Malkah Notman, 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

Information technology in the 21st century has brought dramatic changes to psychiatric practice and psychotherapy. There are many new possibilities and patterns for information use and for communication, as well as new ethical, legal, and clinical problems for the psychiatrist. One can ask how the Internet shifts standards of care required from therapists and whether ethical guidelines should change.

The same boundaries and ethical standards concerning the patient-psychiatrist relationship that existed in the 20th century still apply in the 21st century. While some of the conditions under which boundaries apply may be quite different, such as the potential speed of mutual communication provided by e-mail, the theoretical concepts defining boundaries remain the same. Maintaining confidentiality is an ethical duty for psychiatrists, protected by law. Communications between therapist and patient are privileged, and informed consent is needed to share any information about a patient.

A physician is a fiduciary to his or her patient. A fiduciary relationship exists when one person-the professional-accepts the trust and confidence of another person-the patient-and agrees to act only in the patient’s best interest. Acting in a patient’s best interest requires a professional to refrain from all behaviors that may present an unreasonable risk of harm to the patient.

 In the American Psychiatric Association’s Principles of Medical Ethics, Section 1, a psychiatrist’s first duty is to do no harm. These standards have not changed with the advent of Google, e-mail, social media, or other Internet communications.

In this article, we consider some of these technologies and recognize that there will always be new technologies.

Expect that your patients will Google you. Google yourself to see what you find. Should a therapist Google a patient? When patients post information on the Internet, it becomes public and is not protected. The psychiatrist may want to Google a patient to check whether the patient is delusional or has a criminal record, or to find out what medicines the patient might have taken in a suicide attempt. This is permissible legally-but is it ethically and clinically permissible?

 answered a query from a reader questioning whether it was ethical to Google patients: “We have learned that our psychiatry residents routinely ‘Google’ their patients. . . . Is it ethical . . . ?”

“Googling” a patient is not necessarily unethical. However, it should be done only in the interest of promoting the patient’s care and well-being and never to satisfy the curiosity or needs of the psychiatrist. Also important to consider is how such information will influence treatment and how the clinician will ultimately use this information. Psychiatrists should consider these questions before resorting to a Google search.

The answer also cautioned clinicians that information obtained from a Google search cannot be verified as fact. Although the information provided by Google about a patient may be useful, the information may not be current or accurate, especially for clinical purposes.

Dr M, a resident at a university hospital, reported to her supervisor that she had Googled a patient to verify whether information he had presented in the clinical examination was accurate or delusional. The patient reported that he was a famous author and an authority on posttraumatic stress disorder. Dr M found the patient’s multiple publications via a search on Google. Apparently, Dr M also learned that the patient had been involved in a number of drunk driving incidents and had an ethical charge relating to boundary violations.

Dr M’s dilemma centered on what to do with the information uncovered in the search. She did not know whether to confront the patient with the information or to ignore it because it was not relevant to the patient’s current clinical situation.

The doctor needs to let the patient know that a Google search was done, and then she has to discuss the re-sults with the patient. Material found on the Google search can come from any public record, such as police records.

E-mail certainly offers an additional means of communication and provides access to care for the patient. The use of e-mails can save time and solve the problems of missed calls. E-mails provide a relatively easy way to request and change appointments, order prescription refills, and handle other administrative issues. However, they may be sent and responded to without regard to time and place.

While e-mails may be helpful for administrative purposes, they are not a helpful treatment modality, even when combined with face-to-face therapy. As a general rule, e-mail is not secure: e-mail may be misdirected to the wrong person and read by unintended recipients. The potential number of people who may have access to e-mails poses many confidentiality and privacy problems.

Using e-mail as a therapeutic tool also poses many problems. Questions of reimbursement arise as well as those of confidentiality and security.

 The Health Insurance Portability and Accountability Act (HIPAA) applies whenever there is electronic transmission of personally identifiable health information.

The use of e-mail can increase the risk of breach of confidentiality and violation of HIPAA. The psychiatrist should review with the patient the use of firewalls, passwords, antivirus software, and encryption.

Boundaries of time and place provide a secure therapeutic framework that encourages stability and predictability. While the flexibility of time and place provided by e-mail may make communication easier, it also increases the risk of extending the sessions and disrupting or blurring the therapeutic frame. Moreover, because there are no visual or verbal clues, communication by e-mail may be misconstrued. The rapidity and intensity of e-mail makes familiarity more likely; therefore, transfer-ence and countertransference may be increased.

The use of e-mail may result in boundaries being crossed; it is easy to go from professional communication to the personal. The exchanges may include discussions about books, operas, restaurants, plays, sporting events, health and exercise, and even the frustrations of the therapist with family or other patients; vacation photos may be shared. In some cases, the patient becomes the caregiver of the therapist.

In addition, patients can become consumed and preoccupied by e-mails to and from their therapists. A short sampling of 4 cases reveals a similar pattern. In these cases, there were some 1000 to 3000 e-mails sent between patient and therapist over 3 months to 2 years. Patients described their reactions:

• Patient A: “E-mailing is very intense . . . more so than face-to-face sessions. . . . I keep the e-mails and go over them repeatedly.”

• Patient B: “E-mailing with my therapist is very exciting . . . it is all-consuming. I feel such a strong connection. . . . I am glued to the computer.”

• Patient C: “It takes all my time . . . I read them over and over. . . . I am waiting for a response. I am careful not to let my husband see the e-mails.”

• Patient D: “I am tied to the computer like an addict, waiting for a response. I spend time thinking about my response and what will interest him.”

Although none of the cases involved a sexual relationship, the patients developed a strong attachment to and dependency on their therapists. When the therapists wanted to stop the e-mails, the patients felt abandoned.

Consequently, legal issues ensued. Expert opinion in each case found that the treatment fell below the acceptable standard of care. The patients had kept the e-mails and there was a perfect record of what happened. The e-mails were admissible as evidence in civil cases and board hearings. Eventually, the patients were successful in recovering monetary damages.

Psychiatrists should be careful to minimize liability when using e-mail. Steps should be taken to decrease the chance of potential harm to the patients. If using e-mail for anything other than administrative purposes, the therapist should document in the patient’s file the reasons for using e-mail as part of the treatment plan-make copies of the e-mail and put it in the patient’s file. The language of the e-mails should be professional and the content appropriate for medical treatment. All e-mail communication should be discussed with the patient during face-to-face sessions.

The patient’s informed consent for the use of e-mails is critical. The patient must be advised about the limits of confidentiality.

 E-mails may never be used in an emergency. In discussing privacy and security issues, the patient should be advised about who sees the e-mails, how often they are checked, and when the patient may expect a reply.

There are a variety of online social networking sites, such as Facebook and LinkedIn; new social network sites are being developed regularly and old ones are becoming obsolete. Online social networking sites present many new challenges to psychiatrists. Does the psychiatrist have a Facebook page or a Facebook profile? The Queen of England has recently joined Facebook, but she does not accept friend requests. On the other hand, some physicians accept friend requests from patients.

 Does it make a difference if this is a former patient?

 How are privacy and confidentiality protected?

Should a psychiatrist ever accept a friend request from a patient? What happens when a patient asks to “friend” the psychiatrist? Context often influences the meaning of boundaries. Even in a small or closed community where people know each other, accepting a patient’s “friend” request can raise problems.

Social networking sites are interactive forums that require careful monitoring in a psychiatrist-patient relationship. Confidentiality is the primary guiding consideration, whether ethical, clinical, or legal. The laws in most states require that confidentiality encompasses the identity of the patient unless the patient waives his right. Accepting a “friend” request from a patient could easily violate this right.

Social networking sites also pose potential problems with HIPAA compliance. Whatever information the patient adds to the communication can be viewed by others. With rare exception, the therapist should not accept a “friend” request from a patient.

While self-disclosure has always been a clinical issue, social networking raises the bar to a new level. Although the therapist may not accept a “friend” request from a patient, he must be careful while social networking. Caution must be used in posting anything on a Facebook profile because it may become available for public viewing. Patients may be friends with the psychiatrists’ colleagues’ friends or others, without the patient’s knowledge, and the psychiatrist’s children may be friends with the patient’s children. Even privacy settings may not protect the therapist. Psychiatrists should educate themselves about privacy options.

For all information technology, the privacy and boundary issues that apply are the same as those for social networking. Twitter claims that it cannot guarantee privacy and security.

 Blogging is another concern; the psychiatrist is responsible for all content, even if others are allowed to comment.

The Wall Street Journal reported that “the average 13- to 17-year-old sends and receives 3,339 texts a month-more than 100 per day. . . . ” 

 If you text, apply the same cautions to texting that you apply to e-mail. The texts should be e-mailed to the psychiatrist’s e-mail account, printed out, and put in the patient’s file.

The AMA House of Delegates, in November 2010, adopted a new ethics policy with regard to professionalism and the use of social media.

 The policy reminds physicians of the ethical responsibilities they should consider when they choose to have an online presence. This includes protecting confidentiality and maintaining appropriate boundaries in the online relationship, just as in any other environment.

The flow of unexpected information about a patient or psychiatrist can have both detrimental and helpful consequences. A patient’s knowledge about the private life of a psychiatrist can affect the therapeutic relationship. The traditional neutrality of the therapist is challenged and the therapeutic framework shifts-boundaries become blurred. The intensity of rapid e-mail exchanges and the affect and pseudo intimacy they can arouse need to be anticipated.

There may be some generational differences in the expectations of privacy and self-disclosure, and how these affect the psychiatrist-patient relationship. Awareness of these issues is important. A policy can help in guiding a psychiatrist’s decisions and in providing a context of safety and comfort for the patient.

Boundaries are needed to protect the therapeutic process and ensure that competent professional services are delivered. Boundaries help prevent harm and exploitation of the patient and protect the psychiatrist from possible legal consequences. As always, care must be exercised to protect confidentiality of all psychiatrist-patient communications.

New technologies pose challenges in the need to maintain boundaries and confidentiality. The same boundaries and ethical standards that existed in the 20th century must be thoughtfully applied with all new and developing technologies of the 21st century. Psychiatrists have a special ethical duty to think through how the use of these technologies affects patients.

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 American Psychiatric Association. Ethics Corner. Is it ethical to “Google” patients? 

http://pn.psychiatryonline.org/content/44/9/11.1.full?sid=c2dc0bf6-8db7-4c8e-ac54-2f51bee067c9

 American Medical Association. Guidelines for Physician-Patient Electronic Communications. 2011.

 http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/young-physicians-section/advocacy-resources/guidelines-physician-patient-electronic-communications.shtml

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 American Psychiatric Association, Joint Reference Committee. The Internet in Clinical Psychiatry. October 2009. 

http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/ResourceDocuments/200920.aspx

Preventing Boundary Violations in Clinical Practice

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 Kane B, Sands DZ. Clinical guidelines for the clinical use of electronic mail with patients. 

 Cohen E. Should you ‘friend’ your doctor on Facebook? CNN Health. September 2009. 

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 Jain SH. Practicing medicine in the age of Facebook. 

 American Psychiatric Association. Risk management tips for physician bloggers. 

http://pn.psychiatryonline.org/content/44/18/31

 http://online.wsj.com/article/SB10001424052748703673604575550201949192336.html

 American Medical Association. AMA Policy: Professionalism in the Use of Social Media. November 8, 2010. 

http://www.ama-assn.org/ama/pub/meeting/professionalism-social-media.shtml

New technologies pose challenges in the need to maintain boundaries and confidentiality. The same boundaries and ethical standards that existed in the 20th century must be thoughtfully applied with all new and developing technologies of the 21st century.

Malkah Notman, MD

Articles

College Students Under Stress

A Look at the Ethical, Legal, and Clinical Issues Associated With Information Technology