College Students Under Stress

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CLINICAL HIGHLIGHTS

Providing psychiatric care for college students is different from treating other grown-ups. These emerging adults are in the midst of a tremendous emotional growth spurt and a leap of neurocognitive maturation. During this bewildering life transition, they often cannot articulate straightforwardly what bothers them. They appear mercurial: at times, they may speak in hyperbole and sound very dramatic. At other times, they shroud what ails them in secrecy because of embarrassment, fear, and hopelessness. Eventually, school stress and academic performance problems propel students to seek assistance. Mental health clinicians attending to this population need to keep an open mind and consider a host of differential diagnoses.

Case Vignette

"Jerry" is a 19-year-old sophomore at a liberal arts college in the Northeast who wants to transfer to a prestigious business school. Two months into the fall semester and 1 week before midterms, Jerry reluctantly comes to the counseling service of his college. His dean accompanies him after receiving several alerts from professors about flagging academic performance.

Jerry unenthusiastically agrees to meet with a psychiatrist. He appears tired and says that he feels unmotivated. He is upset with his parents. As an only child, he feels pressured to succeed in business, but is hopeless about ever measuring up to their ambitions for him. He admits to relying on alcohol and marijuana daily for sleep initiation and anxiety management. When asked what would be most helpful to him, Jerry seems surprised by the question: “Everyone tells me that I have an attention problem; my roommate gave me Adderall, and it worked!”

The psychiatric conditions most frequently observed among college students are anxiety, depression, ADHD, substance abuse, and bipolar disorder. Eating disorders carry a high risk for medical comorbidity. Stress and anxiety may worsen during exam periods. Moreover, most psychiatric disorders have their onset during late adolescence and young adulthood. Students in crisis may present with suicidality or psychotic symptoms. Excessive use of alcohol and marijuana pose further health hazards.

When they hit a roadblock with their academic work students like Jerry, who initially reach out to the counseling service for urgent help, often request anxiolytic or stimulant medications for immediate relief. Emboldened by societal opinion and the stubbornly persistent urban myth that stimulants are “smart drugs,” students expect our assistance with cognitive enhancement to prevail in competitive contexts.

Studies estimate that about half of cases with childhood onset of ADHD persist into adulthood.1 However, because of the well-known rates of diversion and abuse, psychiatrists in college health services are wary of prescribing stimulants without a thorough diagnostic work-up.2 An in-depth psychiatric interview, screening with the Adult ADHD Self-Report Scale, and a referral for neuropsychological testing are recommended by a fair number of counseling services before any prescriptions for stimulants are issued. Ideally, the psychiatric work-up should include a basic medical exam, EKG, and routine lab testing. Students are also made aware of the university’s academic support resources.

Students who have come to rely on alcohol and marijuana during adolescence for alleviating anxiety, depression, self-esteem issues, camouflaging inter-personal conflict, and for fun are loath to give this up. They feel culturally emboldened to take advantage of the “medicinal” effects of the various marijuana strains. “I only smoke Blue Dreams,” Jerry announces, referring to a variety of marijuana high in cannabidiol content with purported anxiolytic properties.

How best to treat comorbid mood, anxiety, and substance use disorders has been the subject of a longstanding debate. A review of recent evidence-based studies recommends the integrated treatment of co-occurring mood and substance use disorders to achieve a superior outcome.3 The FDA has approved medications to address alcohol, opiate, and nicotine dependence, but the treatment for excessive marijuana use consists of psychosocial interventions.

Yet, psychiatrists should keep in mind that academic performance problems are a multifactorial phenomenon. They may be related to poor study habits, or academic under-preparedness. This can create a loss of confidence and narcissistic injury among competitive peers or result in oppositional behavior towards authority figures. There can be a lack of motivation because the student’s major was not his or her first choice. Students may be disappointed about not being accepted by their dream school and therefore not apply themselves.

Undergraduate students, in particular, face the difficult task of being away from home and adjusting to life on their own. Despite frequent electronic communication with parents and friends, they may be suffering from homesickness. Maintaining good self-care is surprisingly difficult to achieve. Sometimes the success or failure of the semester is in question because the student fails to establish a predictable sleep/wake cycle and get to class on time. Chronic sleep deprivation is a major contributor to lack of concentration and focus. Without the infrastructure their families provided, students need to learn to eat 3 nutritious meals a day rather than rely on unhealthy snacks. Similarly, in times of stress, it is a challenge to achieve a reasonable work/life balance and have time for leisure activities such as socialization with peers or exercise. Relationship difficulties and romantic disappointments loom large.

Back to Jerry, a fictionalized, albeit typical case. In the initial visit, the psychiatrist explores the nature of the concerns in a non-judgmental fashion, forms rapport with the student, and gains an understanding of his level of psychological maturity and ability to collaborate in making decisions about health care. Creating a shared language about what the basic issues are builds the foundation for a working alliance.

After meeting with the psychiatrist for several sessions, Jerry acknowledges his passion for creative writing. With encouragement, Jerry opens up to his parents. To his surprise, they respond supportively. His anxiety ebbs and he decreases his daily marijuana and alcohol consumption. He is discouraged from using his roommate’s Adderall. He agrees to a referral for CBT for anxiety and insomnia. Jerry’s parents are quite willing to participate in family sessions by conference call. The psychiatrist decides that treatment with medication does not seem necessary for now.

Dr. Kring is Associate Director, Psychiatry Services, Counseling and Wellness Services, New York University, NY.

Acknowledgement-Dr. Kring acknowledges the contribution of the GAP Student Committee: Helene Keable, MD, Alexandra Ackerman MD, Malkah Notman, MD, and David Stern, MD.

References:

1. Faraone S, Biederman J, Spencer R, et al. Attention-deficit/hyperactivity disorder in adults: an overview. Biol Psychiatry. 2000 48:9-20.

2. Prosek E, Giordano AL, Turner KD, et al. Prevalence and correlates of stimulant medication misuse among the collegiate population. J College Student Psychother. 2017. https://www.tandfonline.com/doi/abs/10.1080/87568225.2017.1313691. Accessed February 24, 2018.

3. Pettinati HM, O’Brien CP, Dundon. Current status of co-occurring mood and substance use disorders: a new therapeutic target. Am J Psychiatry. 2013;170:23-30.