1. 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

2. Which medical disorder causes greatest disability? Percent of total YLDs Mental Illness*26.1 Alcohol and drug use11.5 Respiratory disease7.6 Musculoskeletal disease6.8 Sense organ disease6.4 Cardiovascular disease5.0 Alzheimer’s and other dementia4.8 Injuries, including self-inflicted4.7 Digestive diseases3.4 WHO World Health Report 2002 Data for United States and Canada all ages

3. Causes of Disability by Illness Category United States and Canada 15-44 years old WHO World Health Report 2002

4. Causes of Disability by Specific Illness United States and Canada 15-44 years old WHO World Health Report 2002

5. 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

6. When does depression start? Co-morbidity with anxiety = 67.8% with Subst. Abuse = 27.1% Mood DisturbanceAlcohol/Substance Abuse STRESS SLEEP DISTURBANCE Anxiety in childhood/early adolescence Early loss/trauma/stressGenetic vulnerability

7. National College Health Risk Behavior Survey (1995) Current Alcohol Use (>1 drink) Episodic Heavy Use (>5 drinks/1 d) Frequent Use (>20 days) Total70.041.53.4 Male73.248.75.4 Female67.034.81.6 Self –report from 4609 students, ages 18-24, in 2 and 4 year colleges. http://www.cdc.gov/mmwr/preview/mmwrhtml/00049859.htm Percentage in past 30 days:

8. How do we treat depression? Awareness - Screening Referral - Access Therapy – Meds/CBT Follow-up

9. Treating Depression: Different Strokes for Different Folks? Nemeroff et al., PNAS, 2003

10. pCg Depression Remission: Meds vs Therapy treatment-specific changes pCg mF10 CBT vF F9 mF9 Paroxetine Cg25 th F9 P40 hc th F11 Cg24 hc Goldapple et al Arch Gen Psych 2003 hc +4 - 4 mF9 F9 Cg24

11. 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?

12. PF9 thal bg Cg25 P40 hippocampus hth bs a-ins am Summary: Modulation of Common ‘System’ Treatment-Specific Effects drug - - pCg CBT attention-cognition vegetative-circadian mood state mF9/10 oF11 aCg24 SRI only CBT SRI inverse CBT only Emotion- cognition integration

13. 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

15. 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)

16. National College Health Risk Behavior Survey (1995) Seriously Considered Made Plan Suicide Attempt Required Med. Attn. Total10.36.71.50.4 Male 9.77.21.70.5 Female10.86.31.30.3 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:

17. 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 females3.29.4 males7.9 15.6 Overall rate = 7.5/100,000 across 10 year period Silverman et al., 1997

18. How do we prevent suicide- Referral to Hotlines? Limited evidence of their effectiveness for reducing suicide rates Gould et al (2002): only 2% of 9-12 th graders would use hotlines for help SAMHSA currently evaluating potential community impact and other benefits of hotlines

19. 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

20. 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)

21. Air Force Program to Reduce Suicide Knox et al., BMJ, 2003

22. 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”

23. 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”.

24. www.nimh.nih.gov Thanks to Drs. Bernie Arons and Jane Pearson