Michelle B. Riba, MD, MS
Professor, Department of Psychiatry; Co-Director, Workplace Mental Health Solutions, Eisenberg Family Depression Center; Director, PsychOncology Program, University of Michigan Rogel Cancer Center. Editor, College Psychiatry: Strategies to Improve Access to Mental Health (co-editor: Meera Menon, MD).
Interview by Garrett Rossi, MD. Inpatient/consult attending psychiatrist, AtlantiCare Regional Medical Center, Pomona, NJ.
Dr. Riba, expert of this educational activity, has disclosed that she receives book royalties from Springer, Wiley, and APA Publishing. Dr. Aiken has reviewed this educational activity and has determined that there is no commercial bias as a result of this financial relationship. Dr. Rossi has no relevant financial relationship(s) with ineligible companies to disclose.
TCPR: What are the most common psychiatric conditions in the college mental health setting?
Dr. Riba: Anxiety and depression are the most common psychiatric conditions. It is very difficult to get timely psychiatric evaluations and evidence-based treatment. It has been especially difficult during the last two years during COVID, but telehealth has certainly helped. Substance use disorders are also quite prevalent among college students. A lot of students are exposed to these substances for the first time during college, where there is no shortage of opportunities to use alcohol and other substances. Marijuana use is on the rise, in part because of the loosening of state restrictions.
TCPR: How does marijuana affect students?
Dr. Riba: In the 18- to 19-year-old developing brain, the impact of cannabis use can be profound. Recent studies on the long-term use of cannabis are now starting to show the cognitive issues that can develop because of early use (Scott JC et al, JAMA Psychiatry 2018;75(6):585–595). I’ve seen young college students coming in looking psychotic, and it’s related to marijuana use. There’s cause for alarm for those who are overusing marijuana. Students are also getting stimulant medications like amphetamines on the black market, and many of these are laced with drugs like fentanyl and methamphetamine, contributing to very dangerous situations, such as unintentional overdose (www.tinyurl.com/2nn88up4).
TCPR: How do you handle stimulant medications for students with ADHD?
Dr. Riba: We require neuropsychiatric testing before prescribing. We do this because it’s easy for someone to read the DSM criteria and endorse the necessary symptoms to meet criteria. Prescribing stimulants can be harmful if students are taking other medications such as benzodiazepines or are using substances. We do not liberally give out stimulant medications for these reasons.
TCPR: Is there anything we should be mindful of when making a diagnosis or prescribing medications to college students?
Dr. Riba: You need to make sure they have the right diagnosis. Many students have been taking psychotropic medications for years, sometimes for incorrect diagnoses or for conditions that have resolved and no longer require medication treatment. The bright side is more people are able to go to college who have major mental health problems, including schizophrenia. Improved access, early evaluation, treatment, medications, and therapy have made this possible.
TCPR: How has COVID-19 impacted the mental health of college students?
Dr. Riba: Many students have lost the first two years of college life. Compared to 2017–2019, many more students worldwide, not just in the United States, have been depressed and anxious. Suicidal ideation has also increased among college students (Wang C et al, J Am Coll Health 2021:1–8; Gratz KL et al, Psychiatry Res 2021;302:114034). What’s less clear is how long these problems will last and what the best practices will be to handle the consequences of this pandemic on mental health.
TCPR: Any insights on the rise in suicide?
Dr. Riba: An alarming number of college students have had suicidal thoughts or ideation, and it is very frightening. The pandemic has contributed, as have the changes to the college experience during the last few years, including isolation, social media, depression, and loss. We are also seeing the “contagion effect” where suicidal ideation spreads among people who learn of someone’s suicidal ideation or behavior. The effects on the second victims—the friends and classmates of students who died by suicide—are terrible. They feel grief, loss, and self-doubt, wondering if there were clues they missed. It’s very demoralizing and tragic.
TCPR:How is access to mental health care on college campuses?
Dr. Riba: There are campuses where the college mental health service is not located in a place that is easily accessible to students. In some cases, services are too expensive. Telehealth has helped, but some state licensing laws make it very difficult or illegal for mental health professionals at a university or college to continue to care for a student once the student returns home to another state or country.
TCPR: How has telehealth impacted access to services?
Dr. Riba: I think telehealth works best when you already have an established relationship with the patient. You get a lot of valuable information from in-person contact with the student. One solution is to make the first visit in person and transition to telehealth appointments after that. It’s been very promising for people in certain geographic regions and for people with certain disabilities where transportation is an issue to increase access to care (Li Z et al, BMC Psychiatry 2021;21(1):182; Annaswamy TM et al, Disabil Health J 2020;13(4):100973).
TCPR: Do you think social media has a positive or negative impact on college mental health?
Dr. Riba: This generation of students grew up with it, so it’s part of their world. They don’t go anywhere without their phones, and they rarely put their devices down. The problems come up with how people don’t talk to one another in person—instead, their relationships are often just by text or email. Important social cues such as eye contact or body language are lost in the relationship. Social media has helped in a lot of ways, but it can’t be the only form of interaction. And of course, social media can have negative effects, leading to people being bullied or made fun of or unfriended. There was a case in New Jersey several years ago where a college student was outed as gay by his roommate on social media and committed suicide as a result. That was one of the terrible consequences.
TCPR: There was one viral post that I wanted to ask about. A psychiatry resident took a photo of himself taking his psychotropic medication. Do you think this is helpful in reducing stigma?
Dr. Riba: It has positives and negatives. I don’t think being a good doctor means that the doctor must have a psychiatric disorder. We go to a doctor because of their expertise, not necessarily because they have the same problem. A post like this also takes the focus of treatment away from the patient and places it on the physician. Patients need to focus on themselves and their treatment, not that of the person providing the treatment.
TCPR: The trend among the younger generation of physicians seems to be “I’m more relatable to the patient if I’ve experienced similar things.” What are your thoughts on this?
Dr. Riba: As physicians, it is important to have a strong alliance with our patients. Patients are more and more interested in working with physicians who are of the same gender, race, or cultural background as themselves. It is important for patients to be able to choose the clinicians they want to work with and to attain a strong doctor-patient relationship.
TCPR: Is there anything that you recommend for students who are preparing for college that can help build resiliency or prepare them for campus life?
Dr. Riba: I think it’s important for students and families to sit down and talk about the challenges of being away from home and starting college. A lot of students are in treatment prior to starting college and think they can make it back home during breaks to get refills or receive psychotherapy. That’s usually not feasible. For a successful transition to college life, it’s essential to be prepared for all the potential pitfalls and have a plan to deal with them. It is helpful for the student to make an appointment with a mental health professional before they leave home. Further, the medical records should be sent ahead of time, and permission given for the involved clinicians to “hand off” and discuss important information. This will help facilitate excellent care for the student and allow for any needed changes in the treatment in between holidays, breaks, etc.
TCPR: So, there are many aspects to getting prepared to leave for school.
Dr. Riba: Getting prepared to establish treatment and ensure the continuation of psychiatric medications is no different than making sure you have enough insulin if you have diabetes, or speaking with a clinician to see if you need your high blood pressure checked. It’s important to prepare ahead of time and make sure options are available should a crisis occur. Substance use and peer pressure should be discussed as well, given their high prevalence on college campuses. Having a routine, sleeping and eating properly, and getting exercise can go a long way toward building resiliency. Many students are living on their own for the first time, with roommates and with class schedules that change from day to day, so new routines need to be created.
TCPR: How do student loans affect college stress?
Dr. Riba: They are a big problem. We have students graduating with $100,000 or more in student loan debt. This is why community college is a great option. It gives you a place to start without accruing that huge debt (Pisaniello MS et al, BMJ Open 2019;9(7):e029980).
TCPR: Are the mental health issues different for two-year students?
Dr. Riba: Two-year students are generally much more thoughtful about why they’re going to college. They are aware of the financial aspect and take education seriously. The mental health resources available at a two-year college are often not as substantial as a four-year school or university, though. Students in a two-year school may be working during the day and going to school at night, and they usually don’t live in a dorm. These students may not have the resources or time to get proper mental health treatment.
TCPR: What about graduate students? What types of challenges are they facing?
Dr. Riba: Graduate students have always had difficulty adjusting because many are from foreign countries or are enrolled in small programs that lack the resources and time to identify mental health problems. The students also have a lot of pressure to succeed in these programs, coping with demanding work hours and the added fear of returning home ashamed or embarrassed. Some come from cultures that don’t accept mental health as a reason for problems. The price of failure is often much higher for these students, as their livelihood and that of their family may depend on that graduate degree. Graduate students are older and often have families, so studying, working, and family care, including financial pressures, often create additional stresses when compared to undergraduate students.
TCPR: Thank you for your time, Dr. Riba.
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