Mental Health & Prevention (2015) 3, 4147

Psychological complaints of students:

A comparison of eld samples with clients
of a counseling service at a typical
German University$
Volker Krea,b,n, Michael Spertha,b, Frank-Hagen Hofmanna,b,
Rainer Matthias Holm-Hadullaa,b,c

a
University of Heidelberg, Germany
b
Counseling Service for Students, Studierendenwerk Heidelberg, Germany
c
Universidad Diego Portales, Santiago de Chile, Chile

Received 3 April 2015; received in revised form 16 April 2015; accepted 21 April 2015
Available online 1 May 2015

Abstract
In this study, samples of Counseling Center Clients from the last 15 years are presented and
compared to student eld samples with regard to type of distress and severity of symptoms
measured with the Symptom Checklist-90-R, the Psychosocial Complaints List and the Satisfaction
with Life and Studies Scale. While 1215% of the students in the eld sample are severely
impaired, 5458% of the Counseling Center clients suffer from severe mental disorders. Type and
severity of psychological distress in client center samples have remained remarkably stable over
the last 15 years. Implications and consequences for counseling centers are discussed.
& 2015 Elsevier Ltd. All rights reserved.

1. Introduction and values, nd new companions and create an authentic

University students are expected to accomplish academically
but also to develop personally. They transform learned norms
This paper has been made possible by a grant of the Klaus-
Tschira-Stiftung.
n
Corresponding author.
E-mail addresses: Volker.Kress@stw.uni-heidelberg.de (V. Kre),
Michael.Sperth@stw-uni-heidelberg.de (M. Sperth),
Frank-Hagen.Hofmann@stw.uni-heidelberg.de (F.-H. Hofmann),
Rainer.Holm-Hadulla@stw.uni-heidelberg.de (R.M. Holm-Hadulla).
personal, social and professional life style. This process is
frequently connected with crises. Creativity research shows
that these crises may contain a productive potential but can
also lead to mental disorders and failures (Holm-Hadulla,
1996). As a result, many need professional assistance to cope
with and to prevent mental disorders and suicide. The U.S.
Department of Health and Human Services stated in 2012
that mental illnesses are most frequently reported among 18
25 years old students. Stallman (2010) showed the much
higher prevalence of psychological distress among university
students in comparison to the general population in Australia.

http://dx.doi.org/10.1016/j.mhp.2015.04.002
2212-6570/& 2015 Elsevier Ltd. All rights reserved.
42 V. Kre et al.

Zivin, Eisenberg, Gollust and Golberstein (2009) also showed
the importance of this period in regard to the onset of mental
health problems. Bailer (2008) found a prevalence 23% of
mental disorders among students measured by PHQ-D
(n=1100). 14% suffered from clinically relevant depressive
symptoms.
There are many studies that report an increase in levels of
psychopathology over the last decades. Some of them are
based on retrospective interviews with counseling center staff
or directors (e.g. Gallagher et al., 2000). Grayson and Meilman
(2013) i.e. presented data from online-questionnaires that
were given to 28 counseling center directors which had been
in watch for at least 20 years. He found that most of them
reported an increase in student pathology and demand for
appointments. The nature of this nding is rather subjective
and could be driven by the steadily climbing number of clients
per year. As Sharkin and Coulter (2005) argued, college
counselors could perceive severe client problems as more
challenging under the pressure of a high workload.
Other studies suggest no increase in client symptoms sev-
erity. Most of them used client-perceived impairment to
measure overall pathology (i.e. Erickson Cornish et al.,
2000). This is not a viable method either because of the diff-
erence between client and therapists perspective. Changes in
the client perceived distress may not necessarily reect real
changes (see Sharkin, 1997, 2005). They could be clouded by a
higher reactivity to psychological symptoms due to media
attention, high-prole cases or popular movies and theref-
ore an increased willingness to rate higher on a given scale.
Sharkin and Coulter (2005) suggested to use both the clients'
and therapists' perspective to prevent such errors.
Well recognized and publicized was the Benton et al. (2003)
study. They analyzed data from over 13,000 counseling center
clients across 13 years (19882001) and found an increase of
symptom severity in many problem areas. They used data from
an own instrument the Case Descriptor List (CDL) that
indicates which problem areas were addressed during counsel-
ing. Sharkin (2004a, b) criticized the relatively broad cat-
egories that were applied in addition to the fact that there
was no measuring of degrees of problem severity. For example,
if there would be a shift from minor to major depression of all
depressed clients, it could not be detected by an instr-
ument that simply determines the presence or absence of a
problem area.
In the most recent study, Berger et al. (2015) found even a
decrease in symptom severity in medical and psychology
students. In Germany, counseling services are available at
most universities but show very different professional proles
and investigations of students psychological problems. In 1995,
a nationwide representative study in Germany (n=20,000)
showed that 20% of university students reported to be
impaired in their studies by psychological problems (Hahne,
1999). 13% felt in need of professional help but only 7% could
realize their need for professional assistance.
In this study we address the following questions:
1. What kind and frequency of psychological and psychoso-
cial problems report students who visited the counseling
center for university students?
2. Are there correlations between symptoms and satisfac-
tion with life and studies?
3. Is there a change in frequency and kind of problems in
the last 15 years?
4. In what way differ eld samples from clients and patients
consulting the counseling services for university students?
5. What are the consequences and implications for counsel-
ing services?
2. Methods
2.1. Participants and procedure
The participants were students of the University of Heidelberg
(eld samples) (see Berger et al., 2015) and students who
consulted the Counseling Center at the University (client
samples). Available data from four years (1994, 1998, 2007,
2013) were collected (see Table 1) to study changes over time.
The most recent samples (2013) were used to give an overview
over the current trends in mental health concerns.
Students who consulted the psychotherapeutic counseling
service received a questionnaire containing the instruments
described below before their initial meeting with a counse-
lor. After the initial consultation, the counselors provided a
diagnosis according to ICD-10 and rated GAF scores con-
sidering the last 7 days prior to the interview. The students
of the eld samples were chosen randomly during big
lecture sessions of many different courses. They completed
their questionnaires at home and returned it by mail. The
collected data was analyzed to determine changes in
symptom severity and perceived distress across the 20
years. We conducted a series of chi-square tests to check

Table 1 Overview of samples used in this study.

Year Sample size Female (%) Male (%) Mean age SD Clients per year

Client Samples 1994 342 65 35 25.3 4.3 346

1998 129 74 26 25.5 5.3 435
2007 213 74 26 24.9 4.1 547
2013 167 60 40 25.1 4.0 795

Field Samples 1994 346 64 36 24.9 5.1 Berger et al. (2015)

2007 125 72 28 22.7 2.8
2012 293 73 27 22.9 3.7 Berger et al. (2015)
Psychological complaints of students: A comparison of eld samples with clients of a counseling service at a typical
for changes in the PCL scores and a series of t-tests for the
SCL-90-R scores.
2.2. Instruments
2.2.1. Symptom-Checklist (SCL-90-R)
The SCL-90-R (Derogatis and Cleary, 1977; Franke, 2002)
evaluates a broad range of psychopathology and refers to the
last seven days. The SCL-90-R can also be used to measure
change processes within psychological treatment. The 90 items
are distributed to nine primary symptom dimensions, namely
Somatization, obsessive-compulsive, interpersonal sensitivity,
depression, anxiety, hostility, phobic anxiety, paranoid ideation
and psychoticism. Global indices can be computed: the Global
Severity Index (GSI) measures overall psychological distress,
the Positive Symptom Distress Index (PSDI) measures the
intensity of symptoms, and the Positive Symptom Total (PST)
states the number of self-reported symptoms. Internal consis-
tency of the individual subscales ranges between Cronbach's
=0.75 and 0:97. Testretest reliability is between r=0.69
and r=0.92 for retest after a week in a student population.
2.2.2. Psychosocial Complaints List (PCL)
The Psychosocial Complaints List (Holm-Hadulla and Soeder,
1997) is a modied version to the complaints list used in the
11th social survey of the German National Association for
Student Affairs (Deutsches Studentenwerk, 1986). The ques-
tionnaire contains 22 items rated on a six-step rating scale.
The PCL asks for distress due to the following psychosocial
problems: relationship problems, conicts with parents, illness
or death of close persons, own physical illnesses, housing
problems, nancial difculties and strain due to own children.
The PCL also measures the following psychological problems:
work and concentration difculties, test anxiety (fear of
authorities), contact difculties, low self-esteem, inexplicable
fear and anxiety, difculties to control aggression, ocd,
depression, suicidal ideation, sexual problems, psychosomatic
complaints, problems with alcohol or other drugs, drug
dependency, extreme mental distress (severe mental illness)
and other problems as a residual category. Ratings can be
summed up to form a global distress score. Norms from a
student eld sample are available. In this study, internal
consistency (Cronbach's alpha) of the PCL was =0.79. Test
retest reliability of the PCL is r=0.72.
2.2.3. Satisfaction with life and studies Scale (SLSS)
The Satisfaction with life and studies (Holm-Hadulla and
Hofmann, 2007) is a time-efcient and reliable scale to
measure satisfaction of students. The seven items refer to a
general feeling of ability, satisfaction with oneself and the
relation to others as well as satisfaction with one's life in
general but also measure satisfaction with academic course
achievements, the course situation and the general condi-
tions of the academic studies. All questions are rated from 1
(not at all) to 5 (very much). All items load on a common
factor, signifying the close tie between private and aca-
demic life that students feel. Distress in one area might
easily inuence satisfaction with the other. Internal con-
sistency (Cronbach's alpha) of the SLS was = 0.84. Norms
from a student eld sample are available. Evidence of the
validity of Psychosocial complaint list (PCL) and Satisfaction
43
with life and studies (SLS) in terms of the correlations of
both instruments with the SCL-90-R can be found in Table 2.
The total score of the PCL is positively correlated (r= 0.742,
po0:01) with the Global Severity Index (GSI) of the SCL-90-
R. As expected, the SLS correlates negatively (r =  0.547,
po0:01) with the GSI of the SCL-90-R as well as negative
(r =  0.512, po0:01) with the total score the PCL. The
highly signicant correlations between the different instru-
ments suggest that PSB, SCL-90-R and LSZ measure similar
constructs. However, the constructs may not be regarded as
identical due to the fact that all of them have different
underlying intentions as well as different intercorrelations.
In conjunction with the above-reported values for inter-
nal consistency of SLS and PCL can be concluded that both
instruments are reliable, valid and time-economic opportu-
nities for the assessment of mental impairment.
2.2.4. ICD-10 diagnosis
As part of the rst interview, a diagnosis according to ICD-10
was given.
2.2.5. Global assessment of functioning (GAF)
As part of the DSM-IV, an assessment of the global functioning
was made taking into account the psychological, social and
vocational functioning. On a hypothetical continuum of mental
health and illness values between 1 (minimum level of
functioning) and 100 (complete absence of symptoms) will
be awarded. GAF ratings are reliable after a brief training
session (Startup et al., 2002), but there is no mandatory cut-
off value.
3. Results
3.1. Symptom-Checklist-90-R (SCL-90-R)
53.9% of students of the 2013 client sample suffered from
clinically relevant impairment. No signicant gender differ-
ences were found in the SCL-90-R Global Severity Index
(GSI) and the subscales (Table 3). The SCL-90-R GSI was
also not inuenced by age or study progress and re-
mained remarkably stable over the 15 years. On the
subscales depression and obsessive-compulsion, signicantly
increased values were found in comparison to the SCL-90
norm sample. The other scales did not reach the cut-off
(T = 63). The MannWhitney U-Test was conducted to test
the differences between the client samples and the eld
samples. It shows that the PCC clients scored signicantly
higher on the SCL-90-GSI and SCL-90-subscales than parti-
cipants of the eld sample. The point prevalence according
to the SCL-90-R ranges from 5458% for the clients and 12
15% for the eld samples over the years.
3.2. Psychosocial complaint list (PCL)
Table 4 shows the results between 1994 and 2013. 95% of
the clients 2013 scored two or more questions with at least
4. That is about twice as much as in the eld sample (40%).
Considering the total score of the psychosocial complaint
list, an average of 61% of the clients achieve a value of 34 or
above whereas only 16% in the eld sample scored higher
44
than 34 which is considered to be severely impaired. These
numbers can be taken as an one-year prevalence because
the PCL refers to the last 12 months. As expected is the
point prevalence slightly higher than the one-year-
prevalence. We conducted a series of chi-quadrat tests with
data from the counseling center clients (for eld samples
see Berger et al., 2015) to detect changes over time. The
only signicant changes were found on the subscales test
anxiety and partnership problems.
3.3. Satisfaction with life and studies scale (SLSS)
The clients of the counseling center (2013) have a signicantly
lower life satisfaction compared to the eld sample in 2012
(see Table 5). In all samples, the life satisfaction is signicantly
higher than the study-related satisfaction. Neither the total
score of life and satisfaction nor the mean values of the two
subscales showed signicant gender differences. This also app-
lies to the comparison of female and male clients at the level
of individual items, so it can be assumed that there are no
gender differences in both life and study satisfaction. No
changes over time could be found.
3.4. Expert ratings
The Global Assessment of Functioning (GAF) reveals that in
2013, 77% of the clients have a GAF score between 51 and 70.
That means they suffer from at least mild symptoms. 46% of
the subjects got a GAF score below 65. This group can be
considered as a clinically relevant impaired patient group.
The experts also gave ICD-10 diagnoses. 38.3% of the clients
received a neurotic, stress-related or somatoform disorder
and 20.3% an affective disorder. The third most common
diagnostic categories are the personality or behavioral dis-
orders which account for 12.2% of all diagnoses. 13.6% of the
clients were given diagnoses of other categories. Clients with
a sub-clinical adjustment disorder and without an ofcial
ICD-20 diagnosis represent 35.5%.
3.5. Social situation
It seems cruel to mention the social situation of students.
49.5% of the clients stated that they work a considerable
amount of hours beside regular studies. The average is 12 h
per week, the median is 10 h. For 21% of the clients with a
side job require 20 h per week or more, which indicates a
signicant extra load on some students beside direct study-
related requirements. In the student's eld sample, 45.6% of
students work while studying. An important additional nding
Table 2 Intercorrelations of total scores
PCL SCL-90-R
SLS  0.512n  0.547n
PCL  0.742n
n concerns have not increased over the last 15 years in client
po0:01. PCL, Psychosocial Complaint List; SCL, Symptom
Check List; SLS, Satisfaction with life and studies.
V. Kre et al.
shows that students who have a side job are signicantly more
stressed than students who can focus completely on their
studies. These working students score an average of 37 on the
Psychosocial Complaint List, while the average impairment
severity of clients without side job is 31. The difference bet-
ween the two groups is signicant.
3.6. Summary of results
Referring to the questions formulated at the beginning it can
be stated that an average of 56% of the clients who seek help
at a counseling center are signicantly impaired. This is ree-
cted both in total score of the SCL-90-R (last 7 days) and in the
overall score of the PCL (last 12 months) in which 54% of the
cases lie above the cut-off point. The assessment of therapists
(experts) using the GAF conrmed this picture. The therapists
tend to give higher ratings of impairment than the clients in
their self-assessment. Compared to the eld samples, the
clients of the counseling center achieve signicantly greater
impairment on each of the self-rating instruments. The most
signicant differences are in the areas of test anxiety, work
and concentration problems, lack of self-esteem, depressive
moods and vague fears. In the client sample, no gender diff-
erences were found for any of the instruments. Therefore the
degree of mental impairment is negatively correlated with
the life and study satisfaction of the clients. The correla-
tion with life satisfaction is signicantly higher than with the
study satisfaction. The question of the change in the nature
and severity of the impairment over the past 15 years can be
answered that the perceived impairment and the expert
ratings with the GAF score of the client samples has remained
stable.
4. Discussion
The results of our study conrm preliminary studies, accord-
ing to which about 5060% of the client center students
are severely mentally impaired. A majority of these students
used the low-threshold offer of the counseling center for
university students. At least half of these clients or patients
are suffering from clinically relevant disorders. So far, the
counseling centers fulll a diagnostic task and are avail-
able for crisis intervention, counseling, short-term psy-
chotherapy and further placement of these patients. As a
result, the counseling centers must be staffed with qualied
personnel for the diagnosis and initial treatment. For the
other half of the clients, the counseling centers fulll
preventive tasks, which also requires counseling skills and
experience.
Clients and patients consulting a counseling center showed
signicantly greater impairments in comparison to a eld
sample of students of the University in all used scales. The
main symptoms are depressed mood, self-esteem problems
and diffuse anxieties as well as study-related complaints such
as test anxiety and work and concentration difculties.
In respect of the ndings from Prince (2015), the most
interesting nding of our study could be that the mental
samples and even decreased in eld samples (see Berger
et al., 2015). An exception is the signicantly higher number
Psychological complaints of students: A comparison of eld samples with clients of a counseling service at a typical 45

Table 3 SCL-90-R Means of clients 1998, 2007, 2013 and eld samples 1994, 2007, 2012.

1998 2007 2013 Student norm sample 2013 1994 eld 2007 eld 2012 eld
(Franke, 2014)
n =122 n=213 n =167 n =1061 n= 346 n =125 n =293

GSI 1.12 (0.87) 1.15 (0.65) 1.14 (1.31) 0.42 (0.43) 0.51 (0.38) 0.57 (0.46) 0.38 (0.29)
Somatization 0.82 (0.74) 0.84 (0.73) 0.71 (1.12) 0.43 (0.47) 0.42 (0.40) 0.44 (0.40) 0.36 (0.35)
Obsessive- 1.59 (0.84) 1.60 (0.84) 1.56 (0.70) 0.62 (0.59) 0.42 (0.40) 0.44 (0.40) 0.36 (0.35)
compulsive
Interpersonal 1.45 (0.85) 1.33 (0.92) 1.49 (0.64) 0.50 (0.54) 0.69 (0.60) 0.79 (0.70) 0.46 (0.44)
sensitivity
Depression 1.70 (0.80) 1.80 (0.92) 1.45 (0.71) 0.54 (0.59) 0.69 (0.59) 0.87 (0.67) 0.57 (0.53)
Anxiety 1.11 (0.86) 1.19 (0.91) 1.19 (0.60) 0.35 (0.49) 0.42 (0.44) 0.45 (0.53) 0.29 (0.31)
Hostility 0.94 (0.81) 0.93 (0.78) 0.87 (0.63) 0.38 (0.52) 0.46 (0.50) 0.49 (0.61) 0.36 (0.41)
Phobic anxiety 0.64 (0.75) 0.49 (0.69) 0.60 (0.55) 0.17 (0.39) 0.19 (0.29) 0.20 (0.36) 0.10 (0.21)
Paranoid ideation 0.99 (0.81) 0.88 (0.77) 0.79 (0.68) 0.36 (0.50) 0.50 (0.56) 0.48 (0.62) 0.29 (0.40)
Psychoticism 0.76 (0.64) 0.67 (0.67) 0.99 (0.65) 0.24 (0.40) 0.31 (0.38) 0.31 (0.41) 0.19 (0.24)

GSI Global Severity Index, SCL-90 Symptom Check List.

Table 4 PCL: frequency of clinically relevant complaints.

Client samples Field samples

1994 1998 2007 2013 1994 2007 2012

n =342 n =129 n =213 n =167 346 125 293

Total score 34 33.9 33.8 32.3 23.3 22.6 17.3

Test anxiety 37 38 56n 40 19 18 9.2
Work disruption 45 49 53 44 19 21 6
Low self-esteem 48 43 51 49 20 18 8
Diffuse feeling of anxiety 41 35 48 46 12 16 8
Depressed mood 39 37 44 42 13 17 7
Psychosomatic problems 18 15 31 26 10 6 7
Partnership problems 46 46 27n 40 20 16 15
Conicts with parents 27 22 20 20 12 6 8
Social contact problems 20 17 20 13 8 9 3
Obsessive-compulsive thoughts 9 10 12 11 3 3 1
Sexual problems 19 14 9 10 6 10 2
Suicidal ideation 10 4 7 8 2 2 1
Aggression 8 6 5 7 2 2 1
Alcohol or drug abuse 1 2 3 3 1 2 1

Percentage of ratings Z4 (clinically relevant).

n
Indicates signicant changes po0:01.

Table 5 SLS: mean values of the 2013 client sample compared to the 2012 eld sample (Berger et al., 2015).

Client sample 2013 Field sample 2012 t df p

Total score 16.25 (5.13) 19.68 (4.34)  5.961 458 o0:001

Healthiness/productivity 1.60 (1.05) 2.73 (0.88) 18.223 458 o0:001
Getting along with oneself 1.32 (1.06) 2.89 (0.90) 16.293 458 o0:001
Getting along with others 1.26 (1.02) 3.11 (0.76) 17.235 458 o0:001
Satisfaction with life 1.28 (1.01) 2.89 (0.90) 19.382 458 o0:001
Satisfaction with academic performance 1.46 (1.10) 2.63 (0.98) 13.942 458 o0:001
Satisfaction with current study situation 1.43 (1.05) 2.81 (0.93) 21.345 458 o0:001
Satisfaction with general study conditions 1.89(1.02) 2.62 (0.98) 14.234 458 o0:001

SD in brackets. Higher values indicate higher satisfaction.

46
of students with test anxiety in 2007. Maybe the attitude
towards studies changed the introduction of the Bachelor
degree in Germany (which happened in 2006). Maybe stu-
dents perceive tests as more important for their study course
because every exam inuences the overall degree and
therefore feel more anxious about them.
Almost half of the clients of the student counseling
center are working alongside their studies. Due to the
restructuring of the study course, the increased number of
events must be integrated into ones daily routines, which
can lead to more stress. According to that is our nding,
that clients with a side job are more impaired than students
without. Although the overall stress level of the students
did not change over the years, an increasing number of
clients is recognized. The increase in client numbers is
consistent with the ndings of Erdur-Baker and colleagues
(2006), and also the almost unchanged symptom severity is
reported in other studies (Pledge et al., 1998). This can be
taken as an indication that the acceptance of psychother-
apeutic counseling in the student population steadily
increases and the individual threshold to seek help at a
psychotherapeutic counseling center becomes smaller. The
consultants have to focus on the most common problems
which are work and concentration problems as well as test
anxieties and depressive episodes.
At the same time the present results emphasize the imp-
ortance of intensifying research efforts regarding mental impa-
irments of students. This requires a close cooperation between
counseling centers and psychological institutes of universities
and hospitals. Since the current treatment practice rather
consists of a mixture of different counseling approaches, one
goal of the research activities should be the formulation
of consistent counseling models, which would make it available
to a process-outcome research. Besides the question of the
effectiveness of counseling could be investigated, how the
counseling process actually works. The authors have therefore
presented an integrative counseling approach (ABCDE model
(Holm-Hadulla et al., 2011) which integrates science-based
and practice-oriented psychotherapeutic concepts. This model
is currently being evaluated in a Process-Outcome-design.
Our ndings show that the counseling centers have an
important role in primary care (for an overview see Holm-
Hadulla and Koutsoukou-Argyraki, 2015), diagnostics and
further placement of impaired students. They are especially
accepted among students, who would not consult other inst-
itutions like hospitals or therapists. The increase in consulta-
tions requires an expansion of counseling centers and highly
qualied staff.
Conict of interest
None declared.
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