Sitting here in my new home “office” (read corner of my bedroom - the only vaguely quiet spot in a house with four kids doing online school) and gazing out at the wind swept Colorado prairie, rather than the ivy-clad university arts quad I had grown used to seeing through my office window, it’s hard to grasp just how much has changed in the past two semesters. Even my colleagues who are still on campus are sitting alone in socially distanced offices with little of the usual hum of learning, energy, and growth that drew so many of us to go into college mental health in the first place. Yet in spite of the students staying off campus or heading home early for the winter break, there remains a lot of work to be done.
Before the pandemic began, universities were already struggling to keep up with demand for mental health care. According to the 2019 Healthy Minds Study, which surveyed over 62,000 college and university students across the United States, 36% of students reported moderate to major depression, more than one third demonstrated scores consistent with an anxiety disorder as measured by the Generalized Anxiety Disorder-7 (GAD-7) and 14% reported having experienced suicidal ideation in the past year (1). Having spent the last ten plus years working in college mental health, I’ve seen firsthand the struggle to staff psychiatric providers in adequate numbers to address the need. To put it bluntly, most counseling centers in higher ed just don’t have the space or the resources to hire their way out of this, and, nationwide, there is a shortage of psychiatric providers (2) overall. Locating and recruiting specialists, especially those from diverse backgrounds, is particularly problematic in rural areas, which is where many colleges and universities are located. Given we know that students of color and those that identify as LGBTQ, two groups particularly unlikely to seek treatment for mental illness (3), access services more often when they are able to meet with providers who look like them or have similar identities (4), it’s crucial that we find better solutions.
For more straightforward mental health concerns on campus, primary care providers (PCPs) can certainly play a vital role. With their broad background in treating most other general health conditions, PCPs are uniquely positioned to decrease the so-called “silo-ing” of mental health care and can often build on their existing rapport with patients. Although I am grateful for the many PCP’s I work with who help increase access to mental health care, non-psychiatric providers, along with everything else they are required to know and do, may not have the training or the time in their schedules to diagnose and treat significant mental illness adequately (5). In fact, nationwide, only 13% of patients treated for mental health by PCPs are receiving “minimally adequate” care that aligns with evidence-based guidelines (6). Furthermore, a higher rate of patients are referred to mental health providers after being diagnosed with a mental health condition than when given other primary (physical health) diagnoses (7), suggesting that PCPs recognise the need for access to specialists with more extensive training in the art of both diagnosing and treating mental illnesses.
With as many as 24% of college students arriving on campus already having been prescribed psychiatric medication (8), colleges and universities are needing to think outside of the box to find the resources they need to keep students well and performing their best in school. For this, telehealth is a promising and economic approach to increasing access to a diverse group of mental health practitioners specifically experienced in helping transitional aged youth. If using telehealth, regardless of the location of the school itself, campus health centers can recruit highly trained candidates from essentially anywhere nationwide, since providers can practice from any state as long as they are licensed in the state in which the student is located at the time of the appointment. This also makes it possible to offer continuous ongoing care even as students move on and off campus, or home for holidays or summers, which are times that have historically led to disruptions in traditional campus-based services. With the onset of COVID-19, many, if not all, universities with college counseling centers have had to switch over to virtual care at least temporarily, using whatever providers were previously on-site. For those who need help maintaining or growing these services moving forward, there are now telepsychiatry companies focused on making specially trained college health providers available to colleges and universities.
Telemental health, which includes various modalities of communicating and receiving mental health care virtually, also has the ability to support patient self management by offering modules or links to resources such as psychoeducational handouts, empirically supported self-help apps, and crisis intervention services, in addition to real-time video appointments. This may be especially useful for colleges and universities that have switched to a stepped care model in order to maximize the limited resources available on campus. Telepsychiatry can be part of platforms that offer the option of incorporating secure messaging to address side effect questions and treatment goal check ins. As providers, we know that when patients can easily access us with questions or concerns, compliance increases, and the therapeutic relationship, an essential component of the success of mental health treatment, is strengthened.
Although telehealth has been shown to be convenient and affordable, it must be proven effective if it is to become a permanent part of college mental healthcare after the pandemic. Fortunately, even before telehealth was widely implemented on college campuses, data strongly supported virtual care as providing equal or, at times, better treatment than could have been available in person (9). According to the APA online telepsychiatry toolkit “telepsychiatry is equivalent to in-person care in diagnostic accuracy, treatment effectiveness, and patient satisfaction” (10). Indeed, some of the most common mental health diagnoses in college aged youth have been successfully and safely treated via telehealth, including anxiety disorders, PTSD, Major Depressive Disorder, eating disorders, and substance use disorders (11, 12, 13). Outside of medication management, which, of course, is only one piece of treating mental illness, both video-based cognitive behavioral therapy and group therapy as well as other online modalities have demonstrated similar success as face-to-face care (14).
As college and university counseling centers consider continuing online care, it is important to remember that telehealth is not just doing the same thing as when we were talking with patients face-to-face. Special attention must be given to asking about and observing the things that are less apparent when interviewing patients virtually. The smell of alcohol or poor hygiene, physical exam findings such as tremor, involuntary movements, even tears may be harder to notice when the patient and provider aren’t sitting in the same room. Clear protocols for high risk or crisis situations, which may develop quickly and without much warning, need to be in place as do plans to help students access in-person or higher levels of care when appropriate. Finally, the development of rapport can take extra care, skill and attention, although seeing into a patient’s actual home or meeting their favorite pet during a session, can sometimes actually make it easier to find a personal connection (I’ve seen more cute dogs than I ever did when working on campus).
Back in my improvised office, despite having to adjust to working from home, I’m becoming more and more convinced that continuing telehealth services on campus may just be the best way to fill the ongoing gap in care. It is an effective way to provide the treatment that students need to thrive, without compromising outcomes, and gives more students access to providers who look like them or who can be available at times that suit their schedule. I hope online care remains a permanent option for students long after the pandemic is over.
(1) Eisenberg D., Lipson S.K. The Healthy Minds Study. 2019. Accessed from: https://healthymindsnetwork.org/wp-content/uploads/2019/09/HMS_national-2018-19.pdf
(2) National Council Medical Director Institute. The Psychiatric Shortage: Causes and Solutions. Published March 28, 2017. Accessed on April 20, 2020 at: https://www.thenationalcouncil.org/wp-content/uploads/2017/03/Psychiatric-Shortage_National-Council-.pdf?daf=375ateTbd56
(3) Chen, J. A., Stevens, C., Wong, S. H., & Liu, C. H. (2019). Psychiatric symptoms and diagnoses among US college students: A comparison by race and ethnicity. Psychiatric services, 70(6), 442-449
(4) Cabral, R. R., & Smith, T. B. Racial/ethnic matching of clients and therapists in mental health services: A meta-analytic review of preferences, perceptions, and outcomes. Journal of Counseling Psychology. 2011; 58(4), 537
(5) Fraser, K., Oyama, O. Knowledge of Psychotropics and Prescribing Preferences of Family Physicians: A Preliminary Study. Acad Psychiatry. 2013; 37, 325–328. https://doi.org/10.1176/appi.ap.12090160
(6) Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve-Month Use of Mental Health Services in the United States: Results From the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):629–640. doi:10.1001/archpsyc.62.6.629
(7) Geissler K.H., Zeber J.E. Primary Care Physician Referral Patterns for Behavioral Health Diagnoses. Psychiatric Services 2020 71:4, 389-392
(8) Eisenberg D., Lipson S.K. The Healthy Minds Study. 2019. Accessed from: https://healthymindsnetwork.org/wp-content/uploads/2019/09/HMS_national-2018-19.pdf
(9) Carleton KE, Patel UB, Stein D, Mou D, Mallow A, Blackmore MA. Enhancing the scalability of the collaborative care model for depression using mobile technology. Translational Behavioral Medicine. 2020; 10(3): 573–579. doi:10.1093/tbm/ibz146
(10) American Psychiatric Association. Telepsychiatry Toolkit. Accessed from: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit
(11) King S.C., Richner K.A., Tuliao, A.P., et al. A comparison between telehealth and face-to-face delivery of a brief alcohol intervention for college students. Substance Abuse. 2019. DOI: 10.1080/08897077.2019.1675116
(12) Eisenberg D., Lipson S.K. The Healthy Minds Study. 2019. Accessed from: https://healthymindsnetwork.org/wp-content/uploads/2019/09/HMS_national-2018-19.pdf
(13) American Psychiatric Association. Telepsychiatry Toolkit. Accessed from: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit
(14) Hilty, D.M., Maheu, M.M., Drude, K.P. et al. The Need to Implement and Evaluate Telehealth Competency Frameworks to Ensure Quality Care across Behavioral Health Professions. Acad Psychiatry 42, 818–824 (2018). https://doi.org/10.1007/s40596-018-0992-5