We face a growing demand for mental health services at Harvard that is linked to an increasing trend in the prevalence of serious mental illness among enrolled students. These two upward trends reflect what is happening throughout institutions of higher education in the United States. Harvard is no different in this regard. The reasons are attributed to improved medications for serious mental illness and rising expectations for what to demand from a health care system. The Harvard community should embrace both developments. Excellent students who were previously disabled by illness can now, with the help of therapy and medications, accomplish their life goals here; moreover, people have a sense of how good health care can be, and they seek it within the Harvard system. The challenge is how to meet this need in an environment where the costs of health care are becoming significant parts of the budget. For Harvard, as for every other institution responsible for providing health care services, the issue of quality of care has to be addressed in the context of the costs and the benefits of that care.

The quality of mental health services provided to students has been a major focus of our attention. When the University Student Health Coordinating Board (USHCB), of which I am chair, began our work in 2000, we were aided by three relevant previous peer-reviewed reports of University Health Services (UHS). Despite substantial investments prior to this time, these reports identified key problems in student mental health services that fell into two clusters: difficulties getting into care and difficulties once in the process of treatment. In 2000, the majority of issues appeared to lie in the first cluster. We moved fast to address issues of stigma and access because of our concern that unless students found it very easy to seek care, we would miss finding some who really needed professional mental health services.

Over the last three years we can claim progress on several of these issues. First, outreach of all kinds and growing student activism have helped make everyone aware that mental illness is a condition that many people are forced to live with and that can almost always be effectively treated. Second, confidentiality protocols have been strengthened so that essential emergency communications can be sure to occur without the transmission of private and privileged information regarding an individual student’s health status. Third, the time to a student’s first appointment and the time to his or her next follow-up appointment has decreased markedly. For example, at UHS Mental Health, same-day appointments are always available for students with urgent concerns, and the average wait time for an available medication appointment is 1.5 days. These advances result from introduction of additional staff; improvements in appointment and scheduling systems; extended staffing for after-hours urgent care; and adjustments in management protocols so that clinicians always have some clear time every week in their schedules for emergencies. A new triage system allows same-day telephone access to an experienced clinician for students who call, in order to clarify their concerns and arrange a prompt meeting with a clinician whose skills will match their needs.

Still, these improvements have brought with them new issues, or at least have aggravated pre-existing ones. As stigma has lessened, more students are entering the system to seek care. In 2003, UHS Mental Health had 4,871 visits by undergraduates, a 30 percent increase over the 3,401 undergraduate visits in 2001. This is a good development—but it puts more pressure on access. And the measures to improve access have meant that the clinicians are trying to be more efficient, matching student needs with their own time and expertise. This matching process is perhaps one of the reasons students sometimes feel “managed.”

Parallel to these initiatives, the USHCB has been working with UHS and the Bureau of Study Counsel to tackle the second cluster of issues: coordination and content of care. These are harder and more expensive problems to fix, but we see several concrete steps that can be taken.

As many have suggested, UHS and the Bureau need to be more tightly coordinated and linked through staff, systems and oversight to present a seamless and clear mental health program to all students in the University. The steps to get there are underway now.

But whether students enter the mental health system through the Bureau, which is a friendly and inviting place to drop in, or through UHS, which has a more medical feel to it, we must be sure that students receive the same rigorous and compassionate assessment and the same appropriate therapy. We must also be sure that all the clinicians provide the sense of warmth, empathy, listening and attention that all people legitimately seek from their health care providers. This requires adding more clinicians and providing more training and mentoring—expensive additions to a system that already has twice as many mental health clinicians per student as any comparably-sized university health service in the country and that spends nearly three times more per patient than traditional health plans spend per patient on mental health. Designing these steps is also underway.

The imperative to provide mental health services of very high quality and satisfaction has driven increases in the budget and student fees. As a community, we must recognize that there are limits to how much of the University budget can go towards health care and how much burden can be borne by students and their families. When should the need to take very good care of the very mentally ill drive out the capacity to take very good care of those who are less ill but still need therapy or short-term medication support? What part of the mental health budget should be devoted to attending to important concerns of many students, such as stress reduction and management of routine adjustments to college life? How long and under what treatment circumstances should students with serious exacerbations of mental illness be held in an academic environment before determining that their health and safety would be better served in another setting where they can focus on getting sustained professional help?

There is nothing wrong with facing these questions very clearly and bluntly. In fact, it would be irresponsible not to do so. We have more students in our midst with mental illness and we are working very hard to improve the care they need, incurring significant cost increases as a result. The real reason we are all uncomfortable with these questions is that there are no immediate good options. These questions would be much easier to address if our general health system were well fashioned to take care of mental illness, if everyone had health insurance and if everyone had a supportive home to return to.

The USHCB intends to work with the provost, the leaders of UHS and the Bureau and students, faculty and staff in helping to address these outstanding issues. We have made considerable progress, thanks to the enormous hard work of many people. It is important that we approach what remains to be done as a collective community venture, where what is at stake is our health, our values and our sense of common well-being. Very good people, of vast integrity and commitment, are trying to make sense of these problems and fix them as rapidly as possible. Harvard’s mental health system is vigorous, ample, resilient, responsive and without question among the best in the country. Is there room to make it better? Yes, and together we can be sure that the improvements happen on our watch, in short order.

Jennifer Leaning is a professor of international health at the Harvard School of Public Health. She is the chair of the University Student Health Coordinating Board.