1. State some of the potential risk factors for mental health problems in college students.

2. Help college students deal with stress and avoid risk-taking behaviors.

3. Discuss the prevalence of violence on college campuses, as compared to the general population.

4. Describe alternative therapies proven helpful in the treatment of depression and anxiety.

5. Recommend dietary supplements to help treat depression and anxiety.

Transition and Vulnerability: The Mental Health of College Students
Gary Christenson, MD, Associate Clinical Professor of Psychiatry, and Director of Mental Health, Boynton Health Service, University of Minnesota, Minneapolis, Medical School

Introduction: college is period of transition; potential risk factors for mental health problems—vulnerable age (eg, bipolar disorder, schizophrenia, depression, anxiety often first manifest in this age group); less structure; financial pressures; new relationships; loss of previous support network; peer pressure; homesickness; increased access to alcohol and other drugs; irregular sleep patterns; poor eating habits; less physical activity; increased stress (regarding, eg, career, values, culture, competition)

Statistics: from survey conducted on University of Minnesota Twin Cities (UMTC) campus in 2007, but thought to be generally applicable to college campuses; surveyed 6000 of ≈44,000 students; response rate ≈49% (≈3000 completed surveys); 25.1% of students reported ≥1 mental health diagnosis during lifetime; 14.7% reported mental health diagnosis in previous 12 mo; depression most common diagnosis (17% lifetime, 8% 12-mo prevalence), followed by anxiety (13% lifetime, 9% 12-mo); third most common lifetime diagnosis was social phobia, significant because it sometimes accounts for students’ prolonging undergraduate studies for years; 1% of students reported attempting suicide in previous year (most suicide attempts did not result in completion)

Stress: ≈30% of students reported being unable to manage their stress level; stressors include conflicts with roommates (23%), end of relationship (19%), death of someone close (17%; problematic because most colleges do not have bereavement policy), serious illness of someone close, parental conflict, and excessive credit card debt; 20% of students reported experiencing ≥3 stressors during previous 12 mo

Stress and risk-taking behavior: compared to students reporting ≤2 stressors, those reporting ≥3 stressors had more risk-taking behaviors, including tobacco use, high-risk drinking, marijuana use, credit card debt, and gambling; credit card debt—excessive defined as having outstanding balance ≥$1000 in past year; usually not seen in first-year students, but becomes increasingly problematic each successive year, peaking in fifth year among undergraduate students (incidence ≈42%); among graduate students, incidence ≈23%; associated with lower grade-point average (GPA), high-risk alcohol use, tobacco use, and higher number of work hours

Excessive computer use: ≈32% of students surveyed reported problem; 42% of those (13.5% of all students) reported that it affected their academic performance; problem stems from students checking electronic mail (e-mail) too frequently, fascination with exchanging messages, and online gambling, pornography, “surfing,” and gaming

Problem gambling: 2 in 5 students on Twin Cities campus reported gambling in last 12 mo, 1 in 5 in last mo (speaker posits incidence may be even higher at other colleges); 4.3% reported spending ≥$100/mo, and “most of them are pretty convinced that they’re invincible in this”

Other high-risk behaviors: having no health insurance (due to several factors); being underinsured; students usually dropped from parents’ insurance at 24 or 25 yr of age

Utilization of mental health services: data from 14 Minnesota colleges and universities; while 16% of respondents reported receiving mental health diagnosis within last 12 mo, only 6.2% reported seeing mental health counselor or therapist; 6% to 7% reported using antidepressants; use of other psychotropic medications increased from 0.4% in 1998 to 5.1% in 2007; speaker thinks “a lot of this is stimulants, but a fair amount of mood stabilizers and anxiolytics”

Barriers to care: stigma; lack of insurance coverage; limited resources on campus; lack of time; side effects; students unaware of availability of services

Campus suicide: 10% of college students report that they seriously considered suicide, and 1.4% attempted suicide in past year; however, college students commit suicide at one-half rate of their age-matched noncollege peers, suggesting that college campuses offer some degree of protection against suicide; odds that student with suicidal ideation will actually commit suicide, 1000:1

Antidepressants and suicide: increase in or first appearance of suicidality rarely occurs during initiation of antidepressant therapy; compared with suicidality in month before antidepressants started, 60% decrease seen in month after antidepressants started in adults and adolescents; best approach is to prescribe antidepressants when indicated and monitor closely (recommended that college-age patients return in 2 wk, but be strongly encouraged to call at any time if they have thoughts of suicidality)

Violence on college campuses: murder rate on campuses one-twentieth of national rate; rates of almost all forms of violence in college students lower than rates in age-matched peers (only sexual assault equal in both groups); 93% of violent crimes experienced by students happen off campus, and 72% occur at night; among selected categories of employees, rates of all violent crimes lowest among college and university employees (1.6 per 1000 employees; highest among police officers, at 261 per 1000 employees)

Safe School Initiative: devised by US Secret Service and Department of Education; key findings—incidents of targeted violence at school rarely sudden impulsive acts; commonly, other people knew about attacker’s idea and/or plan to attack before incident; most attackers engaged in some behavior before their attack that caused others concern or indicated need for help; most attackers did not threaten their targets directly before their attack; no accurate and useful profile of students who engaged in targeted school violence; most attackers had difficulty coping with significant losses or personal failures; moreover, many had considered or attempted suicide; many attackers felt bullied, persecuted, or injured by others before making their attack; most attackers had access to and used weapons previous to their attack; in many cases, other students involved in some capacity; despite prompt law-enforcement responses, most shooting incidents stopped by means other than law-enforcement intervention

Special concerns when working with college students: all college campuses have medical and psychologic services, which usually provide academic-skills training, career counseling, psychotherapy, and crisis intervention; some students not aware that these services available

Medications: major concerns involving students include impaired cognition, lack of energy, weight gain, impairment of sexual performance (reassure students that this is “potentially negotiable”), and time to response (advise student that it may take 2 to 4 wk for medication to have effect)

Disability: mental health conditions may be eligible for disability considerations; documentation requirements—Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnosis (Axis I and/or II); current impact on life activities (eg, interest, enjoyment, motivation, energy, sleep, concentration, mood stability, attendance); medication side effects; estimated duration of treatment

Resources: www.mentalhealth.umn.edu (some information specific to University of Minnesota, but much applicable to all colleges); www.activemindsoncampus.org (only US peer-to-peer organization dedicated to mental health of college students; serves as young adult voice in mental health advocacy on >70 campuses nationwide)

Alternative Therapies in the Treatment of Anxiety and Depression
Patricia D. Culliton, MA, LAc, Director, Hennepin Faculty Associates, Integrative Medicine Division, Minneapolis

Introduction: studies show pharmaceuticals not necessarily helpful in mild to moderate depression and anxiety; National Center for Complementary and Alternative Medicine (NCCAM) originally defined complementary and alternative medicine (CAM) as “anything people were using for health care that wasn’t taught in a medical school”

Neuropeptide receptors: originally thought that all neuropeptide receptors in brain, but now known to exist throughout body; more neuroreceptors in heart than in brain, which probably led to terms such as “broken heart” and “heart-felt”; studies show that if heart donor had depression, recipient of transplant tends to develop depression; broken-heart syndrome advanced in recent past to explain why someone gets ill or dies after significant loss, especially of loved one; emotions are bridge between mental and physical selves; shown that brain physiology can be changed by thought

Breath work: “Americans don’t breathe very well”; people in other cultures think Americans neglect breath and breath work; benefits of breath practice—improved sleep; decreased stress; management of pain; enhancement of poor digestion; increase in peripheral blood flow; improved concentration; enhancement of physical performance; boost in energy; types of breath work—stimulating breath; relaxing breath; breath that increases concentration

Speaker advocates breath work for everyone, not just those who are depressed or anxious; shown to improve test scores in children; breath work free and available at any time in any place

Most common CAM therapies in 2002: from NCCAM; 43% of people pray for selves, 24% pray for others; other CAM therapies, in descending order, include natural products, deep breathing, prayer group, meditation, chiropractic, yoga, massage, and diets

Diseases and/or conditions for which CAM most frequently used (in descending order): back pain; head cold; neck pain; joint pain; arthritis; anxiety/depression; gastrointestinal distress; headache; recurring pain; insomnia

HeartMath: company “dedicated to facilitating heart-based living, ie, people relying on the intelligence of their heart in concert with their minds to improve health, performance, relationships and well-being at home and in the workplace”; regimen focuses on location of heart, breathing into heart, and feeling heart (“warm the cockles of your heart”); shown helpful in children and adults with anxiety and/or depression; does not require devices (but variety of devices available on their Web site, www.heartmath.com)

Mindfulness-Based Stress Reduction (MBSR): meditation regimen originally developed for recipients of solid organ transplants; shown to improve compliance with medications, reduce number of visits to physicians, and improve insomnia “dramatically”; research now being expanded to other groups, including caregivers of patients with Alzheimer’s disease

Relaxation Response: program and book developed by Harvard University cardiologist Harold Benson in 1970s, in which Dr. Benson showed relaxation response common to all forms of meditation, including prayer, autogenic training, and hypnosis; shown to lower blood pressure, improve circulation, and increase longevity, and generally “felt good”

Happiness: study in Finland of age-adjusted risk ratios for suicide over 20 yr; people who rated themselves happy at beginning of study had 1% suicide rate at 20 yr, and those who rated themselves unhappy at beginning of study had 10% rate at 20 yr; other studies show that marriage slightly decreased individuals’ happiness over 5 yr; on other hand, widowhood produced severe depression for 1 to 2 yr, but by 5 yr, individuals reported return to their baseline level of happiness, suggesting “set point” for happiness

Set point: ongoing research at 2 universities demonstrates that Buddhist monks practicing meditation and loving- kindness can change set point for happiness; functional magnetic resonance imaging (fMRI) studies show changes in brain physiology with daily meditation practice; other ways of changing set points, especially in older people, include learning something new (creates new neural pathways)

Meditation: defined as “any activity that may clear and quiet the mind”; activities used in meditative way (eg, gardening, cooking, golf, craft work, art, music and dancing, walking) may change over lifetime; types of meditation include concentration (eg, transcendental meditation [TM], use of mantra or rosary), awareness (eg, Buddhist, Vipassana [mindfulness meditation]), and movement/expressive (eg, Sufi dancing, yoga, T’ai Chi, Qi Gong, drumming)

Spiritual practice: may or may not involve religion; refers to feeling of connectedness to family, loved ones, and community, to knowing one’s place in world, to being centered, happy, and grounded, and to having joy in one’s heart; speaker suggests creating “sacred space” where one can meditate and do breath work each day (does not have to be elaborate shrine; can be small enough to fit on top of desk or in corner of work cubicle)

Imagery and visualization: concept explored by Carl Jung, who said we need a sacred space and “some kind of divine figure or metaphor and a ritual of transformation that we need for imagery”; Paracelsus thought we need to take “something from the outside and put it inside” (eg, drugs), but believed most important factor in getting well was power of imagination; imagery and visualization currently used mostly for sports-performance training to improve skill, but also useful in relieving anxiety, pain, and side effects of medical procedures

HealthJourneys.com: study at Duke University of women with posttraumatic stress disorder (PTSD) for 30 to 40 yr; treatment consisted of 12 wk of guided daily imagery using electronic device (control group heard classical music); treatment group showed statistically significant improvement in all symptoms; authors concluded that guided imagery may be best treatment for PTSD

Supplements: because of ubiquity of toxins in environment, now recommended that all adults take daily multiple vitamin, in addition to eating healthy diet, to make sure they get optimal amount of vitamins and minerals; speaker also recommends adults take ≈1000 U/day of vitamin D3 (shown to be helpful in depression); other recommendations include 1000 mg eicosapentaenoic acid (EPA) daily (shown to be helpful in mild to moderate depression and in stabilizing mood in people with bipolar disorder; chocolate—products with ≥70% cocoa shown to cause production of endorphins