Exploring the interplay of substance use, mental health, and help-seeking behavior in college student populations

• Analyzed 238,000 + U.S. college students using ACHA-NCHA III data (2019–2022) • Substance use severity positively correlates with mental health diagnoses. • Stigmatized drug use linked to reduced help-seeking for mental health support. • Normalized substances (alcohol, cannabis, tobacco) linked to more help-seeking. • Identified parabolic trend between mental health diagnoses and help-seeking odds. This study examines the intricate relationship between substance use, mental health, and help-seeking behavior, past and future, among United States (U.S.) college students . Data consisting of n = 238,118 students’ responses to the National College Health Assessment from fall 2019 through fall 2022 were employed. Unadjusted and adjusted incidence rate ratios representing the relationship between substance classifications and the number of mental health diagnoses were calculated. Unadjusted and adjusted odds ratios for willingness to seek mental health support, past and future, by substance class were also evaluated. Finally, we assessed unadjusted and adjusted odds of having sought and being willing to seek mental health support by substance risk score among students with varying counts of mental health diagnoses. About 12.66 % (n = 30,001) of students reported three or more mental health diagnoses, 54.01 % (n = 128,286) reported past mental health help utilization, while 82.00 % (n = 193,744) reported that they would seek help from a mental health provider in the future if needed. We found a pronounced correlation between the severity of substance use and the prevalence of mental health diagnoses. Notably, intense use of substances such as prescription opioids, heroin, and cocaine correlates with decreased past mental health support utilization. In contrast, substances more socially accepted, like tobacco, alcohol, and cannabis, are associated with increased help-seeking behavior. The research highlights a significant discrepancy between students’ stated willingness to seek future help and actual past help utilization. Interventions should particularly address students dealing with the dual challenges of substance use and mental health issues.