Depression in the Southern Part of Heaven

Josephine Yurcaba is in freefall. The panic attacks are back. Her chest tightens; her breaths come in spasms. Her mind spirals: grief, loneliness, terror.

She’s new to UNC-Chapel Hill’s campus, a junior transfer student from N.C. State University. She struggles with the difficulties of transitioning, from battles with academic advising to feeling like an outsider in the social scene. The anxiety and depression that have followed her since high school make everyday life a trial. She forces herself to get a job at the daily student newspaper, but it’s hard to talk to people and harder still to get out of bed. She worries about how others see her, convinced her anxiety blazes bright for all to see. Her life seems to be unraveling.

And she is grieving. Her mother — her backbone, her ally — has recently died.

Yurcaba’s mental health problems began in high school, when she fell into a group of mentally abusive friends and attempted suicide as a sophomore. After that, therapy helped a lot, as did her mom’s unwavering support. Things were bad again when she found out her mom was diagnosed with stage 3 primary peritoneal cancer — after surviving breast cancer years earlier — when Yurcaba was a high school senior.

Then came the prognosis. Six to 10 months. Yurcaba, by then a sophomore at N.C. State, couldn’t sleep at night, constantly in the clutch of a panic attack — “my personal form of hell.” She’d sink into paranoia, terrified of someone breaking into her dorm room.

She had thought about transferring from N.C. State to UNC, aiming for a journalism degree. Her mom had always encouraged her to go, and when Yurcaba called her with the news that she got in, her mom dropped the phone and ran out of the house screaming. “I have to do it, even though all this is happening,” Yurcaba thought. She enrolled for the fall of her junior year, and then everything — shaky as it was to begin with — came crashing down. Her mother died before Yurcaba began her first semester at UNC.

As Yurcaba walks from class to class, she can’t shake the feeling that she’s on a different level than everyone else: the grief in her so heavy and deep that it’s hard to talk to anyone about anything but the darkness in her life.

“On this campus, there’s this really strong idea of community, and everyone’s together and we all believe in the same things… and we don’t talk about our problems,” she said. “I feel like that’s a Carolina thing. If you’re not ‘hashtag winning,’ we don’t give a shit about you. Please fade into the background because you have problems we don’t want to deal with.”

Many people with mental disorders feel alone. But the numbers tell a different story.

One in three college students experiences depression, anxiety, suicidal ideation or self-injury, said Daniel Eisenberg, an associate professor of health management and policy at the University of Michigan. Those are some of the more common forms of mental illness, which left untreated, can make the demands of everyday life much more difficult. A 2010 survey of UNC students showed that, of the 1,250 student respondents, almost 40 percent said they think they needed help for mental or emotional problems in the past year.

College can be a hotbed for mental health problems for a number of reasons. Personal development, combined with lots of external factors — a new home, the loss of a familiar support system, academic pressure, extracurricular pressure, a new social landscape, financial stress, the job search and more — make it a time of extreme change for many. And most mental illnesses — 75 percent — have their first onset by age 24.

Early detection and assessment can prevent mental health problems from worsening — and save lives. Mental health disorders are significant predictors of a lower GPA and dropping out. And suicide is the second leading cause of death of college students, despite being largely preventable.

There are economic benefits to investing in student mental health programs, Eisenberg said. Improving mental health can increase student retention, resulting in greater tuition revenue for the university, a higher graduation rate, higher projected earnings for the students in question and more productivity for society in general. Overall, serious mental illness costs the U.S. about $200 billion in lost earnings per year, according to the National Alliance on Mental Illness.

College provides a unique opportunity to reach young people, Eisenberg said. With the combination of residential, academic and social opportunities, access to college students is high — which means this is a place where change can happen.

“How to Be an Unhappy College Student” was the headline. The author, UNC junior Henry Gargan, wasn’t anticipating the response he got: unflagging support and agreement.

His article for the online magazine Thrill City, where he’s editor-in-chief, challenged what he sees as the unrelentingly positive culture of UNC. As someone who has struggled with depression himself, he encouraged students to be more frank with their experiences.

“If this is the greatest place on earth, why don’t I always feel equally great? Why does everyone else seem to be operating on some unattainable plane of collegiate bliss, and how do I get there?” he wrote in October.

This year, The Daily Beast ranked UNC fifth on its list of the country’s happiest colleges, taking into account freshman retention rate (97 percent), student feedback and more. According to The Daily Beast, UNC nabbed near-perfect scores for overall student experience and the category “Would Do It All Over Again.”

One year prior, The Huffington Post ranked UNC in its top 10 for colleges with the happiest students. UNC, the site declared, is “famously well-rounded: beautiful campus, friendly college town, good weather, dynamic social life, five-star academics, and some of the best athletic teams in the country. What’s lacking? Not much.”

Locals call it the Southern part of heaven. Students call it Chapel Thrill.

From its radiant azaleas to its basketball fever, from its 700 student organizations to its ranking as Best Public Value School in the nation, from the University’s favored buzzwords — inclusivity, diversity, collaboration — to its unofficial motto in ‘The Carolina Way,’ it seems from a distance that UNC’s 18,500 undergraduate students are living the life of a college brochure.

But Gargan is critical of a culture that burdens students with too much to handle.

“You think, wow, I’m at an amazing school with so many opportunities. So many kids would kill for this,” he said. “But you do have a right to be unhappy…Seeing so many people who are so excited about things, for some people, it’s only natural to have their life seem outwardly bland by comparison.”

And he said UNC’s culture of involvement mires students in obligations to others, consuming the obligations students have to themselves. He said there needs to be more of a focus on well-being, even if it requires some selfishness.

UNC senior Neal Smith said UNC’s ever-present positivity has made his experience with anxiety even more isolating.

“You’re constantly being bombarded with it,” he said. “I’m not saying it’s a bad thing that we have a culture of involvement. But sometimes we feel pressured to get so involved that we tend to neglect other things. It’s a juggling act.”

A consequence is that students’ problems often go unspoken, he said.

“We’re always talking about the Carolina Way and how a positive attitude is one of those things,” Smith said. “It’s great that we have an environment that encourages good participation and a good attitude, but at the same time, sometimes you feel like you have a hard time expressing your needs.”

Anxiety manifests itself in different ways, but for Smith, it comes as paralysis. He gets lost in small worries that morph into massive roadblocks, obscuring his vision and making it difficult to live in the present. He worries constantly, and when the worry spikes, he has panic attacks: moments of inexplicable, sheer terror.

He wishes people were more open about their difficult moments. He believes UNC is an understanding place, one that would welcome these conversations — but he said it just doesn’t happen.

Every walk to class brought the same intense self-questioning. Every conversation brought the same endless considerations, the same exhausting posturing, the same doubt and fear.

Zack Newbauer, now a UNC junior, was a freshman grappling with how to present his sexuality. He knew he was gay, but he didn’t know how to deal with it in college. He didn’t want to burn any bridges before he built them. And that idea — that college was a place to define himself — became so much of a burden, added so much pressure, that it became all-consuming.

“Every relationship I encountered was put through this filter of not only gaining their acceptance in the way all freshmen intend to — but also the consideration, could I win people’s approval despite this huge thing they didn’t know about me?” he said. “Could I be cool enough, generous enough, adaptable enough for them to possibly ever overlook it?”

Every few minutes alone in a room, he would analyze his previous and future interactions. How could he make them better? Who were his real friends? Was every friendship contingent upon his next steps? He was trapped in his head, the smiling image on the outside dissonant from the isolation and depression within.

And all around him was a culture of excitement and involvement. It was all so much to handle: the transition from home, being alone, not having anyone to talk to.

“I was aware of the term people use today, you know, ‘doing the most,’” he said. “And I was aware of the pressure to do that, and to do it in a way that makes it look like you’re not struggling, that your life doesn’t have these bumps.”

By the middle of his first semester, Newbauer realized something had to change. He blew off some now-forgotten commitment and beelined for UNC’s Counseling and Psychological Services, where he sat down with a therapist and talked for two hours straight, unloading 19 years of pent-up thoughts. He never went back, but that conversation was enough to set change in motion.

During winter break, he started to come out to his family and close friends. From there, as he began to shed the burden of ‘perfect’ relationships, things slowly fell into place. He’s happy now at UNC, grateful for the hard moments that brought him to a good place. But he knows there isn’t a simple solution for everyone.

Sometimes, he said, fear of a diagnosis — depression, anxiety, anything — will keep people from talking about their problems.

“We might posture ourselves as quite a humble population, and one that’s so serving of others, but we really don’t allow ourselves to go there in our heads and appreciate what another person might be going through,” he said. “The environment needs to change… Especially at UNC, there’s pressure to present the most refined version of yourself that you can. There are different norms at different schools. UNC’s norm just happens to be perfect.”

On the quiet third floor of the university’s campus health building, students sit and wait for their appointments with Counseling and Psychological Services. New visitors fill out questionnaires — Have you had feelings of worthlessness none of the time, some of the time, or most of the time? — while others text friends or do homework.

CAPS sees about 12 percent of the student population each year, a number that has been steadily increasing in recent years.

Some students are here for walk-in appointments, which CAPS offers every weekday. The center has a triage system in which three therapists are on hand for any new appointment, emergency or not. No student must wait longer than an hour for an appointment, said Dr. Allen O’Barr, a psychiatrist and CAPS director since 2007.

Students who walk in are given a short session with one of the triage therapists, which will determine the next steps. Brief therapy is a common option: students meet with a therapist to identify an area of concern, such as academic stress or a break-up, and work through it together about once a week. Most students have their issues resolved between three and six sessions, but there is no session cap for brief therapy.

If it becomes clear that a student has a longer-standing issue, such as bipolar disorder or a history with abuse, that student may be referred to a therapist outside of CAPS. A quarter of visitors are referred out in this manner.

Other services include support groups, academic programs and medication management, the latter of which makes up 20 percent of CAPS visits per year. A student can be referred to medication evaluation by a psychiatrist, which is free, and subsequent medication management, which incurs a cost.

UNC’s counselor-to-student ratio is about 1 to 1,850, falling short of the national standard, which is 1 to 1,500. But O’Barr said the center is well-staffed and on par with centers across the country. In all, the center has 16 psychologists and social workers, four psychiatrists, four pre-doctoral interns and a handful of trainees.

CAPS is busiest at the beginning and end of the semester, with occasional surges after breaks. And it’s getting busier overall. CAPS reported 6,733 visits in fall 2013, up 15 percent from the fall 2011 semester.

O’Barr said students have become more involved since he was an undergraduate.

“What you all are expected to do is light years beyond what I was expected to do,” he said. “I’m sure there were some student activities when I was in college, but nothing like I see here. It’s unbelievable.”

And he said the stress can start before UNC, thanks to an admissions process that selects high-achieving students.

“Do we have an outrageously talented student body? Yes,” he said. “They continue to take on too much, and therefore they are stressed.”

O’Barr said the center sees suicidal students every day — so many that, if the administration understood the sheer amount, “it would blow their minds.”

“Would I say that UNC has a higher prevalence of mental illness than other places? No,” O’Barr said. “A higher prevalence of the population being overworked and overstressed and over-partied? Yes.”

Winston Crisp, UNC’s vice chancellor for student affairs, said the University works to create a balance for students, providing mental health resources while also facilitating students’ academic progress.

Crisp said O’Barr is right that most of the community doesn’t understand how common mental health issues are among students, but he said the administration is well-aware of the challenges students face.

He said UNC attracts the best and brightest students, making this a place where students are always pushing each other.

“Our students come in highly motivated and aggressive about pursuing excellence, and because we are also Carolina, a public university, that is bred into our bones about service and activism,” he said.

“That’s part of what this place is: never being satisfied. But, if in fact you are struggling with self-image, self-confidence, anxiety or depression, it doesn’t always help you. It can certainly add to feelings of failure, of pressure.”

Crisp said a lot of the drive students feel — “to do better, to do more, to compete” — can be at odds with self-care.

UNC senior Priya Balagopal was a teenager when she first noticed some strange thoughts. She was usually anxious about school and social groups, but these were more repetitive, more uncomfortable, veering into paranoia. A therapist helped her realize that much of it was anxiety and obsessive-compulsive tendencies. All that anxiety became so exhausting, she said, it eventually manifested into depression.

The academic rigor of boarding school, where she went to high school, brought on isolation and hopelessness and, during her senior year, an attempt at suicide. After a week at a behavioral clinic, she felt revitalized, ready to work on her issues despite her still-wobbly footing. The transition to college was manageable, thanks to her supportive friends and significant other. But when her relationship ended at the beginning of her sophomore year, she noticed depression creeping back in — a dark shadow.

During her junior year, an acquaintance sexually assaulted her, she said. She felt ashamed, and her depression surged. By the time she was a senior, living off-campus, Balagopal stopped going to classes. She stopped responding to texts and emails. She stopped taking medication and seeing her psychiatrist and using social support. Stress consumed her.

“I was just literally falling apart,” she said. “I took a ton of medication, enough to kill me.”

After three weeks in UNC Hospitals, she realized she wasn’t going to be able to graduate in time, so she withdrew for a year, returning in January. She will graduate in May.

Balagopal is now a co-president of UNC’s growing chapter of Active Minds Inc., which promotes awareness of mental health conditions. The group holds events such as 2012’s Send Silence Packing, in which 1,100 backpacks lined the walkway near the Student Union to represent the approximately 1,100 college students who die by suicide each year.

“All of my experiences have given me a lot of sensitivity and awareness of how important language is, and how hard seeking help is, and how big of a deal stigma is,” she said.

UNC’s environment, with a “service-is-sexy” culture and a prestigious academic reputation, can add to the stressors, Balagopal said.

“We’re known as a public ivy and a land of opportunities and affordable education, and there’s all this privilege here, and this pressure to take advantage of it and make a name for yourself,” she said.

It becomes easy to make comparisons, she said, especially since many students ranked at the top of their class in high school, only to find that, at UNC, they’re a drop in the bucket. The pressure to be successful and passionate about something can be overwhelming, she said.

“I’m always reading about how amazing people are at this school and what they go on to do afterward, and the awards they get, the research projects they’re working on, the policy changes they make, and I just feel like, maybe I’m not good enough,” she said. “There’s also this culture that we should man up and be tough and just push through it… So people tend to suffer in silence.”

Another campus group working to educate students about mental illness is Rethink: Psychiatric Illness. Now in its second year within the Campus Y, Rethink has trained more than 310 people about mental health basics, from stigma to resources to how to be an ally. Co-chairwoman Viviana Bonilla-Lopez said trainings are important because people often turn to friends when they need support, but those friends often don’t know how to help.

Bonilla-Lopez has a loved one with a mental illness, and coming to UNC meant leaving behind a group of people who understood her experience.

“I often felt alienated when people would say things like, ‘Oh, the weather is so bipolar today,’ or, ‘That made me want to kill myself,’” she said. “I felt like people didn’t understand what it was really like to have a mental illness… We wanted to create a space where people felt safe to talk about these issues and find a way to open up that conversation.”

Rethink has become a family for many of its members, Bonilla-Lopez said. A place where someone can say, “I’m having a bad day,” and people understand what that really means.

Scientific evidence shows that stress on college campuses has increased in the last decade or so, according to Dr. Charles Raison, an associate professor at the University of Arizona in Tucson and CNN’s mental health expert.

And in a hyper-involved world, things get even more difficult, he said.

“You’ve kinda got a damned-if-you-do, damned-if-you-don’t situation, actually,” he said. “People do better if every minute of their life isn’t planned out…. It’s really important to have free time to just be spontaneous, creative, and fun… But then the problem is while everybody else is living a hyper-scheduled life, you don’t have anybody to hang out with. So it’s a self-fulfilling prophecy.”

Raison studies how the brain and the body are tightly linked. Getting involved in athletics and exercise has big mental health benefits, he said. Another thing that has proved to make a difference in the lives of college students is compassion meditation, which trains people to see the world in a more positive light.

Stress can activate inflammation in the body, which has been linked to a higher risk of depression. Raison said he noticed that the more students practiced compassion meditation, the less upset they got when put in stressful situations, and the less their bodies showed inflammation. In this way, he said, meditation is a good tool to deal with stress in a way that is less damaging to the body — and the brain.

With a combination of treatment and support systems, 70 percent to 90 percent of people with mental health conditions can significantly reduce their symptoms, according to the National Alliance on Mental Illness.

Now, Josephine Yurcaba is a senior. She hasn’t had a panic attack in months, which is monumental. UNC’s counseling services, she said, have been incredibly helpful.

She’s thinking about what she wants to do after graduation.

New York City would bring distraction, a sense of go, go, go. That’s the kind of busy life she says is good for her. With her writing, she wants to address grief, depression, stress and more. She wants to bring about more understanding of these problems, pulling them to the foreground of discussion.

She still feels the anxiety, the everyday worrying, like a voice in the corner of her mind. If you don’t do this, you’re not going to succeed. If you skip this assignment, everyone in class will be better than you.

“Hearing that criticism from yourself all the time is what drives you insane,” she said.

She gets through it by setting small goals. Step by step.

“Every day I try to say to myself, ‘It’ll be OK, I just need to get through the next half hour.’ I literally live trying to focus on the next half hour of my day so the anxiety about my life and what I’m doing wrong or what I might not be doing or if I’m making my mom proud — so that that isn’t weighing down on me,” she said.

She said many people believe that all college students get a little depressed or anxious.

“But they don’t realize there are there are students that have those problems to the extent that they are truly debilitating,” she said. “People really need to think about it before they say, oh, I’m so depressed, I can’t go out tonight. No. You have no idea what that means.”