Public health emergencies may present a range of unanticipated potential stressors to vulnerable patients and communities. Psychiatric patients can be disproportionately affected by these conditions due to pre-existing health disparities, lack of resources, or limited executive functioning under stress, all of which may impede effective responses during an emergency. As college students comprise a demographic with a growing burden of mental illness, public health emergencies pose special challenges to this population.
College students are uniquely vulnerable to both everyday stressors and severe mental illness, and psychiatric symptoms among college students appear to be on the rise. Stress, anxiety, depression, suicidal ideation, and self-harm all appear to be increasing among this population.1-3 Suicide is currently the second most common cause of death in this age range, and the rate of suicide continues to climb.4
These psychiatric symptoms can have a widespread effect on the overall health of students as mental health conditions and viral diseases remain linked by a range of biological and behavioral pathways, with mechanisms varying by viral illness.5 While depression and stress may increase vulnerability to viral infection, depressive symptoms may also lead to a delay in help-seeking or reduced likelihood of detection of health conditions including communicable diseases.6 Studies show that people with severe mental illness (SMI), including schizophrenia, bipolar disorder, schizoaffective disorder, and major depressive disorder, have an excess mortality that is two- or three-fold higher that in the general population, shortening life expectancy by 13 to 30 years.7
The current public health emergency in response to COVID-19 has disrupted life on many university campuses, and increased anxiety and distress in many college students. There are a litany of reasons that college students may encounter unique challenges, stressors, and barriers to mental health treatment.
Many universities have extended spring breaks to delay the return of students to campus so campus leadership can have more time to prepare for a potential health care crisis and implement infection precautions. Other universities have cancelled all events, shifted to online classes, or ended their semester early. Many students have been mandated to vacate their dormitories with only a few days’ notice.
Dormitory evacuation is a stressful scenario for college students. International students may not be able to return home. Students from families with financial stressors, marginal housing, or other challenges that limit their capacity for support may have disproportionate difficulty arranging last-minute transportation and housing. Food insecurity, a significant problem affecting students with limited financial resources, may worsen if college cafeterias close or financial aid for the academic year is cut off.8-10 As local businesses close, it will be more difficult for students to find low-wage jobs to earn income. At home, some students do not have the technological infrastructure to be able to keep up with online classes and engage with their now-virtual social communities, leading to academic stress and further social isolation. The few students who are granted exceptions to the evacuation mandate will be isolated in otherwise vacant campus dormitories with significantly limited services.
Other students may be quarantined due to perceived risk of spreading the virus. These students may lose opportunities critical to their scholarly or professional advancement. The social isolation and decreased activity during quarantine may exacerbate rumination and feelings of hopelessness. The circumstances could understandably perpetuate stress, anxiety, and low mood.
Even students not under quarantine and from well-resourced families are stressed about the rapidly changing and uncertain climate of relocations, academic deadline changes, shifts to online teaching modalities, and cancellation of anticipated events such as graduation ceremonies. In a population that is already vulnerable to mental health problems (eg, anxiety, depression) and is simultaneously experiencing a potentially traumatic public health crisis, these stressors may lead to clinically significant psychiatric symptoms and illness. This is compounded by the social isolation intrinsic to many of the containment efforts as well as the potential stigma and limitations of accessing psychiatric care at home and having to switch from typical sources of on-campus support.
Dr Conrad is a Fellow at Harvard Medical School; Ms Rayala is an MD Candidate at the University of Michigan Medical School; Dr Menon is a Senior Staff Psychiatrist at The Ohio State University and Co-Chair of the American Psychiatric Association Caucus on College Mental Health; Ms Vora is an MD Candidate, Harvard Medical School. The authors report no conflicts of interest concerning the subject matter of this article.
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