David Stern, MD

Providing psychiatric care for college students is different from treating other grown-ups. These emerging adults are in the midst of a tremendous emotional growth spurt and a leap of neurocognitive maturation. During this bewildering life transition, they often cannot articulate straightforwardly what bothers them. They appear mercurial: at times, they may speak in hyperbole and sound very dramatic. At other times, they shroud what ails them in secrecy because of embarrassment, fear, and hopelessness. Eventually, school stress and academic performance problems propel students to seek assistance. Mental health clinicians attending to this population need to keep an open mind and consider a host of differential diagnoses.

"Jerry" is a 19-year-old sophomore at a liberal arts college in the Northeast who wants to transfer to a prestigious business school. Two months into the fall semester and 1 week before midterms, Jerry reluctantly comes to the counseling service of his college. His dean accompanies him after receiving several alerts from professors about flagging academic performance.

Jerry unenthusiastically agrees to meet with a psychiatrist. He appears tired and says that he feels unmotivated. He is upset with his parents. As an only child, he feels pressured to succeed in business, but is hopeless about ever measuring up to their ambitions for him. He admits to relying on alcohol and marijuana daily for sleep initiation and anxiety management. When asked what would be most helpful to him, Jerry seems surprised by the question: “Everyone tells me that I have an attention problem; my roommate gave me Adderall, and it worked!”

The psychiatric conditions most frequently observed among college students are anxiety, depression, ADHD, substance abuse, and bipolar disorder. Eating disorders carry a high risk for medical comorbidity. Stress and anxiety may worsen during exam periods. Moreover, most psychiatric disorders have their onset during late adolescence and young adulthood. Students in crisis may present with suicidality or psychotic symptoms. Excessive use of alcohol and marijuana pose further health hazards.

When they hit a roadblock with their academic work students like Jerry, who initially reach out to the counseling service for urgent help, often request anxiolytic or stimulant medications for immediate relief. Emboldened by societal opinion and the stubbornly persistent urban myth that stimulants are “smart drugs,” students expect our assistance with cognitive enhancement to prevail in competitive contexts.

Studies estimate that about half of cases with childhood onset of ADHD persist into adulthood.1 However, because of the well-known rates of diversion and abuse, psychiatrists in college health services are wary of prescribing stimulants without a thorough diagnostic work-up.2 An in-depth psychiatric interview, screening with the Adult ADHD Self-Report Scale, and a referral for neuropsychological testing are recommended by a fair number of counseling services before any prescriptions for stimulants are issued. Ideally, the psychiatric work-up should include a basic medical exam, EKG, and routine lab testing. Students are also made aware of the university’s academic support resources.

Students who have come to rely on alcohol and marijuana during adolescence for alleviating anxiety, depression, self-esteem issues, camouflaging inter-personal conflict, and for fun are loath to give this up. They feel culturally emboldened to take advantage of the “medicinal” effects of the various marijuana strains. “I only smoke Blue Dreams,” Jerry announces, referring to a variety of marijuana high in cannabidiol content with purported anxiolytic properties.

How best to treat comorbid mood, anxiety, and substance use disorders has been the subject of a longstanding debate. A review of recent evidence-based studies recommends the integrated treatment of co-occurring mood and substance use disorders to achieve a superior outcome.3 The FDA has approved medications to address alcohol, opiate, and nicotine dependence, but the treatment for excessive marijuana use consists of psychosocial interventions.

Yet, psychiatrists should keep in mind that academic performance problems are a multifactorial phenomenon. They may be related to poor study habits, or academic under-preparedness. This can create a loss of confidence and narcissistic injury among competitive peers or result in oppositional behavior towards authority figures. There can be a lack of motivation because the student’s major was not his or her first choice. Students may be disappointed about not being accepted by their dream school and therefore not apply themselves.

Undergraduate students, in particular, face the difficult task of being away from home and adjusting to life on their own. Despite frequent electronic communication with parents and friends, they may be suffering from homesickness. Maintaining good self-care is surprisingly difficult to achieve. Sometimes the success or failure of the semester is in question because the student fails to establish a predictable sleep/wake cycle and get to class on time. Chronic sleep deprivation is a major contributor to lack of concentration and focus. Without the infrastructure their families provided, students need to learn to eat 3 nutritious meals a day rather than rely on unhealthy snacks. Similarly, in times of stress, it is a challenge to achieve a reasonable work/life balance and have time for leisure activities such as socialization with peers or exercise. Relationship difficulties and romantic disappointments loom large.

Back to Jerry, a fictionalized, albeit typical case. In the initial visit, the psychiatrist explores the nature of the concerns in a non-judgmental fashion, forms rapport with the student, and gains an understanding of his level of psychological maturity and ability to collaborate in making decisions about health care. Creating a shared language about what the basic issues are builds the foundation for a working alliance.

After meeting with the psychiatrist for several sessions, Jerry acknowledges his passion for creative writing. With encouragement, Jerry opens up to his parents. To his surprise, they respond supportively. His anxiety ebbs and he decreases his daily marijuana and alcohol consumption. He is discouraged from using his roommate’s Adderall. He agrees to a referral for CBT for anxiety and insomnia. Jerry’s parents are quite willing to participate in family sessions by conference call. The psychiatrist decides that treatment with medication does not seem necessary for now.

Dr. Kring is Associate Director, Psychiatry Services, Counseling and Wellness Services, New York University, NY.

-Dr. Kring acknowledges the contribution of the GAP Student Committee: Helene Keable, MD, Alexandra Ackerman MD, Malkah Notman, MD, and David Stern, MD.

 Faraone S, Biederman J, Spencer R, et al. Attention-deficit/hyperactivity disorder in adults: an overview. Biol Psychiatry. 2000 48:9-20.

 Prosek E, Giordano AL, Turner KD, et al. Prevalence and correlates of stimulant medication misuse among the collegiate population. J College Student Psychother. 2017. 

https://www.tandfonline.com/doi/abs/10.1080/87568225.2017.131369

 Pettinati HM, O’Brien CP, Dundon. Current status of co-occurring mood and substance use disorders: a new therapeutic target. Am J Psychiatry. 2013;170:23-30.

Articles

Emerging adults in the midst of a tremendous emotional growth spurt and a leap of neurocognitive maturation often need guidance articulating what bothers them.

College Students Under Stress

It was during my third year of  medical school when I was first identified as a medical expert. A college  friend asked my opinion about his father’s medical condition and assumed I  would be helpful. “I don’t know anything, why is he asking 

,” I thought. When it happened again, this time about a rash, I  asked my colleagues, “Do your friends and family treat you as a medical  expert?” Many replied they had been “experts” since those close to them found  out they had been 

to medical  school. When I declared an interest in psychiatry I became the psychiatric  expert. Friends still asked what I knew about a particular procedure or wanted  me to advocate with their doctor for them, but they also asked questions about  whether family members were manic, if I thought someone needed an  antidepressant, or even whether I thought someone else was “crazy.”

Today, 4 years out of training, I  am more comfortable dealing with these questions. I am willing to answer or  look for an answer if I think it can be helpful. Perhaps this is because I find  myself more often in the role of the patient. I better understand how important  trusted information is and how frustrating it can be to feel unheard. When  someone asks me a medical question, I draw on my experiences as both physician  and patient. I find myself participating more in conversations about medical  issues and sharing my experiences. Recently, many of these conversations have  focused on cost-frustration that costs are unknowable in advance;  disappointment when claims are denied; confusion about what might constitute  medically necessary treatment or how the appeals process for a denied claim  works.

In my circle no one knows much  about financial issues in medicine: how much procedures really cost; how cost  impacts medical decision-making; whether cost or outcome should determine  direction of care.

 Moreover, no one thinks that I might be an  expert on these issues. Of all the questions I’ve been asked, I’ve never been  asked about cost or reimbursement. Why might that be? The issue is clearly in  the national consciousness: health care cost is cited as likely to bankrupt the  US; the recently passed health care bill is called “The 

 Care Act”; discussions are more prevalent in the  media-on TV, in print, and online. Governments, insurance companies, and  entrepreneurs are trying to make cost information more available to patients  with the idea this will drive down cost.

We physicians are late to the  conversation. Granted, we too are publishing articles and editorials on this  topic. We’ve done surveys that show how bad we are at knowing the cost of the  medications, procedures, and treatments we provide. Several studies have even  attempted to see if providing cost information prospectively to physicians  could modify their behavior and lower costs of treatment without sacrificing  care.

Still, how often do we have  conversations with our patients about how much treatment will cost?

  Clearly issues of quality remain paramount in medicine, ie, which treatment is  likely to provide the best outcome. While it is appropriately pragmatic to  include cost in this calculus, it should remain a part of the decision, not the  only parameter in decisions about treatment. How to balance price and quality  in treatment planning should not be left solely to the patient; the fact is  patients want help 

 in deciding what treatment is most appropriate. How can we help if we do not  understand all aspects of a patient’s care, including cost?

Earlier this year the American College of Physicians  had to spell out that it is ethically appropriate for physicians to 

about cost with patients. This  speaks to how far we as physicians have to go to be fully engaged in this  conversation. Cost issues have been changing the way we practice medicine for a  long time, and we need to become experts, for our friends, family, and  ourselves.


  1.  Allan GM, Lexchin J, Wiebe N. Physician awareness of drug cost: a systematic  review. PLoS Med 2007;4: e283. doi:10.1371/journal.pmed.0040283.
  2.  Allan GM, Lexchin J. Physician awareness of diagnostic and nondrug  therapeutic costs: a systematic review. 

. 2008;24:158-165.
  3. Kaplan R, Porter M. Why medical  bills are a mystery. 

April  15, 2012.  http://www.nytimes.com/2012/04/15/opinion/sunday/why-medical-bills-are-a-mystery.html.  Accessed September 18, 2012.
  4. Miner T,  Stuebing, E. Surgical vampires and rising health care expenditure: reducing the  cost of daily phlebotomy. 

 2011;146:524-527.
  5. Sinaiko A, Rosenthal B.  Increased price transparency in health care: challenges and potential effects. 

Earlier this year the American College of Physicians had to spell out that it is ethically appropriate for physicians to talk about cost with patients. This speaks to how far we as physicians have to go to be fully engaged in this conversation.

David Stern, MD

Articles

College Students Under Stress

Should Physicians Be Experts on Cost?