Preparing and Training the College Mental Health Workforce
More than 20 million individuals are enrolled in 2-year, 4-year, graduate, and professional degree-granting institutions in the USA . We refer to this diverse mix of primarily young people as college students and the broad range of services designed to attend to their mental and emotional health as college mental health. College students constitute a growing and critically important population in need of evidence-based mental health services .
The population is diverse in age, life experience, mental health history, socioeconomic status, and ethnicity. Students range from 18-year-olds entering 2- or 4-year postsecondary education programs directly out of high school to older students heading to college after serving in the military, raising families, or working for several years. Other students choose to pursue advanced degrees, such as in law or business. Within these broad groups are special populations, such as students with chronic medical or mental health disorders, athletes, international students, and first-generation students. Each group brings to campus distinct strengths, vulnerabilities, and needs . As Sood and Martel state, “Acculturation issues, differences in help-seeking behaviors, worries about families left behind, difficulties managing social situations, lack of support networks, discrimination, and post-traumatic stress reactions are just some of the concerns complicating an already stressful life transition” (, p. 70).
Over the past 25 years, many factors have contributed to the increase in the number and diversity of college students, as well as their clinical needs . For example, various iterations of the G.I. Bill (Servicemen’s Readjustment Act of 1944) encourage, allow, and support veterans to return to school . The percentage of enrolled minority students has increased with US population trends and various special programs . Improvements in identification and early intervention of mental health problems in young children and adolescents allow many to attend college who were previously unable to do so [5, 8]. The Americans with Disabilities Act supports students with various physical, learning, and emotional disabilities to seek postsecondary education experiences .
Three-quarters of mental illnesses begin before age 24 , and mental illness, including substance abuse disorders, contribute the greatest proportion of disease burden in young people aged 10–24 years around the world . The late maturation of the prefrontal cortices provide a neural basis for beginning to understand the impulsivity and risk-taking behaviors characteristic of transition age youth and young adults [12, 13]. The complex interrelationships among neurologic, psychological, cognitive, interpersonal, and psychopathologic development all contribute to their vulnerability. For youth with mental illness, the transition from child and adolescent to adult systems of care can add risk to vulnerability because the adult system is not generally trained to deal with the complex developmental issues that young adults present . Copious data link dropping out of college with health, mental health, social, and economic problems later in life [15, 16], such that increasing college retention may itself be viewed as an important public health intervention.
As with any changing community, meeting the mental health needs of the group can be a challenging endeavor, especially within postsecondary education. Training mental health clinicians to support the clinical demands of evolving communities is a goal of academic institutions worldwide. We provide here a snapshot of the current efforts undertaken by clinician-teachers and researchers whose foci include college students of many kinds. First, we provide some history of the college mental health movement and the organizations that have supported these efforts.
History of College Mental Health Care and Organizational Support
The first US student health service was developed at Amherst College in 1861, but it was not until 1910 that the first mental health service was established at Princeton. Students with emotional and personality issues were leaving school without completing their course of study . Similar programs followed, led by psychiatrists at schools such as the University of Wisconsin, United States Military Academy, Dartmouth, Vassar, and Yale University. Several authors have recently documented the history and evolution of college mental health services, including its mission, personnel, administrative structure, and delivery of services [16, 17, 18].
Professionals trained in clinical psychology, psychiatric social work, and nursing, as well as psychiatrists, play various roles in counseling centers. Many colleges maintain small psychiatric consultation services that are affiliated or a part of student health services, whereas others have separate psychological counseling centers. Over the years, funding for student health and mental health services has led to a multidisciplinary approach of counseling services merged with psychiatric and other mental health services at most schools. A new trend on college and university campuses is the integration of counseling and health services . The 2004 Garrett Lee Smith (GLS) Memorial Act provided funds to study and implement suicide prevention programs on college campuses. The Substance Abuse and Mental Health Services Administration Campus Suicide Prevention Grants, funded by the GLS Act, dramatically changed the field from a focus on counseling centers into communities where college mental health has become an incubator of population-based studies and interventions as well as clinical care.
In the face of the changing needs of college students, the American College Health Association (ACHA) has been instrumental in helping to standardize and benchmark college health services, beginning in 1961, with the Recommended Standards and Practices for a College Health Program [20, 21]. The Mental Health Section of the ACHA initiated the Mental Health Annual Program Survey (ACHA-MHAPS) in the 1970s, which helped determine the similarities and differences of college mental health services and data could be pooled from multiple institutions rather than individual colleges and universities on outcomes such as reported suicides [17, 22]. Key organizations, such as the National Institute on Alcohol Abuse and Alcoholism, have recognized the need for education, prevention, and improved services for students regarding alcohol and substance abuse, including opioids .
Other important organizations have also led in systemizing, surveying, and certifying US college mental services and other aspects of college life. The Association for University and College Counseling Center Directors assists college/university directors in providing effective leadership and management of their centers, in accord with professional principles and standards and with special attention to diversity and multiculturalism. The International Association of Counseling Services is the accreditation association for university and 4-year college counseling services, and the non-profit Jed Foundation has promoted emotional health and suicide prevention among college and university students since 2000. Also since 2000 the ACHA has conducted a national research survey twice per year to look at students’ health habits, behaviors, and perceptions; in 2008, it expanded the mental health section of the survey. The American Academy of Child and Adolescent Psychiatry (AACAP) has held a Special Interest Study Group on college student mental health since 2003 and now has a standing committee on transitional age youth and college student mental health, addressing, among other issues, the important transitional issues between adolescence and young adulthood. In addition, monthly meetings and annual presentations are ongoing via the multidisciplinary College Mental Health Task Group of the National Network of Depression Centers.
Over the last 10 years, thought leaders, practitioners, administrators, and scientists in college mental health have pioneered initiatives to better understand the prevalence and scope of this need for services. Some of the activities have included population-based interventions, exploring research needs in college mental health, and determining optimal ways of delivering care in various clinical and non-clinical settings. In 2004, the American Psychiatric Association (APA) organized a college mental health caucus and electronic mailing list that is very active today. The University of Michigan Depression on College Campuses Conference is now in its 13th year and includes student representatives, annual student awards, presentations, and a research symposium. In addition, important initiatives to create databases and standardized approaches have been developed: the Healthy Minds/Healthy Bodies Study at the University of Michigan, the Center for Collegiate Mental Health at Penn State, and the National Research Consortium of Counseling Centers in Higher Education at the University of Texas at Austin. Innovative collaborative care models such as the National College Depression Partnership have also been developed.
With these important organizations and activities as the background, we recognize the vital need to address education and training, that is, how to best assist the psychiatric field to be ready to provide mental health services for this growing group of college and university students. Kay and Schwartz , in 2010, strongly advocated for and described specialized clinical and didactic experiences for trainees from various disciplines. In order to coordinate these efforts, help broaden the discussion, and identify needs, we solicited articles for a special collection in Academic Psychiatry on models of education and training in college mental health. In this collection, we bring to publication up-to-date work in education and training regarding college mental health.
Fundamentals for Training and Education
Most of us have cared for college-aged students (and lived through college), but understanding the intricacies of college mental health from an administrative, legal, clinical, and ethical position may represent uncharted waters. Furthermore, establishing training opportunities remains a challenge of adequate resources and time for educators. This collection proposes several innovations for training and educating the next generation of clinicians and researchers about college mental health.
Whether one treats college-aged students or teaches trainees at any level, several pieces offer guidance on the unique demands of the collegiate patient population. The primer by Chan et al.  provides a detailed map outlining eight key landmarks in the college mental health terrain. Using the fundamental principles of community-focused systems-based care, the authors describe overlapping areas in which the college mental health clinician guides the patient through a network of services. In 2014, Derenne and Martel  surveyed clinical educators to learn about the current pedagogical trends in college mental health and transitional age youth at the fellowship level. In light of their informal findings, they suggest a curriculum with didactic content based on a pilot program that included a 3-month rotation on a college campus. Another pilot program by Romero et al.  resourcefully utilizes an existing fellowship in public psychiatry to enhance offerings in college mental health. Initial outcomes reveal that a public psychiatry curriculum can provide a strong foundation upon which to integrate college mental health topics and, in turn, may complement teaching by exposing trainees to topics salient to the care of transitional age youth who do not attend college. At the resident level, Kirsch and colleagues  describe a model for supporting trainees to bridge the educational gap between child and general psychiatry. By matching the supply of college students in Massachusetts and the demand to better educate trainees about the clinical needs of transitional age youth, this program offers psychiatric consultation to college mental health services, bridging a wide gap. At the practicing clinician level, Martel et al.  share an interactive workshop targeted at continuing education for child and adolescent psychiatrists who need to prepare their patients for transition to college. Using didactics covering basic college mental health topics, group-based learning to generate tasks relevant to the transition, and case vignettes to apply knowledge, the workshop was considered valuable by its participants. For clinicians at all levels, the ethical treatment of patients represents the foundation of quality clinical care. The ethical dilemmas faced in college mental health are complicated and deserve separate attention in the didactic curriculum for general residency training. Sondheimer  addresses these ethical issues in the context of young adult developmental tasks with case vignettes underscoring college-age twists on autonomy, paternalism, beneficence, and maleficence.
No standardized models currently exist for the training of psychiatrists in the care of transitional age youth. The articles collected here suggest several approaches to meet the needs of youth in postsecondary schooling. As Derenne and Martel  indicate, further collaborative work among the APA, AACAP, and the American Association for Directors of Psychiatric Residency Training is needed “to optimize resources and provide opportunities for psychiatrists to learn the special knowledge and skills, in person and online, to help meet the needs of this special population.”
Beyond the Basics
For those who may already work in college mental health or want to learn about more complex issues, several papers address advanced topics found in the care of college student patient populations. Together, they highlight the need for college-aged patients to be treated with greater complexity  and integrative approaches  and for more strategic outreach to bring potential clients to mental health providers . They also provide guidance in how to accomplish these tasks in systems already working near current capacity.
Pedrelli et al.  focus on the prevalence of mental illness, importance of assessing age of onset, and treatment considerations given the developmental stage and issues around non-adherence at college. They highlight substance use issues, childhood onset illness, the necessity of outreach for patient identification and retention, and the importance of including family and other supports in treatment when appropriate.
One might expect that college students would have ample opportunity for mental health care because of relatively affordable insurance and ease of access as compared with the general adult population. Hunt et al.  investigated these and other questions and found that college students suffered a large utilization discrepancy, especially ethnic and minority youth, when compared with national controls.
In general practice, it would be unusual to have a cohort of patients experiencing the same stressor simultaneously. In contrast, college students’ lives are strongly impacted by the academic calendar. Garrick  discusses the predictable and cyclical stressors of the college semester and identifies events that commonly affect patient mental health and lead to consistent ebbs and flows in the volume and nature of patients.
Prevention and Recruitment All in One: Child and Adolescent Mental Health Studies
At any given time, the Child and Adolescent Mental Health Studies (CAMS) program at New York University (NYU) enrolls approximately 20 % of the undergraduate students on its urban campus and generates multimillion-dollar revenue for the division of CAP at NYU . These undergraduate students indicate that broadening their knowledge of youth mental health improves the quality of their lives, influences their career choice, and directs them toward careers involving children and adolescents. Further research investigating how this program has impacted mental health and actual career choice among participants is forthcoming. This program supports the idea that early intervention is the best medicine for creating change. Shatkin and Diamond  share the history and composition of this innovative, popular, high-yield program and some of their preliminary findings.
A host of mental and physical health professionals may care for students (psychiatrists, psychologists, social workers, nurses, primary and specialty care physicians). The CAMS program is a pipeline for such practitioners and also provides an opportunity for students to identify their needs and destigmatize mental illness. We appreciate that the field of college mental health offers an unparalleled opportunity for further study and research.
We hope that the readers of Academic Psychiatry find this special collection stimulating, thought-provoking, and useful in thinking about educating and training in college mental health. Most of all, we encourage readers to fill the gap and care for all transitional age youth fortified with an enhanced understanding of this vibrant community.
The guest editors are indebted to the vision of Laura Roberts, MD, MA, and appreciate the guidance of Ann Tennier at Academic Psychiatry for their incredible help and support for this project.
On behalf of all authors, the corresponding author states that there is no conflict of interest.
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