College Students: Mental Health Problems and Treatment Considerations
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Among college students, alcohol consumption is associated with motor vehicle accidents, another leading cause of death in this age group [ 41 ], accidental injuries, unsafe sex, sexual assaults, and poor classroom performance, as well as impairments in prefrontal cortex functions such as memory and attention [ 39404243 ].
Furthermore, many college students who are heavy drinkers continue to exhibit substance use-related problems after college [ 4445 ] and later develop an AUD [ 46 ].
Drug use disorders are less common, with approximately 1 in 20 students meeting the criteria 4. Marijuana use is very prevalent in this population. A study by Suerken et al. Furthermore, according to the most recent data from the National Survey on Drug Use and Health [ 36 ], approximately Cannabis use has been shown to negatively influence cognitive performance, memory, and achievement motivation, all of which can deleteriously impact educational achievement and lead to higher risk of school dropout, lower occupational attainment, and workforce failure [ 51 — 53 ].
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Among college students, binge drinking and cannabis use often co-occur. College students who drink heavily are approximately ten times more likely to use marijuana than those that are light drinkers [ 54 ]. Data from the National College Health Risk Behavior Survey shows that binge drinking students are nine times more likely to report lifetime use of marijuana than their non-binge drinking peers [ 55 ].
The increased risk for using illicit substances among binge drinkers has serious implications, given that alcohol use in combination with drug use is known to increase substance-related negative consequences [ 56 ], even when controlling for level of drinking [ 57 ].
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In addition to substance use and hazardous alcohol use, college students often engage in non-medical use or misuse of prescription medications, namely taking prescription medications without a prescription or taking more than prescribed. Although in the past 2 years, the rates of non-medical use of pain relievers among young adults have decreased, they continue to be high [ 58 ]. According to the National Survey on Drug Use and Health, approximately one in ten young adults reported non-medical use of pain relievers in the past year [ 59 ].
In a nationwide representative sample of 10, college students, McCabe et al. In a study by Garnier-Dykstra et al. They found that subjects endorsed friends as the most common source of prescription stimulants and the most common reason for use was to study [ 62 ]. Of concern is that over the past 20 years the rates of overdoses involving prescription drugs in the USA have reached epidemic proportions, with increased risk of overdosing for those using opioid analgesics or benzodiazepines and who have multiple prescriptions [ 63 ].
Nonmedical use of prescription medications often co-occur with heavy alcohol use [ 64 ], a worrisome occurrence given that alcohol taken in combination with analgesic opioids may further inhibit activity in the central nervous system, increasing the risk of oversedation, respiratory depression, and death.
Regrettably, college students do not appear to view prescription drug abuse as problematic [ 64 ]. Practitioners should communicate with college students about the ethical, medical, psychological, addictive, and legal issues of prescription drug abuse.
College students should be advised to take their medications as prescribed and not give or sell their medications to others. Safe storage of controlled substances such as benzodiazepines or stimulants is important. Implications of Age of Onset on Trajectory of Psychopathology When assessing college students, it is critical to determine the age of onset of current psychopathology.
Specifically, early age of onset of any mental health disorder is associated with poorer outcome and may be associated with a different presentation from that of later onset. For example, several studies have found that early-onset anxiety disorders are associated with greater severity and chronicity than adult-onset [ 65 ]. Childhood onset anxiety appears to increase the likelihood for the development of other subsequent psychiatric comorbidity [ 6667 ].
Early age of onset of obsessive-compulsive disorder is associated with more symptomatology [ 68 ], higher rates of comorbid tic disorders [ 69 ], and higher frequency of tic-like compulsions [ 70 ].
Multiple studies have shown that childhood onset mood disorders are linked to longer episode duration, a higher number of depressive episodes among women, increased suicidality and need for hospitalization, and increased risk for other co-occurring mental health problems in adulthood [ 71 — 73 ]. Similarly, an earlier onset of bipolar disorder is more problematic as it is associated with higher risk for co-occurring psychiatric and substance use disorders, less lithium responsiveness, more mixed presentations, and increased illness burden [ 74 — 79 ].
Likewise, studies suggest that the onset of schizophrenia before the age of 18 years may correspond to a more chronic form of the disorder [ 80 — 82 ] with studies reporting an overall lower psychosocial functioning and poorer long-term outcome related to early-onset schizophrenia [ 818384 ].
Finally, among college students, age of first alcohol use is associated with heavier use and worse alcohol-related problems [ 85 ].
In summary, mental health problems are prevalent in college students, with substance use, anxiety, and mood disorders being the most common. Traditional college students are in a transitional age, young adulthood, which is associated with numerous stressors and during which many mental health problems often first occur.
Non-traditional college students also face numerous stressors associated with having multiple roles, demands, and financial obligations. College students who have their first onset of mental illness or initiate substance use during childhood or adolescence appear to have a more pernicious trajectory and course of illness. Early identification of college students with mental health problems and thorough assessments are critical in order to provide adequate services and to ensure better outcomes, such as graduation.
Significance of Early Identification of Mental Health Problems and Outreach Strategies Among college students, mental health problems not only are common, but they often persist for several years. The rate of persistence differed among disorders.
Self-injury behavior and suicidal thoughts also persisted. For instance, in a study by Zivin et al. Other studies have also shown that the rates of treatment in college students are very low. A few reasons have been proposed for the low rates of help seeking in this population including fear of personal stigma, not perceiving treatment as urgent or essential, and lack of time [ 8889 ].
The Healthy Minds study also showed that more women receive treatment than men 39 vs. It is concerning that even when students receive treatment it appears that often it is inadequate. The early identification and treatment of psychopathology and substance use disorders impact the ultimate trajectory and sequelae of the disorder s.
With regard to bipolar disorder, it has been shown that the recurrence of episodes is associated with progressive loss of brain volume, that with the progression of the disease patients respond less to both pharmacotherapy and psychotherapy and that early intervention may be neuroprotective [ 90 ]. Similarly, the Treatment and Intervention in Psychosis TIPS project showed that early detection and delivery of standard treatment for psychosis including antipsychotic medication, individual psychosocial treatment, and psychoeducational multifamily groups had positive effects on long-term functional outcome [ 91 ].
Moreover, it was shown that the duration of untreated psychosis has long-term negative effects on the course of the illness [ 91 ]. The presence of psychiatric and substance use problems during college is associated with a wide range of negative outcomes from unemployment, serious social and educational impairment [ 469293 ], and obesity [ 94 ].
Together these studies underline the importance of prompt and adequate treatment of psychopathology to prevent neurocognitive and functional decline.
The problem of low treatment seeking in college students may be addressed by the use of technology. As noted previously, traditional as well as non-traditional students report that they do not seek help because of limited time or because they worry about what others may think [ 8795 ].
Technology-based programs for screening as well as for treatment would have the advantage of providing anonymity and could be available at any time and may be cost-effective. Several studies explored the use of Web-based surveys of depression and anxiety to screen for mood problems among college students [ 97 ].
They reported that such an approach increased the rate of help-seeking behavior among at-risk students. Our team at the Massachusetts General Hospital Depression Clinical and Research Program showed that the use of emails and social networking sites, such as Facebook, is feasible and cost-effective for reaching out to college students and for depression screening [ 99 ].
Taken together, these studies support using Web-based programs with college students as a strategy to enhance treatment seeking. Moreover, it may be advisable to offer computer-based treatments to students who may be afraid of stigma or have limited time. For example, numerous Internet-based cognitive-behavioral therapy approaches are available that have been found effective for treating a range of mental health problems [ — ].
Many students who present at college health centers have mental health problems [ ]. Thus, a collaborative relationship between university health centers and behavioral health services may lead to an increase in identification and referrals for behavioral health treatments of students with mental health problems. A collaborative relationship between university health centers and behavioral health services can be categorized in several ways [ ]. In the integrated model, medical and behavioral health services are delivered in an integrated manner as part of a team program.
In this model, the team members have a treatment plan that includes medical as well as behavioral aspects [ ]. Alternatively, medical and behavioral health services can be co-located, and services are coordinated as a result of medical and behavioral health staff sharing resources and being in the same location. Finally, when medical and behavioral health services are delivered at different locations, the services can be coordinated. In this model, information between health centers and behavioral health centers are exchanged in a formalized and established way [ ].
In the last two models, the clinicians delivering medical care and those delivering behavioral health services are not part of the same team. An important aspect of coordination of services is the use of electronic medical records EMRs.
Specifically, the adoption of the use of EMRs may be associated with better care for college students because its use may enhance communication between providers, coordination, measurement, and decision support [ ]. Treatment Considerations Upon completion of thorough evaluation, evidence-based practice EBP interventions should be employed for the treatment of this population.
Given that numerous resources are available outlining EBP for mental health problems, this commentary will not review them. The American Psychiatric Association APA provides evidence-based recommendations for the assessment and treatment of psychiatric disorders online http: Given that low adherence is a common problem among college students, providers may opt to enhance EBP with Motivational Interviewing MI [ ].
MI has been shown to enhance engagement and adherence to psychosocial as well pharmacological treatments , and thus, it could be useful to address these problems with college students. When treating college students, several issues ought to be considered related to the developmental stage as well as the context college students are in. Some considerations are relevant for the treatment of both traditional and non-traditional students and some are specific to each group.
When treating traditional students, it is important to consider that most of them are still dependent on their parents, thus parental involvement in treatment is advisable. Parents could be invited to attend some of the treatment meetings with their children to address problems involving them or to be enlisted as a support source to facilitate improvement.
When communicating with parents, it is important to educate them on what to expect during the early stages of symptom abatement and recovery, enhancing their ability to support the college student in coping with the cycles of both partial and full remissions and relapses over time.
Allowing feedback and providing access in a proactive, mutually agreeable manner will not only enhance safety, but also facilitate support and treatment of the college student.
Moreover, given the negative effect that parents' mental health problems have on children , providers may consider offering referrals for mental health services to the parents who may need them. Services can be offered to parents even if their offspring are not willing to engage in the treatment.
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For example, the Community Reinforcement and Family Training CRAFT has been shown to help parents facilitate seeking treatment of family members who are substance users [ ]. With regard to prevention interventions, Turrisi et al. While the involvement of the parents can be beneficial, given that most young adults in college are over 18 years of age, the patient's consent is required.
When conducting mental health evaluations of young adults in college, providers should routinely discuss the pros and cons of parental involvement and encourage it. Ideally, parents could be involved at a minimum as a resource for information and to ensure continuity of care. Thus, to ensure that these students receive adequate services, providers should have extended and flexible hours and even child care options.
These students may need additional and different types of services than traditional students such as case management to deal with financial, housing, relational, and child rearing issues. Moreover, to address their family needs, they may be more likely to need couple counseling or family therapy. One important issue to consider for all college students relates to the problem of continuity of care during school breaks.
Providers should ensure continuity of care by establishing services during school breaks or by identifying strategies for maintaining mental health during this period. Care for college students may occur in different ways, and college providers must examine each situation carefully to ensure continuity of care. Some students may have a primary provider where they reside with their parents, may be followed remotely, and may need intermittent support while in college. In this case, the college providers should communicate with the provider at home to be aware of whether the student may be at risk for safety and their needs.
Vice-versa, some students may have a primary provider at their college and may need a provider for either medication management or psychotherapy during breaks. In this scenario, the college's providers should ensure that the student will continue to receive adequate care while away. Not having insurance coverage may be a barrier to continuity of care. Nationals at 10 Jul 31, through Nov. The Boomer List Sept. Ethnic newspapers, radio, television and online publications helped millions of immigrants to America become part of their new country while preserving their ties to their native lands.
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