When our patients head to college, they replace the comfort of parents, teachers, friends, and school activities with unprecedented workloads and ­stressors, leading to an extremely high incidence of mental health disorders. In 2020, out of 30,725 undergraduates, 35% screened positive for major depressive disorder and 39% screened positive for generalized anxiety disorder—which was double the rate of depression and 1.5 times the rate of anxiety reported in 2019 (Chirikov I et al, SERU Consortium, University of California Berkeley 2020). Many universities cannot meet the demand for on-campus mental health services. How can you support your patients during their transition to college life?

Help your patients make the right college decisions

A typical four-year college isn’t the right path for everyone. Some adolescents who are more troubled should stay home for a while after high school to receive ongoing intensive treatment. Others may do better attending community college, undergoing vocational training, working, or pursuing a gap year program. For those who do want to leave home for college, help them decide on the best options. Big universities offer lots of educational opportunities, but they can also feel anonymous and offer less supervision. Small rural schools may be calmer but often have fewer resources for mental health and learning support. Once your patients have an idea of what they are looking for in a school, you can talk to them about getting ready to live away from home.

Preparing for school away from home

As your patients prepare to leave for college, give them advice to help them manage the challenges ahead.

Self-care

Have your patients practice taking medication and picking up prescriptions. Emphasize the importance of developing good eating and sleeping habits, doing laundry, maintaining hygiene, cleaning (from food crumbs to toilets), and simple food preparation. Consider advance directives that describe their wishes for care, including what treatments they would want (eg, ECT) if they become unable to care for themselves due to an exacerbation of their psychiatric condition (www.tinyurl.com/2jvwr99s).

Here are some ways to start these conversations with your patients:

• “Do you know how to get prescriptions from a pharmacy? Tell me what you know about that.”
• “How do you plan to manage healthy sleeping and eating in a busy college situation with studying and socializing?”
• “If you do become overwhelmed, do you know someone to go to for help at school?”
• “Whom do you want to make decisions about your care if you are not able to do that for yourself?”

You can also provide patients with the following free resources:

• A useful checklist on readiness for transition of health care: www.­tinyurl.com/bh9ed69f
• A guide containing more detailed ideas for autistic youths going to college: https://researchautism.org/resources/finding-your-way

Academic stress

Remind your patients and their families how challenging academic pressures can be and provide them with specific tips for how to cope. Balance is the key to managing academic stress. A sense of belonging is the best predictor that a student will pass their first year of college. Help your patients organize their free time and make connections with people.

For patients:

• Have them list groups, sports, or activities they plan to join.
• Talk about substance use as an unhealthy way that some people cope with stress and discuss how they might avoid falling into that trap.
• Remind them that if the school accepted them, then the challenge is usually social comfort, not the workload.
• If they do struggle academically, remind them to seek support/tutoring on campus. Help them look up and access these ­resources.

For parents:

• As with patients, remind parents that if the school accepted their child, then the challenge is usually social rather than academic.
• Reserve expressions of distress over academic challenges and instead discuss how to learn from them.
• Stress that it is important for parents to support activities and friendships.
• Encourage them to think with their child about when or whether a quick visit home might be helpful or excessive.

Dorm life

Some patients are excited to have a roommate. Others are fearful. Ask your patients:

• “Have you ever shared a room? What was that like?”
• “What ideas do you have for avoiding problems with roommates?”

It may be helpful to share with your patients a couple of dramatic facts:

• First-year college students who bring video game equipment to college study 40 minutes less daily and have GPAs that are an average of 0.24 points lower (Stinebrickner R and Stinebrickner T, Frontiers in Economic Analysis & Policy 2008;8:1868).
• The GPAs of male college students drop by as much as 0.25 points if paired with a roommate who has a history of alcohol consumption (Kremer M and Levy D, Journal of Economic Perspectives 2008;22(3):189–206).

In addition, help your patients plan ahead to handle distractions:

• “How do you function in noisy, distracting environments?”
• “What ideas do you want to try if your dorm is noisy or ­distracting?”

Substance use

Prepare your patients for the likelihood that they will be exposed to substances by asking questions like:

• “Some kids drink or smoke or use other substances. Do you plan to use substances at college? If so, how much will you use and how do you plan to manage it?”
• “How do you plan to answer people when you don’t want to use a substance?”

Handling relationships and conflict

Help your patients plan for the inevitable conflicts that will come up in their social life at college. Ask them:

• “What ideas do you have to manage the ups and downs of new friendships?”
• “How do you plan to respond to people with different political, religious, and cultural beliefs?”
• “Do you plan to date? If so, what ideas do you have to stay safe physically and emotionally?”

Should you continue treating?

Consider these questions when deciding whether you should remain the clinician of record when your patients go away to school.

Can you do it legally?

Some states prohibit treating students in another state. Check to see if you are eligible for an expedited licensing process to provide care in another state: www.­tinyurl.com/3rcu56s2

Are your patients stable?

• Consider how often your patients need to see you. If they are stable and can see you in person as often as they would if they lived nearby, you may be able to continue to treat them.
• Have your patients find care nearby or at school if they require ongoing medication adjustment or ­destabilize.

Will patients allow you to work with their school and parents?

• Expand your reach in an emergency and during less urgent situations by obtaining authorization from your patients to talk with parents and the university. This includes health centers, learning and disability centers, registrars, and housing offices. In the US, you must maintain compliance with the Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and Privacy Act (FERPA).
• While you can generally disclose protected health information to parents or other school officials in an emergency situation, ask your patients to find care locally if they decline to sign releases (www.tinyurl.com/vfydbfpz).

Will the school work with you?

• Ask the health center and the registrar how the university interprets the HIPAA and FERPA laws.
• Reach out ahead of time to student disability services, health services, and housing services at the school to create a team to support your ­patients.
• If these services are not responsive and do not provide you with a point of contact, refer your patients to someone locally who has those relationships with the school.

CARLAT REPORT 

Start talking during high school about what happens after highs school. Help your patients develop skills to move on to the next phase of their lives. Think ahead about your patients' stability and plan for good support and mental health care.