A Step Toward Comprehensive Mental Health Treatment for College Students

By Patricia Mathelier, MD, Brunhild Kring, MD, and the College Student Committee of the Group for the Advancement of Psychiatry

Alicia is an undergraduate college student repeating her first year. She attributed her poor academic performance in her freshman year to feeling overly anxious and stressed. Although her anxiety symptoms started in middle school, she had kept that a secret from her parents, who were preoccupied with caring for Alicia’s younger sister, who lives with autism. Alicia sought help at her school’s counseling clinic, where she was assigned to a third-year psychiatry resident, Dr. Smith.

Dr. Smith used the weekly sessions for an extended diagnostic assessment. These sessions included a family meeting with Alicia and her parents. There, it became evident that long-standing symptoms of anxiety and depression had contributed to Alicia’s adjustment problems during freshman year.

Her parents reported that Alicia struggled with completing academic assignments in middle and high school. They had to oversee her daily schedule to make sure she did her homework. Despite their best efforts and Alicia’s intellectual grasp of the material, she often submitted projects late.

Nevertheless, she was allowed to progress in high school without any repercussions despite obvious performance problems. While this accommodation was appreciated by Alicia and her family, it delayed defining a diagnostically accurate identification of the underlying problems.

Developmental Growth Challenges in College Students

It is often assumed that college students, because they are 18 years or older, are similar to other adults. On the contrary, these young adults face specific challenges unique to their age and developmental stage. They can benefit from working with mental health providers who have specific clinical training and discrete insights into their particular life challenges.

Some college students may live far away from their families while undergoing significant emotional developmental growth spurts before maturing into independent adults. In addition, they may subsist on tight budgets while having to study under competitive pressure for future jobs whose starting salaries will not be commensurate with their high level of student debt. Furthermore, young adulthood is a vulnerable time for the onset of major psychiatric disorders.

This is a challenging clinical trifecta.

Meeting the Increasing Mental Health Treatment Needs of College Students

In 2021, the US Surgeon General published an advisory on the youth mental health crisis. Because this generation of young adults, generally known as Gen Z , has an increasing demand for mental health support, educating early-career psychiatrists in the use of holistic bio-psycho-social treatment approaches is invaluable.

From a public health perspective, intervention in young adulthood can have a preventive effect. The emphasis on a social and emotional developmental perspective allows clinicians to adapt to the specific issues of each advancing student cohort. Taking the pulse of each new freshman class uncovers health trends before they become manifest in the population at large.

A Role for Psychiatric Residents

The training curriculum of psychiatric residents includes courses on developmental stages across the lifespan and clinical rotations in child and adolescent psychiatry, emergency psychiatry, and outpatient and inpatient services. An estimated 56% of psychiatry residency programs include rotations in university counseling services during their training. In these rotations, residents see students for weekly outpatient psychotherapy sessions. Such a training opportunity would be desirable for all residents.

In most universities, the primary modality offered to students who seek therapy is short-term psychotherapy, which is limited to 10-12 sessions. When students are informed that treatment is limited to no more than 12 sessions, some react with disbelief. How could so few sessions ever make a difference? Residents are also skeptical of the impact they can have in such a short amount of time. This sense of doubt echoes the sentiments of patients and clinicians unfamiliar with brief therapy techniques.

Yet, ultimately, students are an adaptable patient cohort. The insights gained can have a “eureka” or “aha” effect, enabling them to generalize what they learned in short-term therapy and apply it to other psychological dilemmas. In contrast to the supportive approach in advising, psychotherapy encourages students to become more efficacious and figure out how to help themselves.

Under Dr. Smith’s guidance, Alicia completed an in-depth psychiatric interview, including an Adult ADHD Self Report Scale and a Neuropsychological Testing off campus. These confirmed that she had co-morbid diagnoses of Generalized Anxiety Disorder and Attention Deficit Hyperactive Disorder, inattentive type with impaired executive function skills. Her depressive symptoms were found to be a result of her untreated academic performance problems.

Alicia’s treatment plan was modified and entailed pharmacological treatment with both an anxiolytic antidepressant and a stimulant medication. The focus of psychotherapy shifted to a cognitive behavioral approach, helping her to better cope with symptoms of poor self-confidence and guilt, and to improve her organizational skills. After these interventions, Alicia became more motivated and used her time more efficiently, resulting in improved academic performance.

Although the therapy sessions focused primarily on coping with anxiety and improving her academic performance, Alicia was able to apply the lessons she learned to other areas of her life. For instance, she gained deeper insight into what led to her poor self-esteem and lack of confidence in relationships with family and friends.

By the end of her psychotherapy, Alicia had become a productive student with new skills and increased psychological insight. Dr. Smith had learned to make every session count and to tackle a seemingly hopeless clinical problem, which could have resulted in a significant disruption of her education.

Recommendations

Creating formal rotations and adding early-career psychiatrists to the workforce of student health centers has tangible benefits for all stakeholders. Psychiatric residents are equipped to provide integrated treatment with behavioral and pharmacological interventions.

However, psychiatric residents are salaried physicians. Consequently, university-based counseling centers and nearby residency training programs need to establish inter-institutional agreements to bring these rotations in college mental health into play.

The American Psychiatric Association, the Association of College Psychiatry, and the American Association of Directors of Psychiatric Residency Training are the organizations tasked with promoting excellence in psychiatric training in order to meet the nation’s mental healthcare needs. Ideally, there should be a national mandate for training a psychiatric college mental health workforce.

For example, the Accreditation Council for Graduate Medical Education (ACGME) which oversees residency curriculum requirements, could require graduating psychiatrists to have a competency in college mental health treatment. While student wellness is a shared responsibility of all stakeholders, ultimately universities are responsible for the well-being of their students.

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