Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2019 Jul 15.
Published in final edited form as: Depress Anxiety. 2018 Sep 6;36(1):8–17. doi: 10.1002/da.22830

The prevalence and predictors of mental health diagnoses and suicide among U.S. college students: Implications for addressing disparities in service use

Cindy H Liu 1, Courtney Stevens 2, Sylvia HM Wong 3, Miwa Yasui 4, Justin A Chen 5
PMCID: PMC6628691  NIHMSID: NIHMS1038272  PMID: 30188598

Abstract

Background:

The college years represent a period of increased vulnerability for a wide range of mental health (MH) challenges. The onset of common psychiatric conditions occurs during this period of development. Increases in depression, anxiety, and suicidality among U.S. college students have been observed. This study identified prevalence and correlates of MH diagnoses and suicidality in a recent sample of U.S. college students.

Methods:

The Spring 2015 American College Health Association-National College Health Assessment (ACHA-NCHA) survey assessed MH diagnoses and suicidality from U.S. undergraduate students (n = 67,308) across 108 institutions.

Results:

Stress was strongly associated with a greater likelihood of suicide attempts and MH diagnoses, even among students reporting 1–2 stressful events (OR [odds ratio] range 1.6–2.6, CI [confidence interval] = 1.2–3.2). Bisexual students were more likely to report MH diagnoses and suicidality, compared to heterosexual and gay/lesbian students (OR range 1.5–3.9, CI = 1.8–4.3), with over half engaging in suicidal ideation and self-harm, and over a quarter reporting suicide attempts. Transgender students reported a higher rate of MH diagnoses and suicidality relative to females (OR range 1.9–2.4, CI = 1.1–3.4). Racial/ethnic minority students were generally less likely to report MH diagnoses relative to Whites, although the likelihood for suicidality was mixed.

Conclusions:

The high rate of multiple stress exposures among the U.S. college population and the high impacts of stress on MH and suicidality point to an urgent need for service utilization strategies, especially among racial/ethnic, sexual, or gender minorities. Campuses must consider student experiences to mitigate stress during this developmental period.

Keywords: mental health, minority groups, sexual and gender minorities, suicidal ideation, attempted suicide, universities

1 |. INTRODUCTION

College students face unprecedented levels of distress that affect their mental health (MH) (Mortier et al., 2018). Depression, anxiety, and suicidality rates are rising among U.S. college students (Blanco et al., 2008; Eisenberg, Hunt, & Speer, 2013). In the past decade, students and college counseling directors report increased rates of MH symptomatology and severity (Gallagher, 2012; Twenge et al., 2010). With media attention on incidents from untreated psychological problems (Jolicoeur, 2015), these high rates underscore MH as a growing public health concern within college campuses.

During college, students encounter new experiences, relationships, and living situations (Byrd & Mckinney, 2012, Ketchen Lipson, Gaddis, Heinze, Beck, & Eisenberg, 2015), with greater exploration of racial/ethnic, gender, and sexual identities (Syed & Azmitia, 2009). These factors give rise to stress experiences that can impact MH during college (Soet & Sevig, 2006; Woodford, Han, Craig, Lim, & Matney, 2014). The onset of common psychiatric conditions occurs during late adolescence and early adulthood (Kessler et al., 2007). Together, the college years represent a period of increased vulnerability for the development of a wide range of MH challenges.

Research addressing access to and use of MH services by students in general, and minority students (racial/ethnic, gender, or sexual minority), in particular, is limited (Mayer et al., 2008). Sexual minority students who identify as lesbian, gay, or bisexual appear to utilize MH services more than their heterosexual counterparts (Kerr, Santurri, & Peters, 2013; Oswalt & Wyatt, 2011). However, racial/ethnic minorities show low utilization of MH services (Nestor, Cheek, & Liu, 2016) perhaps due to factors such as stigma (Cheng, Kwan, & Sevig, 2013), lack of culturally sensitive services (Augsberger, Yeung, Dougher, & Hahm, 2015), and different conceptions of MH (Leong, Kim, & Gupta, 2011). This may lead to the probable under-diagnosis among certain minority students, with college campuses facing the task of reaching students that have “hidden” but urgent health concerns.

A major research gap is the lack of update on rates of MH diagnoses and the most severe symptoms among minority students. To our knowledge, there has been no comprehensive analysis conducted based on U.S. minority college students and other sociodemographic factors from the past 10 years, with the last update on MH rates among sexual minorities conducted in 2009 (Oswalt & Wyatt, 2011). The literature tends not to consider marginalized statuses including those who are unsure about their sexual orientation, Asians or Pacific Islanders, American Indian, Alaska Native, or Native Hawaiian, and Multi-racial, often due to low sample size.

To develop a clear strategy for practitioners and policy makers in addressing MH access and stigma on U.S. campuses, the scope of the issue must be well described. We present MH data for U.S. under-graduate college students based on minority statuses using data from the Spring 2015 administration of the American Health Association-National College Health Assessment (ACHA-NCHA). Capitalizing on a large sample size, our analysis simultaneously examines racial/ethnic, gender, and sexual minorities and other sociodemographic factors potentially associated with diagnoses related to depression and anxiety. We juxtaposed these rates of diagnoses (which would require disclosure to a health provider) with the self-report of the most severe MH symptoms, those that require the most urgent need for service, specifically, suicidality and self-harm.

2 |. METHODS

2.1 |. Data source and sample

The Spring 2015 American Health Association-National College Health Assessment (ACHA-NCHA IIB) Reference Group aggregates survey data from postsecondary educational institutions using probability-based sampling methods, which included 93,034 respondents from 108 U.S. institutions. Each institution selected a random sample of enrolled students who were 18 years of age and older. The response rates for Web-based surveys was 18% and the response rate for paper surveys was 89%, with only 7% of participating institutions distributing paper surveys. This analysis was exempt from human subjects review according to the Institutional Review Board.

3 |. MEASURES

3.1 |. MH diagnoses

Participants reported having been diagnosed or treated by a professional within the past 12 months for 15 MH diagnoses: anorexia, anxiety, attention deficit and hyperactivity disorder, bipolar disorder, bulimia, depression, insomnia, other sleep disorder, obsessive–compulsive disorder, panic attacks, phobia, schizophrenia, substance abuse or addiction (alcohol or other drugs), other addiction (e.g., gambling, internet, sexual), and other MH condition. For each condition, participants could respond with “no,” “yes, diagnosed but not treated,” “yes, treated with medication,” “yes, treated with psychotherapy,” “yes, treated with medication and psychotherapy,” or “yes, other treatment.”

We focused on depression and anxiety diagnoses given their prevalence among youth and young adults (Aalto-Setälä, Marttunen, Tuulio-Henriksson, Poikolainen, & Lönnqvist, 2001; Kessler et al., 2005), and collapsed the other disorders to create a category of “other MH conditions.” Two categories were created: “no” for those who did not have a diagnosis in the last 12 months, or “yes” for those who did have a diagnosis, regardless of whether they received treatment from a professional in the last 12 months. Four possible mutually exclusive diagnosis categories included: depression (not co-morbid with anxiety), anxiety (not co-morbid with depression), co-morbid depression and anxiety, and other MH conditions (not including depression or anxiety). Four binary variables were created that coded participants as having the disorder of interest, for example, depression (not co-morbid with anxiety) versus no diagnosis of any kind.

3.2 |. Self-injury and suicidality

We relied on three items: “intentionally cut, burned, bruised, or otherwise injured yourself,” “seriously considered suicide,” and “attempted suicide.” Five options were available to indicate frequency of each feeling or behavior, including, “no, never,” “no, not in the last 12 months,” “yes, in the last 12 months,” “yes, in the last 30 days,” or “yes, in the last 2 weeks.” The options were not mutually exclusive, thus, the “no, never” remained as a category, and the other responses collapsed into “yes.”

3.3 |. Stressful events

Participants responded “yes” or “no” on whether each of 12 possible events had been “traumatic or difficult for you to handle” in the past 12 months. Events included “academics,” “career-related issue,” “death of a family member or friend,” “family problems,” “intimate relationships,” “other social relationships,” “finances,” “health problem of family member or partner,” “personal appearance,” “personal health issue,” “sleep difficulties,” or “other.” Following prior life stress research (Liu & Tronick, 2013b, 2013a,b; Salm Ward, Kanu, & Rubb, 2017) and to account for distributions, the variables were recoded into four levels of stress exposure with roughly equal numbers of students per category: 0 events, 1–2 events, 3–5 events, and 6+ events.

3.4 |. Sociodemographic characteristics

Participants were asked, “How do you usually describe yourself?” Options included “White, “Black,” “Hispanic or Latino/a,” “Asian or Pacific Islander,” “American Indian, Alaska Native, or Native Hawaiian,” “Biracial or Multiracial,” and “Other.” Multiple options were allowed, thus responses were recoded to produce mutually exclusive categories. Those who selected one response, excluding the “Biracial or Multiracial” option, were coded using the identity selected. Those who selected more than one option were combined with those who selected only “Biracial or Multiracial” and referred as “Multiracial.” Participants who selected “Other” only were excluded from the analysis.

Age was recoded to 18–24 years and 25+ years (Araas & Adams, 2009; Brittain & Dinger, 2015; Lindley, Barnett, Brandt, Hardin, & Burcin, 2008). Gender categories included “male,” “female,” and “transgender.” Sexual orientation categories included “heterosexual,” “gay/lesbian,” “bisexual,” and “unsure.” Relationship categories included “not in a relationship,” “in a relationship but not living together,” and “in a relationship and living together.”

We restricted our sample to degree-seeking students. Years in school included: 1, 2, 3, 4, and 5+ years. Transfer and international student status (yes/no) were dichotomously coded.

3.5 |. Data analysis

Following the practice of other studies (Ball et al., 2009), we eliminated respondents who produced implausible height or weight data and retained respondents reporting heights between 120 cm and 210 cm, weights between 35 and 180 kg, and body mass indices between 16 and 65. The sum of the symptoms variable was coded as missing if the participant omitted any answer within the list of 11 symptoms presented or if participants were missing responses to the diagnoses questions. This resulted in 67,308 degree-seeking undergraduate students for analysis.

For the logistic regression analysis, binary outcomes were used for each of the four MH diagnosis outcomes along with suicidal ideation, attempted suicide, and self-injury. Given the sample size and number of comparisons, we set a conservative level of significance at p < 0.01 and report 99% CIs.

4 |. RESULTS

Table 1 presents the sample characteristics. MH diagnoses were common, with one in four students reporting being diagnosed with or treated for a MH disorder in the prior year. One-fifth of all students surveyed had thought about suicide, with 9% reporting having attempted suicide and nearly 20% reporting self-injury.

TABLE 1.

Distribution of descriptive characteristics of American Health Association-National College Health Assessment (ACHA-NCHA IIB) participants, Spring 2015 (n = 67,308)

Characteristic Total
n %
Race
 White 43,330 64.4
 Hispanic  5,980  8.9
 Black  3,002  4.5
 Asian  7,166 10.6
 AI/AN/NH   357  0.5
 Multiracial  7,473 11.1
Age (years)
 18–24 61,422 91.3
 25+  5,886  8.7
Gender
 Male 21,159 31.4
 Female 45,848 68.1
 Transgender   301  0.4
Sexual orientation
 Heterosexual 59,536 88.5
 Gay/Lesbian  2,017  3.0
 Bisexual  3,777  5.6
 Unsure  1,978  2.9
Relationship status
 Not in a relationship 35,620 52.9
 In a relationship, living separately 24,476 36.4
 In a relationship, living together  7,212 10.7
Year in school
 1st 18,228 27.1
 2nd 15,034 22.3
 3rd 16,305 24.2
 4th 13,251 19.7
 ≥5th  4,490  6.7
Transfer student 11,132 16.5
International student  3,364  5.0
Stress exposure
 0 events 16,462 24.5
 1–2 events 16,842 25.0
 3–5 events 19,371 28.8
 6+ events 14,633 21.7
Diagnoses
 Depression  2,283  3.4
 Anxiety  4,083  6.1
 Depression and anxiety  6,734 10.0
 Other  3,662  5.4
Self-injury 13,325 19.8
Suicidal ideation 16,337 24.3
Suicide attempts  6,257  9.3
Open in a new tab

American Indian, AI; Alaska Native, AN; Native Hawaiian, NH.

Table 2 displays rates of MH diagnoses and suicidality within each of the sociodemographic groups. Hispanics, Blacks, and Asians had lower rates of all four MH diagnosis categories relative to Whites but differences in rates of suicidality or self-injury appeared less marked. Transgender students showed particularly elevated rates of all outcomes, with more than half reporting having received a MH diagnosis, over two-thirds endorsing suicidal ideation, and approximately two-thirds reporting self-injury and more than one-third attempting suicide. Sexual minorities showed elevated rates of MH disorders and suicidality/self-injury. Students who reported experiencing at least six events that were traumatic or very difficult to handle in the last 12 months had rates of MH diagnoses three-to-sixteen times higher than those experiencing no such events, with almost half having engaged in suicidal ideation, one-fifth attempting suicide and over two-thirds engaging in self-injury.

TABLE 2.

Rates of mental health diagnosis and suicidality within characteristics

Characteristic Depression diagnosis (n = 2,283) % Anxiety diagnosis (n = 4,083) % Depression and anxiety diagnosis (n = 6,734) % Other diagnosis (n = 3,662) % Self-injury (n = 13,325) % Suicidal ideation (n = 16,337) % Suicide attempts (n = 6,257) %
Race
  White 3.5 7.0 11.6 6.0 20.0 23.9 8.7
  Hispanic 2.9 4.5 6.3 3.9 17.7 19.9 9.0
  Black 2.8 3.5 4.9 4.3 12.8 21.7 9.1
  Asian 2.5 2.8 5.0 3.5 18.3 25.1 10.1
  AI/AN/NH 3.6 6.4 9.0 7.6 19.6 22.1 11.8
  Multiracial 3.8 6.2 10.8 6.1 24.6 30.4 12.2
Age (years)
  18–24 3.2 5.9 9.6 5.2 20.1 24.1 9.1
  25+ 5.3 7.3 14.3 7.7 17.1 25.7 11.7
Gender
  Male 3.0 3.6 6.0 6.3 13.4 21.8 7.7
  Female 3.5 7.2 11.7 5.0 22.4 25.1 9.8
  Transgender 7.3 11.0 36.5 8.0 65.1 68.4 38.2
Sexual orientation
  Heterosexual 3.1 5.9 8.5 5.3 16.8 20.9 7.5
  Gay/Lesbian 5.6 7.8 15.7 7.1 33.3 42.6 19.8
  Bisexual 6.5 8.0 26.2 6.5 51.4 57.8 27.6
  Unsure 5.2 6.8 17.6 5.6 37.3 43.6 16.5
Relationship status
  Not in a relationship 3.3 5.5 9.7 5.4 18.5 24.2 8.7
  In a relationship, living separately 3.3 6.6 9.6 5.2 20.9 23.7 9.3
  In a relationship, living together 4.1 7.2 12.8 6.3 22.5 26.7 12.1
Year in school
  1st 3.3 5.3 8.5 5.3 20.0 24.1 9.4
  2nd 3.2 5.6 10.2 5.3 20.5 25.0 9.2
  3rd 3.3 6.7 10.6 5.5 19.5 23.9 9.1
  4th 3.5 6.5 10.3 5.3 18.9 22.9 8.8
  ≥5th 4.2 7.1 12.7 6.6 20.3 27.8 8.1
Transfer student
  Yes 3.7 6.6 11.3 6.0 20.8 25.6 10.8
  No 3.3 6.0 9.7 5.3 19.6 24.0 9.0
International student
  Yes 3.3 4.8 9.1 4.8 17.4 21.3 9.3
  No 3.4 6.1 10.1 5.5 19.9 24.4 9.3
Stress exposure
  0 events 1.0 3.2 1.7 3.9 7.4 8.0 3.3
  1–2 events 2.3 5.6 4.4 5.6 12.7 14.5 4.7
  3–5 events 4.2 7.7 11.4 6.1 22.8 28.1 9.4
  6+ events 6.2 7.7 23.9 6.2 37.9 48.8 21.1
Open in a new tab

American Indian, AI; Alaska Native, AN; Native Hawaiian, NH.

Table 3 presents results of logistic regression models. Stress exposure exhibited the strongest association with MH diagnosis, suicidality, and self-injury. Sexual minorities were almost all significantly more likely to have received a MH diagnosis, to endorse suicidality, and to engage in self-injury. Racial/ethnic minorities were generally less likely to have received a MH diagnosis. Despite lower rates of MH diagnoses than Whites, Asians exhibited significantly higher levels of suicidal ideation and suicide attempts. Multiracial students also showed significantly elevated rates of suicidal ideation and suicide attempts. Hispanics and Blacks exhibited significantly lower rates of self-injury and suicidal ideation, but no significant differences in suicide attempts relative to Whites.

TABLE 3.

Sociodemographic correlates of mental health diagnoses and suicidality of American Health Association-National College Health Assessment (ACHA-NCHA IIB) participants, Spring 2015

Characteristic Depression diagnosis
 Anxiety diagnosis
 Depression and anxiety diagnosis
 Other diagnosis
 Self-injury
 Suicidal ideation
 Suicide attempts
OR 99% CI OR 99% CI OR 99% CI OR 99% CI OR 99% CI OR 99% CI OR 99% CI
Race
  White 1.0 – 1.0 – 1.0 – 1.0 – 1.0 – 1.0 – 1.0 –
  Hispanic 0.58c 0.47–0.72 0.49c 0.41–0.58 0.36c 0.31–0.42 0.52c 0.43–0.62 0.76c 0.69–0.84 0.66c 0.60–0.73 0.92 0.81–1.05
  Black 0.55c 0.41–0.74 0.37c 0.28–0.48 0.27c 0.21–0.34 0.56c 0.44–0.72 0.52c 0.45–0.61 0.79c 0.69–0.89 0.98 0.82–1.17
  Asian 0.54c 0.44–0.67 0.33c 0.27–0.40 0.32c 0.28–0.38 0.48c 0.40–0.58 0.93 0.85–1.02 1.12c 1.03–1.22 1.25c 1.11–1.41
  AI/AN/NH 0.85 0.40–1.79 0.83 0.47–1.47 0.63 0.37–1.06 1.13 0.67–1.91 0.90 0.62–1.30 0.79 0.55–1.13 1.26 0.81–1.96
  Multiracial 0.83b 0.69–0.98 0.76c 0.66–0.87 0.66c 0.59–0.74 0.91 0.79–1.04 1.07 0.99–1.16 1.11b 1.03–1.20 1.17c 1.05–1.30
Age (years)
  18–24 1.0 – 1.0 – 1.0 – 1.0 – 1.0 – 1.0 – 1.0 –
  25+ 2.06c 1.70–2.50 1.42c 1.21–1.67 1.85c 1.62–2.11 1.69c 1.44–1.98 0.77c 0.69–0.86 1.06 0.96–1.17 1.22c 1.07–1.40
Gender
  Female 1.0 – 1.0 – 1.0 – 1.0 – 1.0 – 1.0 – 1.0 –
  Male 0.88 0.78–1.00 0.48c 0.43–0.53 0.55c 0.50–0.60 1.18c 1.07–1.30 0.64c 0.60–0.68 1.07b 1.01–1.13 0.95 0.87–1.03
  Transgender 2.03b 1.08–3.85 1.89b 1.11–3.24 2.38c 1.59–3.57 2.15b 1.18–3.91 2.38c 1.69–3.36 2.32c 1.62–3.32 2.05c 1.47–2.87
Sexual orientation
  Heterosexual 1.0 – 1.0 – 1.0 – 1.0 – 1.0 – 1.0 – 1.0 –
  Gay/Lesbian 1.85c 1.41–2.42 1.78c 1.41–2.25 2.01c 1.67–2.42 1.38b 1.09–1.75 2.49c 2.18–2.85 2.44c 2.14–2.78 2.60c 2.21–3.04
  Bisexual 2.20c 1.82–2.67 1.50c 1.27–1.79 2.79c 2.48–3.15 1.53c 1.27–1.84 3.82c 3.48–4.20 3.93c 3.57–4.32 3.33c 2.99–3.71
  Unsure 1.68c 1.27–2.22 1.25a 0.98–1.60 1.90c 1.59–2.27 1.18 0.90–1.53 2.46c 2.15–2.80 2.43c 2.13–2.76 1.95c 1.65–2.30
Relationship status
  Not in a relationship 1.0 – 1.0 – 1.0 – 1.0 – 1.0 – 1.0 – 1.0 –
  In a relationship, living separately 1.0 0.88–1.13 1.12b 1.02–1.23 0.93 0.86–1.01 0.97 0.88–1.07 1.18c 1.12–1.25 1.01 0.96–1.07 1.13c 1.05–1.23
  In a relationship, living together 0.97 0.80–1.18 1.07 0.92–1.24 0.98 0.86–1.11 0.98 0.83–1.14 1.36c 1.23–1.49 1.11b 1.01–1.21 1.34c 1.19–1.52
Year in school
  1st 1.0 – 1.0 – 1.0 – 1.0 – 1.0 – 1.0 – 1.0 –
  2nd 0.96 0.82–1.13 1.04 0.91–1.18 1.14b 1.03–1.27 0.99 0.87–1.12 0.97 0.90–1.05 0.98 0.91–1.06 0.92 0.83–1.02
  3rd 0.97 0.83–1.14 1.25c 1.10–1.41 1.18c 1.06–1.31 1.00 0.88–1.13 0.91b 0.85–0.98 0.92b 0.85–0.98 0.86c 0.78–0.96
  4th 1.03 0.87–1.22 1.22c 1.07–1.39 1.18c 1.05–1.32 0.97 0.85–1.11 0.89c 0.82–0.96 0.87c 0.81–0.94 0.86c 0.77–0.96
  ≥ 5th 1.06 0.84–1.35 1.34c 1.12–1.62 1.31b 1.12–1.53 1.12 0.93–1.34 0.93 0.82–1.04 1.02 0.92–1.14 0.95 0.82–1.11
Transfer student 1.06 0.91–1.23 1.13b 1.00–1.26 1.13b 1.03–1.25 1.10 0.97–1.24 1.09b 1.01–1.17 1.06a 0.99–1.13 1.15c 1.05–1.27
International student 1.13 0.87–1.48 1.02 0.82–1.27 1.03 0.86–1.25 1.01 0.81–1.27 0.88c 0.77–1.00 0.81c 0.71–0.91 0.97 0.82–1.15
Stress
  0 events 1.0 – 1.0 – 1.0 – 1.0 – 1.0 – 1.0 – – –
  1–2 events 2.40c 1.89–3.04 1.86c 1.61–2.15 2.64c 2.20–3.18 1.56c 1.37–1.79 1.71c 1.55–1.88 1.89c 1.72–2.08 1.41c 1.21–1.63
  3–5 events 5.07c 4.07–6.33 2.88c 2.51–3.30 7.69c 6.50–9.09 2.03c 1.78–2.32 3.23c 2.95–3.53 4.25c 3.90–4.63 2.76c 2.42–3.14
  6+ events 9.21c 7.38–11.49 3.62c 3.13–4.18 20.0c 16.96–23.62 2.64c 2.29–3.03 6.32c 5.77–6.92 10.06c 9.22– 10.98 6.66c 5.87–7.56
Open in a new tab

American Indian, AI; Alaska Native, AN; Native Hawaiian, NH.

CI, confidence interval; OR, odds ratio.

a

p < 0.05

b

p < 0.01

c

p < 0.001.

Transfer students were more likely than nontransfer students to have an anxiety-related MH diagnosis, to engage in self-injury, and to attempt suicide. International students did not differ significantly from domestic students in likelihood on any of the MH outcomes but showed significantly lower levels of suicidal ideation and self-injury.

5 |. DISCUSSION

5.1 |. Self-injury and suicidality

We observed a 24% rate of suicidal ideation and approximately 9% rate of suicide attempts reported among our undergraduate sample, reflecting higher rates compared to other studies encompassing a wider time period. The lifetime prevalence of suicidal ideation in adults worldwide, through screening, is 9%, and the prevalence of suicide attempts is 2.7% (Nock et al., 2008). Although a major difference across studies is the methodology for assessment (Downs & Eisenberg, 2012; Kisch, Leino, & Silverman, 2005), these rates, based on simple self-report, remain a concern.

Even low levels of stress exposure that were traumatic or very difficult to handle (1 to 2 events) were associated with a nearly twofold increase the likelihood of suicidal ideation across the sample. This is problematic given the high prevalence of stress in this population, with 75% of the sample reporting having been exposed to at least 1 to 2 events. The high rate of multiple stress exposures among the college population and the potential high impacts of stress on MH and suicidality point to an urgent need for strategies to reduce student stress.

Overwhelmingly, sexual minorities had higher rates of suicidality relative to heterosexual students. Over half of bisexual students reported suicidal ideation and self-harm, with over a quarter reporting attempted suicide. Our finding that gay/lesbian and bisexual students were two-to-three times more likely to report suicidal ideation and to attempt suicide is consistent with a systematic review and meta-analysis (King et al., 2008). Our rates are also higher than the 2009 administration of this survey for suicidal ideation (57.8% vs. 47.7%), suicide attempts (27.6% vs. 25.3%), and self-injury (51.4% vs. 44.8%) (Oswalt & Wyatt, 2011). It is concerning that so many U.S. college students identifying as sexual minorities have had thoughts or taken action toward suicide and that the rates have not decreased over time.

Bisexual students in our study had a higher rate of suicidality relative to gay/lesbian students, which is consistent with previous research (Bostwick, Boyd, Hughes, & Mccabe, 2010; Oswalt & Wyatt, 2011). Similar to a previous administration of this survey, bisexual students fared worse than those who indicated being unsure of their sexual orientation (Oswalt & Wyatt, 2011). Bisexual students might face greater stress in navigating different social groups (e.g., both heterosexual or homosexual), with heterosexual and homosexual groups holding negative attitudes toward bisexual individuals (Israel & Mohr, 2004). Some may perceive bisexuality as a transition or denial of one’s actual sexual orientation (Eliason, 2001). More than half of transgender respondents reported suicidal ideation and/or suicide attempts. Transgender individuals may also face stigma from both the majority population and from the LGB community, in navigating different social groups and cultural norms (Bauermeister et al., 2010).

Multiracial students, similar to Asian students, were more likely to engage in suicidal ideation and to have attempted suicide than Whites. Multiracial youth may experience internal conflict in their racial identity development (Nuttgens, 2010; Yeh & Hunter, 2004), experiencing distress when there is a mismatch between their self-identification and how others perceive them (e.g., being perceived as not authentic enough to belong to any particular racial group) (Campbell & Troyer, 2007). Given the increase of those who identify as multiracial, our finding highlights the need for addressing the multiracial experience and the importance of nuances in racial/ethnic categorization.

5.2 |. MH diagnoses

Rates of diagnosis among the MH diagnostic categories ranged from 3.4% to 10%. While we placed restrictions so that each disorder categorized was mutually exclusive, when integrating comorbidity across disorders, they are consistent with previous other studies from the past 10 years (Zivin, Eisenberg, Gollust, & Golberstein, 2009). In line with prior research regarding stress exposure on MH outcomes (Liu & Tronick, 2013b; Mclaughlin, Conron, Koenen, & Gilman, 2010), the presence of stressful events in this college sample was a strong predictor of MH diagnoses.

Sexual minorities were more likely to endorse having had a MH diagnosis. Those unsure of their sexual orientation had rates that were not as elevated as those identified as gay/lesbian and bisexual. Identifying as unsure could reflect concealment of one’s orientation; if so, this could be a source of stress (Grossman & D’Augelli, 2006). However, it is unclear how many of those who are unsure may be concealing their sexual orientation versus taking a more open-minded approach to sexuality and whether endorsing uncertainty about their sexual orientation is related to repercussions of disclosure.

More than half of transgender respondents reported having a MH diagnosis. These high rates are consistent with recent studies on individuals who identify as transgender (Arcelus, Claes, Witcomb, Marshall, & Bouman, 2016; Bockting, Miner, Swinburne Romine, Hamilton, & Coleman, 2013; Dawson, Wymbs, Gidycz, Pride, & Figueroa, 2017), with our large and diverse data set underscoring the major needs of transgender individuals during college. Psychological factors like the expectation of rejection may lead students to feel unworthy and unsafe, leaving them more susceptible to MH challenges compared to their counterparts who classify as cisgender (Bouman et al., 2017; Denton, Rostosky, & Danner, 2014). Notably, these high rates of diagnoses might reflect greater service utilization use among sexual minorities (Kerr et al., 2013; Oswalt & Wyatt, 2011). However, given their very high rates of suicidality and self-injury, a question is the extent to which health provider encounters that result in diagnoses translates to treatment engagement that is effective in reducing severe symptomatology.

In general, racial/ethnic minority students had similar or lower rates of MH diagnoses relative to Whites. Cultural factors including the stigma of MH may lead to lower rates of help-seeking and disclosure of MH symptoms, and consequently, lower rates of diagnoses (Aponte-Rivera et al., 2014; Sanchez, Ybarra, Chapa, & Martinez, 2016). The lack of recognition or ability by minority individuals themselves to detect MH problems may contribute to this lower rate of diagnosis (Huang & Zane, 2016).

Despite a higher likelihood of suicidal ideation and attempted suicide observed in our study, we observed a lower rate of diagnosis among Asians relative to Whites, consistent with prior research (Kisch et al., 2005). An important consideration is that self-reported symptoms of depression have been found to be higher among Asian American college students (Eisenberg et al., 2013). The lower likelihood of disclosure and/or diagnosis of MH problems may result from shame in having a mental illness (Augsberger et al., 2015; Thapa, Sung, Klingbeil, Lee, & Klimes-Dougan, 2015). Black students showed a lower likelihood of reporting all outcomes compared to Whites. This too could be due to underreporting, with views held among Blacks that mental illness is a weakness that should not be disclosed (Conner et al., 2010), and the possibility that the language and framing of the instruments for detecting symptoms may not be sensitive for use among Blacks (Ellis, 2003). The lower rates of MH diagnoses among racial/ethnic minorities may be attributable to stigma, language, and a lack of culturally sensitive interventions that together discourage racial/ethnic minorities from seeking professional help, leading to lower rates of diagnosis.

5.3 |. Transfer and international students, MH, and suicidality

Transfer students were more likely to endorse suicidal ideation, or to attempt suicide compared to students who did not transfer institutions, consistent with prior work using smaller samples (Beiter et al., 2015). The psychological well-being of transfer students is scant; however, their levels of distress may be associated with the inherently stressful experience of moving schools, lower involvement in on-campus social activities, a narrow focus on personal and career goals, and/or financial stress (D’Amico, Dika, Elling, Algozzine, & Ginn, 2014; Ishitani & Mckitrick, 2010).

International students did not differ significantly from domestic students on rates for MH diagnoses and attempted suicide, with the exception of a lower rate of suicidal ideation. International students may face challenges related to communication, homesickness, and acculturation that may cause emotional distress (Kilinc & Granello, 2003; Lee, Koeske, & Sales, 2004; Sümer, Poyrazli, & Grahame, 2008). It is striking that our data showed a lower tendency for international students to engage in suicidal ideation. Studies have found perception of social support to be a major predictor of lower levels of suicidal ideation (Chioqueta & Stiles, 2007), and some studies have found that international students often build social support quickly by relying heavily on peers instead of professionals for social support (Heggins & Jackson, 2003; Hyun, Quinn, Madon, & Lustig, 2007; Rai, 2002).

Although the ACHA-NCHA data set is not inherently generalizable to all U.S. schools and students given the self-selecting nature of the participating schools, the ACHA-NCHA is reliable and valid for representing U.S. college students through multiple comparison approaches. Triangulation methods, which include comparing percentages, conducting item reliability, and construct validity analyses between the ACHA-NCHA and three separate population-level surveys of U.S. college-aged students, demonstrate consistency and replication (ACHA, 2013). The use of multiple approaches increase our confidence that our findings represent U.S. students overall. The majority of institutions (93%) utilized web-based surveys, which had a low response rate of 18%. It is important to note the possibility of response bias among those who received the web-based surveys. This may include higher levels of health risk behaviors (Bosnjak & Tuten, 2001; Kypri, Samaranayaka, Connor, Langley, & Maclennan, 2011) in nonrespondents compared to respondents, although other studies have recently shown high response rates associated with higher rates of suicidality (Mortier et al., 2018); it is difficult to discern the relative impacts of these potential biases. The use of self-reported diagnoses may limit the interpretation of prevalence, due to readiness of disclosure and willingness to seek services. Finally, the sociodemographic factors in this study are broad and do not represent the complex experiences that individuals may face through their self-identified categories.

Aside from research that would address these limitations, this study yields several additional questions for future research. This includes determining the potential for increased vulnerabilities among those who belong to an intersection of identities (e.g., those who identify as both a sexual and racial/ethnic minority), and the extent to which help seeking with nonprofessional supports (e.g., peers and resident advisors) could reduce symptomatology for specific minority groups within the campus setting.

6 |. CONCLUSION

The high rate of multiple stress exposures among the U.S. college population and the potential high impacts of stress on MH and suicidality point to an urgent need for strategies that inoculate students against stress during this developmental period, especially among racial/ethnic, sexual, or gender minorities. MH diagnoses may be attributable to group differences in encounters with MH provider encounters, in contrast to reported suicidality and self-harm. Providers that work with young adults should consider supporting identity formation and concerns about disclosure in ways that consider the specific minority experience, for all students and not just those with acute MH needs. Together, this may address disparities in MH service utilization.

ACKNOWLEDGMENTS

We are grateful to the American College Health Association for providing and approving the use of this dataset: American College Health Association-National College Health Assessment, Spring 2015. Hanover, MD: American College Health Association [producer and distributor]; (April 17, 2017 of distribution). The opinions, findings, and conclusions presented/reported in this article/presentation are those of the author(s), and are in no way meant to represent the corporate opinions, views, or policies of the American College Health Association (ACHA). The ACHA does not warrant nor assume any liability or responsibility for the accuracy, completeness, or usefulness of any information presented in this article/presentation. Support for preparing this manuscript was provided through the Common-wealth Research Center (SCDMH82101008006), NIMH K23 MH 107714–01 A1 award, and the Tynan Faculty Research Fellowship. We also thank Emily Zhang for her assistance on the manuscript preparation.

Funding information

Massachusetts Department of Mental Health, Grant/Award Number: SCDMH82101008006

NIH, Grant/Award Number: K23 MH 107714–01 A1; Tynan Faculty Research Fellowship.

REFERENCES

  1. Aalto-Setälä T, Marttunen M, Tuulio-Henriksson A, Poikolainen K, & Lönnqvist J (2001). One-month prevalence of depression and other DSM-IV disorders among young adults. Psychological Medicine, 31(5), 791–801. 10.1017/S0033291701004081 [DOI] [PubMed] [Google Scholar]
  2. American College Health Association. (2013). American college health association-national college health assessment II: Reliability and validity analyses 2011 Hanover, MD: Author. [Google Scholar]
  3. Aponte-Rivera V, Dunlop BW, Ramirez C, Kelley ME, Schneider R, Blastos B, … Craighead WE (2014). Enhancing Hispanic participation in mental health clinical research: Development of a Spanish-speaking depression research site. Depression and Anxiety, 31(3), 258–267. 10.1002/da.22153 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Araas TE, & Adams TB (2009). Protective behavioral strategies and negative alcohol-related consequences in college students. Journal of Drug Education, 38(3), 211–224. [DOI] [PubMed] [Google Scholar]
  5. Arcelus J, Claes L, Witcomb GL, Marshall E, & Bouman WP (2016). Risk factors for non suicidal self injury among trans youth. Journal of Sexual Medicine, 13(3), 402–412. [DOI] [PubMed] [Google Scholar]
  6. Augsberger A, Yeung A, Dougher M, & Hahm HC (2015). Factors influencing the underutilization of mental health services among Asian American women with a history of depression and suicide. BMC Health Services Research, 15(1), 542 10.1186/s12913-015-1191-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Ball J, Ford J, Russell A, Williams L, & Hockey R (2009). Data cleaning for height and weight—Young and mid-aged Australia: Australian Longitudinal Study on Women’s Health. [Google Scholar]
  8. Bauermeister J, Johns M, Sandfort T, Eisenberg A, Grossman A, & D’Augelli A (2010). Relationship trajectories and psychological well-being among sexual minority youth. Anthony Journal of Youth and Adolescence, 39(10), 1148–1163. 10.1007/s10964-010-9557-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Beiter R, Nash R, Mccrady M, Rhoades D, Linscomb M, Clarahan M, & Sammut S (2015). The prevalence and correlates of depression, anxiety, and stress in a sample of college students. Journal of Affective Disorders, 173, 90–96. 10.1016/j.jad.2014.10.054 [DOI] [PubMed] [Google Scholar]
  10. Blanco C, Okuda M, Wright C, Hasin DS, Grant BF, Liu S-M, & Olfson M (2008). Mental health of college students and their non– college-attending peers: Results from the national epidemiologic study on alcohol and related conditions. Archives of General Psychiatry, 65(12), 1429–1437. 10.1001/archpsyc.65.12.1429 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Bockting WO, Miner MH, Swinburne Romine RE, Hamilton A, & Coleman E (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103(5), 943–951. 10.2105/AJPH.2013.301241 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Bosnjak M, & Tuten TL (2001). Classifying response behaviors in web-based surveys. Journal of Computer-Mediated Communication, 6(3). 10.1111/j.1083-6101.2001.tb00124.x [DOI] [Google Scholar]
  13. Bostwick WB, Boyd CJ, Hughes TL, & Mccabe SE (2010). Dimensions of sexual orientation and the prevalence of mood and anxiety disorders in the United States. American Journal of Public Health, 100(3), 468–475. 10.2105/AJPH.2008.152942 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Bouman WP, Claes L, Brewin N, Crawford JR, Millet N, Fernandez-Aranda F, & Arcelus J (2017). Transgender and anxiety: A comparative study between transgender people and the general population. International Journal of Transgenderism, 18(1), 16–26. 10.1080/15532739.2016.1258352 [DOI] [Google Scholar]
  15. Brittain DR, & Dinger MK (2015). An examination of health inequities among college students by sexual orientation identity and sex. Journal of Public Health Research, 4(1), 414 10.4081/jphr.2015.414 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Byrd DR, & Mckinney KJ (2012). Individual, interpersonal, and institutional level factors associated with the mental health of college students. Journal of American College Health, 60(3), 185–193. 10.1080/07448481.2011.584334 [DOI] [PubMed] [Google Scholar]
  17. Campbell ME, & Troyer L (2007). The implications of racial misclassification by observers. American Sociological Review, 72(5), 750–765. 10.1177/000312240707200505 [DOI] [Google Scholar]
  18. Cheng H-L, Kwan K-L, & Sevig T(2013). Racial and ethnic minority college students’ stigma associated with seeking professional help: Examining psychocultural correlates. Journal of Counseling Psychology, 60(1), 98–111. 10.1037/a0031169 [DOI] [PubMed] [Google Scholar]
  19. Chioqueta AP, & Stiles TC (2007). The relationship between psychological buffers, hopelessness, and suicidal ideation: Identification of protective factors. Crisis, 28(2), 67–73. 10.1027/0227-5910.28.2.67 [DOI] [PubMed] [Google Scholar]
  20. Conner KO, Copeland VC, Grote NK, Koeske G, Rosen D, Reynolds CF, & Brown C (2010). Mental health treatment seeking among older adults with depression: The impact of stigma and race. The American Journal of Geriatric Psychiatry, 18(6), 531–543. 10.1097/JGP.0b013e3181cc0366 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. D’Amico MM, Dika SL, Elling TW, Algozzine B, & Ginn DJ (2014). Early Integration and other outcomes for community college transfer students. Research in Higher Education, 55(4), 370–399. 10.1007/s11162-013-9316-5 [DOI] [Google Scholar]
  22. Dawson AE, Wymbs BT, Gidycz CA, Pride M, & Figueroa W (2017). Exploring rates of transgender individuals and mental health concerns in an online sample. International Journal of Transgenderism, 18(3), 295–304. 10.1080/15532739.2017.1314797 [DOI] [Google Scholar]
  23. Denton FN, Rostosky SS, & Danner F (2014). Stigma-related stressors, coping self-efficacy, and physical health in lesbian, gay, and bisexual individuals. Journal of Counseling Psychology, 61(3), 383–391. 10.1037/a0036707 [DOI] [PubMed] [Google Scholar]
  24. Downs MF, & Eisenberg D (2012). Help seeking and treatment use among suicidal college students. Journal of American College Health, 60(2), 104–114. 10.1080/07448481.2011.619611 [DOI] [PubMed] [Google Scholar]
  25. Eisenberg D, Hunt J, & Speer N (2013). Mental health in American colleges and universities: Variation across student subgroups and across campuses. The Journal of Nervous and Mental Disease, 201(1), 60–67. [DOI] [PubMed] [Google Scholar]
  26. Eliason M (2001). Bi-negativity: The stigma facing bisexual men. Journal of Bisexuality, 1, 137–154. [Google Scholar]
  27. Ellis CG (2003). Cross-cultural aspects of depression in general practice. South African Medical Journal, 93(5), 342–345. [PubMed] [Google Scholar]
  28. Gallagher RP (2012). Thirty years of the national survey of counseling center directors: A personal account. Journal of College Student Psychotherapy, 26(3), 172–184. 10.1080/87568225.2012.685852 [DOI] [Google Scholar]
  29. Grossman AH,& D’Augelli AR (2006). Transgender youth: Invisible and vulnerable. Journal of Homosexuality, 51(1), 111–128. [DOI] [PubMed] [Google Scholar]
  30. Heggins W, & Jackson J (2003). Understanding the collegiate experience for Asian international students at a midwestern research university. College Student Journal, 37(3), 379–391. [Google Scholar]
  31. Huang CY, & Zane N (2016). Cultural influences in mental health treatment. Current Opinion in Psychology, 8, 131–136. 10.1016/j.copsyc.2015.10.009 [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Hyun J, Quinn B, Madon T, & Lustig S (2007). Mental health need, awareness, and use of counseling services among international graduate students. Journal of American College Health, 56(2), 109–118. 10.3200/JACH.56.2.109-118 [DOI] [PubMed] [Google Scholar]
  33. Ishitani TT, & Mckitrick SA (2010). After transfer: The engagement of community college students at a four-year collegiate institution. Community College Journal of Research and Practice, 34(7), 576–594. 10.1080/10668920701831522 [DOI] [Google Scholar]
  34. Israel T, & Mohr JJ (2004). Attitudes towards bisexual women and men. Journal of Bisexuality, 4(1), 117–134. 10.1300/J159v04n01_09 [DOI] [Google Scholar]
  35. Jolicoeur L (2015). After suicides, MIT works to relieve student pressure Retrieved from https://www.npr.org/sections/ed/2015/05/14/406727576/after-suicides-mit-works-to-relieve-student-pressure
  36. Kerr DL, Santurri L, & Peters P (2013). A comparison of lesbian, bisexual, and heterosexual college undergraduate women on selected mental health issues. Journal of American College Health, 61(4), 185–194. 10.1080/07448481.2013.787619 [DOI] [PubMed] [Google Scholar]
  37. Kessler RC, Amminger GP, Aguilar-Gaxiola S, Alonso J, Lee S, & Ustün TB (2007). Age of onset of mental disorders: A review of recent literature. Current Opinion in Psychiatry, 20(4), 359–364. 10.1097/YCO.0b013e32816ebc8c [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, & Walters EE (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62(7), 593–602. [DOI] [PubMed] [Google Scholar]
  39. Ketchen Lipson S, Gaddis SM, Heinze J, Beck K, & Eisenberg D (2015). Variations in student mental health and treatment utilization across U.S. colleges and universities. Journal of American College Health, 63(6), 388–396. [DOI] [PubMed] [Google Scholar]
  40. Kilinc A, & Granello PF (2003). Overall life satisfaction and help-seeking attitudes of Turkish college students in the United States: Implications for college counselors. Journal of College Counseling, 6(1), 56–68. [Google Scholar]
  41. King M, Semlyen J, Tai SS, Killaspy H, Osborn D, Popelyuk D, & Nazareth I (2008). A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry, 8(70). 10.1186/1471-244X-8-70 [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Kisch J, Leino EV, & Silverman MM (2005). Aspects of suicidal behavior, depression, and treatment in college students: Results from the Spring 2000 national college health assessment survey. Suicide and Life-Threatening Behavior, 35(1), 3–13. [DOI] [PubMed] [Google Scholar]
  43. Kypri K, Samaranayaka A, Connor J, Langley JD, & Maclennan B (2011). Non-response bias in a web-based health behavior survey of New Zealand tertiary students. Preventive Medicine, 53(4–5), 274–277. 10.1016/j.ypmed.2011.07.017 [DOI] [PubMed] [Google Scholar]
  44. Lee J-S, Koeske GF, & Sales E (2004). Social support buffering of acculturative stress: A study of mental health symptoms among Korean international student. International Journal of Intercultural Relations, 28, 399–414. [Google Scholar]
  45. Leong F, Kim H, & Gupta A (2011). Attitudes toward professional counseling among Asian-American college students: Acculturation, conceptions of mental illness, and loss of face. Asian American Journal of Psychology, 2(2), 140–153. 10.1037/a0024172 [DOI] [Google Scholar]
  46. Leong F, & Lau A (2001). Barriers to providing effective mental health services to Asian Americans. Mental Health Services Research, 3(4), 201–214. 10.1023/A:1013177014788 [DOI] [PubMed] [Google Scholar]
  47. Lindley LL, Barnett CL, Brandt HM, Hardin JW, & Burcin M (2008). STDs among sexually active female college students: Does sexual orientation make a difference? Perspectives on Sexual and Reproductive Health, 40(4), 212–217. [DOI] [PubMed] [Google Scholar]
  48. Liu CH, & Tronick E (2013a). Rates and predictors of postpartum depression by race and ethnicity: Results from the 2004 to 2007 New York City PRAMS Survey (Pregnancy Risk Assessment Monitoring System). Maternal and Child Health Journal, 17(9), 1599–1610. 10.1007/s10995-012-1171-z [DOI] [PubMed] [Google Scholar]
  49. Liu CH, & Tronick E (2013b). Re-conceptualizing prenatal life stressors in predicting post-partum depression: Cumulative-, specific-, and domain-specific approaches to calculating risk. Paediatric and Perinatal Epidemiology, 27(5), 481–490. 10.1111/ppe.12072 [DOI] [PubMed] [Google Scholar]
  50. Mayer KH, Bradford JB, Makadon HJ, Stall R, Goldhammer H, & Landers S (2008). Sexual and gender minority health: What we know and what needs to be done. American Journal of Public Health, 98(6), 989–995. 10.2105/AJPH.2007.127811 [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Mclaughlin KA, Conron KJ, Koenen KC, & Gilman SE (2010). Childhood adversity, adult stressful life events, and risk of past-year psychiatric disorder: A test of the stress sensitization hypothesis in a population-based sample of adults. Psychological Medicine, 40(10), 1647–1658. 10.1017/S0033291709992121 [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Mortier P, Auerbach RP, Alonso J, Bantjes J, Benjet C, Cuipers P,… Kessler RC (2018). Suicidal thoughts and behaviors among first-year college students: Results from the WMH-ICS project. Journal of the American Academy of Child & Adolescent Psychiatry, 57(4), 263–273. 10.1016/j.jaac.2018.01.018 [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Nestor BA, Cheek SM, & Liu RT (2016). Ethnic and racial differences in mental health service utilization for suicidal ideation and behavior in a nationally representative sample of adolescents. Journal of Affective Disorders, 202, 197–202. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Nock MK, Borges G, Bromet EJ, Alonso JL, Angermeyer M, Beautrais A, … Williams D (2008). Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. The British Journal of Psychiatry, 192(2), 98–105. 10.1192/bjp.bp.107.040113 [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Nuttgens S (2010). Biracial identity theory and research juxtaposed with narrative accounts of a biracial individual. Child and Adolescent Social Work Journal, 27(5), 355–364. 10.1007/s10560-010-0209-6 [DOI] [Google Scholar]
  56. Oswalt SB, & Wyatt TJ (2011). Sexual orientation and differences in mental health, stress, and academic performance in a national sample of U.S. college students. Journal of Homosexuality, 58(9), 1255–1280. 10.1080/00918369.2011.605738 [DOI] [PubMed] [Google Scholar]
  57. Rai GS (2002). Meeting the educational needs of international students. International Social Work, 45(1), 21–33. 10.1177/0020872802045001312 [DOI] [Google Scholar]
  58. Salm Ward T, Kanu F, & Rubb S (2017). Prevalence of stressful life events during pregnancy and its association with postpartum depressive symptoms. Archives of Women’s Mental Health, 20(1), 161–171. 10.1007/s00737-016-0689-2 [DOI] [PubMed] [Google Scholar]
  59. Sanchez K, Ybarra R, Chapa T, & Martinez ON (2016). Eliminating behavioral health disparities and improving outcomes for racial and ethnic minority populations. Psychiatric Services, 67(1), 13–15. 10.1176/appi.ps.201400581 [DOI] [PubMed] [Google Scholar]
  60. Schulte B, & Jackman T (2009). Va. tech gunman’s records reveal dis-organized mental health system. Washington Post Retrieved from https://www.washingtonpost.com/wp-dyn/content/article/2009/08/19/AR2009081902380.html
  61. Soet J, & Sevig T (2006). Mental health issues facing a diverse sample of college students: Results from the college student mental health survey. NASPA Journal, 43(3), 410–431. [Google Scholar]
  62. Sümer S, Poyrazli S, & Grahame K (2008). Predictors of depression and anxiety among international students. Journal of Counseling & Development, 86(4), 429–437. [Google Scholar]
  63. Syed M, & Azmitia M (2009). Longitudinal trajectories of ethnic identity during the college years. Journal of Research on Adolescence, 19(4), 601–624. 10.1111/j.1532-7795.2009.00609.x [DOI] [Google Scholar]
  64. Thapa P, Sung Y, Klingbeil DA, Lee C-YS, & Klimes-Dougan B (2015). Attitudes and perceptions of suicide and suicide prevention messages for Asian Americans. Behavioral Sciences, 5(4), 547–564. 10.3390/bs5040547 [DOI] [PMC free article] [PubMed] [Google Scholar]
  65. Twenge JM, Gentile B, Dewall CN, Ma D, Lacefield K, & Schurtz DR (2010). Birth cohort increases in psychopathology among young Americans, 1938–2007: A cross-temporal meta-analysis of the MMPI. Clinical Psychology Review, 30(2), 145–154. 10.1016/j.cpr.2009.10.005 [DOI] [PubMed] [Google Scholar]
  66. Woodford MR, Han Y, Craig S, Lim C, & Matney MM (2014). Discrimination and mental health among sexual minority college students: The type and form of discrimination does matter. Journal of Gay & Lesbian Mental Health, 18(2), 142–163. 10.1080/19359705.2013.833882 [DOI] [Google Scholar]
  67. Yeh CJ, & Hunter CD (2004). Handbook of racial-cultural psychology: The socialization of self: Understanding shifting and multiple selves across cultures (Vol. 1). New York, NY: John Wiley. [Google Scholar]
  68. Zivin K, Eisenberg D, Gollust SE, & Golberstein E (2009). Persistence of mental health problems and needs in a college student population. Journal of Affective Disorders, 117(3), 190–185. [DOI] [PubMed] [Google Scholar]

RESOURCES