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 % 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 : 200% cost increase at private schools. Income increased 75% Pressure to perform starts earlier

Why Now?Youth Risk Survey ,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 2003 Gallagher % report increased severity of problems 1/1564 is average staffing. Mean psychiatric hours per week is 2.6/ % 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) % increase 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 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% % >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

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!)