A Literature Review of Studies of
Depression and Treatment Outcomes
Among U.S. College Students Since 1990
Elissa J. Miller, M.D., M.P.H.
Henry Chung, M.D.
Objective: The mental health of
U.S. college students is a growing
public health concern. Particular-
ly alarming is the prevalence of
depression and risk of suicide in
this cohort. Methods: A literature
review of PsycINFO, MEDLINE,
and CINAHL databases was con-
ducted in order to identify and
evaluate depression and treat-
ment outcomes among U.S. col-
lege students since 1990. Results:
Four studies documenting de-
pression and treatment outcomes
among U.S. college students were
identified and reviewed. Conclu-
sions: Although research on the
depression and treatment out-
comes among U.S. college stu-
dents exists, it is scarce and incon-
sistent, with varying inclusion and
exclusion criteria and measure-
ment of depression severity and its
treatment. Future work needs to
focus on the development of rea-
sonable benchmarks of depression
and treatment outcomes in the
college population and the inte-
gration of such outcome data into
college mental health practice.
(Psychiatric Services 60:1257–
1260, 2009)
At the time of this report, Dr. Miller was a
Public Psychiatry Fellow at New York State
Psychiatric Institute and Columbia Uni-
versity, New York City. Dr. Chung is asso-
ciate vice-president of student health at
New York University Student Heath Cen-
ter, New York City. Send correspondence
to Dr. Miller at the New York State Psychi-
atric Institute, Columbia University, 1051
Riverside Dr., Box 111, New York, NY
10032 (e-mail: drelissamiller@gmail.com).
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' September 2009 Vol. 60 No. 9
A ccording to the fall 2007 Amer-
ican College Health Associa-
tion–National College Health As-
sessment (1), a national survey of ap-
proximately 20,500 college students
on 39 campuses, 43.2% of the stu-
dents reported “feeling so depressed
it was difficult to function” at least
once in the past 12 months. More
than 3,200 university students re-
ported being diagnosed as having de-
pression, with 39.2% of those stu-
dents diagnosed in the past 12
months, 24.2% currently in therapy
for depression, and 35.8% taking an-
tidepressant medication. Among the
students surveyed, 10.3% admitted
“seriously considering attempting
suicide” within the past 12 months
and 1.9% actually attempted suicide
during that period.
Although the above data may seem
surprising to some, it is not to most
mental health clinicians and admin-
istrators at U.S. colleges. According
to the 2008 National Survey of
Counseling Center Directors, 95%
of respondents believe that there has
been a trend in recent years of an in-
crease in the number of students
with serious psychological problems.
In 2008 an estimated 26% of coun-
seling center clients were taking psy-
chiatric medication, up from 20% in
2003, 17% in 2000, and 9% in 1994
(2). And although the rate of suicide
among college students may have
decreased in recent decades (3), sui-
cide remains the third leading cause
of death among adolescents and
young adults (4).
Many college administrators have
begun to appreciate the effect that a
student’s depression can have on
overall functioning in the college
community. Depression has been
linked to academic difficulties as well
as interpersonal problems at school,
with more severe depression correlat-
ed with higher levels of impairment
(5). The treatment of depression
among college students has been as-
sociated with a protective effect on
these students’ grade point averages
(6). In an effort to diagnose and treat
early and effectively, and thus de-
crease the excess morbidity and risk
of suicide associated with depression,
some U.S. colleges have even begun
to screen students for depression in
the primary care setting (7).
There are unique challenges of
providing treatment to college stu-
dents. These challenges include sig-
nificant academic pressure in semes-
ter-based cycles, extensive semester
breaks that result in discontinuities of
care, and heavy reliance on commu-
nity supports that can be inconsis-
tent. Given the prevalence and im-
pact of depression on college cam-
puses and the varying services of-
fered by university mental health
centers throughout the United States,
there is a significant need to evaluate
successful models of treatment and
their related outcomes.
Methods
The databases PsycINFO, MEDLINE,
and CINAHL were searched for
studies related to depression among
U.S. college students and treatment
outcome by using the following
terms: “depression,” “college or uni-
versity or graduate or junior college
or community college students,”
“colleges,” “community colleges,”
1257
“treatment and prevention,” “em-
pirical study,” and “peer reviewed
journal.” Initially, no limitation was
placed on years included in the
search. Eighteen relevant publica-
tions were read and analyzed closely
for method and content, with partic-
ular focus on location and inclusion
criteria of study participants. Stud-
ies were eliminated if participants
were students at colleges outside of
the United States, if the studies did
not have specific depression criteria
for inclusion, or if the students in-
cluded were at risk of depression
but did not meet criteria for having
depression. Nine remaining articles
were reviewed further, and it was
decided that the five studies pub-
Table 1
Studies after 1990 of outcomes of depression for U.S. college studentsa
Study and depression
criteria for study inclusion
Kelly et al., 2007 (8)
Score ≥15 on the BDI and met
SCID-M criteria for major de-
pressive disorder, not currently
in treatment, and enrolled in an
introductory psychology class
Lara et al., 2000 (9)
Current major depressive epi-
sode as indicated by SCID; onset
less than 6 months; no history of
dysthymia, bipolar disorder, or
psychotic symptoms; no current
alcohol or drug dependence; and
an undergraduate in a psychology
class
Geisner et al., 2006 (10)
Score ≥14 on the BDI and
enrolled in an undergraduate
psychology course
Pace and Dixon, 1993 (11)
Score between 10 and 29 on
the BDI, no history of suicide
attempts, no previous psychiatric
hospitalization, no past or pres-
ent drug or alcohol abuse, no
current involvement in any form
of psychiatric or psychological
treatment, and an undergrad-
uate student
a BDI, Beck Depression Inventory; SCID-M, Mood Module of the Structured Clinical Interview for DSM-IV; SCID, Structured Clinical Interview for
DSM-IV; HAM-D, Modified Hamilton Rating Scale for Depression; LIFE, Longitudinal Interval Follow-Up Evaluation; DDS, DSM-IV-Based De-
pression Scale
1258
lished before 1990 had decreased Results
relevance and would be excluded Table 1 summarizes the four studies
from this review in light of the grow- on depression and treatment out-
ing availability of selective serotonin comes that were reviewed in this
reuptake inhibitor medications study.
since 1990, which substantially In 2007 Kelly and colleagues (8)
changed the treatment of depres- conducted a nonexperimental study
sion among college students. In ad- that recruited from introductory psy-
dition, the demographic character- chology classes university students
istics of U.S. college students may with depression who were not cur-
have changed since the early 1990s, rently in treatment, offering both fi-
with many college counseling center nancial compensation and class cred-
directors noting a trend in recent it for research involvement. Sixty
years of an increase in students with college students (66% Caucasian,
serious psychological problems (2). 57% female) with major depression
Only four articles (8–11) remained were followed for nine weeks with-
for this review of depression and out any treatment to assess for sud-
treatment outcomes of U.S. college den gains (that is, precipitous im-
students. provements in depressive sympto-
Primary Number
Treatment Demographic Final assessment of weeks
modality characteristics N methods of study Outcomes
No treatment Mean±SD age, 60 BDI, 9 60% showed sudden gains;
19.1±2.41; SCID-M then 53% of those who
57% female; showed sudden gains had
67% Caucasian reversal of gains; 20% no
longer met criteria for having
major depressive disorder at
the end of the study
No treatment Mean±SD age, 84 SCID, 26 68% recovered during the
18.9±1.9; 86% HAM-D, study period, but 21% of
female; 51% LIFE those who recovered
Caucasian relapsed into another major
depressive episode during
the study
Randomized Mean±SD age, 177 BDI, 4 Significant improvement with
controlled 19.28±1.97; DDS the education intervention,
study of 70% female; according to the DDS but
education 49% Caucasian; not the BDI; before treat-
intervention 48% Asian; ment began, the BDI scores
versus control 3% other race of 23% of the sample were
reduced to <14
Randomized Mean age, 22.5; 74 BDI 4 to 7 74% of the cognitive therapy
controlled 81% female; group and 33% of the control
study of 100% Caucasian group were classified as
cognitive nondepressed at the end of
therapy the study. At the 1-month
versus control follow-up, 81% of the cogni
tive therapy group and 64%
of the control group were
classified as nondepressed
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' September 2009 Vol. 60 No. 9
matology), remission of depressive
symptoms, and reversal of improve-
ments. The authors found that 60%
of the college students with major
depression experienced sudden
gains over the nine weeks of not re-
ceiving treatment. However, before
the end of the nine-week observa-
tion period, more than half of these
sudden gains reversed. At the end of
the period of not receiving treat-
ment, depression was in remission
for 20% of the students. The authors
concluded that sudden gains may be
part of the natural course of depres-
sion for some college students, irre-
spective of treatment, and that self-
evaluation processes may play an im-
portant role in recovery.
In 2000 Lara and colleagues (9)
conducted a nonexperimental study
in which undergraduate students tak-
ing psychology classes who had a re-
cent-onset major depressive episode
were paid or received course credit
for their research participation.
Eighty-four students (51% Cau-
casian, 86% female) were followed
for 26 weeks to assess whether vari-
ous psychosocial factors predicted the
short-term course of major depres-
sion. The authors found that within
the 26-week period of no treatment,
68% of the college students who were
initially depressed recovered. Among
those who recovered, 21% relapsed
by the end of the 26-week period into
another major depressive episode.
Lara and colleagues concluded that
college students with depression may
sometimes spontaneously recover
and relapse and that harsh discipline
in childhood was significantly associ-
ated with higher mean levels of de-
pression at follow-up and relapse but
not with recovery.
In 2006 Geisner and colleagues
(10) conducted a four-week random-
ized controlled trial of depression
treatment and recruited undergradu-
ates with depression who were en-
rolled in psychology courses to partic-
ipate for course credit. The study en-
rolled 177 students with depression
(49% Caucasian and 48% Asian, 70%
female) who were randomly assigned
either to an intervention group that
received personalized mailed feed-
back or to a control group. The au-
thors found that depressive symp-
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' September 2009 Vol. 60 No. 9
toms improved for both the interven-
tion and control groups, but in the in-
tervention condition there was a sig-
nificantly greater improvement of de-
pressive symptoms, as measured by
the DSM-IV–Based Depression
Scale. There was no significant differ-
ence between the intervention and
control groups on symptoms meas-
ured by the Beck Depression Inven-
tory (BDI). Geisner and colleagues
concluded that an intervention using
personalized mailed feedback may be
useful for reducing depressive symp-
toms among college students.
In 1993 Pace and Dixon (11) con-
ducted a four- to seven-week ran-
domized controlled trial to assess the
treatment effectiveness of individual
cognitive therapy for college students
with depressive symptoms. Partici-
pating undergraduate students
earned course credit for their re-
search involvement. Seventy-four
students (100% Caucasian, 81% fe-
male) who met strict criteria for
study inclusion were randomly as-
signed to either a group that received
individual cognitive therapy or a con-
trol condition where participants did
not receive treatment and were put
on a waiting list for cognitive therapy.
Pace and Dixon found that 74% of
participants in the cognitive therapy
group (versus 33% in control group)
were classified as nondepressed with
BDI scores of less than 10 after four
to seven weeks of treatment. At the
one-month follow-up, 81% of partic-
ipants in the cognitive therapy group
(versus 64% of control group) were
classified as nondepressed. Out-
comes at both time points were sta-
tistically significant in favor of cogni-
tive therapy. The authors concluded
that brief individual cognitive thera-
py may effectively reduce mild to
moderate depressive symptoms as
well as depressive self-schemata
among college students.
Discussion
The current body of literature on de-
pression and treatment outcomes
among U.S. college students is
sparse, and for the four studies we
found, varying inclusion and exclu-
sion criteria, assessment methods,
and lengths of treatment make the
interpretation of results difficult.
Whereas Kelly and colleagues (8)
and Lara and colleagues (9) used the
Structured Clinical Interview for
DSM-IV to diagnose participants
with major depressive disorder, Geis-
ner and colleagues (10) and Pace and
Dixon (11) used self-report scales to
measure depressive symptoms for
study inclusion and Pace and Dixon
excluded students with severe levels
of depressive symptoms. All four
studies recruited students who were
not seeking treatment and who were
offered course credit for participat-
ing, a reward that might have influ-
enced the degree of improvement in
outcomes. There was no consistent
standard used across studies to de-
fine a student with depression, even
when using the same assessment
tool. In terms of length of treatment,
only two of the four reviewed studies
followed students for more than nine
weeks. The length of time over which
students are assessed is especially
critical for the college population,
where time is defined by a semester
calendar, moods are often influenced
by exam schedules, and treatments
are adjusted to accommodate up-
coming vacations (12). Today’s col-
lege mental health services tend to
employ short-term models of care
(eight to 16 sessions), with referral to
outside clinicians if longer-term
treatment is necessary (13). Given
these dynamics, future research in
college mental health will need to es-
tablish quality standards for ongoing
monitoring and follow-up of stu-
dents’ treatment outcomes.
Unfortunately, the results from
these four studies may not be fully ap-
plicable to college students today or
in the future, particularly in light of
the changing demographic character-
istics of those attending universities
as well as the rapidly evolving role of
pharmacology in the treatment of de-
pression. Only two of the four studies
reviewed offered any active treat-
ment for depression, and none of the
studies included any form of pharma-
cological treatment. Consistent with
current medical literature and best
practices, many treatment-seeking
college students diagnosed as having
depression currently receive psy-
chotherapy and psychopharmacologi-
cal treatment (1). Because major de-
1259
pression can be a chronic recurring
condition, future research needs to
evaluate the effectiveness of the vari-
ous treatment modalities used to treat
college students with depression.
This is particularly important in light
of the recent addition of a black-box
warning for the use of antidepressant
medications among young adults
aged 18 to 24 years, which recom-
mends the close monitoring of pa-
tients taking antidepressant medica-
tion for clinical worsening, suicidality,
or unusual changes in behavior.
Conclusions
In light of the high prevalence of de-
pression among college students to-
day and the risks and sequelae this ill-
ness poses if not diagnosed and treat-
ed early and effectively, it is impera-
tive that research funding be in-
creased for both naturalistic and in-
tervention studies of depression and
treatment outcomes in the college
health setting. First, research docu-
menting depression and treatment
outcomes in this cohort should be
identified in order to evaluate the ad-
equacy of current care. Second, re-
search should be directed to assessing
specific short-term or semester-based
interventions for students with de-
pression. Models that explore the ef-
fectiveness of integration with pri-
mary care, care management, med-
1260
ication, and short-term psychothera-
py are all important targets for future
study. By conducting such research,
effective treatment models and
benchmarks of treatment outcome in
the college population can be devel-
oped and integrated into college
mental health practice.
Acknowledgments and disclosures
The authors thank Michael Klein, Ph.D., for
his assistance in the development of this brief
report.
Dr. Chung has served on advisory boards for
Takeda Pharmaceuticals and Lundbeck Phar-
maceuticals and has served as a speaker for
Pfizer and Jazz Pharmaceuticals. Dr. Miller re-
ports no competing interests.
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