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. Author manuscript; available in PMC: 2025 Aug 12.
Published in final edited form as: J Coll Stud Ment Health. 2024 Jul 10;39(3):479–497. doi: 10.1080/28367138.2024.2373946

Barriers to and benefits of mental health services in college students with and without depression, anxiety, and hazardous alcohol use

Sarah J Peterson 1, Brooke J Arterberry 1, Megan E Patrick 1
PMCID: PMC12332521  NIHMSID: NIHMS2012261  PMID: 40786013

Abstract

College students are at risk for mental health concerns and hazardous alcohol use, yet few access services. We examined perceived barriers to and benefits of mental health services utilization (MHSU) among college students with and without symptoms of depression, anxiety, and/or hazardous alcohol use. Second-year students (n=756; 63.4% female, 76.3% White non-Hispanic) were asked about depression, anxiety, alcohol use, and perceived barriers to and benefits of MHSU. Approximately 20% of students reported depression symptoms, anxiety symptoms, and/or hazardous alcohol use. About 40% of students with mental health symptoms and 25% of students engaging in hazardous alcohol use reported MHSU. Cost was the most cited barrier (89.1%), while improved mental health was the most cited benefit (97.7%). Compared to males, females had greater odds of reporting cost, lack of insurance, and not knowing where to go for help as barriers and increased communication as a benefit. Students reporting depression or anxiety symptoms endorsed more barriers than students without symptoms, specifically discomfort sharing feelings with another person, wanting to handle problems on one’s own, and lack of insurance. Campus administrators and counseling centers may benefit from understanding specific perceived benefits and barriers among students to develop strategies for outreach.

Keywords: mental health services utilization, college students, depression, anxiety, alcohol use

Introduction

A growing body of research acknowledges a “mental health crisis” on college campuses, with rates of mental health conditions nearly doubling over the past decade (Lipson et al., 2019; 2022; Oswalt et al., 2020). About one-third of college students screen positive for an anxiety, mood, or substance use disorder (Auerbach et al., 2018; Ebert et al., 2019; Oswalt et al., 2020), and many students report more than one mental health condition (Eisenberg et al., 2013; Lipson et al., 2022). However, few college students with mental health conditions receive treatment (Auerbach et al., 2016; Bruffaerts et al., 2019). Additionally, alcohol use is the most used substance among young adults (Patrick et al., 2023), with up to 34%−53% engaging in hazardous alcohol use (i.e., score of 8+ on the Alcohol Use Disorders Task [AUDIT]; Babor et al., 2001; Babor & Grant, 1989; DeMartini & Carey, 2009; Wallenstein et al., 2007). In 2022, 27.7% of college students reported engaging in binge drinking (4+/5+ drinks per occasion; Patrick et al., 2023). Hazardous alcohol use and mental health conditions among college students can lead to negative consequences including risks to physical and mental health, academic performance, and interpersonal problems (Brown et al., 2009; Bruffaerts et al., 2018; Buchanan, 2012; Evans-Polce et al., 2022; Gallagher, 2015; Patrick et al., 2020). Considering the onset of most mental disorders typically occurs before the age of 24 (Kessler et al., 2005) and nearly three-quarters of U.S. high school students enroll in college or university (Hanson, 2022), the college years are a prescient time for prevention and intervention initiatives targeting young adult mental health and hazardous alcohol use.

Although mental health services utilization (MHSU) has increased among students (Lipson et al., 2019;2022; Oswalt et al., 2020; Watkins et al., 2012), only 30–50% of students receive treatment for mental health (Blanco et al., 2008; Lipson et al., 2019;2022). This is surprising given the unique set of resources available on college campuses (e.g., near-universal health insurance, the availability of free campus mental health and primary care services; Blanco et al., 2008; Eisenberg et al., 2007). Theoretical models of help-seeking behavior, such as the health belief model (Rosenstock, 2005), may help to explain this discrepancy and determine whether an individual will utilize mental health services. The health belief model (Rosenstock, 2005) emphasizes beliefs surrounding how susceptible one is to a particular condition and how serious an impact the condition would have on one’s life. Additionally, perceived benefits of services (i.e. beliefs about how effective treatment might be) and perceived barriers (i.e. how inconvenient, expensive, unpleasant, painful, or upsetting treatment might be) are thought to influence the likelihood that an individual takes action toward service utilization.

The gap between rates of mental health conditions and MHSU, coupled with the theoretical perspectives described above, has led researchers to investigate what college students perceive as barriers to seeking mental health care. One commonly cited barrier is self-reliance (i.e., preference for solving problems on one’s own; Cadigan et al., 2019; Ebert et al., 2019; Gulliver et al., 2010). Other barriers include the cost of services, lack of perceived need, lack of knowledge regarding campus resources, skepticism surrounding treatment effectiveness, and a preference for turning to friends and family for support (Ebert et al., 2019; Eisenberg et al., 2007, 2011, 2012; Gulliver et al., 2010). Barriers may also vary as a function of mental health symptomatology. Ebert and colleagues (2019) found that students who met criteria for major depression or generalized anxiety disorder had the highest odds of reporting embarrassment as a barrier to treatment. Cadigan and colleagues (2019) found that those who reported symptoms of depression endorsed concerns that treatment might negatively impact their work, fears of being hospitalized or prescribed medication, and logistical issues, such as lack of transportation. This preliminary evidence suggests students with depression or anxiety may be more prone to perceive barriers to care. However, there is a gap in the literature examining perceived barriers to treatment among students with co-occurring mental health concerns and students engaging in hazardous alcohol use.

While barriers to treatment have received some research attention, students’ perceived benefits of MHSU are understudied (Vidourek et al., 2014) despite their potential to increase help-seeking for mental health conditions. A small body of work suggests that commonly endorsed benefits include improved mental health and quality of life, increased coping skills and problem solving, and reduced stress (Vidourek et al., 2014, 2019). No studies have examined whether specific perceived benefits vary as a function of mental health condition or hazardous alcohol use. Understanding the perceived benefits of MHSU among students with mental health and hazardous alcohol use concerns may be one way to encourage them to seek services. For example, benefits endorsed by this population could be highlighted in educational interventions directed towards students or incorporated into screening and referral services to motivate students to access available resources. Thus, investigating benefits might be of particular importance.

Few studies have examined whether endorsement of specific barriers to or benefits of MHSU vary across biological sex or racial/ethnic background. Prior work does show that females perceive a greater total number of benefits compared to males (Vidourek et al., 2014), but not which specific benefits show differences. Similar results were found for race/ethnicity, with white students perceiving more benefits compared to non-white students (Vidourek et al., 2014). These characteristics are important to explore given differences in anxiety, depression, hazardous alcohol use, and help-seeking behavior (Eisenberg et al., 2007; Rosenfield & Mouson, 2013). Identifying specific barriers and benefits that are reported by different sociodemographic groups can aid campus administrators and health professionals in designing outreach programming for specific subsets of the student body.

This study expands the current literature on college student MHSU by examining both barriers to and benefits of treatment as a function of symptoms of depression and anxiety, hazardous alcohol use, and the co-occurrence of these conditions. Additionally, we examine differences in the endorsement of barriers and benefits across biological sex and race/ethnicity. We did so with a sample of second year students (average age of 19) to investigate potentially more independent utilization of services once students have more autonomy from their parents (Arnett, 2000; Arnett & Mitra, 2020) and more familiarity with campus or near-campus mental health resources. Using data from a larger study examining the efficacy of an alcohol intervention for incoming college students (Patrick et al., 2020, 2021), the current study aimed to answer three research questions (RQs):

RQ1) What percent of students report MHSU in a college student sample overall, as well as for students reporting symptoms of depression, anxiety, or hazardous alcohol use?

RQ2) What are the most common perceived barriers to and benefits of MHSU among college students?

RQ3) Does the endorsement of perceived barriers to and benefits of MHSU vary as a function of a) sociodemographic characteristics or b) symptoms of depression, anxiety, hazardous alcohol use, or their co-occurrence?

Methods

Participants and procedures

Incoming college students (N=891) from a Midwestern university were recruited for an intervention study designed to reduce binge drinking and alcohol-related consequences (Patrick et al., 2020, 2021). Using the Registrar’s list, 1,500 randomly selected incoming first-year students were invited to participate in 2019. After providing informed consent, participants were then randomized to either an assessment-only control condition (n=300) or an intervention condition (n=591). Analyses control for intervention condition.

Baseline surveys were conducted in August 2019, follow-up 1 surveys in December 2019, follow-up 2 surveys in May 2020, and follow-up 3 surveys in September 2020. Students were mailed a pre-incentive of $5 with the recruitment letter inviting them to participate. They were compensated $25 for completing the baseline survey, $30 for completing the follow-up 1 survey, and $35 each for completing follow-up 2 and follow-up 3 surveys. Study procedures were approved by the university IRB.

Data from the beginning of students’ second year of college (i.e., follow-up 3 in Fall 2020) were used for the analyses of the current study. We selected follow-up 3 for the following reasons. First, follow-up 1 was not used, as it occurred shortly after the intervention (see Patrick et al., 2020 for more detail on the interventions), which could have impacted students’ alcohol use, service utilization, and perceptions regarding benefits and barriers. Second, follow-up 2 was not used because it occurred during the first wave of the COVID-19 pandemic when the university campus was closed and access to services was not consistent. However, follow-up 3 occurred several months after the onset of the COVID-19 pandemic when nearly 80% of our sample had returned to campus and had access to associated resources.

At follow-up 3, 84.8% (756 of 891) of eligible respondents provided data. A total of 19 people (2.5% of observations) were excluded due to missing data on study variables, resulting in a total analytic sample of n=737. The sample was 63.4% female and 76.3% non-Hispanic White, 10.3% non-Hispanic Asian, 3.8% non-Hispanic Black/African American, 1.6% Hispanic/Latinx, and 8.1% other race/multiracial. The average age was 19.12 years (SD=.21).

Measures

Depression symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001). Participants were asked “Over the last 2 weeks, how often have you been bothered by any of the following problems?” (e.g., “Feeling down, depressed, or hopeless”). Response options ranged from 0-“Not at all” to 3-“Nearly every day.” The nine items were summed for a total score (range: 0–27; α=.88). A cut point of ≥10 was used to detect moderate to severe depression symptoms (Kroenke et al., 2001), coded as 1=yes (scores ≥10), 0=no (scores 0–9).

Anxiety symptoms were assessed using the Generalized Anxiety Disorder-7 (GAD-7; Spitzer et al., 2006). Participants were asked “Over the last 2 weeks how often have you been bothered by the following problems?” (e.g., “Feeling nervous, anxious, or on edge”). Response options ranged from 0-“Not at all” to 3-“Nearly every day.” The seven items were summed to create a total score (range: 0–21; α=.91). A cut point of ≥10 was used to detect moderate to severe anxiety symptoms (Spitzer et al., 2006), coded as 1=yes (scores ≥10) and 0=no (scores 0–9).

Hazardous alcohol use was assessed using the Alcohol Use Disorders Identification Task (AUDIT: Babor et al., 1989). This 10-item measure assesses drinking frequency, quantity, and alcohol-related problems. A total score was created by summing all items (range: 0–40; α=.79). A cutoff of ≥8 was used to determine hazardous alcohol use (Babor et al., 2001), coded as 1=yes (scores ≥8), 0=no (scores 0–7).

Co-occurring conditions was coded such that 0=presence of zero or one condition (i.e., depression symptoms, or anxiety symptoms, or hazardous alcohol use), as determined by cut points detailed above, and 1=presence of two or three conditions.

Mental health services utilization (MHSU) was assessed with the item “In the last 3 months, have you used any of the following resources or services?” Participants were asked to respond “yes” or “no” to a list of five options (see Table 1). “Any MHSU” was coded as 1 (0=none).

Table 1:

Mental health, alcohol use, and mental health services utilization characteristics

Variable Mean /N SD/%
Depression (PHQ-9) total score 5.31 4.67
Presence of depression symptoms (PHQ-9 ≥ 10) 128 17.4%
Anxiety (GAD-7) total score 5.70 5.11
Presence of anxiety symptoms (GAD-7 ≥ 10) 155 21.0%
AUDIT total score 4.23 4.15
Hazardous alcohol use (AUDIT ≥ 8) 145 19.6%
Total number of barriers (out of 14) 10.52 3.40
Total number of benefits (out of 14) 11.24 3.37
Any Mental Health Services Utilization 174 23.6%
 On-campus individual counseling or therapy 38 5.2%
 Off-campus individual counseling or therapy 94 12.7%
 Group therapy 9 1.2%
 Support group 8 1.1%
 Self-help websites/books/apps 76 10.3%
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Note. N=737; the range of barriers and benefits endorsed was 1–14 for each.

Perceived barriers to and benefits of MHSU were assessed with respective items “Which of the following do you feel is a barrier for (or benefit of) individuals seeking help for mental health problems?” Participants were asked to mark all that apply from a list of 14 barriers and 14 benefits (see Table 2; Vidourek et al., 2014).

Table 2:

Frequencies of endorsed barriers to and benefits of Mental Health Services Utilization

Perceived Barriers N %
Cost 657 89.1%
Embarrassment 641 87.0%
Denial that there is a problem 638 86.6%
Not feeling comfortable sharing feelings with another person 626 82.8%
Wanting to handle problems on one’s own 590 84.9%
Not wanting to talk to a counselor about personal issues 589 79.9%
Not knowing where to go for help 565 74.7%
Lack of social support 543 76.7%
Lack of insurance 509 69.1%
Not wanting to be labeled as “crazy” 499 67.7%
Not wanting help 499 67.7%
Not wanting to be placed on medication 490 66.5%
Fear of counselors 462 62.7%
Not wanting to be admitted to a hospital 442 60.0%
Perceived Benefits N %
Improved mental health 720 97.7%
Self-awareness/personal growth 670 90.9%
Reduced stress 658 89.3%
Increased self-confidence 627 85.1%
Increased communication 623 84.5%
Increased social support 612 83.0%
Increased comfort sharing feelings with others 607 82.4%
More optimistic attitude 595 80.7%
Resolving one’s problems 590 80.1%
Improved life satisfaction 585 79.4%
Happiness 544 73.8%
Increased relationships 518 70.3%
Improved sleep 480 65.1%
Increased energy 479 65.0%
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Note. N=737

Intervention randomization

Participants were recruited as part of a larger intervention study, so intervention randomization was used as a control variable (0=control condition and 1=intervention condition).

Demographics

Biological sex was coded as female or male. Race/ethnicity was assessed by asking participants to check all that apply: American Indian, Asian, Black/African American, Hispanic/Latinx, Hawaiian/Pacific Islander, White/Caucasian, and Other. Responses were coded as binary (0=non-Hispanic White, 1=Hispanic/non-Hispanic other/multiracial) due to limited sample sizes for some categories.

Analytic strategy

Analyses were conducted in SPSS version 28. RQs 1 and 2 were addressed with descriptive statistics. For RQ3, t-tests were used to examine differences in the mean number of endorsed barriers and benefits of MHSU across biological sex and race/ethnicity, as well as between students with and without symptoms of depression, anxiety, hazardous alcohol use, and co-occurring concerns. We then estimated a series of logistic regression models. First, we modeled associations between biological sex, race/ethnicity, and intervention randomization and each specific barrier or benefit. Next, we examined associations between symptoms of depression, anxiety, hazardous alcohol use, and co-occurring concerns, separately, with each specific barrier or benefit. In these latter models, we included intervention randomization, sex, and race/ethnicity as covariates. Due to multiple comparisons, significance level was set to p<.01 for all logistic regression analyses.

Results

Descriptive characteristics

Descriptive information is provided in Table 1. A total of 304 students (41.2%) reported at least one condition: 128 (17.4%) reported depression symptoms, 155 (21.0%) reported anxiety symptoms, and 145 (19.6%) reported hazardous alcohol use. A total of 107 students (14.5%) reported co-occurring conditions: 69 (9.4%) reported both anxiety and depression symptoms, 13 (1.8%) reported anxiety symptoms and hazardous alcohol use, 8 (1.1%) reported depression symptoms and hazardous alcohol use, and 17 (2.3%) reported depression symptoms, anxiety symptoms, and hazardous alcohol use.

Only 23.6% of students reported any MHSU in the past 3 months, but prevalence was higher among students with mental health concerns. In particular, 39.7% of students with depression symptoms, 42.8% of students with anxiety symptoms, and 24.1% of students engaging in hazardous alcohol use reported past 3-month MHSU. Over half of these students accessed care through off-campus individual counseling or therapy (12.9% of the total sample), followed by use of self-help websites/books/apps (10.4%; see Table 1). The mean total number of barriers endorsed was 10.52 (SD=3.40), and the mean total number of benefits endorsed was 11.24 (SD=3.37). Endorsement rates of specific perceived barriers to and benefits of MHSU are listed in Table 2. The most common perceived barriers were cost, embarrassment, and denial of a problem. The most common perceived benefits were improved mental health, increased self-awareness/personal growth, and reduced stress.

Barriers and benefits associated with sociodemographic characteristics

On average, female students endorsed more barriers (M=10.74, SD=3.32) than male students (M=10.12, SD=3.50; t(735)=2.39, p=.017, d=.18). There was no significant difference between the total number of endorsed benefits between female and male students. However, female students had greater odds of reporting specific benefits of and barriers to MHSU (Table 3). Females had greater odds of reporting “cost” (OR=2.36, p < .001), “lack of insurance” (OR=2.00, p < .001), and “not knowing where to go for help” (OR=2.29, p < .001) as barriers. Female students had greater odds of endorsing “increased communication” as a benefit (OR=1.72, p=.008). There were no significant differences in the total number of perceived barriers or benefits endorsed or in the odds of endorsing specific barriers or benefits found for race/ethnicity.

Table 3.

Odds of endorsing barriers/benefits across sociodemographic characteristics

Female (v. Male) Non-Hispanic White (v. Hispanic/non-Hispanic other/multiracial)
Outcome: Perceived Barrier OR CI OR CI
Cost 2.36 1.27–4.37 0.74 0.34–1.61
Embarrassment 0.81 0.44–1.47 0.90 0.45–1.77
Denial that there is a problem 1.40 0.80–2.46 1.19 0.63–2.26
Not feeling comfortable sharing feelings with another person 1.34 0.78–2.29 1.00 0.54–1.88
Wanting to handle problems on one’s own 0.98 0.60–1.61 1.34 0.78–2.30
Not wanting to talk to a counselor about personal issues 1.38 0.85–2.23 1.07 0.61–1.85
Not knowing where to go for help 2.29 1.45–3.62 0.91 0.53–1.57
Lack of social support .97 0.62–1.52 0.80 0.47–1.35
Lack of insurance 2.00 1.31–3.05 0.65 0.39–1.10
Not wanting to be labeled as “crazy” 1.23 0.81–1.88 0.65 0.39–1.08
Not wanting help 0.93 0.61–1.41 1.00 0.62–1.62
Not wanting to be placed on medication 1.23 0.81–1.86 1.23 0.77–1.96
Fear of counselors 1.21 0.81–1.81 1.02 0.64–1.62
Not wanting to be admitted to a hospital 1.03 0.69–1.54 0.96 0.61–1.52
Outcome: Perceived Benefit OR CI OR CI
Improved mental health 1.04 0.30–3.60 2.41 0.71–8.17
Self-awareness/personal growth 1.69 0.88–3.26 1.28 0.61–2.67
Reduced stress 1.23 0.66–2.28 0.86 0.41–1.80
Increased self-confidence 1.06 0.61–1.83 1.11 0.60–2.05
Increased communication 1.72 1.02–2.91 0.89 0.47–1.67
Increased social support 1.36 0.82–2.27 0.73 0.39–1.37
Increased comfort sharing feelings with others 1.17 0.71–1.95 1.12 0.63–1.99
More optimistic attitude 0.91 0.55–1.51 1.11 0.63–1.93
Resolving one’s problems 0.82 0.50–1.35 0.57 0.30–1.06
Improved life satisfaction 1.15 0.71–1.85 0.95 0.55–1.66
Happiness 0.86 0.55–1.35 1.01 0.61–1.68
Increased relationships 1.30 0.85–1.99 1.01 0.62–1.65
Improved sleep 0.97 0.64–1.46 0.91 0.57–1.47
Increased energy 1.06 0.70–1.60 1.01 0.63–1.61
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Note. N=737. Bold text indicates p<.01. OR=Odds Ratio, CI=99% Confidence Interval. Sex coded as binary (male v. female) with male as the reference group. Race coded as binary (non-Hispanic white v. Hispanic/non-Hispanic other/multiracial) with non-Hispanic white as the reference group. Outcome for each logistic regression was the endorsement (or not) of each listed barrier or benefit. All models controlled for intervention randomization.

Barriers and benefits associated with symptoms of depression, anxiety, and hazardous alcohol use

Depression

On average, students who reported depression symptoms endorsed about one more barrier (M=11.20, SD=2.92) than students who did not report symptoms (M=10.38, SD=3.47; t(735)=2.48, p=.014, d=.26). Regarding specific perceived barriers, students who reported depression symptoms had over twice the odds of endorsing “wanting to handle problems on one’s own” (OR=2.36, p=.005) and almost three times the odds of endorsing “not feeling comfortable sharing feelings with another person” (OR=2.84, p=.007), when compared to those not reporting symptoms (see Table 4). There were no differences in the total number of perceived benefits endorsed or in the odds of endorsing specific benefits between students with and without depression symptoms (Table 4).

Table 4:

Odds of endorsing perceived barriers/benefits as a function of symptoms of depression, anxiety, and hazardous alcohol use

Moderate/Severe Depression Moderate/Severe Anxiety Hazardous Alcohol Use Co-occurring Conditions
Outcome: Perceived Barrier OR CI OR CI OR CI OR CI
Cost 1.54 0.56–4.26 0.76 0.37–1.57 1.59 0.63–4.00 1.12 0.43–2.96
Embarrassment 0.88 0.42–1.85 0.96 0.47–1.96 1.09 0.53–2.23 1.07 0.47–2.46
Denial that there is a problem 1.23 0.55–2.75 1.06 0.52–2.16 1.20 0.57–2.52 2.26 0.79–6.50
Not feeling comfortable sharing feelings with another person 2.84 1.05–7.67 1.27 0.63–2.59 2.02 0.90–4.54 1.93 0.75–4.96
Wanting to handle problems on one’s own 2.36 1.07–5.18 1.06 0.57–1.97 2.28 1.11–4.69 2.64 1.08–6.48
Not wanting to talk to a counselor about personal issues 2.14 0.98–4.69 1.04 0.57–1.90 1.73 0.88–2.41 1.64 0.75–3.60
Not knowing where to go for help 1.18 0.61–2.30 1.02 0.57–1.80 1.36 0.73–2.53 1.34 0.65–2.76
Lack of social support 1.07 0.59–1.93 1.11 0.64–1.94 0.94 0.55–1.62 1.00 0.54–1.88
Lack of insurance 1.38 0.75–2.54 0.86 0.51–1.44 1.91 1.06–3.44 1.30 0.69–2.48
Not wanting to be labeled as “crazy” 1.10 0.62–1.94 0.93 0.56–1.56 1.42 0.83–2.44 1.43 0.76–2.68
Not wanting help 1.17 0.67–2.06 1.14 0.67–1.93 1.08 0.64–1.80 1.35 0.73–2.49
Not wanting to be placed on medication 1.16 0.66–2.03 0.98 0.59–1.64 1.28 0.76–2.16 1.24 0.68–2.27
Fear of counselors 1.77 1.00–3.15 0.94 0.57–1.55 1.65 0.98–2.79 1.67 0.91–3.08
Not wanting to be admitted to a hospital 1.21 0.71–2.06 1.07 0.65–1.76 1.56 0.94–2.59 1.28 0.72–2.28
Outcome: Perceived Benefit OR CI OR CI OR CI OR CI
Improved mental health 2.11 0.29–15.29 1.45 0.27–7.65 1.17 0.22–6.14 1.49 0.21–10.60
Self-awareness/personal growth 1.30 0.49–3.46 1.64 0.62–4.31 1.38 0.56–3.38 1.67 0.53–5.24
Reduced stress 1.11 0.47–2.64 1.10 0.50–2.43 1.12 0.51–2.48 1.12 0.45–2.83
Increased self-confidence 1.16 0.55–2.45 1.21 0.60–2.42 1.69 0.79–3.64 1.16 0.52–2.57
Increased communication 0.97 0.46–2.02 1.06 0.53–2.10 1.08 0.55–2.10 1.00 0.46–2.19
Increased social support 1.24 0.59–2.60 1.28 0.65–2.52 1.00 0.53–1.90 1.08 0.51–2.30
Increased comfort sharing feelings with others 1.06 0.53–2.11 1.51 0.76–2.98 1.38 0.70–2.71 1.3 0.60–2.81
More optimistic attitude 0.99 0.52–1.88 1.24 0.67–2.32 1.85 0.92–3.75 1.19 0.58–2.46
Resolving one’s problems 1.11 0.57–2.15 1.01 0.56–1.83 1.29 0.68–2.42 1.07 0.53–2.15
Improved life satisfaction 1.32 0.67–2.61 1.17 0.64–2.15 1.54 0.81–2.94 1.01 0.51–2.00
Happiness 0.92 0.52–1.64 0.94 0.55–1.61 1.68 0.92–3.07 1.04 0.55–1.94
Increased relationships 0.78 0.45–1.37 1.08 0.64–1.84 1.42 0.82–2.47 0.85 0.47–1.54
Improved sleep 0.89 0.52–1.53 1.00 0.61–1.66 1.15 0.69–1.92 0.87 0.49–1.53
Increased energy 1.06 0.62–1.83 1.25 0.75–2.08 1.21 0.72–2.03 1.17 0.65–2.11
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Note. N=737. Bold text indicates p<.01. OR=Odds Ratio, CI=99% Confidence Interval. Moderate/severe depression was coded as binary, with scores 0–9 v. scores ≥10 on the PHQ-9. Moderate/severe anxiety was coded as binary, with scores 0–9 v. scores ≥10+ on the GAD-7. Hazardous alcohol use was coded as binary, with scores 0–7 v. scores ≥8 on the AUDIT. Outcome for each logistic regression was the endorsement (or not) of each listed barrier or benefit. All models controlled for biological sex, race/ethnicity, and intervention randomization.

Anxiety

On average, students who reported anxiety symptoms endorsed one more barrier (M=11.26, SD=3.03) than students who did not (M=10.33, SD=3.46; t(735)=3.03, p=.003, d=.29). Students who reported anxiety symptoms had approximately two times greater odds of endorsing “lack of insurance” (OR=1.91, p =.005) and “wanting to handle problems on one’s own” (OR=2.28, p=.003) as perceived barriers to MHSU (see Table 4). There were no differences in the total number of perceived benefits endorsed or in the odds of endorsing specific benefits between students with and without anxiety symptoms (Table 4).

Hazardous alcohol use

There were no differences in the total number of endorsed perceived barriers or benefits of MHSU or the odds of endorsing specific barriers or benefits between students who did and did not report hazardous alcohol use (Table 4).

Co-occurring conditions

Students with co-occurring conditions endorsed a greater total number of perceived barriers (M=11.28, SD=2.92) compared to students without co-occurring conditions (M=10.39, SD=3.45; t(735)=2.48, p=.013, d=.28). Students who reported co-occurring conditions had over two times greater odds of endorsing “wanting to handle problems on one’s own” (OR=2.64, p=.005) as a perceived barrier to MHSU compared to students who did not (see Table 4). There were no differences in the total number of perceived benefits endorsed or in the odds of endorsing specific benefits between students with and without co-occurring conditions (Table 4).

Discussion

Results from this study indicated that while about 40% of students endorsed mental health symptoms and/or hazardous alcohol use, relatively few of these students utilized mental health services recently. About 40% of students with mental health symptoms and less than 25% of hazardous drinkers reported MHSU in the past 3-months. These findings are consistent with prior studies suggesting that while rates of MHSU are rising, they are still lower than rates of mental health conditions and hazardous alcohol use among college students (Lipson et al., 2019; 2022; Oswalt et al., 2020).

Despite the lack of widespread MHSU, students nearly universally perceive benefits of mental health treatment, with over 97% identifying improved mental health as a benefit. Other highly endorsed benefits included self-awareness/personal growth, reduced stress, increased self-confidence, and increased communication, similar to prior work (Vidourek et al., 2014, 2019). Perceived benefits did not vary as a function of mental health symptoms or hazardous alcohol use in this study. Students appear aware of the potential effectiveness of mental health treatment; they do not report being skeptical about its efficacy. Benefits were also largely consistent across sociodemographic groups, although female students were more likely than male students to report increased communication as a benefit of MHSU. Outreach efforts to groups dominated by female students (i.e., sororities) might emphasize this particular benefit by describing different ways that services might improve students’ abilities to communicate with friends, family, and romantic partners.

Despite their strong endorsement of possible benefits, students in our sample also endorsed several perceived barriers to MHSU. Knowing the benefits of treatment may not be enough to overcome perceived barriers, especially when experiencing symptoms of depression, anxiety, or problematic substance use that may leave students feeling overwhelmed. As such, a focus on addressing and reducing barriers to MHSU faced by students is necessary. The most commonly endorsed barrier was cost, followed by embarrassment, denial that there is a problem, not feeling comfortable sharing feelings with another person, and wanting to handle problems on one’s own, in line with previous work (Ebert et al., 2019; Eisenberg et al., 2012). That cost was the most endorsed barrier is at odds with access to campus resources, which are typically no- to low-cost (Blanco et al., 2009; Eisenberg et al., 2007). Indeed, students in our sample had access to free services from their university counseling center and were required to have health insurance by the university. This may reflect cost and insurance coverage of off-campus community mental health care providers, or a lack of knowledge about available free services. Given that many university counseling centers operate on a waitlist status throughout the bulk of the academic year (Xiao et al., 2017), freely provided services may not be addressing the needs of many students such that students have to seek services elsewhere for a cost. In our sample, off-campus individual counseling/therapy was the most utilized mental health service, suggesting the need for more providers within the university, expanded mental health insurance coverage for college students, and/or partnerships between university and community services.

Furthermore, cost, lack of insurance, and not knowing where to go for help were endorsed more by female than male students in our sample. Typically, women are more likely engage with mental health services than men (Eisenberg et al., 2012; Sagar-Ouriaghli et al., 2019). Thus, these findings might reflect the higher likelihood of encountering barriers among women since they more frequently seek services. Further research is needed to better understand sex and gender differences in relation to whether and how perceived barriers predict MHSU.

Other top barriers reflect attitudinal reasons for not seeking care. While rates of endorsed stigma (i.e. the extent to which one holds negative beliefs about mental health treatment; Corigan & Row, 2012) among college students are relatively low (Eisenberg et al., 2012; Gaddis et al., 2020), rates of perceived stigma (i.e. the extent to which one believes others will devalue or discriminate against those who receive mental health treatment; Earnshaw & Quinn, 2012) tend to be higher, particularly at larger, public institutions (Gaddis et al., 2020) Thus, students may face concerns about how they will be viewed by peers if they seek services. This may be especially true for students with depression, anxiety, or co-occurring disorders, as we found that these students endorsed, on average, about one additional barrier compared to students without these conditions. Future research would benefit from examining whether multiple barriers, specific barriers, or some combination of mental health concerns and barriers contribute directly to MHSU.

Our findings replicate other work demonstrating self-reliance (i.e., “wanting to handle problems on one’s own”) is a commonly endorsed barrier (Cadigan et al., 2019; Gulliver et al., 2010). Extending this work, we also found that students screening positive for depression along with anxiety or other co-occurring conditions were over twice as likely to endorse self-reliance as a barrier. Students who screened positive for depression were also more likely to report “not feeling comfortable sharing feelings with another person,” consistent with the theme of self-reliance. The frequency with which this barrier appears in the literature (Ebert et al., 2019; Gulliver et al., 2010) speaks to the importance of the development and proliferation of evidence-based self-help material. About 10% of our sample reported using self-help programming via websites, books, or mobile applications. Student affairs professionals and campus administrators should be aware of this and partner with campus mental health services to provide efficacious self-help materials.

Although students may desire to be self-reliant and help themselves in the face of mental health concerns, people do often require professional services for symptom relief. Primary prevention efforts, such as ensuring adequate sleep, nutrition, exercise, stress, time management, and mindfulness interventions, may render early benefits for students and reduce the service burden of counseling centers (Greeson et al., 2014; Stathopoulou et al., 2006; Trockel et al., 2011). University and campus mental health outreach and educational programing beyond clear information about university services and how to access them are likely to be important. Students may be aware of what services are available but do not attempt to access them until their symptoms reach high severity, at which point university clinics are likely operating on a waitlist status. Students would likely benefit from psychoeducation surrounding when their symptoms warrant seeking help, in addition to general awareness of services and financial support.

Notably, no differences were found in perceived barriers or benefits of MHSU among students who did versus did not report hazardous alcohol use. Social norms surrounding alcohol use in college may be at play. Alcohol use and binge drinking during the college years are often thought of as a “rite of passage” (Crawford & Novak, 2010) and students tend to report that their peers drink more alcohol than they do (Merrill & Carey, 2016). As such, those engaging in hazardous alcohol use may not perceive their own drinking behavior to be risky or outside of the norm. Therefore, they may hold views regarding MHSU that are similar to peers who do not engage in hazardous alcohol use.

Limitations

There were limitations to this study. We measured mental health symptoms with validated screening tools which, while efficient and cost-effective, do not equate to a formal clinical diagnosis. Furthermore, other mental health conditions were not assessed in this study. Anxiety and depression are the most common mental health conditions among this population (DeMartini & Carey, 2009; Oswalt et al., 2020), but we cannot determine if other conditions impacted results. Students were asked to endorse perceived barriers/benefits that individuals may face/receive when obtaining mental health care, which have been shown to impact students’ health behavior choices (Von Ah et al., 2003). However, we did not assess direct, personal experiences which could provide additional important information. MHSU was assessed within the past 3 months; we cannot speak to how prevalence rates in our sample might differ if this was assessed across a longer time period (i.e. past year or lifetime). This sample, while large, was limited to one Midwestern university campus with most identifying as White/non-Hispanic. Thus, generalizability may be limited to students attending different institutions and from other racial/ethnic backgrounds. This study was cross-sectional and cannot determine causality.

Data for these analyses were collected during Fall 2020 while campuses were still in the midst of the COVID-19 pandemic, which impacted rates of mental health concerns and alcohol use (Bonar et al., 2021; Kim et al., 2022; Mehus et al., 2023) and temporarily interrupted delivery of in-person mental health services (Rackoff et al., 2023). While we were unable to directly estimate the impacts of the pandemic on mental health symptoms or service utilization in this study, prior work suggests that rates of service utilization rebounded beginning in Fall 2020 (Rackoff et al., 2023). Relatedly, nearly 80% of our sample had physically returned to campus and thus had access to on-campus resources at the time of data collection. Furthermore, rates of mental health symptoms and service utilization among our sample were similar to those found in prior studies (e.g. Lipson et al., 2019; Oswalt et al., 2020). It is less clear how the pandemic might have impacted perceived barriers and benefits of MHSU. There is no evidence to date that suggest there were impacts of the pandemic on these perceptions. Future work should investigate how students’ perceived barriers to and benefits of MHSU have shifted in the wake of the pandemic.

Conclusions

Depression, anxiety, and hazardous alcohol use are relatively common among college student populations, yet the majority of students reporting these concerns do not access mental health services. Findings from this study suggest that while students nearly universally recognize several benefits of mental health care, they also report many perceived barriers to accessing services. This was especially true for students with mental health symptoms. More and better resources, including the bolstering of cost-free campus services, stigma reduction and education campaigns, and the proliferation of evidence-based self-help and prevention strategies, are needed to address the growing mental health crisis among college students.

Funding details:

Data collection and manuscript preparation were supported by grant number R01AA026574 from the National Institute on Alcohol Abuse and Alcoholism. The study sponsors had no role in the study design, collection, analysis or interpretation of the data, writing of the manuscript, or the decision to submit the paper for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the study sponsor.

Footnotes

Disclosures: The authors have no disclosures or conflicts of interest to report.

Data availability:

The datasets generated during and/or analyzed for the current study are available from the corresponding author on reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets generated during and/or analyzed for the current study are available from the corresponding author on reasonable request.

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