Campus Mental Health and Public Safety

1. Campus Mental Health and Public Safety Richard Kadison M.D. Chief, Mental Health Service Harvard University Health Service

2. 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)

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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)

23. 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

24. 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

25. 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

26. 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 .

27. 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

28. 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%

29. 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

30. 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

31. 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

32. 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)

33. Helping Students Help Themselves • In the Dormitory • In the Classroom • At Social Events • Teaching Fishing, not Providing Fish • Best of Intentions, but Sometimes…..

34. 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

35. 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

36. Common Problems • Developmental Adjustment, Relationships • Depression (SADs) • Anxiety • Eating Disorders • Bipolar Disorder • Acute Psychosis • Substance Abuse

37. High Risk Issues • Eating Disorders • Dual diagnosis Substance Abuse/ depression • Bipolar Illness and Psychosis • Reentry from Hospitalization

38. 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

39. 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)

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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)

47. 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

48. Legal Issues • Shin case settled but issues unresolved • Virginia Tech: Refusal of care by student • George Washington, Hunter College student dismissals • Allegheny College Suicide

49. 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

50. 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