Hopelessness is a clinically important state relative to morbidity and suicide risk among university students. We examined its role in relation to presenting concerns, diagnosis, psychopharmacologic treatment and spiritual orientation among students seeking treatment at a university counseling center. The most commonly identified concern was anxiety, followed by stress and depression. Eighty-two percent were given a DSM IV diagnosis. Hopelessness was higher among students dually diagnosed with anxiety and depressive disorders and those who were started on psychiatric medication. Spirituality was inversely correlated with hopelessness and constitutes a personal characteristic warranting further investigation. The concerns bringing students to counseling, the rates of DSM IV diagnosis and the use of psychiatric medication suggest a preponderance of psychopathology over developmental or situational concerns that may be more prominent than has been noted in the counseling literature. In this regard, hopelessness appears to be an important feature even beyond its relationship to suicidality and merits attention and evaluation in student counseling.