Comparing Mental Health Issues Among Undergraduate and Graduate...

American Journal of Health Education, 44, 96-107, 2013Copyright © AAHPERDISSN: 1932-5037 print/2168-3751 onlineDOI: 10.1080/19325037.2013.764248

RoutledgeTaylor & Francis Group

Comparing Mental Health Issues AmongUndergraduate and Graduate Students

Tammy Wyatt and Sara B. OswaltUniversity of Texas at San Antonio

Background: Stress and other mental health issues can negatively impact the health andacademic performance of college students. Purpose: Examine relationships among stress,mental health, and academic classification in a national sample of college students. Methods:Analyses utilized secondary data from 27 387 college students responding to the Fall 2009American College Health Association-National College Health Assessment (ACHA-NCHA)II. Results: In general, undergraduates reported significantly higher rates of feelings andhehaviors related to poor mental health and negative effects on academic performance thangraduate students. Graduate students and undergraduate students reported significantlydifferent levels of stress. x^(4) = 54.34, Cramer's V = .O45, p = .001. Graduate students(74.0%) were also more likely to seek mental health care services in the future thanundergraduates (64.8%), x^(l) = 101.12, Cramer's V = .O61, p = .OOl. Translation toHealth Education Practice: Stress and mental health differences exist betweenundergraduate and graduate students. For universities, understanding such differences iscritical to the delivery of effective health education programs.

BACKGROUND

Stress and other mental health challenges pose a majorproblem for many undergraduate and graduate collegestudents, and both their health and academic performanceare affected negatively. The prevalence and severity ofmental health challenges are increasing in the collegestudent population.' Depression and anxiety affect nearly16% of undergraduate and 13% of graduate students.' Astudy of approximately 3100 graduate students found thatnearly half (44.7%) reported experiencing an emotional orstress-related problem during the previous 12 months.^Similarly, the number of first-year college studentsreporting being frequently overwhelmed is on the rise.'*'^In 1998, 93% of college students seeking treatment throughcampus counseling services were diagnosed with onemental disorder. This percentage increased to 96% in 2009.

Submitted June 5, 2012; accepted August 24, 2012.Correspondence should be addressed to Tammy Wyatt, Department of

Health and Kinesiology, University of Texas at San Antonio, One UTSACircle, San Antonio, TX 78249. E-mail: [email protected]

During this time period, most students were diagnosed withmood disorders, anxiety disorders, adjustment disorders, orproblems related to impaired daily functioning.^

According to the National Survey of Counseling CenterDirectors,' 91% of directors agreed that the number ofstudents with severe psychological problems continues torise. Directors reported that 37.4% of students seekingcampus counseling services have severe psychologicalproblems, with nearly 5.9% so serious that they cannotremain in school or can only do so with extensivepsychological/psychiatric assistance, and 31.2% experiencesevere problems but are able to remain on campus utilizingavailable treatment methods. Moreover, in the past 5 yearsdirectors have noted an increase in the following problems:crises requiring an immediate response, psychiatricmedication use, learning disabilities, illicit drug use, self-injury, alcohol abuse, problems related to earlier sexualabuse, career planning issues, eating disorders, and sexualassault concerns on campus. One third (33%) of centerdirectors also reported a marked increase in student tostudent violence on their campus.'

COLLEGE STUDENTS' MENTAL HEALTH 9 7

IMPACT OF MENTAL HEALTH ON COLLEGECAMPUSES

Poor mental health can impact college campuses in a variety ofways, including student health outcomes, academic perform-ance, and student retention and graduation rates. Mental healthchallenges have a negative impact on the health behaviors ofcollege students. For example, a considerable number of collegestudents report having engaged in self-injurious behavior intheir lifetime.' Individuals who engage in such behaviors aremore likely to report distress' and experience psychiatricdisorders.* Major depression, panic disorders, and generalizedanxiety disorder are strongly associated with cigarette smokingamong college students. Similarly, generalized anxiety disorderis strongly associated with binge drinking,^ which is related toalcohol-related academic challenges such as missing class andfalling behind on schoolwork.'" With smoking, drinking,limited social support, and maladaptive coping strategiesrelated to academic performance and retention," the risk ofthose experiencing mental health challenges also experiencingacademic challenges is high.

Clinically depressed and anxious college students reportsignificantly poorer performance on exams compared tononclinically depressed and anxious students.'^ Haines et al.'^found that depressed mood is negatively associated withacademic performance. High levels of psychological distressare also significantly related to academic performance, withhigher levels of distress associated with increased test anxiety,lower academic self-efficacy, less effective time management,and limited use of study resources.^" Likewise, psychiatricdisorders have been associated with college studentsprematurely ending their education, with anxiety, mooddisorders, substance abuse, and conduct disorders beingsignificant predictors of failure.'^ Similarly, personal andemotional adjustment has been found to be just as importantfor retention as academic adjustment.'^ Furthermore, currentresearch posits that college students with mental illnessesreport less engagement on campus and poorer relationshipswith others. Such factors are also associated with academicperformance and lower graduation rates."

With roughly 20.6 million people enrolled in U.S.colleges and universities—17.6 million undergraduate and2.9 million graduate students"*—it is important to under-stand whether mental health and stress impact undergradu-ate and graduate students differently. There is a perceptionthat the experiences of undergraduate and graduate studentsare different. For example, because college is often a time ofincreased independence, decision making, and transitioninginto an adult role, many undergraduate students havedifficulty and find college to be stressful.'^ In addition,many mental health disorders typically have first onsetduring young adulthood.^" Health risk behaviors such assmoking, drinking, and maladaptive coping have beenassociated with poorer academic achievement amongcollege freshmen. ' ' Similarly, studies among undergraduate

students show that depression is associated with a half-letterdecrease in one's grade point average.^' Moreover,depressed undergraduate students report higher rates ofcareer indecision and dysfunctional career thoughts.^^

Comparatively, graduate and professional school is atime to focus more in-depth on a content area and the stressexperienced is often about academic pressure, finances,career planning, and graduate assistantship responsibil-ities. ^"^^ A connection between academic workload andperceived stress exists among graduate students, withstudents who spent a great deal of time in classes, in labs,and working on assignments reporting high levels ofstress.^^ Furthermore, graduate students often lack healthybalance in their personal lives, with many focusing themajority of their attention on academic work to theexclusion of hobbies, interests, and others in their lives. Inmany instances, graduate students are detached from thesocial and cultural activities that are often targeted to theundergraduate population on college campuses.^^

This study aims to further explore these issues in a nationalsample of undergraduate and graduate students. The rewardsand benefits for understanding the potential differences andsimilarities in undergraduate and graduate student stress andmental health issues are great. Understanding such differencesand similarities can assist university administrators, healtheducators, and mental health specialists in delivering effectiveand appropriate services and programs, which, in turn, mayassist universities in fostering better student health outcomesas well as increase academic performance and studentretention rates.

PURPOSE

This study aims to examine the relationship between stress,mental health issues, and classification as an undergraduateor graduate student among a national sample. The specificresearch question is

What differences exist between undergraduate and graduatestudents concerning mental health issues, diagnoses,services, and academic performance?

METHODS

Procedure and Participants

For this study, institutional review board (IRB) approvalwas secured to analyze the most recently availableAmerican College Health Association-National CollegeHealth Assessment (ACHA-NCHA) II data set (Fall2009).^' This data set contains information collected from34,208 undergraduate and graduate students enrolled parttime and full time at 57 2- and 4-year universities.^^ Onlycolleges and universities that randomly select students or

9 8 T. WYATT AND S. B. OSWALT

that survey students from randomly selected classrooms areincluded in the ACHA-NCHA II database. The ACHA-NCHA n uses a series of comparisons and statisticalanalyses (triangulation) to demonstrate the reliability andvalidity of the instrument. The ACHA-NCHA II appears tobe reliable, valid, and of empirical value for representing theU.S. college population.^^

For the purposes of this study, inclusion/exclusion criteriawere apphed to ensure that the sample related to the researchfocus. Students who did not identify their classification as anundergraduate or graduate/professional student were notincluded in the analyses; therefore, students who indicated"not seeking a degree" or "other" were not included. Likewise,individuals who were 50 years old or older were not includedbecause the majority of college students (96.2%)'^ are under50 regardless of status as an undergraduate or graduatestudent. Respondents attending universities outside the UnitedStates were also excluded.

Measures

The ACHA-NCHA II includes demographic items as wellas items associated with heath, health education, and safety;alcohol, tobacco, and drugs; sexual behavior and contra-ception; weight, nutrition, and exercise; physical health;mental health; and impediments to academic performance.The authors selected all mental health-related items becausethey were relevant to the research question and focus of thestudy. As a result, mental health issues in 4 main categorieswere examined: feelings and behaviors related to poormental health, mental health diagnoses, use of mental healthservices, and perceived impact of mental health onacademics. These categories were labeled as such to bestrepresent the intent of the items. In addition, demographicitems included age, gender, disability, sexual orientation,year in school, relationship status, residence, and otherstudent status (e.g., full- or part-time student, international).

Feelings and Behaviors Related to Poor MentalHealth

The participants were asked about feelings and behaviorsoften associated with a poor mental health state. This itemasked the respondents to identify the frequency of 11different feelings or behaviors: "felt things were hopeless";"felt overwhelmed by all you had to do"; "felt exhausted(not from physical activity)"; "felt very lonely"; "felt verysad"; "felt so depressed that it was difficult to function";"felt overwhelming anxiety"; "felt overwhelming anger";"intentionally cut, burned, bruised, or otherwise injuredyourself; "seriously considered suicide"; and "attemptedsuicide." The participants could choose 1 of 5 responses:"no, never"; "no, not in the last 12 months"; "yes, in the lasttwo weeks"; "yes, in the last 30 days"; or "yes, in the last 12months." For this study, because we were interested in

experiences relevant to their current situation, the responseswere collapsed into 3 categories: "no, never"; "no, not in thelast 12 months"; and "yes, in the last 2 weeks, 30 days, or 12months."

The students were also asked whether they hadencountered situations that had been traumatic or verydifficult to handle in the last 12 months; these included avariety of college life components (e.g., academics, career-related issues) and personal issues (e.g., family problems,intimate relationships). The participants indicated yes or noas a response. Another item specifically asked about thestudents' perceived stress levels. The item requestedparticipants to consider the last 12 months and rate theiroverall stress level as "no stress"; "less than average stress";"more than average stress"; or "tremendous stress."

Diagnosed Mental Health Issues

The participants were asked whether they had been diagnosedor treated by a professional within the last 12 months for somemental health conditions, specifically, anxiety, bipolardisorder, depression, obsessive—compulsive disorder, panicattacks, or substance abuse/addiction. Individuals couldrespond: "no"; "yes, diagnosed but not treated"; "yes, treatedwith medication"; "yes, treated with psychotherapy"; "yes,treated with medication and psychotherapy"; or "yes, othertreatment." For this study, because we were not examiningtreatment differences, we collapsed the responses into 3categories: "no"; "yes, diagnosed but not treated"; and "yes,diagnosed and treated." There was also a yes-no question thatasked whether the respondents had ever been diagnosed withdepression.

Use of Mental Health Services

Examining usage of mental health services was alsoincluded in the ACHA-NCHA II. Four items asked whetherthe participant had ever received psychological or mentalhealth services from a variety of providers (i.e., counselor/therapist/psychologist, psychiatrist, other medical careprovider, or minister/priest/rabbi/other clergy). Theseitems had a response option of yes-no. The students werealso asked whether they had ever received psychological ormental health services from their current college oruniversity's counseling or health services and whetherthey would seek mental health services in the future if theyhad a problem that was "really bothering" them. Bothquestions offered yes-no response options.

Perceived Effects of Mentai Health on AcademicPerformance

The ACHA-NCHA II survey has a section that asks therespondents to consider how a variety of health issues haveaffected their academic performance in the last 12 months.The participants can respond: "this did not happen to me/not

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applicable"; "I have experienced this issue but myacademics have not been affected"; "received a lowergrade on an exam or important project"; "received a lowergrade in the course"; "received an incomplete or droppedthe course"; or "significant disruption in thesis, dissertation,research, or practicum work." For this study, we examinedhow anxiety, concern for a troubled friend or familymember, depression, relationship difficulties, sleep difficul-ties, and stress impacted these academic factors. TheACHA-NCHA II includes items that ask about the impact ofother issues on academics, but these items were mostrelevant to the research question and focus of this study.

Analysis

Descriptive analyses were calculated using the PASWStatistics 18.0 for Windows.""* To examine the primaryresearch focus, 43 separate cross-tabulations were con-ducted to determine chi-square and Cramer's V. Cramer's Vis robust regardless of table size and can be used withnondichotomous data.^' In order to control for type I error,Bonferroni adjustment was performed (.05/43) settingstatistical significance at p < .001.

RESULTS

Participant Demographics

After applying the inclusion/exclusion criteria, the totalresulting sample was 27 387 students. These students werefrom 55 different universities from all regions of the UnitedStates. Most student respondents were enrolled in a 4-yearcollege or university (94.6%). Almost two thirds (62.0%)attended public institutions, with 12.3% attending religiouslyaffiliated institutions. Most of the participants wereundergraduate students (88.9%, n = 24 347). Other demo-graphic data with a breakdown between undergraduate andgraduate students are included in Table 1. There weresignificant differences in gender (higher percentage of femalesin the undergraduate sample), ethnicity (higher percentage ofthose identifying as AsianTPacific Islander in the graduatepopulation), relationship status (more graduate students in arelationship and living together), and location of residence(more graduate students living off-campus).

Because the primary research focus addressed mentalhealth, differences between graduate and undergraduatestudents regarding related disability and medical conditionswere also examined. Undergraduate respondents weresignificantly more likely to report having attentiondeficit-hyperactivity disorder, x^(l) = 22.396, p < .001,and a learning disability, x^(l) = 18.038, p< .001. Noother differences related to disability were found.

The number of hours per week spent working orvolunteering was also examined; there were significantdifferences for both number of hours worked.

COLLEGE STUDENTS' MENTAL HEALTH 101

TABLE 2Feelings and Behaviors Related to Mental Health

) Response Among Students

Undergraduate Graduate Cramer's V

Felt hopeless(N=21 155)

Felt overwhelmed(N = 27 250)

Felt exhausted(N = 27 235)

Felt lonely(N=21

Felt sad(N=21 179)

Felt depressed

Felt anxiety

Felt anger(N = 27 147)

Self-injury(N = 27 254)

Considered suicide(W = 27 269)

Attempted suicide(N=21 190)

No, neverYes, but not inYes in the lastNo, neverYes, but not inYes in the lastNo, neverYes, but not inYes in the lastNo, neverYes, but not inYes in the lastNo, neverYes, but not inYes in the lastNo, neverYes, but not inYes in the lastNo, neverYes, but not inYes in the lastNo, neverYes, but not inYes in the lastNo, neverYes, but not inYes in the lastNo, neverYes, but not inYes in the lastNo, neverYes, but not inYes in the last

last 12 months12 months











34.619.246.110.04.8

85.213.96.6

79.524.819.156.122.217.860.149.021.829.137.315.547.241.420.538.183.5lt.2

5.381.512.26.4

92.46.41.3

39.022.838.215.06.5

78.515.77.4

76.927.022.450.625.320.754.048.124.627.238.717.543.8'46.024.629.487.410.0

2.785.511.72.8

93.75.50.7

69.50

93.61

10.74

35.58

40.82

13.23

15.07

88.72

46.05

61.42

10.29

.051*

.059*

.020

.036*

.039*

.022*

.024*

.057*

.041*

.047*

.019

.001; **p = .OOl.

X (6) = 1287.91,/? < .001, and number of hours volunteeredper week, x^(6) = 96.47, p < .001, between undergraduateand graduate students. These data were collected in ranges, someans cannot be calculated, but the percentages indicate thatmore graduate students work more hours and more graduatestudents volunteer more hours, though more undergraduatestudents volunteer between 1 and 9 hr per week (32.7% vs.28.1%).

Feelings and Behaviors Related to Poor Mental Health

The participants were asked about feelings and behaviorsoften associated with a poor mental health state. Of these 11items, 7 had significant values of Cramer's V whenexamining undergraduate and graduate student responses.For 5 of the 7 significant items, undergraduate studentsreported higher rates of negative feelings and behaviors inthe previous 12 months but graduate students reportedhigher rates occurring before the previous 12 months. For

the items regarding self-injury and considering suicide,more undergraduate students reported lifetime occurrenceand frequency in the previous 12 months. The response ratescan be found in Table 2.

The participants were also asked whether situations arosethat had been traumatic or very difficult to handle in the last12 months. There were significant differences betweenundergraduate students and graduate students for all itemsexcept one—"personal health issue," x^(l) = 9.80,p = .007. For all issues excluding career-related issues,more undergraduate students identified the issue astraumatic or difficult to handle within the last 12 months.More graduate students identified career-related issues astraumatic or difficult to handle within the last 12 months.See Table 3 for the response rates and chi-square values.

Another item specifically inquired about the participants'perceived stress level. The question asked the students toconsider the last 12 months and rate their overall stress levelas "no stress," "less than average stress," "more than


TABLE 3Issues Identified as Traumatic or Difficult to Handle Within the Last 12 Months

Academics (N = 27 245)Career-related issues (N = 21 213)Death of a family member or friend (A = 27 219)Family problems (Ai = 27 231)Intimate relationships (N = 27 222)Other social relationships (N = 27 228)Finances (N = 27 693)Health problem of a family member or partner (Ai = 27 218)Personal appearance (A = 27 209)Personal health issue (Ai = 27 197)Sleep difficulties (Ai = 27 200)

% Response Among

Undergraduate

43.521.016.228.330.924.736.618.421.416.624.5

Students

Graduate

37.932.911.118.526.415.631.315.612.614.419.6

x'34.21

220.9153.71

131.1425.04

122.2932.6914.70

126.829.81

34.78

Cramer's V

.035*

.090*

.044*

.069*

.030*

.067*

.035*

.023*

.068*

.019

.036*

> < .001.

average stress," or "tremendous stress." This item was alsofound to be statistically significant, x^(4) = 54.34, Cramer'sy = .045, p < .001. Undergraduate and graduate studentsreported similar levels of no stress (2.6% and 2.1%,respectively). However, more graduate students reportedhaving tremendous stress (10.3% vs. 9.4%), more thanaverage stress (44.2% vs. 39.3%), and less than averagestress (10.2% vs. 9.1%). More undergraduate studentsreported having average stress (39.7% vs. 33.1%).

Diagnosed Mental Health Issues

Participants' responses regarding diagnosis and treatment ofspecific mental health issues within the last 12 months—anxiety, bipolar disorder, depression, obsessive-compul-sive disorder, panic attacks, and substance use/addiction—showed no significant differences between undergraduateand graduate students. The response rates for ever beingdiagnosed with depression were almost identical, 17.1% ofundergraduates and 17.0% of graduate students,X^(l) = .001, Cramer's V = .000, p = .969.

Use of Mental Health Services

Several items asked about usage of mental health services,specifically, what type of provider had been used, whetherthe respondent had accessed services on his or her currentcampus, and whether the student would consider seekinghelp from a mental health provider in the future. There wereno significant differences between undergraduate andgraduate students in the type of mental health providerthat had been previously used (counselor/therapist/psychol-ogist; psychiatrist; other medical provider [e.g., physician,nurse practitioner]; or minister/priest/rabbi/other clergy)and in the use of their current college/university'scounseling or health services. There was a significant

difference when asked whether they would consider seekingmental health care in the future, with graduate students(74.0%) more likely to respond affirmatively thanundergraduates (64.8%),V = .061,p=.001.

X ( l ) = 101.12, Cramer's

Perceived Effects of Mental Health on AcademicPerformance

Students were asked about the impact of mental health issuesand life experiences on their academics. Chi-square valueswere significant for all cross-tabulations. For all items exceptdepression, more graduate students reported not experien-cing the issue compared to undergraduate students. Like-wise, fewer graduate students reported that the issue resultedin a lower course grade or lower grade on an exam or project;however, graduate students consistently reported moredisruptions of thesis, dissertation, research, or practicumwork than undergraduate students. See Table 4 for details.

DISCUSSION

Although this study did not find significant differencesregarding clinical diagnoses and treatment of specificmental health issues for undergraduate and graduatestudents, undergraduate students consistently reportedhigher rates of feelings and behaviors related to poormental health. Undergraduates also reported experiencingtraumatic situations within the last 12 months at higher ratesthan graduate students. These findings are consistent withthe literature regarding undergraduate students' difficulty intransitioning from adolescence to adulthood and how thelack of previous experience and coping skills may increaseundergraduate students' vulnerability to stress.^^ Having astrong social network, good physical health, and sense ofcontrol over one's personal life and academics have a

COLLEGE STUDENTS' MENTAL HEALTH 1 0 3

TABLE 4Mental Health Issues Effect on Academic Performance

% Response Among Students

practicum work

practieum work

practicum work

practicum work

practicum work

practicum work

practicum work

Undergraduate

59.821.713.22.01.50.8

64.025.67.22.10.70.5

83.410.93.31.40.60.4

77.012.15.93.1I.I0.7

67.223.16.72.00.30.59.6

29.915.33.70.61.0

29.942.419.95.31.31.2

Graduate

60.927.07.81.70.72.1

67.925.34.21.20.50.9

86.610.12.10.40.30.6

76.415.04.61.60.62.0

69.923.54.11.10.31.0

59.830.76.71.10.31.5

31.351.711.42.40.62.5

Cramer's V

Anxiety (A^= 27 063)

Concern for family member or friend(N = 27 063)

Death of family member or friend(N = 27 030)

Depression {N = 26 970)

Relationship difficulties {N = 27 028)

Sleep difficulties {N = 21 004)

Stress (Af= 27 047)

Not happened to meExperienced, no effectLower grade on exam/projectLower grade in courseIncomplete or dropped courseDisrupt thesis, dissertation, research.Not happened to meExperienced, no effectLower grade on exam/projectLower grade in courseIncomplete or dropped courseDisrupt thesis, dissertation, research.Not happened to meExperienced, no effectLower grade on exam/projectLower grade in courseIncomplete or dropped courseDisrupt thesis, dissertation, research.Not happened to meExperienced, no effectLower grade on exam/projectLower grade in courseIncomplete or dropped courseDisrupt thesis, dissertation, research.Not happened to meExperienced, no effectLower grade on exam/projectLower grade in courseIncomplete or dropped courseDisrupt thesis, dissertation, research.Not happened to meExperienced, no effectLower grade on exam/projectLower grade in courseIncomplete or dropped courseDisrupt thesis, dissertation, research.Not happened to meExperienced, no effectLower grade on exam/projectLower grade in courseIncomplete or dropped courseDisrupt thesis, dissertation, research.

171.79 .080*

64.40 .049*

44.83 .041*

99.96 .061*

53.99 .045*

259.94 .098*

244.92 .095*

'p < .001.

positive effect on an undergraduate student's ability totolerate stress,^^ and universities could incorporate improv-ing that skill set in first-year experience programs.

As indicated previously, mental health challenges impactacademic performance directly as well as through health riskbehaviors. With undergraduate students reporting higher ratesof feelings and behaviors related to poor mental health, healtheducators and university officials may wish to track health riskbehavior trends on their campus to proactively identifystudents at risk for poor academic performance. Additionally,health promotion programs addressing maladaptive health

risk behaviors commonly exhibited by students with mentalhealth issues, such as smoking, drinking, and self-injury,should be implemented and targeted toward undergraduatestudents, particularly college freshmen. ' '

Twenty-nine percent of graduate students in this studyidentified as Asian/Pacific Islander. Current research compar-ing depressive symptoms and psychological distress ofEuropean American and Asian American college students isconfiicting. Studies indicate similar levels, "'"^^ lowerlevels,''^'^^ and higher levels^^ of depressive symptoms anddistress among Asian Americans. Nevertheless, evidence


Strongly suggests that Asian American college students havegreater self-concealment,^ ' * less favorable help-seekingattitudes, greater mental health stigma, and lower levels ofstigma tolerance and interpersonal openness^* and are lesslikely to utilize psychological services than EuropeanAmerican college students.^^ The large percentage of Asian/Pacific Islander graduate student respondents may explain thelower rates of reported mental health issues among graduatestudents. Another explanation may be that individuals whohave less mental health issues and Stressors may be able tocontinue with graduate or professional school compared tothose who have less effective coping skills.

Though graduate students reported lower rates of mentalhealth issues than undergraduates, they did report higherrates of stress. Given the nature of graduate school, thisresult does not seem surprising. Several studies havehighlighted high rates of stress among graduate stu-dents.' ' '*' ' ^ The common sources of stress reported bygraduate students include schoolwork, finances, graduate/teaching assistantships, career planning, and familyissues. •'"^^ Stress management programs targeting thecommon sources of stress should be provided to graduatestudents. Specific challenges to graduate school should beopenly discussed along with the various forms of assistanceavailable on campus. Similarly, graduate advisors can playan integral role. It is documented that among graduatestudents who experienced a stress-related or emotionalproblem that significantly affected their academic perform-ance over the past year, those who had a better relationshipwith their advisors were more likely to use counselingservices.^ Because graduate students report high stresslevels due to financial reasons, universities should ensurethat graduate students have access to adequate mental healthinsurance and high-quality counseling services.^^

Graduate students are also more detached from campus,which may negatively affect their mental health and stresslevels. University-related activities and organizations oftentarget the undergraduate student population. In an attempt toincrease campus engagement among graduate students,universities should encourage and support graduate andprofessional student organizations that go beyond academic orprofessional matters. Similarly, health educators and univer-sity student affairs should develop campus-wide activitiestargeting the social and cultural needs of graduate students.^^

The perceived negative effects of mental health issues onacademic performance were reported more frequently byundergraduate students. These included lower grades onexams/projects, lower grades in courses, and a higherfrequency of incomplete or dropped courses due to mentalhealth challenges. Many undergraduate students are notinvolved in research or a practicum or writing a thesis ordissertation; thus, the disruption in thesis, dissertation,research, or practicum work due to mental health issuesimpacting more graduate students is expected. Academicprograms need to understand this possible effect because it

may appear that graduate students are doing fine becausegrades on exams/projects or courses may not be low but thestudent may still be experiencing extreme stress or a mentalhealth issue. Many universities provide tutoring, supplementalinstruction, and academic assistance to undergraduatestudents. To alleviate stress among graduate students, suchassistance, particularly focusing on the issues of academicwriting and successful completion of a thesis or dissertation,should be provided.

Mental health disorders cire widespread among collegestudents. Though the majority of students with mentalhealth challenges are aware of the need for treatment, mostdo not receive it.''''' ° The findings from this study indicate nodifferences on previous use of mental health services;however, graduate students are more likely to seek futureservices. Yorgason et al.^' found that having fewer years incollege was related to less knowledge about universitymental health services, which may explain graduatestudents' greater receptiveness to services. This study'sfindings suggest the need for university health services toheavily promote and market services, particularly mentalhealth and counseling services, available to students,especially undergraduate students, on campus.

Stigma also infiuences college students' abilities toaccess appropriate services.'*' ''' A lack of understandingamong family and friends, fear of appearing weak, andlimited knowledge of how to access services are cited asadditional major reasons for refusal to seekhelp. Interestingly, when students do seek assistance fromuniversity services, they often find great value in theacademic and counseling services they receive.'*^

Technology has become an integral part of individuals',particularly young adults' and college students', lives.Technology such as smartphones, texting, Facebook, etc.,have changed how individuals interact with one anothersocially as well as academically. Text messaging has beenreported as an effective means of communicating with andsupporting the needs of college students with mental healthproblems. Such an approach provides a means ofmaintaining continuous contact between the student andprovider,"*"* which may make the difference betweenacademic success and failure.

The effective use of online learning communities to addressstudent mental health has also been documented. Richards andTangney"* reported that onUne learning communities formental health support and education appear to disinhibitparticipants and increase disclosure, act as a gateway for furthersupport, and allow access for students who do not ordinarily useface-to-face services. Similarly, Moreno et al.^ reported thatcollege students frequently display symptoms consistent withdepression on Facebook. Those who receive online supportfrom friends are more likely to openly discuss their depressivesymptoms. As a result, health educators and mental healthspecialists may use technology such as online learningcommunities or social networking sites in conjunction with a


social marketing campaign to highlight the services provided bythe university and debunk the stigma surrounding mental healthby providing an open and nonthreatening forum for disclosure.Likewise, on-campus buddy systems for first-year students, thatmay or may not include technology, could assist in increasingthe number of undergraduate students seeking mental health

services on campuses,43

LIMITATIONS

As with any study, there were limitations in this project. Thereare concerns about the response rates and generalizability ofdata with the ACHA-NCHA 11. The mean response proportionfor this data set was 36% and the median response proportionwas 23%, with much higher rates for paper administration(mean response proportion 90%) versus web surveyadministration (mean response rate 21%). This low responserate as well as the fact that the respondent group was not a truerandom sample of U.S. college students does affect general-izability. At the same time, previous studies have demon-strated that the ACHA-NCHA II provides similar results tonationally representative surveys** ; however, these mainlyaddress undergraduate issues.

A second limitation of this study relates to the correctionmethod used in the data analyses. To control for type 1 errorgiven the large sample size, Bonferroni adjustment wasperformed. The use of the Bonferroni correction may haveyielded more conservative results compared to othercorrection methods. Another limitation may relate toresponder bias. As this study and the literature suggest,graduate students are experiencing high levels of stress dueto a variety of factors. Given the low levels of mental healthissues, it is possible that graduate students who were toostressed opted not to respond to this survey. Graduatestudents experiencing extremely high levels of stress or amental health issue may not have the energy or desire tocomplete the survey instrument. As a result, our findingsmay be more refiective of those graduate students with lesssevere mental health challenges. Additionally, gender andethnic variables were not examined within this study. Asstated previously, Asian American college students are lesslikely to self-disclose, report greater mental health stigma,and are less likely to utilize mental health services.^'''^^ Thelarge percentage of graduate students who identify as Asian/Pacific Islander may have impacted the results of this study.Future research should be conducted to examine ethnicityand gender and their impact on academic performance.

One final limitation is inherent in all quantitativestudies—the absence of context for participants' responses.With stress and mental health issues, understanding thebackground that affects these issues is critical. As identifiedby Robotham,'*^ further research on stress and collegestudents needs to be qualitative and longitudinal.

TRANSLATION TO HEALTH EDUCATIONPRACTICE

Understanding potential differences in undergraduate andgraduate student stress and mental health issues is critical toeffective service delivery. Individual (self-esteem, copingabilities, self-perceptions, etc.), interpersonal (ability tofunction in a social environment, satisfaction with socialand academic aspects of college, etc.), and institutional-level factors (academic requirements, institutional climate,peer and academic personnel support, availability ofservices, etc.) are associated with college students' mentalhealth. Recent research suggests that simultaneouslyaddressing individual and institutional-level influences tomental health through program and policy developmentmay be most effective at addressing college students'mental health needs.'*^ The results of this study suggest thatmental health and stress differences among undergraduateand graduate students should be considered to effectivelydeliver such programs and services.

To address the needs of undergraduate students, healtheducators and university officials should incorporate first-year experience programs that focus on the nonacademic aswell as academic needs of freshmen; track health riskbehavior trends and implement health risk behaviorprograms known to impact academic performance; createinnovative campaigns and programs designed to debunk thestigma of mental health and increase usage of mental healthservices; and incorporate the use of technology to betterfacilitate counseling services. Conversely, activities toincrease student engagement on campus; support forgraduate student organizations; opportunities for academicassistance surrounding writing and thesis/dissertationcompletion; supportive academic advisors; and access tocounseling services should be provided to meet the mentalhealth needs of graduate students.

In closing, health educators and university administratorsshould take an interest in the connection of mental healthissues and other health-related behaviors to academicperformance and retention rates. The rewards and benefitsfor understanding the potential differences and similaritiesare great. In addition to better student health outcomes,universities may see increases in academic performance andstudent retention because several associations betweenhealth issues and academic success and retention exist.

Helminiak and McNeil^° recommended that healtheducators and university officials address the following in anattempt to enhance student health and academic success andretention: (1) integrate academics into the vision/mission ofuniversity health services and college health programs; (2)infuse effective health promotion strategies into health-relatedcurricula; (3) link health promotion to the university's overalleducation goals; and (4) integrate health promotion into thevision/mission of the university. These priority areas arerelevant to mental health and stress. By making the mental


health and well-being of college students a focus, universitiesand health educators are taking a proactive approach to studentacademic success and retention.

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