Aad Goudappel
"I don’t understand it—she’s always been a confident, cheerful kid,” my friend says over lunch, soon after both our children have started college. She’s worried about her daughter, a varsity athlete who has been benched for episodes of heart racing and faintness on the field that were recently diagnosed as panic attacks.
Another friend’s son unexpectedly comes home on leave in the middle of the semester: he so underperformed academically that he was on the brink of dismissal. Once home, he won’t leave his room.
Late one evening, I hear from yet another friend, voice shaky over the phone: her child, returning to their dorm room after a busy evening, discovered a roommate who had just killed himself.
My friends turn to me not only because, as friends, we all worry about our kids, but also because I’m a psychiatrist specialized in treating college students. For years, I’ve observed the decline in young-adult mental health, so I don’t share my friends’ surprise. But I’m as alarmed as they are by how universal these difficulties
have become.
Many of us fondly recall our “bright college years,” but for a growing number of students, college is a tumultuous and difficult time. We’ve long known that nearly 75 percent of psychiatric illnesses first emerge by ages that coincide with college attendance, but something has changed. Yes, the COVID-19 pandemic doubled youth anxiety and depression symptoms, but even before that, college students were reporting ever-increasing rates of stress and emotional suffering.
The changes are dramatic. The 2023 Healthy Minds Study, which assessed students across hundreds of American colleges, found that 41 percent of students screened positive for depression, 36 percent for problematic anxiety, and 14 percent for serious thoughts of suicide, compared to 21 percent, 22 percent, and 10 percent, respectively, in 2014. Around a quarter of students take psychiatric medications, with one study showing a 41 percent increase in medication use in 2021 compared to 2015–2019.
Administrators have noticed, too. In surveys of their top concerns between September 2020 and April 2021, university presidents most frequently named student mental health as a pressing problem.
What are we to make of all this, and how can we reverse the trends? Some of the increase in reported campus distress is undoubtedly due to earlier detection of problems that previously went unaddressed. As depression, anxiety, ADHD, neurodivergence, and other mental health issues are identified and treated earlier, adolescents who might never have made it to college now have a chance to go—but often need continued support once they get there. Other students might have suffered without access to care before college, and for them, college is the moment to finally seek help. Still others first experience trouble in college. Available support varies significantly among colleges. Even with the increases in college counseling center staff implemented in the wake of the pandemic, demand still often outstrips supply.
And even as the numbers tick upward, we are still not reaching everyone who needs support. Students from groups with traditionally marginalized identities—including racial minority students, LGBTQ+ students, and students with disabilities—are particularly vulnerable to mental health issues, and they are sometimes more distrustful of counseling. Studies show that racist microaggressions, experiences of identity concealment or family rejection, and internalized LGBTQ-phobia significantly affect psychological health in college. Financial stress and debt also worsen mental health, so first-generation students and students from lower socioeconomic families face higher risk, too. As the cost of college has soared much faster than the consumer price index, more students I see lament a pressure to “be a good return on my parent’s investment”— yes, they use those terms—and they suffer when they fear they fall short.
Not all emotional distress signals psychiatric illness. Like my friend’s son who came home mid-semester, some students may not be quite ready yet for college, or they may have ended up at a school that’s a poor fit for their interests. But recent cultural and societal factors have changed the developmental trajectory of young adulthood, and the types of problems we see. My colleagues and I sometimes struggle to determine which student crises are normal and transient, and which constitute illnesses that need professional intervention. This distinction stymies families, faculty, and even the students themselves.
Aad Goudappel
Delaying adulthood
Adolescence used to be considered the life stage during which we wrestled with identity, trying on beliefs and behaviors that sometimes led to stupid risks. This used to happen within the (usually) protective environment of the family. But in 2000, psychologist Jeffrey Arnett argued that in post-industrial countries worldwide, identity solidification was in fact happening later. He coined the term “emerging adulthood” to describe a new, distinct stage of psychological development in 18- to 25-year-olds. By 2014, psychologists had adjusted the upper limit of this stage to age 29, reflecting the reality of an even longer transitional period.
Post-industrial economies require higher educational levels for success, so emerging adults delay the traditional milestones of adulthood—marriage, entering the workforce, and settling in one place. It is now in emerging adulthood that people experience the most life instability, high-risk behaviors (such as binge drinking or unprotected sex), and mental health issues. The lives of college-bound adolescents—especially those who hope to get into Yale or other similarly selective schools—have become increasingly constrained with AP classes and extracurricular activities. There’s less unstructured socializing. Identity seems more entwined with external achievement; there’s more interpersonal fragility. Their faith in their own ability to weather challenges seems shakier.
Changes in parenting have also contributed to the delay of adulthood. The “helicopter parenting” of the late twentieth century, in which parents overmanaged every detail of their child’s life, has given way to “snowplow parenting” in the 2020s. Snowplow parents actively clear any perceived obstacles from their child’s path to happiness and success. This is particularly intense in families or communities with extreme pressure on teenagers to gain elite college admission. As a parent, I too experienced this powerful desire to solve my children’s problems so their lives would be easier, but I tried to resist: as a campus psychiatrist, I’ve seen how destructive this can be. When it comes to college admission, for example, students who are rejected from particular schools are left feeling inadequate, while many admitted students struggle with impostor feelings or start college so burned out that they’re unable to take full advantage of their opportunities. When it comes to life, taking over problem-solving for our children deprives them of necessary life skills.
Not all college students experience snowplow parenting, but as a generation, most emerging adults have grown up both more sheltered from routine difficulties—and more exposed to a host of new and very real threats. They’ve been raised on active shooter drills, survived the lockdowns of a global pandemic, witnessed divisive national elections, and seen a storming of the US Capitol. They’re conscious of systemic inequities based on race, gender, class, sexual orientation, and other factors in a way their predecessors were not. They face the realities of climate change, even as they grapple with life in a “post-truth society,” in which public leaders discredit the findings of experts or the process of critical thinking in favor of personal beliefs. They’re immersed in debates over free speech, but as they try to work out the impact and limits of self-expression, their campus experiences are broadcast to the nation and the world. They must navigate cancel culture and doxing.
Aad Goudappel
Living online
Every generation differs from its predecessors in world view, but according to psychologist Jean Twenge, Gen Z—born between 1995 and 2012—also differs in how it spends its time. Gen Z is often on a smartphone, and often alone. In her book Generations, Twenge describes this most ethnically and racially diverse American group as highly individualistic, more gender-fluid, and more likely to substitute online interactions for real-life ones. More emerging adults than ever before enter college without ever having tried alcohol or sex, driven a car on their own, or gone on a date. Twenge’s research also finds that fewer college-aged people of all genders have sex compared to previous generations, and instead often substitute porn or masturbation.
Students are also lonelier than ever before—twice as lonely, in fact, as people over 65. This prompted US surgeon general Vivek Murthy ’03MD, ’03MBA, to launch a “We Are Made To Connect” tour of college campuses in the fall of 2023. Because forming relationships is such a crucial part of the psychological work of emerging adulthood, young adults who feel socially adrift are at higher risk of depression and other mental health problems. Students from groups with traditionally marginalized identities are particularly vulnerable to loneliness. Social media amplifies normal insecurities when students compare their own lives to the highly curated digital narratives of their peers.
But does too much time online cause emotional problems, or do depressed people turn too much to the Internet? Both are probably true. Virtual forums do connect students who feel marginalized, destigmatizing suffering and providing community. But social media also can pathologize common normal difficulties, which can escalate the misuse of psychiatric diagnoses by expansion. Psychiatrist Allen Frances, among others, has warned of this problem and suggested that certain corporate interests—such as the pharmaceutical industry and a host of online treatment platforms—benefit by “selling the ill to peddle the pill,” in Frances’s words.
There are well-documented recent instances of this phenomenon. For example, several online telehealth platforms that blossomed during the pandemic, such as Cerebral and Done, have been shut down or are currently under federal investigation for prescribing stimulants “for no legitimate medical purpose” after cursory or incomplete mental health evaluations. Ads on social media, or reels filmed by young “influencers,” often describe common emotional difficulties, and then ascribe them to illness, sending more emerging adults in search of mental health diagnoses.
In the same way that news or ideas can go viral, so can medical misinformation. In 2020, neurologists saw a sudden increase in tic-like behaviors in teenage girls and young women, which were subsequently linked to TikTok videos connected by the rapidly proliferating hashtags #tic, #Tourette, or #Tourettes. When systematically studied, the tic-like behaviors differed significantly from true tic disorders. They’re now considered an example of a “mass sociogenic illness, which involves behaviors, emotions, or conditions spreading spontaneously through a group.” There are similar concerns about ADHD videos, which describe common concentration and motivation difficulties and lead some students without any past diagnosis or symptoms to conclude that their academic challenges in college must signal an underlying disorder.
Students with no previous psychiatric history now more often come to their initial appointment with me convinced they know their diagnosis and the specific medicine I should prescribe, most commonly when they would like Adderall. Prescriptions for stimulant medications in adults rose dramatically between 2016 and 2021, spiking most noticeably between 2020 and 2021, especially in young women. Since 2022, pharmacies have routinely experienced stimulant shortages. Not all of this can possibly be ADHD that was missed earlier, but no one wants to hear that their lifestyle or excessive digital consumption may be eroding their focus or equanimity.
Data increasingly show that excessive social media use is not benign. One brain-imaging study of middle-school students found that over three years, those who most often checked their social media feeds had different patterns of neural development in areas of the brain that regulate our ability to control impulsive or habitual behaviors. The developing brain—which we now know continues to significantly change until around age 25—is highly attuned to social rewards and novel stimuli. This makes the mix of online social approval and highly engaging content particularly irresistible to youth, who increasingly get their news and other vital information from social media.
Unlike real-life interactions, virtual interactions rely on algorithms which govern exactly what we’ll most readily see, with the goal of keeping us engaged with the platform. Social psychologists find evidence that these algorithms magnify exactly the kind of information our brains are particularly sensitive to: “prestigious, in-group, moral, and emotional information,” which they’ve called PRIME. PRIME helps in the real world, but less online. In real life, for example, we benefit when we pay attention to impressive people, because they can teach us things that benefit us. Online, people can fake prestige, drawing our attention to those whose main skill is self-promotion. Algorithms often selectively amplify extreme political views, capitalizing on our attraction to information that makes us feel a strong emotion. Young adults then incorrectly conclude their peers are more polarized than is true. This mistaken belief then drives actual or further polarization, along with more intense emotions.
Aad Goudappel
What colleges—and parents—can do
Continually figuring out how and how much to interact online is one necessary skill for good mental health, especially in the college years—and earlier. But because the college mental health crisis has no single cause, there are no simple resolutions. Most colleges now recognize that hiring more counselors is not enough: we must also create caring campus cultures, where everyone—from the dining hall staff to the faculty to the bus drivers shuttling students—actively encourages mental health as a facet of overall health. The Jed Foundation, a nonprofit that promotes youth well-being and suicide prevention, supports this type of holistic campus approach. Beginning with health promotion, colleges prioritize opportunities for students to connect socially and to learn life skills (such as managing a budget, handling arguments, time management, healthy responses to stress). Then, everyone on campus is encouraged to learn to recognize signs of emotional distress in students, and to respond. Not every response must be clinical: human connection and simply caring matter.
Universities are increasingly creating stepped models of care, which better match the level of distress to the type of intervention. This means a campus might offer peer counseling, mindfulness meditation and yoga classes, or professionally run workshops to students with common developmental concerns, such as loneliness, mild anxiety, or academic struggles. They’d offer individual or group counseling for more significant anxiety, depression, eating concerns, substance misuse, or other problems, with psychiatric evaluation and treatment available as needed. Finally, they’d refer to a network of off-campus specialists (including hospitals) for more severe or long-standing difficulties which would benefit from a longer or more intensive approach.
Many colleges are exploring partnerships with telehealth providers to increase access to diverse therapists and therapies, as well as to provide libraries of life skills videos which benefit the entire student community. There’s a new national equivalent of 911 for mental health emergencies: 988. There are crisis hotlines specifically for students of color (the Steve Fund’s Text “STEVE” to 741741) or LGBTQ youth (the Trevor Project’s text “START” to 678678).
Students themselves are advocating for campus changes that support mental health. These include increased counseling services, clinician diversity that more closely reflects student body diversity, and simplified, more transparent, and more equitable administrative policies that support student well-being rather than, in their view, penalizing students who seek help. Many institutions have modified or clarified leave of absence policies in recent years. At Yale, students can now take a medical leave from the university rather than a medical withdrawal. This simple language change makes a needed break seem less like an abandonment of their college aspirations. It also allows students to return after much less onerous requirements than before. Fearing a loss of student status can be an impediment to treatment, and some students lose access to care or to medical insurance if they leave college. More colleges are therefore allowing students with mental health difficulties to carry lower than full-time course loads, so they can stay in school while receiving treatment.
Some of the cultural changes that will support emerging adults are more complex or difficult to implement. Limiting time on electronic devices is a challenge for us all, yet it’s increasingly clear this improves sleep, mood, and concentration. Accepting that human capacities are limited, even as technological powers continue to increase, is even harder, especially for young adults. Some students hate when I ask whether their expectations for themselves are realistic. They want to keep carrying a course overload while juggling several extracurricular activities, or varsity sports participation, or sometimes all this in addition to a job. They seek the solution—preferably a medication—that will allow them to remain calm and focused after averaging five hours a night of sleep. Or while continuing to use cannabis daily, or while pushing themselves through an internship they hate toward an equally soul-crushing career. Such solutions don’t exist, despite the claims of those with something to sell us. Ensuring students get accurate information is essential.
We parents can help by being present and attuned to our child’s life, supporting them without rescuing them from ordinary, age-appropriate difficulties. Sometimes, this means having difficult conversations or letting them cry or rage or express fear without overreacting with alarm or our own rage or fear. Not all stress is unhealthy. There’s some evidence that just as vaccines protect against infectious diseases by introducing a small, manageable amount of antigen to the body so it learns to protect itself from larger amounts later, exposure to age-appropriate emotional stressors early in life can have a similar so-called stress-inoculation effect for the brain. This does not apply to abuse or neglect, which overwhelm the nervous system. Rather, allowing children, adolescents, and then emerging adults to manage the problems which they can handle instead of stepping in with solutions makes them ever more resilient.
It’s now been years since my friend’s daughter graduated from college. She excelled at her sport once she got treatment for her panic. Most of the kids I know who had to take time off ultimately finished their degrees, and, more importantly, found fulfilling paths in their lives. Like all of us, they still encounter mental health challenges from time to time. Mental health is not all or nothing, and it does not begin or end in the treatment room. For young adults, the college years are a particularly crucial window of opportunity to learn that.
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