Factors Affecting Mental Health Service Utilization Among California Public College and University Students

Undergraduate and graduate students and faculty and staff completed an online survey during spring and fall semesters of 2013. The UC chancellor’s office invited all ten UC campuses to participate; eight chose to participate. The CSU chancellor’s office invited all 23 CSU campuses to participate; nine chose to participate. The CCC president’s office invited all 30 CCC campuses receiving CalMHSA-supported grants and 30 randomly selected CCC campuses not receiving such grants to participate; 14 of the former and eight of the latter agreed to participate. The most common reasons for not participating were competing demands and insufficient staff and resources. Compared with participating campuses, nonparticipating campuses generally were smaller, had fewer students, and had higher percentages of Latino and African-American students. Staff representatives at participating campuses were responsible for contacting students and staff and faculty and were instructed to invite large numbers of students and staff and faculty to participate. Staff representatives at participating campuses used preexisting lists of students and faculty to distribute survey invitations and information. The RAND Institutional Review Board approved the study.

Students were primarily full-time (84%) undergraduates (82%). Sixty-four percent were female, 52% were age 21 or younger, 23% were ages 22 to 25, and 25% were age 26 or older. Current serious psychological distress was reported by 19% of students; 11% of students reported significant mental health–related academic impairment in the prior 12 months. Twenty percent of students reported use of campus or off-campus mental health services (hereafter referred to as “combined mental health services”) while in college, with 10% reporting use of campus services and 10% reporting use of off-campus services. Table 2 provides additional information about student and campus characteristics and rates of use of mental health services.

This study was one of the largest assessments to date of factors influencing mental health service utilization among college students. Rates of self-reported current serious psychological distress (19%) were consistent with those reported by other studies in postsecondary educational settings (24). More than 10% of college students in our survey indicated that mental health problems substantially affected their academic success. We are aware of no other multicampus study that has examined academic impairment associated with mental health problems.

One of this study’s major contributions is documenting the substantial influence of campus climate on students’ use of mental health services, both on and off campus. For example, if the culture of every California public college campus was supportive of mental wellness, use of services among students with current mental health symptoms or recent mental health–related academic impairment would be expected to rise by an average of 39%. Our findings underscore the importance of improving campus mental health climates and reducing the stigma related to seeking help for mental health problems (25). To avoid the unintended consequence of decreasing a student’s willingness to seek mental health services, campuses should support individualized approaches for students with mental health problems, for example, by revisiting policies requiring some students receiving campus mental health services to take a leave of absence (26,27).

CalMHSA’s innovative and ambitious student mental health initiatives contained a range of prevention and early intervention activities designed to improve campus climates with respect to mental health. These activities consisted of disseminating information and training students, staff, and faculty through empirically supported approaches to recognizing and supporting individuals with mental health problems (28,29); conducting campus training sessions and social media campaigns to reduce stigma around mental health issues and to motivate students to help others (30); conducting programming to enhance students’ skills in coping with stress and more quickly seeking support when needed; and developing policies, programs, and collaborative partnerships that facilitate access to effective resources and treatment for students. These activities complement more traditional approaches, such as screening for mental health problems (31) and increasing the number and availability of mental health providers on campus (32), by seeking to reach and support students with mental health problems sooner. Further evaluation is needed to understand the impact of these efforts.

We found substantial use of off-campus services, particularly among CCC students—possibly because community college students predominantly reside off campus and have easier access to off-campus services or because of the absence of a formal system of mental health services on CCC campuses. However, CCC students remained significantly less likely to receive mental health services compared with their UC and CSU peers. Our findings suggest that a formal system of campus services with sufficient providers to meet demand (32) could potentially reduce unmet need for treatment. But even on campuses with mental health clinics, there was substantial off-campus service use, highlighting the importance of enhancing collaboration between higher education institutions and community mental health resources (33).

Helping students deal with stress is another important objective—we found that students with active coping skills were consistently more likely to use mental health services compared with comparable students who did not possess such skills. Enhancing coping skills may be particularly beneficial for students on campuses without mental health services, given that obtaining services off campus may require additional initiative and effort. Because students with less active coping skills appear to be at greater risk of mental health problems (34), programs to enhance coping skills, whether in person or online, may prevent the occurrence or exacerbation of mental health problems.

Prior studies have found that rates of mental health service utilization are higher among female (2,4,35) and nonheterosexual (4,5,36) young adults and lower among members of racial-ethnic minority groups (2,4,5,37). Our findings of similar disparities reinforce the importance of ensuring equitable access and encouraging utilization by all individuals. Reaching out to students from underserved racial-ethnic minority groups in culturally appropriate ways (38), distributing best-practice toolkits (38), and implementing culturally informed social-marketing campaigns (39) are a few of the approaches available to administrators and others to address disparities in service use.

Our study had limitations. Not all campuses invited to participate did so. Our approach to surveying a convenience sample was similar to that of other large higher-education surveys (40–43), but given that each campus was responsible for inviting students and faculty and staff to participate, we have no information about the numbers or characteristics of nonrespondents. We sought to mitigate effects of selection bias by weighting our sample to represent each campus’s general student body, allowing us to adjust for selection bias associated with available demographic characteristics. The rates of mental health problems in the weighted sample were also comparable to rates in random sample studies of college students, providing some reassurance that respondents were unlikely to have higher rates of mental health problems than the general student body. Still, we had no way to assess response bias—it is possible that respondents were more likely than nonrespondents to seek services and to perceive their campus climate as supportive of mental health issues. Also, we do not know to what extent our findings represent nonparticipating campuses or other higher education institutions. Nor do we know how early CalMHSA activities on campuses might have influenced survey responses, although the majority of these activities occurred after the study period.

Our estimate of mental health–related academic impairment was likely conservative because we operationalized impairment on the basis of just six behavioral health issues (17); thus we did not capture academic impairment related to other behavioral health issues, such as drug use or posttraumatic stress disorder. Our cross-sectional study design also prevented us from assessing causality. For example, coping strategies and perceptions of campus climate could influence service utilization, but the inverse could be true as well. Our assessment of recent mental health problems (past 30 days) covered a different time frame than our assessment of mental health service utilization (while at college), so we do not know the extent of students’ symptoms while they were receiving services. We underestimated off-campus service use, to the extent that individuals who used campus mental health services may have also used off-campus services. We also had no information on student’s socioeconomic status, which has been associated with asking for assistance among youths (44) and may be an important unobserved predictor of coping.

Despite its limitations, our study broke new ground by incorporating academic impairment, coping skills, and student and faculty and staff perspectives on campus climates. This study revealed that at least half of students with mental health issues, especially those with active coping skills, sought services off campus—a finding that underscores for colleges and universities the importance of developing solid collaborative relationships with community-based organizations, such as county departments of mental health, that can help support students in times of need. Our findings also reinforce how important it is that postsecondary educators, practitioners, and staff ensure that students understand where and how to access services, that they believe that the campus environment where they work is supportive—not stigmatizing—of students with mental health issues and needs, and that they personally have resources at hand to respond to students in distress.

The California Mental Health Services Authority (CalMHSA) provided support for this study. The authors thank Elizabeth May, Ph.D., Erin-Elizabeth Johnson, M.A., Gina Boyd, M.L.I.S., and Hilary Peterson, B.A., of the RAND Corporation for research assistance and assistance with manuscript preparation; Ann Collentine, M.P.P.A., of CalMHSA; Taisha L. Caldwell, Ph.D., of the University of California; Ray Murillo and Ana Aguayo-Bryant of the California State University Office of the Chancellor; Betsy Sheldon of the California Community Colleges Chancellor’s Office; and Robert F. Saltz, Ph.D., and Richard P. McGaffigan of the Pacific Institute for Research and Evaluation. Without their tireless support and valuable input, this work would never have been done.