COLLEGE MENTAL HEALTH
State medical boards restrict the practice of medicine across state lines. This paper reports on challenges faced by college psychiatrists working with college students who are temporarily out of state. The conclusions highlight the negative outcomes experienced by students from this disruption of care and lend support to a federal bill that would grant college psychiatrists a waiver to treat students in all fifty states. Such a bill would decrease treatment barriers, ensure continuity of care, and reduce poor outcomes.
There is a health crisis on university campuses across the United States. The need for mental health services for college students is staggering. The proportion of students with mental health conditions and the utilization of mental health services on campuses has continuously increased over the past decade.1 A survey of college students in the United States in the 2018 to 2019 academic year reported that 36% of students experienced depression, 31% experienced anxiety, 24% reported engaging in self-injury behavior, and 14% had suicidal thoughts.2 This translates to nearly 7 million students nationwide with mental health needs.
Many colleges and universities provide mental health services for their students on campus. However, college students are mobile, and college psychiatrists have long faced difficulties in ensuring continuity of care when students are away from school during summer and holiday breaks. This issue was amplified by the COVID-19 pandemic when students were abruptly sent home in the middle of the Spring 2020 semester. Due to federal and state regulations that mandate physicians to obtain licensure in the state where their patients are located, it has proven exceedingly difficult for college psychiatrists to meet the mental health needs of students who travel to other states. During the pandemic, licensure restrictions in most states were eased temporarily, and a law is being introduced to make licensing accommodations uniform across states.3-5 However,after the expiration of the temporary easing of regulations due to COVID-19, the longstanding issue of helping the mobile college population will still not be addressed. Malpractice insurance also varies in coverage for the practice of medicine across state lines, adding to the barrier of providing treatment for out-of-state students.6
To better understand the specific challenges of treating out-of-state students, an anonymous national survey of college psychiatrists was conducted. We hypothesized that college psychiatrists would face common challenges in ensuring continuity of care, and the survey results would lend support to a federal bill granting college psychiatrists a licensure waiver to treat students across state lines on a permanent basis.
Development of survey
A survey of 11 questions (Q) was initially developed to provide data concerning the introduction of a federal bill to address licensure regulations for college psychiatrists (scroll down for Appendix). Of the 11 questions, 9 were multiple choice and 2 (#10 and #11) requested respondents to provide a narrative response. Two of the multiple choice questions (#7 and #9) allowed respondents to select more than 1 choice. The survey was created using the free online version of Survey Planet (www.surveyplanet.com). After review of the survey results, the authors decided to publish the results in the hope that they may garner more interest and support for advocacy efforts.
The survey was emailed to a listserv of 467 members of the American Psychiatric Association’s (APA) Caucus on College Mental Health. Members on the listserv included medical students, residents, fellows, attending-level psychiatrists, nurse practitioners, and physician’s assistants. Only attending-level psychiatrists were asked to respond to the survey. The survey was encouraged to be shared with other attending-level college psychiatrists who may not be members of the Caucus. The authors are attending-level college psychiatrists and completed the survey as well. The survey was sent on May 14th, 2020, and participants were asked to respond by May 20th, 2020. Several respondents completed the survey through May 29th, 2020, and their results were included. No identifying information of the respondents were collected.
Institutional Review Board exemption
The survey was self-determined to be eligible for Institutional Review Board exemption for existing data according to exemption 45 CFR 46.101 (b)(4).7 Exemption status was documented and confirmed with completion of the Exempt Self-Determination Tool provided by the University of California, Irvine, Institutional Review Board.
Analysis of results
Results of the multiple choice questions were analyzed by the Survey Planet program. The qualitative data of the 2 narrative responses (#10 and #11) was analyzed by identifying unique negative outcomes or challenges noted by each respondent, and each outcome or challenge was tabulated in a frequency table. Responses that were related to 1 theme were grouped together by consensus of the authors.
Q 1 and Q 2: Respondents
A total of 85 responses were received: 82 attending psychiatrists and 3 non-attending psychiatrists. Only the results of the 82 attending psychiatrists are reported.
The majority of psychiatrists reported employment within a counseling center (n = 33, 40.2%). The rest worked with college students at a student health center (n = 24, 29.3%), the university department of psychiatry (n = 10, 12.2%), in group or private practice (n = 8, 9.8%) or other settings (n = 7, 8.5%).
Q 3: Number of states students were dispersed
Once the COVID-19 health emergency was declared, the majority of psychiatrists reported that students were dispersed to between 1 to10 states (n = 44, 53.7%). A smaller number reported that students were dispersed to 11 to 20 states (n = 18, 22%); 21 to 30 states (n = 10, 12.2 %); or more than 30 states (n = 7, 8.5%). Fewer than 4% of psychiatrists reported students were either not dispersed (n = 1) or unknown (n = 2).
Q 4: Out-of-state waivers
In order to comply with current state regulations, the majority of psychiatrists would need to apply for 1 to 10 waivers (n = 46, 56.1%). A smaller number would need to apply for 11 to 20 waivers (n = 12, 14.6%); 21 to 30 waivers (n=6, 7.3%); and 30+ waivers (n = 2, 2.4%). Approximately 2.4% (n = 2) did not know how many waivers they would need, and 17.1% (n = 14) did not need a waiver or did not apply for a waiver because they only worked with students in state, provided limited referral services, or for other reasons.
Q 5: Delay in processing time for waivers
For psychiatrists who did apply for state waivers (n = 25), 28% (n = 7) stated that treatment was delayed due to processing time and 72% (n = 18) reported there was no delay.
Q 6: Ethical dilemma
During the COVID-19 pandemic, a large majority of psychiatrists (n = 72, 87.8%) reported facing the dilemma of choosing between providing psychiatric care to students across state lines without a waiver versus abandoning students. Approximately 12.2% (n = 10) reported not facing the dilemma.
Q 7: Services provided out of state during the COVID-19 pandemic
Respondents were able to select more than 1 response to this question; therefore, the total n is greater than 82. Only 3 psychiatrists stopped all communications with the students. The rest provided a range of services, and the range of services provided included referrals only (n = 14), referrals plus bridge care (n = 48), full comprehensive psychiatric care via telephone (n = 48) and/or video conferencing (n = 49). A small number (n = 2) provided other services depending on availability of state waivers.
Q 8: Students without psychiatric coverage
Approximately 18.3% (n = 15) of psychiatrists reported that over 51% of their students went without care when students were out of state. Additionally, 19.5% (n = 16) of psychiatrists reported that 26% to 50% of their students went without care, and 50% (n = 41) of psychiatrists reported that 1% to 25% of their students went without care. Approximately 12.2% (n = 10) reported no students went without care.
Q 9: Primary reason students have not received care
Respondents were able to select more than one response to this question; therefore, the total n is greater than 82. The primary reasons given for students going without care when out of state included (in order of decreasing frequency) include lack of availability of care (n = 61); financial and insurance reasons (n = 56); frequent travel preventing establishment of care (n = 41); family/community opposition (n = 38); stigma with receiving care (n = 22); and other reasons (n = 13), including the student being out of the country, lack of initiative or confusion on the part of the student, or the student deciding to stop treatment.
Q 10: Negative outcome as results of interruption of care
Negative outcomes as a result of interruption of care that were commonly cited are summarized in Table 1. No negative outcome was reported by 13% (n = 11), and in 18% (n = 15), responses were not applicable or unrelated.
Q 11: Challenges in providing care to students during the COVID-19 pandemic
Despite the availability of state waivers, there were many challenges in providing care to students (Table 2). Concerns that were most frequently mentioned were related to licensing and waivers, including difficulties navigating the ever-changing, variable, and complex state requirements. Student-related factors included lack of motivation to engage in treatment, non-adherence or dropping out of treatment, students traveling state to state or out of the country, students not being aware of available resources, unsupportive family environments, and lack of insurance or financial support.
Concerns less frequently mentioned (by less than 10% of psychiatrists) are summarized in Table 2 and elaborated here. Access to care issues include lack of resources and limited psychiatrists in certain locations. Barriers in prescribing out of state include difficulty with prescription of controlled substances in other states and COVID-19-related delays in pharmacy services. Obstacles in caring for complex cases out of state include concerns about hospitalizations, delay of referrals to subspecialty services, access to higher levels of care for severely ill patients, and taking care of severely depressed patients. Problems related to telehealth include connecting students to telehealth, privacy issues, and internet connectivity. Approximately 14.6% (n = 12) reported no challenges and in 12.2% (n = 10), responses were not applicable or unrelated.
The results indicate the difficulties faced by college psychiatrists in providing care to students across state lines during the pandemic. Although many states offered waivers for licensing requirements, this did not alleviate the problem. Navigating the complexity of licensing requirements from state to state was one of the most difficult challenges for psychiatrists. Nearly 90% of psychiatrists faced an ethical dilemma: risking their license and practicing without malpractice insurance coverage or abandoning their students. Our survey showed that the vast majority of psychiatrists continued to provide care via phone or video. Many also worked to connect their students to local care.
Of major concern is that 37.8% of psychiatrists reported that over one-quarter of their students went without psychiatric care and 18.3% reported that more than 51% of their students went without psychiatric care when not in school pre-COVID-19. This result indicated that continuity of care is not a new issue in college mental health. There are many barriers for students receiving care during breaks when away from school. Reasons endorsed by psychiatrists included lack of availability of care, financial and insurance reasons, frequent travel preventing establishment of care, family and community opposition, and stigma with receiving care. Although not part of the survey questions, gaps in psychiatric care are also an issue when services on campus are closed for the summer months or when campuses face staffing shortages and cannot meet the demand in service. The survey demonstrates that the inconsistency in a student’s treatment throughout college years can result in a myriad of negative consequences, including students dropping out of treatment, worsening of symptoms/relapsing, hospitalization, and experiencing suicidality. Less commonly reported negative outcomes include persistence of symptoms; needing a higher level of care; and negative financial, academic, or work consequences.
"Even though more research can be done, the need for legislative action now is clear. College students deserve continuity of psychiatric care. We need to adjust licensing and malpractice regulations so they can receive that care in the long term, not just during emergency situations."
These poor outcomes should prompt a change of licensing and malpractice regulations for college psychiatrists now that telemedicine is an available and reliable treatment modality. Congress, universities, and governmental agencies need to collaborate to provide a standardized license across state lines for college psychiatrists. There exists a precedent of the federal government intervening to ease regulations on interstate medical care. With the passage of the Clarity Act in 2018,8 sports medicine providers are allowed to care for their student athletes in states where the provider is not licensed as long as they maintain a license in 1 state. The Clarity Act can serve as a blueprint for future developments in the regulation of interstate treatment for college psychiatrists. Telepsychiatry has shown efficacy in general psychiatry settings and university settings.9,10 If state licensure restrictions were to be lifted, telepsychiatry has the potential to solve continuity of care challenges.
One limitation of the present study is the pool from which respondents were drawn. It is possible that the responses cannot be generalized to all college psychiatrists. Not all college psychiatrists are on the APA College Mental Health Caucus listserv. Most respondents were APA members given that this listserv was used. A review of the 3 respondents whose responses were excluded because they were not attending psychiatrists revealed that their concerns were consistent with the other responses. There may also be a selection bias in those who chose to participate in the survey.
Even though more research can be done, the need for legislative action now is clear. College students deserve continuity of psychiatric care. We need to adjust licensing and malpractice regulations so they can receive that care in the long term, not just during emergency situations.
The survey results highlight the challenges college psychiatrists face in the United States in ensuring continuity of care for students who are away from school. The main challenges reported during the COVID-19 pandemic include the time-consuming process of securing waivers and state licensures, complexities related to state licensure requirements, and ever-changing state laws. College psychiatrists also reported that continuity of care was an issue before the pandemic and led to significant negative outcomes. These concerns will continue to affect the treatment of mental health disorders in college students after the pandemic has abated, just as they did before the pandemic. The challenges and negative outcomes highlighted in this study lend support to a legislative solution which would grant college psychiatrists a permanent waiver to work with college students in the United States when they travel within the country.
Dr Choy is staff psychiatrist, Student Health Center, University of California, Irvine. Dr Schweitzer is chief, Psychiatric Services, Harrison Health Center, St John's College, Annapolis, MD. Dr Bohle-Frankel is staff psychiatrist, Counseling and Psychological Services, and Feinberg School of Medicine, Northwestern University, Evanston, IL. Dr Menon is senior staff psychiatrist the Ohio State University Counseling and Consultation Service, Columbus, OH. The authors report no conflicts of interest concerning the subject matter of this article.
1. Lipson SK, Lattie EG, Eisenberg D. Increased rates of mental health service utilization by U.S. college Students: 10-year population-level trends (2007-2017). Psychiatr Serv. 2019;70:60-63.
2. Eisenberg D, Lipson SK. The Healthy Minds Study 2018-2019. Healthy Minds Network. Accessed October 5, 2020. https://healthymindsnetwork.org/wp-content/uploads/2019/09/HMS_national-2018-19.pdf
3. Federation of State Medical Boards. US States and Territories Modifying Requirements for Telehealth in Response to COVID-19. Accessed October 5, 2020. https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf
4. Wein EH, Goodman RB, Ferrante TB. COVID-19: States waive in-state licensing, requirements for health care providers. National Law Review. Accessed October 5, 2020.https://www.natlawreview.com/article/covid-19-states-waive-state-licensing-requirements-health-care-providers
5. Equal Access to Care Act. October 5, 2020. https://www.cruz.senate.gov/files/documents/Bills/2020.06.17%20-%20Equal%20Access%20to%20Care%20Act.pdf
6. Center for Connected Health Policy. Malpractice. Accessed October 5, 2020. https://www.cchpca.org/telehealth-policy/malpractice
7. Office for Human Research Protections. Human subjects regulations decision chart. U.S. Department of Health and Human Services.Accessed October 5, 2020. https://www.hhs.gov/ohrp/regulations-and-policy/decision-charts/index.html#c5.
8. US Congress. Sports Medicine Licensure Clarity Act of 2017 (H.R. 302).Accessed October 5, 2020. https://www.congress.gov/bill/115th-congress/senate-bill/808.
9. Hubley S, Lynch SB, Schneck C, et al. Review of key telepsychiatry outcomes. World J Psychiatry. 2016;6(2):269-282.
10. Khasanshina EV, Wolfe WL, Emerson EN, Stachura ME. Counseling Center-based Tele-mental for Students at a Rural University. Telemed J E Health. 2020;26(2):131-146.
APPENDIX. Survey of College Psychiatrists
1. What is your discipline?
a) Attending psychiatrist (MD/DO)
b) Resident or fellow physician in training
c) Nurse practitioner
d) Physician’s assistant
f) Other mental health professional
2. In what setting do you see college students?
a) I am employed within a University or College Counseling Center
b) I am employed within a University or College Student Health Center
c) I am employed in a University setting but under the Dept of Psychiatry
d) I am in a group or private practice seeing college students
e) I see students as a contracted consultant to a University campus
f) Other work settings
3. Once COVID-19 health emergency was declared, the students you treated were dispersed to how many states (please approximate)?
a) All students stayed in state
b) Between 1-10
c) Between 11-20
d) Between 21-30
e) More than 30
4. How many out-of-state temporary licenses or waivers would you need to apply for to be in compliance with current regulations?
a) None - did not need waiver (only treated students in state)
b) None - did not apply but provided limited referral services
c) Would need to apply for 1-10 state waivers
d) Would need to apply for 11-20 state waivers
e) Would need to apply for 21-30 state waivers
f) Would need to apply for 30+ waivers
5. If you applied for a state waiver, was treatment delayed due to processing time?
c) Not applicable
6. Did you face the dilemma of choosing between providing psychiatric care to students across state lines without a waiver versus abandoning them?
7. What types of services are you providing to students across state lines? (Select all that apply)
a) No service at all (stop all communication once students leave state)
b) Limited service - provide referrals
c) Limited service - provide referrals and bridge care until students connected with local providers
d) Provide psychiatric services via telephone
e) Provide telepsychiatry service via video conferencing
8. Prior to COVID-19, what percentage of your students go without psychiatric coverage during the summer months and on breaks while they are not on campus and out of state?
9. Prior to COVID-19, what are the primary reasons that your students have not gotten care while in another state? (Select all that apply)
a) Lack of availability of care
b) Stigma with receiving care
c) Financial and insurance reasons
d) Family/community opposition
e) Frequent travel preventing establishment of care
10. If there were negative outcomes during those breaks due to lack of care (eg, safety/medical/hospitalization, worsening of symptoms) please describe below the negative outcomes and number of cases you recall. Please do not include any identifying information. [Essay]
11. Did you experience any specific challenges in following-up with students’ care during COVID-19 pandemic despite availability of state waivers? Please do not include any identifying information. [Essay]