Effects of COVID-19 on College Students’ Mental Health in the United States: Interview Survey Study

<jats:sec><jats:title>Background</jats:title><jats:p>Student mental health in higher education has been an increasing concern. The COVID-19 pandemic situation has brought this vulnerable population into renewed focus.</jats:p></jats:sec><jats:sec><jats:title>Objective</jats:title><jats:p>Our study aims to conduct a timely assessment of the effects of the COVID-19 pandemic on the mental health of college students.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>We conducted interview surveys with 195 students at a large public university in the United States to understand the effects of the pandemic on their mental health and well-being. The data were analyzed through quantitative and qualitative methods.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Of the 195 students, 138 (71%) indicated increased stress and anxiety due to the COVID-19 outbreak. Multiple stressors were identified that contributed to the increased levels of stress, anxiety, and depressive thoughts among students. These included fear and worry about their own health and of their loved ones (177/195, 91% reported negative impacts of the pandemic), difficulty in concentrating (173/195, 89%), disruptions to sleeping patterns (168/195, 86%), decreased social interactions due to physical distancing (167/195, 86%), and increased concerns on academic performance (159/195, 82%). To cope with stress and anxiety, participants have sought support from others and helped themselves by adopting either negative or positive coping mechanisms.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Due to the long-lasting pandemic situation and onerous measures such as lockdown and stay-at-home orders, the COVID-19 pandemic brings negative impacts on higher education. The findings of our study highlight the urgent need to develop interventions and preventive strategies to address the mental health of college students.</jats:p></jats:sec>

section_content: The 2019 Annual Report summarizes data contributed to CCMH during the 2018-2019 academic year, beginning July 1, 2018 and ending on June 30, 2019. De-identified data were contributed by 163 college and university counseling centers, describing 207,818 unique college students seeking mental health treatment, 4,059 clinicians, and 1,580,951 appointments. 

The following are critical to understand when reading this report:

1. This report describes college students receiving mental health services, NOT the general college student population. 

2. Year-to-year changes in the number of students in this report are unrelated to changes in counseling center utilization. These changes are more likely due to the number and type of centers contributing data from one year to the next. 

3. This report is NOT a survey. The data summarized herein is gathered during routine clinical practice at participating counseling centers, de-identified, then contributed to CCMH. 

4. The number of clients will vary by question due to variations in clinical procedure and whether counseling centers choose to administer the particular question. 

5. Counseling centers are required to receive Institutional Review Board (IRB) approval at their institution to participate in data contribution to CCMH. 

Although CCMH maintains membership of over 600 institutional counseling centers, only a percentage of these institutions participate in data contribution. 

C H A N G E S F O R 2 019

• Mental Health Trends: Beginning in 2019, we have changed the layout of mental health trend graphs by using "sparklines" depicting change over time, along with adding more detail about the lowest/ highest values, most recent value, and total change. See pages 13-14. 

• Monthly Trends: New this year, we present monthly trends throughout the academic year in initial CCAPS scores and CLICC concerns. See pages 16-17. 

• Tabular Breakdowns: Also starting in 2019, Standardized Data Set items (pages 25 through 32) have been simplified to present "overall" rates, rather than by demographic groups. Item breakdowns by demographic variables continue to be available online at the CCMH Data Navigator (https://ccmh-data. vmhost. psu. edu/login). 

• 2015 -Between Fall 2009 and Spring 2015, counseling center utilization increased by an average of 30-40%, while enrollment increased by only 5%. Increasing demand is primarily characterized by a growing frequency of students with a lifetime prevalence of threat-to-self indicators. These students also used 20-30% more services than students without threat-to-self characteristics. 

• 2016 -Between Fall 2010 and Spring 2016, counseling center resources devoted to "rapid access" services increased by 28% on average, whereas resources allocated to "routine treatment" decreased slightly by 7. 6%. 

• 2017 -Treatment provided by counseling centers was found to be effective in reducing mental health distress, comparable to results from randomized clinical trials. While some students improve quickly with a few sessions of therapy, others need more extended services to achieve the same level of change. 

• 2018 -Counseling centers that use a treatment model (students assigned to a counselor when an opening exists) versus an absorption model (clinicians expected to acquire clients for routine care regardless of availability) provided students with more sessions with fewer days in between appointments, as well as demonstrated greater symptom reduction in clients receiving services. Additionally, the question of Electronic Medical Record (EMR) sharing policy between counseling and health center staff was examined. No differences in treatment outcomes were found between centers who share EMRs with health centers compared to those with separate EMRs. 

2
section_name: Report Introduction

section_content: The following are key findings and implications contained in this year's report:

• To better measure comparable staff levels and related impacts across counseling centers nationally, CCMH developed the Clinical Load Index (CLI) during the 2018-2019 year with support from the Association for University and College Counseling Center Directors (AUCCCD) and International Accreditation of Counseling Services (IACS). The CLI provides each counseling center with a standardized and comparable score that can be thought of as "clients per standardized counselor" (per year) or the "standardized caseload" for the counseling center. 

• Findings demonstrated that higher CLI scores are associated with the following:

• Institutions with larger enrollments and counseling centers that serve more unique students

• The provision of significantly lower treatment dosages (fewer appointments with more days between appointments)

• Significantly less improvement in depression, anxiety, and general distress by students receiving treatment
section_name: H I G H L I G H T S

section_content: • As assessed by clinicians, anxiety and depression continue to be the most common general or top concerns experienced by students (Page 19). As a general and top concern, anxiety showed a minimal increase in the past year, whereas depression demonstrated a small decrease (Page 15). Notably, trauma, as both a general and top concern, has increased in the past six years and particularly since 2016-2017. 

• Th e self-reported lifetime prevalence rates of "threat to-self " characteristics (non-suicidal self-injury, 28. 7%; serious suicidal ideation, 36. 7%; and suicide attempts, 10. 6%) increased for the ninth year in a row among students receiving counseling services (Page 13). Importantly, 39. 6% of students seeking treatment report some suicidal ideation within the last two weeks (Page 13), but clinicians report suicidality as a presenting concern for just over 10% of students (Page 19). 

• The rate of prior counseling (56%) has demonstrated an upward trend for the last four years (Page 13). 

Taken a medication for psychological reasons slightly increased the past year, and hospitalization for mental health concerns somewhat decreased, but overall they have remained relatively flat for the past several years. 

• Average rates of student self-reported anxiety and depression increased over the past eight years. In the past two years, eating concerns increased, while family distress increased over the past four years (Page 14). Academic distress, hostility, and substance use have remained flat or slightly decreased over the past several years. 

Special Section: Introducing the Clinical Load Index (CLI)

Over the last decade, CCMH has examined increasingly macro-level questions regarding the mental health of college students. This year's special section zooms out again to explore the relationship between staffing of counseling centers and student treatment outcomes. 

Starting in 1970, counseling center staffing levels have been guided by what is known as the "recommended staff to student ratio" (https://iacsinc. org/staff-to-student-ratios/), or the ratio between counseling center staff and enrolled students. Originally set at one staff member per 1750 enrolled students (1:1750) in 1980, the recommended ratio was gradually adjusted to be a range (1:1000 to 1:1500) depending on contextual factors. The recommended ratio has achieved legislative significance in several states and is widely used. However, as post-secondary education and mental health services have grown and evolved over the last 50 years, the recommended ratio has become an insufficient standard for many smaller institutions and untenable for many large institutions. In addition, the two key assumptions underlying the ratio are no longer reliable:

1. Utilization: Whereas the recommended ratio assumes a constant level of utilization across institutions (averaging 11. 8% in 2018), the actual percentage of the student body that utilizes mental health services ranges widely from <1% to more than 40% (AUCCCD Directors Annual Survey, 2018).
section_name: OT H E R H I G H L I G H T S

section_content: The recommended ratio assumes that each staff member will provide the same amount of clinical services, but the actual time that any one staff member devotes to clinical service varies significantly (from 0 to 30 hours/week) depending on role, institutional factors, center size, and administrative complexity. 

To better account for these variables and more accurately describe the landscape of staffing levels across counseling centers, CCMH, with support from the Association for University and College Counseling Center Directors (AUCCCD) and International Accreditation of Counseling Services (IACS), methodically developed the Clinical Load Index (CLI) during the 2018-2019 year. A detailed description of the CLI, including a white-paper, and online tools (with peer comparisons) can be found here: https://ccmh. psu. edu/clinical-load-index/. 

For the purpose of this annual report, readers should understand that the CLI provides each counseling center with a standardized and comparable score that can be thought of as "clients per standardized counselor" (per year) or the "standardized caseload" of the counseling center. The purpose of the CLI is not to recommend a specific score; instead, the CLI distribution describes the landscape of staffing levels that institutions have implemented (in 2017-2018). The findings discussed below illustrate how the CLI can be used to inform college and university leaders seeking to understand and respond to the growing demand for mental health services. 

Because CLI scores are a measure of clients per standardized counselor it is important to understand the difference between "students served" at a counselor center and the "need" for mental-health services within the student population at the institution. As a rule, counseling centers are typically operating at full capacity, which means that the number of students served is a proxy for treatment capacity but not population need. As a result, a counseling center that serves a very small proportion of students (and is operating at capacity) could have a low CLI score but not be meeting the needs of the student population. 

According to the Centers for Disease Control (CDC), "1 in 5 Americans will experience a mental illness in a given year" (Center for Behavioral Health Statistics and Quality, 2016). Regarding college students specifically, student surveys report that roughly 1 out of 3 students screen positive for a current mental health concern (Healthy Minds Study) or having been diagnosed/treated for a mental health concern in the last 12 months (ACHA-NCHA). Similarly, a 2018 World Health Organization survey of students in eight countries found that roughly 1 out of 3 students screened positive for a mentalhealth disorder (Auerbach et al., 2018). Collectively, these sources suggest that approximately 20-35% of students might need mental health treatment in a given year. 

In contrast, CCMH has found that reliance on student self-report may be contributing to exaggerated prevalence rates. As just one example, CCMH found that, 40% of students seeking services nationally report having "thoughts of ending my life" (in the last two weeks) (Page 13). Clinicians, on the other hand, indicate that suicidality is a concern for only 10. 3% of the same students (Page 19). In other words, students report the presence of suicidal thoughts at almost four times the rate at which clinicians judge that the thoughts rise to the level of a presenting concern warranting treatment. This differential suggests caution in solely using self-report surveys to determine prevalence or need. 

Nevertheless, it seems evident nationally that there is some level of unmet mental health need within the general student population given the prevalence estimates (20-35%) and the average counseling center utilization rates (11. 8%). However, it is important to note the percent of students utilizing counseling services at each institution varies tremendously around this average, which is caused by many factors. For example, the chart below illustrates the relationship between school size (enrollment) and the percentage of the student body using the counseling center (percent utilization) across 432 institutions. 

This chart shows that counseling centers at smaller institutions tend to serve a much greater proportion of the student body compared to counseling centers at larger schools. This relationship underscores the apparent difficulty in scaling services for institutions with higher enrollments while also highlighting that demand for services can exceed 40% of the student body. 

An additional perspective on need is offered by the next chart, which illustrates the relationship between the percent of the student body served in the counseling center and the average initial distress (CCAPS Distress Index raw score) of students served. The graph to the right is based on 75,580 students from 119 schools.
section_name: Clinical Capacity:

section_content: This chart shows that as a counseling center serves a larger proportion of the study body, the average initial distress of students served decreases. This, in turn, suggests that centers serving a smaller percentage of the student body are treating students with higher levels of distress, perhaps focusing services on students with greater needs at the expense of serving students with milder symptoms who could still benefit from treatment. 

This brief overview of the "need" for mental-health services in higher education suggests that 20-35% of the college student population might be in "need" each year, although this estimate might be somewhat inflated due to the aforementioned problems of reliance on self-report data. 

In comparison, the national average rate of counseling center utilization is 11. 8%, ranging from <1% to more than 40% (AUCCCD Directors Annual Survey, 2018), suggesting some level of unmet need within the college student population. The variation in utilization, a proxy for treatment capacity, makes it clear that colleges and universities are making very different decisions in response to the growing demand/need for mental health services. However, when evaluating the CLI for a given institution, it will be critical for each institution to "mind the gap" between students served and the actual need on campus. 

The Clinical Load Index distribution is a snapshot in time, representing the current range of staffing levels across hundreds of counseling centers. For this report, the CLI distribution includes 432 counseling centers during the 2017-2018 year. CLI scores range from 37 to 308 with a mean of 118. As a quick reminder, an individual CLI score can be thought of as the annual "clients per standardized counselor" or the "standardized caseload" of a counseling center. One can easily imagine that the experience of seeking or providing treatment will feel very different in a center where a counselor is responsible for 37 students per year versus 308. Preliminary discussions with a limited number of counseling centers in the CLI distribution suggest that centers with very low CLI scores provide traditional weekly counseling with few usage limits, whereas centers with very high CLI scores function more as crisis and referral operations, providing minimal ongoing care. Centers in the middle employ a range of strategies to balance supply and demand. 

With the CLI distribution established, an individual counseling center can now enter their data points (at the CLI website using Enrollment, Utilization, Clinical Capacity) and then immediately see how their staffing level compares to others in the distribution. The image below represents the full distribution of 432 CLI scores for the 2017-2018 year:

The next step is to explore how CLI scores relate to other variables that impact counseling center staffing and treatment. 

To begin, the following chart illustrates the relationship between CLI scores and school size (Enrollment):

Although variability exists, this chart demonstrates that high CLI scores tend to be associated with larger institutions and low CLI scores tend to be associated with smaller institutions. Similar to the finding related to initial distress by percent utilization (page 7), this relationship reinforces the conclusion that institutions are scaling mental health services in different ways, and that these decisions are partially driven by the size of the school. More specifically, these two charts (Enrollment by Percent Utilization and CLI by School Size) reveal that counseling center clinicians working at larger schools generally have higher annual caseloads, which suggests that institutions with larger enrollments are struggling to maintain the same level of clinical staffing as smaller institutions. 

Because we know that the percentage of students who seek services varies across institutions, the next chart illustrates the relationship between CLI and the actual number of students who make an appointment (Utilization):

Similar to Enrollment by CLI, this chart shows that counseling centers that serve more students (Utilization) tend to have higher CLI scores. Collectively, these results indicate that counselors working within larger institutions and centers tend to carry higher annual caseloads. Additionally, when institutions encounter growing demand for services, larger institutions and centers appear to be asking each "counselor" to serve more students rather than maintaining an optimal staffing/caseload level. 

If the annual caseload of a standardized counselor (CLI) tends to rise with enrollment and utilization, does the CLI of a center also impact the types of services students receive? As discussed in our 2017 Annual Report (Center for Collegiate Mental Health, 2017), treatment provided by counseling centers works, but outcomes vary depending on the dosage of treatment provided. To evaluate this we examined how CLI scores relate to the average dosage of treatment provided in each center (number of appointments and days between appointments). For these analyses, CLI scores were combined with treatment outcome data provided by a large, nationally representative sample of 94 counseling centers representing 106,024 students. 

These two charts demonstrate as CLI scores increase, centers provided fewer appointments per student with more days between appointments. In other words, as the CLI (standardized caseload) increases, the average dosage of treatment decreases and becomes diluted. This relationship illustrates an important cost of higher CLI scores: students receive less treatment. 

If high CLI scores are associated with reduced quantity and frequency of treatment, are treatment outcomes impacted?

To answer this question, a sample of 119 counseling centers representing 23,814 students was used. The relationship between CLI and treatment outcomes is illustrated in the following chart, which displays CLI Scores and average symptom reduction per center, measured by the Distress Index (DI) of the CCAPS-34:

This chart indicates that clients who receive services in counseling centers with higher CLI scores tend to experience less improvement in distress. In other words, as "clients per standardized counselor" increases, the students treated in the center will, on average, demonstrate less improvement in their symptoms. This relationship was replicated with other CCAPS Subscales including the most common presenting concerns of Depression and Anxiety. 

To summarize the findings above, higher CLI scores (i. e., higher annual standardized caseloads) are associated with the following:

1. Institutions with larger enrollments and counseling centers that serve more unique students 2. Provision of significantly lower treatment dosages (fewer appointments with more days between appointments)

3. Significantly less improvement in depression, anxiety, and general distress by students receiving treatment

Although there are many potential implications of these findings and future research needed, institutions should pay attention to the following when deciding how to respond to increasing demand:

1. Institution Size (Enrollment): While the relationship between institution size and CLI highlights variability in institutional responses to growing demand, it is important to recognize that smaller institutions are successfully delivering mental health services to a much larger percentage of their student body that are more consistent with the estimated need. While many factors may drive this differential, the priority assigned to mental health services at each institution will need to be considered, and further research will be needed to understand why mental health services are not typically scaled to match institution size at larger institutions. In particular, institutions should seek to understand the "need" for mental-health care on their campus when evaluating treatment capacity, as mental health needs greatly vary by campus. 

2. Impact on Counseling Centers: Staff working in centers with high CLI scores are likely to experience greater stress as they try to manage more students per counselor with fewer resources. From a systems perspective, counseling centers with high CLI scores are likely to implement a variety of demand-limiters (e. g., scope of service policies, eligibility requirements, treatment limits, reducing non-clinical services, triage, waitlists, prioritizing urgent needs, etc. ) and adjustments to the overall mission of the center. It is important to align institutional expectations with staffing levels. 

3. Treatment Dosage, Student Outcomes, and Institutional Philosophy: As a counseling center's CLI score (standardized caseload) increases, the following impacts will likely be experienced by the counseling center and institution: (a) each clinician in the center will be responsible for more students per year; (b) students will receive smaller doses of diluted treatment (fewer appointments that are scheduled farther apart); and (c) students will show less improvement on average. Centers with very low CLI scores are likely to provide easy access to routine counseling services, whereas centers with very high CLI scores may only be able to operate in a crisis and referral capacity. 

The broader implications of the relationship between CLI scores and average treatment outcomes by center should be carefully considered by administrators. These findings replicate well-established research on mental-health treatment dose and response (Hansen, Lambert, & Forman, 2002) and confirm the critical relationship between effective treatment and positive outcomes, which have been largely ignored as institutions have sought to respond to growing demand by emphasizing access at the expense of providing sufficient treatment dosages. While it is reasonable to explore systemic efficiencies in systems (e. g., triage), multiple forms of treatment (e. g., self-help, online help, or single-session treatment), and clinical systems that emphasize urgent care -it is also reasonable to expect institutions to transparently articulate their "philosophy of service" and the policy/funding decisions used to implement the philosophy. If an institution's philosophy of service is that students seeking routine mental-health treatment should be seen quickly and receive sufficient treatment to recover, then the institution will need to support a CLI that enables this desired outcome. However, if an institution's philosophy emphasizes urgent care, brief follow-up, and off-campus referrals for ongoing treatment, then a higher CLI is more reasonable. In both cases, it is critical that institutions are transparent about their philosophy so that counseling centers can adjust service levels accordingly, and realistic stakeholder expectations can be established.
section_name: I N I T I A L D I S T R E S S B Y P E R C E N T U T I L I Z AT I O N

section_name: Annual Trends

section_content: As of this report, CCMH has generated nine annual data sets (2010-2011 through 2018-2019), making it possible to examine numerous years of trends among college students seeking mental health services. To examine trends across key mental health indicators, items from the Mental Health History section of the Standardized Data Set (SDS) were simplified to "Yes" or "No," providing a proxy for the lifetime prevalence of each item. These items may have changed slightly over time; please refer to prior versions of the SDS for specifics. Specifically, the wording for many items changed in 2012, resulting in a larger change in response rate to some items after that year.
section_name: M E N TA L H E A LT H T R E N D S

section_content: The below table summarizes the amount of data contributed to CCMH over the past nine academic years. It is important to note the annual changes in number of clients merely reflect an increase in data that has been contributed by counseling centers and not an increase in utilization of counseling center services. The Clinician Index of Client Concerns (CLICC) captures the presenting concerns of counseling center clients, as assessed by the clinician during an initial appointment. The CLICC includes 54 concerns and asks the clinician (a) to check all that apply and (b) to identify the "top concern" of those selected. 

The graphs below display notable trends in some of the CLICC items. Depression and Anxiety demonstrated minimal changes in the past two years after years of increases. Of note, Trauma has increased over the past six years, and particularly since 2016-2017 as both a "check all" and "top concern".
section_name: Data Sets

section_content: Monthly Trends

The charts below illustrate the average CCAPS subscale scores of students presenting for treatment during each month across the course of the 2018-2019 academic year. Although all subscales show some fluctuation throughout the year, Academic Distress shows more meaningful increases during times of year that are traditionally more academically stressful.
section_name: CLICC Trends (Check All That Apply): Percentage of Clients with Each Concern from 2013-2019 CLICC Trends (Top Concern): Percentage of Clients with Each Concern from 2013-2019

section_name: Monthly CCAPS Scores

section_content: Data from 2018-2019 was analyzed to determine how counseling center resources were distributed among students seeking services. The following points describe how counseling center appointments were utilized by 192,832 students across participating CCMH centers:

• The most common number of appointments per client per year was one. 

• Clients averaged 5. 51 total attended appointments of any kind, with a median of 3 appointments, and a range of 1-102 appointments. 

• Clients averaged 4. 51 attended Individual Treatment (initial clinical evaluations and individual counseling) appointments, with a median of 3 attended appointments, and a range of 1-74 attended appointments. 

• 20% of clients accounted for 55% of all appointments, averaging 15 appointments. 

• 10% of clients accounted for 37% of all appointments, averaging 20 appointments. 

• 5% of clients accounted for 23% of all appointments, averaging 25 appointments. 

• 1% of clients accounted for 7% of all appointments, averaging 37 appointments. 

• 10 clients utilized a total of 876 appointments.
section_name: Counseling Center Resource Utilization by Students

section_content: The Standardized Data Set (SDS) is a set of standardized data materials used by counseling centers during routine clinical practice. In this section, we provide a closer analysis of selected forms from the SDS: the Clinician Index of Client Concerns (CLICC); the Case Closure Form; and client, provider, center, and institutional demographic information.
section_name: Standardized Data Set (SDS)

section_content: The CLICC was designed by CCMH to capture and facilitate reporting on the most common presenting concerns of counseling center clients, as assessed by the clinician during an initial appointment The resulting data allows individual centers and CCMH to quickly and easily report on the most common client concerns in addition to supporting a wide array of research. The CLICC includes 54 concerns, and starting in July 2017, the category of "Anxiety" was expanded to include options for 6 specific types of anxiety, including Generalized, Social, Test Anxiety, Panic Attacks, Specific Phobias, as well as unspecified/other. 

The graph on the next page illustrates the presenting concerns of 82,685 clients during the 2018-2019 academic year. For each client, clinicians are asked to "check all that apply" from the list of CLICC concerns (as one client can have many concurrent concerns). The blue bars on the right portion of the graph illustrate the frequency of each concern regardless of how many other concerns a student experienced. 

Clinicians are then asked to choose one primary concern (i. e., the top concern) per client. The red bars on the left in the graph provide the frequency of each primary (top) concern. 

Taken together, the two bars highlight the proportion of clients who were experiencing each concern in general (check all that apply) and the proportion for which the specific concern was the primary problem (top concern). For example, while many clients experienced sleep as a concern, it was the top concern for far fewer clients. On the other hand, few clients had Relationship problem (specific) endorsed as a concern, but of those clients, a higher proportion had it endorsed as their top concern. The Anxiety category is displayed broken out into the specific types of anxiety below the main graph.
section_name: Clinician Index of Client Concerns (CLICC)

section_name: Client Factor Reasons

section_name: Percent

section_name: Academic Status Reasons

section_content: The Case Closure Form captures a wide array of reasons (academic, clinical, and client factors) why services ended, as well as significant events that might have occurred during the course of a student's services. Clinicians are asked to complete this form following the end of their service provision with a client. Clinicians can "select all that apply" from a checklist of 20 reasons why services may have ended for a given client and indicate the top reason. They can also specify any of 14 significant events that might have occurred during services. 

This graph describes the frequency of various reasons why services ended for students who received treatment during the 2018-2019 academic year (N = 63,190). Of note, the top two most endorsed reasons for ending of services were the timing of the academic term, followed by the client not returning for their last appointment.
section_name: Case Closure Form

section_content: The Standardized Data Set (SDS) for client demographic information contains numerous different questions, and the tables below include the item question and number. The SDS has "core" or required items and a larger number of optional items that are typically asked of students seeking services. The number of clients will vary by question due to variations in clinical procedure and whether the center chooses to administer the specific question to students.
section_name: Client Demographic Information

section_name: Acknowledgements

section_name: R E F E R E N C E S

section_content: • Auerbach, R. P., Mortier, P., Bruffaerts, R., Alonso, J., Benjet, C., Cuijpers, P., Demyttenaere, K., Ebert, D. D., Green, J. G., Hasking, P., Murray, E., Nock, M. K., Pinder-Amaker, S., Sampson, N. A. 

The charts below illustrate the monthly percentage of clients presenting with different CLICC concerns as a "check all" and a "top concern. " Academic performance shows similar patterns to Academic Distress in the CCAPS graph above. Many other concerns also show interesting increases and decreases throughout the academic year.
section_name: R E F E R E N C E S

section_content: The information below describes the 163 colleges and universities that contributed data to the 2018-2019 CCMH data set.
section_name: Center Information

section_content: Frequency
section_name: Does your counseling center currently have an APA accredited pre-doctoral training program?