College Students' Experiences with,and Willingness to Use,Different Types of Telemental Health Resources: Do Gender,Depression/Anxiety,or Stress Levels Matter?

Abstract

Objective:

Telemental health (TMH) resources are plentiful; however, we know little about college students' opinions about such resources. We aimed to examine students' previous use of and willingness to use several types of TMH resources.

Participants:

Students (N = 662) from two U.S. Midwestern colleges participated.

Methods:

Using an online survey in spring 2017, we measured students' depression, anxiety, stress, and suicidal thoughts, preferences for care options during distress, and use and interest in anonymous chats with trained nonprofessionals, online therapy, and self-help resources.

Results:

Overall, 10.1–13.8% had experience with these TMH resources; however, 24.6–40.1% expressed willingness to try them. At-risk students, especially those higher in depression/anxiety scores, showed greater use of and willingness to use some applications.

Conclusions:

Counseling centers might consider endorsing TMH resources as potential pathways to care. TMH resources might help broaden reach with minimal cost, reduce mental health help-seeking barriers, and provide support to at-risk populations.

Introduction

Approximately 50,000 college students sought treatment at counseling centers in more than 400 U.S. universities during the period 2015–2016.¹ This represents a substantial increase in student counseling center use. From 2010 to 2015, colleges reported a 30% average increase in counseling center usage.¹ During the same period, average enrollment increased only 5%, which has left many counseling centers challenged with balancing a stagnated budget with increased student needs.^1,2 Notably, students are presenting with more complicated and severe problems,³ including self-harm and suicidality²; however, the top concerns of students who visit student counseling centers are consistently reported as anxiety, depression, and stress.^1,3,4

Despite increases in counseling service utilization across campuses, substantial numbers of college students do not seek treatment for their psychological distress.^5

–8 An oft-cited study on mental health help-seeking (MHHS) behaviors among college-age individuals found that fewer than 25% of those with any type of mental disorder had sought treatment within the past year.⁵ Moreover, only 36% of college students with depression only and 52% with anxiety only received treatment in the past year.⁷ These findings mimic others with college samples. A survey of college students across 26 campuses revealed that only 36% of those with mental health issues had sought treatment,⁹ and in another study, only 56% of students who experienced suicidal ideation in college sought treatment in young adulthood.¹⁰

Barriers to MHHS are actively researched. Consistently across the literature, stigma has been cited as a significant barrier.^10

–15 Barriers also include distrust in mental health service providers, hesitance in self-disclosure, and perceived devaluation,^12,15 as well as lack of knowledge/familiarity with treatment¹⁵ and lack of clarity/urgency about whether one needs help.^9,10,12 Unfortunately, this problem can be cyclical for those with higher levels of depression, and lack of support predicts higher stigma.¹⁴ This may explain why college students with serious distress often choose to deal with their issue(s) themselves.^12,16 Gender might also be a barrier to treatment. Women exhibit more depression, anxiety, and stress symptoms than men,^17,18 and some of these mental health symptoms may be related to high rates of sexual victimization among college women.¹⁹ Moreover, women with mental health problems and suicidal ideation are more likely than men with these issues to seek treatment.^8,9

In the face of both increased demands for care and low prevalence of MHHS, counseling centers must make tough budgeting decisions. Urgent care and continual care for students at risk for suicide are continual areas of need.²⁰ However, with high rates of mental health issues among the general college population,⁵ it is critical to reach those not already seeking treatment. Eisenberg et al.⁶ proposed, “New strategies may prove to be especially important for changing the behavior of the large number of students who are not using services despite reporting positive attitudes and beliefs about treatment” (p. 229). These novel approaches could include telemental health (TMH) online treatments and interactive software,²¹ which may be perceived as more confidential and less stigmatized methods of therapeutic support.^22
–24 As few college students engage with university resources²⁵ and the majority prefer informal over formal resources,¹⁰ these informal mechanisms might serve as a conduit for counseling centers to expand their reach and provide pathways to formal care.²⁴

In recent years, there has been a surge in TMH applications and websites,²⁶ many claiming to rely upon traditional therapeutic approaches, such as cognitive-behavioral therapy (CBT), to help with stress, mental health problems, and/or suicidal ideation.^{21,27

–33} However, although there are many mental health applications available to consumers, very few are evidence based.^34,35 As an example, a recent review showed that ∼90% of CBT applications for depression fail to incorporate evidence-based CBT principles.³⁶ Nevertheless, college-age adults, who are prolific users of technology, the Internet, and social media,^37,38 appear to be very open to these online treatments.^22,23,39 In fact, a recent study with 572 university students showed that students facing emotional problems were more likely to seek help online than face to face.³⁹ However, in previous research, college students expressed preferences for face-to-face over online counseling,²³ and few students with history of suicidal ideation and formal treatment used Internet sources when facing psychological distress.¹⁰ This incongruity between interest in and usage of TMH resources may be attributable to a lack of knowledge.^23,40 As technology and TMH resources become more accessible, it is important for counseling centers to continually reassess college students' use of and willingness to engage with TMH.

Research Aims

Our aims were to assess college students' preferences for, previous experience with, and willingness to use TMH (including anonymous chat with a trained nonprofessional, online therapy, and self-help resources). A limitation identified in previous research was students' limited knowledge of these platforms^23,40; therefore, we prefaced our questions with descriptions of at least two online resources in each category. Moreover, we extended previous research by analyzing whether those in high-risk categories (i.e., women, high stress, and high depression/anxiety scores) differed from low-risk students in their prior use of and willingness to engage with TMH.

Methods

Sample and Data Collection

Participants were 662 college students (438 women and 211 men^*) who were enrolled at two northeast Indiana universities (enrollments of 12,000 and 2,000) during spring 2017. Their mean age was 20.91 (SD = 1.69) years, and their ethnicities were non-Hispanic white (76.9%), followed by Latino (8.3%), Asian, (4.7%), African American or black (3.3%), South Asian or Indian (1.4%), Native American (1.2%), Middle Eastern (0.8%), and other or multiracial (3.2%).

After securing approval from the Parkview Health Institutional Review Board and university authorities, university administrators sent private, blinded recruitment e-mails, and up to three reminders, to currently enrolled students. Each e-mail recruited university students between the ages of 18 and 24 to complete an online SurveyMonkey survey. Survey Monkey is compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA),⁴¹ using a secure socket layer to encrypt sensitive information. Participants who completed the survey and provided an e-mail address received a follow-up e-mail that included a link to a $20 Amazon electronic gift card. All e-mail addresses collected were retained in a password-protected file within a secured shared drive to protect participants' confidentiality.

Measures

The 35-question survey assessed college students' experience with and preferences for TMH technologies and identified sources for information and pathways to mental healthcare. The survey contained demographic questions (i.e., age, gender, and race/ethnicity) and additional measures. For each measure listed, participants had an additional option of “prefer not to answer,” and these responses were excluded pairwise from analyses.

Stress level was measured with a single question adapted from the American Psychological Association's Stress in America™ survey.⁴² Students rated their stress level over the previous month using a 10-point scale (0 = no stress at all, 10 = a great deal of stress).

Depression and Anxiety symptoms were measured using the Patient Health Questionnaire-4 (PHQ-4),⁴³ an ultrabrief measure of depression and anxiety,^43
–45 which has been validated as a mass screening tool for young adults, with an internal reliability of α = 0.81 (depression/anxiety total score), α = 0.82 (anxiety subscale), and α = 0.76 (depression subscale).⁴⁶ Students responded on a four-point Likert scale (0 = not at all, 3 = nearly every day) about how often in the last 2 weeks they had experienced depression and anxiety symptoms. Cronbach's alphas for this sample were α = 0.82 (depression/anxiety total score), α = 0.76 (depression), and α = 0.82 (anxiety). For depression/anxiety total, scores of 0–5 are normal to mild and scores of 6–12 are moderate to severe.⁴³

Suicidal ideation was measured with one question from the Youth Risk Behavior Surveillance System (YRBSS) survey.^47,48 Participants were asked, “In the last 12 months, did you ever seriously consider attempting suicide?” Students responded on a categorical scale (1 = yes, 0 = no).^†

Feelings of persistent sadness/hopelessness were measured with one question from the YRBSS survey.⁴⁷ Participants were asked, “In the last 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you stopped doing some usual activities?” Students responded on a categorical scale (1 = yes, 0 = no).

Prior experience with a mental health professional was assessed in one question: “Have you ever been to a mental health professional (for example, psychiatrist, psychologist, therapist, or counselor)?” Participants responded on a four-point categorical scale (1 = yes, and it was helpful, 2 = yes, but it was not helpful, 3 = I don't know, and 4 = no). For ease of comparison, we collapsed these responses into a binary variable (1 = yes, 0 = no or I don't know).

Previous use of TMH was assessed with three questions. Brief, written descriptions of and hyperlinks to existing TMH technologies were included as examples before students were questioned about their use (Appendix 1). Participants were asked questions about previous usage of anonymous chat with a trained nonprofessional, online therapy, and self-help resources. For each question, students were given categorical choices ranging from “yes, and it was helpful” to “no.” For analysis, categories were collapsed into a binary variable (1 = yes, 0 = no or I don't know).

Willingness to use TMH was measured with three questions measuring willingness to engage in anonymous chat with a trained nonprofessional, an online therapist, and self-help resources. Participants responded on a five-point Likert scale (1 = no, definitely not, 5 = yes, definitely). For analysis, categories were collapsed into three scale points (1 = yes, 2 = maybe, and 3 = no).

Preferences for communication when facing distress were measured with a single item—“Would you rather talk about your stress or problems…?” Participants responded on a five-point categorical scale (1 = one-on-one with someone you know in real life, 2 = by posting them on social media or a blog, 3 = with a healthcare professional, 4 = anonymously online with someone you do not know in real life, and 5 = with no one).

Comfort with face-to-face and online therapy was measured with two items: “How comfortable would you be talking to a counselor or therapist: (1) face to face in real life and (2) using technology, such as video chat or online messaging?” Participants responded on a five-point scale (1 = very uncomfortable, 5 = very comfortable).

Data Analyses

From the original sample, 12 participants were excluded after consent because they completed zero survey items, and 108 duplicate responses^‡ were also deleted. Due to the sensitive nature of questions, the survey was designed so that students could decline to answer questions. To maintain representativeness in the sample, those participants who provided partial data were retained; thus, analyses were conducted with pairwise deletions. We conducted all analyses with IBM SPSS 24, using ANOVAs and t-tests (two-tailed) to compare continuous variables and chi-squared tests to compare categorical variables.

Results

Preliminary Analyses

Table 1 shows means for mental health measures for the whole sample, men, and women. In the total sample, stress and PHQ-4 score means were above the scale midpoint. Additionally, in the last year, 31% had persistent feelings of sadness/hopelessness and 9% had contemplated suicide. Finally, 35% had ever visited a mental health professional. As Table 1 shows, women had higher scores than men on each measure, with the exception of suicidal ideation.

Table 1.

Means for Stress, Patient Health Questionnaire-4 Scores, and Percentages of College Students Who Reported Depression, Suicidal Ideation, and Prior Visits to Mental Health Professionals, by Gender

	TOTAL SAMPLE, M (SD)/N (%)	WOMEN, M (SD)/N (%)	MEN, M (SD)/N (%)	F OR X²
Stress level	6.45 (2.25)	6.96 (1.98)	5.57 (2.37)	61.44^*
PHQ-4 total	4.37 (3.22)	4.89 (3.25)	3.38 (2.94)	32.47^*
PHQ-4 anxiety^a	2.64 (1.92)	3.03 (1.90)	1.93 (1.77)	49.55^*
PHQ-4 depression^a	1.72 (1.70)	1.86 (1.76)	1.45 (1.56)	8.25^*
Depressive symptoms^b	186 (31)	142 (35%)	44 (22%)	X² (610) = 10.12^*
Suicidal ideation^b	56 (9)	36 (9)	20 (10)	X² (604) = 0.33
Prior visit MHP	210 (35)	162 (39)	48 (24)	X² (620) = 13.25^*

Subscales of PHQ-4.

Within the last 12 months; feelings of persistent sadness/hopelessness and considered suicide.

p < 0.05.

MHP, mental health professional; PHQ-4, Patient Health Questionnaire-4.

Students' Previous Use of TMH

Approximately 1 in 10 students had used the TMH resources we introduced (Table 2). The same percentage (13.8%) had used anonymous online chats with trained nonprofessionals or an online therapist; however, only 36/88 (40.9%) reported using both. Additionally, as Table 2 shows, self-help resources were least utilized.

Table 2.

Number and Percentage of College Students Who Have Used Anonymous Online Chats, Online Therapists, and Self-Help Resources, by Gender, Depression/Anxiety, and Stress Levels

	TOTAL YES, N (%)	YES, N (%)	NO, N (%)	X²
Anonymous chat	88 (13.8)
Women		52 (12.3)	371 (87.7)	X² (n = 629) = 2.08
Men		34 (16.5)	172 (83.5)	X² (n = 629) = 2.08
Dep/Anx high		40 (18.3)	179 (81.7)	X² (n = 637) = 5.55^*
Dep/Anx low		48 (11.5)	370 (88.5)	X² (n = 637) = 5.55^*
Stress high		45 (12.4)	318 (87.6)	X² (n = 639) = 1.06
Stress low		42 (15.2)	234 (84.8)	X² (n = 639) = 1.06
Online therapist	88 (13.8)
Women		59 (13.9)	366 (86.1)	X² (n = 628) = 0.29
Men		22 (10.8)	181 (89.2)	X² (n = 628) = 0.29
Dep/Anx high		39 (17.9)	179 (82.1)	X² (n = 637) = 4.62^*
Dep/Anx low		49 (11.7)	370 (88.3)	X² (n = 637) = 4.62^*
Stress high		43 (11.9)	319 (88.1)	X² (n = 638) = 2.20
Stress low		44 (15.9)	232 (84.1)	X² (n = 638) = 2.20
Self-help resources	65 (10.1)
Women		53 (12.4)	374 (87.6)	X² (n = 630) = 7.37^**
Men		11 (5.4)	192 (94.6)	X² (n = 630) = 7.37^**
Dep/Anx high		29 (13.3)	189 (86.7)	X² (n = 633) = 3.73^†
Dep/Anx low		35 (8.4)	380 (91.6)	X² (n = 633) = 3.73^†
Stress high		45 (12.2)	325 (87.8)	X² (n = 640) = 4.56^*
Stress low		19 (7.0)	251 (93.0)	X² (n = 640) = 4.56^*

Dep/Anx, moderate or severe depression and anxiety; Dep/Anx low, no or mild depression and anxiety; stress high, 7+ on stress scale; stress low, <7 on stress scale; total yes, total number of respondents who indicated yes they had used a resource.

p < 0.05; ^** p < 0.01; ^† p < 0.10.

Those with higher depression/anxiety symptom scores were significantly more likely than those with lower depression/anxiety scores to have used all three types of TMH resources. Additionally, women were significantly more likely than men, and those with high stress were significantly more likely than those with lower stress, to report previous use of self-help resources.

Students' Willingness to Use TMH

Most respondents (68.3%) expressed preferences for talking to someone about their stress or problems in person. Far fewer preferred text or online chat (16.8%), a phone call (9.2%), video chat (1.8%), social media (0.8%), or something else (1.2%). Preferences were collapsed into in person (1) and any other contact type (0). Chi-squared analyses showed no significant differences between women and men (68.1% vs. 75.1%, X ² [n = 631] = 3.30, p = 0.07), those with higher depression/anxiety versus those with lower depression/anxiety (70.2% vs. 69.6%, X ²[n = 633] = 0.02, p = 0.89), or those with higher stress versus lower stress (71.5% vs. 67.2%, X ²[n = 633] = 0.02, p = 0.90) in their preference for speaking to someone face to face compared with other types of contacts.

College students were also more comfortable with meeting a therapist face to face than online (M = 3.21, SD = 1.09 vs. M = 2.83, SD = 1.02, respectively; t[627] = 7.44, p < 0.001). Repeated measures ANOVAs with gender, depression, and stress levels as separate between-subjects factors showed that there were no significant interactions for gender × therapist preference (F[1, 615] = 1.25, p = 0.27), depression level × therapist preference (F[1, 624] = 0.26, p = 0.61), or stress level × therapist preference (F[1, 625] = 2.55, p = 0.11). Thus, regardless of gender, depression, or stress level, the average college student expressed a preference for face-to-face versus online therapy.

Finally, with regard to willingness to use TMH resources, as Table 3 shows, students reported the most interest in using self-help resources (40.1%), followed by an online therapist (28.8%), followed by anonymous online chats with trained nonprofessionals (24.6%). Again, those with higher depression/anxiety scores were significantly more likely than those with lower depression/anxiety to express willingness to use online chat sites and self-help resources. However, there were no differences between these groups in their willingness to engage with an online therapist. Additionally, women were significantly more likely than men, and those with high stress were significantly more likely than those with lower stress, to be willing to use self-help resources.

Table 3.

Number and Percentage of College Students Who Were Willing to Use Anonymous Online Chats, Online Therapists, and Self-Help Resources, by Gender, Depression/Anxiety, and Stress Levels

	TOTAL YES, N (%)	YES, N (%)	MAYBE, N (%)	NO, N (%)	X²
Anonymous chat	158 (24.6)
Women		101 (23.8)	110 (25.9)	213 (50.2)	X² (n = 630) = 0.29
Men		53 (25.7)	53 (25.7)	100 (48.5)	X² (n = 630) = 0.29
Dep/Anx high		70 (32.1)	59 (27.1)	89 (40.8)	X² (n = 638) = 12.21^*
Dep/Anx low		87 (20.7)	109 (26)	224 (53.3)	X² (n = 638) = 12.21^*
Stress high		94 (25.8)	101 (27.7)	169 (46.4)	X² (n = 640) = 2.63
Stress low		63 (22.8)	67 (24.3)	146 (52.9)	X² (n = 640) = 2.63
Online therapist	184 (28.8)
Women		123 (29.0)	85 (20.0)	216 (50.9)	X² (n = 627) = 0.13
Men		57 (28.1)	43 (21.2)	103 (50.7)	X² (n = 627) = 0.13
Dep/Anx high		66 (30.3)	39 (17.9)	113 (51.8)	X² (n = 636) = 1.51
Dep/Anx low		118 (28.2)	92 (22.0)	208 (49.8)	X² (n = 636) = 1.51
Stress high		109 (29.9)	67 (18.4)	188 (51.6)	X² (n = 637) = 2.84
Stress low		74 (27.1)	65 (23.9)	134 (49.1)	X² (n = 637) = 2.84
Self-help resources	258 (40.1)
Women		185 (43.2)	147 (34.3)	96 (22.4)	X² (n = 631) = 18.67^*
Men		69 (34.0)	55 (27.1)	79 (38.9)	X² (n = 631) = 18.67^*
Dep/Anx high		112 (51.4)	59 (27.1)	47 (21.6)	X² (n = 635) = 16.97^*
Dep/Anx low		144 (34.5)	147 (35.3)	126 (30.2)	X² (n = 635) = 16.97^*
Stress high		171 (46.5)	116 (31.5)	81 (22.0)	X² (n = 642) = 19.22^*
Stress low		86 (31.4)	91 (33.2)	97 (35.4)	X² (n = 642) = 19.22^*

Dep/Anx high, moderate or severe depression and anxiety; Dep/Anx low, no or mild depression and anxiety; stress high, 7+ on stress scale; stress low, <7 on stress scale; total yes, total number of respondents who indicated yes they would use the resource.

p < 0.05.

Discussion

Consistent with previous research,⁵ mental health problems were common in our sample of college students: 31% reported depressive symptoms and 9% had contemplated suicide in the past year. Additionally, 33% had seen a mental health provider. Although women reported significantly more symptoms of depression, anxiety, and stress than men—a common finding across studies^17,18—women and men were equally likely to have contemplated suicide. Thus, as other researchers have suggested, gender needs to be a consideration in delivering solutions for stress and/or mental health¹⁸; however, suicide prevention strategies in college should target men and women equally.

With regard to current mental healthcare practices, most students expressed preferences for face-to-face over online resources, including professional help, when they faced stress or life problems. Consequently, despite the pervasive use of technology in this age group, college counseling centers should still focus on widening the reach and impact of face-to-face services. However, as others have suggested,^23,40 we expect that some of this preference for face-to-face care is attributable to previous experience. Few students had utilized the TMH we mentioned; however, when we gave descriptors and examples of these online options, 25–40% expressed willingness to try TMH, which aligns with previous work showing a significant gap between students' TMH usage and potential interest.⁴⁰

Counseling centers should view this gap as an opportunity to overcome a major MHHS barrier—lack of knowledge. Education and marketing, even through informal TMH advertisements (e.g., during orientations), could help fill this gap. Minimally, the use of informal sources may promote higher levels of well-being.²⁵ However, as many TMH applications and websites provide links to health treatment services,²² introducing college students to these informal, accessible, and less stigmatized resources could serve a much greater purpose. Specifically, it might lead to increases in their MHHS behaviors¹⁷ and open gateways to formalized care. With these potential benefits in mind, counseling centers must be careful when selecting applications and websites to endorse. They should seek resources that are effective in guiding students toward formal treatment as although researchers have found that some forms of TMH are useful to young people, TMH usage does not necessarily increase professional help seeking.²²

Of the TMH resources we introduced, students were most interested in self-help applications. This was unsurprising considering that self-help bypasses several major barriers to MHHS, such as stigma, distrust in healthcare providers, and hesitance to self-disclose.^10

–15 Accordingly, these informal sources are potentially important gateways on the care pathway. However, the lesser endorsed anonymous chats and online therapy might be even more promising support mechanisms. Research has shown that peer support is linked with more problem-focused coping and diminished stigma.¹⁴ Hence, chatting with a trained peer or professional might help to destigmatize formalized care. More importantly, interactive chats with others might help students overcome ambivalence toward treatment and increase clarity about treatment needs/urgency, which is another major barrier to MHHS.^9,10,12 Additionally, online chats provide a unique window into the linguistic patterns of those who seek psychological help. Building off recent studies that have examined these chats in terms of conversational dynamics⁴⁹ and emotional states and helper behaviors,⁵⁰ a promising direction for TMH studies is to analyze features of help-seeking language and behavioral outcomes associated with this language.

Finally, a novel finding was that TMH resources are utilized by and appealing to those in high-risk groups. Those with higher depression/anxiety scores had used all three resources significantly more than those with low depression/anxiety and they were significantly more willing to use online anonymous chats with nonprofessionals and self-help resources than those with low depression/anxiety. Additionally, women and those with high stress were significantly more likely than men and those with low-moderate stress, respectively, to have used and be willing to use self-help resources. Considered together, these findings suggest that TMH resources might fill needs for some high-risk students.

Limitations

Our study does have limitations that need mention. First, this was a relatively small convenience sample comprising 66% women, and we did not measure the response rate from each of the universities. Thus, women's preferences and responses from a single university may have been driving the results, which limit their generalizability. However, our statistics for TMH resource use are similar to other recent findings²³ and this consistency across studies helps with generalization. Second, a fairly large number of data points (108) were excluded because they were duplicate responses, and some participants provided only partial data (preferring not to answer some questions). Future studies should employ larger samples and discourage multiple responses (through ballot-stuffing prevention techniques) to increase the representativeness of the sample. Finally, we asked students about their use and interest in only three general resources. Clearly, there are many other types of TMH resources available (e.g., web-based discussion threads and support groups), and our data give no information about these other resources. We look to future research to evaluate students' interest in other technologies for mental health support.

Conclusions

Decisions about where to invest resources for the treatment of college students' mental health problems must be driven by cost, need, and potential reach. TMH resources, such as self-help resources, online anonymous chats, and online therapy, may provide pathways to care that fill current gaps in treatment and overcome major barriers in MHHS among college students. These resources, especially self-help resources, might be particularly appealing to those in high-risk groups, such as those with moderate to high depression/anxiety scores, high stress levels, and women.

Footnotes

Acknowledgments

The authors would like to acknowledge those who contributed to this project, including Robin Newman at Indiana University Purdue University Fort Wayne; St. Francis University; Mindy Flanagan; Marcia Haaff; and The Lutheran Foundation of Fort Wayne. Support for this research was provided by the Robert Wood Johnson Foundation (Grant No. 73055); views expressed here do not necessarily reflect the views of the Foundation.

Disclosure Statement

No competing financial interests exist.

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