College Mental Health

Margaret S. McKenna, M.D.

Mental Health Service

Harvard University Health Service

The Challenges of College

• The best years of your life? Expectations..• Even positive change is stressful• Greater academic demands• Unstructured time• Decreased adult availability• Being on your own in a new environment• Changing relations with family

Challenges of College: Choices

• Alcohol and other drugs

• Sex-identity, values, practices

• Food

• Sleep

• Balancing Academic and Extracurricular

• Roommates

What is going on in College and should we be worried about it?

• The data reported by college students and research is FRIGHTENING

• Depression Doubled, Suicidal Ideation Tripled, Sexual Assaults quadrupled over 13 years

• 45% students self report depression• 10% report serious suicidal ideation and 44%

binge drink

Chickering Group 2003

• 12.1% of prescriptions antidepressants• 800% increase from 1990/ mostly first half

of decade• 4 yr. MH cost increase 64% (140/student)• Psychotropic costs increase 45%, 23.5% of total drug claims (excludes generics) (Student health spectrum 2001, 2003)

Why Now?

• More Diversity-Cultural, Socioeconomic, “Family Dreams”

• Availability of medications

• Financial Stress 1981-1994: 200% cost increase at private schools. Income increased 75%

• Pressure to perform starts earlier

Why Now?Youth Risk Survey 2001

13,600 High Schoolers • 28.3% sad or hopeless almost every day

> 2 wks/ stopped some activity due to symptoms

• 19 percent of students reported that they seriously considered attempting suicide

• 14.8 percent had made a specific plan to attempt suicide.

• 8.8 percent had attempted suicide in the previous year [Grunbaum et al 2002].

Stress

• Biggest problem described by students

• Amazing simple accurate test

• Picture of 2 identical dolphins

• Careful scientific study shows that if you perceive 2 or more differences between the dolphins

• You have a high level of stress and need a vacation…

Stress Test

Obstacles

• Most people who need care don’t seek it or receive it

• Stigma, cultural pressure, mistrust, lack of information keep people out of care

• So do lack of resources; treatment and medication are expensive

• Care is disjointed• Some schools don’t see emotional well-

being and growth as in their “mission”

Staffing Levels- AUCCCD 2003Gallagher 2002

• 81.4% report increased severity of problems• 1/1564 is average staffing. Mean psychiatric

hours per week is 2.6/1000• 23.6% had new positions• 30% open in evening• 60.9% of time in direct care seeing 9.8% of

student body

Common problems

• Relationship problems• Depression• Anxiety• Eating Disorders • Substance Abuse• Sleep Problems

Depression

• Common, often unrecognized

• Emotional: sadness, loss of pleasure, feeling hopeless/worthless, irritability, weeping

• Mental: poor concentration,loss of interest

• Physical: Sleep disturbance, appetite change, “aches and pains”

• Symptoms persist beyond two weeks

Suicide

• Acute Risk Factors: Severe Anxiety, Agitation, Insomnia

• Recent onset Alcohol Abuse• ALWAYS take talk about suicide seriously• Contracts for Safety Meaningless: 77% in

hospital denied ideation or had contract• 45 of 76 suicides occurred during first week post

hospitalization• Fawcett, Jan Update on Suicide Risk Factors: Currents in Affective Illness Vol XXIII, Number 9 Sept. 2004

Anxiety

• Situational

• Developmental

• Generalized anxiety disorder

• Performance

• Panic disorder, OCD, phobias

Eating Disorders

• Glamour survey- 33,000 women 6% happy with their bodies

• 5% Bulimia, 1% Anorexia, 20% disordered eating. 40% overwt. 60% diet

• Anorexia, Bulimia, ED NOS

• 5-15% mortality from anorexia

• 1/3 of people don’t improve from serious anorexia

Alcohol

Alcohol Abuse

• Binge Drinking- 5 or more drinks one sitting in past 2 weeks

• 44% meet criteria in national surveys

• 41% did something they regretted

• 31 % forgot what they did

• 9.7% unprotected sex

• 17% physically injured

Stimulant Abuse

• 900% increase in production of methylphenidate (Ritalin) 1990-2000

• 40% increase 2000-2002 despite release of Metadate and Concerta

• 3-7% school age kids ADHD

• 50% carries over into college

• 16% use recreationally by mouth, snorting or (rarely) by injection

Sleep

Sleep Problems

• 35% of adult population experience insomnia

• 11% of college students get a “good night’s sleep”

• Loss of cognitive functioning, driving

• Increased risk of depression

• < 7 hours yields sleep deprivation

Who is Responsible? Everyone.

• Dining hall staff see eating disorders first, maintenance sees alcohol

• Other students see changes in peers• Residence staff see behavioral changes • Faculty sees loss of motivation and

withdrawal• Senior administration must take student

well-being seriously and provide resources

What should colleges do?

• Gather Data• Provide Rapid Access to Care• Offer Education and Outreach• Involve Students• Coordinate Care• Be aware of community resources• Understand your limits

Gather Data

• Documentation

• How busy is counseling? Identify patterns and peak times of use.

• Where else do students get care?

• How many students take time off for medical reasons? Who comes back?

• How many students are hospitalized?

Rapid Access to Care

• Triage: Who needs to be seen today?

• Episode of care

• Use groups

• Offer evening appointments

• Adequate staffing

• Access to crisis team

Education and Outreach

• Be known. Get out in the community.• Train residence staff to recognize warning signs

of common problems.• Serve as liaisons/consultants to residence staff,

deans, coaches. • Supervise student groups: peer

counselors,wellness reps, advocacy groups• Offer for-credit course to freshmen on stress

and time management

Wellness Activities

• Start a Wellness Center on campus• Focus on prevention: Eat, Sleep, Exercise• Engage Students in community- study breaks,

hikes, massage• Teach yoga, sleep hygiene, relaxation response

as part of leading balanced life.• Have annual “wellness” or “caring events” or

“maximize academic potential, minimize stress”• Student Wellness Reps.

Use the Web!

• Include mental health in campus website: bios, on-campus resources, information

• Online screenings: Mentalhealthscreening.org/college

• Guide students to good web resources (JED, Mystudentbody.com,afsp.org

• Student made DVD to incoming students

Involve Your Students

• “Ultimately, the only people who can get through to students with any consistency are the students themselves…”

Involve Your Students!

• Peer Counseling/ Education Programs

• Student Health Advisory Group

• Wellness representatives in the dorms

• Mental Health Advocacy Group

• Involve in screenings and education

Coordinate Care

• For complex cases, form a team.

• Team members: counselor, PCP, prescriber, residence staff/deans/coaches when indicated

• Use email or voice mail to share information, recognizing limits

• Contracts for continuing in residence

• Transitions are Crucial Times: Monitor

Coordinating Board

• All stakeholders: Students, Financial and Student Service Deans, Residence, Safety, Ministry, Health, Counseling, Disability

• Community wide programs for education from top down and bottom up

• Advisory to Counseling/MH• Strategic, Realistic Planning• Community vs. Individual needs: Insurance

Community Resources

• Inside vs. Outside Care

• Referrals

• Hospitalizations

• Day treatment

• Insurance

Understand Your Limits

• Legal issues

• Confidentiality

• What about parents?

• How much care for whom? How are sickest students cared for?

• When should students take a medical leave of absence? Re-entry?

Legal Issues

• Handbook Language for Notification/LOA• Medical Privacy Laws • FERPA (Family Education Rights and Privacy

Act)• Prohibits disclosure of education records• Permits disclosure gained through observation• Permits disclosure of safety emergency

Confidentiality

• Never promise complete confidentiality

• What is expectation of privacy (what is in the student handbook)

• Considerations include sensitivity of information

• What is the “need to know” of the recipient

• Involve student in planned disclosure

What about Parents?

• Orient them and make them partners • Don’t say “I can’t talk to you.”• Process of communication is key: don’t shut

them out• Invite them to get permission • Discuss general concerns, suggestions without

breaching confidentiality

When things go wrong: litigation

• Pine Manor: security liability

• Ferrum College: “shared responsibility” accepted in settlement (2003)/precedent

• MIT: Shin $27 million lawsuit alleges negligence in failure to provide adequate care/ who was in charge?/ parents not notified/ who is responsible?

How Much Care for Whom?

• Balancing needs of individual and community

• Balancing care and education

• How are sickest students cared for?

• When should students take a medical leave of absence?

• Re-entry

Return on Investment

• Emotional and physical well-being are crucial for academic success

• The entire student body benefits from a strong counseling program

• The institution benefits by increased retention and graduation, which enhance reputation

Retention

• 562 students asking for counseling followed over 2 year period

• 0 sessions 65% 1-12 79% >13 83%• Several studies followed people over 5 years all

showed dramatically higher retention rates, averaging more than 10% for students who used counseling services

Steve Wilson, Terry Mason, Evaluating the impact of receiving university based counseling services on student retention

Journal of Counseling Psychology 1997 vol 44. no 3 p. 316-320

Retention

• Counseling records of 2365 students and student body records of 67,026 over 6 years(473 /13,400) at Western Land Grant University.

• 70% report that personal problems were affecting their academic progress

• 70.9% retention of students in counseling 58.6% retention in control group over 6 years (annual, eventual, graduation and total retention)

• Annual rates were 85.2 vs. 73.8%• Andrew Turner Journal of College Student Development, Nov. Dec 2000

The Takeaway

• Academic performance is enhanced by physical and emotional health

• We can learn to recognize problems much earlier

• Depression, Anxiety and Stress are treatable• Education, Psychotherapy and Medication are

all effective • Self Care--eat, sleep, exercise--is a cornerstone

of health (for all of us!)