 proposed a new period of the life cycle in the US-

. According to this theory, distinct features characterize young people who are roughly 18 through 25 years old. This stage differs from the developmental stages of late adolescence and young adulthood. Differences include, but are not limited to, instability from successive changes in residence and romantic partners, intense introspection about future careers and intimate relationships, significant struggles in identity consolidation, and persistent ambivalence about reliance on others.

Despite the fact that there is now a professional society and journal devoted to the study of emerging adulthood and that those in child and adolescent psychiatry/psychology and college mental health, for example, wish to demarcate an area of specialty practice, emerging adulthood as a concept remains controversial and without robust research support.

 In part, this lack of research reflects that the study of adult development takes many years, is inextricably linked with cohort effects, and is highly dependent on the era in which people live. Poverty, family constellation shifts, trends in substance use, demographic changes, ethnic and gender diversity, and economics are but a few of the factors we face during our rapidly changing lifetime.

This 2-part Special Report on Young Adult Psychiatry reflects my belief that many of the clinical challenges in the treatment of young adult patients are developmentally continuous with and heavily influenced by pre-existing vulnerabilities. The challenges in providing mental health care to the college community, for example, are significant and have been well documented given the large number of students matriculating to institutions of higher education with previous psychiatric diagnoses and treatment in conjunction with those seeking mental health services for the first time.

[[{"type":"media","view_mode":"media_crop","fid":"44412","attributes":{"alt":"Â© Sergey Nivens/shutterstock.com","class":"media-image media-image-right","id":"media_crop_414655566936","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4960","media_crop_rotate":"0","media_crop_scale_h":"124","media_crop_scale_w":"175","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â© Sergey Nivens/shutterstock.com","typeof":"foaf:Image"}}]]Epidemiologically, many psychiatric disorders are disorders of young people and occur in precollege students. These include those related to substance abuse, mood and anxiety disorders, attention disorders, eating disorders, phobias, personality disorders, gender identity issues, maltreatment and abuse experiences, and schizophrenia. Although the prevalence of some of these disorders does increase between the ages of 18 and 25-and others decrease-I remind clinicians to examine childhood and adolescent development prior to high school graduation to appreciate gene-

Many of the clinical challenges in the treatment of young adult patients are developmentally continuous with and heavily influenced by pre-existing vulnerabilities.

 conducted by the CDC sampled more than 13,500 9th through 12th graders and demonstrated, among many findings, that before the 12 months of the survey

• 14.8% had been electronically bullied, and 19.6% had been bullied on school property

• 29.9% felt so sad or hopeless almost daily for at least 2 weeks that they discontinued some usual activities

• 17% seriously considered suicide; 13.6% made a suicide plan; and 8.0% made an attempt, of which 2.7% were treated by a health care professional for either overdose, injury, or poisoning

• 18.6% drank alcohol for the first time before the age of 13, and 20.8% had 5 or more drinks in a row on at least one occasion (the definition of binge drinking)

• 23.4% used marijuana on at least one occasion

• 47.7% tried to lose weight, and approximately 5% vomited, took laxatives, or used diet pills

• 7.3% were forced to have unwanted intercourse, and 17.8% had taken non-prescribed drugs (painkillers, stimulants, benzodiazepines) at least once in their life

It is undoubtedly true that the transition from high school to college is a critical time for many. Yet the identification of students who are emotionally unprepared for higher education is a major public health focus, since college mental health services are 

As the articles in this Special Report illustrate, access to psychiatric care is critical, but so too is the identification of young persons at risk-both those in college and their non-college peers (including active armed forces members and veterans)-because the consequences of untreated problems pose significant threat for lifelong success. Mindfulness and positive-psychology–based interventions are common and often helpful to many students who access college mental health programs. However, as the evidence cited in this article also reinforces, psychiatrists must treat complex disorders and behavioral problems that require sophisticated clinical psychotherapeutic and psychopharmacologic interventions, beyond stress reduction approaches.

Dr Kay is Emeritus Professor in the department of psychiatry at the Boonshoft School of Medicine of Wright State University in Dayton, OH, and Clinical Professor of Psychiatry at Tulane University School of Medicine in New Orleans. He reports no conflicts of interest concerning the subject matter of this Special Report.

 Arnett JJ. Emerging adulthood: a theory of development from the late tweens through the twenties.

Emerging Adulthood: The Winding Road From the Late Teens Through the Twenties

. 2nd ed. New York: Oxford University Press; 2014.

 Beardslee WR, Vaillant G. Adult development. In: Tasman A, Kay J, Lieberman JA, et al, eds. 

. 4th ed. Chichester, UK: John R. Wiley and Sons, Ltd; 2015. In press.

Mental Health Care in the College Community

. London: John R. Wiley and Sons, Ltd; 2010.

 Tanner JL, Reinherz HZ, Beardslee WR, et al. Change in prevalence of psychiatric disorders from ages 21 to 30 in a community sample. 

 Kann L, Kinchen S, Shanklin SL, et al. Youth risk behavior surveillance-United States, 2013. 

 First year college experience. National survey of 1,502 first-year college students examines challenging transition from high school to college [press release]. New York: The Jed Foundation; October 8, 2015.

Articles

The challenges in providing mental health care to the college community are significant. Here's a brief look at the issues.

Introduction: A Demographic With a Challenging Set of Problems

There has never been a drug that has inspired as much passion as marijuana. People join societies, go to cannabis events, join political causes, and even elect politicians based on their opinions about cannabis. Supporting cannabis legalization has become trendy and progressive, whereas opposing legalization is considered stodgy, conservative, and reactionary. And yet, for all its popular appeal, the science that has emerged on cannabis use does not look good, especially for the teenage brain.

Marijuana is by far the most commonly used illicit substance among adolescents and young adults, even surpassing tobacco use. About 45% of 12th graders and more than 50% of 18- to 25-year-olds have tried cannabis, and use is steadily increasing. In most Western societies, 15- to 24-year-olds have higher rates of cannabis use than those aged 25 and older, which demonstrates that marijuana use is particularly problematic among teenagers.

 Research has consistently shown that earlier use is associated with worse outcomes, primarily because the brain is still developing and is more vulnerable to the effects of drugs. Adolescent marijuana use has been associated with impaired memory, difficulty in learning, poorer life outcomes, and even changes in the structure and function of specific brain regions. Adolescents and young adults are also more likely than older adults to become addicted to marijuana, which has negative effects on physical, emotional, and psychological health.

To understand all the effects of marijuana on the brain, it is important to first understand what happens when delta-9-tetrahydrocannabinol (THC), the main psychoactive compound found in marijuana, enters the brain. THC acts on cannabinoid receptors, which are located throughout the brain. The endocannabinoid system helps regulate a variety of functions by monitoring how active neurons are and how much neurotransmitter is released. The neurotransmitters that are affected by THC affect pleasure, mood, pain, appetite, motivation, memory, and muscle activity.

The endocannabinoid system helps keep brain cell activity in balance, and when THC artificially stimulates cannabinoid receptors, this disrupts the function of the natural cannabinoids. An overstimulation of these receptors in key brain areas produces the marijuana “high,” as well as its other effects on mental processes. Over time, this overstimulation can alter the function of cannabinoid receptors, which-along with other changes in the brain-can lead to addiction and to withdrawal symptoms when drug use stops. The endocannabinoid system is also important in regulating brain development. Because it helps control neuron activity, it plays a major role in brain wiring (ie, how brain cells “learn” when to grow new synapses and how to connect to other neurons).

[[{"type":"media","view_mode":"media_crop","fid":"44419","attributes":{"alt":"Â© nisargmedia.com/shutterstock.com","class":"media-image media-image-right","height":"140","id":"media_crop_5850791849746","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4963","media_crop_rotate":"0","media_crop_scale_h":"127","media_crop_scale_w":"125","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â© nisargmedia.com/shutterstock.com","typeof":"foaf:Image","width":"138"}}]]One of the reasons that many people think that cannabis is harmless is that there are many myths about marijuana (

). The most common myth is that marijuana is not addictive. This has clearly been debunked by science; marijuana is addictive, particularly for young people. Marijuana addiction resembles other drug addictions: it is characterized by loss of control over consumption, loss of interest in activities not involving cannabis, recurrent use resulting in failure to fulfill major obligations, continued use despite negative consequences, and even its own cannabis withdrawal syndrome.

As with other addictions, cannabis-dependent individuals are characterized by compulsive drug-seeking, loss of control, and the use of marijuana despite significant problems associated with its consumption. About 90% of those who seek treatment for cannabis-related substance disorders report difficulty in achieving and maintaining abstinence.

 Adults who seek treatment for marijuana dependence average more than 10 years of daily or almost daily use and about 6 attempts to reduce or stop consumption.

Perhaps the myth that marijuana is not addictive began because among adults the addiction rate is 9% (meaning that drug dependence develops in 9% of marijuana users); thus, it is not as addictive as other drugs such as cocaine and tobacco (

 However, 9% of 18 million marijuana users is a considerable number. Furthermore, for adolescents, the addiction rate jumps to 17%, meaning that dependence will develop in nearly 1 out of every 6 teenage marijuana users. For daily marijuana users, it is estimated that 25% to 50% will become addicted.

The second myth is that marijuana use has no long-term effects. This is a tough myth to dispel because, unfortunately, few studies have actually examined long-term effects. Longitudinal studies in general are notoriously expensive and difficult to complete, and marijuana use in particular simply was not a focus of attention until very recently. Probably the most thorough long-term study was published in 2012.

 In this study, researchers assessed IQ in children aged 7, 9, 11, and 13 years, before the onset of cannabis use, as well as over several years in adulthood. Participants who used marijuana most regularly had an 8-point drop in IQ from childhood to adulthood. One of the most striking findings was that this IQ drop occurred only in those users who had cannabis dependence before the age of 18. Adolescent marijuana users exhibit worse cannabis-related effects on learning and memory than adult users. MRI scans show that cannabis exposure during adolescence has significant effects on brain volume, the folding patterns of the cortex, neural connectivity, and white matter integrity.

An issue to consider with long-term research is that these studies are testing people who started using cannabis 20 or 30 years ago. The marijuana that was smoked back then is very different from what is smoked today-it is practically a different drug. THC is present at much higher doses today than it was even in 1990.

 Animal studies have shown that THC has dose-dependent neurotoxic effects on brain regions rich in cannabinoid receptors, which means the effects are greater at higher doses. It is plausible that studies on long-term effects of cannabis underestimate the effects on the brain.

The media spreads many myths regarding marijuana as a treatment for mental health disorders such as depression, anxiety, and even PTSD. However, there is little evidence of this; in fact, research has shown that cannabis use is associated with an increased risk of developing mental health disorders, particularly psychotic disorders. This is especially true in persons who start using cannabis during adolescence. Although a causative role of cannabis for psychosis is still being debated, epidemiological and neurobiological research suggests that individuals with a predisposition to schizophrenia are more vulnerable to the psychosis-inducing effects of marijuana.

One of the first studies on marijuana and schizophrenia followed 50,465 Swedish adolescents over 15 years and found that individuals who used cannabis heavily by age 18 were 6 times more likely to develop schizophrenia than those who did not use cannabis.9 Several longitudinal studies have also shown an increased risk of depression in cannabis users compared with non- users, and the level of risk increases with earlier initiation and more frequent use.

 It is important to note that many other variables such as age of exposure, amount of cannabis use, childhood trauma, and a family history of psychotic illness affect the relationship between marijuana use and the development of mental health issues. But almost universally, these relationships tend to be strongest in those who start to use when they are young.

So what does all this mean for clinicians? This is a particularly important question because teenagers are likely receiving mixed messages from parents, teachers, friends, and especially the media. I would start with a few things that we can say confidently. First, we know that marijuana is addictive. Maybe not for everyone, and maybe not as addictive as tobacco, but we know that 1 in 6 teenagers will become addicted, and this addiction-just like addiction to alcohol or cigarettes or cocaine-affects neural mechanisms underlying tolerance, changes the reward system of the brain, and is associated with a distinctive withdrawal syndrome.

Second, we know that marijuana affects learning and memory. We do not know precisely how robust these effects are, how long-lasting they are, or whether they resolve after abstinence-more research needs to be done-but what we do know is that marijuana affects learning, memory, and decision-making capacity.

Third, although we may someday discover therapeutic components of cannabis that can be purified-which may eventually be useful for mental health treatment-the current state of science does not show the benefit of smoked marijuana for psychological conditions; in fact, marijuana use likely worsens symptoms. Fourth, and of greatest importance to teenagers, we know that nearly all negative effects of marijuana (eg, brain changes, neurocognitive deficits, addictive potential) are worse in teenage than in adult users.

These facts underscore the need for useful clinical interventions, including prevention, early detection, and treatment, for cannabis use disorder among adolescents. Prevention is the most promising approach to reducing cannabis use in teenagers. Many prevention programs can be implemented in schools. A meta-analysis of school-based prevention programs found that the most effective programs reduced cannabis use in adolescents by 27.9%.

Another promising area for reducing cannabis use disorders is effective screening. The CRAFFT questionnaire and the Brief Screener for Tobacco, Alcohol and Other Drugs can be used with youths.

 There are a variety of treatments to help teenagers with problematic marijuana use. Brief interventions may be effective; adolescents who received a brief motivational intervention called Project CHAT used less cannabis compared with a control group who received usual care.

More comprehensive treatment may be needed if teenagers develop patterns of problematic use. These treatments include cognitive behavioral therapy (CBT), motivational enhancement therapy (MET), family therapy, and contingency management. The largest psychotherapy trial to date is the Cannabis Youth Treatment Study, which included 600 adolescent cannabis users randomized to 5 treatment interventions that were different combinations of CBT, MET, and family therapy.

None of the 5 interventions was superior to the others, but all treatments reduced the amount of cannabis use, demonstrating that any intervention in which teenagers can talk about and reflect on their drug use may be effective. There are currently no pharmacological treatments for cannabis use disorders, although some are being developed.

Teenagers need to know that cannabis has very real effects on how they think, process information, and make decisions, and that it may even affect their mental health. Young people face unique challenges during the transition from adolescence to young adulthood, and this is a formative time for them to make important decisions about college, career choices, and relationships-decisions that require clear thought. Although everyone is entitled to their opinion on the pros and cons of marijuana legalization, health practitioners need to counter, with scientific facts, the message that cannabis is harmless to the teenage brain.

Dr Gilman is Assistant Professor in the department of psychiatry at Harvard Medical School, and a neuroscientist at the Center for Addiction Medicine of the Massachusetts General Hospital in Boston. She reports no conflicts of interest concerning the subject matter of this article.

 Jonston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the future: national results on adolescent drug use. 2012. 

http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2011.pdf

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 Copeland J, Rooke S, Swift W. Changes in cannabis use among young people: impact on mental health. 

 Anthony JC, Warner LA, Kessler RC. Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants; basic findings from the National Comorbidity Survey. 

 Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. 

 Lisdahl KM, Wright NE, Kirchner-Medina C, et al. The effects of regular cannabis use on neurocognition in adolescents and young adults. 

 Wrege J, Schmidt A, Walter A, et al. Effects of cannabis on impulsivity: a systematic review of neuroimaging findings. 

 Office of National Drug Control Policy: Executive Office of the President. April 2012. 

 AndrÃ©asson S, Engstrom A, Allebeck P, Rydberg U. Cannabis and schizophrenia: a longitudinal study of Swedish conscripts. 

 Brook DW, Brook JS, Zhang C, et al. Drug use and the risk of major depressive disorder, alcohol dependence, and substance use disorders. 

 Fergusson DM, Horwood LJ, Swain-Campbell N. Cannabis use and psychosocial adjustment in adolescence and young adulthood. 

 Patton GC, Carlin JB, Degenhardt L, et al. Cannabis use and mental health in young people: cohort study. 

 Rey JM, Sawyer MC, Raphael B, et al. Mental health of teenagers who use cannabis: results of an Australian survey. 

 Porath-Waller AJ, Beasley E, Beirness DJ. A meta-analytic review of school-based prevention for cannabis use. 

 Kelly SM, Gryczynski J, Mitchell SG, et al. Validity of brief screening instrument for adolescent tobacco, alcohol, and drug use. 

 Knight JR, Sherritt L, Harris SK, et al. Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT, POSIT, CAGE, and CRAFFT. 

 D’Amico EJ, Miles NJ, Stern SA, Meredith LS. Brief motivational interviewing for teens at risk of substance use consequences: a randomized pilot study in a primary care clinic. 

 Dennis M, Godley SH, Diamond G, et al. The Cannabis Youth Treatment (CYT) Study: main findings from two randomized trials. 

 Gray KM, Watson NL, Carpenter WJ, et al. N-acetylcysteine (NAC) in young marijuana users: an open-label pilot study. 

For all its popular appeal, the science that has emerged on cannabis use does not look good--especially for the teenage brain.

Cannabis Use in Young Adults: Challenges During the Transition to Adulthood

There are 4706 degree-granting institutions of higher education (IHE) in the US with 21 million students.

 Of these IHEs, 63% are traditional 4-year schools that typically provide mental health care for enrolled students. A much lower percentage of 2-year schools provide these services. These institutions are seen as a pathway to a better life by US students and close to 1 million international students.

 An increasingly diverse cohort of students is coming to campus with a wide array of mental health challenges and concerns. The nature of the setting and the types of students who are coming to campus are essential to understanding the context for this article.

Decades ago, students in these settings would seek care for developmental issues, relationships, and life direction. Medications were few and far between (eg, TCAs, diazepam, chlordiazepoxide, chlorpromazine), and many were problematic by today’s standards. Today more serious issues such as suicide, self-injury, eating disorders, substance abuse, and bipolar disorders are common concerns. The medications have become better, with greater efficacy and fewer adverse effects. College mental health today looks more like community mental health as students are matriculating with more significant mental health histories than in the past.

[[{"type":"media","view_mode":"media_crop","fid":"44423","attributes":{"alt":"Â© wavebreakmedia/shutterstock.com","class":"media-image media-image-right","id":"media_crop_614154258740","media_crop_h":"206","media_crop_image_style":"-1","media_crop_instance":"4964","media_crop_rotate":"0","media_crop_scale_h":"158","media_crop_scale_w":"200","media_crop_w":"260","media_crop_x":"7","media_crop_y":"3","style":"float: right;","title":"Â© wavebreakmedia/shutterstock.com","typeof":"foaf:Image"}}]]As evidence of the level of distress seen nowadays among university students, the American College Health Association’s survey based on 79,266 students at 140 IHEs in 2014 revealed that at some point in the previous 12 months, 33% of students reported feeling so depressed that it was difficult to function, 46% of students felt hopeless, 54% experienced overwhelming anxiety, 8% seriously considered suicide, and 1% attempted suicide.

 It is also noteworthy that nationwide the percentage of adults who have serious thoughts about suicide is highest among persons aged 18 to 25 (7.4%).

 The number of completed suicides among college students is half that of their non-student peers, largely thought to be because of restrictions on firearms on college campuses.

There are several explanations for the growth in serious difficulties. The first is that medications are frequently started in middle school and high school but often without the benefit of counseling. Or only limited counseling is provided in school, which-with parental support-helps students graduate from high school. In college, symptoms increase when students encounter greater academic and psychosocial challenges.

Second, the Americans With Disabilities Act requires schools to provide reasonable accommodations for students with disabilities, and mental health issues fall under that category. Historically, students often hid their disability, but now they declare it and seek accommodations.

Finally, while infrequent on any given campus, recent high-profile acts of violence as well as the threat assessment movement have shaped the national dialogue and given college mental health a higher profile. Consequently, IHEs have developed an increased sense of responsibility for providing comprehensive mental health care to students, and many campuses have experienced an increase in staffing and programs for both outreach and treatment.

Every day, counseling center directors are typically faced with balancing increased clinical demands, providing training to new professionals, overseeing outreach to the community, ensuring that electronic patient records systems are working appropriately, maintaining quality control, and keeping up staff morale. At the same time, they must wrestle with stable and sustainable models for funding these efforts.

Providing mental health care for students at today’s IHEs involves responding to expanding levels of complexity. It requires strong clinical skills and a willingness to participate in a highly interactive and interpersonally connected community. Psychiatrists who practice in these settings are usually part of agencies with a focus on the entire campus community, beyond the individual patients. This involves consultation with colleagues in the clinics where they work, such as therapists and primary care physicians, and in the academic world, such as deans, faculty members, and student affairs personnel. Many of the patients have recently become legal adults; however, their parents expect ongoing involvement in their care, and the students experience ambivalence about such involvement.

A basic issue regarding psychiatry on campus is whether it is actually available. The most recent Association for University and College Counseling Center Directors Survey indicates that one-third of IHEs have no psychiatric services; on another third, services are available only at the counseling service; and on 13% of campuses, psychiatry is available only in the health service.

 On campuses where no psychiatric services are available, psychotropic medications are prescribed by psychiatrists in the local community or by primary care physicians in the student health center with limited collaboration with therapists, or medication is not available at all.

Working with campus health and counseling services

Psychiatrists who work within a health service can facilitate access to essential medical workups to clarify complicated diagnoses, which can sometimes be attributed to physical causes. Once a diagnosis has been established, they can prescribe the most appropriate medication. On the other hand, reporting within a counseling service can make collaborating and sharing information with counseling center psychotherapists much easier.

Although the role of psychiatrists is often medication management because of budgetary reasons, many psychiatrists also provide significant support and insight to student patients. With somewhat longer follow-up appointments and shorter waiting periods between appointments than typically found in the community, a deeper treatment relationship can develop than one might have in a more typical “medication management” role.

Psychiatric residents sometimes provide care in college mental health centers. This involvement is less common and typically occurs when a university’s training program is affiliated with its student health center or when there is a relationship between the counseling center and a residency program. These may be short elective rotations, although they work better when a resident can be present for a full semester or academic year. Post-residency fellowships are also a very good fit for longer-term training in college mental health.

Within the varied administrative structures, psychiatrists who work in IHEs are confronted with a level of psychopathology that defies common stereotypes. The Center for Collegiate Mental Health, a data bank of nearly 300 college counseling services that provide care to more than 100,000 students, has reported that nearly one-third of students presenting for care have already had at least one trial of psychotropic medication; approximately 10% have had a psychiatric hospitalization; 30% reported seriously considering suicide; and 9% had attempted suicide.

These data provide a thumbnail sketch of the type of cases a psychiatrist in higher education may be asked to treat. The college years encompass the age of first onset for multiple psychiatric illnesses; therefore, psychiatrists are often on the front lines in responding to students who experience their initial episode of a bipolar disorder, their first psychotic break, or their first major depressive episode. Psychiatrists in IHEs are involved in risk assessments and transferring students to local hospitals as needed. They also are point people for communicating with the hospital during treatment and follow-up care at discharge.

Alcohol abuse continues to be a prevalent challenge, is sometimes combined with abuse of other drugs, and is frequently comorbid with other mental health disorders. The diversion of prescription medications is another serious concern. This is common with medications prescribed to treat ADHD. Students frequently seek prescriptions for stimulants to help them focus and give them an edge in highly competitive academic environments, opening up the pathways for considerable abuse.

Determining the need for medications is time-consuming and complex. Different settings have different solutions: while some IHEs do not allow stimulants to be prescribed, some have restrictive policies, and others have no clear rules. The hardy nature of this age group often means psychiatrists can see very high levels of substance use that do not immediately affect students’ academic functioning, although there may be other serious consequences such as physical injury, blackouts, trouble with the law, and sex without consent.

Eating disorders are another common concern that can go undiagnosed in this setting. Students present with a wide range of these symptoms from sub-threshold levels to life-threatening presentations. Many students need a higher level of care but are so focused on their academic work that they are unwilling to seek that care voluntarily. Meanwhile, psychiatrists and other mental health care clinicians are expected to develop plans to respond effectively.

Sexual assault continues to garner considerable national attention. Practicing in this setting requires an understanding of the US Department of Education Office of Civil Rights Title IX regulations about the rules and responsibilities of faculty and staff at an IHE. Having a keen multicultural understanding is also essential to this work. Issues related to racism and bias can negatively affect students’ willingness to seek care, and data show that microaggressions and blatant incidents of bias have a negative impact on student mental health.

 Given this complexity, it is important to understand what the day-to-day work of psychiatrists in this setting looks like.

W is an 18-year-old Asian American freshman majoring in engineering. She grew up in Queens, NY, with her biological parents and younger brother. She is a first-generation college student. Upon moving to campus, she became self-conscious and felt that others were criticizing her appearance and social skills. She focused solely on her academic work and isolated herself. Social contact was limited to the dining hall and library. She made no close friends over the semester and finished with a grade point average disappointing to both her and her parents.

W dreaded returning to school after winter break, but her parents pushed her to return. At school, she began going out on weekends with students from her residence hall, using alcohol to feel accepted and less fearful. Over the following month she drank 3 or 4 nights a week, consuming 8 to 10 drinks a night with occasional blackouts. One evening her residence advisor (RA) found her in the hallway, intoxicated and tearful. The RA attempted to refer her to the counseling service but she refused, fearing her parents’ disappointment. She was willing to go to a “Let’s Talk” counseling center outreach site near her residence hall to informally consult with a counselor from the university’s counseling service.

 At the Let’s Talk visit the next day, she revealed sleeping up to 12 hours, eating one meal a day, a loss of interest in schoolwork, difficulty concentrating, trouble motivating herself, and low energy. In addition, she hesitantly shared that she often felt that others were watching her, whispering her name and laughing. She said that for the first time in her life she wondered if she would be better off dead.

The Let’s Talk counselor walked W to the counseling service and scheduled her for a same-day psychiatric intake appointment. The psychiatrist made a diagnosis of major depression, single episode, severe with psychosis, alcohol use disorder, and a rule out social phobia, and recommended that W begin a trial of citalopram and aripiprazole. W refused medication saying that her parents were against it. She agreed to abstain from alcohol and to meet with her academic advisor to discuss a reduction in her course load.

She followed up with a counselor 2 days later and with the psychiatrist later the same week. In the subsequent therapy session she reported that she felt unsafe in her room, hearing people outside of her window criticizing her. When asked about suicidal thoughts, she acknowledged that she was contemplating walking into a field with a bottle of vodka and drinking until she passed out, hoping she would freeze to death. Her treatment team engaged campus police and the ambulance service and had her transferred to a local hospital. She was successfully treated and received support from the school’s mental health staff. With her permission, her family was contacted and became involved in decisions about her treatment. W took a voluntary medical leave of absence but continued on her medication. She returned to campus 8 months later and reinitiated supportive treatment with the therapist and psychiatrist.

The care provided through counseling and medication management in W’s case worked. National data support the conclusion that mental health care provided on university campuses produces “positive change observed . . . equivalent to that documented in Randomized Controlled Trials for Depression, Generalized Anxiety, Social Anxiety, Eating Concerns, and Hostility.”

Practicing at an IHE often allows for access to medical consultation, specialized psychotherapy, laboratory services, community outreach, and other services difficult to find in many community settings. The treatment of the concerns outlined in the case vignette and the potential for rapid evaluation and treatment increase the likelihood that students will remain in school and achieve academic success. Working with a population that is motivated, intelligent, and insightful makes the university setting a particularly rewarding environment.

Dr Meilman is Director of Counseling and Psychiatric Services and Professor in the department of psychiatry at Georgetown University in Washington, DC; Dr Eells is Director of Counseling and Psychological Services and Associate Director of Gannett Health Services at Cornell University in Ithaca, NY; Dr Mendola is Assistant Director for Psychiatry, Counseling and Psychological Services at Cornell University; Dr Lillrank is Assistant Director for Psychiatry, Counseling and Psychiatric Services at Georgetown University. The authors report no conflicts of interest concerning the subject matter of this article.

 National Center for Education Statistics. Fast Facts. 2015. 

https://nces.ed.gov/fastfacts/display.asp?id=84

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http://www.iie.org/Who-We-Are/News-and-Events/Press-Center/Press-Releases/2014/2014-11-17-Open-Doors-Data

 American College Health Association National College Health Assessment II. Spring 2014 Reference Group Executive Summary.

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 Drum DJ, Brownson C, Denmark AB, Smith SE. New data on the nature of suicidal crises in college students: shifting the paradigm. 

 Association for University and College Counseling Center Directors Annual Survey. Reporting period: September 1, 2013 through August 31, 2014. 

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 Center for Collegiate Mental Health. 2014 Annual Report. 

http://ccmh.psu.edu/wp-content/uploads/sites/3058/2015/02/2014-CCMH-Annual-Report.pdf

 Boone M, Eells GT. Reaching students who won’t walk in: innovative outreach programs offer options. 2008. 

https://www.gannett.cornell.edu/cms/services/counseling/caps/talk/upload/Reaching-Students-Who-Won-t-Walk-In.pdf

 New J. A ‘chilly climate’ on campus. January 8, 2015. 

https://www.insidehighered.com/news/2015/01/08/report-details-microaggressions-campuses-students-color-and-women

Psychiatrists can provide significant support and insight to patients who are now coming to campus with a wide array of mental health challenges.

Working Within a Campus Health Service: A Challenge With Many Rewards

Young adult psychiatry addresses the needs of transitional-age youth typically between the ages of 15 and 26 years. The phenomena of transitional age difficulties are a result of cultural and societal changes in which physiologic maturity (as marked by chronological age and biological development) and the acquisition of skills necessary for independent adult life in modern society are not aligned; this may be due to chronic illness in childhood, which is on the rise, or changes in parenting or other psychosocial difficulties. Society is confused about the roles and responsibilities of youth, as noted by Giedd:

Age-of-consent questions are particularly enmeshed in political and social contexts. For example, currently in the United States a person must be at least 15 to 17 years old . . . to drive, at least 18 to vote, buy cigarettes, or be in the military, and at least 21 to drink alcohol. The minimum age for holding political office varies . . . some municipalities allow mayors as young as 16 . . . , governors from 18 to 30. The age of consent to sexual relations varies worldwide from puberty . . . to age 18.

The inverse situation is illustrated in the legal entity of emancipated minors, which recognizes certain youth as developmentally or functionally advanced beyond their chronological age of less than 18 years once they demonstrate certain adult competencies (eg, financial self-sufficiency, marriage, caretaking of children, military service).

[[{"type":"media","view_mode":"media_crop","fid":"44425","attributes":{"alt":"Â© Alex Tor/shutterstock.com","class":"media-image media-image-right","id":"media_crop_8283121832594","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4965","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 94px; width: 150px; float: right;","title":"Â© Alex Tor/shutterstock.com","typeof":"foaf:Image"}}]]Young adulthood is a time of increased motivation, opportunity, and risk-taking, but also of increased risk for the onset of multiple, highly prevalent psychiatric disorders. Mood and anxiety disorders typically present during late adolescence and in the early twenties. There is a heightened risk of substance abuse disorders due to incompletely developed impulse control coupled with increased access to drugs. Eating disorders and the first break for early-onset psychosis also peak within this age range.

Disorders from childhood and adolescence, such as ADHD and autism spectrum disorders, continue to affect function, but at a higher degree that cannot be as easily accommodated by families and educational or therapeutic systems. Popular expressions such as “extended adolescence” or “failure to launch” focus concern on the individual’s deficits, but it is important to consider a developmental perspective that recognizes the challenges of the family and the clinical system in transitioning youth as well. So, who is responsible for treating the adolescent and young adult and when and how should transitions in care occur?

When to refer a young patient to an adult psychiatrist

Child and adolescent psychiatrists practice within a moving developmental frame and may work with adolescents and young adults as they enter adulthood for continuity of care. However, pediatric psychiatrists may choose to refer the patient to an adult psychiatrist for several reasons. The volume of emerging young adults would quickly saturate pediatric providers’ patient load. Educational or employment transitions can result in a geographic move that makes access to childhood providers difficult. Child and adolescent psychiatrists may treat multiple members of a family, and referral to another clinician may help separation and foster the patient’s individuation process.

When a patient is reluctant to transition to adult services, pediatric psychiatrists may recognize dynamics that resist change to the treatment configuration, such as avoidance due to anxiety about more independent functioning, leaving an established doctor-patient relationship, unacknowledged dependence on the family support that pediatric treatment providers offer, and reaction to an enactment of parental loss or abandonment. With support, the patient can be guided through the sense of loss and normal grief in such a transition. Thus, planning for the transition, on the part of the child psychiatrist as well as the receiving adult psychiatrist, requires forethought as much as a year before the actual transition if possible.

Issues in accepting transitioning patients

When adult providers begin to work with adolescents and young adults and their families who have transitioned from child psychiatry, reviewing confidentiality and setting treatment boundaries avoid confusion between the treatment models. Pediatric psychiatrists operate with a family-informed developmental model that may incorporate routine communication with parents to direct supportive changes in the home. Families may have the expectation that their child’s treating psychiatrist will freely release information. A review of confidentiality policies at the first meeting should outline how information (that will be more regulated in its release and with the child’s permission) will be exchanged by the adult psychiatrist with the family.

As children negotiate their own space apart from parents, there may be a greater need to establish clear boundaries. Information-gathering meetings with the family should be discussed beforehand with patients to define the level of disclosure and role of the session. Family sessions may also be balanced with separate meetings with significant others and families of choice, as this recognizes the importance of extra-familial relationships and invites other adult perspectives on a patient’s history.

Developmental discontinuity to adult functioning

There are several situations that can hinder a smooth segue to adult functioning. Young adulthood is a period when mood or psychotic disorders may first present, and it may be a difficult, clinically unstable period. For youths who have had periods of severe symptomatology, their caretakers may have provided too much accommodation out of a sense of overprotection, thereby enabling avoidance of challenges during adolescence. Consequently, these youths may not have had opportunities to develop skills to function autonomously, and they may stall from anxiety or regress when adult expectations are placed on them.

Alternately, if an adolescent received inadequate supervision, there may be hidden or minimized development of symptoms that worsened with disengagement from treatment. With the additional loss of parental support at 18, these youths fall off the treatment radar until nonadherence results in relapse. With decreased supervision, young adults may have increased access to settings where recreational drugs are available, just as they have also reached the legal age limit for the purchase of alcohol. Some vulnerable youth may have undertreated substance abuse or be self-treating mood and anxiety symptoms with substances, all of which can undermine appropriate adult coping.

Not every young person has mastered skills of independent functioning by the age of 18, so the transitional age range reflects the discontinuity that can appear between chronological age and developmental maturity. Some families (such as those with high-conflict divorces or another family member with chronic illness) may be dependent on the child’s presence or other benefits they bring to the household, and the family destabilizes when the adolescent attempts to functionally individuate or leave. The young adult experiences himself or herself as the cause of the family’s distress and delays transitioning in order to stabilize the family.

J is a 17-year-old high-performing junior at a competitive high school when she presents for psychiatric care for acute MDD with suicidal ideation and prominent anxiety features, in the context of increasing academic demands, declining grades, new-onset self-injury, and social withdrawal. She requires 2 inpatient hospitalizations for recurrent suicidal ideation of jumping in front of the subway en route to school.

Her distress decreases as academic adjustments are discussed, antidepressant medication is initiated, and her parents agree to therapeutic support for her. However, she has difficulty stepping down to a partial hospitalization program as she finds family meetings hard to tolerate because of the high level of tension between her parents, and she is often absent from the program the day after family meetings. She engages in individual outpatient medication management and psychotherapy more easily but is nonverbal or angry during periodic family sessions. This is followed by worsening urges for self-injury and thoughts of self-denigration and punishment.

J is unable to return for her senior year in high school because of exacerbation of symptoms, and she ambivalently receives home instruction. She continues in outpatient treatment, but with no clear progress developmentally or educationally.

After several months, J discloses in therapy that there is longstanding, mutual physical domestic violence between her parents, and she is frequently drawn into the fights in her attempts to stop their conflicts. She is concerned about her mother’s apparent depression and her father’s dissociative reactions after fights.

It is identified that the mother’s strong positive transference to J’s individual therapist has been particularly helpful in opening up the parents to treatment, but this secret has never been revealed outside the home. J realizes her perfectionism and academic excellence had initially served to refocus her parents and reduced the number of fights at home in her early years, and now the onset of her MDD and academic failure serves the same purpose. She states that she is afraid to leave home for fear that without her presence and intervention, her parents could inadvertently disable or kill each other.

After a discussion with the entire family, child protective services is contacted and the report is filed with a concurrent request from the parents for voluntary home-based services. The parents also agree to begin couples’ therapy to address relationship dynamics that existed before J was born, and to start to consider individual treatment. This allows J to release some of the caretaking and sense of responsibility she has toward her parents. J chooses to pursue her senior year of high school at a therapeutic boarding school that offers support for her anxiety and depression symptoms, and she is able to consider applying to local colleges.

As J’s 18th birthday approaches, transition to adult care is discussed with her and her parents. Although J has a strong therapeutic alliance with her adolescent psychiatrist and psychotherapist who have worked with her since her first hospitalization, she expresses a desire to find treatment closer to her boarding school and to separate from those who are working collaboratively with her parents. She feels that her parents will continue to struggle with safety in their relationship; although she restricts communication, her mother continues to leave messages for J’s therapist.

Several options that accept J’s insurance are identified and discussed with her over several months. She chooses an adult mental health center that offers group therapy options and specialized treatment for trauma. She allows communication between her pediatric and new adult teams, but restricts communication with her parents despite their expressed preference. She successfully transitions to living in a dorm at a college within the state but outside of her hometown.

Because adolescents and young adults have experience with pediatric providers who use a range of developmental approaches and may be family focused, transition-age patients are usually more comfortable with a practical, emotionally “real” therapeutic engagement with adult therapists. Changes in continuity of care are always challenging. When providing care to transitional patients, consider selective, therapeutically appropriate emotional disclosure during initial sessions to convey your concern, worry, or interest to foster the patient’s engagement and trust.

Building a quick alliance by joining a rejecting stance toward the family of origin is equivalent to building on sand, because this serves to externalize blame and erodes opportunities for reflection and practicing mature responsibility. This also sets up a framework for the projection of blame onto other responsible adults in the young adult’s life, such as bosses, teachers, and friends, which may later extend to the new therapist.

If families are too easily blamed for mistakes that the young adult makes, it impedes the patient from being motivated to problem-solve and may later emotionally block the patient from reaching out to his family when the family can be a supportive resource. A more balanced stance toward the family as a resource-available but separate from the patient-is less likely to result in scapegoating and emotional isolation. Recognize the practical support that families provide to young adults (financial, educational, access to health care, cultural, interpersonal) rather than discard access to these resources, while balancing appropriate boundaries to allow room for individuation.

Assume that young adult patients have not yet mastered independent living skills or achieved functional autonomy, although they may present themselves as doing so. Ask for examples of functioning, and listen for feedback from peers and family members to assess the actual level of independence. Colluding with a young adult’s self-idealization will create a therapeutic dilemma when the patient must acknowledge that he is in trouble. The patient may instead present with a series of crises or perceived victimizations over time due to repeated losses of jobs, housing, and relationships due to unperceived skills deficits.

Make an opportunity early in treatment to hear concerns from the family, and then openly review these concerns with the patient with therapeutic curiosity in a separate session. Note the specific language that is used by families to describe the patient’s historical roles or symptoms, because these labels and stories will be a window into the patient’s view of himself.

Managing confidential information and records

The ability to control access to confidential medical information comes with legal adult status. Youths may not be aware of how their treatment information was released or managed in the past, so a careful review of this history with parents can avoid unpleasant surprises. Young adults may need to be encouraged to allow transfer of medical files and records from pediatric services, and guided through the decision to release information to work or educational settings for appropriate support. Some patients benefit from receiving a hard copy of their records followed by a review with a clinician; this will enable patients to answer questions about their treatment and learn how to provide a medical and psychiatric history.

Spend some time reviewing who should receive updates on treatment, and ask the patient to sign appropriate release forms in sessions without the presence of parents to minimize pressure on the patient to release information. Proactively addressing the change in communication with the parents will avoid conflicts that can later arise from perceived rejection or estrangement. Review with family members that providers may receive unrestricted information from the outside, but are limited by confidentiality to release information, so that the parents understand that sharing their concerns with providers continues to be a valuable way to support their child.

Young adults beginning treatment with new adult providers benefit from a thorough review of their medication. They may have assumed independent management of their medication administration and can benefit from a simplified regimen if possible to maximize adherence. It is common for young adults to express a desire to discontinue medications taken since childhood. This may stem from differing views on pathology, a symbolic pushing away of parental labels, or a desire to distance themselves from their illness history. To avoid nonadherence, it is appropriate to redo the informed consent process and review indications for each medication, which will remind the patient of how the medication can help him in functioning and reaching goals. Risks and benefits of each medication should be presented to the patient, because the effects and adverse effects that his parents agreed to in the past may no longer be acceptable. Closely screen for the patient’s current level of substance use, which may have changed with decreased supervision, for the possible impact on regimen adherence, medication levels, and treatment effectiveness.

Patients who have both psychiatric and medical illnesses, particularly young adults with chronic illness (autism spectrum disorder, HIV infection, diabetes) or severe or terminal illnesses (which may require timely review of end-of-life planning), may require additional supports. Maintenance of health in young adults with chronic illnesses strongly depends on a smooth transition to adult care.

Although experiencing the loss of a caring doctor-patient relationship is difficult, providers reluctant to transfer care after long-term work may need to assess their own countertransference. Consider transitioning in a graduated stepwise manner, or plan a multidisciplinary meeting and structured communication between pediatric and adult services; consider including parents, especially if the parents are divorced and there is considerable animosity. The 

 provides suggestions for making the transition easier.

Young adults who are transitioning out of foster care, state custody, or probation placement must master adult skills without the normal scaffolding of family support and may also require additional meetings with agency providers. The presence of a developmental delay or intellectual or other permanent disabilities presents additional challenges. Services may be divided into separate treatment tunnels (eg, school services, employment support, family treatment, therapeutic services) and require extra communication to transition services.

Dr Yoon is an Assistant Attending Psychiatrist at the New York Presbyterian Hospital and an Assistant Professor of Psychiatry in the Division of Child and Adolescent Psychiatry at Weill Cornell Medical College in New York. Dr Pao is Clinical Professor in the Department of Psychiatry at the Georgetown University School of Medicine and Clinical Director of the National Institute of Mental Health, National Institutes of Health, in Bethesda, MD.

 Giedd J. Adolescent brain maturation. Encyclopedia on Early Childhood Development. November 2010. 

http://www.child-encyclopedia.com/brain/according-experts/adolescent-brain-maturation

 Turkel S, Pao M. Late consequences of pediatric chronic illness. 

• AACAP’s Youth in Transition: Moving into Adulthood Resource Center: 

http://www.aacap.org/AACAP/Families_and_Youth/Resource_Centers/Home.aspx

• National Alliance on Mental Illness (NAMI) Teens & Young Adults Section 

http://www.nami.org/Find-Support/Teens-and-Young-Adults

• Got Transition by the nonprofit Center for Health Care 

• National Collaborative on Workforce & Disability for Youth (NCWD-Youth) 

Who is responsible for treating the adolescent and young adult with psychiatric issues -- and when and how should transitions in care occur? 

Challenges of Transitioning From Pediatric to Adult-Oriented Care

We’ll live and love with all our might.

I’ve been this way since seventh grade.

But this morning I couldn’t recall the name

my wife tells me, Just another normal, age-

related change in memory. But I never forget

patients’ stories, their drugs and dosages,

every co-pay, deductible, and tiered pharmacy

benefit insurance companies use to bully me

High, mocking me with names like “prescriber”

and “provider” when they know I’m a doctor,

helpless as the moment a medic at a military

physical gropes your groin and orders, “Turn

your head and cough,” me just another Boomer

flying through the corporate spawn of LeMay’s

Buddy Holly over Clear Lake, still practicing

three chord rock, practicing with all my might.poe

My penmanship sucks. So does my typing. I’ve been this way since seventh grade...

Still Practicing

The Fisher Wallace website declares: “New pilot study finds the Stimulator ® effective in treating bipolar depression: FDA-cleared wearable device available to treat six million bipolar depression patients.”

Is this true? Well, it’s true that such a study has been published-a small randomized trial in patients with bipolar II.

 Now it’s up to you to evaluate the results, because patients who have $700 may be asking you to sign the authorization form to buy one of these devices ($600 for veterans-an interesting twist). Or they can just buy an Alpha-Stim, another device used for cranial electrotherapy stimulation (CES), without any authorization. Perhaps you should buy one of these devices and make it available for patients to try, so they won’t spend their cash until they know it works for them.

The author scrutinizes the results of a new pilot study that finds the Fisher Wallace Stimulator® effective in treating bipolar depression.

Vol 32 No 12

Introduction: A Demographic With a Challenging Set of Problems

Cannabis Use in Young Adults: Challenges During the Transition to Adulthood

Working Within a Campus Health Service: A Challenge With Many Rewards

Challenges of Transitioning From Pediatric to Adult-Oriented Care

Still Practicing

Cranial Electrotherapy Stimulation for Bipolar Depression: New Data

Physician Health and Professional Secrecy

No News Is Not Good News

Psychiatric Care of Peripartum Women

The Evil Hours

Update on Bipolar Disorder, Part 2: Bipolar Depression and Cyclothymic Disorder

Psychiatry’s Solid Center

Delayed Suicides of “The Forgotten Battalion”