Academic journal article Current Psychiatry

College Mental Health: How to Provide Care for Students in Need: Successful Practice Relies on Understanding the Unique Vicissitudes of Student Life

Academic journal article Current Psychiatry

College Mental Health: How to Provide Care for Students in Need: Successful Practice Relies on Understanding the Unique Vicissitudes of Student Life

Article excerpt

Each year thousands of college students seek treatment at their school's mental health service, but few psychiatrists are delivering this care. Most of the 4,500 degree-granting institutions of higher education (IHEs) in the United States (1) provide some type of psychological or mental health counseling support to their students, and approximately 10% of the student body seeks care annually. (2) In 2010, nearly 24% of students who visited their college counseling service were taking psychiatric medications at the time of their visit, up from 9% in 1994. (2)

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Nevertheless, for various historical and practical reasons, psychiatrists have played--and continue to play -- a somewhat peripheral role in college mental health systems. Although interest in psychiatric care at IHEs has been increasing (Box I), (3) until recently, most college counseling services had no direct access to psychiatric services and currently <1% of college services are directed by psychiatrists. (2)

This article examines some of the unique challenges faced by psychiatrists who work in a college mental health service, including how this setting may affect assessment, medication management, and crisis counseling. I use the terms "counseling services" and "mental health services" interchangeably because schools differ in the name they use for this office.

Managing medications and crises

Most college mental health services are directed by psychologists because of how IHEs historically structured these services (Box 2, page 24). (4) Although counseling center staffing generally includes relatively few psychiatrists, those who do serve in this setting typically serve 2 primary roles: medication managers and crisis clinicians.

Medication management. Counseling centers are seeing more students who are either already taking psychotropics or need assessment and medication management. In the United States, 14% of students seen at college counseling centers are referred for psychiatric evaluation; however, on average, schools provide 2 hours of psychiatric services per week for every 1,000 students. (2)

Managing medications for college students poses several challenges. For most students, interaction with their college's health and/or mental health system may be the first time they receive care not under the direct oversight of their family. Families and their feelings about psychiatric medication can play a major role in planning, executing, and managing psychiatric care, even for students who are legal adults. Family attitudes toward psychiatry and patients' fears of disappointing parents who may feel distraught because their child has a psychiatric illness may impact a young person's decision to accept medication or comply with treatment. Students often are insured by their family, and parents might receive an Explanation of Benefits and will learn of the student's pharmacotherapy even if the student does not want them to know. College psychiatrists and students always need to consider decisions about how and when to include parents in discussions about medications.

College psychiatrists also must be sensitive to the unique vicissitudes of the school calendar and the developmental trajectory of college life. Decisions about when to start a medication or even which medication to prescribe might depend on how close a students is to exams or summer break. For example, a student experiencing severe anxiety a week before exams probably is better treated with a short-term benzodiazepine prescribed on an as-needed basis than a selective serotonin reuptake inhibitor, which in the first few weeks might only disrupt the student's ability to function academically and not improve symptoms. (5)

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. …

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