College Students and Mental Illness: Strategies for Optimal Results

The number of college students who are struggling with mental health issues continues to rise. On the front lines are the university and college counseling and health centers that are facing amplified demands for psychiatric treatment. In addition to the surge of identified psychiatric diagnoses on campus, 94% of college counseling center directors report a substantial increase in students seeking treatment for more severe psychological problems. Unfortunately, only 60% of colleges and universities have a psychiatrist on staff at their health or counseling centers.

Most psychopathology is of mild to moderate severity and can be treated at the college counseling center or by outpatient community providers. However, students with more severe symptoms-including suicidal or homicidal ideation and intent and/or active psychoses-may require more intensive treatment, including inpatient hospitalization. Currently, suicide is the second leading cause of death among college students.¹ An alarming 8% of college students contemplate suicide at least once within a year, and 1% to 2% attempt suicide.² Perhaps it is in response to this increase in acuity of psychiatric symptomatology that psychiatric hospitalization rates for college students have tripled since 1994.³

The challenges

While university and college counseling centers face growing demands for psychiatric services-including hospitalization-inadequate protocols and poor communication between psychiatric hospitals and institutions of higher education can compromise the quality and continuity of care that students need. Concerns include whether the student has adequate insurance to cover the cost of services, traumatic transport to the hospital with the presence of police and peers, students returning to the college counseling center with no communication between the hospital and the college, premature discharges, and lack of understanding by hospital staff of the unique challenges that exist in a college environment.

[[{"type":"media","view_mode":"media_crop","fid":"48870","attributes":{"alt":"©wrangler/shutterstock.com","class":"media-image media-image-right","id":"media_crop_9283973220159","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5863","media_crop_rotate":"0","media_crop_scale_h":"235","media_crop_scale_w":"100","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"©wrangler/shutterstock.com","typeof":"foaf:Image"}}]]When a student is identified as needing an evaluation for inpatient hospitalization, often the first issue that arises is whether the student has insurance, and if so, what services are covered. Insurance coverage varies widely, and not all students have the coverage they need for hospitalization, which significantly limits their access to services.

When a student needs hospitalization, he or she is frequently transported by ambulance with police presence, which often occurs in front of peers. Embarrassed and often traumatized by this highly visible process, students arrive in an emergency department (ED) that can be filled with patients with serious mental illness. These experiences can leave students frightened and overwhelmed and cause them to retract complaints of suicidal thoughts and plans, which can result in their premature discharge. Not surprisingly, many of these same students return to the ED within a short time following a suicide attempt. When students are admitted, it is often to general psychiatric units with mixed-age patients who have diverse diagnoses; these patients can be perceived as threatening and intimidating. As a result, students feel disconnected and isolate themselves on the unit.

Parents of these young adults often find themselves grappling with the heartbreaking first episode of a serious mental illness in their child, while simultaneously having to navigate their way through the university’s bureaucracy regarding tuition reimbursement, their student’s academic status, and the uncertainty of whether their son or daughter will be allowed to return to school.

Moreover, because of the paucity of communication between the hospital and the university, students are often discharged from the hospital without knowledge of their standing in school or how to negotiate the re-entry process. This adds enormous stress to the complexity of their clinical situation. While both the hospital and university have the students’ best interest at heart, the end result is often suboptimal.

The Behavioral Health College Partnership

In 2009, in response to the growing number of students presenting with psychiatric illnesses on college/university campuses, Northwell Health (formerly the North Shore-LIJ Health System) created the Behavioral Health College Partnership (BHCP) at Zucker Hillside Hospital in Queens, NY. BHCP is a community program that works closely with 45 affiliated colleges and universities and their student counseling centers to address acute behavioral health issues that affect undergraduate and graduate students. The key elements of the program address the challenges outlined above by coordinating psychiatric transportation, specialized emergency evaluations, and offering a young adult inpatient unit and outpatient services that are tailored to the college population.

Insurance. Many schools offer insurance that provides coverage tailored to the needs of students. With the rising cost of tuition, families are mindful of cost and may be reluctant to purchase the student plan if the student is covered by a parent’s plan. While some plans provide comprehensive coverage regardless of where the student resides, others limit coverage to emergency department care when the student is out of state. In such cases, students may have to return home to receive the care they need, which can compromise the continuity and collaboration of care with the college. BHCP, Zucker Hillside Hospital, and Northwell Health work closely with students, their parents, and their insurance companies to consistently be able to serve partner schools’ students in need.

Psychiatric emergency transport. In considering transportation to the hospital, it is important to do so in a manner that respects the student’s privacy. Taking this into consideration, BHPC has partnered with Northwell Health Center for Emergency Medical Services to develop a transportation arrangement with colleges that allows for the transport of students to the hospital without police involvement and avoids any public display. Predetermined quiet locations for student pick-up have been established at each college/university to protect the privacy of students and minimize psychological trauma. It is important to note that this transportation protocol is only initiated when the student is not violent and not in need of immediate medical attention.

Emergency assessment and disposition. BHCP emergency assessment protocol consists of established systems of communicating with school personnel that allows the school to provide information to the ED’s attending psychiatrist regarding mental health history, current behavior that has led to the need for an emergency assessment, and expressed suicidality and/or homicidality. ED and hospital staff are trained to weigh this information alongside their direct evaluation of the student and inform the school referent of the disposition.

Psychiatric hospitalization. Once admitted to the BHCP young adult/college unit, the student is surrounded by fellow college-age patients who are often struggling with similar mental health issues. Students report that the homogeneity of the unit is comforting and normalizing. The unit has established special clinical programming to address and destigmatize the most common diagnoses of MDD with comorbid borderline personality disorder, bipolar disorder, and psychotic disorders.

Group and individual treatment focuses on common concerns of college students, including how to navigate conversations with peers and school personnel regarding school absence, the importance of healthy lifestyle choices, psychoeducation on the importance of sleep and circadian rhythms, eating habits, substance use, post-hospitalization treatment compliance, distress tolerance, and emotional regulation skills. With the student’s permission, parents are encouraged to engage in parent groups that provide psychoeducation regarding the prevalence of mental illness in the college population, diagnoses, how parents can best support their child post-hospitalization, and the importance of outpatient and medication treatment compliance.

Collaborative care and discharge planning. Whether the student is evaluated and released from the hospital ED or admitted to an inpatient unit, it is essential for the hospital to notify the college and discuss the recommended treatment plan prior to the student’s discharge. BHCP harnesses the talents and best intentions of both the college and the psychiatric hospital by providing formal mechanisms and protocols that allow communication to seamlessly flow between the hospital and the college for the benefit of students.

Preexisting relationships between BHCP and school personnel, knowledge of individual school policies, and predetermined mutually agreed-on protocols allow BHCP liaison coordinators to communicate quickly with the schools on behalf of students regarding academic issues. These coordinators can inform professors of a student’s medical absence, help activate class withdrawals, and discuss longer medical leaves and/or academic accommodations that might be needed upon the student’s return to school.

With student approval, a comprehensive aftercare treatment plan is put in place, which takes into consideration the unique needs of the returning student. These procedures reassure and eliminate uncertainty about academic standing and allow students and their families to focus on health and healing.

Finally, when a student is returning to campus after a psychiatric hospitalization and his post-discharge treatment is with a community provider, it is important to ensure that at-risk students are complying with the treatment agreement and keeping appointments. To avoid having students fall through the cracks, some type of monitoring system is needed.

When putting a monitoring system in place, transparency is key. Reassure the student that the therapy between the student and clinician is confidential and the content of sessions will not be shared. Rather, the counseling center will only be informed if the student is not keeping appointments as agreed upon or if there is an emergency (eg, student is hospitalized). Before signing a release authorizing the communication between the counseling center and the community provider, it is important for the student to review the documentation packet that will be shared between the counseling center and the community provider, outlining the treatment agreement and the tracking process. The delicate balance between the student’s right to privacy and the need for safety is recognized by BHCP protocol, which specifies that outpatient monitoring is on a case-by-case basis in collaboration with the school and the student.

Conclusion

Developing partnerships and establishing clear protocols/agreements with area hospitals and community providers help provide the best array of care for students and help prevent at-risk students from falling through the cracks. Given the increasing numbers of students who require this higher level of care, it is essential that we examine existing policies, systems, and protocols to ensure that students are getting the care they need in the best way possible.

Disclosures:

Dr Roy is Clinical Associate Professor in the department of psychiatry at the Yale School of Medicine in New Haven, CT, and Clinical Director of the Jed Foundation in New York, NY. Dr Braider is Director of the Northwell Health Behavioral Health College Partnership in Glen Oaks, NY, and Assistant Professor of Psychiatry at the Hofstra Northwell School of Medicine in Hempstead, NY. The authors report no conflicts of interest concerning the subject matter of this article.

References:

1. Gallagher RP. National Survey of Counseling Center Directors; 2014. http://www.collegecounseling.org/wp-content/uploads/NCCCS2014_v2.pdf. Accessed January 13, 2016.

2. Centers for Disease Control and Prevention. National Suicide Statistics. http://www.cdc.gov/violenceprevention/suicide/statistics; 2015. Accessed January 13, 2016.

3. American College Health Association. National College Health Assessment II: Reference Group Executive Summary Spring 2014. http://www.acha-ncha.org/docs/ACHA-NCHA-II_ReferenceGroup_ExecutiveSummary_Spring2014.pdf. Accessed January 13, 2016.