, but students from minority groups appear to be particularly vulnerable to being left behind by mainstream providers of mental health support. Culturally tailored institutional or peer-led services that directly and proactively address psychoeducation, stigma, and privacy concerns may go a long way toward ensuring that increasingly diverse college student populations feel supported along their educational journeys. Universities are particularly well positioned to promote the mental health of young people, given that they interface with nearly all domains of students’ lives (38).
Limitations and Strengths
These results must be interpreted within the context of the study design, and several limitations existed. This data set does not allow post hoc extrapolation of psychiatric diagnoses on the basis of reported symptoms and duration, in contrast to other studies (e.g., the Healthy Minds Study or the National Epidemiologic Survey on Alcohol and Related Conditions [39]). Self-report data are susceptible to recall and other forms of bias, especially concerning stigmatized topics. This data set is lacking information about important student factors, including income and socioeconomic status (which may be highly correlated with race), as well as racial differences in perceptions of and willingness to acknowledge mental illness. Without these data, it remains difficult to elucidate the underlying factors that may contribute to psychiatric disparities.
Race and ethnicity are challenging to define; the term “Hispanic” is actually an ethnonym but is treated in this survey as a racial category. Collapsing students’ responses in several areas, including race, may have eliminated some nuance in students’ self-reported identity. The multiracial label in particular may encompass significant heterogeneity, and its use warrants further exploration. First-year students’ reported symptoms may have existed before entering college. Few significant differences were found among AI/AN/NH respondents, likely because of the small sample size and limited statistical power for detecting differences in this group. Finally, institutional self-selection limits generalizability of the data to all U.S. college students, although prior triangulation-based comparisons with other population-based surveys have demonstrated validity and replicability (40).
This study also possessed several strengths, including a large sample size, a large number of institutions surveyed, and geographic diversity of participants. Additionally, the data include a wide range of racial-ethnic groups, in contrast with many prior studies that focus on just one or two racial-ethnic groups. Multiple risk factors were included in the statistical models to appropriately control for confounding variables. This study assessed a range of outcome measures, including rates of both diagnosis and specific symptoms of concern, distinguishing it from other comparable large-scale surveys, such as the Healthy Minds study. Finally, the recency of the data (from 2015) is an important strength given the changing demographic make-up on college campuses and the fact that most of the literature in this area focuses on data obtained over a decade ago.
Conclusions
This study is the most recent large-scale examination of racial-ethnic differences in symptoms and diagnoses of mental illness among U.S. college students. Respondents from minority groups demonstrated similar or lower rates of psychiatric diagnosis than their white peers. However, Asian/Pacific Islander and multiracial students endorsed significantly elevated rates of concerning mental health indicators, including suicidal ideation and suicide attempts. These results suggest that these students may be underdiagnosed and therefore represent a group of students who are at particularly high risk of psychiatric illnesses and their sequelae. Universities may benefit from implementing proactive and targeted approaches to help increase mental health awareness and engagement among students from racial-ethnic minority groups, given the increasing diversity of student populations. The annual ACHA-NCHA survey may benefit from improved psychiatric screening measures, especially considering the disproportionate influence of psychological distress on college students’ overall health. Future research should examine the help-seeking patterns of students from minority groups with and without psychiatric diagnoses and also incorporate qualitative measures to better characterize factors that influence the patterns seen in this study.
Acknowledgments
The authors thank the American College Health Association (ACHA) for providing and approving the use of this data set (date of distribution, December 4, 2017).
Footnote
Support for preparing the manuscript was provided through the Commonwealth Research Center (SCDMH82101008006), the National Institutes of Health (K23 MH 107714-01 A1), and the Tynan Faculty Research Fellowship.
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Information & Authors
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Cover: XXXX
History
Received: 20 August 2018
Revision received: 27 December 2018
Accepted: 17 January 2019
Published online: 27 March 2019
Published in print: June 01, 2019
Keywords
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Competing Interests
The authors report no financial relationships with commercial interests.
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