Journal of American College Health
ISSN: 0744-8481 (Print) 1940-3208 (Online) Journal homepage: http://www.tandfonline.com/loi/vach20
Psychiatrically Hospitalized College Students: A Pilot Study Arthur S. Rosecan MD , Richard L. Goldberg MD & Thomas N. Wise MD To cite this article: Arthur S. Rosecan MD , Richard L. Goldberg MD & Thomas N. Wise MD (1992) Psychiatrically Hospitalized College Students: A Pilot Study, Journal of American College Health, 41:1, 11-15 To link to this article: http://dx.doi.org/10.1080/07448481.1992.9936301
Published online: 09 Jul 2010.
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Date: 14 November 2015, At: 09:45
Psychiatrically Hospitalized College Students: A Pilot Study
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Arthur S. Rosecan, MD; Richard L. Goldberg, MD; and Thomas N. Wise, MD
Abstmct. This pilot study presents data on an underreported group: college students who require psychiatric hospitalization. Although the study is too small to sustain broad generalizations, the authors found indications of significant correlations between students’ hospitalization and the academic cycle, substance abuse, and distance from home. It is hoped that other institutions will undertake similar studies of this group of students to provide a broader body of data from which to draw inferences regarding prevention, intervention, and psychiatric hospitalization. Key Words. psychiatric diagnoses, psychiatric hospitalization, psychiatric treatment, substance abuse
ost college students who seek mental health evaluation or treatment are not psychiatrically hospitalized. A 1985 study of psychiatric emergencies in college students reported that 28.3% of psychiatric emergencies seen at the University of Rochester’s Psychiatric Emergency Department were admitted to the psychiatry service.’ The psychiatric literature has characterized the student population in the outpatient but has not focused on the characteristics of college students who required hospitalization. This pilot study describes Georgetown University undergraduate students admitted to an inpatient psychiatry unit at Georgetown University Hospital over a 3-year period. We examined demographic information, history of previous treatment, presence of alcohol or drug abuse, stressors, family involvement, changes in global assessment of functioning, and discharge diagnoses and disposition. In our evaluation of these data, we addressed two basic questions: (1) What are the characteristics and needs of college students in a university Arthur S. Rosecan is a psychiatrist in private practice in Leesburg, Virginia; Richard L. Gohiberg is a p r o f a o r and chairman of the Department of Psychiatry at Georgetown University Hospital in Washington, DC; and Thomas N. Wke is vice chairman of the Department of Psychiatty at Georgetown and chairman of the Department of Psychiatry at the Fairfa Hospital in Fairfa, Virginia. VOL41, JULY 1992
teaching hospital mental healthcare unit? (2) What are the implications regarding evaluation and treatment of college students for mental healthcare professionals? METHOD
We reviewed patient logs, discharge summaries, and hospital charts from the mental healthcare unit to identify Georgetown University undergraduates among the patients admitted between January 1, 1987, and December 31, 1989. The unit is an unlocked, voluntary, general adult psychiatry unit for patients 16 years of age and older. We collected demographic data for each student admitted to the unit and, when feasible, assessed and quantified the student’s functioning at the time of hospital admission and at discharge, using the Global Assessment of Functioning (GAF) Scale. The GAF is a standardized instrument developed for this purpose6 and used as Axis V of the DSM-I11 (Diagnostic and Statktical Manual of Mental Dkordem, 3rd ed, American Psychiatric Association) multiaxial diagnosis. Although students from other area universities were hospitalized at Georgetown University Hospital during the 3 years we studied, we included only Georgetown University students in the study for two reasons. First, dormitory residence advisors, deans, and roommates could make more information available about preadmission functioning, predischarge meetings on the ward, and postdischarge plans for Georgetown students than we could get for undergraduates from other universities. Second, Georgetown University undergraduates constituted. a uniquely identifiable population. Those who were psychiatrically hospitalized could be reasonably compared with their peers who sought outpatient mental health services or with other Georgetown undergraduates in a future study. RESULTS
Forty-eight separate admissions of Georgetown students to the mental healthcare unit occurred over the 11
COLLEGE HEALTH
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3-year period of our study. One student was admitted twice in 1989, and another was admitted twice, once in 1987 and again in 1989. The remaining 44 admissions correspond with individual students hospitalized one time at Georgetown University Hospital.
TABLE 1 College Students Admitted to Mental Healthcare Unit by Month of the Year
Month
1987
1988
1989
Total
1
0
0 0 2 2 0
1 1 1 1 1 1
1 3 4 4 3 1 2 1 10 7 6 4
Gender. In 1987, 5 men and 10 women were admitted to the inpatient unit. The predominance of women was reversed in 1988 (9 men and 6 women admitted) and in 1989 (10 men and 8 women). The proportion of 24 male and 24 female students reflected the ratio in the Georgetown undergraduate population as a whole, which is 49% male, 51% female. We found no significant differences between the men and the women associated with race or class year; mean GAF scores at admission, discharge, or during the year before hospitalization; or the mean length of stay in the hospital.
January February March April May June July August September October November December
Race. Thirty-five (76%) of the students in this sample were white, 8 (17%) were black, and 2 (4%) were Asian, and the race of 1 was not listed. These figures closely resembled the racial background of all undergraduates admitted to Georgetown’s entering class of 1989: 77% white, 10% black, 8% Asian, and 5% Hispanic, ~ ’ ( 1 )= .414, p = .5198.
?Two students were admitted twice.
College class. We found no significant association between college year and either a history or admitting diagnosis of drug or alcohol abuse. College year was not associated with GAF change when GAF change was partitioned above and below the median. There was also no significant association with college year and family involvement or past medical or psychiatric history. Birth order. No significant differences in the birth order of the students admitted to the inpatient unit were found. Seasonal variance. There was a significant relationship with seasonal time of admission, in that sophomores and freshmen were more likely to be admitted in the first 2 months of each term, whereas juniors and seniors were more often admitted in the other months of the academic year, ~ ~ ( = 1 ) 10.54, p = .005 (Table 1). Previous psychiatric treatment. Thirty students had plcvious outpatient mental health treatment and 9 students (7 women and 2 men) had previously been hospitalized for psychiatric treatment. Family psychiatric history. Twenty-five students had a family history of psychiatric illness. Past medical history. Nine undergraduates had a history of past or current medical illness serious enough to require hospitalization, surgery, invasive procedures, or chronic medical care. Alcohol or substance abuse. Ten students (aU men) presented evidence of alcohol abuse at admission. Twelve students (10 men), seven of whom were among 12
0 2 3 1
0 0 0 0 2 1 2
1 1 2 3
0 6
2
2
2 -
1 -
1 -
-
13
15
18
46t
3
those who had alcohol abuse at admission, also reported a history of past alcohol abuse. Three had evidence of current drug abuse at admission, and 13 (9 men) admitted to past drug abuse. Nine students had a prior history of both alcohol and substance abuse. All diagnoses of substance abuse were comorbid with other major psychiatric diagnoses. Suicidal ideation at admission. Thirty-three students (59%)were admitted with suicidal ideation. Accompaniment to the hospital. Records of who, if anyone, accompanied the student to the hospital were frequently incomplete. Of the 23 admissions where data were available, 2 individuals were mentioned most frequently: 9 of the students were accompanied by resident directors or resident assistants of the campus residential life program, and 8 were accompanied by roommates or friends. Distance from home. Twenty-one of the admitted undergraduates’ homes were more than 500 miles away from the university; 17 were from between 100 and 500 miles away; and homes of 4 students were less than 100 miles away. The distance from home could not be obtained for 4 students. Thus, 90% of the hospitalized students’ homes were more than 100 miles from school. The data also revealed a significant association between distance from home and family involvement on the inpatient unit. When students were closer to home, families were more frequently involved on the inpatient unit, ~ ’ ( 3 )= 10.179, p = .017. Stressors. The most common identifiable stressors for hospitalized students (48%) were related to the academic cycle (eg, return to school, midterm examinations, holidays, end of school year). Academic difficulties and pressure (17010), family discord (12%), sexual JACH
PSYCHlATRICALLY HOSPITALIZED STUDENTS
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identity issues (9Oro), and roommate problems (8%) were also noted. Length of stay. We found significant annual variation in students’ length of stay in the psychiatric unit. In 1988, more patients stayed more than the median of 14 days, g(2) = 10.819, p = .0044. As noted, we did not find any difference in length of stay for men and women. First-year students were not overrepresented during any of the 3 years we studied. The length of stay was more commonly below the median of 14 days if the patient had a prior drug history, ~ ‘ ( 1 )= 4.74, p = .03, or had documented drug use upon admission, Fisher’s exact test p = .OO01. By contrast, there was no significant association of length of stay and alcohol abuse, either at admission or by prior history of such abuse. Finally, the length of stay was more frequently above 14 days when the student had a past medical history, Fisher’s exact test p = .OO01. Family involvement. Thirty-two (67070) of the hospitalized students had some family involvement, with one or both parents attending a meeting during the hospital stay. This involvement was strongly encouraged and facilitated by the unit staff. As already mentioned, there was a significant correlation between family involvement and nearness to home. Family involvement, however, did not correlate with a difference in the length of 3 ) .89, p = .387, or change in glohospital stay, ~ ~ ( 4 = bal assessment of functioning between admission and discharge from the unit, ~’(41)= .86, p = .392. Global assessment of functioning. The GAF scores at admission, discharge, and during the year prior to admission did not significantly correlate with a history of previous drug use or of drug usage on admission, nor with a history of alcohol abuse in the past or at admission, nor in cases with family involvement. The mean GAF at admission did significantly improve by discharge, t(42) = 11.63, p = .OO01. The correlation between GAF measures and the length of stay was not significant. Return to college. Of the 48 admissions, 27 (56%) showed students had returned to college following discharge. Fourteen of the students (29%) did not return to school immediately, most opting to arrange for a medical leave of absence. Post-discharge data on 7 students were not available. Irregular discharges. Eight undergraduates were discharged against medical advice. One was discovered to have gone AWOL, did not return, and was discharged. Another was administratively discharged after refusing repeated attempts to engage her in treatment; the other six patients signed AMA discharge papers. Medication at discharge. Twenty-two students (46%) were on psychotropic medication at discharge.
diagnoses, major depressive episode (29Vo) and adjustment disorder (21%), accounted for 24 of the 48 primary diagnoses. Bipolar disorder and eating disorders accounted for an additional 18% of the primary diagnoses. Eleven other diagnostic entities account for the remaining 19 primary diagnoses (Table 2). DISCUSSION
An average of 16 undergraduates a year requiring psychiatric hospitalization out of a total undergraduate population at Georgetown University of 5,547 in 19887 represents an incidence rate of 2.9 per 1,OOO undergraduates per year. How this rate compares with other campuses is unknown because of a lack of published data. The equal proportion of male and female students admitted, although it reflects the ratio in the undergradOne uate population as a whole, is rather intere~ting.~ might have predicted a higher proportion of female admissions, mirroring prevalence rates in other clinical settings. Failure to find this gender effect in undergraduate psychiatric admissions may be the result of a tendency of male students to delay, or to reject, seeking help in the outpatient setting until a problem grows to crisis proportions and necessitates admission. From the standpoint of mental health professionals who see college students, several points are noteworthy, regardless of treatment setting. Analysis of the data revealed that first-year students and sophomores were more likely to be admitted to the hospital in the first 2 months of each term, often before any major academic testing. Although students across all 4 years identified stressors related to the academic cycle as the major contributors to their hospitalization, first-year and sophomore students may be more vulnerable to the psychological aspects of separating from the home setting. Leav-
TABLE 2 Discharge Diagnoses of College Students Admitted to Mental Healthcare UnR
Diagnosis Major depressive episode Adjustment disorder with depressed mood or depressed and anxious mood Bipolar affective disorder, manic or mixed Anorexiahulimia nervosa Drug abuse Borderline personality disorder Organic affective disorder Organic delirium Panic disorder Schizoaffective disorder
Schizophrenifonndisorder Alcohol abuse Dysthymic disorder Personality disorder, not other specified Total
Number 14 10 5 4 3
3 2 1 1 1 1 1 1 1 48
Discharge diagnoses. The two most frequent primary VOL 41, JULY 1992
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COLLEGE HEALTH
ing home and familial loved ones to attend college represents, for most late adolescents, the longest and most significant separation of their lives. This can create and exacerbate vulnerabilities in students who are at risk for psychiatric problems. Distance from home could play a role in the perceived magnitude of separation: 90% of the students hospitalized were more than 100 miles away from home. Data about distance from home were not available to compare this hospitalized student population with the total student population, but Georgetown University is not a community college, so it is probable that most students’ homes were more than 100 miles from Washington, DC. Our data did, however, suggest that greater geographic distance led to less family involvement when the patient was on the inpatient unit. Geographic distance could also be an obstacle for student health personnel and resident life directors in promptly getting in touch with parents to avert a crisis. An activist stance for university staff members functioning in loco parentis seems justified in a crisis. Sixty-five percent of the hospitalized students had a prior psychiatric history, and 54% had a family history of psychiatric illness. Although comparisons with the general student population were not possible, these percentages might demonstrate that students with previous psychiatric treatment (especially psychiatric hospitalization) and family psychiatric histories may also be at increased risk. Because separation issues in the first 2 years of college may play a role leading to psychiatric hospitalization, it would be particularly interesting to discern whether such childhood psychiatric conditions related to separation issues as school phobia are later proportionally overrepresented in the population of college students who are psychiatrically hospitalized. Students with those risk factors already noted may require the active intervention of campus mental health professionals and the university system. The availability of residence life advisors, counseling center professionals, pastoral counselors, student health psychiatrists, and academic advisors represents a network of primary prevention for identifying and stabilizing students who are at risk. The data on accompaniment to the hospital are an indication of this vital role. The use of partial hospitalization, day hospital, or day treatment programs may be useful for stabilizing these students. This activist approach may be especially appropriate for the 56% of students in this study who returned to college after discharge from the hospital. Proper arrangements for these students to be followed as outpatients in student mental health settings need to be made by hospital staff prior to hospital discharge. Students whose admission is known to the residential life staff could also be monitored by that staff in an ongoing manner to assure compliance with outpatient follow-up. The data in our study also contain implications for mental health professionals who are working on an inpatient psychiatry unit. College students are a distinct 14
population on such units. They typically present in crisis, stabilize in hours or days, and focus very quickly on discharge. Multidisciplinary staff members face the challenges of stabilizing the student in crisis, dealing with safety issues, conducting a diagnostic evaluation, forming a treatment plan, engaging family members in the process, performing liaison roles with university administration and student health services, and facilitating outpatient (including substance abuse) follow-up. These tasks must be undertaken within an average 14-day stay (an exception occurs when the student presents with concomitant medical illness) for college students on the unit studied and with students’ family members usually living at some distance. The challenges of treating this population in the acute hospital setting, therefore, require an adequate multidisciplinary team during peak seasonal periods. The clinical usefulness of hospitalization for these students is demonstrated by significantly improved mean GAF scores at the time of hospital discharge for the total student group hospitalized. The capacity for reintegration reflected in these numbers is not surprising, given that students represent a preselected group chosen by an office of undergraduate admissions and that admission is based on, among other qualities, past accomplishment and personal adaptivity. The range of discharge diagnoses assigned to the study subjects does not differ substantially from that described in a study of an outpatient university population: “Depressive symptoms, irrespective of severity, presence of clear precipitants, pattern of recurrence, or chronicity, account for the majority of this population’s diagnostic ~ariance.”~ The presence of bipolar affective disorders, eating disorders, substance abuse, personality disorders, organic brain disorders, panic and psychotic disorders round out the picture of those students who required psychiatric hospitalization. SUMMARY
We have reported on a retrospective study of a small group of students from a single university who were followed only briefly after discharge. Unfortunately, no comparison group was available and the psychiatric literature reports virtually no similar studies. These limitations make it impossible to draw broad generalizations from the data presented. The experience in treating college students reported here, however, may offer a glimpse of who requires hospitalization and when and may suggest some implications for mental health professionals who see college students. It is hoped that other university medical centers will undertake similar studies and thus establish a databank on psychiatrically hospitalized college students. The information provided would be helpful in preventing and treating mental illness in this group, whose potential for regression is balanced by their potential for personal growth and contributions to society. JACH
PSYCHIATRICALLY HOSPITALIZED STUDENTS REFERENCES
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1. Perlmutter RA, Schwartz AJ, Reifler CB. The college student psychiatric emergency: 11, Diagnosis and disposition. J Am Coll Health. 1985;33:152-158. 2. R i m e r J, Halikas JA, Schuckit MA. Prevalence and incidence of psychiatric illness in college students: A four-year mospective study. J Am Coll Health. 1982:30207-211. - 3. Stangler RS, Printz AM. DSM-111: Psychiatric diagnosis in a university population. Am J Psychiatry. 1980;137(8): 937-940.
Promote a Healthier Campus With Three New Resources from ACHA
4. Thompson JR, Bentz WK, Liptzin MB. The prevalence of psychiatric disorder in an undergraduate population. J Am Coll Health. 1973;21:415-422. 5. Reifler CB. Epidemiological aspects of college mental health. J Am Coll Health. 1971;19:157-163. 6. Endicott J, Spitzer RL, Fleiss J, et al. The Global Assessment Scale. Arch Gen Psych. 1976;33:766-771. 7. Georgetown 1989, Profile for Schools and Candidates. Washington, DC: Office of Undergraduate Admissions, Georgetown University, 1989.
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VOL 41, JULY 1992
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15
ISSN: 0744-8481 (Print) 1940-3208 (Online) Journal homepage: http://www.tandfonline.com/loi/vach20
Psychiatrically Hospitalized College Students: A Pilot Study Arthur S. Rosecan MD , Richard L. Goldberg MD & Thomas N. Wise MD To cite this article: Arthur S. Rosecan MD , Richard L. Goldberg MD & Thomas N. Wise MD (1992) Psychiatrically Hospitalized College Students: A Pilot Study, Journal of American College Health, 41:1, 11-15 To link to this article: http://dx.doi.org/10.1080/07448481.1992.9936301
Published online: 09 Jul 2010.
Submit your article to this journal
Article views: 7
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Citing articles: 2 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=vach20 Download by: [Deakin University Library]
Date: 14 November 2015, At: 09:45
Psychiatrically Hospitalized College Students: A Pilot Study
Downloaded by [Deakin University Library] at 09:45 14 November 2015
Arthur S. Rosecan, MD; Richard L. Goldberg, MD; and Thomas N. Wise, MD
Abstmct. This pilot study presents data on an underreported group: college students who require psychiatric hospitalization. Although the study is too small to sustain broad generalizations, the authors found indications of significant correlations between students’ hospitalization and the academic cycle, substance abuse, and distance from home. It is hoped that other institutions will undertake similar studies of this group of students to provide a broader body of data from which to draw inferences regarding prevention, intervention, and psychiatric hospitalization. Key Words. psychiatric diagnoses, psychiatric hospitalization, psychiatric treatment, substance abuse
ost college students who seek mental health evaluation or treatment are not psychiatrically hospitalized. A 1985 study of psychiatric emergencies in college students reported that 28.3% of psychiatric emergencies seen at the University of Rochester’s Psychiatric Emergency Department were admitted to the psychiatry service.’ The psychiatric literature has characterized the student population in the outpatient but has not focused on the characteristics of college students who required hospitalization. This pilot study describes Georgetown University undergraduate students admitted to an inpatient psychiatry unit at Georgetown University Hospital over a 3-year period. We examined demographic information, history of previous treatment, presence of alcohol or drug abuse, stressors, family involvement, changes in global assessment of functioning, and discharge diagnoses and disposition. In our evaluation of these data, we addressed two basic questions: (1) What are the characteristics and needs of college students in a university Arthur S. Rosecan is a psychiatrist in private practice in Leesburg, Virginia; Richard L. Gohiberg is a p r o f a o r and chairman of the Department of Psychiatry at Georgetown University Hospital in Washington, DC; and Thomas N. Wke is vice chairman of the Department of Psychiatty at Georgetown and chairman of the Department of Psychiatry at the Fairfa Hospital in Fairfa, Virginia. VOL41, JULY 1992
teaching hospital mental healthcare unit? (2) What are the implications regarding evaluation and treatment of college students for mental healthcare professionals? METHOD
We reviewed patient logs, discharge summaries, and hospital charts from the mental healthcare unit to identify Georgetown University undergraduates among the patients admitted between January 1, 1987, and December 31, 1989. The unit is an unlocked, voluntary, general adult psychiatry unit for patients 16 years of age and older. We collected demographic data for each student admitted to the unit and, when feasible, assessed and quantified the student’s functioning at the time of hospital admission and at discharge, using the Global Assessment of Functioning (GAF) Scale. The GAF is a standardized instrument developed for this purpose6 and used as Axis V of the DSM-I11 (Diagnostic and Statktical Manual of Mental Dkordem, 3rd ed, American Psychiatric Association) multiaxial diagnosis. Although students from other area universities were hospitalized at Georgetown University Hospital during the 3 years we studied, we included only Georgetown University students in the study for two reasons. First, dormitory residence advisors, deans, and roommates could make more information available about preadmission functioning, predischarge meetings on the ward, and postdischarge plans for Georgetown students than we could get for undergraduates from other universities. Second, Georgetown University undergraduates constituted. a uniquely identifiable population. Those who were psychiatrically hospitalized could be reasonably compared with their peers who sought outpatient mental health services or with other Georgetown undergraduates in a future study. RESULTS
Forty-eight separate admissions of Georgetown students to the mental healthcare unit occurred over the 11
COLLEGE HEALTH
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3-year period of our study. One student was admitted twice in 1989, and another was admitted twice, once in 1987 and again in 1989. The remaining 44 admissions correspond with individual students hospitalized one time at Georgetown University Hospital.
TABLE 1 College Students Admitted to Mental Healthcare Unit by Month of the Year
Month
1987
1988
1989
Total
1
0
0 0 2 2 0
1 1 1 1 1 1
1 3 4 4 3 1 2 1 10 7 6 4
Gender. In 1987, 5 men and 10 women were admitted to the inpatient unit. The predominance of women was reversed in 1988 (9 men and 6 women admitted) and in 1989 (10 men and 8 women). The proportion of 24 male and 24 female students reflected the ratio in the Georgetown undergraduate population as a whole, which is 49% male, 51% female. We found no significant differences between the men and the women associated with race or class year; mean GAF scores at admission, discharge, or during the year before hospitalization; or the mean length of stay in the hospital.
January February March April May June July August September October November December
Race. Thirty-five (76%) of the students in this sample were white, 8 (17%) were black, and 2 (4%) were Asian, and the race of 1 was not listed. These figures closely resembled the racial background of all undergraduates admitted to Georgetown’s entering class of 1989: 77% white, 10% black, 8% Asian, and 5% Hispanic, ~ ’ ( 1 )= .414, p = .5198.
?Two students were admitted twice.
College class. We found no significant association between college year and either a history or admitting diagnosis of drug or alcohol abuse. College year was not associated with GAF change when GAF change was partitioned above and below the median. There was also no significant association with college year and family involvement or past medical or psychiatric history. Birth order. No significant differences in the birth order of the students admitted to the inpatient unit were found. Seasonal variance. There was a significant relationship with seasonal time of admission, in that sophomores and freshmen were more likely to be admitted in the first 2 months of each term, whereas juniors and seniors were more often admitted in the other months of the academic year, ~ ~ ( = 1 ) 10.54, p = .005 (Table 1). Previous psychiatric treatment. Thirty students had plcvious outpatient mental health treatment and 9 students (7 women and 2 men) had previously been hospitalized for psychiatric treatment. Family psychiatric history. Twenty-five students had a family history of psychiatric illness. Past medical history. Nine undergraduates had a history of past or current medical illness serious enough to require hospitalization, surgery, invasive procedures, or chronic medical care. Alcohol or substance abuse. Ten students (aU men) presented evidence of alcohol abuse at admission. Twelve students (10 men), seven of whom were among 12
0 2 3 1
0 0 0 0 2 1 2
1 1 2 3
0 6
2
2
2 -
1 -
1 -
-
13
15
18
46t
3
those who had alcohol abuse at admission, also reported a history of past alcohol abuse. Three had evidence of current drug abuse at admission, and 13 (9 men) admitted to past drug abuse. Nine students had a prior history of both alcohol and substance abuse. All diagnoses of substance abuse were comorbid with other major psychiatric diagnoses. Suicidal ideation at admission. Thirty-three students (59%)were admitted with suicidal ideation. Accompaniment to the hospital. Records of who, if anyone, accompanied the student to the hospital were frequently incomplete. Of the 23 admissions where data were available, 2 individuals were mentioned most frequently: 9 of the students were accompanied by resident directors or resident assistants of the campus residential life program, and 8 were accompanied by roommates or friends. Distance from home. Twenty-one of the admitted undergraduates’ homes were more than 500 miles away from the university; 17 were from between 100 and 500 miles away; and homes of 4 students were less than 100 miles away. The distance from home could not be obtained for 4 students. Thus, 90% of the hospitalized students’ homes were more than 100 miles from school. The data also revealed a significant association between distance from home and family involvement on the inpatient unit. When students were closer to home, families were more frequently involved on the inpatient unit, ~ ’ ( 3 )= 10.179, p = .017. Stressors. The most common identifiable stressors for hospitalized students (48%) were related to the academic cycle (eg, return to school, midterm examinations, holidays, end of school year). Academic difficulties and pressure (17010), family discord (12%), sexual JACH
PSYCHlATRICALLY HOSPITALIZED STUDENTS
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identity issues (9Oro), and roommate problems (8%) were also noted. Length of stay. We found significant annual variation in students’ length of stay in the psychiatric unit. In 1988, more patients stayed more than the median of 14 days, g(2) = 10.819, p = .0044. As noted, we did not find any difference in length of stay for men and women. First-year students were not overrepresented during any of the 3 years we studied. The length of stay was more commonly below the median of 14 days if the patient had a prior drug history, ~ ‘ ( 1 )= 4.74, p = .03, or had documented drug use upon admission, Fisher’s exact test p = .OO01. By contrast, there was no significant association of length of stay and alcohol abuse, either at admission or by prior history of such abuse. Finally, the length of stay was more frequently above 14 days when the student had a past medical history, Fisher’s exact test p = .OO01. Family involvement. Thirty-two (67070) of the hospitalized students had some family involvement, with one or both parents attending a meeting during the hospital stay. This involvement was strongly encouraged and facilitated by the unit staff. As already mentioned, there was a significant correlation between family involvement and nearness to home. Family involvement, however, did not correlate with a difference in the length of 3 ) .89, p = .387, or change in glohospital stay, ~ ~ ( 4 = bal assessment of functioning between admission and discharge from the unit, ~’(41)= .86, p = .392. Global assessment of functioning. The GAF scores at admission, discharge, and during the year prior to admission did not significantly correlate with a history of previous drug use or of drug usage on admission, nor with a history of alcohol abuse in the past or at admission, nor in cases with family involvement. The mean GAF at admission did significantly improve by discharge, t(42) = 11.63, p = .OO01. The correlation between GAF measures and the length of stay was not significant. Return to college. Of the 48 admissions, 27 (56%) showed students had returned to college following discharge. Fourteen of the students (29%) did not return to school immediately, most opting to arrange for a medical leave of absence. Post-discharge data on 7 students were not available. Irregular discharges. Eight undergraduates were discharged against medical advice. One was discovered to have gone AWOL, did not return, and was discharged. Another was administratively discharged after refusing repeated attempts to engage her in treatment; the other six patients signed AMA discharge papers. Medication at discharge. Twenty-two students (46%) were on psychotropic medication at discharge.
diagnoses, major depressive episode (29Vo) and adjustment disorder (21%), accounted for 24 of the 48 primary diagnoses. Bipolar disorder and eating disorders accounted for an additional 18% of the primary diagnoses. Eleven other diagnostic entities account for the remaining 19 primary diagnoses (Table 2). DISCUSSION
An average of 16 undergraduates a year requiring psychiatric hospitalization out of a total undergraduate population at Georgetown University of 5,547 in 19887 represents an incidence rate of 2.9 per 1,OOO undergraduates per year. How this rate compares with other campuses is unknown because of a lack of published data. The equal proportion of male and female students admitted, although it reflects the ratio in the undergradOne uate population as a whole, is rather intere~ting.~ might have predicted a higher proportion of female admissions, mirroring prevalence rates in other clinical settings. Failure to find this gender effect in undergraduate psychiatric admissions may be the result of a tendency of male students to delay, or to reject, seeking help in the outpatient setting until a problem grows to crisis proportions and necessitates admission. From the standpoint of mental health professionals who see college students, several points are noteworthy, regardless of treatment setting. Analysis of the data revealed that first-year students and sophomores were more likely to be admitted to the hospital in the first 2 months of each term, often before any major academic testing. Although students across all 4 years identified stressors related to the academic cycle as the major contributors to their hospitalization, first-year and sophomore students may be more vulnerable to the psychological aspects of separating from the home setting. Leav-
TABLE 2 Discharge Diagnoses of College Students Admitted to Mental Healthcare UnR
Diagnosis Major depressive episode Adjustment disorder with depressed mood or depressed and anxious mood Bipolar affective disorder, manic or mixed Anorexiahulimia nervosa Drug abuse Borderline personality disorder Organic affective disorder Organic delirium Panic disorder Schizoaffective disorder
Schizophrenifonndisorder Alcohol abuse Dysthymic disorder Personality disorder, not other specified Total
Number 14 10 5 4 3
3 2 1 1 1 1 1 1 1 48
Discharge diagnoses. The two most frequent primary VOL 41, JULY 1992
13
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COLLEGE HEALTH
ing home and familial loved ones to attend college represents, for most late adolescents, the longest and most significant separation of their lives. This can create and exacerbate vulnerabilities in students who are at risk for psychiatric problems. Distance from home could play a role in the perceived magnitude of separation: 90% of the students hospitalized were more than 100 miles away from home. Data about distance from home were not available to compare this hospitalized student population with the total student population, but Georgetown University is not a community college, so it is probable that most students’ homes were more than 100 miles from Washington, DC. Our data did, however, suggest that greater geographic distance led to less family involvement when the patient was on the inpatient unit. Geographic distance could also be an obstacle for student health personnel and resident life directors in promptly getting in touch with parents to avert a crisis. An activist stance for university staff members functioning in loco parentis seems justified in a crisis. Sixty-five percent of the hospitalized students had a prior psychiatric history, and 54% had a family history of psychiatric illness. Although comparisons with the general student population were not possible, these percentages might demonstrate that students with previous psychiatric treatment (especially psychiatric hospitalization) and family psychiatric histories may also be at increased risk. Because separation issues in the first 2 years of college may play a role leading to psychiatric hospitalization, it would be particularly interesting to discern whether such childhood psychiatric conditions related to separation issues as school phobia are later proportionally overrepresented in the population of college students who are psychiatrically hospitalized. Students with those risk factors already noted may require the active intervention of campus mental health professionals and the university system. The availability of residence life advisors, counseling center professionals, pastoral counselors, student health psychiatrists, and academic advisors represents a network of primary prevention for identifying and stabilizing students who are at risk. The data on accompaniment to the hospital are an indication of this vital role. The use of partial hospitalization, day hospital, or day treatment programs may be useful for stabilizing these students. This activist approach may be especially appropriate for the 56% of students in this study who returned to college after discharge from the hospital. Proper arrangements for these students to be followed as outpatients in student mental health settings need to be made by hospital staff prior to hospital discharge. Students whose admission is known to the residential life staff could also be monitored by that staff in an ongoing manner to assure compliance with outpatient follow-up. The data in our study also contain implications for mental health professionals who are working on an inpatient psychiatry unit. College students are a distinct 14
population on such units. They typically present in crisis, stabilize in hours or days, and focus very quickly on discharge. Multidisciplinary staff members face the challenges of stabilizing the student in crisis, dealing with safety issues, conducting a diagnostic evaluation, forming a treatment plan, engaging family members in the process, performing liaison roles with university administration and student health services, and facilitating outpatient (including substance abuse) follow-up. These tasks must be undertaken within an average 14-day stay (an exception occurs when the student presents with concomitant medical illness) for college students on the unit studied and with students’ family members usually living at some distance. The challenges of treating this population in the acute hospital setting, therefore, require an adequate multidisciplinary team during peak seasonal periods. The clinical usefulness of hospitalization for these students is demonstrated by significantly improved mean GAF scores at the time of hospital discharge for the total student group hospitalized. The capacity for reintegration reflected in these numbers is not surprising, given that students represent a preselected group chosen by an office of undergraduate admissions and that admission is based on, among other qualities, past accomplishment and personal adaptivity. The range of discharge diagnoses assigned to the study subjects does not differ substantially from that described in a study of an outpatient university population: “Depressive symptoms, irrespective of severity, presence of clear precipitants, pattern of recurrence, or chronicity, account for the majority of this population’s diagnostic ~ariance.”~ The presence of bipolar affective disorders, eating disorders, substance abuse, personality disorders, organic brain disorders, panic and psychotic disorders round out the picture of those students who required psychiatric hospitalization. SUMMARY
We have reported on a retrospective study of a small group of students from a single university who were followed only briefly after discharge. Unfortunately, no comparison group was available and the psychiatric literature reports virtually no similar studies. These limitations make it impossible to draw broad generalizations from the data presented. The experience in treating college students reported here, however, may offer a glimpse of who requires hospitalization and when and may suggest some implications for mental health professionals who see college students. It is hoped that other university medical centers will undertake similar studies and thus establish a databank on psychiatrically hospitalized college students. The information provided would be helpful in preventing and treating mental illness in this group, whose potential for regression is balanced by their potential for personal growth and contributions to society. JACH
PSYCHIATRICALLY HOSPITALIZED STUDENTS REFERENCES
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1. Perlmutter RA, Schwartz AJ, Reifler CB. The college student psychiatric emergency: 11, Diagnosis and disposition. J Am Coll Health. 1985;33:152-158. 2. R i m e r J, Halikas JA, Schuckit MA. Prevalence and incidence of psychiatric illness in college students: A four-year mospective study. J Am Coll Health. 1982:30207-211. - 3. Stangler RS, Printz AM. DSM-111: Psychiatric diagnosis in a university population. Am J Psychiatry. 1980;137(8): 937-940.
Promote a Healthier Campus With Three New Resources from ACHA
4. Thompson JR, Bentz WK, Liptzin MB. The prevalence of psychiatric disorder in an undergraduate population. J Am Coll Health. 1973;21:415-422. 5. Reifler CB. Epidemiological aspects of college mental health. J Am Coll Health. 1971;19:157-163. 6. Endicott J, Spitzer RL, Fleiss J, et al. The Global Assessment Scale. Arch Gen Psych. 1976;33:766-771. 7. Georgetown 1989, Profile for Schools and Candidates. Washington, DC: Office of Undergraduate Admissions, Georgetown University, 1989.
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If You Think Childhood Diseases Can’t Kill Adults
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VOL 41, JULY 1992
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