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Depression on the College Campus:Connections to Stress, Sleep, and Alcohol

Thomas R. Insel, M.D.Director, National Institute Mental Health

Bethesda, MD

Depression on the College Campus:Connections to Stress, Sleep, and Alcohol

Thomas R. Insel, M.D.Director, National Institute Mental Health

Bethesda, MD

Which medical disorder causes greatest disability?

Percent of total YLDs

Mental Illness* 26.1

Alcohol and drug use 11.5

Respiratory disease 7.6

Musculoskeletal disease 6.8

Sense organ disease 6.4

Cardiovascular disease 5.0

Alzheimer’s and other dementia 4.8

Injuries, including self-inflicted 4.7

Digestive diseases 3.4

WHO World Health Report 2002Data for United States and Canada

all ages

Causes of Disability by Illness CategoryUnited States and Canada

15-44 years old

0 5 10 15 20 25 30 35 40

Mental Illness*

Alcohol and drug use

Injuries, including self-inflicted

Respiratory disease

Musculoskeletal disease

Sense organ disease

Cardiovascular disease

Migraine

Infectious disease, excluding HIV

WHO World Health Report 2002

Causes of Disability by Specific IllnessUnited States and Canada

15-44 years old

0 5 10 15 20 25 30

Unipolar depression

Alcohol use

Drug use

Bipolar disorder

Schizophrenia

Hearing loss

Migraine

Iron deficient anemia

Diabetes mellitus

WHO World Health Report 2002

U.S. Prevalence of Major Depression

One year prevalence: 6.6% (13.1 – 14.1 million adults)

Lifetime prevalence: 16.2% (32.6 – 35.1 million adults)

(Severe or very severe role impairment in 59.3%)

51.6% receive health care treatment, but only 21.7% receive adequate treatment

Kessler et al., JAMA 2003

When does depression start?

Co-morbidity with anxiety = 67.8% with Subst. Abuse = 27.1%

Mood Disturbance Alcohol/Substance Abuse

STRESSSLEEP DISTURBANCE

Anxiety in childhood/early adolescence

Early loss/trauma/stress Genetic vulnerability

How do we treat depression?

Awareness - ScreeningReferral - Access

Therapy – Meds/CBT

Follow-up

Treating Depression: Different Strokes for Different Folks?

Nemeroff et al., PNAS, 2003

pCg

Depression Remission: Meds vs Therapytreatment-specific changes

pCg

mF10

CBT

vF

F9

mF9

Paroxetine

Cg25th

F9

P40hc

th

F11

Cg24

hc

Goldapple et al Arch Gen Psych 2003

hc

+4

- 4

mF9F9

Cg24

SSRIs in College Students?

FDA is currently reviewing the risk of suicide in adolescence on SSRIs:

Is suicide an effect of the disease or the treatment?

What is a greater source of mortality: suicide or homicide?

Approx 30,000 suicides/year (10.7/100,000)

Deaths from homicide: 18,000/year AIDS: 20,000/year Prostate Ca: 28,900/year

Suicide in College Students

Suicides for 15-19 year olds nearly doubled between 1970-1990

Age-related Risk Factors: carry a weapon, drive after drinking, impulsive/aggressive personality, rarely use seatbelts, depression

Campus Risk Factors: Stress, clusters of suicides, loss of social support

NOTE: Some studies in general population have estimated a 10-30 fold increase in risk due to availability of firearms (Kellerman et al., NEJM 1992)

National College Health Risk Behavior Survey (1995)

SeriouslyConsidered

MadePlan

SuicideAttempt

RequiredMed. Attn.

Total 10.3 6.7 1.5 0.4

Male 9.7 7.2 1.7 0.5

Female 10.8 6.3 1.3 0.3

Self –report from 4609 students, ages 18-24, in 2 and 4 year colleges.Higher rate among African American males?

http://www.cdc.gov/mmwr/preview/mmwrhtml/00049859.htm

Percentage in past 12 months:

Suicide on Campus – Big Ten Study

Review of 261 suicides on 12 Midwestern campuses from 1980 – 1990

Rates of suicide highest in older students:age <25 age >25

females 3.2 9.4males 7.9 15.6

Overall rate = 7.5/100,000 across 10 year period

Silverman et al., 1997

How do we prevent suicide?

Reducing risk

Referral - Screening

Rx/Hospitalization

Follow-up

Increase protective factors

Safeguarding your students against suicide – NMHA and Jed Found.

The National Strategy for Suicide Prevention – U.S. Surgeon General

Air Force Program to Reduce Suicide

Knox et al., BMJ, 2003

Community awareness and reduction of stigma(Priority for senior officers, training at all levels, buddy system)

Coordination of social services and social support(Distributed support in schools, work sites, community facilities)

Focus on high risk situations(Legal investigations, protections of privacy)

Air Force Program to Reduce Suicide

Knox et al., BMJ, 2003

What can the Air Force Study teach us about reducing suicide

on college campuses?

Stigma – Top down message that mental health is part of health

Norms – Community-wide investment to increase protective factors and increase social support

Beliefs – “Real men do seek help” “It takes courage to change”

Summary

Mental disorders are the most disabling medical illnesses, beginning early in life and usually following a chronic course.

Depression is common among college-aged students, often associated with substance abuse. Depression can be treated successfully.

Suicide risk in college students is increased by depression and substance abuse, but can occur in the absence of either.

Suicide can be reduced – “it takes a village”.

www.nimh.nih.govwww.nimh.nih.gov

Thanks to Drs. Bernie Arons and Jane Pearson