Mental Health & Prevention (2015) 3, 4856

Mental health of students and its

development between 1994 and 2012
Hanna Bergera,n, Gabriele Helga Frankeb,
Frank-Hagen Hofmanna,c,1, Michael Spertha,c,1,
Rainer Matthias Holm-Hadullaa,c,d,1

a
Counseling Service for Students, Heidelberg University, Gartenstrasse 2, D-69115 Heidelberg, Germany
b
University of Magdeburg-Stendal, Psychology of Rehabilitation, Osterburger Strae 25, 39576 Hansestadt
Stendal, Germany
c
Studentenwerk Heidelberg, Psychosoziale Beratung fr Studierende, Gartenstr. 2, 69115 Heidelberg, Germany
d
Universidad Diego Portales, Santiago de Chile, Chile

Received 26 July 2014; received in revised form 28 October 2014; accepted 14 January 2015
Available online 23 January 2015

KEYWORDS Abstract
Medical students; The present study investigated the prevalence of psychological distress in medical and
Psychology students; psychology students (n =293) at a German University. Sampling structure, questionnaire and
Mental health pro- process of this study were a reproduction of a prior study carried out at the same university in
blems; 1994 (n =346) which allowed for assessing changes over time. Results show that 12% of students
Psychological
suffered from clinically relevant psychological complaints. Compared to 1994, self-reported
disorder;
mental health problems have signicantly decreased. Possible explanations such as an
Development over
time; improvement of health care, economic conditions and study conditions are discussed.
Health care & 2015 Elsevier GmbH. All rights reserved.

1. Introduction entailed signicant changes in most study paths, concerns

Stimulated in part by the implementation of the Bologna-
Process that led to the introduction of the Bachelor-/
Master-degrees to the German educational system and
n
Corresponding author. Tel.: +49 1751135146.
E-mail addresses: H.Berger@stud.uni-heidelberg.de (H. Berger),
ghfranke@t-online.de (G.H. Franke),
frank-hagen.hofmann@stw.uni-heidelberg.de (F.-H. Hofmann),
michael.sperth@stw.uni-heidelberg.de (M. Sperth),
rainer.holm-hadulla@stw.uni-heidelberg.de (R.M. Holm-Hadulla).
1
Tel.: +49 6221543750.
were voiced that many students might have difculties
adapting to the new system. Consequently, the mental
health of students has received growing attention in the
last few years. Mass media coverage focused on seemingly
increasing demands that students have to face and reported
that many would either drop out completely or risk mental
health issues, also pointing at the increasing incidence of
mental illness in Germany. Health insurance companies have
indeed recorded an increase of psychological disorders in
the German population since the 1990s (Grobe & Drning,
2011; TK Stress Studie, 2012). Whether this development
is due to an actual increase of morbidity or rather to

http://dx.doi.org/10.1016/j.mhp.2015.01.001
2212-6570/& 2015 Elsevier GmbH. All rights reserved.
Mental health of students and its development between 1994 and 2012
methodical distortions, e.g. through modied diagnostic
criteria, remains unclear (Jacobi, 2013).
A recent study has found a 12-month prevalence of 27.7%
for any kind of psychological disorder (Jacobi, Her, &
Strehle, 2014) in the German general population.
Studies on the prevalence of psychological disorders in
university students remain scarce, however. In the United
States of America, research on student's mental health was
strongly stimulated by the fact that suicide constitutes the
second leading death cause in American college students
(Garlow et al., 2008; Hunt & Eisenberg, 2010; Van Orden
et al., 2008; Wilcox et al., 2010), hinting at severe mental
problems in this population. In their most recent survey
based on data from over 80,000 college students, the
American College Health Association found that a total of
14.9% of students reported having been diagnosed with a
depressive disorder at some point during their studies while
32% (n= 3746) of those had been diagnosed within the past
12 months (ACHA, 2009).
In Germany, a representative survey carried out by the
German Student Services (Deutsches Studentenwerk,
DSW) found that 27% of students reported to have been
impaired in their studies by psychological distress, while
10% of all students felt severely impaired. The prevalence of
depressive symptoms varied between 14% and 22% depend-
ing on age and gender. Participants mostly complained
about difculties with academic performance, lacking self-
esteem, depressiveness, test anxiety and general anxiety
(Hahne, 1999). A more recent survey initiated by the DSW
showed that 7% of the participating students rated them-
selves as signicantly impaired in their studies due to health
problems, 42% of which mentioning mental disorders
(Middendorff, Apolinarski, Poskowsky, Kandulla, & Netz,
2013). In another study that focused solely on disabled
students and students suffering from chronic diseases, 45%
of the participants indicated that mental disorders had a
debilitating effect on their studies with depression, anxiety
disorders, eating disorders, and personality disorders being
the most prevalent (Unger et al., 2012).
In a screening survey conducted at a German university,
about 22% of the students met the criteria for at least one
psychological disorder as dened by the PHQ-D (Bailer
et al., 2008).
Compared to the general population students seem to be
rather more affected by psychological complaints. In a
meta-analysis including 40 studies on psychological com-
plaints of medical students in the USA and Canada, pre-
valence rates for depression and anxiety were consistently
higher than in the general population between 1980
and 2005 (Dyrbye, Thomas, & Shanafelt, 2006). The DEGS1-
survey on the health of German adults showed that psycho-
logical disorders in the German population are most frequent
in the age group of 1835, which includes students as well
(Jacobi et al., 2014). European studies largely conrm these
results (Seliger & Brhler, 2007; Bro et al., 2010).
Studies nding no difference between students and non-
student peers are only sporadic (Hunt & Eisenberg, 2010).
Scientic literature on the development of mental health
problems in students over time is scarce and results are
heterogeneous. According to an investigation on the devel-
opment of psychological distress in samples taken of a
campus counselling center in Kansas between 1988 and
49
2001 (n =13,257 in total) most complaints increased, includ-
ing anxiety, depression, suicidal ideas and personality dis-
orders (Benton et al., 2003).
In contrast to that, both type and extent of psychological
distress in clients consulting the psychosocial counselling
center of the University of Heidelberg remained rather
stable between 1993 and 2008 (Holm-Hadulla et al.,
2009). Only some problems such as somatoform disorders
and test anxiety showed an increase.
The evaluation of two eld samples that had been
investigated in the scope of that survey as well (n = 471 in
total) resulted in stable prevalence rates over time (Holm-
Hadulla et al., 2009). An up-to-date study analyzing data of
the psychotherapeutic ambulance for students at the Uni-
versity of Goettingen even found a slight decrease of mental
health problems between 2006 and 2010 (Klug, Strack, &
Reich, 2013).
On the other hand studies focusing on the impact of the
Bologna reform on students self-reported distress levels
present rather high distress levels in Bachelor students after
the implementation of the reform (e.g. Middendorff,
Poskowsky, & Isserstedt, 2012; Ortenburg, 2013). According
to a large survey on 4037 German Bachelor students 59%
reported to have currently experienced nervous and anxious
feelings and about half of the students felt overstrained.
The present study was motivated by the decient data
situation concerning the development of mental health
problems in eld study populations of students and the
contradicting results from different psychotherapeutic
counselling centers. A detailed survey at the University of
Heidelberg contributes new data to student's mental health
problems, accounting for the satisfaction with life and
studies and socio-demographic factors as well. A comparison
with data of a very similar study carried out in Heidelberg in
1994 (Soeder, 1995) allowed for assessing changes over
time.
2. Methods
2.1. Process of the study
A sample of medical and psychology students (n= 293) was
collected at the University of Heidelberg in the 2012/2013
winter semester following the model of a historical control
study carried out at the University of Heidelberg in 1994
(n = 346).
The current cross-sectional study was supposed to match
the historical control as well as possible, including sample
structure and data collection. In both samples, psychologi-
cal distress was measured with the Psychosocial Complaints
List (PCL; Holm-Hadulla & Soeder, 1997) and the Symptom-
Checklist 90 (SCL-90; Franke, 2002). Additionally, the
Satisfaction with Life and Studies Scale (SLSS;
Holm-Hadulla & Hofmann, 2007) served for assessing the
student's level of general satisfaction in the investigation
of 2012.
Expecting a response rate of 46% (Soeder, 1995), 800
questionnaires were distributed in a total of 24 courses to
medical and psychology students of different stages of
studies (rst year to nal year). Courses were not selected
randomly but were limited to well attended, compulsory
50 H. Berger et al.

courses, thus providing best possible representativeness for
each subject. Students were supposed to return completed
questionnaires via the post boxes of student ofces in the
Department of Psychology, the Department of Anatomy and
the clinic for internal medicine.
2.2. Measuring instruments
2.2.1. Psychosocial complaints list (PCL)
22 items comprise subjectively perceived psychological and
psychosocial strains referring to the past 12 months. A six
level scale grades the severity of impairment. All items are
listed in greater detail in Table 4. The responses to all single
items add up to a total score. Based on previous investiga-
tions a score 43 concerning single items and a total score
427.34 can be classied as clinically relevant (Holm-Hadulla
& Soeder, 1997; Sperth, Hofmann, & Holm-Hadulla, 2014).
The retest-reliability is r= 0.72 and the internal consis-
tency = 0.76.
2.2.2. Symptom-checklist SCL-90
The SCL-90 (Franke, 2002) is a standardized instrument for
the self-evaluation of psychological and psychosomatic
complaints. A total of 90 questions refer to the past 7 days
and are assigned to 9 categories (see Table 5). A ve point
Likert scale species the extent of the subjective suffering.
Global scores give information about the overall psycholo-
gical distress level. The Global Severity Index (GSI) is the
mean score of all responses and measures the psychological
distress in relation to all 90 questions. The Positive Symp-
tom Distress Index (PSDI) measures the overall intensity of
positive responses and the Positive Symptom Total (PST)
comprises the number of items with positive responses. The
manual states a retest-reliabilty between r= 0.69 and
r= 0.93. The internal consistency for the subscales range
from = 0.75 to =0.97 (Franke, 2002).
2.2.3. Satisfaction with life and studies scale (SLSS)
The SLSS (Holm-Hadulla & Hofmann, 2007) comprises 7 ques-
tions on the overall satisfaction of students. Among others,
the questions include the global satisfaction with life,
satisfaction with personal accomplishments or with social
surroundings. For details see Table 2.
The responses are ranked on a scale ranging from 1 ( = not
at all) to 5 (= very much).
The internal consistency is = 0.84.
3. Statistical methods
Data analysis was supported by SPSS 21. In addition, the online
tool GraphPad was used for comparing means with the
historical control for which no raw data were available. Mean,
median and SD were calculated for continuous data. The
KolmogorovSmirnov-test showed a left skewed distribution
which was to be expected as the sample did not consist of
patients. Provided the Levene-test resulted in homogeneity of
variance t-tests for independent samples and variance ana-
lyses were applied for assessing differences between the
samples of 2012 and 1994. The comparison of global scores
between the norm sample of the general population and the
student sample of 2012 were carried out analogously.
Uni- and multivariate variance analyses described the inu-
ence of socio-demographic variables on psychological distress
levels.
All p-values should only be interpreted with regard to the
exploratory and not conrmatory study design. The sample size
was geared to the historical control (n=346), leading to a
Cohen's effect size of ca. 0.09 (given an -error=0.05 and a
power (1 ) of 0.8). The level of signicance was dened as
pr0.05.
4. Results
A return rate of 38% resulted in a sample size of n= 293.
Table 1 shows the sample's most important socio-
demographic features.
Compared to the University of Heidelberg's student
statistics female students were overrepresented by 10%
both in the 2012 and 1994 student samples. In both samples
the average age was lower than the one of the entire
student body in the corresponding years. In the 2012/2013

Table 1 Sociodemographic variables of the 2012 and 1994 samples.

2012 1994

Total Medicine Psycho-logy Total Medicine Psycho-logy

(n=293) (n= 164) (n =129) (n =346) (n =190) (n=156)

Gender
Female N 214 101 113 221 98 123
Percentage (%) 73 61.6 87.6 63.9 51.6 78.8
Male N 79 63 16 125 92 33
Percentage (%) 27 38.4 12.4 36.1 48.4 21.2

Age Mean 22.89 22.9 22.88 24.3 22.7 26.1

SD 3.705 3.199 4.276 4.0
Median 22 22.0 22.0 23 22.0 25.0

Semester Mean 4.39 5.05 4.77 4.64 4.1 5.3

SD 2.835 2.420 3.292
Median 5.0 7 5
Mental health of students and its development between 1994 and 2012
winter semester the average age of all psychology students
in Heidelberg plus all medical students at the faculties of
medicine in Heidelberg and Mannheim was 26 with a median
of 25 (Universitt Heidelberg, 2014).
5. Results of the SLSS
Table 2 lists the mean values relating to the total 2012
student sample.
Pearson correlation coefcients display the interrelation
between the satisfaction with life and studies and psycho-
logical distress measured by using the PCL and the SCL-90.
All of the SLSS's three total scores correlated signicantly
and negatively with all total scores of the PCL and SCL-90
(in each case pr 0.0001).
6. Results of the PCL
Tables 3 and 4 demonstrate the recent project results, the
main results are presented next to the data of 1994. The
portion of students excessing the cut-off point for clinically
relevant impairment was 15.7% in the 2012 sample. In the
univariate variance analysis, the subject of studies showed a
signicant effect both on the PCL total score and the score
for psychological problems (in each case p= 0.032), but
missed statistical signicance when analyzing the whole
model. Neither age nor gender had any signicant effects.
There were no interaction effects. Mild difculties to work-
and concentrate occurred most frequently. More severe
impairments concerned test anxiety most frequently, fol-
lowed by general anxiety, lacking self-esteem, psychoso-
matic symptoms and depressiveness (see Table 4).
T-tests showed that both the PCL total score and it's two
subscores were signicantly reduced in the 2012 sample
compared to historical control. The difference between the
two samples was higher for psychological than for psycho-
social problems (see Table 3).
The effect sizes were middle range altogether (Cohen's d
between d= 0.3 for the subscore psychosocial problems
and d= 0.5 for the PCL total score) and highest for psycho-
logical problems (d= 0.6).
Table 2 SLSS: mean values of the 2012 student sample.
Mean
Healthiness/productivity 2.73 (0.88)
Being content with oneself 2.89 (0.90)
Getting along with others 3.11 (0.76)
Satisfaction with life 2.89 (0.90)
Satisfaction with academic performance 2.63 (0.98)
Satisfaction with current study situation 2.81 (0.93)
Satisfaction with general study conditions 2.62 (0.98)
Total score 19.68 (4.34)
Subscore satisfaction with life 11.62 (2.71)
Subscore satisfaction with studies 8.06 (2.31)
SD in brackets.
51
7. Results of the SCL-90
After normalizing transformations to T-scores on the basis of
a recent norm sample (n =1061; Franke, 2014), 11.9%
(n = 35) of students in the 2012 sample suffered from
clinically relevant psychological impairment (T-values on
two subscales and/or T-GSI Z63). Here, depressiveness
constituted the major problem area. The overall psycholo-
gical impairment of the 2012 students sample was in
accordance with the one of the norm sample.
The current SCL-90 student norm sample had been
collected in the years 2011/2012 and consists of 51.6%
females and 48.4% males. Various subjects of study and
different universities in former eastern and western
Germany were involved and ensure good representativeness
for German university students (Franke, 2014).
Uni- and multivariate analyses testing the effect of socio-
demographic variables with the GSI as dependent variable
did not yield any signicant effects including interaction
effects.
When comparing the different subscales of the SCL-90
simultaneously, females scored signicantly higher on the
subscales phobic anxiety (p= 0.040) and somatization (p=
0.005).
Psychology students scored signicantly higher than
medical students on the subscales anxiety (p= 0.011) and
hostility (p= 0.022). Age and stage of studies did not show
any signicant effect.
Overall, psychological distress levels were signicantly
reduced in the 2012 students sample compared to 1994
including all subscales and the global scores GSI and PSDI
(see Table 5).
Effect sizes were middle range or small, for the GSI a
Cohen's d= 0.38, and for the PSDI d= 0.21.
The decrease was most evident on the subscales inter-
personal sensitivity and paranoid ideation, followed by
obsessivecompulsive, anxiety and depression which are
problems typical of students (see below). In this context,
compulsiveness should rather be interpreted in the meaning
of difculties to work and concentrate as these are, next to
compulsiveness in a narrower sense, equally covered by this
subscale (Soeder, 1995). When regarding the mean values of
the subscale's single items, those describing rather difcul-
ties to work and concentrate were highest and showed the
largest decrease compared to 1994.
When comparing the single items belonging to the sub-
scale paranoid ideation, the mean value for ideas and
perceptions others don't share showed the largest decrease
since 1994.
8. Comparison with the general population
In Table 6, the results of the SCL-90 for the 2012 student
sample are contrasted with those of a recent norm sample
representative for the German population (n= 2025; 2014).
Details to the norm sample have been published elsewhere
(Franke, 2014).
Table 7 contains the p-values belonging to the comparison
of means with the 2012 student sample. At rst glance
psychological distress levels seem to be lower in students
than in the general population. However, the difference of
52 H. Berger et al.

Table 3 PCL: Total score and subscores for the 2012 and 1994 student samples.

2012 (n= 293) 1994 (n= 346) p Mean difference Condence interval
n
Total score 17.3 (10.8) 23.3 (13.1) o0.0001 6.000 7.887 to 4.113
Psychosocial problems 6.9 (4.6)n 8.1 (5.1) o0.002 1.200 1.961 to 0.439
Psychological problems 10.5 (7.7)n 15.2 (9.8) o0.0001 4.700 6.088 to 3.312

Mean values (SD in brackets). p-values resulting from t-tests. Asterisks mark signicant results.

depression this difference of mean scores reached

Table 4 PCL: Results of the 2012 student sample. statistical signicance.
Percentage
9. Discussion
Psychosocial problems Score Score
40 43 9.1. Prevalence of mental health problems in
Partnership problems 66.1 15.1 students
Conicts with parents 55.6 7.8
Disease or death of close 51.9 13.3 In the 2012 student sample, a proportion of 11.915.7% of
friends/ relatives medical and psychology students reported clinically rele-
Physical diseases 57 5.5 vant mental health problems. These gures are in accor-
Housing problems 46.4 6.5 dance with data of sample of students at the University of
Financial problems 48.1 7.2 Heidelberg obtained between 2007 and 2008 (Holm-Hadulla
Considerable strain due to own child 3.1 0.3 et al., 2009) and with the large DSW-survey from 1999
(Hahne, 1999).
Psychological problems Score Score However, it should be mentioned that German medical
40 43 and psychology students distinguish themselves from most
other subjects by the strictly limited access (numerous
Difculties to work and concentrate 77.1 6.1 clausus). From that point of view, one has to expect that
Test anxiety/feelings of insecurity 66.2 9.2 typical student-problems such as lack of motivation and
Towards authorities ambivalence towards the professional perspective will not
Contact problems 47.9 2.7 occur as much as in an average student population. For this
Low self-esteem 70 7.5 reason the data of the present survey were compared to the
Feelings of anxiety that I cannot explain 58.7 7.8 current SCL-90 student norm sample (Franke, 2014). As
Feelings of aggression that are 23.2 0.7 regards the latter, generalizability to German university
hard to control students can be assumed due to the involvement of various
Compulsive thoughts. compulsive acts 20.5 0.7 subjects of study and institutions from different parts of
Depressiveness 64.2 6.5 Germany (Franke, 2014). Normalizing transformations to
Suicidal thoughts 9.9 1.4 T-values displayed average psychological distress levels in
Sexual problems 27.6 2.4 the 2012 student sample measured with the SCL-90. Conse-
Psychosomatic complaints 59.5 6.9 quently, the current survey at the University of Heidelberg
Problems with alcohol or drugs 12.6 0.7 did not feature any subject-specic or regional deviances of
Medicince-dependency 1 0 psychological distress levels in students. Still, generaliza-
Extreme psychological distress 3.4 0.7 bilty of the study results to students of other subjects is not
Other problems/complaints 32.4 4.4 given due to the limited sample coming along with the focus
Frequency of complaints in percent for all scores 40 and for on replicating a historical control study.
clinically relevant impairment with scores 43. Severely impaired students were probably underrepre-
sented because they are less likely to attend courses
regularly and might be less willing to take the extra effort
of participating in a survey.
mean GSI values misses statistical signicance using a t-test. Owing to this selection bias, the proportion of 12% of
Conversely, the mean PSDI was signicantly higher in the clinically relevant mental health problems as found in the
2012 student sample than in the general population 2012 survey probably underestimates the actual rate con-
(p= 0.0023). cerning medical and psychology students.
Die PSDI indicates the average extent of impairment of
those items with a value 40 whereas the GSI includes the 9.2. Frequent mental health problems in students
average impairment of all 90 items.
With a Cohens' d =0.2 the effect size was small, though. The data analysis of both the PCL and the SCL-90 featured
Moreover, students scored higher on the subscales depres- the same characteristic problem areas which prevail in
sion, interpersonal sensitivity and obsessivecompulsive national and international studies of the past 20 years as
compared to the general population. Only in the case of well (Bundesministerium fr Bildung und Wissenschaft,
Mental health of students and its development between 1994 and 2012 53

Table 5 SCL-90: Mean values of the 2012 and 1994 student samples next to the recent norm sample.

2013 Norm sample 2012 Student 1994 Student P Mean Condence

(students) sample, Heidelberg sample, Heidelberg difference interval
(n= 1061) (n = 293) (n = 346)

Hostility 0.38 (0.52) 0.36 (0.41)n 0.46 (0.50) o0.0065 0.1000 0.1719 to
0.0281
Anxiety 0.35 (0.49) 0.29 (0.31)n 0.42 (0.44) o0.0001 0.1300 0.1902 to
0.0698
Depression 0.54 (0.59) 0.57 (0.53)n 0.69 (0.59) o0.0075 0.1200 0.2079 to
0.0321
Paranoid Ideation 0.36 (0.50) 0.29 (0.40)n 0.50 (0.56) o0.0001 0.2100 0.2869 to
0.1331
Phobic Anxiety 0.17 (0.39) 0.10 (0.21)n 0.19 (0.29) o0.0001 0.0900 0.1300 to
0.0500
Psychoticism 0.24 (0.40) 0.19 (0.24)n 0.31 (0.38) o0.0001 0.1200 0.1705 to
0.0695
Somatization 0.43 (0.47) 0.36 (0.35)n 0.42 (0.40) o0.0459 0.0600 0.1189 to
0.0011
Interpersonal 0.50 (0.54) 0.46 (0.44)n 0.69 (0.60) o0.0001 0.2300 0.3131 to
Sensitivity 0.1469
Obsessive compulsive 0.62 (0.59) 0.59 (0.48)n 0.72 (0.55) o0.0017 0.1300 0.2110 to
0.0490
GSI 0.42 (0.43) 0.38 (0.29)n 0.51 (0.38) o0.0001 0.1300 0.1833 to
0.0767
PST 23.69 (17.52) 23.19 (13.21)
PSDI 1.42 (0.52) 1.38 (0.34)n 1.46 (0.41) o0.0081 0.0800 0.1392 to
0.0208

SD in brackets. P-values, mean differences and condence intervals resulting from t-tests comparing mean values of the 2012 and 1994
student samples. Asterisks mark signicant results.

Table 6 SCL-90: Mean values of the 2012 student sample compared to the norm sample of the general population.

2012 Student sample, Heidelberg 2013 Norm sample of adults

Total Males Females Total Males Females

(n = 293) (n= 79) (n= 214) (n = 2025) (n= 1.012) (n= 1013)

Hostility 0.36 (0.41) 0.35 (0.45) 0.36 (0.40) 0.37 (0.49) 0.37 (0.48) 0.38 (0.50)
Anxiety 0.29 (0.31) 0.26 (0.31) 0.31 (0.31) 0.32 (0.47) 0.29 (0.42) 0.35 (0.51)
Depression 0.57 (0.53)n 0.50 (0.54) 0.60 (0.52) 0.49 (0.59) 0.47 (0.57) 0.52 (0.61)
Paranoid Ideation 0.29 (0.40)n 0.32 (0.42)n 0.28 (0.39)n 0.48 (0.59) 0.49 (0.56) 0.46 (0.62)
Phobic anxiety 0.10 (0.21)n 0.06 (0.14)n 0.11 (0.23)n 0.17 (0.36) 0.15 (0.32) 0.18 (0.40)
Psychoticism 0.19 (0.24) 0.22 (0.26) 0.17 (0.23) 0.23 (0.42) 0.23 (0.39) 0.23 (0.45)
Somatization 0.36 (0.35)n 0.27 (0.23)n 0.39 (0.38)n 0.50 (0.50) 0.46 (0.50) 0.54 (0.50)
Interpersonal 0.46 (0.44) 0.39 (0.39) 0.48 (0.46) 0.44 (0.54) 0.42 (0.50) 0.45 (0.57)
sensitvity
Obessivecompulsive 0.59 (0.48) 0.59 (0.51) 0.59 (0.47) 0.55 (0.58) 0.56 (0.57) 0.54 (0.58)
GSI 0.38 (0.29) 0.34 (0.28) 0.40 (0.30) 0.41 (0.45) 0.40 (0.42) 0.43 (0.47)
PST 23.19 (13.21) 21.54 (14.28) 23.80 (12.78) 24.99 (18.04) 24.32 (18.07) 25.65 (18.00)
PSDI 1.38 (0.34)n 1.35 (0.32) 1.40 (0.35)n 1.30 (0.43) 1.28 (0.43) 1.32 (0.42)

SD in brackets. Those values that were higher in students than in the general population are written in bold. Asterisks mark signicant
results.

1986, Hahne, 1999; Holm-Hadulla et al., 2009; Knigge-Illner, lacking self-esteem and accordingly interpersonal sensitivity
2002; Wynaden, Wichmann, & Murray, 2013). These are as well as test anxiety, depending on the measuring instru-
difculties to work and concentrate, depressiveness, ment. Apart from the latter, the rst three positions are
54 H. Berger et al.

Table 7 P-values. mean differences and condence intervals for the comparison between the 2012 student sample and the
total 2013 norm sample of the general population.

P total P males P females Mean difference Condence interval

Hostility o0.7393 o0.7202 o0.5830 0.0100 0.0690 to 0.0490

Anxiety o0.2894 o0.5343 o0.2695 0.0300 0.0856 to 0.0256
Depression o0.0282 o0.6512 o0.0743 0.0800 0.0084 to 0.1516
Paranoid ideation o0.0001 o0.0084 o0.0001 0.1900 0.2599 to 0.1201
Phobic anxiety o0.0012 o0.0133 o0.0135 0.0700 0.1123 to 0.0277
Psychoticism o0.1113 o0.8228 o0.0579 0.0400 0.0893 to 0.0093
Somatization o0.0001 o0.0008 o0.0001 0.1400 0.1994 to 0.0806
Interpersonal sensitivity o0.5449 o0.6025 o0.4706 0.0200 0.0460 to 0.0860
Obsessivecompulsive o0.2603 o0.6501 o0.2376 0.0400 0.0298 to 0.1098
GSI o0.2679 o0.2986 o0.3705 0.0300 0.0832 to 0.0232
PSDI o0.0023 o0.1570 o0.0094 0.0800 0.0285 to 0.1315

consistent with the survey of 1994. Eventually, the results of
the recent SCL-90 norm sample also conrm the ndings of
the present study (Franke, 2002, 2014).
Not only are these major problem areas relevant due to
their frequent occurrence in students, but also due to their
negative impact on the general satisfaction with life.
The SCL-90 subscales reecting these problems evidenced
the greatest negative correlations with the SLSS-score
Satisfaction with life.
9.3. Mental health problems in students
compared to the general population
Compared to the recent SCL-90 norm sample of the general
population (Franke, 2014), the overall psychological distress
levels in the 2012 student sample were largely the same.
However, medical and psychology students from Heidel-
berg were slightly more affected by depressiveness, com-
pulsiveness and social insecurity. Remarkable is the
signicantly increased mean PSDI in the 2012 student
sample compared to the norm sample of the general
population in combination with an approximately equal
mean GSI. This could imply that psychological complaints
in medical and psychology students are less diverse than in
the general population, but more frequent and more severe
in some typical problem areas. This seems plausible as
students form a social subgroup featuring a more homo-
geneous distribution of specic risk factors, external con-
ditions and biographical features such as age and level of
education.
9.4. Development over time
The prevalence of mental health problems was signicantly
lower in the 2012 student sample than in the one of 1994.
The difference was biggest for problem areas typical of
students. The considerable decrease on the SCL-90 subscale
paranoid ideation could be explained by an increasing
cultural diversity and variety of ideologies at universities
as the item ideas and opinions others do not share showed
the largest difference of means.
As to the interpretation of the PCL it should be noted that
the cut-off point dening clinically relevant impairment had
been slightly modied since 1994. In the present study a
cut-off point of 27.34 (Sperth et al., 2014) was applied,
whereas a cut-off point of 34 had been valid at the time the
historical control study was carried out (Soeder, 1995).
Consequently, the effect size of the decrease of psycholo-
gical distress levels as calculated in the present study
thereby slightly underestimates the actual effect size.
There is little scientic literature conrming decreasing
mental health problems in students so far (Klug et al.,
2013). Sporadic European studies present at least consistent
prevalence rates of psychological distress in students over
time (Holm-Hadulla et al., 2009; Knigge-Illner, 2002; Quince
et al., 2012).
According to a recently published paper prevalence rates
of psychological disorders have been rather constant since
1989 in the general population in Germany (Jacobi et al.,
2014).
On account of limited reference data from previous
investigations sampling errors and selection bias have to
be considered as well. However, a descriptive comparison
with large norm samples of 2002 and 2013 displays similar
tendencies supporting the ndings of the present study.
Here too, the decrease of psychological distress levels is
most evident for typical problems reported particularly
frequently by students (Franke, 2002, 2014). The decline
of psychological complaints does not extend to the repre-
sentative norm samples of the general population (Franke,
1995, 2002, 2014) possibly implying a gradual approximation
of distress levels in both groups.
A quantitative and qualitative improvement of the gen-
eral health care situation or either greater utilization of
counselling services and therapy are two of many possible
explanations for the observed decline in prevalence rates of
mental health problems in students.
The universities' psychological counselling centers for
instance present increasing numbers of clients (Knigge-
Illner, 2002; PBS, 2010) and also the demand for ambulatory
psychotherapeutic care by students has increased during the
last few years (Holm-Hadulla et al., 2009; Knigge-Illner,
2002; TK Stress Studie, 2012). Furthermore, student coun-
selling services have become more effective (Skopinceva
Mental health of students and its development between 1994 and 2012
et al., 2013; Sperth et al., 2014). Besides, growing eco-
nomic prosperity and more favorable study conditions might
be signicant in this context as well. The employment
market is generally more promising than 10 or 20 years
before, not least for medical students who face a growing
demand for physicians in Germany.
Modernized university programs with greater diversity of
training schemes and forms of learning and atter hierar-
chies offer more opportunities to students possibly prevent-
ing study-related psychological distress to a certain degree.
This might also extend to reforms leading to more struc-
tured framework conditions for students, possibly facilitat-
ing organization and self-management throughout the
course of studies. Examples of such reforms are the new
medical course at the University of Heidelberg implemented
in 2001 or even the controversially discussed Bologna-
reform. The latter is quite often cited to increase academic
pressure and subjectively perceived stress levels in students
(Gusy, Lohmann, & Drewes, 2010; Gusy, Lohmann, & Marcus,
2012; Thees et al., 2012; Sieverding, Schmidt, Obergfell, &
Scheiter, 2013) but actually there is no study showing an
increase of mental disorders by reason of the Bologna-
process.
Indeed, self-reported stress levels of Bachelor students
seem to be high (Ortenburg, 2013) but maybe this does not
necessarily imply an increasing susceptibility to mental
health problems. It is remarkable that a large survey on
German Bachelor students did not only nd high distress
levels but also a proportion of 90% of students feeling able
to cope with difcult study-related problems.
The observed decline of psychological distress according
to the present study and data of the norm samples discussed
(Franke, 2002, 2014; Klug et al., 2013) is based on a decline
of self-reported complaints. In view of our performance-
oriented society it is also conceivable that not the actual
complaints have declined but only the willingness of admit-
ting to them in a non-therapeutic setting.
A certain stigmatization of people impaired in their
productivity seems plausible and can be found in the
general population as well (Jacobi et al., 2014) where
psychological disorders attract negative attention in a
working environment with high demands to social skills. In
this context this leads to a higher demand for psychother-
apeutic counselling and psychotropic drugs (Jacobi et al.,
2014) which can also be found in case of students (Holm-
Hadulla et al., 2009; Grobe & Drning, 2011; Knigge-Illner,
2002; Middendorff et al., 2012; Quince et al., 2012; PBS,
2010; TK Stress Studie, 2012).
9.5. Sample and methodical limits
Neither the 2012 nor the 1994 sample are representative
random samples which entails possible distortions. The
lower average age of the recent sample compared to the
student statistics of the University of Heidelberg can partly
be ascribed to an overrepresentation of psychology students
in the Bachelor's program compared to the Master's pro-
gram. Furthermore, advanced students not attending
courses while preparing for their nal exams, earning a
doctorate or, in case of medical students, completing their
nal and exclusively practical year, could not be included.
55
As regards sample size and structure, the 2012 sample
matches the historical control very well, ensuring a valid
comparison between the two. All in all, the decline of
mental health problems in students as observed in the
present study seems plausible when recent data of other
German universities are taken into account (Franke, 2014;
Klug et al., 2013).
10. Conclusions
Constituting the rst study of its' kind in Europe the present
paper compares psychological distress levels found in two
analogously conducted cross-sectional studies on student
samples of a German university collected at different points
in time featuring very similar sample sizes and structures.
The observed decrease of psychological complaints in
students represents the central nding of this study and
hints to a new epidemiological development. Although
sample-related distortions have to be taken into account
and other recent surveys hint to increasing complaints
about study-related stress and excessive demands at uni-
versities, the results are in accordance with some new data
existing on the topic in Germany. The diversity in the
discussed results may be caused by the fact that the
compared ndings nearly always have their origin in self
report data of students. These reports are inuenced by
many different factors and trends. To increase the validity
and reliability of research-outcomes in the topic of mental
health problems of students we need a representative study
that is based on psychodiagnostic instruments and inter-
views applied by psychological experts and that would refer
to the diagnostic categories of international classication
systems.
Possibly, the observed development is due to an improve-
ment of health care utilization, economic conditions and
study conditions or to an unwillingness of communicating
mental health problems in the face of a growing pressure to
perform.
Conict of interest
The present study has been carried out with the approval of
the ethics committee of the faculty of medicine at the
University of Heidelberg.There has been no funding of the
study and no conict of interest.
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