Residents Help Meet Demand For College MH Services

An 18-year-old woman with a stellar academic record and 1400-plus scores on her SATs approaches her first college mid-term exams with fear and trepidation. When the once all-A student receives C grades or lower on her exams, she descends into despair, unable to work or socialize.

The scenario is one that psychiatrists and educators tell Psychiatric News is typical of young people who are seeking mental health treatment at college and university health centers in increasing numbers.

Very often students arrive on campus having been diagnosed and treated for mental illness in their high school years or earlier. Some of these students might never have gotten past high school in an earlier generation, while others experience a first episode of mental illness as they confront the rigors of college and the social stresses of late adolescence.

“We have had a steadily increasing demand for psychiatric services,” said psychiatrist John Vanin, M.D., director of student mental health services at West Virginia University. “Students are coming to school with diagnoses such as clinical depression, bipolar disorder, panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, adult attention-deficit-hyperactivity disorder, and alcohol/substance abuse. Many are on medications and also require psychotherapy, and many are in school and being diagnosed with major mental disorders and treated for the first time.”

Vanin, who is a member of APA's Presidential Task Force on Mental Health on College Campuses, echoed remarks from clinicians and campus leaders at schools large and small, prestigious and unheralded. West Virginia University has 26,000 students.

A paper in the April 23, 2003, Journal of the American Medical Association titled “Mounting Student Depression Taxing Campus Mental Health Services” cited several studies that confirm those anecdotal reports.

The paper reported on research at Kansas State University in Manhattan, Kan., showing that between the period from 1988 to 1992 and the period from 1996 to 2001, the proportion of students who came to its counseling center with depression increased from 21 percent to 41 percent.

Todd Sevig, Ph.D., director of the University of Michigan Counseling and Psychological Services, examined 1992 to 2002 utilization data from counseling centers at the 11 universities that make up the Big Ten Conference and found a 42 percent increase in the number of students seeking services. And Kirstine Girard, M.D., chief of mental health services at the Massachusetts Institute of Technology (MIT), reported that the proportion of students seeking counseling at MIT jumped from 8 percent to 12 percent between 1995 and 2000, according to JAMA.

Typically, services provided at campus health centers are paid for out of student tuition and fees and involve at most a small copayment at the time of a visit. Young people and their parents welcome the availability of mental health services at colleges, where they are regarded as attractions in a highly competitive market.

“In addition to providing for the well-being of the student, we feel availability of psychiatric services is vital to recruitment and retention of students,” Vanin told Psychiatric News. “It is no doubt very comforting for students and families to know that adequate, timely, and affordable psychiatric services are available, especially when a student with a major health problem is away from home.”

On at least some campuses around the country, the demand for college mental health services is being met, in part, by affiliated medical school residency programs that see a unique clinical and educational opportunity for psychiatric trainees. These programs offer elective or required service at campus health service clinics.

“I think it's a win-win on both sides, for the trainees and the university,” said Carol Bernstein, M.D., psychiatry residency director at New York University School of Medicine. “It's a great opportunity for residents and a tremendous service to undergraduates who need treatment.”

She is also associate professor of psychiatry and senior assistant dean for graduate medical education.

Bernstein told Psychiatric News that her program offers 10 third-year residents a four-hour-a-week elective to work in the counseling service at New York University's downtown campus. Trainees in their fourth year have the option of either four or eight hours a week for the entire academic year.

Residents provide initial screening and evaluation and brief treatment for undergraduates who are allowed 12 to 15 free visits. Students may also be referred to Bellevue Hospital or the New York University Behavioral Health Center; both of those facilities charge for treatment on a sliding scale.

Bernstein joins other residency training directors in saying that exposure to students in campus health clinics offers trainees an experience they are not likely to get in more traditional inpatient or outpatient mental health settings. Student-patients tend to be bright, verbal, and—apart from whatever mental health condition they may have—otherwise healthy.

When they are not already taking medication for a previously diagnosed disorder, they are usually presenting with the first episode of a mental illness, providing a unique opportunity to intervene at a crucial period in a young person's life.

“I think it is an extremely valuable experience,” said Hal Elliott, M.D., who is an attending psychiatrist at the Wake Forest University Student Health Center and the director of adult psychiatry inpatient services at Wake Forest University School of Medicine. “You have very intelligent, articulate patients who push you a lot more intellectually than other patients will. And trainees get to see new-onset psychiatric symptoms, since this is the age when people have a first episode of mania or a first psychotic break, or when their obsessive-compulsive disorder gets to be unmanageable.”

Elliott said the transition from home to college is for many students a first taste of adult responsibility, an experience that can be disorienting.“ As you ratchet up the academic intensity and decrease the structure, it brings out a lot of things,” he said. “At home a lot of kids have had their parents doing everything else so they can just study and go to school. Some of them, for instance, have never taken a script to a pharmacy before.”

And some students—like the A student who had 1400-plus SATs and performs poorly on midterms—may have skated through high school on the strength of their intellect, despite an undiagnosed attention deficit disorder.

“When they are somewhere that really requires them to read, they find they can't do it,” Elliott said. “You find out they are working six hours where someone else is working two.”

He told Psychiatric News that Wake Forest for many years had a program in which the primary psychiatrist at the university student health service was a resident who was supervised by faculty at the medical school, but not on site. Later, the university sought to have an attending psychiatrist from the medical school on site, a position for which Elliott volunteered.

“For three years I was there with the resident one day a week,” he said.

In response to the increasing demand for services, the university last year offered Elliott a half-time position at the student health service. At the same time, however, the residency position, for reasons related to funding, was eliminated.

Elliott hopes to revive the program. “In an era of tighter management of who private patients can see, this kind of program gives residents an opportunity to see a different population than they would otherwise see,” he said.

Paul Mohl, M.D., training director at the University of Texas Southwest, agreed. His third-year residents spend a half-day a week at health services on one of three separate University of Texas campuses.

“Like most medical schools, our primary patient population are indigent folks, so the educational advantage of these programs is that it gives our residents exposure to a younger age group,” he said.“ They are going to see patients who are having their first episode and who are somewhat more educated and upwardly mobile.

“It expands the range of patients they would be exposed to,” he said.

David Fassler, M.D., cochair of APA's Presidential Task Force on Mental Health on College Campuses, said the task force supports the concept.“ College counseling services are ideal settings for residency training,” he said. “They provide realworld experience in assessment, crisis intervention, consultation, and ongoing treatment. These rotations are most successful when the programs build in adequate time for supervision by senior psychiatric staff.”

Fassler is an APA trustee and professor of psychiatry at the University of Vermont College of Medicine. Also cochairing the task force is Rachel Glick, M.D., a clinical associate professor of psychiatry at the University of Michigan Health System.

Fassler said the task force is developing policy statements, job descriptions, and proposed staffing patterns to help schools assess the adequacy and appropriateness of their existing services.

“We are also exploring ways to enhance the funding available to support improved access to psychiatric care for college students,” he said. “In addition, we've established a list serve for psychiatrists who are working at or with colleges and college students.”

On the basis of testimony from clinicians and campus leaders, the need is significant.

“It's a myth that the students we are seeing are kids who just broke up with their girlfriend,” said Elliott. “That's not what it's about. What we are seeing are serious psychiatric disorders.”

Said Vanin, of West Virginia University, “We are seeing hundreds of students in our outpatient mental health clinic who would no doubt be unable to come to school or stay in school without the services our university mental health service provides.”

The JAMA report is posted at<http://jama.ama-assn.org/cgi/content/full/289/16/2055>. APA's Web site on college mental health can be accessed at<www.healthyminds.org/collegementalhealth.cfm>.▪