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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.
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.
College mental health services must swiftly respond to this changing landscape to support their students during this stressful and potentially isolating experience. Many are attempting to rapidly shift to virtual visits and other forms of telemental health. However, building technological infrastructure and negotiating reimbursement takes time. While a range of legislative and regulatory hurdles had previously restricted the use of telemental health, state governors and regulatory agencies are taking action to eliminate barriers and expand use of telehealth to both protect clinicians and improve access for patients.
New York Governor Andrew Cuomo authorized the New York Licensed Office of Mental Health Programs to waive sections of regulatory requirements pertaining to telehealth to reduce barriers and increase access to mental health treatment across the state (Ann Marie Sullivan, MD, personal communication, March 11, 2020). This aims to streamline the approval process governing telehealth in order to increase the number of providers who can utilize telehealth to treat patients.
The Ohio Department of Mental Health and Addiction Services announced expansion of telehealth for the treatment of mental health and substance use concerns during the COVID-19 pandemic (Lori Criss, personal communication, March 14, 2020). This measure will permit telephone encounters, eliminate the requirement that new patients must be seen in-person for their initial encounter, and increase flexibility of monitoring medication-assisted treatment of opioid use disorders. This will allow patients to establish and continue mental health and substance use treatments during the pandemic.
Massachusetts Governor Charles Baker has mandated that health insurers must cover telehealth services, reimburse these services at the same rates as in-person encounters, and cannot require prior authorizations on these services.11 Furthermore, an additional executive order mandated that providers in Massachusetts can provide care to patients in other states who were enrolled in college in Massachusetts during this academic year.12
Requirements that clinicians have a license to practice in the state where the patient physically resides is a significant barrier for college students continuing mental health treatment after their campus evacuation. Many students may stay with family members in a state different from their university and be left unable to receive services from on-campus mental health providers.
Some universities who had implemented a telemental health platform in a limited capacity prior to the pandemic were often able to more rapidly roll out online resources with relative ease. For example, Johns Hopkins University was able to provide their entire student body access to a secure online cognitive behavioral therapy program within one week because of a prior trial based on a grant from the Substance Abuse and Mental Health Services Administration (Holly Wilcox, MA, PhD, personal communication, March 12, 2020).
Less conventional communication modalities may create access for students who are juggling logistical challenges and find it difficult to regularly attend in-person appointments during a relocation or quarantine. Many clinicians have expanded their use of telephone appointments as hurdles related to both privacy and billing have been gradually addressed (Melissa Eshelman, MD, personal communication, March 16, 2020).
Some universities are inviting students within driving distance to attend in-person appointments although students are encouraged to reschedule or use telehealth if they are medically symptomatic. A few psychiatrists, who are seeing patients in-person, have relocated to larger offices to maintain social distancing during sessions (Melissa Eshelman, MD, personal communication, March 16, 2020). However, as the pandemic expands, many such as The Ohio State University are transitioning to solely telehealth appointments and encouraging staff to work from home as much as possible.
As mental health clinicians provide services with more flexibility, psychiatrists are reducing barriers as well. Programs that had previously enforced policies regarding providing medication refills only during in-person appointments have liberalized their stance to include prescribing refills based on a phone encounter, allocating more refills, or providing 90-day rather than 30-day prescriptions. Many college mental health clinics are implementing practices typically utilized at the end of the semester in preparation for potential coverage gaps during summer break.
Some Intensive Outpatient Programs (IOPs) and Partial Hospitalization Programs (PHPs) are transitioning to telemental health delivery while others have stopped accepting new patients. IOPs and PHP are important levels of care for our system to both limit psychiatric hospitalizations and facilitate safer discharges from psychiatric hospitals. As these programs care for the highest-risk patients outside of psychiatric hospitalizations, it is crucial to develop innovative ways to deliver these services.
Anticipated clinician shortages across the entire health care system may affect university mental health clinics as well as clinicians, as family members are quarantined and schools and childcare centers close. While many programs hope to facilitate telehealth appointments that can be utilized from clinicians’ homes, if resource scarcity and clinician shortages become severe, it may be necessary to triage urgent appointments while minimizing routine follow-up.
College students are psychiatrically vulnerable, psychiatric patients are physically vulnerable, and the current circumstances on college campuses are exceedingly stressful and potentially socially isolating. Given these factors, college students are likely at an elevated psychiatric risk right now, and college mental health services must adapt to support their students during these circumstances. Continued enactment of legislation and regulatory changes that facilitates telemental health and allow treatment across state lines is critical to ensuring adequate mental health treatment access for college students during this pandemic.
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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