Students who regularly used marijuana and those who increased their use mid-college utilized health care services more often and had higher levels of depressive and anxiety-related symptoms up to 7 years after college.8 Substance use may also be an independent risk factor for suicide, and it is important to recognize this during risk assessments, especially in adolescents and young adults. In college students, the co-occurrence of substance use behaviors and mental health problems (eg, major depression, panic disorder, generalized anxiety disorder) was associated with higher odds of cigarette smoking. Among the 67% with co-occurring frequent binge drinking and mental health problems, only 38% received mental health services in the past year.9
The most recent data from the National College Health Assessment survey reported that 35% of undergraduates felt so depressed it was difficult to function in the past year, 58% felt overwhelming anxiety, and a staggering 10% seriously contemplated suicide.10 This contrasts with low reports of college students who received treatment for depression (13%), anxiety (15.8%), and substance abuse (1%). Given the established bidirectional relationship between substance abuse and depression and anxiety, as well as the clear increased risk of suicide with substance abuse, this information is alarming for families, college campuses, and mental health providers alike.
Among the 20.2 million adults aged 18 or older in 2014 who had a past substance use disorder, 2.3 million (11.3%) also had a serious mental illness.6[PDF] It is clear that substance abuse during the early college years is significant and that the potential consequences are not only imminent but may be lasting. However, this also presents an opportunity to make a change early because a large number of youths transitioning to adulthood on college campuses can be reached during this vulnerable period.
Primary prevention on college campuses
Colleges and universities are especially critical for early intervention, given that they are the gateway to adulthood for nearly half of the US population and that the college years are the period during which young adults initiate or increase drug use.1
In terms of comorbidities, approximately 1% of adults in the general population met criteria for both mental illness and substance use disorder in the past year.6 Delivering interventions in settings where students who have problems with alcohol are most likely to be seen, such as in health or counseling centers, may be most effective. Research shows that several carefully conducted community initiatives aimed at reducing alcohol problems among college-age youths have been effective, leading to reductions in underage drinking, alcohol-related assaults, emergency department visits, and alcohol-related crashes.11
One strategy to increase participation in these interventions is to make screening routine in university health centers and to use new technology to reach a larger percentage of students.12 A review of computerized and web-based brief interventions for college students suggested that personalized feedback may be the key component in this strategy’s success, both in motivating students and in helping them learn the skills they need to successfully change their behavior.13
Anonymous mandatory surveys during new and returning student orientation could dually serve to increase college administrators’ awareness of the prevalence of substance use and allow the student to reflect on his or her substance use patterns. However, using universal screenings as a means of mandating treatment referrals may result in under-reporting and thus limit their utility to both administrators and students. New college students, in particular, are only beginning to appreciate that honest information does not always result in restriction or punishment. This allows an opportunity to establish a relationship that is more likely to result in a partnership with college administrators and potentially with clinicians in the future.
Another strategy to improve prevention and increase participation of students is to develop a system of referral and financial penalties for students who are disciplined for substance-related infractions, such as a mandated intervention at campus student health. These types of practices may prevent the escalation of alcohol or drug use in students who are just beginning to experiment with substances.
The most critical skill for clinicians is to recognize problem drinking or substance use behaviors. Keep in mind that most college students have only recently been released from parental oversight; thus, the most effective approach is likely to be non-confrontational and nonjudgmental and to lack paternalism. The AUDIT (Alcohol Use Disorders Identification Test) is a commonly used 10-item alcohol screening tool.14 It has been shown to be effective in the college population, with a sensitivity of 91% when compared with a more comprehensive diagnostic interview. Findings indicate that the AUDIT-C, which consists of the first 3 items from the AUDIT, is effective at detecting at-risk drinking in the college population (Figure 1).15
Dr Blevins and Dr Khanna are third-year psychiatry residents in the department of psychiatry and neurobehavioral sciences at the University of Virginia Medical School in Charlottesville, VA. The authors report no conflicts of interest concerning the subject matter of this article.
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