Personal Wellbeing, Depression, and Alcohol Use among Community College Students Receiving Services from a Student Health Center

Abstract

This article describes the age, gender, and ethnicity of thirty-five community college students who were in treatment for mental health conditions, as well as their Personal Wellbeing Index-A (PWI-A), Patient Health Questionnaire-9 (PHQ-9), and Alcohol Use Disorders Identification Test (AUDIT) scores. The results indicated that the majority of participants were female, ranging in age from 18 to 42 years, with a mean age of 22.43 (SD = 5.89). Students scored in the moderately high range on the PWI-A (Mean = 48.57), moderately depressed range on the PHQ-9 (Mean = 14.06), and low risk for alcohol misuse on the AUDIT (Mean = 1.89). A higher score on the PWI-A scale was found to be strongly associated with a lower score on the PHQ-9. The scores on the AUDIT were not found to be associated with either the PWI-A or the PHQ-9 scores. Clinical implications are provided. Areas for future research are outlined.

Introduction

According to the 2016 Annual Report by the Center for Collegiate Mental Health (CCMH),² 7.6 percent of students reported having a diagnosis of one or more psychiatric conditions. Fifteen percent reported that depression affected their academic performance negatively. Ten percent reported that they considered suicide in the past twelve months. Additionally, 64.2 percent of students reported that they used alcohol in the last thirty days and 20.3 percent reported that they drove a car after drinking alcohol. Of the students who sought counseling on college campuses, 39.7 percent reported that they engaged in binge drinking in the past two weeks. Prior research indicated that community college students receiving mental health treatment at a student health center scored low on the Personal Wellness Indicator (PWI-A)³; moderate on the Patient Health Questionnaire (PHQ-9)⁴; and low on the Alcohol Use Disorders Identification Test (AUDIT).⁵ It is unclear if these factors are related and how that information may lead to a better understanding of the students’ treatment needs.

The purposes of this exploratory study are to assess the personal well-being of students who sought mental health services; to examine the depression levels of students who sought mental health services; to examine alcohol use among students who sought mental health services; and to examine the relationships between personal well-being, depression, and alcohol-use scores among students who sought mental health services from a community college health center.

Literature Review

Mental health issues are prevalent among college students and are typically due to a pile up of stressors.⁶ Iarovici reports that anxiety or stress are on the rise as primary treatment concerns in student counseling centers.⁷ She describes anxiety as related to either developmentally normal or short-lived situational anxiety or to a diagnosable anxiety disorder. If untreated, anxiety can become a chronic, debilitating condition. The 2016 survey conducted by American College Health Association (ACHA) found that 24.9 percent of students who reported having anxiety, 15.4 percent of students who reported having depression, and 3.3 percent of students who reported alcohol misuse indicated that this condition affected their academic performance.⁸

The ACHA (2016) reported that college students who were drinking experienced: unprotected sex (20.0%), sex with someone without their consent (0.6%), sex without their consent (1.8%), physically injuring self (14.4%), physically injuring another person (2.4%), and seriously considering suicide (2.2%).⁹ The academic impacts of drinking include receiving a lower grade on an exam or project; receiving a lower grade in a course; receiving an incomplete or dropping a course; and/or experiencing a significant disruption in thesis, dissertation, research, or practicum work.

Assessment and treatment of students who present with co-occurring disorders, such as, substance misuse and psychiatric conditions, offer a challenge to counselors. Students often present with depression or anxiety but describe their alcohol use as a way of coping with their mental health condition.¹⁰ Alternatively, if students use alcohol excessively and their academic performance drops, they may develop anxiety or depression as a result. In these cases, further assessment with standardized tools may offer additional insight into the diagnostic picture. Since the majority of students present with stress, anxiety, or depression, most counseling centers use clinical indicators (e.g., measures of depression or anxiety) for assessment purposes.¹¹ Thus, integrating the use of the AUDIT, with other screening measures, can provide a more accurate clinical picture.

Methods

Permission for this study was obtained from the Institutional Review Board at California State University, Long Beach. This exploratory study was conducted using existing data with no personal identifiers. Data were gathered during the fall semester of 2016 (i.e., September through December). The participants were recruited as clients registered for an intake assessment at the student health center at a southern California community college. Surveys were provided by staff at the front desk and placed by clients into a secured box in the waiting room.

In addition to questions on age, gender, and ethnicity, the self-administered instrument included the PHQ-9,¹² the fifth edition of the Personal Wellbeing Index-Adult (PWI-A),¹³ and the AUDIT.¹⁴

The PHQ-9 is a nine-item depression scale. As a severity measure, the PHQ-9 score can range from 0 to 27, since each of the nine items can be scored from 0 (not at all) to 3 (nearly every day). An item was also added to the end of the diagnostic portion of the PHQ-9 asking patients who checked off any problems on the questionnaire: “How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?” In the present study, the Cronbach’s alpha for the total scale was 0.89.

The PWI-A is an eight-item questionnaire designed to assess satisfaction with life as a whole. Possible responses range from 0 to 10, with higher scores indicating higher levels of wellbeing. The aspects of well-being assessed are standard of living, health, achievement in life, personal relationships, safety, sense of community, future security, and spirituality or religion. The PWI-A has excellent psychometric properties when used with a variety of samples.¹⁵ The final item (on spirituality or religion) is optional. In this study, the average score across all eight items was used versus the total score. In the present study, the Cronbach’s alpha for the total scale was 0.87.

The AUDIT is a ten-item scale that includes questions to assess the amount and frequency of alcohol intake (items 1–3), alcohol dependence (questions 4–6), and problems related to alcohol consumption (items 7–10). Scores range from 0 to 40, and the generally accepted cut-off point of the scale to identify potentially hazardous alcohol intake is eight. In the present study, Cronbach’s alpha for the total scale was 0.71. Frequencies, percentages, means, and standard deviations were used to report individual items and total scale scores. To assess the relationship between scale scores, Pearson’s r tests were used. The Statistical Package for the Social Sciences, Version 24, was used for all analyses.

Results

As shown in Table 1, the females were the majority. The sample was primarily comprised of white, European Americans (37.1%), and Latinos (31.4%). The mean age was 22.43 (SD = 5.89) years.

Table 1:

Characteristics of Student Health Center Clients (n = 35)

Characteristic	f (%)
Gender
Female	24 (68.6)
Male	11 (31.4)
Race/Ethnicity
European-American	13 (37.1)
Hispanic/Latino	11 (31.4)
Asian American	8 (22.9)
African American	1 (2.9)
Other or Biracial	1 (2.9)
	Mean (SD)
Age	22.43 (5.89)

Table 2 depicts reliability scores for the scales. As observed on Table 2, the PH-Q9 and PWI-A reliability measures are very strong at 0.89 and 0.87, respectively. The reliability measure was moderately strong for the AUDIT at 0.71. The mean scores (14.06) on the PHQ-9 indicate moderate depression. The mean score (6.07) on the PWI-A indicates a low level of personal wellbeing. For the AUDIT, the mean score (1.80) indicates a low level of risk, but it is important to note that the standard deviation (SD = 2.92) is fairly high on this scale.

Table 2:

Scale Scores

Scale	Alpha	Mean	SD
PHQ-9	0.89	14.06	6.83
AUDIT	0.71	1.80	2.92
PWI-A	0.87	6.07	1.91

There are seven subscales on the PWI-A. The eighth, spirituality or religion, is an optional subscale. In this study, all eight subscales were used, with the possible scores ranging from 0–10. As indicated on Table 3, the highest mean score was regarding sense of safety at 7.40 and the lowest was personal relationship at 5.57.

Table 3:

Subscales of PWI-A

PWI-A Subscales	Mean	SD
Standard of Living	6.29	2.27
Health	5.71	2.48
Achievement in Life	5.77	2.45
Personal Relationships	5.57	2.89
Safety	7.40	2.65
Sense of Community	5.88	2.68
Future Security	6.08	2.38
Spirituality or Religion	5.85	3.18

The relationship between these three scales is shown in Table 4. As indicated in Table 3, there was a very strong relationship between the PHQ-9 and the PWI-A scores (r = −0.578, p = 0.0001). The scores on the AUDIT were not found to be correlated either with the PHQ-9 or the PWI-A.

Table 4:

Relationship between Scales

	PHQ-9	AUDIT	PWI-A
Item or Scale
PHQ-9	--	−0.023	−0.578***
AUDIT	−0.023	--	−0.047
PWI-A	0.578***	−0.047	--

^*p < 0.05

^**p < 0.01

^***p < 0.001

The relationship between the subscales of the PWI-A and the PHQ-9 were compared to have a better understanding of the relationship between personal wellbeing and depression. As indicated on Table 5, all of the PWI-A subscales were significantly associated with the scores on the PHQ-9 future security. The strongest relationships were the impact of health (r = −0.546, p = 0.001), achievement in life (r = −0.474, p = 0.004, sense of community (r = −0.431, p = 0.01) and spirituality or religion (r = −0.458, p = 0.006) on depresion. For all of these, a higher mean score was significantly associated with a lower depression score.

Table 5:

Subscales of the PWI-A by the PHQ-9

PWI-A subscales	PHQ-9
Standard of Living	0.363*
Health	−0.546**
Achievement in Life	−0.474**
Personal Relationships	−0.381*
Safety	−0.411*
Sense of Community	−0.431**
Future Security	−0.299
Spirituality or Religion	−0.458**

^*p < 0.05

^**p < 0.01

^***p < 0.001

Discussion

This study compared the scores on the PHQ-9, PWI-A, and the AUDIT from thirty-five students who received mental health services through the student health center at a southern California community college during academic year 2016–2017. The results indicated that the majority of participants were female, with an average age of 22.43 years. This finding is consistent with earlier studies from the same community college.¹⁶ Prior research found that men tend to underutilize health care services generally, including both physical and mental health services. Based on a survey for the American Association of Community Colleges, Juszkiewicz reported a gender difference in current enrollment, with women representing 57 percent of the student population.¹⁷ This may partially account for the greater number of women in this study.

Students scored in the moderately high range on the PWI-A (Mean = 48.57), moderately depressed range on the PHQ-9 (Mean = 14.06), and low risk for alcohol misuse on the AUDIT (Mean = 1.89). A higher score on the PWI-A scale was found to be strongly associated with a lower score on the PHQ-9. Seven of the subscales (i.e., standard of living, health, achievement in life, personal relationships, safety, sense of community, and spirituality or religion) of the PWI-A were found to be significantly associated with the PWI-A. The future security subscale of the PWI-A was not found to be associated with scores on the PHQ-9. The scores on the AUDIT were not found to be associated with either the PWI-A or the PHQ-9 scores.

The results in this study were similar to comparable studies. Brocato, Kleinpeter, and Potts found that students who were receiving mental health services scored 2.70 on the AUDIT as compared to students in a general classroom sample of 4.44.¹⁸ It appears that when clients are in treatment, they may under-report actual drinking patterns. Kleinpeter, Potts, and Bachmann reported that PHQ-9 scores of 143 mental health patients had a mean of 12.31, which is similar to the current findings.¹⁹ The results of the PWI-A are similar to previous research by Kleinpeter, Potts, and Ranney that reported students who sought mental health services has a mean score of 5.75, which is similar to the current findings.²⁰

Clinical Implications

The PWI being strongly correlated with the PHQ-9 suggests that the use of these two scales to assess the psychological needs of college students provides important clinical information. Further, all but one of the subscales of the PWI-A was found to be associated with the total score of the PHQ-9. With this information, counselors may work toward improving wellness by using a holistic approach in helping students identify interventions to reduce depression. Interventions such as increasing peer relationships, connecting with campus religious organizations, and engaging in activities that build a sense of community may improve a sense of wellness and reduce depression. Such initiatives could include peer mentoring, support groups such as NAMI, and clubs that educate and advocate for those with mental health conditions including Active Minds. Adding these supports in the academic community may assist students’ suffering with mental health conditions to stay in school and demonstrate improved academic performance. The use of the AUDIT to assess drinking patterns, including binge drinking, among college student needs further investigation.

Limitations and Future Research

Limitations of the present study include the fact that only one community college (two-year) in a southern California urban area was used. Community college students would likely be younger than their four-year counterparts. Many comparison studies discussed here were conducted at four-year institutions. It may be the case that community college students differ from four-year students.

The instruments used in this study were self-report measures; students may not report their feelings or behaviors accurately. A self-report instrument is insufficient to fully assess human behavior. This study used the PWI as a screening tool for wellbeing, and it would be useful to try other screening tools appropriate in the college setting in future research.

Social desirability bias likely influenced scores on the AUDIT since all of the students in this study completed surveys before having face-to-face meetings with health center staff. Prior research indicated that students who were given the AUDIT in a general classroom sample scored higher than the current study, however still within the low risk category.²¹ It is also possible that the AUDIT may not be as sensitive in identifying problem drinking in college students as it may be for adults. Further research focused on binge drinking behavior among the general student body of a college campus versus those seeking services from a health center. Finally, the lack of association between future security and depression warrants further research.