From impostor syndrome and other feelings of being out of place, to periods of isolation and to constant short- and long-term deadlines, graduate school presents serious potential challenges to students’ mental health. There’s also financial strain, navigating complex relationships with advisers and colleagues, the job market, and myriad other worries.

Despite that, there are relatively little large-scale data on graduate student mental health. There isn’t much research on the topic to begin with, and those studies that do exist tend to be small in scale or have low response rates, or both. Things are changing: a widely cited study from earlier this year involving several thousand graduate students found that they were six times more likely than the general population to experience anxiety and depression. It called the matter a "crisis." Still, most campus efforts at improving students’ psychological well-being have been focused on undergraduates.

New research on graduate students’ mental health at Harvard University calls for more attention to the issue and suggests that the battle can’t be fought by graduate students or campus health services alone. Departments, which are responsible for some of the environmental factors that impact students’ outlook and health, also must change, the authors insist.

“We can't build a counseling center big enough to deal with this problem,” said Paul Barreira, director of Harvard’s University Health Service, the Henry K. Oliver Professor of Hygiene and an associate professor of psychiatry. “Here we have 45 full-time-equivalent clinicians, or 55 people, for 20,000 students. That’s like one clinician for every 400 students. We’re overwhelmed, and that should tell us that the system is broken -- that our approach to this has been wrong and needs to be rethought. And there are many programs that aren’t as fortunate as we are.”

Suggested interventions included in a new working paper by Barreira and colleagues include encouraging students to take on research or activities that “provide a sense of meaning and usefulness to them in the short term,” to help students “hedge against failure.” Provide continuous engagement, “making clear to students that someone cares about their success in the program,” the paper says. “Support students in preparing the best possible job market paper and dissertation regardless of the students' ambitions or career preferences” and “make the coursework years as useful and relevant to the research years as possible.”

"Discuss failure with advisees early on" and “commit to being their supportive adviser first and their evaluator second,” the paper further suggests. “Partner with your university's counseling center to educate students and faculty and to publicize clinical services. Let students know that their mental health and wellbeing is a priority for you and should be a priority for them.”

Mental Health, by Program

Barreira and several colleagues set out to study graduate student mental health data at the department level. They wanted to establish rates of depression, anxiety and other measures, such as suicide risk, eating disorders, impostor syndrome (feeling secretly inadequate in a given milieu), attention deficits, self-esteem issues, loneliness, and sleep, exercise and alcohol consumption levels.

Next, the researchers wanted to identify critical environmental factors contributing to stress or well-being. And they wanted to involve students in the crafting of their survey instrument: beyond the prescreening questions on depression, anxiety and other issues, students -- initially from the economics department, and then others (the list continues to grow) -- helped draft questions about the environment. Departments in the natural sciences wanted to add questions about laboratory time, for example.

Barreira and his colleagues have found that levels of depression and anxiety vary widely across programs, suggesting that environmental factors are at play in graduate student mental health. An initial analysis involving five programs and hundreds of students, which Barreira presented at the American College Health Association -- and which saw notably high response rates, of between 44 percent and 79 percent of students -- found that depression rates varied from 15 percent in one department to 30 percent in another. Anxiety rates varied from 12 percent to 30 percent. Those rates are somewhat consistent with other graduate student-specific data and significantly higher than general rates of adult depression and anxiety.

In one unspecified program, 10 percent of students had moderately severe or severe depression symptoms. Twelve percent had severe anxiety symptoms. Four percent of respondents had both moderately severe or severe depressive symptoms and severe anxiety. About 13 percent of the sample was in treatment for anxiety, and 13 percent for depression. The five students suffering from moderately severe or severe depressive symptoms were not in treatment. One-third of the students with severe anxiety symptoms were getting treatment.

Lessons From Economics Departments

Barreira’s new paper is based on eight programs in economics, housed at Harvard, Columbia, Princeton and Yale Universities, the University of Michigan, the Massachusetts Institute of Technology, and the University of California campuses in Berkeley and San Diego.

About 18 percent of students experienced moderate to severe symptoms of depression and anxiety, compared to about 6 percent and 4 percent, respectively, among 25- to 34-year-olds in the general U.S. population, according to one 2013 study. Eleven percent of respondents, or 56 people, reported having suicidal thoughts on at least several days within the previous two weeks. One-quarter of students had been previously diagnosed with a mental health issue, about half of them before the Ph.D. program and half after.

Of those experiencing moderate to severe symptoms of depression, only 27 percent were receiving treatment for it. About 21 percent of those experiencing anxiety were getting treatment and only 27 percent of those who recently thought about suicide were getting help.

Moreover, the study says, “the prevalence of depression and anxiety symptoms among economics Ph.D. students is comparable to the prevalence found in incarcerated populations.” Loneliness and isolation are major issues, too, as “the average economics Ph.D. student feels considerably lonelier and more isolated than a retired American.” Women and international students are most affected.

Interestingly, the majority of those who received mental health treatment didn't ping high on depression or anxiety. So, the report says, “contrary to social stigma, seeing a mental health professional is not the same thing as having poor mental health. Many of those who seek help are doing better than those who do not.”

Economics students tend to regret how they organize their time and engage with their studies, the paper says. Just 26 percent reported feeling like their work is useful always or most of the time, compared to 70 percent of economics faculty members and 63 percent of the entire working-age population. Yet 62 percent of students worried always or most of the time about work when not there. Twenty percent said they were too tired for activities in private life. Thirteen percent of students had seriously contemplated quitting their programs once in the previous two weeks.

Regarding advisers, 96 percent of students said they'd met with their main advisers at least once in the last two months. But they reported fearing making a bad impression, doubts about their work, and lack of progress as barriers to meeting more frequently.

Many students said they were unable to be honest with their advisers about the challenges they were experiencing. In order of frequency, these honesty “gaps” are due to nonacademic career options, preparing for the job market, research progress, issues with other advisers and issues arising from co-authorship with the faculty member. Almost half of students said they wouldn’t know where to go if they had an issue with their adviser.

Few students feel comfortable raising their hand in a seminar setting, and just 19 percent of women said they would be comfortable doing so, compared to 35 percent of men.

Sixteen percent of students had experienced some form of sexual harassment. Twenty-two percent of women have experienced sexual harassment, compared to 13 percent of men. Nearly two-thirds of the instances of sexual harassment were perpetrated by another graduate student, while 19 percent came from a professor.

That finding recalls recommendations included in a June report from the National Academies of Sciences, Engineering and Medicine. The document centered on what it called “unchecked” sexual harassment and noted that sexual harassment has been found to negatively impact targets’ mental health and performance. Among other things, that study advised departments to adopt mentoring networks or committee-based advising that allows for a “diversity of potential pathways for advice, funding, support and informal reporting of harassment.”

Older cohorts tend to fare worse than younger ones in terms of mental health. In a parallel finding, 7 percent of first-year students reported contemplating suicide in the last two weeks, compared to 13 percent of those with five or more years in.

Twenty-seven percent of those who said they regret doing the Ph.D. and 20 percent of those who regret their choice of advisee reported recently contemplating suicide. Those who said they wished they’d engaged more with their studies and organized time more effectively have “substantially lower rates of suicidal ideation.”

Students who “perceive their peers as competitive, who do not have very good friends in the department, and who in general do not have many people with whom they can openly discuss their private feelings without having to hold back have worse mental health,” the paper says.

At the same time, mental health issues do not appear to affect students with disparate values differently. In particular, the study says, “students who believe that tenure at an academic institution is very important for their success in life are not more or less likely to have mental health issues than students who believe that income or recognition or a family are very important for success in life.”

Encouraging Interventions

Barreira and his co-authors wanted to foster conversations about interventions. Already, he said, he’s witnessed conversations within Harvard departments about a perennial stressor to students: advising.

“There are conversations about how responses on questions on advising correlate to responses on anxiety,” for example, he said. “This is not unique to us -- advising is an important topic at universities across the country. But what we’re seeing is that for departments, it’s all kind of theoretical until they have the data -- and then, suddenly, there’s an urgency to do something.”

Barreira and his colleagues continue to help departments survey their students. The plan is that data will be gathered annually, to gauge progress.

Several other institutions have attempted to tackle graduate student mental health on their own terms. A task force at Johns Hopkins University that looked at both undergraduate and graduate mental health found earlier this year that the university should promote a “climate of awareness and support” for student mental health, wellness and stress reduction, and improve access to services. Training for students, faculty and staff about resources must be improved, too, it said.

Margaret Daniele Fallin, co-chair of that task force and Sylvia and Harold Halpert Professor and chair of mental health, said this week that department climate is indeed “a big issue.”

“There needs to be a true sense that the department cares about the well-being of students and supports positive infrastructure and behaviors,” she said. “We focused on addressing stigma, creating an environment of inclusion and awareness, and promoting wellness practices, training and respect for time to do these things.”

That can include helping students understand they may miss a class for a mental health appointment, just as if they had the flu, Fallin said.

So far at Hopkins, as a result of the report, there have been more frequent interactions across divisions about student mental health, more exchanges about best practices, more support for student-led efforts and better coordination of disability services with health and academic services, Fallin said. A wellness committee actively adopts and monitors student mental health initiatives.

Asked about faculty resistance to mental health efforts at the department level, Barreira said “the way things have always been” is no excuse to perpetuate harm, and that it’s not clear that things have always been “this way” anyway. Before professors faced quite so much pressure to publish and win grants, there was more time for and emphasis put on positive mentorship.

“Faculty knew students better than they know them now.”

Student-Led Efforts

Some initiatives have been student-led. In 2014, the Graduate Assembly at Berkeley conducted a study of mental health among peers. Members found grave concerns about finances, social support, advising and career prospects. They found top predictors of depression among their ranks to be sleep, overall health and academic engagement.

Graduate students wanted more help, including a designated space so that they wouldn’t have to encounter students they taught in campus health services. Last year, Amy Honigam, graduate well specialist on campus, became that someone. She sees students one-on-one in a graduate student suite but also works to promote awareness and change across campus. This semester alone, she’s spoken approximately 60 times about graduate student wellbeing.

In one instance, she said, 150 students showed up to a science resilience talk on turning self-criticism into kindness. Another project of Honigman’s is identifying well-liked faculty mentors to train other faculty members to be better advisers.

“These people are here because they love research and love their work, but they’re not all here to be teachers,” she said of faculty members. “There is a sometimes a boot camp mentality. And you don’t want to pander to students. But you don’t have to say to them, ‘That’s the worst thing I’ve ever seen.’”

The root issue, Honigman said, is that “students need to feel more valued. It could just be simple conversation or simply emailing somebody back.” They are not just on campus to help faculty members, she said, but rather to learn.

Honigman defined her philosophy like this: "Self-compassion is the foundation for resilience.” She added, “You have to be patient with the process. You don’t know everything yet -- that’s why you’re here.”

As for Barreira's research, Honigman said that departments need to help promote graduate student mental health, whether they like it or not. “We can’t hire enough counselors,” she said. “It can’t be all about intervention, it has to be about prevention. Places like Berkeley are so big, cultural change is not going to happen all at once, but at that ground level, departments can be so much more effective.”

Kaylynne Glover, a Ph.D. candidate in biology at the University of Kentucky and director of legislative affairs for the National Association of Graduate-Professional Students, said most graduate students struggling with mental health due to “poor relationships with their advisors and program directors. They feel overburdened, with little to no allowance for a life outside of work.”

Many report working in the evenings and weekends on top of their every day work, she said, and the “constant criticism, designed to help us become better researchers and thinkers, has the side effect of making us feel worthless and inadequate." Such pressures don't exist to the same degree for undergraduates, but are "nearly universal as a graduate student," she added.

Similar to Honigman, Glover stressed the importance of distress prevention among graduate students, rather than responding “retroactively.” But she emphasized a need to rethink how graduate school works as a whole.

While undergraduate distress is often due to “a lack of social network and of being away from home for the first time,” she said, graduate student issues often stem from the “direct power relationships they have with their faculty advisors and supervisors.” And the only way to fix that, Glover said, “is by comprehensively addressing the nature of graduate school -- of academia itself -- and changing the culture,” to one where work-life balance is valued and power relationships between students and professors are more balanced. Glover and her colleagues at the association help to educate policy makers on these issues at the institutional, state and federal level.

Thomas Clements, a lecturer in biological sciences at Vanderbilt University who struggled with anxiety as a graduate student, said he was struck by Barreira’s findings on the prevalence of suicidal thoughts, which he said he never experienced. Loneliness seemed more familiar, however. Even though Clements was surrounded by people during my graduate school, he said, “I felt that I couldn't share my failures with others,” or could only socialize after periods of academic success -- further isolating him in times of intense academic stress.

Clements agreed that advisors are a big part of the problem, including when they push the tenure-track career paths on students. While Clements was lucky that his advisor supported his teaching-oriented ambitions, he said, “I saw firsthand that other advisors hindered their students' experiences in these types activities, in the goal of maximizing research output for their own benefit.”

He further agreed that advisors should check in with their students more, not just about work and even openly about mental health. As to the new paper’s recommendation on helping students “hedge against failure,” however, Clements bucked.

Science is “so unpredictable” that one can’t hedge against failure, but should instead “put in the effort to help your student navigate through a difficult project that may not have many victories up front.”