A case for college mental health services

Abstract

College represents a crucial developmental period, fraught with numerous challenges across the academic, social and personal domains. Most students successfully overcome these challenges to achieve their potential. However, in a significant proportion, these stressors interact with genetic and psychosocial adversities, increasing the likelihood of mental health issues1. Mental health issues are prevalent among college students. There are robust and consistent reports from across the world that students in colleges have higher rates of depression, anxiety and substance use1234. The World Mental Health Survey among college students across 21 countries has reported that a fifth (20.3%) had experienced DSM-IV/CIDI (The Diagnostic and Statistical Manual of Mental Disorders-IV/ The Composite International Diagnostic Interview) psychiatric disorders in the preceding 12 months1. Similar findings have also been reported from various States in India234. Late adolescence and early adulthood also have a greater incidence of severe mental illness owing to the neurodevelopmental trajectory. It is estimated that 75 per cent of those with severe mental illness would have experienced significant symptoms by the age of 25 yr5. Thus, a sub-group of students are likely to experience the onset of severe mental illness during their time in college. The higher rates of suicide among college students also correlate with mental illness6. Worldwide, the annual rates for suicidal ideations, plans and attempts among college students have been estimated to be 16, 3 and 1.2 per cent, respectively6. In 2018, as many as 10,000 student suicides have been reported in our country7. Of atmost concern, is the consistent finding of increased vulnerability among students from the lower socio-economic strata, minorities or disadvantaged communities189. Mental health issues in young individuals ‘cluster’ with physical underactivity and unhealthy diet which increase the risk of non-communicable diseases (NCD)10. Additional lifestyle choices like tobacco and alcohol use, and high-risk sexual behaviour are also part of this cluster10. Higher levels of distress have been associated with increased food intake, poor diet quality and consequent obesity. Globally, these risk behaviours concurrently account for almost two-thirds of cardiovascular deaths and a 3.35-fold increase in cancer mortality11. Mental health issues in colleges across the world have been showing a marked increase both in numbers and severity1213, presumably owning to rapid socio-economic transitions, migration, the disintegration of social networks and substance use813. Educational factors like intensive curriculum, heightened competition, academic difficulties and poor competence of instructors also contribute to distress14. Although many of these factors remain understudied in the Indian context, the cross-cultural commonalities of risk factors suggest that this is likely to be applicable here too. Mental health problems have a profound impact on college students. In addition to drop-outs and poor academic achievement, it can also have long-term adverse impacts on employment, social relationships and health1815. Although this period has a confluence of risk factors, it also presents a window of opportunity for prevention, health promotion and early interventions18. Most colleges in India and many parts of the world, do not currently have the infrastructure to address mental health problems among its students141617. Ideally, all higher educational institutions should have an accessible, culturally and developmentally integrated system of mental health support18. Clinical triaging at the first point of contact needs to ensure that the vast majority of students presenting with transient situational crises are provided the least resource-intensive counselling interventions on campus. Considering the increasing body of evidence supporting its effectiveness, internet-based interventions can be made available to bridge the shortage in mental health resources18. Most college students are familiar with newer technologies, and these have additional advantages of easy accessibility with minimal stigma18. As social and academic vulnerabilities also contribute to distress, counsellors can facilitate scholarships, additional academic support, and provide links to support groups for further help919. Access to off-campus (community) mental healthcare including psychiatric inputs should not be delayed in those with severe mental illness, uncontrolled substance use, or high risk of suicide20. This sub-group may require emergency psychiatric care, in-patient input and continued psychotropic medications (Figure). This stepped care approach will ensure access to appropriate interventions within our resource-limited setting. Considering the profound heterogeneity across Indian institutions, a ‘one size fits all’ strategy is unlikely to work. A broad framework may be prescribed; with individualized protoc