Balancing Mental Health and COVID Safety
There were stretches in the spring, sometimes for days, when Lucy Wickings ’22 could barely bring herself to get out of bed. Moments before scheduled class meetings, she would open her laptop and connect via Zoom, but keep her camera off, in a mental state she describes as “hardly there.” Wickings, who is homeless and thus was allowed to stay on campus after most students were sent home as the coronavirus spread, had struggled with her mental health before the College all but emptied out in March. After a month of extreme isolation, and with no family support to fall back on, she slipped into depression—and sought help. But her emails to administrators went unanswered at first, she says, and later resulted in conversations with staff not trained in mental-health services. Nor was it immediately clear whether Harvard’s Counseling and Mental Health Services (CAMHS) would be able to refer her to a therapist willing to waive a copayment. After weeks of her own research, she found a therapist who waived the copayment, and her condition improved. As universities weigh how to respond to the pandemic, she says, they must pay more attention to students’ mental health. Otherwise, “we will lose people.”
Recently, Wickings and more than 160 others, most of them students, signed an open letter published July 8 and addressed to the Faculty of Arts and Sciences Fall Planning Committee, demanding increased attention and improved care for students’ mental health.
Their concerns, and rising demand for mental-health services on campuses nationwide, coincided with Harvard’s concurrent focus on the need for care. In early 2019, University provost Alan Garber convened a Task Force on Managing Student Mental Health to study and address growing mental-health concerns among undergraduate and graduate students. Composed of students, faculty, administrators, and mental-health professionals of various backgrounds, the task force worked for 15 months to review data, speak with the Harvard community, and formulate recommendations. By the time the pandemic closed the campus, nearly all of its work had been completed. The task force released its report on July 23, finding that “Harvard students are experiencing rising levels of depression and anxiety disorders, and high and widespread levels of anxiety, depression, loneliness, and other conditions.” From 2014 to 2018, for example, the share of students who reported having or thinking they might have depression increased from 22 percent to 31 percent. For anxiety disorders, the corresponding reported incidence rose from 19 percent to 30 percent.
The task force made eight recommendations, the central one being to create a University-wide team to work on student affairs, with a focus on mental health. Four of the recommendations involve convening more committees or further examining the issue, suggesting there is much work to be done. The recommendations were not modified to account for COVID-19, but in a statement accompanying its release, Garber said, “The Task Force has thoroughly examined the challenges that our students were facing even before the COVID-19 pandemic upended their lives.” He emphasized that the needs identified in the report (“for greater connection, for wider adoption of and help with self-care, for more accessible support in dealing with everyday struggles as well as mental health conditions, and for better coordination of mental health strategies across the University”) have been made “even more pressing by the uncertainty and isolation that everyone experiences now.”
The pandemic has placed unprecedented strain on universities across the globe. Plans for the fall semester range from Harvard College’s fully remote learning to a hybrid of in-person and online classes on other campuses, with the goal of protecting public health. Less visible in the unfolding narrative of higher education’s tentative reopening is students’ mental health under the punishing conditions.
Even before the pandemic, mental-health issues among college-age people have become increasingly prevalent in recent years, says John Torous, an instructor in psychiatry at Harvard Medical School who directs the division of digital psychiatry at Beth Israel Deaconess Medical Center. The pandemic has only exacerbated the problems. People in their late teens and early twenties, Torous explains, face an elevated risk for new mental illnesses and psychological difficulties: as the brain is completing maturation, they are exposed to new social and academic stresses on campus, where they may try alcohol and drugs for the first time.
The shift to remote learning, though necessary to stem infections, has shattered protective factors for students’ mental health, including social connections, a strong sense of purpose, and regular sleep and exercise. Many students must cope simultaneously with isolation, economic insecurities, fear of contracting the virus, care for their families, and academic pressures. Recent studies, says professor of psychiatry Matcheri Keshavan, describe sharp increases in depression, anxiety, substance abuse, and suicidal thoughts among college-age students since the pandemic’s onset, and those with preexisting psychiatric disorders are especially at risk—a trend he expects to continue. Keshavan, too, signed the letter regarding provisions for mental health in the fall. Public health and mental health, he says, are in conflict: any reopening of schools inevitably leads to increased virus transmission, but not opening schools (or opening them with severe constraints on social interaction) may have serious mental-health consequences. The task force report largely shares the views expressed by Torous and Keshavan, noting that “the dramatic disruptions to social life created by the pandemic will affect, and in some cases worsen, the problems we have identified.”
Chief of CAMHS Barbara Lewis, M.D., wrote in a statement responding to questions that after the pandemic hit, CAMHS rapidly shifted to training staff and clinicians in how to provide telephone and telemedicine therapy. “Throughout the spring term, CAMHS remained fully operational, with all CAMHS clinicians offering telemedicine and telephone therapy options for all patients,” she continued. “CAMHS’ patient numbers remained almost identical to our patient volume when students were on campus.” CAMHS has also provided occasional workshops and group therapy throughout the spring and summer.
What are students’ concerns, given the College’s plan for limited residential operation and fully remote learning this fall? The open letter that Wickings and Keshavan signed begins, “We urge you to revise the Fall 2020 Plan to ensure that Harvard students’ mental health is protected. Merely informing Harvard undergraduates of the existence of CAMHS (Counseling and Mental Health Services) will not be an adequate response if the Plan actively puts students in a harmful situation.” (The task force report is consistent with this argument, and recommends proactive messaging about mental-health care and encouraging students to seek help when needed. One recommendation included the suggestion to “Consider instituting regular check-ins with students.”)
Amir Hamilton ’21 decided to write the letter after reading Harvard’s “residential community compact,” a six-page document emailed to undergraduates on July 6 that provides guidelines for students living on campus during fall semester. The compact lays out clear rules in some detail relating to physical distancing, self-isolation, hygiene, travel, building access, and regular testing and contact tracing for COVID-19. But Hamilton didn’t see a mention of mental health in the compact or in other FAS emails, an omission he believed was problematic.
Undergraduates further into their education, who will mostly be living off-campus, have and will continue to face severe challenges to their mental health, as outlined by Keshavan and Torous. And Hamilton says that even for those physically returning, the reopening plans describe a dreary campus with limited opportunities to socialize, and monotonous cycling between dorm and dining hall. He is worried about first-year students, who will be far from home and may not know how to advocate for their mental health or navigate University resources. Even before COVID-19, loneliness and imposter syndrome (a condition in which students feel they do not belong at Harvard, despite being capable and qualified) were prevalent among undergraduates: the mental-health task force found that in the first week of classes, 62 percent of first-years scored in the high range on the UCLA loneliness scale and 61 percent reported frequent or intense feelings of being an imposter—struggles, the report states, that magnify the negative effects of stress and are unlikely to abate throughout a student’s time at college.
Hamilton wrote the open letter after asking the planning committee about its plan to support student mental health and being told they were considering the issue but had not yet arrived at definite plans. (Since April, public-health experts have been speaking out with increasingly urgent concern about the mental-health fallout from the pandemic, including for college students, and have called for increased support for students.) The open letter was Hamilton’s next step. “Unfortunately, the [reopening] guidelines that Harvard has given out so far are relatively bare bones,” he says. He finds the ambiguity frustrating, but also sees it as an opportunity to shape better support for students this fall.
Both Hamilton and the task force note that undergraduates often do not know when or how to seek help for themselves or their peers. The task force reports that even before the pandemic, students generally felt the University’s guidance on mental-health issues was inconsistent. “Some students reported being unclear about what kind of stress is normal and when they should ask for help,” the report states. “Students, faculty, teaching fellows, and staff all expressed a desire for more training on recognizing and responding to the range of mental health issues that they encounter in their own lives, in their interactions with friends, and in their work with students. Even those involved in peer support organizations noted the wide gap between the training they receive on responding to issues like sexual assault and the training they receive on mental-health issues and resources at the University, emphasizing that while the former is important, the latter is something they encounter on a nearly constant basis in their work with students.”
In signatories’ comments appended to the open letter, the most common suggestion, Hamilton says, has been for the University to have mental-health professionals check in regularly with all students, both on and off campus.
Students have long complained that the current system of receiving mental-health care through CAMHS is a lengthy process that usually involves waiting several days to weeks for an appointment, during which a student’s condition can change dramatically. (Wait times for mental-health care for the public at large are often similar or worse: one 2018 survey found a severe shortage of psychiatrists in 77 percent of U.S. counties, and a 2019 survey of outpatient psychiatric services in Boston, Houston, and Chicago found the average wait time to be 25 days for a first appointment.)
During a pandemic, Hamilton says, such gaps are untenable. The task force found that although CAMHS has increased its workforce by 40 percent since 2015, the current ratio of students (undergraduate and graduate) to CAMHS staff is 468 to one. In 2019, the median wait time between seeking help and having a phone consultation ranged from days to two weeks, and the median wait between a phone consultation and an appointment ranged from two to three weeks. Accessibility of therapy is also a concern; even minimal copays are unaffordable for some students, such as Wickings. The task force report notes that this issue as well is not unique to college campuses—high cost and insufficient health coverage remain a key barrier to mental-health-care access across the nation—and that many Harvard students are unaware of their options for overcoming cost barriers to such care at Harvard.
Hamilton’s letter echoes the concerns of some medical experts. Torous says continued remote learning means universities will see spikes in mental-health difficulties and a corresponding “surge in demand for mental-health services, and certainly telehealth.” Keshavan agrees that virtual mental-health care is a necessity for universities in the fall semester. “One has to be very cautious in opening up schools too quickly,” he says, but at the same time, continuing with mostly virtual learning will have “negative psychological effects. So universities should really build enough of a workforce to address those mental-health concerns by having more freely accessible and available services, telehealth-wise.” In recent years, he adds, “A lot of tele-mental-health is already a rule of the day, rather than the exception.”
One letter signatory, Thuong Ho, is an incoming first-year student from St. Louis. As a first-generation and low-income (FGLI) student, she worries that uncertainty about the form and availability of first-year resources (such as office hours, peer-advising fellows, and proctors, all part of what the task force report calls “a robust system of support for first-year students”) will hamper her efforts to adapt to Harvard’s academic and social environment. The task force report notes that “Certain populations of students”—FGLI students, along with BGLTQ students and those from historically underrepresented groups—“were more likely to experience mental health issues…and to experience greater barriers when accessing help.” The pandemic potentially magnifies these disparities in mental health, perhaps putting students from less privileged backgrounds into acute financial distress or causing some to be sent home to families not supportive of their gender and/or sexual orientation. Ho also hopes Harvard can provide regular check-ins. “Harvard shouldn’t rely on students to reach out,” she says. “They should be the one that reaches out to students, because I know sometimes it can be very difficult to take the initiative.”
Such regular check-ins, of course, pose logistical, financial, and personal hurdles—especially for already-vulnerable populations. Teletherapy requires a stable internet connection and a space the patient feels safe calling from, both of which many students lack. And regardless, CAMHS would likely need to hire many more counselors. “There are economic difficulties as well for universities to maintain the workforce: college counselors and other mental-health personnel,” Keshavan acknowledges. Yet to best protect their students’ mental well-being, he adds, “In general, universities will have to put in a lot more resources than before.”
Jamelle Watson-Daniels, another signatory and a Ph.D. student in applied math/computer science, is a resident tutor in Lowell House; she is concerned that the University has not yet clearly outlined tutors’ responsibilities to those students living on-campus in the fall who may face mental distress. Tutors already have many other responsibilities and are not trained to address mental-health issues. (Harvard Public Affairs and Communications did not respond specifically to questions about administrative plans for tutor responsibilities.) Watson-Daniels also worries that the current situation puts her in a bind in responding to acute student crises, such as an anxiety attack or a student contemplating self-harm. Under those circumstances, telemedicine would be ineffective and in-person intervention would be necessary. Resident tutors would be the nearest adult, but intervening would risk coronavirus exposure. Regular check-ins might help limit such incidents. “It puts resident tutors in a lose-lose situation. You do more work than what is required… and also risk exposing your own family,” she says. “I have a newborn baby. It’s not really fair for me to have to expose my own family just to support students. At the same time, I want to make sure students feel supported. I would be heartbroken if I heard that a student in close proximity to me had some sort of crisis and I could have helped, and I just didn’t because I didn’t want to expose myself. I think it’s going to put a strain on the mental health of residential staff.”
Finally, the letter urges Harvard to consider loosening its restrictions on physical interaction and social spaces, arguing that mandatory mask-wearing, sanitation stations, regular testing, and capacity limits could keep students safe in public spaces. The residential community compact, however, stresses that Harvard’s plans are in accordance with national public-health guidelines. The Centers for Disease Control recommends keeping shared spaces closed in on-campus housing. University officials have acknowledged that this will be a hardship for students, but one necessary to keep them safe. Says Ho: “I really hope that they can figure out ways so we can have more social interaction.”