2. Staying Healthy at Tufts Student Mental Health and Success Richard Kadison M.D. Chief, Mental Health Service Harvard University Health Service

3. Challenges Reduce Stigma, Manage Stress Reduce Stigma, Manage Stress Convince Universities that health and counseling resources are wise investments Convince Universities that health and counseling resources are wise investments Coordination of care between health, counseling, residence, faculty, and administration Coordination of care between health, counseling, residence, faculty, and administration Integrating Cultural Sensitivity and competence into our work Integrating Cultural Sensitivity and competence into our work

4. Current issues Integration of Academic Work with student health and development Integration of Academic Work with student health and development EVERYONE on campus is responsible for student well being. EVERYONE on campus is responsible for student well being. Coordination of care Coordination of care More serious mental health problems on campus. Helping high risk students More serious mental health problems on campus. Helping high risk students

5. Stress on Staying Healthy Eat, Sleep, Exercise Eat, Sleep, Exercise Stay connected with friends/ community Stay connected with friends/ community Provide tools to manage stress Provide tools to manage stress Educate community to reduce stigma thru education about common problems and how to recognize warning signs. Educate community to reduce stigma thru education about common problems and how to recognize warning signs. Create multiple portals of entry to care Create multiple portals of entry to care

6. Staying Healthy Stressing Personal and professional Development Stressing Personal and professional Development Service Opportunities: Engaged Learning Service Opportunities: Engaged Learning Health Education and Information (MRSA) Health Education and Information (MRSA) Alcohol and Nutrition info: (BAL + BMI) Alcohol and Nutrition info: (BAL + BMI) Complementary Services: Acupuncture, Massage, Yoga, Mindfulness Complementary Services: Acupuncture, Massage, Yoga, Mindfulness

7. Student Participation/ Engagement Key for Successful Outreach Key for Successful Outreach Peer Counseling/ Education Programs Peer Counseling/ Education Programs Student Health Advisory Group Student Health Advisory Group Wellness representatives in the dorms Wellness representatives in the dorms Mental Health Advocacy Group/Active Minds Mental Health Advocacy Group/Active Minds Involve in screenings and education Involve in screenings and education

8. Getting Care Multiple ways to access care Multiple ways to access care Chaplains, Advising system, residence system Chaplains, Advising system, residence system Information about resources and warning signs for parents and families Information about resources and warning signs for parents and families Stress relieving events and workshops at high stress times (massage, food, activities/ workshops) Stress relieving events and workshops at high stress times (massage, food, activities/ workshops)

9. Access to Care Triage system: Who needs to be seen today Triage system: Who needs to be seen today Inside vs. Outside Care Inside vs. Outside Care Community Resources Community Resources Hospital and Medical Leave, Reentry Hospital and Medical Leave, Reentry When should students go home? How to decide When should students go home? How to decide Teach Wellness: Eat, Sleep, Exercise Teach Wellness: Eat, Sleep, Exercise

10. Lessons from Virginia Tech Students in distress often don’t seek or avoid care Students in distress often don’t seek or avoid care When students are mandated for “assessment”, there must be follow up and clear consequences When students are mandated for “assessment”, there must be follow up and clear consequences When students return from hospital care, a careful internal review process is critical When students return from hospital care, a careful internal review process is critical

11. Lessons from Virginia Tech Violence is very rare and difficult to predict (prior violence best predictor) Violence is very rare and difficult to predict (prior violence best predictor) There must be a community effort to reduce stigma, recognize risk factors, and find portals to care. Educate everyone There must be a community effort to reduce stigma, recognize risk factors, and find portals to care. Educate everyone Counseling and Health Services can and should provide consultation to the community (students, faculty and staff) Counseling and Health Services can and should provide consultation to the community (students, faculty and staff)

12. Lessons from Virginia Tech Schools must find ways to respect medical privacy, but coordinate concerns Schools must find ways to respect medical privacy, but coordinate concerns If students can’t expect privacy, they won’t seek care If students can’t expect privacy, they won’t seek care There must be communication, sometimes one way, between faculty, administration, family, counseling when concerns arise about a student There must be communication, sometimes one way, between faculty, administration, family, counseling when concerns arise about a student FERPA and HIPAA FERPA and HIPAA

13. Youth Risk Survey 2001 13,600 HS students 28.3% sad or hopeless almost every day> 2 wks stopped some activity due to symptoms 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 19 percent of students reported that they seriously considered attempting suicide 14.8 percent had made a specific plan to attempt 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]. 8.8 percent had attempted suicide in the previous year [Grunbaum et al 2002].

14. College Data ACHA and Kansas State Depression Doubled, Suicidal Ideation Tripled, Sexual Assaults quadrupled over 13 years Depression Doubled, Suicidal Ideation Tripled, Sexual Assaults quadrupled over 13 years 45% students self report depression 45% students self report depression 10% report serious suicidal ideation and 44% binge drink 10% report serious suicidal ideation and 44% binge drink These are the best years of your life These are the best years of your life

15. ACHA College Data 9% seriously consider suicide 1% attempt 9% seriously consider suicide 1% attempt Depressed 52-42% 2000/2006 Depressed 52-42% 2000/2006 No Sexual partners 40% vs. 5% perceived No Sexual partners 40% vs. 5% perceived Medication for depression 36-42% Medication for depression 36-42%

16. Graduate Students Often at higher risk, higher suicide rates Often at higher risk, higher suicide rates Economically in worse shape, many have no insurance. Economically in worse shape, many have no insurance. Berkeley Graduate Student Mental Health Survey Dec. 2004 showed similar findings to undergrad surveys Berkeley Graduate Student Mental Health Survey Dec. 2004 showed similar findings to undergrad surveys

17. Berkeley Grad School Survey 45.3% respondents experienced emotional or stress related problem SIGNIFICANTLY affected well being/ academic performance 45.3% respondents experienced emotional or stress related problem SIGNIFICANTLY affected well being/ academic performance 9.9% seriously thought about suicide 9.9% seriously thought about suicide 52% considered using counseling less than 33% did use 52% considered using counseling less than 33% did use 25% unaware they were available 25% unaware they were available

18. Learning from Each Other Learning from Each Other Peter Leviness undergraduate student survey engaged students to highlight and address campus stress U. Richmond Peter Leviness undergraduate student survey engaged students to highlight and address campus stress U. Richmond Jan Collins-Eaglin 1 st. Generation, multicultural students need language for therapy, Wayne State Jan Collins-Eaglin 1 st. Generation, multicultural students need language for therapy, Wayne State Ron Chapman Pre and post counseling GPA changes- increased 1.0 BYU Ron Chapman Pre and post counseling GPA changes- increased 1.0 BYU

19. Stories to Spread the Word Educate the community to reduce Stigma: College Wide Events Educate the community to reduce Stigma: College Wide Events Being Depressed at HBS Being Depressed at HBS Walk the walk of the student on your campus: illness in family, high fever, serious alcohol problem. How do you get help? Web? Walk the walk of the student on your campus: illness in family, high fever, serious alcohol problem. How do you get help? Web?

20. Healthcare 2007 BIG changes in the last decade BIG changes in the last decade Severity of Problems of students making it to college Severity of Problems of students making it to college Managed Care= Shorter Hospital Stays and more alternative treatments Managed Care= Shorter Hospital Stays and more alternative treatments Reduced outpatient community resources Reduced outpatient community resources Higher insurance costs for students Higher insurance costs for students

21. Impediments to Academic Success Impediments to Academic Success Stress 32.4% Stress 32.4% Cold/Flu 25.6% Cold/Flu 25.6% Sleep Problems 24.6% Sleep Problems 24.6% Depression 15.3% Depression 15.3% Internet Use/ Games 13.4% (3-6% of students addicted to internet pornography; 20% are women) Internet Use/ Games 13.4% (3-6% of students addicted to internet pornography; 20% are women)

22. Sleep Problems 35% of adult population experience insomnia 35% of adult population experience insomnia 11% of college students get a “good night’s sleep” 11% of college students get a “good night’s sleep” Loss of cognitive functioning, driving Loss of cognitive functioning, driving Increased risk of depression Increased risk of depression < 7 hours yields sleep deprivation < 7 hours yields sleep deprivation

23. Common Problems Developmental Adjustment, Relationships Developmental Adjustment, Relationships Depression Depression Anxiety Anxiety Eating Disorders Eating Disorders Bipolar Disorder Bipolar Disorder Acute Psychosis Acute Psychosis Substance Abuse Substance Abuse

24. High Risk Issues Eating Disorders Eating Disorders Dual diagnosis Substance Abuse/ depression Dual diagnosis Substance Abuse/ depression Bipolar Illness and Psychosis Bipolar Illness and Psychosis Reentry from Hospitalization Reentry from Hospitalization

25. Eating Disorders Anorexia, Bulimia, EDNOS Anorexia, Bulimia, EDNOS 1% Anorexia, 3-5% Bulimia, 15-20% DE 1% Anorexia, 3-5% Bulimia, 15-20% DE 5-15% mortality from anorexia 5-15% mortality from anorexia 1/3 of people don’t improve from serious anorexia 1/3 of people don’t improve from serious anorexia

26. Substance Abuse Binge Drinking- 5 or more drinks one sitting in past 2 weeks Binge Drinking- 5 or more drinks one sitting in past 2 weeks 44% meet criteria in national surveys 44% meet criteria in national surveys 41% did something they regretted 41% did something they regretted 31 % forgot what they did 31 % forgot what they did 9.7% unprotected sex 9.7% unprotected sex 17% physically injured 17% physically injured

27. Substance Abuse Don’t stigmatize medical services. Separate from Judicial Don’t stigmatize medical services. Separate from Judicial BASICS: Motivational interviewing and education shows best results with reducing high risk drinking BASICS: Motivational interviewing and education shows best results with reducing high risk drinking Consistent enforcement policies and consequences for students with identified AODS team on campus Consistent enforcement policies and consequences for students with identified AODS team on campus

28. Stimulant Abuse 900% increase in production of methylphenidate (Ritalin) 1990-2000 900% increase in production of methylphenidate (Ritalin) 1990-2000 3-7% school age kids ADHD 3-7% school age kids ADHD 50% carries over into college 50% carries over into college 16% use recreationally by mouth, snorting or by injection 30% share 16% use recreationally by mouth, snorting or by injection 30% share

29. Suicide Long Term Risk factors Long Term Risk factors Prior attempts Prior attempts Feelings of hopelessness Feelings of hopelessness Suicidal plan, isolation, prior attempts Suicidal plan, isolation, prior attempts 10% attempters die over 10 years 10% attempters die over 10 years 45 of 76 suicides occurred during first week post hospitalization 45 of 76 suicides occurred during first week post hospitalization

30. Legal Issues Shin case settled but issues unresolved Shin case settled but issues unresolved Virginia Tech: Refusal of care by student Virginia Tech: Refusal of care by student George Washington, Hunter College student dismissals George Washington, Hunter College student dismissals Allegheny College Suicide Allegheny College Suicide

31. Legal Issues Handbook Language for Notification/LOA Handbook Language for Notification/LOA Medical Privacy Laws very strict Medical Privacy Laws very strict FERPA (Family Education Rights and Privacy Act); HIPAA FERPA (Family Education Rights and Privacy Act); HIPAA Prohibits disclosure of education records Prohibits disclosure of education records Permits disclosure gained through observation Permits disclosure gained through observation Permits disclosure of safety emergency Permits disclosure of safety emergency

32. Leave of Absence and Return Students rarely want to take time off, but may need to Students rarely want to take time off, but may need to When students return, important to review their readiness to be back at school internally When students return, important to review their readiness to be back at school internally Contracts and Riders Contracts and Riders

33. Retention 562 students asking for counseling followed over 2 year period 562 students asking for counseling followed over 2 year period 0 sessions 65% 1-12 79% >13 83% 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 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

34. Retention Social Isolation single most important determinent of dropout rates Pascarella and Terrazini, 1979 Social Isolation single most important determinent of dropout rates Pascarella and Terrazini, 1979 Emotional- Social Adjustment items predicted attrition better than academic items Gerdes and Mallinckrodt 1994 Emotional- Social Adjustment items predicted attrition better than academic items Gerdes and Mallinckrodt 1994 5 year study of Berkeley students and those making use of counseling had higher graduation rates Frank and Kirk 1975 5 year study of Berkeley students and those making use of counseling had higher graduation rates Frank and Kirk 1975

35. Medication Polarized attitudes of students and staff Polarized attitudes of students and staff Antidepressants: benefits and risks (bipolar) and side effects Antidepressants: benefits and risks (bipolar) and side effects Sleep Medications Sleep Medications Anxiety Medications Anxiety Medications Stimulants: Newer preparations Stimulants: Newer preparations Role with disabilities and judicial issues Role with disabilities and judicial issues

36. Medication Antidepressant and Stimulant Safety Controversy Antidepressant and Stimulant Safety Controversy Reduction of 20% in prescribing since black box warning Reduction of 20% in prescribing since black box warning Most prescribed medications on college campuses: 12% of pharmacy budget for antidepressants Most prescribed medications on college campuses: 12% of pharmacy budget for antidepressants Side Effects: Kiss of death Side Effects: Kiss of death

37. Multicultural Students Present emotional problems physically Present emotional problems physically Metabolize medications differently Metabolize medications differently May be more comfortable with Pastoral Resources: follow path of least resistance May be more comfortable with Pastoral Resources: follow path of least resistance Vulnerability in language/cultural adjustment and symptom presentation Vulnerability in language/cultural adjustment and symptom presentation Staff sensitivity to cultural beliefs Staff sensitivity to cultural beliefs

38. Diversity Considerations Create a culturally competent community Create a culturally competent community Learn and respect different values and cultures Learn and respect different values and cultures Celebrate the diversity of your community by events that encourage sharing; art, music, and other traditions. Celebrate the diversity of your community by events that encourage sharing; art, music, and other traditions. Diversity may be via culture, race, ethnicity, sexual orientation, economics Diversity may be via culture, race, ethnicity, sexual orientation, economics

39. Coordination of Care Handbook expectations: who gets notified about hospitalization/ return Handbook expectations: who gets notified about hospitalization/ return Identifying high-risk students Identifying high-risk students How is residence involved with worrisome students? How is residence involved with worrisome students? Eating Disordered or Substance Abusing students in residence, what happens? Eating Disordered or Substance Abusing students in residence, what happens? Contracts: When to invoke them Contracts: When to invoke them

40. Parents 70-80 % of students get their health information from their parents 70-80 % of students get their health information from their parents They often feel they are supposed to let go of students and need help staying engaged without being intrusive They often feel they are supposed to let go of students and need help staying engaged without being intrusive Help “ helicopter parents ” teach their students to fish and become “ emerging adults ” Help “ helicopter parents ” teach their students to fish and become “ emerging adults ”

41. What Must We do? Engage our students in the community: Life is richer and more satisfying for students who are engaged in learning Engage our students in the community: Life is richer and more satisfying for students who are engaged in learning Stress Health and Wellness on campus and create opportunities for connections Stress Health and Wellness on campus and create opportunities for connections

42. Wellness Activities Engage Students in community- study breaks, hikes, encourage student groups Engage Students in community- study breaks, hikes, encourage student groups Teach yoga, sleep hygiene, mindfulness, relaxation response Teach yoga, sleep hygiene, mindfulness, relaxation response Have annual “wellness or caring events” like this one or “maximize academic potential, minimize stress” Have annual “wellness or caring events” like this one or “maximize academic potential, minimize stress” Student Wellness Reps. Student Wellness Reps.

43. Coordinating Board All stakeholders: Students, Financial and Student Service Deans, Residence, Public Safety, Ministry, Health, Counseling, Disability All stakeholders: Students, Financial and Student Service Deans, Residence, Public Safety, Ministry, Health, Counseling, Disability Community wide programs for education from top down and bottom up; set priorities! Community wide programs for education from top down and bottom up; set priorities!

44. Coordinating Board Advisory to Counseling/MH Advisory to Counseling/MH Strategic, Realistic Planning Strategic, Realistic Planning Community vs. Individual needs: Insurance Community vs. Individual needs: Insurance Consider having regional meetings with shareholders in other area schools to share good ideas and increase leverage with local medical/ community resources Consider having regional meetings with shareholders in other area schools to share good ideas and increase leverage with local medical/ community resources

45. Web Information Online screenings: Mentalhealthscreening.org; ULifeline.org Online screenings: Mentalhealthscreening.org; ULifeline.org Information/education about alcohol Information/education about alcohol Student made DVD to incoming students Student made DVD to incoming students Information about resources Information about resources Many good web resources (JED (Ulifeline), Mystudentbody.com, Alcohol.edu) Many good web resources (JED (Ulifeline), Mystudentbody.com, Alcohol.edu) Launching mentalhealth.edu Launching mentalhealth.edu

46. Summary Emotional and Physical Well-Being are crucial for Academic Success Emotional and Physical Well-Being are crucial for Academic Success We all have to work together We all have to work together Focus on Staying Healthy and Learning Healthy Lifestyles: Eat, Sleep and Exercise Focus on Staying Healthy and Learning Healthy Lifestyles: Eat, Sleep and Exercise