CCPR: How does psychiatric care transfer to the college environment? What’s the most common story you hear?
Dr. Ross: Most college students are completely fine. But students with significant mental health histories often arrive without any care plan. Some wind down therapy or medication before college, assuming their problems will resolve in the new environment. College actually elevates risk, though, because everything changes at once: support network, learning style, sleep schedule, and access to substances. Independence without structure is a powerful stressor. Even without ADHD (or other psychiatric disorders), an 18-year-old’s executive function still isn’t fully formed (Mousley A et al, Nat Commun 2025;16(1):10055). When students run out of medication and haven’t lined up a new prescriber, the risks compound quickly. By October, many students are in crisis.

CCPR: Why October?
Dr. Ross: Six or eight weeks into the semester, poor self-care and underdeveloped executive function catch up with students. They typically haven’t been sleeping enough; they can get by on six hours per night for a week, but not for eight weeks. Caffeine overload, mounting assignments, the arrival of midterms, and the demanding nature of the work all start to accumulate.

CCPR: What challenges do college students face accessing mental health services?
Dr. Ross: Students arrive with full pill bottles but never get around to arranging follow-up. Many have never picked up a prescription. Teenagers 16 or older should start doing that. Insurance is also an issue. Despite online directories listing hundreds of therapists, there’s no guarantee any have openings. Mental health coverage is often limited out of state, especially for partial hospital, intensive outpatient programs, and pharmacy options. Even adults struggle to navigate insurance systems.

CCPR: Do you have tips for helping students line up care?
Dr. Ross: Have the student (not the parent) contact the student health and student disabilities offices before arriving on campus and ask: “What should I do?” We love this proactive planning. These offices can help arrange for on- or off-campus care and accommodations. Also, encourage them to sign consent for parental contact with college staff.

CCPR: What are the trends in substance use you’re seeing on campus?
Dr. Ross: At selective schools, alcohol use is way down, but marijuana is a different matter (www.tinyurl.com/yc87nn8j). I spend about a third of my time encouraging students whose marijuana use is impairing their function to cut back or stop. Motivational interviewing works well here. Young people are genuinely open when you approach it in good faith. When I suggest a two-week hiatus, they often come back saying, “Wow, my concentration and motivation are better.” They don’t want to be told what to do, but they do want to be productive adults. When they see that something is getting in the way of that, they’re willing to try. (Editor’s note: For more, see our webinar “Motivational Interviewing for Teens: Focus on Marijuana”: www.tinyurl.com/2abwm27d.)

CCPR: College is a peak period of onset for serious psychiatric illnesses: bipolar disorder, first-episode psychosis, eating disorders (Beck C et al, Acta Psychiatr Scand 2024;149(6):467–478). How do you identify and engage students who may not seek help on their own?
Dr. Ross: Most residential universities have support systems for students, and at BU we have a respected program called Terriers Connect that trains faculty and staff to recognize and talk with students who may not be okay. If someone is reluctant to engage with us, a trusted staff member (an athletic trainer or an advisor) will walk the student over. Once we get them here, we work to keep them coming back. We also maintain a list of high-risk students and keep tabs on them. In the university setting, students get grades frequently, which creates a relatively objective, recurring measurement of how someone is functioning. A dip or improvement in grades is a useful signal for prodromal changes, or a sign that a student’s functioning has improved, that most practice settings don’t have.

“Call the counseling center at the university where your patient is enrolling. Introduce yourself. Say, ‘I’m Dr. X and I’m treating this student for an anxiety disorder. Here’s my number.’ That open line of communication is critical.” - Mathilde Ross, MD

CCPR: How should we approach medication prescribing for college students differently from general outpatient practice?
Dr. Ross: Cost is issue number one, two, and three. Students are rarely on a brand-name medication unless they were on it at home or came out of a hospital stay on it. Consider using generics and coupon programs for medications when you have patients heading to college. Beyond cost, chaotic schedules make consistency harder. For antidepressants, I favor long half-life SSRIs: fluoxetine and sertraline. I almost never start venlafaxine since missing a dose or two can create real problems. For anxiety, I much prefer propranolol over benzodiazepines (BZDs). It won’t sedate them, and there’s less danger if combined with substances. For mood stabilizers, lithium has no cognitive side effects, usually no weight gain, no sexual side effects, and is inexpensive. Our primary care clinic upstairs makes it easy for us to get labs. Outside clinicians can coordinate with school health services to get labs, too.

CCPR: Are there medications you avoid due to their cognitive (academic) side effects?
Dr. Ross: Most antiepileptic drugs carry cognitive burdens in this population. Topiramate is off the table. When students arrive on valproate, we try to reduce the dose or switch quickly. Lamotrigine has better tolerability, particularly at lower doses, though I’ve seen cognitive side effects at higher doses (Tumay Y et al, Clin Neuropharmacol 2013;36(2):55–58; Shafiyev J and Karadaş Ö, Neurol Sci 2024;45(10):5011–5021). Strong D2-blocking antipsychotics (typicals or risperidone) cause more cognitive problems than other atypicals. We use BZDs extremely sparingly. Lithium stands out favorably with no cognitive fog, which matters enormously for students.

CCPR: Sexual side effects are underreported in any population, especially in college youths. How do you raise the issue with your patients, and does it change your prescribing?
Dr. Ross: It doesn’t change prescribing, but it changes the conversation. Many students are well informed and want to avoid sexual or weight problems. We steer away from all-or-nothing thinking: Sexual side effects don’t always occur, and when they do, they’re often mild and reversible, which is reassuring. It helps enormously when we raise the topic first: “This medication sometimes causes [XYZ]. Have you had similar difficulties?” This makes it easier for the student to bring it up later. The same goes for concerns about weight gain on medications, which is also an opportunity to talk about healthy lifestyles.

CCPR: Stimulants are both widely prescribed and widely diverted on college campuses. How does that shape how you evaluate and manage ADHD?
Dr. Ross: All patients, whether they are seen on campus or not, need a well-planned approach. Every patient we’re considering prescribing for receives a comprehensive ADHD assessment, including a urine drug screen (UDS), and then a UDS once a semester. Like other universities, at BU, we use the state prescription monitoring program (MassPAT), which has cross-state reciprocity, to verify what prescriptions they’re receiving. We prefer long-acting stimulants: fewer pills per month, lower misuse potential, and probably less diversion. We used to require neuropsychological testing, but we phased that out because it was a barrier for students who couldn’t afford it. I’ve been here 18 years and have encountered perhaps a couple of students who I’m fairly certain were misusing certain prescriptions. For the most part, students who genuinely have ADHD value their medication. They don’t want other people to take it, and they follow the rules (Rabiner DL et al, J Atten Disord 2009;13(2):144–153). These are life-changing medications for the students who need them. We maintain guardrails and parameters, revisit the issue periodically, and feel comfortable stopping if something doesn’t look right.

CCPR: Do you prescribe stimulants via telehealth or require in-person visits?
Dr. Ross: We use telehealth and follow Massachusetts rules, which do not require all stimulant visits to be in person. But telehealth is a convenience, not a replacement. For every student on stimulants, I record when they were last seen in person. I check blood pressure twice a year anyway, so they have to come in.

CCPR: What do you wish a student’s home provider had done before that student arrived on campus?
Dr. Ross: This is why I was so keen on this interview! With the telehealth era, more students get care from a remote provider. That can work, but there are real problems when that provider doesn’t know the local emergency services or needs someone near the student to get involved. At a minimum, have a release of information on file before the student leaves for college. If you have concerns about a student’s well-being, you need to be able to call someone at the university. At BU, if an outside provider calls in, we can get a message to the right person within a couple of hours.

CCPR: Can you give an example of how this plays out?
Dr. Ross: This past fall, I had a student who was hypomanic in the dorms for weeks. The outside provider was aware, but it wasn’t at the red-alert stage. The problem was that we didn’t know about it, and the provider didn’t know who to call. It ended up fine, but it could easily not have. The missing release caused a delay that mattered. For an A+, call the counseling center at the university where your patient is enrolling. Introduce yourself. Say, “I’m Dr. X and I’m treating this student for an anxiety disorder. Here’s my number.” We’d say, “Great—nice to meet you.” That open line of communication is critical. In my experience, young patients are often more comfortable with collaborative, cross-provider communication than clinicians expect. They’re pragmatic about getting help.

CCPR: Beyond having a release on file, what should a home provider prepare before a student departs for college (in terms of medication documentation, clinical handoff, and communication with the campus)?
Dr. Ross: The home provider should help prepare the student to interact with the health care system as an adult. It’s the student’s responsibility to know their diagnosis, the contact information for their recent providers, the names and purposes of their medications, any medications they have had adverse reactions to, and how to access their insurance information. We want to hear from outside providers about worrisome clinical information, but college is about developing independence, including in health care.

CCPR: Some students prefer to stay with their home provider throughout college. How does that work out?
Dr. Ross: Staying with a hometown provider can work with students whose college is close to home or those with stable diagnoses (eg, ADHD, anxiety disorders) or when the individual’s problems were developmental (eg, peer group issues in middle school) and have largely resolved. However, conditions such as bipolar disorders and eating disorders can deteriorate rapidly at college, as can a student with a prior suicide attempt, particularly if it occurred in the past year. These students should have treatment lined up before they step on campus.

CCPR: When an outside provider suspects their college-student patient is destabilizing, what’s the right move?
Dr. Ross: The wrong move is to do nothing. Call the counseling center. All students fall under their purview, even those who haven’t been seen. This will start a paper trail. The counseling center may already be hearing from other sources and can determine what level of outreach is needed, whether it’s a soft check-in, bringing the student in for assessment, or involving campus safety and hospitalizing the student. Out-of-state providers cannot hospitalize patients in Massachusetts. Depending on the situation, a good option may be to call the parents, who may already be familiar with the college’s resources, the student’s roommate, or another adult in the dorm. They may also be willing and able to visit the student on campus, which can go a long way toward stabilizing a situation.

CCPR: What should a home provider assess when a student returns from campus, whether for the summer or following a medical leave?
Dr. Ross: Check how they are getting along with their parents and address any significant ongoing difficulties. Negotiating an adult relationship with one’s parents during college is a central developmental task and prognostic sign. Also assess other relationships, substance use, sleep and study patterns. These problems might not show up in their grades. If grades are suffering, you may need to look more deeply into why, including co-occurring conditions and even undiagnosed learning disorders.

CCPR: Home providers worry about the legality of prescribing across state lines, especially for stimulants or controlled substances. What’s your advice?
Dr. Ross: Stick to prescribing controlled substances in the state where you are licensed. Practically speaking, the receiving pharmacy won’t fill a prescription that isn’t accepted by state law. Some students go home periodically to pick up prescriptions or have a parent bring them to campus. Mailing stimulant prescriptions is illegal under federal law (only DEA-approved entities can do this) and also creates a risk for loss or theft.

CCPR: Thank you for your time, Dr. Ross.

(Editor’s note: For more on supporting college-bound students, see CCPR Jul/Aug/Sep 2024; for autism-specific considerations, see our interview with Dr. Baker-Ericzen in CCPR Jan/Feb/Mar 2026.)