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Students Rate Mental Health Services

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This opinion article Valium and the New Normal by Robin Marantz Henig is must reading for all college health professionals and therapists to stimulate discussion among us about what we have done in the past in our prescribing habits and what we continue to do.

We need to be serious in our self-examination of how we respond therapeutically to our student-patients’ challenges and anxieties.   If  “normal” is a prescription-medicated state for over 25% of our patient population (far higher if considering the number on daily synthetic hormones), in addition to those who self-medicate regularly with recreational substances, what are we actually accomplishing in helping prepare students for their lives outside the ivory tower?  That all solutions are found in a bottle of one sort or another?

The sought-for “normal,” in otherwise healthy individuals, has become a quest to quash unpleasant feelings and emotions.  Is that really what we want to accomplish with our patients? Or should we be helping them learn (after all, they are in college to learn) the art of resiliency and coping?

As a wise relative would say to me when I felt I couldn’t handle yet another stress while I was in school:  “this too shall pass.”

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Persistent Cannabis users show neuropsychological decline from childhood to midlife  

This recent study published in the Proceedings of the National Academy of Sciences warrants attention among college health providers who are seeing nearly a third of their student-patients using cannabis in various forms within the previous thirty days, primarily for recreational purposes, but increasingly as legal treatment for medical diagnoses.

if you believe the extremely vocal marijuana proponents, cannabis can treat almost any condition under the sun, and in a number of states now is being prescribed and encouraged for everything from anxiety to insomnia to sinusitis to asthma to arthritis to headaches to premenstrual syndrome.  If you are simply alive, there is a good chance you have at least one symptom that warrants a medical marijuana card. It is a fine example of not-so-modern snake oil, as it has been around for thousands of years, except now we have multiple state legislative bodies putting their stamp of approval on it.  I’m concerned our nation’s overwhelming drug abuse statistics will not decline with the legalization of the possession of small amounts of marijuana for medicinal purposes,  in addition to open marketing, sale and distribution.  We are simply bringing the dealers and pushers out of the shadows–not a bad thing if we can all agree that a staggering percentage of the population, including our brain-development-vulnerable adolescents, suffer symptoms deemed worthy of being medicated with a mood altering substance well known to cause dependency, not to mention a host of psychiatric problems including new onset panic disorder, dissociative symptoms and psychosis in vulnerable individuals.

Patients who have antipathy for the pharmaceutical industry or for government agencies responsible for studies of drug safety and effectiveness seem to lose their skepticism when confronting the for-profit motivation of marijuana growers, brokers and storefront sellers.  These patients prefer to trust a physician/chiropractor/naturopath sitting in a temporary booth at a Hemp Fest willing to pocket $150 cash for a ten minute assessment of symptoms in exchange for a signature on a medical marijuana card. Many choose not to be followed by responsible health care providers who might actually take a thorough history, do a complete examination and lab tests including drugs of abuse testing, possibly order confirmatory imaging studies, and might actually recommend treatment that is proven in multiple controlled studies to be effective.

In my university health center clinic I’ve been asked by several otherwise healthy teenage college students if I would prescribe medical marijuana for their stress-related headaches.  These young people have friends who have gotten their medical marijuana card elsewhere so they can “smoke whenever they need to” without fear of being found in possession by law enforcement.  They want the “get out of jail free” card, or better yet, “never get arrested to begin with” card.  They have symptoms, as all of us do, but none of these are patients with chronic disease found unresponsive to other treatment.   These are patients who have never had more than a cursory headache evaluation, never had a trial of non-pharmaceutical modalities like relaxation techniques or massage, or prophylaxis with non-addictive medication.  Yet they are willing to sign on to a substance that has, at best, a shadowy origin with no quality standards in production, distribution or dosing, is traditionally and most expediently used only by inhaling smoke or vapor, and has well-studied adverse effects on short and long term memory, focus and reaction time.   All this defies logic, especially in a college student who needs every neuron at the ready to absorb, retain and process complex information, something marijuana has proven ability to impair.  I’m perplexed at how easily these leaves of grass are given a pass by young and old, rich and poor, professional and blue collar, liberal and conservative.

Certainly marijuana is the “least” of the problem recreational drugs, not as physically devastating nor by itself  responsible for overdose fatalities like alcohol, benzodiazepines, cocaine, methamphetamines, or opiates, but it still has the potential to ruin lives.   In its twenty first century ultra high concentrated version,  far more powerful than the weed of the sixties and seventies, it renders people so much less alive and engaged with the world.   They are anesthetized to all the opportunities and challenges of life.  You can see it in their eyes and hear it in their voices.  In a young person who uses regularly, which a significant percentage choose to do in their fervent belief in its touted “safety”, it can mean more than temporary anesthesia to the unpleasantness of every day hassles.  They never really experience life in its full emotional range from joy to sadness, learning the sensitivity of becoming vulnerable, the lessons of experiencing discomfort and coping, and the healing balm of a resilient spirit.  Instead, it is all about avoidance, emotional anesthesia and getting high.

Benumbed, blunted, and stunted.  Surely yet another indication for the prescription of medical marijuana.

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Along with millions of Americans, I’ve tried to comprehend the tragic mass school shootings at Virginia Tech, Northern Illinois University, and others, as well as those perpetrated by former University students in Tucson and Aurora.  We have to reach deep within ourselves to find compassion for young men who forever change the world for themselves and others through their violent actions.

For those of us who assess, diagnose and treat college students struggling with mental illness while trying to succeed in their academic pursuits, the events leading up to such tragic deaths are chilling indeed.  As a college health physician, I and my colleagues all have known progressively destabilizing students like these shooters, have tried valiantly to keep them in school while coordinating complex therapy and medical treatment and we all have, at times, failed to turn things around.

As I have tried to remind myself over two decades of this work, the primary mission of an institution of higher learning is not to be a residential psychiatric treatment center, but this level of care often is expected by students, their families and the general public.  They say: how can a college remove a student from school when he was showing signs of illness?  Didn’t the college understand that removing him from school would make things worse and remove him from daily monitoring of his behavior?  Wasn’t there a way to compel him to get psychiatric assessment and treatment?

From being on the mental health treatment side of those questions,  there are times when the student simply can’t remain in the classroom, yet won’t cooperate with seeing a psychiatrist, and is not impaired enough for the state to go through commitment proceedings.  They are truly lost–no longer appropriate for school due to aberrant (but not illegal) behavior, angry about being suspended for behavior that cannot be tolerated on campus, but within their civil rights to remain unevaluated and untreated.

Most students I have seen with disruptive or impairing mental illness symptoms agree to take a medical withdrawal to invest full time in their recovery for a few months or a year, or occasionally they choose entirely on their own to drop out, never to return.  Very few are so gravely disabled they are committed to mental hospitals or end up in jail because of extreme behaviors that harm others.  Tragically, some commit suicide, most without ever seeking help.  Rarely, they become too disruptive or dangerous to self or others so they have to be suspended from school until they can demonstrate stability and fitness to return.  One in a million will kill others.   Those of us who see mentally ill students every day understand all too well what is at stake.  I have had numerous students and families tell me that the routine of school is the only thing that will keep things from destabilizing more.  It is the only place mental health treatment is easily available and affordable.  It will surely cause increased stress for the student to leave the academic pressure cooker, getting behind in their course sequence, delaying graduation and a career,  even if that student is not attending class, not completing assignments, not making progress, possibly exhibiting disruptive or threatening behavior.   Too often, there is simply no stable home for the student to return to for treatment and recovery.   Much of our time is spent assisting students in making that transition to care outside of the campus environment as there may not be family members who can help.

Young adult students are living with more academic and social stress than they’ve ever known before at a vulnerable time in their development:  their support system is changing with families broken and fragmented, their identities are still forming, their values and moral underpinnings are continually being challenged, and their brains are still developing.   Add to that mix the ubiquitous and noxious presence of alcohol and recreational drugs that exacerbate or even trigger mental illness, and it is not surprising that some college students find they cannot cope with life.  The epidemic of depression, suicidal ideation and behavior among college students is a crushing reality.  I have personally gone to apartments where I suspect a “no show for an appointment” student is holed up, not reaching out for help, planning to commit suicide, and talked them into agreeing to a psychiatric inpatient hospitalization to keep them safe.

Despite deep budget cuts, many institutions of higher learning are still doing everything possible to address exploding student mental health needs, and must handle crises twenty four hours a day.  Psychiatric prescribing is standard student health care on many campuses for increasingly complex students as there is rarely affordable access to mental health care off campus in a timely fashion.   Some students arrive at the University on five or six psychiatric medications considered crucial to their stability–some families make the decision about which college to attend based on the quality of the mental health care available on campus.  It takes seasoned expertise to help a student manage that kind of pharmacopeia and still stay awake in class, sleep soundly at night, and maintain balance in their social life.  We are doing our best to help keep these students in school, even when their behavior seems odd, or their thinking is tangential, or they struggle to keep both feet in everyday reality.

College is a time for learning–that is something we can all agree on.  It is also our responsibility to keep the academic environment safe, free from threats, while supporting students with mental illness who need help to learn to live and let live.   When that support is not sufficient, when a student is unable to “learn” effectively due to the degree and severity of their illness, or their symptoms are compromising the learning of other students,  they must take a break to work full time on learning how to manage their illness.   I have seen many return after that break and be successful in completing their degree.  Even better than the diploma earned is the knowledge they have overcome the challenges of mental illness to make it happen.

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