Int J Adolesc Med Health 2023; 35(1): 109–117

Maria Koschig*, Ines Conrad and Steffi G. Riedel-Heller

Experiences and attitudes towards mental

health problems in first year German university
students
https://doi.org/10.1515/ijamh-2021-0026 Keywords: adolescence; college issues; discrimination/
Received February 23, 2021; accepted April 18, 2021; stereotypes (bias, prejudice); gender; mental health/
published online May 21, 2021
psychopathology.

Abstract

Objectives: The study should show how familiar Introduction

German first year university students are with mental
health issues and what their attitudes are regarding Late adolescence and early adulthood is an important
mental illness. developmental phase. First, career decisions are made,
Methods: The study sample consisted of 293 first year including the decision to study at a university. First year
German university students (20.37 years ± 1.88), most of university students, in particular, are confronted with a
them women (82.9%). The majority (77.6%) was studying a number of unique challenges. They have to manage new
social type subject. An additive focus group consisted of situations on their own for the first time in their lives.
four experts. The participants of the quantitative part were Leaving home, finding new friends, living with room-
recruited at prevention workshops that were offered during mates, and living independently in an apartment present
the induction week at the beginning of the semester at 15 real challenges for students [1]. In addition, they face
German universities. Experts of the focus group were new academic demands requiring self-directed study
recruited by telephone call. In addition to quantitative and must adjust to different academic assessment
analysis, we realized a focus group with experts of our methods.
target group concerns and university system. For statistical Most mental disorders start in adolescence and early
analysis, we used statistic software programme “SPSS” 24 adulthood [2]. It has been shown that students and espe-
to conduct t-tests. We used content-analytical evaluation cially in the first year are particularly vulnerable. Studies
to build a category system. from several countries have shown, that mental health
Results: Every fourth participant reported having had a problems are common in college freshmen [3–5]. However,
mental health problem. Male participants had a slightly there have been no reports on German first year university
greater desire for social distance (p=0.008; df=288) and students so far. It has been shown that mental health
slightly stronger stereotypes (p<0.001; df=289). problems negatively affect academic functioning over the
Conclusions: The present study shows that first year uni- subsequent years [4, 6]. Furthermore, a reduction in help-
versity students in Germany have substantial experience seeking behavior has been reported [7–9]. Several authors
with mental health problems. have highlighted that stigmatizing attitudes are a barrier to
help-seeking behavior in students [7–9].
Therefore, university students in their first year
appear to be a special target group for efforts regarding
interventions to promote prevention and help-seeking in
those affected. According to a German health insurance
*Corresponding author: Maria Koschig, Institute of Social Medicine, company report, university students (6.44%) were more
Occupational Health and Public Health, University of Leipzig, Philipp- likely to be diagnosed with depression according to
Rosenthal-Straße 55, 04103 Leipzig, Germany, Phone: +493419715477, ICD-10 criteria than persons of the same age who were
Fax: +493419715409, E-mail: [email protected] not studying at a university (5.79%). In addition, a
Ines Conrad and Steffi G. Riedel-Heller, Institute of Social Medicine,
greater use of antidepressants in students was found
Occupational Health and Public Health, University of Leipzig, Leipzig,
Germany, E-mail: [email protected] (I. Conrad), [10]. These data underpin the need for research
steffi[email protected] (S.G. Riedel-Heller) in German students, their experiences with mental
Open Access. © 2021 Maria Koschig et al., published by De Gruyter. This work is licensed under the Creative Commons Attribution 4.0
International License.
110 Koschig et al.: Students attitudes towards mental health

health problems and their attitudes toward mental a universal preventive program that informs young students
illness and help-seeking behavior. about mental crisis and mental well-being. Other aspects are help
seeking behavior and low-threshold offerings at university. In
consequence, we contacted experts at the university who offer these
Objectives of the study help for students to discuss their use and experiences in the last years.

This paper seeks to answer following questions: Study period

(1) How familiar are German first year university students
with mental health issues? How many German first The study started in October 2017 and ended in December 2018.

year university students experienced mental health

problems and core-depression symptoms over a two Sampling method
week period ever in their live times? Are there any
differences regarding gender or subject studied? The participants of the quantitative part were recruited in 2017 and
2018 at workshops named, “Studying and Staying Mentally Healthy”
(quantitative)
that were offered during the induction week at the beginning of the
(2) What attitudes do German first year university students semester at 15 German universities. Students were asked to fill out a
hold regarding mental illness in terms of stereotypes, questionnaire when entering the workshop room.
stigmatization and the desire for social distance? Are The experts for mental problems of students were contacted per
there any differences in attitudes regarding gender or telephone after a short search of addresses. We invited them for a focus
group after the quantitative analysis was final.
subject studied? (quantitative)
(3) What is the “Status quo” of mental health culture at
German university (practice example)? (qualitative) Sample size calculation

We did not calculated a sample size because inferential statistic was

not the priority of the study.
Method
Instruments
Study design

A questionnaire was developed to collect sociodemographic informa-

The study follows a mixed-method-approach. A quantitative analysis
tion including age, gender, area of study, number of semesters, pre-
based on questionnaires had been complemented by focus group in-
vious study experiences and self-reported information on mental
terviews with experts. It is a cross sectional study.
health issues. In order to evaluate a prior mental health problem, stu-
dents were asked if they have ever suffered from two core symptoms of
Study population depression (a lack of interest and sadness) for a minimum of two weeks
ever in their lifetime (“Did you ever have in your life a minimum two-week-
A total of 643 persons filled out the questionnaire, 327 were first year phase of reduced interest and joy on more than half of the days?”; “Did you
students. For quantitative analysis we were able to include 293 stu- ever have in your life a minimum two-week-phase of sadness on more than
dents in their first year of studies (freshmen) with valid data in the final half of the days?”). This brief assessment may indicate a past depressive
analytic sample. The final sample consisted of 293 German college episode. In addition, there were three items which measured how
freshmen with a mean age of 20.37 years (+1.88), most of them women familiar German first year university students are with mental disorders
(82.9%). The majority (77.6%) of the sample was studying a social type (“Do you know someone with mental illness?” – yes/no; “Have you read
subject. The response rate was 82%. or heard something about mental illness?” – yes/no; “Have you had
For qualitative analysis, we built a focus group with four experts. your own experiences with mental health problems?” – yes, repeatedly
All of them worked at university at the time of the focus group dis- recurring/yes, infrequently/yes, once/no, but I’m afraid that I might
cussion. They had to do with mental health concerns, worries and have a problem/no).
mental crisis of students in different areas: central advisory office of Attitudes toward mental illness in terms of stigmatization,
the University, psychosocial counseling center of the “Studentenwerk” stereotypes and a desire for social distance were measured by the
(the “Studentenwerk” is a service provider for students with a social Social Distance Scale [11] adapted by Paulus and colleagues [12].
mission for food, housing, financing, culture etc.), psychosocial The participants were asked to rate their agreement regarding given
counseling center of the Student Council (“StuRa”) and psychological statements on a Likert scale 1–5; from “strongly disagree” to
counseling center. “strongly agree”. There are three subscales: social distance (10
items), stigmatization (five items), and stereotypes (five items).
Single items developed by researchers were not validated
Study area separately. These items are not part of the statistical analyses. For
the focus group, we used a semi-structured interview guide. All
The quantitative part took place at a workshop for study beginners. participants were asked to fill out an informed consent. The discussion
The workshop named “Studying and staying mentally healthy” is was recorded.
Koschig et al.: Students attitudes towards mental health 111

Analysis attitudes that did not reflect negative stereotypes and

stigmatization of mentally ill people. The subscale “social
The questionnaire was mainly descriptively analyzed. Item values distance” had a scale mean of 1.41 indicating an extremely
(range 1–5) as well as calculated sum scores of each attitude subscale low desire to distance people with mental health problems.
were used to analyze the sample. Similar to the procedure used by
Similarly, the “stereotype” subscale had a mean score of
Kroenke and colleagues [13], we computed a sum score for mental
1.65 reflecting an extremely low endorsement of stereo-
problems in lifetime (range: 0–6 points) and used the cut-off value of
three to split the group into students with past mental health problems typical beliefs. Interestingly, the stigmatization subscale
and students without (or few) past experience with mental health mean score was moderate at 2.92.
problems. To classify participants area of study, we followed Destatis’ Single item analysis revealed that the social distance
categorization of study subjects [14]. In addition we split the sample subscale item, “I would be embarrassed or ashamed
into area of study and classified first year students as either “social
if my friends knew that someone in my family was
type” subject (like social work, sociology, psychology) or “no social
type” subject (like informatics, medicine, politics) to test group dif- mentally ill” had higher levels (Tables 1–3). For the
ferences. t-tests were computed to analyze group differences in social stigmatization subscale, the item, “Most adults have a
distance mean scores regarding gender and subject. We used SPSS 24 prejudice against someone with mental illness” was
for statistics. the strongest (M=3.58). For the stereotype subscale, re-
Using the record version of the focus group, we wrote a protocol
spondents agreed most strongly with the item, “Someone
for qualitative content analysis.
who has had mental illness cannot be good at university”
(M=1.92).
Ethical statement A two-tailed t-test showed significant (p<0.05) gender
differences in two subscales. The male students had a
Ethical approval was obtained. The ethic committee of University of slight but significant greater desire for social distance (M
Leipzig (medical faculty; address: Käthe-Kollwitz-Str. 82, 04109 Leipzig, male=1.59; M female=1.38; p=0.008; df=288) and slightly
Germany) gave a positive ethic vote at 14/11/2017, number 424/17-ek. stronger stereotypes (M male=1.91; M female=1.60;
p<0.001; df=289) (Figure 1). We found no gender specific
differences in the stigmatization subscale. Overall, the men
as well as the women in our sample had low social distance
Results
values.
Next to gender specific differences, we analyzed sub-
Familiarity with mental illness and
ject type differences. Tables 1–3 show the item means of
experiences with self-defined mental health students studying a social subject and those studying a
problem non-social subject. There are no significant subscale dif-
ferences. Single item analysis shows significant differences
The majority (88.6%) of participants knew someone in all performance-related items. First year students
with a mental illness and 96.6% had read or heard some- beginning study of a social subject have a slightly more
thing about it. Almost two-thirds (63.7%) of those ques- negative attitude about the performance of a mentally ill
tioned stated that they have had their own experiences with person than students beginning a non-social subject.
mental health problems, with 23.6% reporting a recurring
problem. Every third first year student (33.3%) reported
having had a minimum two-week-phase of reduced interest Mental health university culture – case
and joy on more than half of the days. In addition, every example
third participant (32.7%) has had a two-week-phase of
sadness on more than half of the days in the past. The Using the content analysis, we conducted a category system
analysis of the sum score shows, that approximately one- (Fig Appendix 1). The participants reported that there are
fourth (26.1%) of our sample has had a minimum two-week- more students asking for help and more users of metal
phase of exhibited indicators of depression in the past. health services. There are internal offers for students with
regard to mental health themes but they are unsystematic
and the University hasn’t a clear health goal. The university
Attitudes toward mental illness in the case example of the present study has its own in-
stitutions (f.e. student services, “Studentenwerk”) to realize
Overall, the German first year university students in our mental health goals but there are only a few external part-
sample had a low desire for social distance and expressed ners. Additionally, internal offers are not sufficient to meet
112 Koschig et al.: Students attitudes towards mental health

Table : Social distance subscale “Social distance” with scale statistics (value range –). Values are item means with SD in parentheses,
gender specific item means and subject specific items means.

Subscale: social distance Gender specific Subject specific

Scale mean: . ± . (n=) Item mean, SD Female, M Male, M p-Value Non-social, M Social, M p-Value

I would be afraid to talk to someone who is . (.) . . . . . .
mentally ill.
I could imagine making friends with someone who is . (.) . . . . . .
mentally ill.
I would be embarrassed or ashamed if my friends knew . (.) . . . . . .
that someone in my family was mentally ill.
If the person sitting next to me in class developed . (.) . . .* . . .
mental illness, I would rather sit somewhere else.
If one of my friends developed mental illness, . (.) . . .* . . .
I would go and see him/her at the hospital.
I would not invite someone who has had mental illness . (.) . . .* . . .
to my party.
I would not bring along someone who is mentally ill when . (.) . . .* . . .
I meet my friends.
When going on a class outing, someone who is mentally . (.) . . . . . .*
ill should rather stay at home.
I would never fall in love with someone who is . (.) . . . . . .
mentally ill.
Someone who is mentally ill should not work in jobs . (.) . . . . . .*
that involve taking care of children or young people.
Someone who is mentally ill should not go to university. . (.) . . . . . .*

*Significant p-Values (p<.) are highlighted in bold.

Table : Social distance subscale “Stigmatization” with scale statistics (value range –). Values are item means with SD in parentheses,
gender specific item means and subject specific items means.

Subscale: stigmatization Gender specific Subject specific

Scale mean: . ± . (n=) Item mean, SD Female, M Male, M p-Value Non-social, M Social, M p-Value

Most adults have a prejudice against someone . (.) . . . . . .
with mentally illness.
Most young people have a prejudice against . (.) . . . . . .
someone with mentally illness.
Most people don’t have a problem being friends with . (.) . . . . . .
someone who is mentally ill.
Someone with mental illness can find a partner just . (.) . . .* . . .
as well as other people.
Someone with mental illness has problems with . (.) . . . . . .*
finding an apprenticeship/study/work place.

*Significant p-Values (p<.) are highlighted in bold.

the needs of the students; further steps need to be taken of motivation to learn something about “Healthy Univer-
(compare Fig Appendix 1). sity”. Beneficial factors for a “mentally healthy university”
Discussed barriers to the development of a mental are f.e. regular offers, development of new structures,
health university center are f.e.: no health goal, inflexible networking, service presenting, good reachability, clear
structures, lack of support from university management, information for students and university staff and initiative
lack of knowledge (university staff), lack of money and lack of external partners.
Koschig et al.: Students attitudes towards mental health 113

Table : Social distance subscale “Stereotypes” with scale statistics (value range –). Values are item means with SD in parentheses,
gender specific item means and subject specific items means.

Subscale: stereotypes Gender specific Subject specific

Scale mean: . ± . (n=) Item mean, SD Female, M Male, M p-Value Non-social, M Social, M p-Value

Someone who has had mental illness has . (.) . . .* . . .*
to blame her/himself.
Someone who has had mental illness cannot . (.) . . . . . .
be helped by doctors.
Someone who has had mental illness overreacts . (.) . . . . . .
to small matters.
Someone who has had mental illness poses . (.) . . . . . .
a threat to other people.
Someone who has had mental illness cannot . (.) . . . . . .*
be good at university.

*Significant p-Values (p<.) are highlighted in bold.

students and to examine their attitudes around that topic.

Additionally, the interview of experts should generate a
structural perspective around the topic “Mental health
concerns at German university”.
It is known that beginning higher education is a poten-
tially high stressful time. Moreover, it is the period of life when
most mental diseases occur for the first time. It is necessary to
understand the associated concerns and problems of the
target group to develop an adequate preventive program.

How much experience did German first year

university students have with mental health
problems?
Figure 1: Gender specific differences for the three subscales and
global social distance scale (value range 1–5). Almost every participant in the sample had already had
some contact with the topic either because of a friend with
mental health problems or their own experiences. Every
The four experts talked about existing preventive of- third student reported having had a minimum two-week-
fers at the case example with regard to mental health and phase of emotional difficulty in past. The present results for
mental crisis. The inclusion plan of the University gives German first year university students can be compared with
advice about psychological counseling offers. The work- data on American college students between age 18 and 24
shop “long night of procrastinated works” try to offer in- [15]. 34.5% of the American college students reported that
formation about pressure, stress and test anxiety. A general they felt so depressed during the last 12 months that it was
mentoring program shall help students with worries and difficult to function. The German findings are also compa-
uncertainties. Additionally, there is a great variety of sports rable with a representative Belgian sample of 4,921 first year
classes for students. university students [4]. Every third Belgian first year student
(34.9%) reported a mental health problem in the past year.
However, different instruments were used to assess mental
Discussion health. In contrast, the rate of depressive and anxiety
symptoms in a Chinese sample was considerably higher
The aim of the study was to evaluate past experiences with than the measured and reported rates of the Western
mental health problems in German first year university industrial states [16]. A Mexican study measured depressive
114 Koschig et al.: Students attitudes towards mental health

symptoms in 1,122 students (mean age=20 ± 1.98). Depres- Are there any group effects regarding gender
sive symptoms were observed in 20.4% of the students and study subject?
(24.2% women and 15.7% men, p<0.01) [17].
Our analysis showed that the male students in our sample
had significantly higher social distance scores for ste-
How strong are stereotypes, stigmatization reotypes and social distance subscales and global score,
and the desire for greater social distance? as seen in Figure 1. A similar gender effect was reported
by Corrieri and colleagues [20, 21] in a school-based
Overall, the desire for social distance towards mentally mental fitness coaching project. They measured social
ill people was low in our sample compared to the general distance with the same questionnaire [11]. Participants
population attitudes towards persons with depression or consisted of 592 students (range: 12–16 years). Boys had a
eating disorders [18, 19]. Unfortunately, there are no higher social distance than girls. The researchers also
comparable data from other first year students. Howev- reported a “type of school” effect, indicating that higher
er, we can compare our findings with social distance educated students had lower social distance scores.
data on children in a school-based mental fitness project These findings fit to the relatively low social distance
[20]. The children (range: 12–16 years) had quite similar scores in the present study of a sample with high-
low levels of stigmatization, stereotypes and social educated participants.
distance. Subject differences with regards to stereotypes, stig-
On social distance subscale, the item with the highest matization and social distance occur only for performance-
agreement in our sample was: “I would be embarrassed or related items. Students studying a social welfare subject
ashamed if my friends knew that someone in my family was more often expect poor performance and problems at uni-
mentally ill.” In comparison with other findings, it is versity than the other first year students. It could be
striking to see that statements with personal involvement hypothesized that they might be more sensitized to the topic.
provoke the highest social distance scores. For instance, However, there are no data on this in other studies.
Dyrbye and colleagues [7] investigated 873 medical
students. They measured the highest agreement to the
item, “If I were to receive treatment for an emotional/ Status quo – “The Mentally Healthy German
mental health problem, I would hide it from people.” In University”
this case, 47.8% of respondents agreed and 14.1% of re-
spondents strongly agreed with this item, reflecting a form The focus group discussion showed some barriers for the
of self-stigmatization. development of university culture with mental health
On subscale stigmatization the items: “Most adults goals. The lack of an overall mental health goal seemed to
have a prejudice against someone with mentally illness.” be most important. Other barriers were lack of knowledge,
and “Most people don’t have a problem being friends with lack of motivation (of university staff) to inform about
someone who is mentally ill.” (inverted item) had highest mental health, inflexible structures at the university, lack
agreement. Moreover, the majority of our sample disagreed of support from university management.
with all stereotypical statements, so there is a relatively low A short look at the literature showed effective pro-
level of stereotyping. The only performance-based item grams and emphasized the reported lack of knowledge;
(“Someone who has had mentally illness cannot be good at f.e.: A meta-analysis of randomized controlled trials
university.”) had a little higher agreement level with an showed that cognitive-behavioral and mindfulness-based
item mean of 1.92. These results are similar to those of prevention programs are effective in reducing depression
Dyrbye and colleagues [7]. More than 50% of the medical and anxiety symptoms in university students [22]. Another
students from the Dyrbye sample agreed with the meta-analysis of internet interventions for mental health in
performance-based item, “My supervisors (e.g., faculty, university students found low effects in reducing depres-
residents, deans) would see me in a less favorable way if sion, anxiety and stress; and moderate effects in reducing
they believed that I had an emotional/mental health eating disorder symptoms [23].
problem.” In conclusion, performance beliefs seem to be Gulliver and colleagues [24] investigated staff ex-
associated with mental health stigmatizations in university periences of students with mental health problems and
students. their perceptions of staff training needs. This survey-
Koschig et al.: Students attitudes towards mental health 115

based study found similar barriers like reported from the towards mental health. Fernandez and colleagues [26]
focus group members of the present study: Between 70 published a meta-analysis of interventions to promote
and 83% of the university staff reported moderate con- mental health at universities. They showed that the most
fidence in their ability to provide emotional help for successful programs were courses included in curricula
students. More than the half (60%) felt under-equipped with more sessions and practical help e.g. using new
to handle mental crisis of their students and almost the media. A study by Conley and colleagues [27] highlighted
half had no possibility for formal training. The last point the role of supervised practice components. Cognitive
indeed structural problems at the university, which behavioral and mindfulness-based approaches are most
focus group members reported, too. effective for depression and anxiety [22]. The university can
take a leading role in the development of student mental
health care [28].
Limitations

The study did not have a randomized design because Recommendation

data collection was conducted via participation in the
program “Studying and Staying Mentally Healthy” under A relevant part of young students who started at university
real life conditions. The program was open to all stu- had or have own experience with metal crisis. From litera-
dents at almost all joining universities. The program was ture, we know that they are in a sensible transition phase.
mainly designed for students in their first semester. It Mental problems at this time have the potential to manifest
might be reasonably assumed that students joined the in adulthood. Therefore, it is necessary to implement low-
session were particularly interested in the theme. This threshold offerings at university.
may have led to a selection bias. With 75.5% studying a
social type subject, these students were over represented
in our sample. Highlights
Every fourth young student reported having had a mental
health problem.
There is a lack of an overall mental health goal at
Conclusion & future research
university.
Low-threshold offerings at university are necessary.
All together, the present study showed that first year
Networking between offerings and external centers can be
German university students have had considerable expe-
a beneficial factor in developing mentally healthy univer-
riences with mental health problems. The rates of sadness
sity strategies.
and reduced interest are comparable to other first year
students in Western industrial states. There is a gender
effect towards social distance, stereotypes and stigmati- Acknowledgments: We thank all students for their partic-
zation with regards to mental illness for German university ipation, the “Irrsinnig Menschlich” society for the collab-
students in their first year. Stigmatizations occurred at low oration, the proofreader and the reviewers for commenting
levels. this manuscript.
How can we protect students from becoming mentally Research funding: This work was supported by the
ill or manifesting a mental illness? Serious mental health BARMER Gesundheitskasse.
problems in college students are associated with lower Author contributions: All authors have accepted
academic performance and reduced help-seeking behavior responsibility for the entire content of this manuscript
[3, 6–9]. The idea is to reduce barriers, like stigmatization, and approved its submission.
to mental health treatment in order to improve access to Competing interests: Authors state no conflict of interest.
care and ultimately to improve the mental health of college Informed consent: Informed consent was obtained from all
students. Telles-Correia and colleagues [25] intervened individuals included in this study.
with medical students with mental illness problems and Ethical approval: The local Institutional Review Board
significantly reversed negative and dysfunctional attitudes deemed the study exempt from review.
116 Koschig et al.: Students attitudes towards mental health

Appendix

Appendix 1: Category system of the focus group discussion.

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