Campus Mental Health and Public Safety

Richard Kadison M.D.

Chief, Mental Health Service

Harvard University Health Service

Challenges

• Reduce Stigma, Manage Stress

• Coordination of care between health, counseling, residence, public safety, faculty, and administration

• Integrating Cultural Sensitivity into our work ( Police and Counseling= trouble)

Orientation for Students and Parents

• Should include counseling and public safety information

• Normalize Common Problems (help with alcohol, depression)

• Contact information and resources on Website

Mental Health Staffing Challenges

• Counselors need time to provide consultation, education, and outreach to other campus agencies. Staffing is a challenge on most campuses. How much care for whom?

• Coordination with student health, admin. Residence

• Insurance and support for prescriptions

Public Safety Challenges

• Marketing: Part of team to support students, not the enemy

• Fear of consequences, put into role of punitive parents

• Sorting out Bad Behavior from Mental Illness (Not unusual to have both)

• Consequences

WHY DO STUDENTS NOT SEEK HELP?

• 320/729 (56%) REPORTED NEEDING BUT NOT SEEKING HELP– 97 - negative expectations– 78 – too busy/no time– 63 – shame or stigma– 40 – bizarre structure– 16 – privacy concerns– 13 – appointment scheduling a hassle– 11- too long to get an appointment– 11- too depressed to seek help– 10- inaccessible hours

Herbstman C’07, Senior Thesis

Current Issues

• Integration of Academic Work with student health and development

• EVERYONE on campus is responsible for student well being.

• Coordination of care “Need to Know

• More coordination with campus safety

Current Issues

• Diverse Needs for diverse campuses (large vs. small, urban vs. rural, 1st. Generation students)

• Drunk: Can I trust the “Man”, Judicial vs. Counseling

• Managing High Risk Students with support and consequences

DON’T WORRY ALONE

• Response to 9/11 Setting alarm off

• Roommate of Drunk Student called HUPD to bring to Clinic

• Scared Dean calls Counseling after hostile email. Counseling calls HUPD

• Weird Behavior Crosses Boundary into disruption

Collaboration

• Meetings with Counseling, Public Safety, Residence and Administration to have dialogue about concerns

• Student altercation with female, assaulted campus police, arrested, required to withdraw. What is reentry process?

• Christmas involuntary hospitalization

Collaboration

• Mental Health vs. Judicial

• Consistent Policies: underage drinking, hazing, alleged sexual assault

• Campus alerts for Assault, Robbery, etc.

• Criminal behavior vs. Judiciary

• Courts decide first, then school

Sexual Assault

• Mandatory Reporting: Educate Staff about steps to be taken and information needed

• Campus safety part of residence training

• Evidence collection vs. taking action

• Female officers and clinicians for support

• Explanation of Legal Options

Learning from Each Other

• Beg, Borrow or Steal any good idea from other campuses

• Joint efforts across campuses for screenings, progress ( BHM 20, OQ45), suicide prevention ( JED foundation site), gatekeeper training, 1st. Gen and diversity

• Talk with peer institutions

Stress on Staying Healthy

• Eat, Sleep, Exercise

• Stay connected with friends/ community

• Provide tools to manage stress

• Educate community to reduce stigma thru education about common problems and how to recognize warning signs.

• Create multiple portals of entry to care

Staying Healthy

• Stressing Personal and professional Development

• Service Opportunities: Engaged Learning

• Health Education and Information (MRSA)

• Alcohol and Nutrition info: (BAL + BMI)

• Complementary Services: Acupuncture, Massage, Yoga, Mindfulness

Sleep Problems

• 35% of adult population experience insomnia (11% of college students get a “good night’s sleep”)

• Loss of cognitive functioning, driving

• Impairs immune system, Increased risk of depression

• < 7 hours yields sleep deprivation

Sleep Hygiene

• Great educational opportunity

• Dark Cool room

• No caffeine after 2 PM (soda also)

• Wind down 45 minutes prior to bed time (no bright LCD screen); melatonin

• If not sleeping, get out of bed until tired

• Exercise during the day

Student Participation/ Engagement

• Key for Successful Outreach

• Peer Counseling/ Education Programs

• Student Health Advisory Group

• DAPA; Drug/Alcohol Peer Advisers

• Mental Health Advocacy Group/Active Minds

• Involve in screenings and education

Multicultural Students

• Present emotional problems physically

• Metabolize medications differently

• May be more comfortable with Pastoral Resources: follow path of least resistance

• Vulnerability in language/cultural adjustment and symptom presentation

• Staff sensitivity to cultural beliefs

Diversity Considerations

• Create a culturally competent community• Learn and respect different values and

cultures• Celebrate the diversity of your community

by events that encourage sharing; art, music, and other traditions.

• Diversity may be via culture, race, ethnicity, sexual orientation, economics

First Generation/Diverse Students

Parents BA+ =82% H.S. 54% < 36%

• Finish College (BA) 68% vs. 24% parents with less than H.S. degree

• Challenges: new culture, isolation, financial challenges, pressure on job choice, continue to support family

Getting Care

• Multiple ways to access care• Chaplains, Advising system, residence

system• Information about resources and warning

signs for parents and families• Stress relieving events and workshops at

high stress times (massage, food, activities/ workshops)

Access to Care

• Triage system: Who needs to be seen today

• Inside vs. Outside Care

• Community Resources

• Hospital and Medical Leave, Reentry

• When should students go home? How to decide (Hunter/ GW)

• Teach Wellness: Eat, Sleep, Exercise

Retention

• 562 students asking for counseling followed over 2 year period

• 0 sessions 65% 1-12 79% >13 83%• Several studies followed people over 5 years all

showed dramatically higher retention rates, averaging more than 10% for students who used counseling services

Steve Wilson, Terry Mason, Evaluating the impact of receiving university based counseling services on student retention

Journal of Counseling Psychology 1997 vol 44. no 3 p. 316-320

Retention

• Social Isolation single most important determinent of dropout rates Pascarella and Terrazini,

1979

• Emotional- Social Adjustment items predicted attrition better than academic items Gerdes and Mallinckrodt 1994

• 5 year study of Berkeley students and those making use of counseling had higher graduation rates Frank and Kirk 1975

Youth Risk Survey 2006 13,600 HS students

• 28.3% sad or hopeless almost every day> 2 wks stopped some activity due to symptoms

• 19 percent of students reported that they seriously considered attempting suicide

• 14.8 percent had made a specific plan to attempt suicide.

• 8.8 percent had attempted suicide in the previous year .

College Data ACHA and Kansas State

• Depression Doubled, Suicidal Ideation Tripled, Sexual Assaults quadrupled over 13 years

• 45% students self report depression

• 10% report serious suicidal ideation and 44% binge drink

• These are the best years of your life

ACHA College Data

• 9% seriously consider suicide 1% attempt

• Depressed 52-42% 2000/2006

• No Sexual partners 40% vs. 5% perceived

• Medication for depression 36-42%

Graduate Students

• Often at higher risk, higher suicide rates

• Economically in worse shape, many have no insurance.

• Berkeley Graduate Student Mental Health Survey Dec. 2004 showed similar findings to undergrad surveys

Berkeley Grad School Survey

• 45.3% respondents experienced emotional or stress related problem SIGNIFICANTLY affected well being/ academic performance

• 9.9% seriously thought about suicide

• 52% considered using counseling less than 33% did use

• 25% unaware they were available

Healthcare 2007

• BIG changes in the last decade

• Severity of Problems of students making it to college

• Managed Care= Shorter Hospital Stays and more alternative treatments

• Reduced outpatient community resources

• Higher insurance costs for students

Impediments to Academic Success

• Stress 32.4%

• Cold/Flu 25.6%

• Sleep Problems 24.6%

• Depression 15.3%

• Internet Use/ Games 13.4% (3-6% of students addicted to internet pornography; 20% are women)

Helping Students Help Themselves

• In the Dormitory

• In the Classroom

• At Social Events

• Teaching Fishing, not Providing Fish

• Best of Intentions, but Sometimes…..

Medication

• Polarized attitudes of students and staff

• Antidepressants: benefits and risks (bipolar) and side effects

• Sleep Medications

• Anxiety Medications

• Stimulants: Newer preparations

• Role with disabilities and judicial issues

Medication

• Antidepressant and Stimulant Safety Controversy

• Reduction of 20% in prescribing since black box warning

• Most prescribed medications on college campuses: 12% of pharmacy budget for antidepressants

• Side Effects: Kiss of death

Common Problems

• Developmental Adjustment, Relationships

• Depression (SADs)

• Anxiety

• Eating Disorders

• Bipolar Disorder

• Acute Psychosis

• Substance Abuse

High Risk Issues

• Eating Disorders

• Dual diagnosis Substance Abuse/ depression

• Bipolar Illness and Psychosis

• Reentry from Hospitalization

Eating Disorders

• Anorexia, Bulimia, EDNOS

• 1% Anorexia, 3-5% Bulimia, 15-20% DE

• 5-15% mortality from anorexia

• 1/3 of people don’t improve from serious anorexia

Bipolar Disorder

• Onset often in college, sometimes triggered by antidepressant trial

• Get careful family history (strong genetic)

• Students reluctant to see it as problem

• Depressive symptoms can be intractable, complicated medication management (multiple drugs and side effects, lamictal)

Bipolar Disorder

• Symptoms: very labile moods, euphoria, no sleep, impulsive (spending, sex, travel, very impaired judgment)

• Grandiose ( academic work perfect, win Nobel prize)

• Paranoid, highly irritable, poor social judgment

Substance Abuse

• Binge Drinking- 5 or more drinks one sitting in past 2 weeks

• 44% meet criteria in national surveys

• 41% did something they regretted

• 31 % forgot what they did

• 9.7% unprotected sex

• 17% physically injured

Substance Abuse

• Don’t stigmatize medical services. Separate from Judicial

• BASICS: Motivational interviewing and education shows best results with reducing high risk drinking

• Consistent enforcement policies and consequences for students with identified AODS team on campus

Stimulant Abuse

• 900% increase in production of methylphenidate (Ritalin) 1990-2000

• 3-7% school age kids ADHD

• 50% carries over into college

• 16% use recreationally by mouth, snorting or by injection 30% share

Suicide

• Long Term Risk factors

• Prior attempts

• Feelings of hopelessness

• Suicidal plan, isolation, prior attempts

• 10% attempters die over 10 years

• 45 of 76 suicides occurred during first week post hospitalization

Lessons from Virginia Tech

• Students in distress often don’t seek or avoid care

• When students are mandated for “assessment”, there must be follow up and clear consequences

• When students return from hospital care, a careful internal review process is critical

Lessons from Virginia Tech

• Violence is very rare and difficult to predict (prior violence best predictor)

• There must be a community effort to reduce stigma, recognize risk factors, and find portals to care. Educate everyone

• Counseling and Health Services can and should provide consultation to the community (students, faculty and staff)

Lessons from Virginia Tech

• Schools must find ways to respect medical privacy, but coordinate concerns

• If students can’t expect privacy, they won’t seek care

• There must be communication, sometimes one way, between faculty, administration, public safety, family, counseling, when concerns arise about a student

• FERPA and HIPAA

Legal Issues

• Shin case settled but issues unresolved

• Virginia Tech: Refusal of care by student

• George Washington, Hunter College student dismissals

• Allegheny College Suicide

Legal Issues

• Handbook Language for Notification/LOA

• Medical Privacy Laws very strict

• FERPA (Family Education Rights and Privacy Act); HIPAA

• Prohibits disclosure of education records

• Permits disclosure gained through observation

• Permits disclosure of safety emergency

Leave of Absence and Return

• Students rarely want to take time off, but may need to

• When students return, important to review their readiness to be back at school internally

• Contracts and Riders

Contracts

• Very helpful to have expectations for return when leaving for psychological issues

• Contract should come from residence/administration with counseling input

• Contracts based on behavior, not diag.

Coordination of Care

• Handbook expectations: who gets notified about hospitalization/ return

• Identifying high-risk students• How is residence involved with worrisome

students?• Eating Disordered or Substance Abusing

students in residence, what happens?• Contracts: When to invoke them

Parents

• 70-80 % of students get their health information from their parents

• They often feel they are supposed to let go of students and need help staying engaged without being intrusive

• Help “helicopter parents” teach their students to fish and become “emerging adults”

Wellness Activities

• Engage Students in community- study breaks, hikes, encourage student groups

• Teach yoga, sleep hygiene, mindfulness, relaxation response

• Have annual “wellness or caring events” like this one or “maximize academic potential, minimize stress”

• Student Wellness Reps.

Coordinating Board

• All stakeholders: Students, Admin. Residence, Public Safety, Ministry, Health, Counseling, Disability

• Strategic, Realistic Planning• Community vs. Individual needs: Insurance• Community wide programs for education from

top down and bottom up; set priorities!

Web Information

• Online screenings: Mentalhealthscreening.org; ULifeline.org

• Information/education about alcohol

• Student made DVD to incoming students

• Information about resources

• Many good web resources (JED (Ulifeline), Mystudentbody.com, Alcohol.edu)

• Launching mentalhealth.edu

Summary

• Emotional and Physical Well-Being are crucial for Academic Success

• We all have to work together

• Focus on Staying Healthy and Learning Healthy Lifestyles: Eat, Sleep and Exercise