College mental health: How to provide care for students in need
Successful practice relies on understanding the unique vicissitudes of student life
Each year thousands of college students seek treatment at their school’s mental health service, but few psychiatrists are delivering this care. Most of the 4,500 degree-granting institutions of higher education (IHEs) in the United States1 provide some type of psychological or mental health counseling support to their students, and approximately 10% of the student body seeks care annually.2 In 2010, nearly 24% of students who visited their college counseling service were taking psychiatric medications at the time of their visit, up from 9% in 1994.2
Nevertheless, for various historical and practical reasons, psychiatrists have played—and continue to play—a somewhat peripheral role in college mental health systems. Although interest in psychiatric care at IHEs has been increasing (Box 1),3 until recently, most college counseling services had no direct access to psychiatric services and currently <1% of college services are directed by psychiatrists.2
This article examines some of the unique challenges faced by psychiatrists who work in a college mental health service, including how this setting may affect assessment, medication management, and crisis counseling. I use the terms “counseling services” and “mental health services” interchangeably because schools differ in the name they use for this office.
Interest in college psychiatry is growing
In recent years, the psychiatric community has begun to take steps to recognize college mental health as a specific practice area.3 In 2004, as president of the American Psychiatric Association (APA), Current Psychiatry Section Editor Michelle B. Riba, MD, MS convened a task force on college mental health. Subsequently, the APA added a section on college mental health to its public information Web site “Healthy Minds. Healthy Lives” (www.healthyminds.org).
The University of Michigan has taken a national leadership role in college psychiatry and college mental health. Since 2003, the University of Michigan Depression Center has hosted a yearly Depression on College Campuses national conference. Content from past conferences is available at www.depressioncenter.org/docc.
Organizations dedicated to college mental health and suicide prevention also have taken a role in disseminating information. Chief among them are the Jed Foundation, Active Minds on Campus, the Suicide Prevention Resource Center, Penn State’s Center for Collegiate Mental Health, and the National Research Consortium of Counseling Centers in Higher Education. More needs to be done to expand efforts related to college mental health and educate the psychiatric community and community at large about these vital concerns.
Managing medications and crises
Most college mental health services are directed by psychologists because of how IHEs historically structured these services (Box 2).4 Although counseling center staffing generally includes relatively few psychiatrists, those who do serve in this setting typically serve 2 primary roles: medication managers and crisis clinicians.
Medication management. Counseling centers are seeing more students who are either already taking psychotropics or need assessment and medication management. In the United States, 14% of students seen at college counseling centers are referred for psychiatric evaluation; however, on average, schools provide 2 hours of psychiatric services per week for every 1,000 students.2
Managing medications for college students poses several challenges. For most students, interaction with their college’s health and/or mental health system may be the first time they receive care not under the direct oversight of their family. Families and their feelings about psychiatric medication can play a major role in planning, executing, and managing psychiatric care, even for students who are legal adults. Family attitudes toward psychiatry and patients’ fears of disappointing parents who may feel distraught because their child has a psychiatric illness may impact a young person’s decision to accept medication or comply with treatment. Students often are insured by their family, and parents might receive an Explanation of Benefits and will learn of the student’s pharmacotherapy even if the student does not want them to know. College psychiatrists and students always need to consider decisions about how and when to include parents in discussions about medications.
College psychiatrists also must be sensitive to the unique vicissitudes of the school calendar and the developmental trajectory of college life. Decisions about when to start a medication or even which medication to prescribe might depend on how close a students is to exams or summer break. For example, a student experiencing severe anxiety a week before exams probably is better treated with a short-term benzodiazepine prescribed on an as-needed basis than a selective serotonin reuptake inhibitor, which in the first few weeks might only disrupt the student’s ability to function academically and not improve symptoms.5
Assessment also must consider the context of the academic year. For example, students may be “homesick” when they first enter college. Although such students may present with prominent and seemingly severe symptoms of anxiety or depression, more often than not the condition is self-limiting and resolves with support and watchful waiting. For example, many years ago a student presented to my institution’s counseling office in severe acute panic at the beginning of his first year at college. He had never been away from home, had not yet received his dorm phone, and did not know how to use a pay phone. His anxiety resolved as soon as I let him use my office phone to call his family. He ultimately made an excellent adjustment to college life.
Because most counseling services are set up primarily to provide talk therapy, most students who receive psychiatric medication also are engaged in psychotherapy. In these situations, psychiatrists must manage the same challenges in communication and coordination of care that occur in any split treatment agreement. These problems may be more easily addressed when the psychotherapist and prescriber both work in the college counseling center. Unfortunately, at some institutions, the psychiatrist or prescribing physician assistant or nurse practitioner may be based at the college’s health service,6 which can make coordination of care more challenging.
Crisis management. College counseling centers often manage students in crisis. Each year, approximately 6% of college students report suicidal ideation and 1% to 2% report suicide attempts.7 In 2010 there were 14 psychiatric hospitalizations for every 10,000 students on college campuses.2 Because psychiatrists are trained to manage patients with severe pathology and have emergency room training, college counseling psychiatrists often are looked to for assessment and consultation for students in crisis. In many cases, a student in crisis also will need psychopharmacologic intervention. In the event of a suicide or death on campus, the college psychiatrist often is called upon to address postvention planning and management of the clinical and community response.
Psychiatrists who manage student crises need to be cognizant of the unique elements of college life: Does the student live in a dormitory or with family? Could a relative who lives nearby help supervise an anxious patient who is cutting herself? Is the student in treatment with a therapist “back home” who could provide history or intervene? A crisis that occurs early in the school year, when a new student is less likely to have a network of friends or other supports, may need to be managed differently from one that occurs later, when the student might have people who could provide some comfort for a short time. The psychiatrist should know what level of support and supervision is available in the residence halls.
Although it is helpful for college counseling centers to maintain ongoing communication and coordination of services with local clinics and/or university medical centers, it is especially important for those who manage crises to have strong communication with local emergency rooms (ERs) and community crisis services. Because these services likely are managed by physicians, the campus psychiatrist is well placed to consult and coordinate care with local ERs because during a crisis, physician-to-physician communication often is more effective than campus counselor-to-ER physician communication. Ideally, college psychiatrists should have regular communication with ER physicians to discuss campus trends—such as particular drugs being used with unusual frequency or suicides on campus that might raise concerns of suicide contagion—and educate ER clinicians about services and programs the college offers.8
How college mental health services were established
Barreira and Snider4 described the early development of college counseling services as flowing from 2 separate streams. Counseling services at colleges began to appear in the middle of the 20th century and grew out of academic and career advising offices. These programs typically had a “developmental”—as opposed to a clinical—orientation. Most of these services were and continue to be directed by counseling psychologists.
At the same time, some larger institutions—particularly the “Ivys”—hired psychiatrists to provide mental health care. Sometimes these clinicians were based at the school health service, while other institutions had parallel systems of counseling and mental health services. Today most colleges have integrated these programs into a single service.
An opportunity for training
Psychiatrists’ training may make them well-suited to address clinical issues that typically arise among college students. For example, students who have difficulty in college often struggle with issues at the border of physical and emotional health. Many students experience significant levels of stress, and many struggle with poor or inconsistent eating and nutrition and inadequate sleep. In fact, severely sleep-deprived students may present with symptoms that mimic depression.5 Psychiatrists have credibility in addressing these issues with individual students and the campus community. Psychiatrists also have training and experience in diagnosing and managing patients with substance abuse and can educate students, parents, faculty, and university administrators about these disorders.
College mental health services can be valuable training venues for senior psychiatric residents and child and adolescent fellows.9 College students can provide exposure to a broad array of problems—such as anxiety disorders, obsessive-compulsive disorder, dysthymic disorder, adjustment disorders, and panic disorder—that psychiatric trainees may not confront in a hospital clinic. Students are particularly responsive to short-term talk therapies with or without medication management, and working with this population can be a strong antidote to the “therapeutic nihilism”—the unfortunate sense that talk therapies are of limited effectiveness and that only pharmacotherapy can help psychiatric problems—often experienced by psychiatric trainees who spend much of their time working with patients with serious, chronic illnesses. Psychiatric residents can be particularly helpful in managing student patients who require combined medication and talk therapy.
College-based psychiatrists are well suited for educating residents about developmental issues of “emerging adulthood,” including:
- exploration of and anxieties about relationships and sexuality
- balancing connectedness to family with increasing sense of autonomy and independence
- establishing personal life goals and values and career choices and goals.10
College counseling services also are an excellent setting for residents to learn principles of community mental health and medico-legal concepts related to confidentiality, duty to warn, and disability law.11
Treatment outside college
Because college students have high rates of substance abuse12 and other psychiatric disorders, it is important for psychiatrists who treat these patients in private practice or community-based clinics to develop a basic awareness of and competency in relevant developmental and clinical issues. Psychiatrists who work in emergency services in areas with high concentrations of college students need to be particularly attuned to issues related to college mental health, substance abuse, and life on campus.8
- The Jed Foundation. www.jedfoundation.org.
- National Research Consortium of Counseling Centers in Higher Education. www.cmhc.utexas.edu/researchconsortium.html.
Dr. Schwartz reports no financial relationship with any companies whose products are mentioned in this article or with manufacturers of competing products.
1. US Department of Education National Center for Education Statistics. Degree-granting institutions by control and type of institution: Selected years, 1949-50 through 2009-10. http://nces.ed.gov/programs/digest/d10/tables/dt10_275.asp. Accessed August 22, 2011.
2. Gallagher RP. National survey of counseling center directors 2010. International Association of Counseling Services. http://www.iacsinc.org. Accessed August 22 2011.
3. Schwartz V, Kay J. The crisis in college and university mental health. Psychiatric Times. July 27 2009.
4. Barreira P, Snider M. History of college counseling and mental health services and role of the community mental health model. In: Kay J Schwartz V, eds. Mental health care in the college community. Hoboken, NJ: Wiley and Sons; 2010:21–31.
5. Schwartz V. Medications. In: Grayson PA Meilman PW, eds. College mental health practice. New York, NY: Routledge; 2006:59–78.
6. Barr V, Rando R, Krylowicz B, et al. The Association for University and College Counseling Centers Directors Annual Survey. 2010. http://aucccd.org/img/pdfs/aucccd_directors_survey_monograph_2010.pdf. Accessed September 1, 2011.
7. American College Health Association. National college health assessment II: reference group executive summary Fall 2010. Linthicum MD: American College Health Association; 2011.
8. Glick RL, Schwartz V. Assessment and management: special considerations for college students in psychiatric crisis. Psychiatric Issues in Emergency Care Settings. 2007;6(4):7-13.
9. Kay J, Schwartz V. Psychiatry residency training in college mental health services. In: Kay J Schwartz V, eds. Mental health care in the college community. Hoboken, NJ: Wiley and Sons; 2010.
10. Arnett JJ. Emerging adulthood: the winding road from the late teens through the twenties. New York NY: Oxford University Press; 2004.
11. Bower K, Schwartz V. Legal and ethical issues in college mental health. In: Kay J Schwartz V, eds. Mental health care in the college community. Hoboken, NJ: Wiley and Sons; 2010.
12. Hingson R, White A. Magnitude and prevention of college alcohol and drug misuse. In: Kay J Schwartz V, eds. Mental health care in the college community. Hoboken, NJ: Wiley and Sons; 2010.