College students and the lives they lead are a source of much interest and curiosity. Usually this is directed toward their social and sex lives, their academic achievements and career choices, their initiation rites, and their athletic achievements. More recently, this interest has been directed towards their mental health concerns. Frequently, these issues have been front-page news. Many newspapers and magazines in the last several years have featured articles about the increasing number of students coming to college mental health services, about student drinking patterns, and student suicide. Some of the statistics cited are:
The 2004 National Survey of College Counseling Directors states that 85 percent of the directors of counseling services have reported an increase in severe psychopathology in the students they are seeing.
Most of these directors have seen a 50 percent increase in the number of students coming to their services, and in many instances, the numbers have doubled over the last five years.
92 percent of counseling center directors saw an increase in the number of students coming to college already on psychiatric medications.
The American College Health Association survey of students in 2003 indicated that 40 percent of students at least once during the year had felt so depressed that it was difficult to function.
There have also been prominent accounts of suicides that have occurred among students on the campuses of prestigious universities. Though the suicide rate on college campuses is roughly half the suicide rate in the population at large for the 19 to 25 age group, many colleges are addressing these tragic events by increasing access to counseling and mental health services to try to reduce the number further.
These points raise many questions. Why, for example, would there be an increase in the number of students coming to college counseling and mental health services? How are we to account for the increase in severity of illness?
There are no definitive answers to these questions, though several are frequently mentioned. One is that there has been a decrease in the stigma associated with obtaining mental health care. Thus, students feel free to go to campus services for help. A second reason mentioned is that there has been improved treatment of depressed students in high school. These students are now completing high school and going on to college, which they would not have been able to do before. Another reason offered is the effect of the change in family structure, often with inadequate childcare available. This may adversely affect genetically vulnerable children.
The growth of these problems means that we, as analytic clinicians, will increasingly be seeing troubled college students. When we are consulted in such situations, there are important considerations we should attend to during the assessment, and in recommending an ongoing treatment. We need to keep in mind the psychological vulnerability of students during these years. The transition from home to college to an independent adult life, and the necessity to negotiate many complicated developmental issues, are phenomena psychoanalysts are familiar with. Along with these crucially important psychological developmental tasks, however, it is also important to keep in mind some of the genetic, anatomical, and physiological changes that are still taking place during this period.
For instance, recent studies at the National Institute of Mental Health (NIMH) using imaging techniques have shown that the brain continues to develop until the mid-twenties. During this time, there is a consolidation of neural pathways, which is necessary for the optimal adult functioning of the higher level abilities of judgment, mature decision making, and the ability to integrate paradoxical and contradictory material. This continuing development contributes to the difficulty we have in making definitive adult diagnoses in this late adolescent age group.
The difficulty of diagnosis is compounded by the genetic unfolding of major mental illness, which, as we know, first occurs during the years 17 to 25. Thus, when we see a sophomore who seems “confused” and has loose associations, we may be seeing the developmental regression and uncertainty of an ordinary sophomore who next year will seem well put together; or one might be seeing what, a year later, will turn out to be a major mental illness. Also, what may seem like a college prank one year, turns out to be a mania the next. It is extremely important to keep an open mind about diagnostic issues as development unfolds, both psychologically and physically. This is also an important consideration in prescribing medications.
In clinically assessing a patient in this college age group and, particularly, in undertaking any intensive therapy, we, as analysts, should be cautious in assessing the material as it emerges, and in coming to an understanding of the students. This is a very exciting time in students' lives, and it is a privilege to be working with them during these important transitional years. At the same time, we do need to be alert to the genetic, physiological, and psychological complexities of this period if we are to facilitate the students' development and understanding.
Lorraine D. Siggins, M.D., is psychiatrist-in-chief at Yale University Health Service, clinical professor of psychiatry at the Yale School of Medicine, and training and supervising analyst at the Western New England Institute.