College Psychiatry: Strategies to Improve Access to Mental Health (Psychiatry Update, 1) 3030694674, 9783030694678

Table of contents :
Foreword
Preface
References
Contents
Contributors
1: National Trends in College Mental Health
Introduction/Scope of the Problem
Epidemiology
Subsections
Strategies for Improving Services
Other Considerations
Conclusion
References
2: Systems and Models of Psychiatric Care for College Students
Introduction
Epidemiology
Systems of Care
Student Demographics
Geography
Institutional Size and Setting
Affiliation with an Academic or Community Medical Center
Budget and Funding Models
Organizational Structure
Models of Care
Who
What
When
Where
How
Ways to Improve
Conclusion
Key Points
Glossary
References
Resources
3: The Parent Factor: Collaborating with Parents to Promote Mental Health Treatment
Introduction: The Power of Parent Involvement and Collaboration
The Best Times to Collaborate with Parents: Guidelines and Case Examples
What Parents Can Provide
Developmental History and Family History Necessary for Diagnosis and Treatment
Additional Support When a Student Is in Distress
Safety Management with a High-Risk Patient Who Misses an Appointment
Shared Decision-Making
Problem-Solving for Insurance Challenges
Help During National Emergencies: The COVID-19 Pandemic and the Use of Telepsychiatry
What College Psychiatric Providers Can Offer Parents
Epidemiology: Studies Showing Benefits of Parent Involvement and Social Support
When Students Don’t Want to Involve Parents: Legal Aspects of the Parent-Student-Institution Relationship in College Mental Health
The Evolution of Federal Privacy Laws Concerning Education Records
The Privacy of Mental Health Treatment Records: FERPA, HIPAA, and State Laws
State Courts Give Greater Responsibility to Universities to Prevent Suicide
Ways to Improve
Conclusion
Key Points for Psychiatrists and Other Psychiatric Providers Working with College Students
Appendix
Glossary
References
Resources
Family Support Groups
Online Resources
Books
4: No Wrong Door: Improving Access Through Collaboration
Introduction
Epidemiology: Symptom Severity and Utilization Rates on University and College Campuses
The Shifting Student Demographics
Integrated and Collaborative Healthcare Models
The Behavioral Health Consultation Model
The Impact of BHC on Primary Care Physician, Psychiatrists, and Counseling Center
Managing Utilization of Psychiatry Services
Managing Utilization of Primary Care Services
Managing Utilization of University and College Counseling Center Services
Implementing the Behavioral Health Consultation at Florida State University: Practical Approach and Lessons Learned
Conclusion
Appendix
Glossary
References
Resources
Below are a few resources for integrated care concepts and models:
Two guides listed in the references are particularly helpful:
5: Working with LGBTQ Students
Introduction
Minority Identities and Disparate Health Outcomes
Intersectionality
Spectrum of Sexual Orientation and Gender Identity
Affirming Mental Health Services
Gender Dysphoria
Working with Transgender and Nonbinary Students
Gender Pronouns
Transitioning
Transfeminine Hormonal Therapies and Affirming Surgeries
Transmasculine Therapies and Affirmative Surgeries
Advocacy
Forming an LGBTQ-Affirming Practice, Center, and Campus
Going Forward
References
Resources
6: Mental Health Considerations for Black, Indigenous, and People of Color: Trends, Barriers, and Recommendations for Collegiate Mental Health
Introduction
Undergraduate Students’ Mental Health Needs
The Impact of Racism
Stigma and Barriers to Seeking Care
Mental Health Considerations in Specific BIPOC Populations
Black Student Population
Asian and Asian American Student Population
Latinx Student Population
Indigenous/Native American/Alaskan Native Student Population
Intersectionality
Improving Access to Care for BIPOC Students: Culturally Competent Care
Outreach Efforts
Key Points and Considerations for College Mental Health Clinicians
Conclusion
Glossary
References
Resources
7: Taking Care of Our Own: Shoring Up Resilience and Preventing Suicide in Mental Health Professionals
Introduction
Suicide Rates in the United States
Suicide Risk Factors
Health Factors
Historical Factors
Social and Environmental Factors
Conceptual Framework for Wellness
Internal Structure and Characteristics of the Coping Reservoir
Depleting Factors (Negative Inputs)
Replenishing Factors (Positive Inputs)
The Nature of the Coping Reservoir
How to Keep the Reservoir Full (Enough)
Addressing Workplace Culture
Identify and Assist Persons at Risk
Increase Help-Seeking
Access to Mental Health Resources and Treatment Services
Enhancing Self-Care and Resilience
Conclusion
References
8: Navigating a Leave of Absence
Introduction
When to Consider a Leave of Absence
Voluntary Versus Involuntary
Common Student Concerns
Recommendations for University Leave of Absence Procedures
What to Do During a Leave: Advising Students and Parents
Planning for Return to School
Assessing upon Return and Making Recommendations to Students
Conclusion
Appendix
Glossary
References
Resources
Support Groups
Online Resources
Book
9: Threat Assessment on College Campuses
Introduction
Background and Trends
Perpetrator Thinking and Behaviors on the Pathway to Violence
Prevention and Best Practices
Steps in Case Assessment and Management
Ways to Improve
Conclusion
Key Points
References
10: Preventing Suicide and Promoting Mental Health Among College Students: The Jed Foundation
Introduction
The Comprehensive Approach to Suicide Prevention and Mental Health Promotion
JED Campus (https://www.jedcampus.org/)
Current Status
Results
Future Plans
References
11: Telemental Health and Telepsychiatry in the College Setting
Introduction/Scope of the Problem
Epidemiology
Definitions
Brief Historical Summary
The Effectiveness of Telemental Health Services
Risks and Limitations of Telemental Health
Guidelines for Telemental Health in the University Setting
Legal Considerations
The Cost of Offering Telehealth in the University Setting
Ways to Improve/Future Considerations
Conclusion
Key Points
Appendix
Glossary
References
Resources
Correction to: Taking Care of Our Own: Shoring Up Resilience and Preventing Suicide in Mental Health Professionals
Correction to: Chapter 7 in: M. B. Riba, M. Menon (eds.), College Psychiatry, Psychiatry Update 1 https://doi.org/10.1007/978-3-030-69468-5_7
Index

Citation preview

Psychiatry Update 1 Series Editor: Michelle B. Riba

Michelle B. Riba Meera Menon Editors

College Psychiatry Strategies to Improve Access to Mental Health

Psychiatry Update 1 Series Editor Michelle B. Riba University of Michigan, Department of Psychiatry, University of Michigan Eisenberg Family Depression Center Ann Arbor, MI, USA

Psychiatry Update 1 will encompass all areas of psychiatry research and clinical diagnosis and treatment. Chapters will publish randomly though out the year culminating in volumes throughout the year. More information about this series at http://www.springer.com/series/16222

Michelle B. Riba  •  Meera Menon Editors

College Psychiatry Strategies to Improve Access to Mental Health

Editors Michelle B. Riba University of Michigan, Department of Psychiatry, University of Michigan Eisenberg Family Depression Center Ann Arbor, MI USA

Meera Menon Counseling and Consultation Service The Ohio State University Columbus, OH USA

ISSN 2524-8316     ISSN 2524-8324 (electronic) Psychiatry Update 1 ISBN 978-3-030-69467-8    ISBN 978-3-030-69468-5 (eBook) https://doi.org/10.1007/978-3-030-69468-5 © Springer Nature Switzerland AG 2021, corrected publication 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

Improving mental wellness on college campuses has proven to be a formidable challenge. This book describes creative steps to help win the battle. Its eminent authors provide ideas of value for college administrators, parents, and healthcare providers, and for various reasons, this is especially timely. After defining the scope of the problem and the need for a strategy shift, please permit me to justify the designation of “timely.” Mental health challenges for college campuses almost seem to be “built in.” A first reason is that the ages 15–24 are the most common ages for onset of most major depression, bipolar illnesses, anxieties, sleep disturbances, most substance misuse, PTSD, and suicidal ideation, and these ages coincide with entry into college. Second, stressors produce well-established accentuations for psychiatric illnesses and starting college is indisputably stressful. Third, access to treatment is a horrendous hurdle for everyone in the USA, sometimes even more so for college students. While campus resources for mental health are relatively scarce, demand is relatively high and rapidly growing as stigma is being overcome and more students seek treatments. As a result, appointments are often delayed even when crises call for imminent intervention. Fourth, meaningful numbers, perhaps 15% or more, of students arrive at college after having started mental health treatment at home, arriving with medications in hand but having left their clinicians behind. They then encounter uncertainty about how or where to obtain continuation treatment, and in the shuffle, many discontinue treatment and experience the consequences. For these and other reasons, prevalence rates of psychiatric diagnoses among college students remain high. They actually may be trickling upward. New models are needed. This book provides both new and deliverable models. That is a major reason for calling it timely. The authors convey an array of new strategies for implementation. It is notable that collaboration appears crucial to almost all of them. As examples, campus programs need collaborative approaches that make parents allies rather than intermittent opponents. Equally important, collaboration among providers on campuses is essential. When students seek treatment, we know that a common message is “you need to see someone else at … (fill in the blank for a different clinic or program). A bold, new approach described in this book is that “There should be no wrong door!” To achieve this aim, revamping divergent college venues so they are innately collaborative will be necessary. A word of preparation is that the adoption of “no wrong door” may require better v

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information-sharing technologies across divergent campus programs and the force and backing of university leaders such as presidents or provosts. The rewards may be life-saving for some students. Such programs should be a priority for all campuses. “Timeliness” for this book is fueled by accelerating social shifts in this country. Campuses need to develop dedicated programs for students of color and LGBTQ students. Constructive suggestions are provided. Further justifying timeliness, this book is arriving in the midst of the COVID-19 pandemic. Emergency rooms are impacted, health professionals are stressed, people feel isolated, media coverage seems endless, students often are in lockdown, and healthcare delivery struggles receive endless attention. Relevant to mental health problems, numerous experts characterize the situation as really being a “dual pandemic,” the viral one being accompanied by the mental health one. We must grab the moment to advocate for and implement enhanced mental health programs and resources to address that part of the dual pandemic while resisting the temptation to just do “more of the same.” It is time to be creative. For example, the pandemic has catalyzed the importance and power of telemental health and telepsychiatry. While these delivery approaches are most often described for rural areas, aged patients, or those with transportation difficulties, for an array of reasons, they could and already are playing pivotal roles for mental health delivery in some college settings. It is time for expansion. A closing major reason for prioritizing collaborative strategies from this book is that there may be growing numbers of powerful partners. Foundations such as The Jed Foundation and the American Foundation for Suicide Prevention continue to guide our way; campus collaborations should be forged with them. The National Network of Depression Centers, housed in 26 universities throughout the country, provide sources of excellence for campuses and students struggling with treatment problems. The University of Michigan’s Depression on College Campuses, a fertile venue for exchange of creative ideas, is now in its twentieth year. The National Academies of Sciences, Engineering and Medicine recently held a conference to address wellness on campus settings. They constitute powerful voices. And there are others. It is time to partner. So, the time to mobilize is now. I would hope that as we do so, we incorporate strategies to rigorously evaluate outcomes. Then, I look forward to an updated version of this book 5 years from now. John F. Greden, MD Rachel Upjohn Professor Emeritus of Psychiatry and Clinical Neurosciences, Founding Director, University of Michigan Depression Center, Founding Chair, National Network of Depression Centers (NNDC), Chair Emeritus, University of Michigan, Department of Psychiatry, Ann Arbor, MI, USA

Preface

In 2007, my daughters, Alissa and Erica, and I wrote an article on work–life balance [1]. Thirteen years later, we report that college mental health has been a major focus in our professional careers and we continue to try to juggle and balance. Since 1993, I (MBR) have been on the faculty at the University of Michigan in Ann Arbor, Michigan. As one of the great college towns in the United States, Ann Arbor hosts exciting and interesting opportunities  – musical theatre, dance, art, architecture, athletics, and a superb healthcare system. The University of Michigan also educates large groups of undergraduates and graduate students, and students and parents expect a certain level of mentorship and oversight, especially when it comes to mental health. For many students throughout the nation, it is difficult to receive mental health care and to bridge expectations and needs. The realities of providing timely care include sometimes long wait times at college counseling services; insurance coverage problems if being seen in the community; students’ right to confidentiality and parents’ frustration with not being kept informed; academic issues versus mental health issues; and systems of care that are not integrated and in fact fragmented. Students’ psychiatric problems can be very serious, acute as well as chronic – substance use, depression, anxiety, eating disorders, suicidality, bipolar disorder, and schizophrenia. When I became president of the American Psychiatric Association in 2003–2004, I made college mental health a major priority and set up a college mental health Presidential Task Force, asking David Fassler, MD, and Rachel Glick, MD, to co-­ chair. Others, such as Victor Schwartz, MD, and Jerald Kay, MD, served on this august group and edited, in 2010, a groundbreaking book, Mental Health Care in the College Community [2], which is still an important guide. We set up a college mental health list which helped connect psychiatrists who were working in this area. We appreciated the support of Laura Roberts, MD, at APPI for allowing us to put together a special issue on psychiatric education and college mental health for Academic Psychiatry [3]. I very much appreciated the opportunity to work with Daniel Kirsch, MD, who served with me as the first co-chair of the National Network of Depression Center’s College Mental Health Task Force, and later with Sarah Lipson, PhD, and now with Marcia Morris, MD, all wonderful collaborators. Dr. Roberts went on to edit a highly acclaimed text, Student Mental Health: A Guide for Psychiatrist, Psychologists and Leaders Serving in Higher Education [4]. vii

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Dr. John F. Greden, executive director of the University of Michigan Depression Center and former chair of the University of Michigan Department of Psychiatry, led the nation in hosting a yearly Depression on College Campus (DOCC) Annual Conference at the University of Michigan. For 16 years, the DOCC has brought together leading experts in college mental health. We greatly appreciated Daniel Eisenberg, PhD, for chairing a research symposium on college mental health connected to the DOCC and leading the much acclaimed Healthy Minds Survey/ Healthy Minds Network. This survey, launched in 2007, is an annual web-based study, fielded at over 320 colleges and universities, examining mental health, service utilization, and related issues among undergraduate and graduate students. It is still clear, though, that there is a growing need for psychiatrists to be more involved in college mental health and for departments of psychiatry to link to services on their college campus. Some of the issues that have arisen, especially during the COVID pandemic, such as the need for telepsychiatry and licensure issues for psychiatrists and other mental health professionals, point to the need to anticipate and being nimble in finding resolutions to needed clinical issues. Erica Riba received her MSW from the University of Michigan and served in a clinical capacity at Eastern Michigan University and Wayne State University in their Counseling and Psychological Services (CAPS) departments before moving to NYC to work at The Jed Foundation, where she has been a campus advisor and now is the director of higher education and student engagement. Using JED’s comprehensive approach, Erica advises colleges and universities on promising practices to protect emotional health and prevent suicide among college students. Alissa Roger graduated from Suffolk University Law School and provided career counseling assistance at New England College of Law before serving in her current career counseling role at the University of Rochester. Our lives have intersected in many ways, but interestingly, we have recognized the incredible needs of students, their parents, and faculty regarding college mental health. Further, it has been inspiring to witness the ways our various professions (psychiatrist, social worker, lawyer) all can be part of some of the solutions. Over the years, we have worked with and learned so much from the esteemed authors of this book and appreciate their efforts to help build and improve the field of college mental health. There is still so much more to do, though. It is our hope that this book provides a roadmap for some of the areas that merit focus now and provides ideas for future directions. We thank you for being so supportive of our work. It has been a sincere honor to work with Meera Menon, MD, who has been incredibly innovative and visionary in her leadership in college mental health at The Ohio State University and nationally. We want to thank Dhanapal Palanisamy for superb work as project coordinator (books) at Springer Nature and Richard Lansing at Springer Nature for his strong encouragement and support. Ann Arbor, MI, USA Rochester, NY, USA New York City, NY, USA

Michelle B. Riba, MD, MS Alissa Roger, Esq. Erica Riba, LCSW

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References 1. Riba M, Riba A, Riba E. Life as a balance beam: practical ideas for balancing work and home. Acad Psychiatry. 2007;31(2):135–7. 2. Kay J, Schwartz V, editors. Mental health care in the college community. Chichester: Wiley; 2010. 3. Riba M, Kirsch D, Martel A, Goldsmith M. Preparing and training the college mental health workforce [Editorial]. Acad Psychiatry. 2015;39(5):498–502. 4. Roberts L, editor. A student mental health: a guide for psychiatrist, psychologists and leaders serving higher education. Washington, DC: American Psychiatric Association Publishing; 2018.

Contents

1 National Trends in College Mental Health����������������������������������������������   1 Amy Alexander, Steven Siegel, and Mehak Chopra 2 Systems and Models of Psychiatric Care for College Students�������������  21 Lindsey Mortenson 3 The Parent Factor: Collaborating with Parents to Promote Mental Health Treatment��������������������������������������������������������������������������  37 Marcia R. Morris 4 No Wrong Door: Improving Access Through Collaboration����������������  55 Ludmila De Faria, Carlos J. Gomez, and Alex Johnson 5 Working with LGBTQ Students��������������������������������������������������������������  71 Leigh Anne White 6 Mental Health Considerations for Black, Indigenous, and People of Color: Trends, Barriers, and Recommendations for Collegiate Mental Health��������������������������������������������������������������������  85 Swapna Hingwe 7 Taking Care of Our Own: Shoring Up Resilience and Preventing Suicide in Mental Health Professionals������������������������  97 Christine Moutier and Maggie Mortali 8 Navigating a Leave of Absence������������������������������������������������������������������ 113 Lillian Mezey 9 Threat Assessment on College Campuses������������������������������������������������ 123 Philip A. Saragoza, Stephen G. White, and Victor Hong 10 Preventing Suicide and Promoting Mental Health Among College Students: The Jed Foundation �������������������������������������� 135 Victor Schwartz

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11 Telemental Health and Telepsychiatry in the College Setting���������������� 141 Nora Immordino Feldpausch  Correction to: Taking Care of Our Own: Shoring Up Resilience and Preventing Suicide in Mental Health Professionals. . . . . . . . . . . . . . . . . C1 Index�������������������������������������������������������������������������������������������������������������������� 155

Contributors

Amy Alexander, MD  Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA Mehak Chopra, DO  Sports Psychiatry Clinic Faculty, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA Ludmila De Faria, MD  University of Florida, Gainesville, FL, USA Nora Immordino Feldpausch, MD  Medical Director Wellround Provider Group/ Mantra Health– Telehealth Provider, Greeley, CO, USA Michigan State University Counseling and Psychiatric Services, East Lansing, MI, USA Carlos J. Gomez, PhD  Florida State University, Tallahassee, FL, USA John F. Greden, MD  Rachel Upjohn Professor Emeritus of Psychiatry and Clinical Neurosciences, Founding Director, University of Michigan Depression Center, Founding Chair, National Network of Depression Centers (NNDC), Chair Emeritus, University of Michigan, Department of Psychiatry, Ann Arbor, MI, USA Swapna Hingwe, DO, MA  Counseling and Psychiatric Services, Michigan State University, East Lansing, MI, USA Victor  Hong, MD  Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA Alex Johnson, PsyD  Florida State University, Tallahassee, FL, USA Meera  Menon, MD  Counseling and Consultation Service, The Ohio State University, Columbus, OH, USA Lillian  Mezey, MD  University of Virginia, Student Health and Wellness, Charlottesville, VA, USA Marcia  R.  Morris, MD  Student Health Care Center Psychiatry, Department of Psychiatry, University of Florida, Gainesville, FL, USA Maggie  Mortali, MPH  American Foundation for Suicide Prevention, New York, NY, USA

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Contributors

Lindsey  Mortenson, MD  University Health Service, University of Michigan, Ann Arbor, MI, USA Christine  Moutier, MD  American Foundation for Suicide Prevention, New York, NY, USA Michelle  B.  Riba, MD, MS  University of Michigan, Department of Psychiatry, University of Michigan Eisenberg Family Depression Center, Ann Arbor, MI, USA Erica Riba, LCSW   The Jed Foundation, New York, New York, USA Alissa Rogér, Esq.  University of Rochester, Rochester, New York, USA Philip A. Saragoza, MD  Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA Victor Schwartz, MD  NYU Grossman School of Medicine, New York, NY, USA Steven Siegel, MD, PhD  Department of Psychiatry and Behavioral Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA Leigh  Anne  White, MD  Counseling & Psychiatric Services, Michigan State University, East Lansing, MI, USA Stephen G. White, PhD  Work Trauma Services, Inc., San Francisco, CA, USA

1

National Trends in College Mental Health Amy Alexander, Steven Siegel, and Mehak Chopra

Introduction/Scope of the Problem There is an expanding need for mental health services on college campuses. In the National Survey of Counseling Center Directors, 87% of Directors report increased demand for services, and 90% of Directors report that there are greater numbers of students with severe psychological problems [1]. Students also report feeling “overwhelmed,” nearly half felt “so depressed that it was difficult to function,” and almost one in ten had “seriously considered suicide” [2]. More students take psychiatric medications now than previously—at college counseling centers, 24% now take medication [1]. The acuity and volume of mental health problems on college campuses have steadily and dramatically increased over the past several decades [3–6]. This is due in part to increased access to college for students with significant mental health and developmental difficulties [7]. It is also due, in part, to an ever-escalating increase in the psychological stressors placed on adolescents and young adults to achieve extraordinary levels of competence and specialization at younger ages [8]. For example, a decade ago, a few Advanced Placement (AP) classes during senior year were the signs of a truly gifted student. Now, any student who is not taking

A. Alexander (*) Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA S. Siegel Department of Psychiatry and Behavioral Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA M. Chopra Sports Psychiatry Clinic Faculty, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA © Springer Nature Switzerland AG 2021 M. B. Riba, M. Menon (eds.), College Psychiatry, Psychiatry Update 1, https://doi.org/10.1007/978-3-030-69468-5_1

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A. Alexander et al.

exclusively AP classes starting in ninth grade and beyond abdicates the ability to be among the most competitive group and have access to the most competitive universities [9]. A similar escalation has occurred across all domains of life, with junior high school students now requiring previously professional-level dedication and year-round practice schedules just to be viable as high school athletes. Regardless of how one views the causes of increased mental health incidence, one cannot deny that upward of 40% of college students now report significant mental health problems [10–12]. Many, if not most, of these students display such severe anxiety, depression, and associated symptoms that they qualify for mental health disorders. Thus, college campuses have become the new setting in which major mental illnesses are emerging, potentially causing deflections in life trajectory. In this backdrop, college counseling centers have largely remained tethered to traditional and outdated models of treating psychiatric patients as student-clients, and major psychiatric disorders as situational problems. As such, the gap between need and services has been widening at an unprecedented pace. Specifically, colleges continue to put resources into college counseling center models staffed by college counselors (largely Master’s and Ph.D. level therapists) in lieu of building or incorporating a major mental health clinical enterprise capable of addressing major psychiatric illnesses, with all the emphasis it would have for community crisis outpatient mental health services. This chapter addresses the gap between acute need and traditional response, in both funding and philosophical terms. Indeed, it will be critical to address both issues through innovative funding approaches and an honest re-­ evaluation of the student mental health model in general, and college counseling centers in particular.

Epidemiology In this new decade, mental health issues continue to rise. As of 2017, 17.3 million adults in the United States had at least one major depressive episode which is about 7.1% of all US adults [13]. Depression in females had a higher prevalence (8.7%) compared to males (5.3%), and the age group with the highest prevalence was young adults from ages 18–25 (13.1%) [13]. Depression is also the number one cause of disability in the United States. The adolescent population prevalence of depression continues to increase with about 3.2 million adolescents from ages 12–17 in the United States having at least one major depressive episode [13]. The ratio of females to males is quite wide, as the prevalence was 20.0% in females and 6.8% in males, and the highest number in adolescents reporting being from two or more races (16.9%) [13]. This leads to an estimated 2.3 million adolescents from ages 12–17 having one major depressive episode with severe impairment, which is about 9.4% of the US population in that age group [13]. Students are a subset of the adolescent population. The recent Healthy Minds Study, which gathered data from students in 2020, indicates the need for specialized mental health care for this population. The study showed that 37% of students

1  National Trends in College Mental Health

3

reported a positive PHQ-9 screen, 31% reported a positive GAD-7 screen, 11% reported a positive screening for eating disorders (SCOFF screen), 23% reported non-suicidal self-injuries, 14% reported suicidal ideations, 35% had a lifetime diagnosis of mental health disorders, and 22% were on psychotropic medications in the past year [14]. In addition to these statistics, it also revealed the stigma associated with accessing or engaging in mental health care. It was found that 51% of students agreed with the idea: “most people would think less of someone who has received mental health treatment” [14]. PERCEIVED NEED 3% Strongly Disagree 9% Disagree 10% Somewhat Disagree

25% Strongly Agree

28% Somewhat Agree

24% Agree

Perceived Need (current): Percent of students who responded with each answer to the statement, “I currently need help for emotional or mental health problems such as feeling sad, blue, anxious or nervous.”

ACADEMIC IMPAIRMENT

28% 6 or more Days

17% None

29% 1-2 Days

26% 3-5 Days Academic Impairment: In the past 4 weeks, how many days have you felt that emotional or mental difficulties have hurt your academic performance?

Healthy Minds Study [14]

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There is an urgent need to address the mental health issues of the adolescent population since these are the individuals who are graduating high schools and attending colleges and universities. In a recent report by the ACHA-National College Health Assessment, it was found that 60% reported feeling “overwhelming anxiety” and 40% felt so depressed they felt they couldn’t function [15]. The number of students who visited campus counseling centers rose by 30% from fall 2009 to spring 2015 [15]. These statistics indicate the increased need for services on campuses and funding. The rates of depression, anxiety, and other mental health conditions in the student population are on the rise. Thus, this calls for preventative treatment starting in adolescence and continuing to provide that support on campuses. Suicide is the tenth leading cause of death in the United States [16]. The most recent statistics from 2017 indicate that 47,173 Americans died by suicide and 1,400,000 attempted suicide [16]. The age-adjusted suicide rate in 2017 was 14.0 per 100,000 individuals [16]. The data concluded that there were 129 suicides a day, 50.57% of deaths were with firearms, white males accounted for 69.76% of the deaths, and men were 3.54 times more likely than women to die by suicide [16]. Suicide is a major health concern, and the rates continue to rise in every age group and cultural ethnicity. The suicide rate was 14.46  in young adults ages 15–24 years old [16]. The rate is still lower when compared to other age groups but continues to rise. The suicide rate in young adults ages 15–24 has tripled since the 1950s [17]. Suicide is the second most common cause of death in college students [17]. There are many factors that are contributing to the increased rates including increased mental illness, lack of support systems, disrupted sleeping and eating patterns, academic stressors, substance abuse, and social issues. A recent study published consisting of 67,000 college students from over 100 institutions indicated that 1 out of every 5 students has had suicidal thoughts [17]. It indicated that 9% made an attempt and 20% reported self-injury [17]. The suicide rates in females from ages 15–19 doubled from 2007 to 2015, and in males from ages 15–19, the rate increased by 30% [17]. Thus, the data concludes that the there is a need for specialized care for this age population as the rates of suicide, depression, anxiety, and other mental health diagnoses continue to increase.

Subsections Lack of Psychiatric Services on College Campuses  Only 46.6% of Counseling Center Directors reported that psychiatric services are offered on their campuses [1]. 57.0% of Directors whose centers have psychiatric services reported that they would need to provide more hours of psychiatric services than they currently do, in order to meet student needs [1]. Physician Leadership in College Psychiatry  Historically, there is a lack of psychiatrists in leadership positions in college counseling centers. Specifically, less than 5% of Counseling Center Directors are psychiatrists [1]. The majority of Directors hold Ph.D. and Psy.D. degrees rather than M.D.’s [1]. Furthermore, the lack of access to psychiatrists leads to an inability to consult with, or obtain

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supervision from, individuals with the broadest and deepest understanding of mental health and medical issues that may present as initially mild to moderate selfdisclosed symptoms. Challenges and Difficulty Recruiting Psychiatrists to College Counseling Centers  Historically, college counseling centers have had difficulty recruiting and retaining psychiatrists. Salaries are typically below-market rates, and far below private practice income in the same location [1]. There is relatively high liability: campus suicides, suicide clusters, mass violence, and sexual assaults often attract public attention, media, and intense scrutiny. Lawsuits against colleges may also name the psychiatrists who provided mental health care for the student involved. There is often turnover in counseling center staff, as described next, which may indicate a challenging work environment [1]. The economic disincentives to incorporate the highest level of mental health professionals affect the care and referrals of students to the community, where reimbursement rates paid by most commercial and public insurance carriers are woefully out of step with market rates or appropriate compensation for mental health professionals. As such, students are often left without meaningful access to either long-term therapy or psychiatric services. Turnover in Counseling Center Staff  51.8% of centers had one or more counseling center positions turned over during the past year [1]. Low staff salaries and problematic center work conditions were reported factors in a significant proportion of this turnover [1]. Additionally, college campuses often place an undue amount of responsibility for the mental health of its student population on the counseling center, while not addressing many of the systemic causes of severe anxiety and distress among students. These may include the presence of pervasive drug and alcohol issues embedded within the social structure on campus [18]; lack of adequately addressing sexual violence; academic systemic structures that add undue stress and burden to students; and inadequate regulation of faculty members, who may impose gratuitous and inappropriate rules, while relegating many of the meaningful interactions to graduate assistants who may have little experience and varying interest in teaching. Part-Time Job Status  The average full-time equivalent (FTE) for psychiatrists in college counseling centers is 0.61 [1]; that is, college psychiatry positions are more often part-time jobs, and not full-time job positions. FTEs are often decided upon by the availability of funding and the annual budget, determined more often by university administrators than by medical professionals; and as noted earlier, even the Directors of college counseling centers who may be involved in this decision are rarely physicians. Part-time positions offer fewer benefits, and may or may not cover health insurance. Part-time job status is another reason why college psychiatry jobs may be unattractive and may be difficult to fill; this is especially true for graduating psychiatry residents who want the security of stable, full-time positions with full benefits for their first jobs. In addition, the estimate for population-based access to psychiatrists and therapists suggests that there should be 2 therapists and 1 psychiatrist for every 6000 members of the population. This assumes a population which spans the entire age

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range, and likely underestimates the needs for 18–30-year-old college students. Furthermore, college counselors typically engage in a host of non-clinical activities, which reduces their functional clinical activity to roughly 66% of that which would be required in private practice or community mental health centers. While this is less the case for counseling center psychiatrists, they too will typically have lower case numbers, with higher demands per patient than in other settings. Thus, a ratio of 5 therapists and 2 psychiatrists per 10,000 students is likely the minimum number of mental health clinicians needed to effectively treat students. This number assumes that there is also administrative support and case management serving ancillary roles, such as working with campus partners for leaves of absences, collaborating with parents, and providing accommodations for students. Salary Comparison  According to the 2018 AUCCCD Survey, the mean amount that colleges spent on counseling centers was ~$1 million for combined salaries and benefits for all staff working in the center, and ~$92,000 for the annual operating budget [1]. For schools with 30,000–35,000 students, the average budget was ~$2 million for combined salaries and benefits, with operating budgets of $300,000, which cover [1]: • ~20 FTE therapists • 1.7 FTE psychiatrists • 4 FTE support staff In comparison, when referencing 2020 College Basketball Coach salaries, the highest paid coaches at 70 institutions were paid >$1 million each [19]. And for 2019 College Football Coach salaries, the highest paid coaches at 80 institutions were paid >$1 million each [20]. Such comparisons are obviously not unique to college settings, with societal priorities setting a broader tone that values entertainment above basic human needs. However, a more meaningful comparison would be to compare salaries for college counseling center clinicians with the productivity-adjusted peers in the community. The average private psychiatrist in the greater Los Angeles area earns approximately $325–350 K and sees 35–40 hours a week of face-to-face clinical interactions in the private practice setting. A comparable private therapist performing the median amount of work performs 28–30 hours of clinical interactions and earns approximately $125–150 K. College counseling centers typically pay roughly 60–70% of these amounts, albeit with comparably lower productivity expectations for therapists and roughly 80% comparable productivity for psychiatrists. Thus, these clinicians are often compensated for both their clinical work and non-clinical work that could be done by Bachelor’s or Master’s level staff, and their salaries reflect this. One potential solution would be to separate the clinical and non-clinical activities into different job descriptions, so as to increase pay and productivity for the clinicians, while paying other individuals to perform the functions that do not require a high level of clinical training and expertise. Barriers in the Workplace Culture to Innovation and Improvement  In 2018, college campuses had mean staffing ratios of 1 therapist per 1400 students [1]. There are approximately 3000 people per licensed therapist in the United States [21]. Thus, there

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are twice as many therapists per potential patient in counseling centers than there are for the general population. Furthermore, current models of counseling centers assume that the same population of counselors will participate in both clinical and non-clinical activities. For example, licensed therapists will often be engaged in community outreach, community educational activities, and individual interactions with campus partners. As such, clinical activities in counseling centers often make up only a portion of clinicians’ efforts. Adjusting for this reduced clinical load, one can estimate the number of full-time therapists needed to provide the same amount of clinical work to be approximately 960 students per counselor. Thus, true comparison to the general population suggests that even at 2018 staffing ratios, college students have three times as much access to therapists as the general population. Given how inadequately many counseling centers are able to meet the demand, these data suggest that there are additional factors that impede the ability of college counselors to function similarly to their private and public clinical counterparts. For example, it is typical for counselors to expect processing time after each visit, and additional non-clinical time for paperwork, phone calls, emails, etc. The entrenched workplace culture itself requires a high activation energy to overcome resistance to the kinds of innovative changes that are needed. Outreach to Special Populations on College Campuses  College campuses today are composed of many groups of students; some groups are known to be at higher risk for mental disorders, and some experience challenges and barriers accessing care. It is incumbent for college campuses to be aware of these groups of special populations, the challenges they face, and how to provide mental health care for these groups. These groups include student athletes, students in fraternities and sororities, graduate students in health care, international students, racial and ethnic minorities, and sexual and gender minorities, to name a few. Historically underrepresented students, especially, are enrolling in higher numbers with >40% of the almost 20 million US college students identifying as an ethnic or racial minority [22]. Minorities may face higher rates of discrimination and harassment, and report more negative perceptions of campus climate compared with nonminorities. They may require mental health care at similar rates as nonminorities, but greatest distress was found at intake in Asian American students, followed by Latinx, African-American, and Caucasian students [23]. Unfortunately, higher enrollment has not resulted in higher graduation rates, except for Asian students, with only half or less of ethnic minority students finishing their degree. The difference in graduation rates may be due to multiple barriers, including perceived, felt, or internalized bias; immigration status; access to mentoring; bullying; isolation; and lack of support [24]. Here are some of the vulnerabilities and risks present in different student groups, and the need for increasing outreach and access to care for them. Further exploration of some of these topics will continue in Chaps. 5 and 6: (1) Student athletes: The research on student athletes is mixed, mostly showing that being involved in a sport or being an athlete may be a protective factor against depression and may correlate with higher levels of self-esteem, purpose, and social connectedness [25]. Some studies have shown that athletes did not appear

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to have a higher risk of suicide [26]. However, a 2013 study indicated that student athletes had a higher risk of death from violent causes such as accidents, murders, and suicide [26]. It is important to keep in mind that each sport has its own set of challenges and the risk may vary from sport to sport. From studies analyzed, it has been concluded that suicide statistics/rates vary depending on sport, gender, and ethnicity [26]. Thus, it indicates that more research needs to be conducted to identify the associations regarding suicide and suicidal ideation along with the causal mechanism in this student athlete population [26]. Generally, areas of distress specific to student athletes include time management, coping with heavy practice demands, lack of sleep, perfectionism, postinjury and recovery, retirement, eating disorders, and substance abuse [25]. (2) Fraternities and sororities: Fraternities and sororities pose specific challenges at many colleges. These organizations are primary locations for parties at which alcohol and drug use is particularly prevalent. As such, they also tend to be venues which disproportionally contribute to substance-related problems, including binge drinking, other alcohol-related problems, and sexual misconduct, with far-reaching implications for mental health [27–31]. (3) Medical students: Higher rates of emotional distress compared to age-matched controls have been found, including more suicidal ideation in medical students, residents, and physicians, compared with the general population [32– 35]. Treatment considerations include privacy concerns, stigma, and transference/countertransference issues. (4) Veterinary students: Veterinarians are a highly trained group of health-care professionals with an extremely high risk of suicide, estimated to be 3–4x as great as the general population, and 2x as great as other health-care professionals [36]. Interventions are likely needed at the student level. (5) Graduate students: Graduate students have reported lower percentages of psychiatric problems compared with undergraduates [37]. Among graduate students, however, studies have identified high-risk groups, including Arts and Humanities majors, LGBTQ students, international and undocumented students, and minority students [38]. (6) International students: The Institute of International Education, with sponsorship from the US Department of State, estimates that there are over one million international students enrolled in colleges in the United States, most of them from Asia [39]. International students are as likely as domestic students to report emotional and stress-related problems, but were less likely to be aware of mental health services or to utilize them [40]. (7) Sexual minority students: Sexual minority students were almost twice as likely to use any mental health services, but usually seek off-campus services due to perceived barriers [41]. Sexual minority students endorsed higher rates of psychological distress and mental health-related academic impairment compared with heterosexual students. (8) Transgender students: Transgender students reported more mental health diagnoses, trauma, and suicidality; experienced more violence and less safety; reported more sex partners and sexually transmitted infections (STIs) and higher rates of illicit and nonprescription substance use and binge drinking while engaging in less harm reduction behavior; and reported more barriers to academic success

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[42]. In the 2015 US Transgender Survey, 33% reported at least one negative experience with their healthcare providers, and 23% reported they did not seek health care they needed due to fear of being mistreated as a transgender person [43]. There is a great need to improve access to care for these students. (9) Muslim students: Muslim students face significant threats, and this has increased under the current political climate. Many have experienced recent episodes of bullying, and women who wear hijab (headscarf) are especially at risk. Prior research has found that Muslim Americans’ discrimination experiences are associated with increased risk of mental health problems. A study of Muslim American college students found that perceived discrimination was positively associated with severity of depression and anxiety symptoms. Also, having a strong Muslim American identity exacerbated the relationship between perceived discrimination and anxiety symptoms [44]. There is a need on campuses to reduce discrimination and harassment toward Muslim students, and to provide more outreach and support to students with strong Muslim identity. In addition, campus policies should be inclusive and respectful of the religious practices of Muslim students. (10) African-American/Black students: African-American college students are less likely to access mental health services than students of other races [45]. Additionally, issues of social injustice, systemic racism, and police brutality have recently been brought to light in the wake of multiple police shootings of black unarmed people. Research has shown that exposure to the killing of unarmed black people at the hands of police results in worse mental health outcomes [46]. Addressing issues of mental health access for AfricanAmerican students should be prioritized, given current times. (11) Asian students: Perceived racial discrimination has been associated with depression, anxiety, suicidal ideation, and substance use in Asian American youth [47]. In a large survey, Asian students were the least likely to obtain treatment for mental health problems, with roughly 80% of cases being untreated, and 23% experiencing perceived stigma [48]. (12) Latinx students: Members of the Latinx community are the largest and fastest-­ growing minority group in the nation, but they historically have some of the lowest educational attainment level. In recent years, college degree attainment has improved, although some equity gaps in graduation rates still remain [49]. Between 2000 and 2016, Latino undergraduate enrollment more than doubled (a 134% increase from 1.4 million to 3.2 million students) [22]. Positive associations were found between cultural stressors (including discrimination and acculturation stress), and the presence of mental health symptoms, including anxiety, depressive, and psychological stress. Negative associations were found between cultural values of familismo (dedication, commitment, and loyalty to family), respeto (respect), religiosity, and mental health symptoms [50]. These findings support helping Latinx college students remain connected to their families and cultural values as a way of promoting their mental health. (13) DACA students: The Deferred Action for Childhood Arrivals (DACA) program allowed undocumented students to attend college. Despite the benefits provided under DACA, students struggle with mental health issues due to different factors, including acculturation issues, the current political climate, and increased hostility toward undocumented immigrants.

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Strategies for Improving Services Access and Engagement  The first part of providing excellent care is to simply be available to patients. Many health systems and college counseling centers struggle with this first, most elemental aspect of demonstrating care for patients. Some systems, like the University of Southern California (USC), tried to increase initial access by providing brief, phone screen interviews to help triage patients to the appropriate services. While such screens can be done more rapidly and expediently, they lacked the fundamental element of connection and left students feeling like they had not been treated. Thus, the enormous investment of effort and time to provide 30-minute phone screens was not engendering a sense that any care had been rendered. At USC, this was especially true when students who were not in crisis were referred out or given intake appointments that were many weeks away. Some students truly believed, and propagated the sense, that student health had not offered them any services. Rather, they experienced the phone contact as a diversion from care, resulting in future reluctance to engage the system that failed them previously [51]. As a result, those same students often refused to engage with student health systems when they were in true mental health crises at a later time. Specifically, we learned that phone screen contact was not an effective way of engaging students. It failed to convey the sense of being cared for, and indeed the clinicians who came from a traditional college counseling model felt they had not established a doctor-­ patient relationship. The counselors felt absolved of any responsibility to the patient since they had not established what they considered a therapeutic relationship. To address both major inadequacies, we discontinued initial phone screens in favor of face-to-face, 1-hour initial evaluations, during which the clinician is expected to provide both an evaluation and treatment plan. The result was a significant improvement in meaningful access, with improved engagement of students and improved accountability for clinicians. Counseling Center Culture  There are many options for improving the state of college mental health care. The most common, albeit least productive in our opinion, is to simply add more counselors within college counseling centers without addressing the fundamental mismatch between need and system. This approach advocates for lowering the ratio of counselors to students, in an apparently endless battle to keep up. The fundamental flaw in this approach is that it does not examine long-held assumptions and practices that are ingrained in college counseling culture. As such, counselors adhere to outmoded beliefs about the amount of time needed for a session, as well as continuing to spend inordinate amounts of time dedicated to non-clinical activities. Alternatively, college counseling centers could undergo radical change that recognizes the limitations of student health fee-based services and is intentional about change. For example, a typical health fee does not pay nearly enough to provide true mental health care for the large number of students who now present with mental health disorders on campuses. Colleges and universities can therefore choose to set up clinical practices with limited scope and mission as an entry into the mental

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health system. Such a model would employ crisis counselors who could rapidly engage, evaluate, and triage students to determine the appropriate level of care. All students with ongoing needs would then be referred to insurance-based practices, similar to surgical or other specialty care. However, the problem with this solution is that many communities lack sufficient numbers of mental health clinicians locally, and insurance pays roughly 2/3 of the needed rate. Thus, students lack meaningful access. As noted above, colleges and universities do often have resources for other priorities, such as sports and building new facilities. As an alternative, they could become much more intentional about paying for mental health services in one of the two ways. First, they could invest in simply providing more resources for mental health services by increasing funding to the current model of counseling center-­ based care. This has the disadvantage of investing in older systems and often leaves the mental health care for students under the purview of student affairs and outside of an academic medical center or health system. Alternatively, they can create insurance-­based practices for students at their own academic medical center and underwrite the losses that may be incurred due to inadequate payments by insurance companies. We advocate for a modified approach as was done by one of the authors at the University of Southern California (USC). Namely, college mental health services were first brought into the university healthcare system and placed under the direction of the Department of Psychiatry. This created an environment in which productivity, regulatory oversight, and standards could be elevated to match that throughout the rest of the university healthcare system. Next, USC invested resources into the Department of Psychiatry to build a better and more robust college counseling system with expanded numbers of counselors and psychiatrists (from 30 to 60 over a period of 3 years). Finally, USC allowed the Department of Psychiatry to design and open a large insurance-based practice with 20 additional mental health clinicians exclusively for students, while underwriting the gaps between market salaries and reimbursement. The latter allows USC to recapture insurance-based payments, while also offering higher-quality care in a setting that is also more convenient for students. This aspect of transforming the college counseling culture to embrace a medical model of accountability, with medical standards consistent across the entire student health system, has been among the most challenging and rewarding aspects of transformation since the Department of Psychiatry took over Student Mental Health services at USC.  This is an example of how one university was able to overhaul, redesign, and update their college mental health system to match their students’ increased need and demand for mental health care using a medical model. Further detailed discussion about models of care in college mental health will follow in the next Chap. 2. Need for Diverse and Culturally Competent Providers and Psychiatrists  As discussed earlier, there is a need for diverse and culturally competent care, given the increase in racial and ethnic minorities enrolling in college [22, 52]. Some

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universities have hired clinicians with the same ethnic/racial/sexual minority as the students they will be offering services to, in order to improve access, reduce stigma, and accommodate some student preferences. Substance Abuse Treatment  A significant number of college students experience difficulties related to illicit drugs and alcohol. One recent study found that 14% of college students report substance use and abuse as a major health challenge [53]. Another study found that substance use in college is associated with increased odds of depression, anxiety, and suicidal ideation, regardless of gender [54]. A survey of USC college students in 2018 indicated that students who engage in the Greek system were much more likely to have used illicit drugs and alcohol in the past 30 days than their non-Greek counterparts. Also, college students with the highest rates of binge drinking and cigarette/marijuana use were found to have the highest rates of mental health diagnoses, psychological symptoms, and self-injurious thoughts/ behavior [55]. It is equally important to recognize that there is a reciprocal relationship between substance use and mental health symptoms. While substance use can lead to increased mental health issues, the converse is also likely the case. The relationship among specific mental conditions and drug of choice was found to vary among different cultural groups [56]. For example, one study found that attention deficits were associated with stimulant misuse, while psychological distress was associated with marijuana use, among Caucasian students. Inattention was associated with cocaine and prescription stimulant use among Latinx populations. Alternatively, psychological distress was associated with tobacco use and prescription painkiller abuse. Additionally, both higher marijuana and higher drug use are significantly associated with greater mental health problems, indicating that drug and alcohol interventions should be made available for those students as a means to attenuate mental health disorders and distress [56, 57]. These data strongly suggest that college mental health systems should incorporate substance use treatment expertise, as well as partnerships for detoxification, rehabilitation, and residential recovery. The Haven at College (https://thehavenatcollege.com/) is one such program that has been particularly successful as a partner for mental health and substance use disorders at USC. The model of care incorporates addressing the needs of students with substance use disorders by allowing them to live in highly structured, monitored programs while attending college. The students are further supported by having pre-­existing memorandums of understanding between student health, the Department of Psychiatry, and community partners such as the Haven to coordinate services across sites and practices. Facilitating Access to Mental Health Care  Some college campuses have expanded opportunities for care beyond the traditional college counseling center on campus. As discussed earlier, some student groups face barriers accessing care, and having other avenues available can improve access to care. For example, some universities have hired psychiatrists dedicated only to the treatment of medical students. Ohio State University has multiple embedded clinicians who all report to the Director of the counseling center. They are located within various offices and

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departments on campus. This includes the College of Nursing; College of Public Health; College of Engineering; College of Business; College of Dentistry; College of Law; Office of Diversity and Inclusion; College of Food, Agricultural, and Environmental Sciences; College of Optometry; College of Pharmacy; College of Social Work; and a residence hall. These embedded clinicians include therapists and case managers. The College of Medicine and College of Veterinary Medicine have funded their own therapists and psychiatrists outside the usual system, who report to their administrations. Students in those departments have the option of seeing clinicians on campus or seeing their embedded providers. The decision to embed clinicians within a specific space may be based on situations such as the following: noticing increased service utilization of a certain population, sentinel events and the desire to prevent bad outcomes, and extreme underutilization by a marginalized population. Some departments themselves put forth the funding for such positions. The goals of embedded programs are to reduce stigma in special populations and ease access. These programs may also be specifically tasked with conducting outreach services for their students. Nevertheless, some students may be reluctant to seek services within their colleges and opt to be seen on campus services instead, citing privacy concerns. An Academic Pathway  Even while located on the same college campuses, college counseling centers are historically separate from medical centers. College counseling center psychiatrists often work for, and therefore report into, the university, and not the medical center. As such, college counseling center psychiatrists are often hired as clinicians only; the positions are historically not academic positions; and many times, these college psychiatrists are not members in their respective Departments of Psychiatry. As discussed above, college psychiatry positions in counseling centers are often part-time positions, offer few or no benefits, but also potentially carry the risk of increased liability when sentinel events (suicide, mass violence and school shootings, sexual assaults, etc.) occur. In addition, there are often no psychiatrists involved in the reporting structure for these campus psychiatrists. A more recent trend we are noticing nationally is college psychiatrists being brought under the Department of Psychiatry. Often, these college psychiatrists will do part or all of their clinical work at the college counseling center, but they will also have an academic appointment within their School of Medicine’s Department of Psychiatry. Some college psychiatrists do all their work within the college counseling center; some college psychiatrists have dual appointments and divide their time between the college counseling center and the Department of Psychiatry doing clinical or administrative work; and others work solely within the Department of Psychiatry primarily seeing college students. We view this trend as a potentially positive one for several reasons: • The academic appointment affords an academic career and path for college psychiatrists, where there is opportunity to move up the professoriate lines and be part of the academic community. In comparison, a purely college psychiatry

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clinician position may not afford this opportunity, if there is no academic appointment also. The academic role includes in its expectations the education of trainees, including teaching classes for medical students, residents, and fellows, in addition to supervision roles, to encourage trainees into the field of college psychiatry. Promotion up the academic lines may be dependent on involvement in education. The academic position often seeks out the highest academically qualified candidates and evaluates candidates on academic promise, including research and teaching potential. An academic appointment provides access to the Department of Psychiatry, including psychiatry colleagues and peers, grand rounds, and other educational opportunities. College psychiatrists may benefit from the additional resources within the Department of Psychiatry, including expanded support staff, resources for research, and hospital legal and risk management services. These college psychiatrists may work partly or fully out of the Department of Psychiatry, instead of the college counseling center. One example of this is at Stanford, where students are typically seen for short-term care at the college counseling center, but students with more complicated needs are referred to the Department of Psychiatry for longer-term care. One benefit to seeing students within the Department of Psychiatry is that there is more flexibility and fewer constraints than at the college counseling center: –– Students can be seen for longer-term care, if necessary, lasting for several years potentially. –– Students can continue to be seen in the Department of Psychiatry after graduation and when they are no longer a student on that campus. –– Students who do not have student insurance, due to being on leave, taking breaks from their education, and not registered or enrolled in classes, can still be seen. –– Other students, including community college students and students attending other local colleges, can be seen. –– Students living at home for the summer but attending other colleges, including out-of-state colleges, can be seen. –– Transitional-age youth who are not attending college, including students who have dropped out or been expelled, and may have the greatest mental health needs, can be seen. While the reporting structure at the college counseling center may be to nonphysicians and university administrators, the reporting structure within the Department of Psychiatry is to psychiatrists and other physicians, who tend to understand the psychiatric needs and psychiatric care of patients better than nonmedical professionals. Positions within the Department of Psychiatry are often offered at 1.0 FTE. They are often full-time positions with full benefits, similar to the other full-time psychiatry positions within the Department. The pay is likely to be more commensurate to and competitive with other psychiatrists within the Department. This is as opposed to the salary of the