College mental health: How to provide care for students in need
Successful practice relies on understanding the unique vicissitudes of student life
Assessment also must consider the context of the academic year. For example, students may be “homesick” when they first enter college. Although such students may present with prominent and seemingly severe symptoms of anxiety or depression, more often than not the condition is self-limiting and resolves with support and watchful waiting. For example, many years ago a student presented to my institution’s counseling office in severe acute panic at the beginning of his first year at college. He had never been away from home, had not yet received his dorm phone, and did not know how to use a pay phone. His anxiety resolved as soon as I let him use my office phone to call his family. He ultimately made an excellent adjustment to college life.
Because most counseling services are set up primarily to provide talk therapy, most students who receive psychiatric medication also are engaged in psychotherapy. In these situations, psychiatrists must manage the same challenges in communication and coordination of care that occur in any split treatment agreement. These problems may be more easily addressed when the psychotherapist and prescriber both work in the college counseling center. Unfortunately, at some institutions, the psychiatrist or prescribing physician assistant or nurse practitioner may be based at the college’s health service,6 which can make coordination of care more challenging.
Crisis management. College counseling centers often manage students in crisis. Each year, approximately 6% of college students report suicidal ideation and 1% to 2% report suicide attempts.7 In 2010 there were 14 psychiatric hospitalizations for every 10,000 students on college campuses.2 Because psychiatrists are trained to manage patients with severe pathology and have emergency room training, college counseling psychiatrists often are looked to for assessment and consultation for students in crisis. In many cases, a student in crisis also will need psychopharmacologic intervention. In the event of a suicide or death on campus, the college psychiatrist often is called upon to address postvention planning and management of the clinical and community response.
Psychiatrists who manage student crises need to be cognizant of the unique elements of college life: Does the student live in a dormitory or with family? Could a relative who lives nearby help supervise an anxious patient who is cutting herself? Is the student in treatment with a therapist “back home” who could provide history or intervene? A crisis that occurs early in the school year, when a new student is less likely to have a network of friends or other supports, may need to be managed differently from one that occurs later, when the student might have people who could provide some comfort for a short time. The psychiatrist should know what level of support and supervision is available in the residence halls.
Although it is helpful for college counseling centers to maintain ongoing communication and coordination of services with local clinics and/or university medical centers, it is especially important for those who manage crises to have strong communication with local emergency rooms (ERs) and community crisis services. Because these services likely are managed by physicians, the campus psychiatrist is well placed to consult and coordinate care with local ERs because during a crisis, physician-to-physician communication often is more effective than campus counselor-to-ER physician communication. Ideally, college psychiatrists should have regular communication with ER physicians to discuss campus trends—such as particular drugs being used with unusual frequency or suicides on campus that might raise concerns of suicide contagion—and educate ER clinicians about services and programs the college offers.8
Barreira and Snider4 described the early development of college counseling services as flowing from 2 separate streams. Counseling services at colleges began to appear in the middle of the 20th century and grew out of academic and career advising offices. These programs typically had a “developmental”—as opposed to a clinical—orientation. Most of these services were and continue to be directed by counseling psychologists.
At the same time, some larger institutions—particularly the “Ivys”—hired psychiatrists to provide mental health care. Sometimes these clinicians were based at the school health service, while other institutions had parallel systems of counseling and mental health services. Today most colleges have integrated these programs into a single service.
An opportunity for training
Psychiatrists’ training may make them well-suited to address clinical issues that typically arise among college students. For example, students who have difficulty in college often struggle with issues at the border of physical and emotional health. Many students experience significant levels of stress, and many struggle with poor or inconsistent eating and nutrition and inadequate sleep. In fact, severely sleep-deprived students may present with symptoms that mimic depression.5 Psychiatrists have credibility in addressing these issues with individual students and the campus community. Psychiatrists also have training and experience in diagnosing and managing patients with substance abuse and can educate students, parents, faculty, and university administrators about these disorders.
