Journal of Adolescent Health 55 (2014) 598e599
www.jahonline.org Editorial
Improving the Identification of Mental Health Need on College Campuses As a random walk around a college campus might reveal, students who populate American colleges and universities today are a very different lot than their predecessors of the 1950s and 1960s. They are increasingly diverse with respect to gender, race/ ethnicity, national origin, and sociodemographic status [1e3]. They are seemingly also very different in their evaluated needs for mental health services. Approximately half of all college students were found to have a psychiatric disorder in a large national study [4]. Depression, suicidal ideation, and anxiety disorders are also prevalent among this population [5], and data from the American College Health Association survey reveal that suicide is the leading cause of death among college students [6]. Unfortunately, there are formidable barriers to seeking help for such needs, and only between a fifth and half of all college students with mental health burdens seek treatment services [5]. How might colleges and universities better address the mental health needs of their enrolled student population? One logical locus of intervention is with resident advisors (RAs), who are tasked with learning about residents and helping them navigate university life. This is a particular application of “task shifting,” where nonprofessionals are trained to identify possible health and mental health needs among members of their community and then to either deliver or facilitate the delivery of appropriate interventions to individuals demonstrating such needs. One such intervention approach is Mental Health First Aid (MHFA), which is “. help provided to a person developing a mental health problem or in a mental health crisis. The first aid is given until appropriate professional treatment is received or until the crisis resolves” [7]. The effectiveness and efficacy of MHFA have been demonstrated through at least two randomized control trials, an uncontrolled trial, and a qualitative study. It is currently in use in Canada, England, Finland, Hong Kong, Ireland, Scotland and Singapore; four other countries are engaged in adapting this program [7]. It has not, however, yet been studied among a college student population, a lacuna in the literature that Lipson et al. [8] address in their carefully constructed, methodologically rigorous, and spatially ambitious study published in this issue of the Journal of Adolescent Health. Between 2009 and 2011, these scholars recruited 32 colleges and universities in the United States, ran-
domized matched pairs of residence halls into MHFA and control conditions, and studied pre- and post-intervention outcomes among 553 RAs and 1990 students residing in these residence halls. They also gathered administrative information from campus counseling/mental health centers regarding utilization of mental health services by students (although not specifically for study participants), aggregated by residence hall. Their results are a mix of the null and the counter intuitive. Student participants did not differ between MHFA and control conditions with respect to their mental health knowledge, personal stigma, use of mental health services, or personal psychological distress. Instead, student participants living in residence halls that were in the MHFA condition reported lower odds of mental health impairment, treatment, and receiving informal support. MHFA also did not increase the utilization of campus-based mental health services. Its benefits seem to largely accrue to the RA trainees. RAs trained in MHFA exhibited greater amounts of mental healtherelated knowledge, greater self-perceived ability to identify mental health need among students, and increased confidence in their ability to help. In their explanations of these results, Lipson et al. examine a variety of possibilities (subsumed, rather modestly, under Limitations). They discuss biases in selection of colleges and universities into the study; methodological concerns such as timing of data collection, appropriateness of instrumentation, and conduct of multiple comparisons; and biases due to student and RA attrition over time. All these ultimately prove unsatisfactory explanations of these null effects. What, then, are we to make of these results? Conceptually, null results might be due to an ineffective intervention being deployed (intervention failure), due to an effective intervention being deployed incorrectly (implementation failure), or due to some combination of both factors. Lipson et al. primarily argue for the former, calling for more and intensive training, targeting the intervention to other nonprofessionals, and questioning their set of outcomes. Undoubtedly, these may be valid points. However, none of these explain the fact that this study may be an example of where “usual care” seems extraordinarily like the intervention. Across both conditions, roughly equal numbers of RAs report providing support to students (64% control vs. 61.3%
See Related Article p. 612
1054-139X/Ó 2014 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2014.08.007
Editorial / Journal of Adolescent Health 55 (2014) 598e599
intervention), helping students in crisis (17.1% vs. 14.1%), referring students to professional services (41.9% vs. 37.7%), and having a student receive services after such a referral (37.7% control vs. 32% intervention). At least on these study-related outcomes, RAs seem to be delivering high-quality usual care, a marked contrast from the usual care literature in adult settings [9,10], and from some of the child and adolescent mental health services literature [11], which displays clear superiority of intervention conditions over controls. In fact, the child and adolescent mental health literature on usual care is somewhat more equivocal because of the fact that clinicians in the intervention condition do not always seem to deliver what they are supposed to, and that clinicians in the control condition deliver some of the active ingredients contained in the intervention condition (please see Garland et al. for a review [12]). Should the findings of this study, therefore, be interpreted as a testimony to the excellence of American higher education in addressing the mental health needs of its students and, therefore, as grounds for complacency? Not at all, given what we know about unmet needs for mental health services among this population [13]. But it does suggest that once a student presents to an RA, the “pipeline” to services seems to be working equally effectively across MHFA and control residence halls. The challengeda variant of the “last mile” problem [14]dmay lie in getting students with mental health needs into contact with RAs (or other mental health navigators) who can assist them to seek services. In the argot of public health, this is called surveillance and encompasses activities at multiple levels on campus, including the students themselves through education, and stigma reduction, and by paying special attention to student populations at heightened risk of developing mental disorder. It would involve the social ecology of the student, including his or her academic and residence hall advisors. And ultimately, such efforts might result in campus-wide cultures and climates where mental health needs are identified and expressed without prejudice to the student. Such repurposing of goals and activities is critical to the effective reduction of mental health burdens on campus, and the stellar work of Lipson et al. goes a long way in pointing out the direction that such a repurposing might take.
599
Ramesh Raghavan, M.D., Ph.D. Brown School and Department of Psychiatry School of Medicine Washington University in St. Louis St. Louis, Missouri
References [1] Pascarella ET, Terenzini PT. Studying college students in the 21st century: Meeting new challenges. Rev Higher Edu 1997;21:151e65. [2] The chronicle of higher education. Almanac of higher education. Available at: http://chronicle.com/section/Almanac-of-Higher-Education/801/?sn; 2014. Accessed August 18, 2014. [3] Kitzrow MA. The mental health needs of today’s college students: Challenges and recommendations. NASPA J 2009;46:646e60. [4] Blanco C, Okuda M, Wright C, et al. Mental health of college students and their nonecollege-attending peers: Results from the National Epidemiologic Study on Alcohol and Related Conditions. Arch Gen Psychiatry 2008; 65:1429e37. [5] Hunt J, Eisenberg D. Mental health problems and help-seeking behavior among college students. J Adolesc Health 2010;46:3e10. [6] Turner JC. Leading causes of mortality among American college students at 4-year institutions. Presented at American Public Health Association 139th Annual Meeting Washington, DC, November 2, 2011. [7] Kitchener BA, Jorm AF. Mental health first aid: An international programme for early intervention. Early Intervention in Psychiatry 2008;2:55e61. [8] Lipson SK, Speer N, Brunwasser S, et al. Gatekeeper training and access to mental health care at universities and colleges. J Adolesc Health 2014;55: 612e9. [9] Lehman AF, Steinwachs DM, Dixon LB, et al. Patterns of usual care for schizophrenia: Initial results from the Schizophrenia Patient outcomes Research Team (PORT) Client survey. Schizophr Bull 1998;24: 11e20. [10] Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: Impact on depression in primary care. JAMA 1995; 273:1026e31. [11] Weisz JR, Jensen-Doss A, Hawley KM. Evidence-based youth psychotherapies versus usual clinical care: A meta-analysis of direct comparisons. Am Psychol 2006;61:671e89. [12] Garland AF, Bickman L, Chorpita BF. Change what? Identifying quality improvement targets by investigating usual mental health care. Adm Policy Ment Health Ment Health Serv Res 2010;37:15e26. [13] Eisenberg D, Hunt J, Speer N, Zivin K. Mental health service utilization among college students in the United States. J Nerv Ment Dis 2011;199: 301e8. [14] McCoy J. Overcoming the challenges of the last mile: A model of riders for health. In: Denton BT, ed. Handbook of Healthcare Operations Management. New York, NY: Springer; 2013:483e509.
www.jahonline.org Editorial
Improving the Identification of Mental Health Need on College Campuses As a random walk around a college campus might reveal, students who populate American colleges and universities today are a very different lot than their predecessors of the 1950s and 1960s. They are increasingly diverse with respect to gender, race/ ethnicity, national origin, and sociodemographic status [1e3]. They are seemingly also very different in their evaluated needs for mental health services. Approximately half of all college students were found to have a psychiatric disorder in a large national study [4]. Depression, suicidal ideation, and anxiety disorders are also prevalent among this population [5], and data from the American College Health Association survey reveal that suicide is the leading cause of death among college students [6]. Unfortunately, there are formidable barriers to seeking help for such needs, and only between a fifth and half of all college students with mental health burdens seek treatment services [5]. How might colleges and universities better address the mental health needs of their enrolled student population? One logical locus of intervention is with resident advisors (RAs), who are tasked with learning about residents and helping them navigate university life. This is a particular application of “task shifting,” where nonprofessionals are trained to identify possible health and mental health needs among members of their community and then to either deliver or facilitate the delivery of appropriate interventions to individuals demonstrating such needs. One such intervention approach is Mental Health First Aid (MHFA), which is “. help provided to a person developing a mental health problem or in a mental health crisis. The first aid is given until appropriate professional treatment is received or until the crisis resolves” [7]. The effectiveness and efficacy of MHFA have been demonstrated through at least two randomized control trials, an uncontrolled trial, and a qualitative study. It is currently in use in Canada, England, Finland, Hong Kong, Ireland, Scotland and Singapore; four other countries are engaged in adapting this program [7]. It has not, however, yet been studied among a college student population, a lacuna in the literature that Lipson et al. [8] address in their carefully constructed, methodologically rigorous, and spatially ambitious study published in this issue of the Journal of Adolescent Health. Between 2009 and 2011, these scholars recruited 32 colleges and universities in the United States, ran-
domized matched pairs of residence halls into MHFA and control conditions, and studied pre- and post-intervention outcomes among 553 RAs and 1990 students residing in these residence halls. They also gathered administrative information from campus counseling/mental health centers regarding utilization of mental health services by students (although not specifically for study participants), aggregated by residence hall. Their results are a mix of the null and the counter intuitive. Student participants did not differ between MHFA and control conditions with respect to their mental health knowledge, personal stigma, use of mental health services, or personal psychological distress. Instead, student participants living in residence halls that were in the MHFA condition reported lower odds of mental health impairment, treatment, and receiving informal support. MHFA also did not increase the utilization of campus-based mental health services. Its benefits seem to largely accrue to the RA trainees. RAs trained in MHFA exhibited greater amounts of mental healtherelated knowledge, greater self-perceived ability to identify mental health need among students, and increased confidence in their ability to help. In their explanations of these results, Lipson et al. examine a variety of possibilities (subsumed, rather modestly, under Limitations). They discuss biases in selection of colleges and universities into the study; methodological concerns such as timing of data collection, appropriateness of instrumentation, and conduct of multiple comparisons; and biases due to student and RA attrition over time. All these ultimately prove unsatisfactory explanations of these null effects. What, then, are we to make of these results? Conceptually, null results might be due to an ineffective intervention being deployed (intervention failure), due to an effective intervention being deployed incorrectly (implementation failure), or due to some combination of both factors. Lipson et al. primarily argue for the former, calling for more and intensive training, targeting the intervention to other nonprofessionals, and questioning their set of outcomes. Undoubtedly, these may be valid points. However, none of these explain the fact that this study may be an example of where “usual care” seems extraordinarily like the intervention. Across both conditions, roughly equal numbers of RAs report providing support to students (64% control vs. 61.3%
See Related Article p. 612
1054-139X/Ó 2014 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2014.08.007
Editorial / Journal of Adolescent Health 55 (2014) 598e599
intervention), helping students in crisis (17.1% vs. 14.1%), referring students to professional services (41.9% vs. 37.7%), and having a student receive services after such a referral (37.7% control vs. 32% intervention). At least on these study-related outcomes, RAs seem to be delivering high-quality usual care, a marked contrast from the usual care literature in adult settings [9,10], and from some of the child and adolescent mental health services literature [11], which displays clear superiority of intervention conditions over controls. In fact, the child and adolescent mental health literature on usual care is somewhat more equivocal because of the fact that clinicians in the intervention condition do not always seem to deliver what they are supposed to, and that clinicians in the control condition deliver some of the active ingredients contained in the intervention condition (please see Garland et al. for a review [12]). Should the findings of this study, therefore, be interpreted as a testimony to the excellence of American higher education in addressing the mental health needs of its students and, therefore, as grounds for complacency? Not at all, given what we know about unmet needs for mental health services among this population [13]. But it does suggest that once a student presents to an RA, the “pipeline” to services seems to be working equally effectively across MHFA and control residence halls. The challengeda variant of the “last mile” problem [14]dmay lie in getting students with mental health needs into contact with RAs (or other mental health navigators) who can assist them to seek services. In the argot of public health, this is called surveillance and encompasses activities at multiple levels on campus, including the students themselves through education, and stigma reduction, and by paying special attention to student populations at heightened risk of developing mental disorder. It would involve the social ecology of the student, including his or her academic and residence hall advisors. And ultimately, such efforts might result in campus-wide cultures and climates where mental health needs are identified and expressed without prejudice to the student. Such repurposing of goals and activities is critical to the effective reduction of mental health burdens on campus, and the stellar work of Lipson et al. goes a long way in pointing out the direction that such a repurposing might take.
599
Ramesh Raghavan, M.D., Ph.D. Brown School and Department of Psychiatry School of Medicine Washington University in St. Louis St. Louis, Missouri
References [1] Pascarella ET, Terenzini PT. Studying college students in the 21st century: Meeting new challenges. Rev Higher Edu 1997;21:151e65. [2] The chronicle of higher education. Almanac of higher education. Available at: http://chronicle.com/section/Almanac-of-Higher-Education/801/?sn; 2014. Accessed August 18, 2014. [3] Kitzrow MA. The mental health needs of today’s college students: Challenges and recommendations. NASPA J 2009;46:646e60. [4] Blanco C, Okuda M, Wright C, et al. Mental health of college students and their nonecollege-attending peers: Results from the National Epidemiologic Study on Alcohol and Related Conditions. Arch Gen Psychiatry 2008; 65:1429e37. [5] Hunt J, Eisenberg D. Mental health problems and help-seeking behavior among college students. J Adolesc Health 2010;46:3e10. [6] Turner JC. Leading causes of mortality among American college students at 4-year institutions. Presented at American Public Health Association 139th Annual Meeting Washington, DC, November 2, 2011. [7] Kitchener BA, Jorm AF. Mental health first aid: An international programme for early intervention. Early Intervention in Psychiatry 2008;2:55e61. [8] Lipson SK, Speer N, Brunwasser S, et al. Gatekeeper training and access to mental health care at universities and colleges. J Adolesc Health 2014;55: 612e9. [9] Lehman AF, Steinwachs DM, Dixon LB, et al. Patterns of usual care for schizophrenia: Initial results from the Schizophrenia Patient outcomes Research Team (PORT) Client survey. Schizophr Bull 1998;24: 11e20. [10] Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: Impact on depression in primary care. JAMA 1995; 273:1026e31. [11] Weisz JR, Jensen-Doss A, Hawley KM. Evidence-based youth psychotherapies versus usual clinical care: A meta-analysis of direct comparisons. Am Psychol 2006;61:671e89. [12] Garland AF, Bickman L, Chorpita BF. Change what? Identifying quality improvement targets by investigating usual mental health care. Adm Policy Ment Health Ment Health Serv Res 2010;37:15e26. [13] Eisenberg D, Hunt J, Speer N, Zivin K. Mental health service utilization among college students in the United States. J Nerv Ment Dis 2011;199: 301e8. [14] McCoy J. Overcoming the challenges of the last mile: A model of riders for health. In: Denton BT, ed. Handbook of Healthcare Operations Management. New York, NY: Springer; 2013:483e509.
