Hoya Paxa

Rebuilding the Commonwealth by Improving Campus Mental Health (Doyle Symposium Second Place)

Early this month, I wrote a paper for one of my global health classes about maintaining mental health on college campuses through task sharing. I received a 95 percent on my paper, with my instructor commenting “Great paper, but now who do we talk to make it happen?”  A few days later, I received the email calling for submissions to the Doyle Symposium on how to “Rebuild the Commonweal” here at Georgetown by combating stigma and inequality—a perfect forum to present my paper in. I believe that one powerful way to bring the Georgetown community back together is through maintaining good mental health on campus. Mental illness in a college setting is not only incredibly debilitating, but also extremely divisive to community. People with mental illnesses often become isolated and stigmatized. In many cases, their mental illness can lead to attempts to hurt themselves or others, shattering the safety of communities. I have seen this first hand as an EMT on Georgetown Emergency Medical Response Service. Often, we are the ones called when there is a mental health crisis so severe that someone is injured or almost injured. I have seen—and heard from my fellow EMS providers of—too many suffering students who believe that their only options are to cut themselves, overdose on medication, or jump. Consequently, in order to prevent these mental health crises, we need to become serious about filling in the gaps in our mental health services here at Georgetown. I believe that this can be effectively done by task sharing—through students helping other students.

Maintaining Mental Health on College Campuses with Task Sharing
In this essay I argue that mental health disorders on college campuses could be better treated through task sharing—by utilizing students as community mental health care workers. Discussed first is the prevalence of mental health disorders and the worldwide dearth in mental health care workers. Of all the populations affected by mental health disorders, college-age adolescents present a unique opportunity because targeting them for interventions allows mental health disorders to be cured before they create adverse economic, social, and health outcomes in adulthood. However, college campuses resemble many low and middle income countries where mental health professionals are scarce and spread too thinly to adequately provide for all students’ mental health needs. Consequently, a solution that has been successful in low and middle income countries—task sharing—should be applied on college campuses. Students should be trained as community mental health care workers to provide relief to other students.

Mental health is increasingly becoming a priority of the global health community. Indeed, the World Health Organization has declared that there can be “no health without mental health” (Prince et al., 2007). And although mental illnesses account for 14 percent of the global burden of disease (Prince et al., 2007), at least “two-thirds of all persons” worldwide go untreated and “in low resource countries this figure exceeds 90%” (Patel and Thornicroft, 2009). Interestingly, the large treatment gap in mental health is not limited to low and middle income countries. In the United States—which arguably has the best resourced health care system—60 percent of individuals with a diagnosable mental health disorder had not received any kind of health care treatment in the past year (Wang et al., 2005). The gap in treatment of mental health disorders in the United States is particularly severe on college campuses. Multiple studies have found that untreated mental disorders are “highly prevalent in student populations” with anywhere between 50 to 76 percent of college students with a mental disorder failing to utilize mental health services (Hunt and Eisenberg, 2010). This treatment gap is particularly concerning as mental health disorders “appear to be increasing in number and severity” in college populations (Hunt and Eisenberg, 2010).

Mental disorders account for a “large proportion of the disease burden in young people [ages 12-24] in all societies” with at minimum “one out of every four to five young people” suffering from “at least one mental disorder in any given year” (Patel et al., 2007). Apart from causing significant disability, mental health disorders are also responsible for high rates of mortality in youth, triggering suicide and injury (Patel et al., 2007). Despite the privileged environment, college campuses are not immune to the plague of mental health disorders affecting adolescents (Blanco et al., 2008). In 2008, the National College Health Assessment reported that “more than one in three undergraduates reported ‘feeling so depressed it was difficult to function’ at least once in the previous year, and nearly one in 10 reported ‘seriously considering attempting suicide’ in the previous year” (Hunt and Eisenberg, 2010). Other studies have found that “almost half of college students met the DSM-IV criteria for at least one mental disorder in the previous year” (Hunt and Eisenberg, 2010).

Although, maintaining good mental health through adolescence and college is extremely important, the mental health problems of college students are becoming increasingly visible and severe as more students seek treatment and advances in psychiatric care enable individuals with serious mental disorders to attend and stay in college for the first time. Indeed, during the last decade, “university and college counseling centers have reported a shift in the needs of students seeking counseling services, from more benign developmental and informational needs, to more severe psychological problems" (Kitzrow, 2003). These more severe mental disorders include suicidality, substance abuse, depression, eating disorders, history of psychiatric hospitalization and sexual assault. Additionally, the mental health of adolescents has received a national spotlight with the many well-publicized suicides of college students and school shootings perpetrated by adolescents. The growing visibility and severity of mental disorders in college students begs the question, why should maintaining mental health in college students be a public health priority?

Treating mental health is important if colleges are serious about keeping their students safe and physically healthy. Obviously, maintaining mental health in college students is important to prevent violence—whether the violence is self-inflicted (e.g. substance abuse) or directed towards others. In addition to being intricately connected to violence, mental health illnesses are also linked to physical well-being. Mental and physical health problems are often co-morbid and syndemic—they do not just occur together, but rather interact to make each other worse. For example, diabetics with depression have lower adherence to diet/exercise recommendations and to medication regimes (Prince et al., 2007). Having a mental health illness negatively affects these individuals’ desire and ability to take of themselves. As well as exacerbating existing physical health problems, mental health disorders can increase susceptibility to communicable diseases. For example, individuals with mental health issues are vulnerable to HIV transmission because they are more likely to engage in risky sexual behavior and drug use. Finally, mental health problems affect all aspects of a “student’s physical, emotional, cognitive, and interpersonal functioning” (Kitzrow, 2003). And although the prevalence of mental health disorders in adolescents in college campuses is a serious problem, it also presents a tremendous opportunity.

Targeting college students for mental health treatment is an opportunity because adolescence is an extremely important period of life for mental health. This is largely because most lifetime mental disorders have a “first onset by age 24 years” (Hunt and Eisenberg, 2010). This creates the opportunity for early identification and treatment of mental health disorders in college before the individual enters adult life, improving the mental health of the general population for generations to come. Additionally, “the college years represent a developmentally challenging transition to adulthood, and untreated mental illness may have significant implications for academic success, productivity, substance use, and social relationships" (Hunt and Eisenberg, 2010). As Becker and Kleinman eloquently state, “adolescent mental health is a neglected area that is of great concern given the strong evidence that mental disorders are predictors of adverse economic, social, and health outcomes in adulthood, resulting in costs that are difficult to measure but easy to appreciate” (2013). If universities are serious about creating a safe and supportive environment for their students while preparing them to succeed socially and economically in the future, then maintaining the mental health of students needs to be a top priority of university administrations.

Right now, there are two major problems with maintaining mental health in college students: the perceived barriers by students to seeking help and the shortage of mental health professionals on college campuses. Training students to be community mental health workers is an elegant solution to both problems. Multiple studies have found that common barriers to college students seeking professional help for their mental disorders include: lack of time, unwillingness to be emotionally open with school staff, lack of a perceived need for help, being unaware of services or insurance coverage, and financial constraints (Hunt and Eisenberg, 2010). Using students as community mental health workers eliminates many of these concerns: student mental health workers would able to meet with other students outside of normal business hours and in their own residences; student mental health workers would not be a paid service; and most importantly, students are more likely to confide in their peers (Hennig et al., 1998).

The other major problem with delivering effective mental health care to college students is the shortage of mental health professionals on college campuses. According to the 2008 survey, “the overall ratio of students to psychological counselors is about 1,900:1, with even higher ratios at larger institutions” (Hunt and Eisenberg, 2010). Another survey found that common concerns of directors of campus mental health services were all related to a lack of resources: “finding community referrals for students requiring long-term care (67%), dealing with the growing demand of services without a concurrent increase in resources (60%), and…handling an increasing number of students with serious psychological problems (50%)” (Hunt and Eisenberg, 2010). With these problems, college campuses resemble many low and middle income countries where there is a severe shortage of mental health professionals. For example, in India there are 3,000 psychiatrists for a population of 1.2 billion (a ratio of 1 mental health professional to 400,000 people). Consequently, college campuses have much to learn from how low and middle income countries have been narrowing the treatment gap in mental health care: task sharing through the training of community mental health workers.

Vikram Patel, a leading expert on mental health task sharing, describes the concept of community mental health workers as using “whoever is available in the community” and training them “to provide a range of health care interventions” (Patel “Video,” 2013). Task sharing is becoming increasingly prevalent in the global health community. In this model, the role of the mental health specialist is “reconfigured…to emphasize training, supervision, and tertiary care while transferring the bulk of direct service delivery to community health workers or primary care professionals who would receive specific training and supervision in mental health” (Becker and Kleinman, 2013). And this model of task sharing has been proven to be effective, with several studies providing conceptual support.

In 2003, Bolton et al. demonstrated that ordinary people could deliver interpersonal psychotherapy for depression and, using a randomized control trial, showed that 90 percent of people receiving this intervention recovered as compared to 40 percent in comparison villages. Other studies have shown similar results, with 75 percent (compared with 45 percent in matched villages) of mothers with depression in rural Pakistan recovering due to cognitive behavioral therapy administered by community health workers (Rahamn et al., 2008). In 2011, Patel et al. showed a 70 percent (compared with 50 percent in matched villages) recovery rate in depression and anxiety of individuals in rural India who received psychosocial interventions from lay counselors. Task sharing works. Lay people can and should be trained to deliver effective mental health interventions in order to narrow the treatment gap in mental health.

On college campuses, the limited number of mental health professionals should focus on training and supervising student mental health workers. Students acting as community mental health workers offers multiple advantages, as mentioned above. Primarily, it is because students are more likely to confide in other students (Hennig et al., 1998). Additionally, because mental illnesses are shaped by a patient’s culture, having a variety of students functioning as mental health works ensures that someone with the same culture, background, or current situation as the patient that will be available to properly understand and treat the illness. On college campuses, student mental health workers could be assigned to patients based on similarity of background and current situation. This is especially important on college campuses since studies have found that mental health service utilization is “especially infrequent among students from lower socioeconomic backgrounds, international students, and Asian American students” (Hunt and Eisenberg, 2010). Finally, with students acting as community health workers and seeing to routine and ongoing mental health care, the limited number of mental health professionals would have more time to focus on patients that have severe mental illnesses and deal with emergency mental health situations.

I strongly believe that college students could effectively treat the mental health illnesses of their peers. Indeed, the model Vikram Patel uses to treat depression in India could easily be applied in a college setting. Patel teaches his community mental health workers to focus on problem solving, behavior activation and rumination (Patel “Video,” 2013). With problem solving, community mental health workers attempt to solve social issues that co-exist with mental health problems. In a college setting, an example social issue might be an abusive relationship. A peer mental health worker could direct the patient to other supportive community resources on how to get help and leave the relationship. Behavioral activation and rumination focus on changing how the patient thinks, primarily by getting patients to think about rewarding activities and re-engage with them. These are simple interventions that could be applied by student mental health workers to have a profound effect.

In addition to ongoing treatment of mental illnesses, student mental health workers would be able to act as educators on college campuses. Student mental health workers would raise awareness about mental illnesses, help reduce stigma surrounding the issue, and most importantly, identify new individuals who need treatment. Indeed, a program that uses students to raise awareness on and treat sexual assault already exists at Georgetown University. In this program, trained Sexual Assault Peer Educators work to transform the Georgetown community’s understanding of sexual assault while providing survivor support. It would not be a huge step to create a similar program focusing on mental health or even to train the SAPE representatives to also treat and raise awareness about mental health disorders.

I truly believe that college students working as mental health workers have the power to transform mental health treatment on college campuses. The mental health needs of our adolescents are not being met. College students with untreated mental health disorders are harming themselves and harming others while creating adverse economic, social, and health outcomes that follow them into adulthood. Consequently, the college environment presents a unique opportunity to treat mental illness early in life. However, there are not enough mental health resources on college campuses to do this effectively. A solution that has been successful in low and middle income countries facing similar shortages of mental health professionals—task sharing—should be applied on college campuses. Students should be trained as peer mental health workers to provide relief to other students. In the words of Virkram Patel, “what's truly [attractive] about the idea of task shifting…isn't that it simply makes health care more accessible and affordable but that it is also fundamentally empowering. It empowers ordinary people to be more effective in caring for the health of others in their community, and in doing so, to become better guardians of their own health…task shifting is the ultimate example of the democratization of medical knowledge, and therefore, medical power” (Patel “Video,” 2013).  

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