Converging Data, Diverging Strategies: The Implications of Mental Health Epidemiological Data for Co

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Converging Data, Diverging Strategies The
Implications of Mental Health Epidemiological
Data for Counseling Center Directors

• Jonathan Perry, University of Arkansas
• Christopher Flynn, Virginia Tech
• AUCCCD, Asheville, 27 Oct 2009

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Overview of this session

• Explore reasons for a CC director to be
  interested in psychiatric epidemiological data
• Discuss some of the major studies and findings of
  relevance in understanding student mental health
  issues
• Consider implications for campus student mental
  health initiatives

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Learning Objectives

• Participants will learn why, in understanding the
  problems of college students, we need to be aware
  of the base rates in the general population
• Participants will learn how, in risk assessment,
  base rates have great implications for evaluation
  and management
• Participants will discuss why treatment efforts
  and foci need to be determined by needs of
  students, both those who come in for treatment
  and those who do not
• Participants will consider how, from the
  perspective of CC director as the campus CMHO,
  these data illuminate the relevance of counseling
  centers and student mental health data for
  retention and graduation rates

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REAL Learning Objectives

• Youll maybe find some data and ways to use them
  that will strengthen your position with your vice
  president
• Youll have data that will explain to key
  stakeholders of your campus community the reasons
  behind some of their experiences with students
• Youll have a perspective on student mental
  health issues that will help get buy in from
  thes key stakeholders

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Revisiting Rosie Binghams Keynote

• Presidents and vice presidents are going to turn
  to us when there is a campus crisis
• They are getting epidemiological survey data
  too
• Theyre scared by their perceptions, accurate or
  not, of how much of that stuff there is on
  campus, and theyre concerned about the
  (negative) perceptions of important stakeholders
• Retention/perseverance and graduation rates have
  become very important, so there is pressure on
  campuses to identify any and all issues that
  negatively impact those ratesincluding student
  psychological and emotional problems
• Some of them may actually care about the
  well-being and success of their students, both
  the ones who get to us and the ones who dont
• Other campus agents are becoming more aware of
  and sophisticated about the existence of and
  disability and dysfunction caused by mental
  illness 

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Definition of epidemiology (Merriam-Webster
online)

• a branch of medical science that deals with the
  incidence, distribution, and control of disease
  in a population
• 2. the sum of the factors controlling the
  presence or absence of a disease or pathogen

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Epidemiology in its broad sense

• How much of this stuff is really out there?
• The data from these studies are information that
  can illuminate this question
• These studies do not deliver the definitive
  answer they provide some evidence to consider in
  understanding what we do

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Why Should We Care? (the role of the CC director)

• Lead a team of clinical service providers
• Provide a quality training site for any mental
  health profession graduate students on campus
• Function as the campus center of expertise on the
  interaction between college student developmental
  issues, mental health issues, and the specific
  challenges of the college experience
• Anticipate trends in college mental health issues
  that will affect campus constituencies, esp.
  faculty and student affairs staff
• Develop a defined and constructive role in the
  event of campus crises, esp. student suicides and
  other deaths
• Serve as CMHO in those events
• How knowledge of epidemiology fits into this
  conception

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The Regulative Ideal

• A regulative ideal is a statement of an ideal set
  of conditions that is unattainable but
  nevertheless serves to guide decisions and
  actions
• Pledge of Allegiance, Universal Declaration of
  Human Rights, Four Bodhisattva Vows
• No University of Arkansas student will have his
  or her academic career compromised by
  psychological or emotional disorders

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How Much?

• Suicidal ideation and behavior
• Social anxiety
• GAD
• Eating disorders
• Cutting
• Bipolar disorder
• Sexual identity issues
• Alcohol/substance use and abuse
• Functional disability

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Two Illuminated Issues

• Veterans, trauma, and PTSD
• The tyranny of the semester

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Pause for discussion
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Major Categories of Psychological Disorders
12-Month Prevalence (Kessler Wang 2008)
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Psychological Disorders within Twelve Month
Period(Kessler )
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Epidemiologic Catchment Area (ECA) and National
Comorbidity Study (NCS) Add Functional
Impairment (Narrow et al 2002)
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Major Categories of Psychological Disorders
(NCS-R) Lifetime Prevalence (Kessler Wang
2008)
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(No Transcript)
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Mental Health College and Non-College Peers19-25
Year-Olds NESARC (Blanco et al 2008)
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Twelve-month prevalence and severity
(NCS-R)Kessler and Wang 2008
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Number of Disorders by Severity (NCS-R)Kessler
Wang 2008
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Median Age of Onset (NCS-R)

• Anxiety Disorders 11 IQR 6-21
• Impulse Control Disorders 11 IQR 7-15
• Substance Use Disorders 20 IQR 18-27
• Mood Disorders 30 IQR 18-43
• 50 of individuals with any disorder will have
  symptoms by age 14, 75 by age 24.
• Interquartile ranges number of years between
  25th and 75th percentiles smaller number equals
  a narrower range of distribution.

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12-Month Prevalence NCS-R (Kessler et al)
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Mental Disorders and Subsequent Educational
AttainmentNCS-R (Breslau et al 2008)

• What is the association of the presence of mental
  disorders with likelihood of (1) finishing
  primary school, (2) completing high school, (3)
  entering college (4) completing college?
• Anxiety, mood, impulse control, substance use
  disorders most strongly associated with not
  completing high school rather than other
  categories.
• Having three or more disorders strongest
  predictor of not completing high school.
• For students in college, the following predicted
  failure to complete degree
• Any impulse control disorder
• Any substance abuse disorder
• Panic disorder (not other anxiety disorders)
• Bi-polar disorder (not other mood disorders)

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Self Reported ProblemsNational College Health
Assessment
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Leading Causes of DeathNational Vital Statistics
Report U.S. National Center for Health Statistics
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Death Rates from Suicide 1990-2005Rates per
100,000 U.S. National Center for Health
Statistics 2007
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Suicide Rates for Young Adults 20-24 (per
100,000) Morbidity and Mortality Report September
2007 (CDC)
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Suicidality in the College Population

• 10 of college students seriously considered
  suicide in past year
• 2 will make one or more suicide attempts in a
  year
• 7.5 of 100,000 students will commit suicide in a
  year, compared to non-college rate of 15 per
  100,000.
• With 18,000,000 in college nationally, 1350
  suicides a year
• Virginia has 252,640 students in public and
  private colleges can expect 18-19 suicides per
  year.

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Suicide Related Outcomes NCS and NCS-R10 year
follow-up (Borges 2008)

• Lifetime Prevalence at Baseline 12-month
  prevalence (NCHRBS)
• Suicidal Ideation 13.3 10.3
• Suicidal Plan 4.0 6.7
• Suicidal Gesture 2.3
• Suicide Attempt 2.2 1.9 (may inc. gesture)
• Persistence of SRO at Follow-up after 10 Years
• Suicidal ideation 35.0 (of baseline)
• Suicidal Plan 21.2
• Suicidal Gesture 10.8
• Suicidal Attempt 15.4
• Prior ideation negatively related to plan and
  attempt at follow-up.
• With increasing years, subsequent ideation and
  plan decreases.
• Only a history of prior attempts is related to
  future attempts.
• Mental disorder at baseline predicts future
  ideation at follow-up.
• Mental disorder among ideators does not predict
  future gesture or attempt.

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Characteristics of Completed SuicidesNational
Violent Death Reporting System (2006)
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Which occurred before considering attempt (12
months)Research Consortium (Brownson 2008)

• Recent family problems 41.96
• Recent academic problems 37.57
• Recent loss of romantic
• relationship 36.00
• Recent financial problems 34.53
• Intentional self-harm (nonsuicidal) 27.67
• Recent loss of friendship 27.56
• Recent death of friend/family 16.42
• Sexual Assault 9.22
• Recent Trauma 8.32
• Recent conflict regarding
• sexual orientation 6.75
• Recent suicide of friend/family 5.74
• Relationship violence 5.62

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Lifetime Prevalence Alcohol and Drug AbuseNCS-R
(Kessler 2009)
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National Survey on Drug Use and Health2002
18-21 Year-olds (Wu et al) 2001 19-21
Year-olds (Slutske)
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Past Year Illicit Drug Use 18-25 Year-OldsNSDUH
2007 (SAMSHA)
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Past Month Illicit Drug UseNSDUH (SAMSHA 2007)
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Median Age of Onset (NCS-R)

• Anxiety Disorders 11 IQR 6-21
• Impulse Control Disorders 11 IQR 7-15
• Substance Use Disorders 20 IQR 18-27
• Mood Disorders 30 IQR 18-43
• 50 of individuals with any disorder will have
  symptoms by age 14, 75 by age 24.
• Interquartile ranges number of years between
  25th and 75th percentiles smaller number equals
  a narrower range of distribution.

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Number of Disorders by Severity (NCS-R)Kessler
Wang 2008
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U.S. Educational Pipeline Females by
Race/EthnicityCSRC Research Report 2006
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Are Problems of College Students More Severe
Today?

• Research reports are mixed Benton et al (2003)
  found more students rated as depressed, and more
  students referred for medication over 13 year
  period.
• Schwartz (2007), Kettman et al (2007) find no
  increased pathology but found increased
  referrals for medication.
• Directors report feeling that more serious cases
  are being treated in counseling centers.

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More Severe?

• Research is clear on some issues that might
  account for counseling centers feeling pressure
• More students are coming to college having been
  treated in the past.
• More students are on medication and this, with
  counseling, may enable them to stay in school.
• Students today are more likely to seek
  counseling 10 increase over ten years in use of
  treatment.
• Increased demand, but are resources increasing at
  a similar rate?

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12-month Prevalence Mental Health Treatment (18
and older)SAMSHA (NSDUH)
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Past Year Antidepressant UseCollaborative
Psychiatric Epidemiology Surveys (NSAL and NCS-R)
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Minimally Adequate Care Past Twelve
MonthsNCS-R (Kessler et al 2008)

• Human Services Sector 16.9
• General Medical 33.4
• Mental Health Specialty 48.3
• Any Service Use 32.7
• Likelihood of Receiving Mental Health Care Is
  Directly Proportional to Increase in Education.
• Little Difference in Adequacy of Care Between
  Psychiatrists and Psychologists

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Minimally Adequate Treatment for Patients Past
Year NCS-R (Kessler et al 2008)

• Anxiety Disorder 51.5
• Mood Disorder 52.3
• Impulse Control Dis. 36.4
• Substance Abuse 34.9
• Any Disorder 48.3

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Minimally Adequate Care Past 12 Months United
StatesWorld Health Initiative (Kessler et al
2008)

• Mild 4.9
• Moderate 24.8
• Severe 41.8

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Student Usage of Counseling Centers

• Student usage of counseling centers varies widely
  across the country with between 1 and 30 of the
  student body seeking services in a given year.
• In the 272 schools surveyed by Gallagher, 9.3 of
  students sought services in the previous year.
• As a particular cohort continues in school, a
  greater proportion will seek counseling, e.g. if
  9.3 of freshman seek counseling, by the time
  they graduate, almost 40 may have sought
  counseling.

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Student Counseling Past and Present

• The Research Consortium surveyed 1,500 students
  at 15 colleges and universities.
• 4.6 of students surveyed said that they were in
  counseling at the present time.
• 27.3 of students said that they had received
  counseling in the past.

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Counseling Use on the College Campus (4-year
schools)

• 9.0 of student body received counseling in past
  year, according to Gallagher survey.
• 10. according to AUCCCD Annual Survey
• 5.5 Average Number of Sessions (AUCCCD)
• 4.5 of college seniors report receiving
  frequent counseling in past year.
• 22.4 of seniors report occasional counseling
  in past year.
• 73.1 of seniors did not receive counseling at
  all (College Senior Survey, CIRP, 2009)

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Alcohol Use Disorders and Use of Treatment Among
College-Age Young Adults (Wu et al 2007)
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Mental Health Need, Awareness and Use of
Counseling Graduate Students(Hyun, J. et al JACH
2007)
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Disabled and Non-disabled Students in Higher
EducationU.S. National Center for Education
Statistics
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Epidemiologic Surveys

• Behavioral Risk Factor Surveillance System
  Telephone based reporting system sponsored by
  CDC.
• Epidemiologic Catchment Area Survey (ECA)
  Structured Psychiatric Interview in Five Areas,
  including Baltimore, New Haven, Raleigh-Durham,
  St. Louis, and Los Angeles. 20,861 respondents
  directly interviewed (http//webapp.icpsr.umich.e
  du/cocoon/ICPSR-Study/06153.xml)
• National Comorbidity Study (NCS) and NCS-R Face
  to face computer assisted interviewing of
  nationally representative sample. NCS included
  8,098 respondents in 1990-1992. NCS-R 9,282
  respondents including follow-up of sub-sample of
  NCS (2001-2002)

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Epidemiologic Surveys (continued)

• National Epidemiologic Survey on Alcohol and
  Related Conditions (NESARC). Face to face
  interviewer administered to 43,093 in 2001-2002.
• National Survey on Drug Use and Health (NSDUH)
  Annual survey conducted through face to face
  interviews with 67,870 respondents including ages
  12-17, 18-25, and 26 and older.
• National Survey of American Life (NSAL) Survey,
  largely face to face with African-American
  (3,570) and blacks of Caribbean descent (1,621)
  in 2001-2003.
• National Latino and Asian American Study(NLAAS)
  Survey of face to face interviews with 2,095
  Asian respondents, 2,544 Latino respondents
  conducted in 2002-2003.
• Go to Collaborative Psychiatric Epidemiologic
  Surveys for NCS-R, NSAL, NLAAS data
  http//www.icpsr.umich.edu/cocoon/cpes/using.xml?s
  ectionIntroduction

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Surveys of Interest

• Research Consortium of Counseling Psychological
  Services in Higher Education (Univ. of Texas
  Counseling)
• National College Health Risk Behavior Survey
  United States, 1995. CDC Morbidity and Mortality
  Report, November 14, 1997.
• College Senior Survey 2008. Cooperative
  Institutional Research Program, UCLA.
• American College Health Assessment, American
  College Health Association, 2008.
• Surveillance for Violent Deaths National
  Violent Death Reporting System, 16 States,
  Morbidity and Mortality Report, March 20, 2009,
  CDC.
• Center for the Study of College Student Mental
  Health, Penn State University.

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What is the possible meaning of the reports of
increasing demand AND increasing severity?

• A genuine population-wide increase, of which our
  increase is a part
• An increase in demand feels like an increase in
  severity
• The small handful of much more difficult cases
  has a halo effect on our perceptions of our
  entire caseloads
• Our staff (and we) are doing a higher percentage
  of clinical work as other CC functions have
  migrated to other campus agents, e.g., career
  services, academic skills centers, wellness
  educators, womens centers, multicultural centers
  and offices, etc., and more clinical service is
  truly draining and demanding
• We have succeeded, and our campus colleagues have
  succeeded, in identifying and getting to us (via
  referral, pressure, mandate) a higher percentage
  of the more troubled students, and these more
  serious cases are crowding out the less serious
  student problems and challengesthe pathology
  pushing aside the developmental. BUTthis does
  not necessarily translate into there being more
  psychopathology in the college student
  population. It may be a case-finding
  phenomenon (hence my name for our program)

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Lets Crunch Some Numbers!

• At U of Arkansas, about 20,000 students
• Assume 25 have some serious need during the year
  5000 students
• Assume identify and successfully refer half of
  those 2500 students
• To receive adequate episode of counseling/therapy
  (10 sessions) 25,000 contacts
• Assume average number (6 sessions) 15000
  contacts
• Average clinician number 950 contacts yr 15.8
  FTE clinical staff members
• AINT GONNA HAPPEN!

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George Albee

• Famous psychologist
• Demonstrated in 1950s that we cannot mean the
  need for help with the numbers of professionals
  we can train
• We need strategic alternatives to the
  clinical/counseling service model of individual
  or even small-group treatment by a professional