Mental Health & Prevention (2015) 3, 1–4

Mental health of students in a globalized

world: Prevalence of complaints
and disorders, methods and effectivity
of counseling, structure of mental health
services for students
Rainer Matthias Holm-Hadullaa,b,n, Asimina Koutsoukou-Argyrakia

a
Counseling Service for Students, Heidelberg University, Gartenstrasse 2, D-69115 Heidelberg, Germany
b
Universidad Diego Portales, Santiago de Chile, Chile

Received 30 March 2015; accepted 21 April 2015

Available online 30 April 2015

KEYWORDS Abstract
Mental health; In our globalized world the necessity for student flexibility is increasing. Psychological problems
Students; and mental disorders are frequent, and students seek help at the places where they study. This
Depression; special issue presents data on the prevalence of complaints and disorders reported by students
Anxiety; around the world. Examples of counseling services and the methods they employ are given.
Counseling
Proposals for the structure and the methods of mental health services for students are derived
from international perspectives.
& 2015 Elsevier GmbH. All rights reserved.

1. Introduction can be found in the letters and autobiographical notes of the

Since the classical period in European culture, there has been
no shortage of descriptions of psychological crises, adjustment
disorders, anxiety and depressive episodes recorded by young
people studying at colleges and universities. The most detailed
reports of psychological problems besetting university students
n overcome his crisis. Like modern counselors, he made use of
Corresponding author
E-mail address: rainer.holm-hadulla@stw.uni-heidelberg.de
(R.M. Holm-Hadulla).
politician, scientist and poet J. W. v. Goethe (Holm-Hadulla,
Roussel, Hofmann & 2010). Academic disillusion and rejection
by a young lady caused states of anxiety and melancholic moods
that led to a depressive episode. During this episode, which
lasted more than a year, he was forced to return to parental
custody, as his mother and father feared that his suicidal
ideations could become reality. Fortunately, he developed
coping and self-therapeutic strategies that helped him to
helping alliances, cognitive-behavioral techniques, psychody-
namic reflection, and existential understanding (Holm-Hadulla,

http://dx.doi.org/10.1016/j.mhp.2015.04.003
2212-6570/& 2015 Elsevier GmbH. All rights reserved.
2 R.M. Holm-Hadulla, A. Koutsoukou-Argyraki
2013) In masterpieces like “The Sufferings of Young Werther”
and “Faust: A Tragedy”, he described his melancholic moods
and suicidal ideas and transformed them into art. But not every
student can draw upon the talent and the favorable circum-
stances that helped Goethe to cope with crisis creatively. A
famous example is pop icon Jim Morrison, who consulted a
counselor or psychotherapist. He had only one session and could
not be prevented from killing his creativity and himself with
alcohol and drugs (Holm-Hadulla & Bertolino, 2014). Many
students need professional assistance to cope with psychosocial
conflicts and mental disorders.
2. Results
Our survey demonstrates that student mental health and
specialized services helping students to come to terms with
psychological problems and disorders are an important
professional issue worldwide. In the United States of
America several studies show increasing mental health
issues among students (Prince, 2015). Tragic incidents at
educational institutions are frequent. Accordingly, the
mental health of students has become a major national
concern in the United States. Specific examples from the
University of California at Berkeley illustrate themes that
are common nationwide, e.g. the increase of students
seeking counseling and the increase in the severity of their
mental health issues. One nationwide study indicates that
37% of college students in the United States had reported
feelings of overwhelming anxiety in the previous 12 months;
approximately one-third reported feeling so depressed that
it was difficult for them to function; and 9% reported having
attempted suicide at some point in their lifetime (American
College Health Association, 2014). The demand for counsel-
ing services has increased significantly over the last year.
The first counseling services for students were established
in the United States in the late 1940s (Prince, 2015). They
focused on career counseling and assessment. In the 1960s,
personal counseling and psychotherapy gradually became a
focus in the work of counseling centers, a development
followed by more rigorous training and licensing require-
ments for staff members. Today, the typical staff member of
a university counseling service in the United States holds a
license to practice, typically as a psychologist, and the
primary student disorders at present are anxiety and depres-
sion (Gallagher, 2013). Current practice at the counseling
services focuses on four essential functions: individual and
group counseling; prevention and outreach; consultation for
faculty and staff; contributions to campus safety.
Risk management has become a key concern at many
colleges, and most universities have increased their efforts
toward preventing mental health problems by means of a
public health model designed to address environmental
factors at campus that influence students' mental health. A
major challenge is adapting to increasing globalization.
Mostly, counseling staff are not sufficiently well trained to
provide internationally informed, culturally congruent, and
accessible counseling and mental health services (Davidson &
Locke, 2010). Hyun, Quinn, Madon and Lustig (2007) report
that 44% of the international graduate students questioned in
their study reported emotional or stress-related problems
that significantly interfered with their academic performance
or their personal well-being. They also found that interna-
tional students were less likely to seek advice from services
provided by campus counseling centers. From the United
States perspective, Prince (2015) concludes that “counseling
centers have become a key resource, not only for helping
students with problems that interfere with learning, but also
for keeping the campus safe … Similar trends and challenges
are occurring in colleges and universities globally”.
From a South American perspective, Villacura et al. (2015)
describe the problems and disorders of students consulting the
counseling service at the University of Chile. They show that
the most frequent reasons for consultation are academic
problems (21%), anxieties (19%), affective problems (18%),
and adverse life events (19%). In 2014, the following diagnoses
were the most frequent on Axis I of the DSM-IV: “Other
problems that might be subject to clinical care” (58%), anxiety
disorders (10%), mood disorders (12%), and adjustment dis-
orders (7%). This squares with German studies indicating that
more than 50% consult the counseling service because of
subclinical problems (Kress, Sperth, Hofmann, & Holm-
Hadulla, 2015). Between 2010 and 2014, the demand for
consultation at the University of Chile increased by almost 80%.
Also in China there is a growing demand for student
counseling. Yang, Lin, Zhu & Liang (2015) give an overview
of mental health services in China and report on a special
counseling strategy that is deeply rooted in traditional
Chinese philosophy. Kulygina and Loginov (2015) describe
mental health problems of students in Russia and suggest a
multistage and multidisciplinary prevention program aiming
both at the psychosocial adjustment of students and the
promotion of their personal growth.
In Europe, a recent health survey shows that 33.3% of the
population suffer from some kind of mental disorder in the
course of a given year (Rückert, 2015). But there is strong
criticism with respect to diagnostic criteria. The most
reliable studies performed in the UK, Sweden, Norway,
and Germany show prevalence rates among students of
between 20% and 25% (Kress et al., 2015). Depression and
anxiety are the most frequent diagnoses. 90% of the
students diagnosed with depressive or anxiety disorders feel
unable to pursue their studies. Villacura et al. (2015) shows
that mental disorders and stress interact negatively with
identity development. Although most European countries
provide counseling service for students, quality and quan-
tity differ greatly. Some offer information only, others offer
qualified counseling and even short-term psychotherapy.
Methods applied individually or in groups are mostly cogni-
tive-behavioral, psychodynamic, and integrative (Holm-
Hadulla, Sperth & Hofmann, 2011; Hofmann, Kress, Sperth
& Holm-Hadulla, 2015). The special problems of interna-
tional students are being increasingly addressed. There is a
need to develop international standards of student counsel-
ing (Villacura et al., 2015).
In Germany, systematic data on the mental health of
students have been made available since 1987. At the time,
a nationwide survey (n=20,000) showed that about 20% of
students feel impaired in their studies by psychological
problems. Nearly half of this group believe they are able to
solve their problems by themselves. 10% of the representa-
tive sample feel in need of professional assistance. This
finding was confirmed in subsequent years (Kress et al.,
2009). Despite the dominant popular view that mental health
Mental health of students in a globalized world: Prevalence of complaints and disorders,
problems have increased in the last few decades, Berger,
Franke, Hofmann, Sperth and Holm-Hadulla (2015) show that
this widespread opinion cannot be confirmed. Their study
shows a decrease in the frequency and severity of mental
health problems among students of psychology and medicine.
Nonetheless, problems caused by mental health issues are
common, frequently ending in academic failure and leading
often to personal and societal tragedies.
The main complaints of university students are anxiety,
depressive moods, lack of self-esteem, psychosomatic pro-
blems, alcohol and substance abuse, and suicidality. Besides
adverse life events and academic problems, these are also
the main reasons for consulting a counseling service (Kress
et al., 2015). The objective of counseling centers is to
promote academic success and positive personal develop-
ment of their clients. Well-trained counselors and psy-
chotherapists assist in coping with psychosocial crises and
do their best to prevent mental disorders, suicide, and
violence. Many counseling services can also offer crisis
intervention and short-term psychotherapy. If 10% of students
consulted a counseling service and an average of 5 sessions
per client could be offered, five qualified psychosocial
counselors would be needed for every 10,000 students. An
average of five sessions per client or patient would only be
sufficient in the case of effective cooperation with psy-
chotherapists and psychiatrists in private practices and/or
clinical institutions. The job of counseling centers is to offer
diagnostic assessment, individual counseling, crisis interven-
tion, and group counseling with a view to enhancing social
competence, enabling the students to cope with academic
problems, and overcoming psychic disability. Telephone and
online counseling help to reduce the inhibitions preventing
young people from seeking help.
At the University of Heidelberg, a model for integrative
counseling and short-term psychotherapy has been developed
(Holm-Hadulla et al., 2011; Holm-Hadulla & Hofmann, 2012).
It works on the following principles: (a) establishment of a
trustful, empathic, and respectful alliance; (b) behavior
change; (c) correction of dysfunctional meanings and beliefs;
(d) psychodynamic reflection; and (e) reinforcement of
existential creativity (Holm-Hadulla, 2013). An empirical
outcome study shows that 85% of the participants achieve a
significant improvement in their satisfaction with their lives
and their studies and display a significant and clinically
relevant reduction of symptoms. The effect sizes are high
(Hofmann et al., 2015).
3. Conclusion
Psychological and mental disorders in students are frequent.
Effective methods of counseling exist that are designed to
to prevent tragic outcomes, help to cope with crises, and
treat certain disorders. Counseling services should be avail-
able at every college and every university. Counselors are to
be psychologically qualified academics. They should be able
to offer qualified assessments, diagnoses, crisis interven-
tion, individual counseling, and counseling in groups, and in
many centers also short-term psychotherapy. Discretion and
confidentiality are central issues. Flexible opening hours
and services free of charge lower the inhibition threshold
preventing students from consulting the service. Online
3
counseling and telephone counseling are helpful in certain
cases. Consultations with tutors and the initiation and
supervision of student-to-student coaching are also of
value. Cooperation with psychotherapists and psychiatrists
in private practice is essential. In severe and acute cases,
close collaboration with the psychiatric departments of the
universities is necessary. Cooperations with psychological
departments and with psychotherapeutic training institutes
provide opportunities for research.
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