This commentary on Kindt et al. [1] and Rabkow et al. [2] by the authors addresses possible consequences of elevated levels of depression in students that were reported in both papers.

Unfortunately, it is safe to say that depression has become one of the most worrisome health challenges of our time, with Major Depression reaching an estimated lifetime prevalence of 15% [3]. While the World Health Organization [4] predicted that depression may become the leading cause of disability-adjusted life years (DALYs) by 2030, Wittchen et al. [5] state that depression already represents “the most burdensome disorder of all diseases in the EU”. Crucially, the prevalence of depressive symptoms is highest among 18- to 29-year-olds [6], an age group congruent with most university students. The heavy burden on students’ mental health is alarmingly apparent not only in reports by a leading German health insurance company [7] and international studies primarily focusing on the health of medical students [8] but also in our recent investigations on depressive symptoms in students studying law, psychology or medicine [1,2]. A Beck Depression Inventory-II (BDI-II) sum score of ≥ 13 points indicates mild, moderate or severe depressive symptoms – a symptom burden reported by 22% of medical students, 28% of psychology students [1], and 33% of law students [2] thus the prevalence in all three groups exceeds the prevalence of depressive symptoms among 18- to 29-year-olds of the general population [6]. While it is important to note that the BDI-II assesses self-reports of depressive symptoms and does not provide diagnosis, we want to point out the high concordance between results of the BDI-II and clinical diagnosis [9].

This commentary echoes these numbers, gives a brief insight into the investigated risk and resilience factors, and, most importantly, calls for and discusses urgently needed consequences.

Due to the multifactorial genesis of depression [10], studies on risk and resilience factors for this mood disorder seem to mimic a Sisyphean task with various confounding factors. Yet, investigations of these factors are imperative to help those affected and to implement effective preventive measures. In accordance with previous research [6,11-14], we were able to replicate associations between depression and the following risk factors: female gender, trait neuroticism, positive family history of mental disorders, financial worries, and abuse of prescription drugs or illicit drugs. Moreover, paying special attention to the university context, we found that performance pressure, excessive demands, time pressure, competition among students, and uncertain prospects represent study-related stress factors associated with depressive symptoms. Notably, excessive demands and performance pressure are most correlated with self-reported depression, r = 0.28-0.32, and r = 0.27-0.38, respectively, and reported by more than 50% of the students surveyed [1,2]. The pressure to perform is particularly pronounced among law and psychology students, which could be because, for psychology students, the grades in the bachelor’s program determine admission to the master’s program (master’s programs are limited and competition is high), and for law students, the result of the bar examination determines their entire professional prospects. Following this logic, it is not surprising that students studying law or psychology more frequently report competition among themselves and uncertain prospects. Medical students, in turn, predominantly experience time pressure [1,15] while also reporting the highest workload [16].

Fortunately, risk factors represent only one side of the coin. On the other side is resilience, i.e., variables that can contribute to mental health and play an important role in prevention [17]. We identified five resilience factors associated with an amelioration of depressive symptoms: study satisfaction, emotional support, healthy diet, sport, and time for social contacts, with the highest correlation found for emotional support. Although we would like to point out that the presence of only two resilience factors may be sufficient to substantially reduce depressive symptoms [1,2], it is crucial to note that resilience is not independent of vulnerability [18]. For example, social contact is considered a resilience factor, yet, only 21-34% of the students surveyed reported having enough time for social contacts, which could be due to stressors related to the university context (e.g., excessive demands or pressure to perform). Hence, we propose that a decrease in stress factors related to the university context (e.g., performance pressure) can increase resilience (e.g., more time for social contacts).

Finally, we note that our studies only take up a selection of potential risk and resilience factors. Thus, this topic not only remains a salient area for further research, but it is also essential to step beyond the proverbial “been there done that” and consider potential implications.

There are two types of consequences to be derived from our results: One that comes naturally and one that we must demand to prevent the former. By the former, we refer to consequences that often result from (untreated) depressive symptoms such as increased distress, poorer academic performance, and an elevated risk of dropping out of the course [19]. In the long term, these effects may also be detrimental to the future occupation of those affected; for example, doctors suffering from depression make six times more medication errors than their healthy colleagues [20]. Furthermore, stress and depressive symptoms can impair the effectiveness of therapy as well as the quality of the therapist-patient relationship [21].

The latter type of consequences is one that we must draw from the results obtained, hence consequences enhancing students’ mental health. On a positive note, most universities already offer psychosocial counseling; here, it is essential to promote existing services making them more visible and accessible for students. Moreover, our results concerning potential risk and resilience factors allow for good starting points to establish further interventions helping students to cope with study-related strains (e.g., planning their courses). In this regard, Pereira et al. [22] were able to show that an elective course in which medical students learned to adopt positive coping strategies to deal with stress resulted in an improvement in students’ stress levels and coping skills.

Additionally, and consistent with previous findings by Cairns et al. [12], we observed a positive association between the risk factor “drug abuse” and the BDI-II sum score. Thus, promoting evidence-based drug prevention programs may serve as another beneficial intervention. However, the interventions mentioned require time commitment - a barrier that prevents many students from seeking mental health support, which is moreover still surrounded by stigma [23]. Whereas stigma is a barrier to seeking professional help, it is not for getting self-help [24], and self-help interventions are instrumental in reducing stigma, specifically the stigma associated with depression [25]. Hence, one option may be to extend beyond what is offered by the university and other public institutions and help students help themselves. In this context, we would like to refer to the Nightline Service, a confidential night-time listening service provided by and for students, initiated at the University of Essex in 1970 [26] and now available to students across the UK and several universities in Germany, Switzerland, France, and Austria. Considering that fellow students share similar experiences, speak the same language, and have the same frame of reference, a self-help approach such as the ‘Nightline’ can be particularly potent in providing a low-threshold service that is a fertile environment for reducing stigma and enhancing social and emotional support. Moreover, for example, Schomerus et al. [27] suggest that knowledge, more specifically knowledge about depression, is associated with less discrimination and a more accurate self-assessment of personal problems, which, in turn, is positively associated with seeking professional support. Accordingly, students may benefit from health-related campus programs that serve to destigmatize and impart knowledge.

In a nutshell; this area is ripe for further ideas, discussions and investigations with input from all – scientists, faculty, and students.

Our studies add to existing findings regarding distress among university students and reveal an elevated level of depressive symptoms – it is time to respond. Hence, we stress the urge for a broader range of mental health support services adapted to the needs of the students and advocate a self-help approach as a key ingredient in reducing stigma. Finally, there is nothing worth jeopardizing mental health for, neither a GPA nor a title. Mental health cannot be students' stake for passing their course, and with that in mind, this is a call to reflect on the consequences and pay particular attention to those we can positively impact.