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Understanding depression and suicide in college athletes: emerging concepts and future directions

1. 1 Department of Family Medicine, University of Washington, Seattle, Washington, USA

2. 2 Department of Family, Community, and Preventive Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA

Correspondence to Dr Ashwin L Rao, University of Washington Sports Medicine, P.O. Box 354060, 3800 Montlake Blvd NE, Seattle, WA 98195, USA; ashwin{at}uw.edu

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Depression and suicide remain major public health concerns affecting broad segments of the population. The prevalence rates for depression are notably high in young adults. According to the US Department of Health and Human Services, the prevalence of depression in individuals aged 18-25 years is 8.7%.1 Clinically significant depression symptoms appear to be as prevalent in collegiate athletes as in the general college student population.2 Suicide remains the third leading cause of death among individuals of collegiate age and is reported as the second leading cause of death among the general college student population.3 , 4 In college athletes, a suicide ranks fourth as a leading cause of death.5 Current estimates of depression and suicide prevalence in these populations are challenged by the lack of consistent methodology, inconsistent reporting by schools and a poor understanding of relevant screening tools to effectively evaluate athletes. Thus, under-reporting of mental health concerns in athletes is a significant concern, and depression and suicide are tangible concerns to address in athletes of all ages and levels of ability.

Some studies suggest ...

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# data[].attributes.attachment_link.title
Understanding depression and suicide in college athletes: emerging concepts and future directions

# data[].attributes.attachment_link.description
Depression and suicide remain major public health concerns affecting broad segments of the population. The prevalence rates for depression are notably high in young adults.

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This article is about how common it is for college student athletes to have mental disorders.

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Cited by 199

This article has been cited by the following publications. This list is generated based on data provided by CrossRef.

Bártolo, Ana Monteiro, Sara and Pereira, Anabela 2017. Factor structure and construct validity of the Generalized Anxiety Disorder 7-item (GAD-7) among Portuguese college students. Cadernos de Saúde Pública, Vol. 33, Issue. 9,

Ebert, David Daniel Cuijpers, Pim Muñoz, Ricardo F. and Baumeister, Harald 2017. Prevention of Mental Health Disorders Using Internet- and Mobile-Based Interventions: A Narrative Review and Recommendations for Future Research. Frontiers in Psychiatry, Vol. 8, Issue. ,

Auerbach, R. P. Alonso, J. Axinn, W. G. Cuijpers, P. Ebert, D. D. Green, J. G. Hwang, I. Kessler, R. C. Liu, H. Mortier, P. Nock, M. K. Pinder-Amaker, S. Sampson, N. A. Aguilar-Gaxiola, S. Al-Hamzawi, A. Andrade, L. H. Benjet, C. Caldas-de-Almeida, J. M. Demyttenaere, K. Florescu, S. de Girolamo, G. Gureje, O. Haro, J. M. Karam, E. G. Kiejna, A. Kovess-Masfety, V. Lee, S. McGrath, J. J. O'Neill, S. Pennell, B.-E. Scott, K. ten Have, M. Torres, Y. Zaslavsky, A. M. Zarkov, Z. and Bruffaerts, R. 2017. Mental disorders among college students in the World Health Organization World Mental Health Surveys - CORRIGENDUM. Psychological Medicine, Vol. 47, Issue. 15, p. 2737.

McLafferty, Margaret Lapsley, Coral R. Ennis, Edel Armour, Cherie Murphy, Sam Bunting, Brendan P. Bjourson, Anthony J. Murray, Elaine K. O'Neill, Siobhan M. and Sasayama, Daimei 2017. Mental health, behavioural problems and treatment seeking among students commencing university in Northern Ireland. PLOS ONE, Vol. 12, Issue. 12, p. e0188785.

Alonso, Jordi Mortier, Philippe Auerbach, Randy P. Bruffaerts, Ronny Vilagut, Gemma Cuijpers, Pim Demyttenaere, Koen Ebert, David D. Ennis, Edel Gutiérrez-García, Raul A. Green, Jennifer Greif Hasking, Penelope Lochner, Christine Nock, Matthew K. Pinder-Amaker, Stephanie Sampson, Nancy A. Zaslavsky, Alan M. and Kessler, Ronald C. 2018. Severe role impairment associated with mental disorders: Results of the WHO World Mental Health Surveys International College Student Project. Depression and Anxiety, Vol. 35, Issue. 9, p. 802.

Kasteenpohja, Teija Marttunen, Mauri Aalto-Setälä, Terhi Perälä, Jonna Saarni, Samuli I. and Suvisaari, Jaana 2018. Outcome of depressive and anxiety disorders among young adults: Results from the Longitudinal Finnish Health 2011 Study. Nordic Journal of Psychiatry, Vol. 72, Issue. 3, p. 205.

O'Neill, Siobhan McLafferty, Margaret Ennis, Edel Lapsley, Coral Bjourson, Tony Armour, Cherie Murphy, Sam Bunting, Brendan and Murray, Elaine 2018. Socio-demographic, mental health and childhood adversity risk factors for self-harm and suicidal behaviour in College students in Northern Ireland. Journal of Affective Disorders, Vol. 239, Issue. , p. 58.

Hasking, Penelope Boyes, Mark and Greves, Stuart 2018. Self-efficacy and emotionally dysregulated behaviour: An exploratory test of the role of emotion regulatory and behaviour-specific beliefs. Psychiatry Research, Vol. 270, Issue. , p. 335.

Hoffman, Lauren J. Guerry, John D. and Albano, Anne Marie 2018. Launching Anxious Young Adults: A Specialized Cognitive-Behavioral Intervention for Transitional Aged Youth. Current Psychiatry Reports, Vol. 20, Issue. 4,

Sarac, Nikolas Sarac, Benjamin Pedroza, Angela and Borchers, James 2018. Epidemiology of mental health conditions in incoming division I collegiate athletes. The Physician and Sportsmedicine, Vol. 46, Issue. 2, p. 242.

Mortier, P. Cuijpers, P. Kiekens, G. Auerbach, R. P. Demyttenaere, K. Green, J. G. Kessler, R. C. Nock, M. K. and Bruffaerts, R. 2018. The prevalence of suicidal thoughts and behaviours among college students: a meta-analysis. Psychological Medicine, Vol. 48, Issue. 4, p. 554.

Sano, Akane Taylor, Sara McHill, Andrew W Phillips, Andrew JK Barger, Laura K Klerman, Elizabeth and Picard, Rosalind 2018. Identifying Objective Physiological Markers and Modifiable Behaviors for Self-Reported Stress and Mental Health Status Using Wearable Sensors and Mobile Phones: Observational Study. Journal of Medical Internet Research, Vol. 20, Issue. 6, p. e210.

Mall, Sumaya Mortier, Philippe Taljaard, Lian Roos, Janine Stein, Dan J. and Lochner, Christine 2018. The relationship between childhood adversity, recent stressors, and depression in college students attending a South African university. BMC Psychiatry, Vol. 18, Issue. 1,

Tang, Fang Byrne, Majella and Qin, Ping 2018. Psychological distress and risk for suicidal behavior among university students in contemporary China. Journal of Affective Disorders, Vol. 228, Issue. , p. 101.

Hall, Brian J. Xiong, Peng Guo, Xinqi Sou, Elvo Kuai Long Chou, Un I and Shen, Zhuozhuo 2018. An evaluation of a low intensity mHealth enhanced mindfulness intervention for Chinese university students: A randomized controlled trial. Psychiatry Research, Vol. 270, Issue. , p. 394.

Hennemann, Severin Böhme, Katja Baumeister, Harald Bendig, Eileen Kleinstäuber, Maria Ebert, David Daniel and Witthöft, Michael 2018. Efficacy of a guided internet-based intervention (iSOMA) for somatic symptoms and related distress in university students: study protocol of a randomised controlled trial. BMJ Open, Vol. 8, Issue. 12, p. e024929.

Jordan, Hallie R. Villarosa-Hurlocker, Margo C. Ashley, Asia L. and Madson, Michael B. 2018. Protective Behavioral Strategies and Hazardous Drinking Among College Students: The Moderating Role of Psychological Distress. Journal of Drug Education, Vol. 48, Issue. 1-2, p. 3.

Uwatoko, Teruhisa Luo, Yan Sakata, Masatsugu Kobayashi, Daisuke Sakagami, Yu Takemoto, Kazumi Collins, Linda M. Watkins, Ed Hollon, Steven D. Wason, James Noma, Hisashi Horikoshi, Masaru Kawamura, Takashi Iwami, Taku and Furukawa, Toshi A. 2018. Healthy Campus Trial: a multiphase optimization strategy (MOST) fully factorial trial to optimize the smartphone cognitive behavioral therapy (CBT) app for mental health promotion among university students: study protocol for a randomized controlled trial. Trials, Vol. 19, Issue. 1,

Balayssac, David Pereira, Bruno Darfeuille, Maxime Cuq, Pierre Vernhet, Laurent Collin, Aurore Vennat, Brigitte and Authier, Nicolas 2018. Use of Psychotropic Medications and Illegal Drugs, and Related Consequences Among French Pharmacy Students - SCEP Study: A Nationwide Cross-Sectional Study. Frontiers in Pharmacology, Vol. 9, Issue. ,

Dickinson, David L. Wolkow, Alexander P. Rajaratnam, Shantha M. W. and Drummond, Sean P. A. 2018. Personal sleep debt and daytime sleepiness mediate the relationship between sleep and mental health outcomes in young adults. Depression and Anxiety, Vol. 35, Issue. 8, p. 775.

Background

Although mental disorders are significant predictors of educational attainment throughout the entire educational career, most research on mental disorders among students has focused on the primary and secondary school years.

Method

The World Health Organization World Mental Health Surveys were used to examine the associations of mental disorders with college entry and attrition by comparing college students (n = 1572) and non-students in the same age range (18-22 years; n = 4178), including non-students who recently left college without graduating (n = 702) based on surveys in 21 countries (four low/lower-middle income, five upper-middle-income, one lower-middle or upper-middle at the times of two different surveys, and 11 high income). Lifetime and 12-month prevalence and age-of-onset of DSM-IV anxiety, mood, behavioral and substance disorders were assessed with the Composite International Diagnostic Interview (CIDI).

Results

One-fifth (20.3%) of college students had 12-month DSM-IV/CIDI disorders; 83.1% of these cases had pre-matriculation onsets. Disorders with pre-matriculation onsets were more important than those with post-matriculation onsets in predicting subsequent college attrition, with substance disorders and, among women, major depression the most important such disorders. Only 16.4% of students with 12-month disorders received any 12-month healthcare treatment for their mental disorders.

Conclusions

Mental disorders are common among college students, have onsets that mostly occur prior to college entry, in the case of pre-matriculation disorders are associated with college attrition, and are typically untreated. Detection and effective treatment of these disorders early in the college career might reduce attrition and improve educational and psychosocial functioning.

Cited by 199

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Bártolo, Ana Monteiro, Sara and Pereira, Anabela 2017. Factor structure and construct validity of the Generalized Anxiety Disorder 7-item (GAD-7) among Portuguese college students. Cadernos de Saúde Pública, Vol. 33, Issue. 9,

Ebert, David Daniel Cuijpers, Pim Muñoz, Ricardo F. and Baumeister, Harald 2017. Prevention of Mental Health Disorders Using Internet- and Mobile-Based Interventions: A Narrative Review and Recommendations for Future Research. Frontiers in Psychiatry, Vol. 8, Issue. ,

Auerbach, R. P. Alonso, J. Axinn, W. G. Cuijpers, P. Ebert, D. D. Green, J. G. Hwang, I. Kessler, R. C. Liu, H. Mortier, P. Nock, M. K. Pinder-Amaker, S. Sampson, N. A. Aguilar-Gaxiola, S. Al-Hamzawi, A. Andrade, L. H. Benjet, C. Caldas-de-Almeida, J. M. Demyttenaere, K. Florescu, S. de Girolamo, G. Gureje, O. Haro, J. M. Karam, E. G. Kiejna, A. Kovess-Masfety, V. Lee, S. McGrath, J. J. O'Neill, S. Pennell, B.-E. Scott, K. ten Have, M. Torres, Y. Zaslavsky, A. M. Zarkov, Z. and Bruffaerts, R. 2017. Mental disorders among college students in the World Health Organization World Mental Health Surveys - CORRIGENDUM. Psychological Medicine, Vol. 47, Issue. 15, p. 2737.

McLafferty, Margaret Lapsley, Coral R. Ennis, Edel Armour, Cherie Murphy, Sam Bunting, Brendan P. Bjourson, Anthony J. Murray, Elaine K. O'Neill, Siobhan M. and Sasayama, Daimei 2017. Mental health, behavioural problems and treatment seeking among students commencing university in Northern Ireland. PLOS ONE, Vol. 12, Issue. 12, p. e0188785.

Alonso, Jordi Mortier, Philippe Auerbach, Randy P. Bruffaerts, Ronny Vilagut, Gemma Cuijpers, Pim Demyttenaere, Koen Ebert, David D. Ennis, Edel Gutiérrez-García, Raul A. Green, Jennifer Greif Hasking, Penelope Lochner, Christine Nock, Matthew K. Pinder-Amaker, Stephanie Sampson, Nancy A. Zaslavsky, Alan M. and Kessler, Ronald C. 2018. Severe role impairment associated with mental disorders: Results of the WHO World Mental Health Surveys International College Student Project. Depression and Anxiety, Vol. 35, Issue. 9, p. 802.

Kasteenpohja, Teija Marttunen, Mauri Aalto-Setälä, Terhi Perälä, Jonna Saarni, Samuli I. and Suvisaari, Jaana 2018. Outcome of depressive and anxiety disorders among young adults: Results from the Longitudinal Finnish Health 2011 Study. Nordic Journal of Psychiatry, Vol. 72, Issue. 3, p. 205.

O'Neill, Siobhan McLafferty, Margaret Ennis, Edel Lapsley, Coral Bjourson, Tony Armour, Cherie Murphy, Sam Bunting, Brendan and Murray, Elaine 2018. Socio-demographic, mental health and childhood adversity risk factors for self-harm and suicidal behaviour in College students in Northern Ireland. Journal of Affective Disorders, Vol. 239, Issue. , p. 58.

Hasking, Penelope Boyes, Mark and Greves, Stuart 2018. Self-efficacy and emotionally dysregulated behaviour: An exploratory test of the role of emotion regulatory and behaviour-specific beliefs. Psychiatry Research, Vol. 270, Issue. , p. 335.

Hoffman, Lauren J. Guerry, John D. and Albano, Anne Marie 2018. Launching Anxious Young Adults: A Specialized Cognitive-Behavioral Intervention for Transitional Aged Youth. Current Psychiatry Reports, Vol. 20, Issue. 4,

Sarac, Nikolas Sarac, Benjamin Pedroza, Angela and Borchers, James 2018. Epidemiology of mental health conditions in incoming division I collegiate athletes. The Physician and Sportsmedicine, Vol. 46, Issue. 2, p. 242.

Mortier, P. Cuijpers, P. Kiekens, G. Auerbach, R. P. Demyttenaere, K. Green, J. G. Kessler, R. C. Nock, M. K. and Bruffaerts, R. 2018. The prevalence of suicidal thoughts and behaviours among college students: a meta-analysis. Psychological Medicine, Vol. 48, Issue. 4, p. 554.

Sano, Akane Taylor, Sara McHill, Andrew W Phillips, Andrew JK Barger, Laura K Klerman, Elizabeth and Picard, Rosalind 2018. Identifying Objective Physiological Markers and Modifiable Behaviors for Self-Reported Stress and Mental Health Status Using Wearable Sensors and Mobile Phones: Observational Study. Journal of Medical Internet Research, Vol. 20, Issue. 6, p. e210.

Mall, Sumaya Mortier, Philippe Taljaard, Lian Roos, Janine Stein, Dan J. and Lochner, Christine 2018. The relationship between childhood adversity, recent stressors, and depression in college students attending a South African university. BMC Psychiatry, Vol. 18, Issue. 1,

Tang, Fang Byrne, Majella and Qin, Ping 2018. Psychological distress and risk for suicidal behavior among university students in contemporary China. Journal of Affective Disorders, Vol. 228, Issue. , p. 101.

Hall, Brian J. Xiong, Peng Guo, Xinqi Sou, Elvo Kuai Long Chou, Un I and Shen, Zhuozhuo 2018. An evaluation of a low intensity mHealth enhanced mindfulness intervention for Chinese university students: A randomized controlled trial. Psychiatry Research, Vol. 270, Issue. , p. 394.

Hennemann, Severin Böhme, Katja Baumeister, Harald Bendig, Eileen Kleinstäuber, Maria Ebert, David Daniel and Witthöft, Michael 2018. Efficacy of a guided internet-based intervention (iSOMA) for somatic symptoms and related distress in university students: study protocol of a randomised controlled trial. BMJ Open, Vol. 8, Issue. 12, p. e024929.

Jordan, Hallie R. Villarosa-Hurlocker, Margo C. Ashley, Asia L. and Madson, Michael B. 2018. Protective Behavioral Strategies and Hazardous Drinking Among College Students: The Moderating Role of Psychological Distress. Journal of Drug Education, Vol. 48, Issue. 1-2, p. 3.

Uwatoko, Teruhisa Luo, Yan Sakata, Masatsugu Kobayashi, Daisuke Sakagami, Yu Takemoto, Kazumi Collins, Linda M. Watkins, Ed Hollon, Steven D. Wason, James Noma, Hisashi Horikoshi, Masaru Kawamura, Takashi Iwami, Taku and Furukawa, Toshi A. 2018. Healthy Campus Trial: a multiphase optimization strategy (MOST) fully factorial trial to optimize the smartphone cognitive behavioral therapy (CBT) app for mental health promotion among university students: study protocol for a randomized controlled trial. Trials, Vol. 19, Issue. 1,

Balayssac, David Pereira, Bruno Darfeuille, Maxime Cuq, Pierre Vernhet, Laurent Collin, Aurore Vennat, Brigitte and Authier, Nicolas 2018. Use of Psychotropic Medications and Illegal Drugs, and Related Consequences Among French Pharmacy Students - SCEP Study: A Nationwide Cross-Sectional Study. Frontiers in Pharmacology, Vol. 9, Issue. ,

Dickinson, David L. Wolkow, Alexander P. Rajaratnam, Shantha M. W. and Drummond, Sean P. A. 2018. Personal sleep debt and daytime sleepiness mediate the relationship between sleep and mental health outcomes in young adults. Depression and Anxiety, Vol. 35, Issue. 8, p. 775.

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Mental disorders among college students in the World Health Organization World Mental Health Surveys | Psychological Medicine | Cambridge Core

# data[].attributes.attachment_link.description
Cited by 199 This article has been cited by the following publications. This list is generated based on data provided by CrossRef. Bártolo, Ana Monteiro, Sara and Pereira, Anabela 2017. Factor structure and construct validity of the Generalized Anxiety Disorder 7-item (GAD-7) among Portuguese college students. Cadernos de Saúde Pública, Vol.

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College athletes are far from their metal health resources when they need them most 

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College athletes are far from their metal health resources when they need them most 

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This article is about how mental health is far out of college athletes mindset, especially away from college in a pandemic.

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This article was published through the NCAA and talks about how to support student athletes mental wellness.

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NCAA.org - The Official Site of the NCAA

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Intercollegiate athletics embodies a unique and demanding culture. The pressures and demands on 18- to 21-year-old student-athletes are great. Their wins and losses are seen by many, questioned by many, and often criticized publicly.

Even within the athletics environment, student-athletes' time demands are enormous - daily practices, competitions that may involve travel (some across time zones), a full academic course load, strength and conditioning programs, and sports medicine/rehab appointments present a demanding schedule indeed. Social interactions and relationships often take a back seat to the athletically related challenges and commitments.

It is no surprise that these pressures can affect a student-athlete's mental health. A well-trained psychologist with expertise in sport psychology is an ideal resource to provide care and services. But over the past 20 years, the sports psychologist's role in college sports has evolved more slowly than student-athletes' needs.

The ways colleges and universities use sport psychologists also vary, often depending on resources and how well the athletics department understands how to incorporate these services.

The following explains both the challenges related to the integration of sport psychologists within college athletics, and the models schools currently use when they do take advantage of such expertise.

* * * *

First, here are the challenges related to the slow growth of psychologists in the arena of student-athlete mental health care.

The ongoing "stigma" within the sport context. Student-athletes, coaches and staff tend to minimize mental disorders or psychological distress because of the expectations of strength, stability and "mental toughness" inherent in the sports culture. As a result, student-athletes often avoid disclosing a mental health concern, especially if the perceived negative consequence includes being rejected by teammates or coaches due to the disclosure. In many ways, this stigma further exacerbates the problem of student-athlete mental health as it inhibits effective dialogue, education and development of resources to address these issues.

Once a mental health issue is identified, resources may be limited or difficult to access. As sports medicine and athletic training have evolved, it is now common for a Division I athletics department to employ four or more full-time certified athletic trainers. Some schools even have in-house sports medicine physicians specifically providing medical care for student-athletes. Additionally, more and more athletics departments employ registered dietitians/sport nutritionists to provide optimal nutritional care for their athletes. However, not many programs employ full-time or even part-time licensed psychologists. Instead, they depend on campus resources such as student counseling centers to refer for mental health issues. The problem there is that few student counseling centers employ a psychologist who has the training/education to address student-athletes' unique psychological needs.

The issue of "sport" psychology vs. "clinical/counseling" psychology is often confusing to athletics department personnel. In most of the 50 states, if not all, the term "psychologist" (in any form) is protected as a licensed profession. If professionals identify themselves as "sport psychologists," then they should be able to produce their license number within their state of practice. The "sport" designation, for those licensed psychologists, should denote a competency in their training. Competency, as defined in most states, includes academic preparation, training, supervision and experience within a specific domain (for example, child psychology, forensic psychology). Therefore, a licensed psychologist identifying as a "sport psychologist" should also be able to demonstrate training (such as graduate coursework, or perhaps a master's degree in physical education and ongoing supervised experiences) in sport psychology. Further clarifying this distinction in training and competency is a key element in enhancing the ongoing development of providers for collegiate student-athletes.

The competency of licensed mental health providers/psychologists to understand the unique nature of the collegiate athletics environment. Whether it be a Division I, II or III athletics department, it is important for the provider to understand the culture of the athletics environment to best understand the external stressors, motivations and dynamics (team, for example) within that athletics environment. This often requires that a licensed provider have previous experience as perhaps a student-athlete or coach, or a prior role within an athletics department (like an academic adviser), or have supervised experience during their training (for example, as a pre-doctoral intern with a rotation in sport psychology/athletics). This immersive experience offers observational and experiential learning opportunities for the psychologist, which builds competency to provide care for the athlete.

Lack of training models for psychologists and mental health providers in the domain of sport and performance psychology. As the role of psychologists within collegiate athletics has increased, it is important to note that many clinical/counseling psychology programs do not typically offer graduate coursework in the domain of sport and performance psychology. However, a few programs train students to be doctoral-level psychologists and provide graduate training/experience in the domain of sport psychology (the University of North Texas and Indiana University, Bloomington, do so, for example, both in counseling psychology).

Professional "contamination" and disruption of current services. Because collegiate athletics continues to focus on concepts such as "performance excellence" and "mental toughness," the realm of "motivational gurus" and "mental coaches" finds college athletics a prime target for their services, and they may very well ignore, minimize or neglect the real issues of psychological health. Individuals not trained in mental health/psychology often say they will refer any athlete with a personal issue, but if they are not trained in diagnostic interviewing, then they are not likely to identify potential issues. Thus, the athletics administrator must struggle with the challenge of providing effective mental health services for student-athletes, as well as providing a resource to teach coaches and student-athletes psychological skills to enhance sports performance. Competent and well-trained licensed psychologists can often provide both services within a collegiate athletics department. They also may be able to supervise and coordinate an effective "sport psychology team" for both performance and personal counseling services.

* * * *

With those challenges as a backdrop, here are the models college athletics departments currently use to provide student-athlete mental health services. The depth and breadth of these models of course depend on the commitment of the athletics administration, sports medicine, academic services, compliance and coaching staffs to optimize psychological resources for their student-athletes.

The most common models include:

Full-time athletics department sport psychologist. This position is typically held by a licensed counseling/clinical psychologist with graduate training (often a master's degree) in physical education/sport psychology. The sport psychologist usually provides:

Individual counseling for student-athletes (mental health concerns such as anxiety disorders, mood disorders, and performance-related counseling for issues related to performance anxiety and confidence issues);

Coordination of substance abuse/eating disorder services for student-athletes (often being involved with NCAA and institutional drug-testing referrals); team consultations for both clinical (for example, grief counseling) and performance (for example, team-building) issues;

Staff education and consultation; and

Consultation with athletics administrators on psychological care issues within the athletics department (for example, establishing postgraduate support programs for former student-athletes).

These positions are typically housed in the athletics department, either within sports medicine, academic services or an office affiliated with athletics.

Schools that have incorporated this model include Oklahoma, Virginia, Ohio State, Virginia Tech, Arizona, Southern California, Washington, Iowa, Arkansas, LSU, Missouri, Kansas and New Mexico.

Part-time consultation model. Some athletics departments retain external consultants or counseling center staff psychologists who are given time to work within the athletics department. These people typically provide the same services as their full-time counterparts, though with less time per week (about 10-30 hours as opposed to 40-50), there is less service provision.

Athletics departments wanting to develop sport psychology/psychological care for their student-athletes but do not have the budget to develop a full-time position with benefits often choose this model. It's economically more efficient and allows an athletics department with limited funds or resources to provide "in-house" services for their student-athletes.

A skilled provider on a part-time consulting contract may also be able to coordinate a sport psychology services "program" that identifies specific individuals (for example, substance abuse counselor at counseling center, mental skills consultant in physical education department) to be part of the team that the primary consultant coordinates, supervises and directs.

Most of these providers have an office within athletics to provide the services, and the department often will market this position within its department website/directory.

Among schools incorporating this model include Purdue, Wisconsin, Stanford, Oregon State, Minnesota, Nevada, Maryland and Oklahoma State.

Referral model of services. This model does not employ or retain an "in-house" provider; rather, it identifies a specific provider within the community or counseling center that will take referrals for student-athlete psychological issues.

This model tends to be more of an "intervention" (rather than prevention/education), as the student-athlete often has to present with psychological distress or self-referral in order to access this system.

The provider typically does not have an "in-house" office, so the student-athlete is referred to the provider's office for services. This is not an immersive model of care, but rather a "referral" model in which the athletics department can indicate that it provides services, but only through external referral. (For more on how to make the referral model effective, see Chris Klenck's article in Chapter 6.)

* * * *

So, which of these models is the best fit? It is important that schools explore all the options for a psychological services model for their student-athletes.

Clearly, an immersed program with full-time or part-time licensed psychologists allows for better service, communication and delivery of services. Having an immersed sport psychologist allows the athletics department to best address the variety of psychological issues (individual, team, staff) that may be present. Providing a psychologist as part of the support staff also helps to de-stigmatize and normalize the issues related to student-athlete mental health.

Just as having a full-time sports medicine physician and athletic training staff does not eliminate musculoskeletal injuries, having an immersed full-time/part-time sport psychologist will not eliminate mental health issues. However, as sports medicine care has greatly enhanced prevention, intervention and rehabilitation of athletics injuries, an immersed and comprehensive sport psychology program can enhance the prevention, intervention/counseling and care of student-athlete mental health/psychological issues.

A key element in improving student-athletes' emotional well-being is to establish a strong working alliance with the university counseling center, regardless of whether an athletics department has the services of a sport psychologist available.

University counseling centers offer unique services and benefits to student-athletes, including professionals who are highly skilled in treating the mental health concerns common to college students and who are of diverse backgrounds and embrace all walks of life. Counseling centers also offer student-athletes a high level of confidentiality.

To properly address student-athletes' psychological concerns, it is best to incorporate the services of a sport psychologist into your mental health team. Student-athletes will reap the benefit of this collaboration through improved emotional well-being.

The good news in all of this is that the role of the licensed counseling/clinical psychologist in the mental health care of collegiate student-athletes continues to evolve in a positive direction.

As more athletics departments create sport psychologist positions (either full-time or part-time) that are immersed within the department, there will be greater education opportunities, greater awareness of student-athlete mental health concerns, greater opportunities for coaches/staff to have positive interactions with psychologists, and greater training opportunities in the future for aspiring psychologists who desire to work with athletes as clients.

Chris Carr is a psychologist at St. Vincent Sports Performance in Indianapolis and a counseling sport psychologist and coordinator of sport psychology services for the Purdue University athletics department. Carr also provides individual counseling and consultation services, and he is a licensed psychologist in the state of Indiana. He is currently the consulting sport psychologist for the Indiana Pacers and has previously been the counseling sport psychologist for Indiana University, Bloomington, The Ohio State University and Washington State University. Carr played football while receiving his B.A. in psychology at Wabash College. He has an M.A. in counseling psychology from Ball State University, where he was a graduate assistant football coach from 1983 to 1984. He completed his Ph.D. in counseling psychology (with a doctoral minor in sport and exercise psychology) at Ball State and did a one-year clinical research assistant position in sport psychology at the United States Olympic Training Center in Colorado Springs, Colorado.

Jamie Davidson is a licensed psychologist with more than 20 years of clinical practice in higher education. He serves as the associate vice president for student wellness at the University of Nevada, Las Vegas, after having previously been the director of student counseling and psychological services there. Under Davidson's leadership, the UNLV student wellness center has received national and regional awards for innovation and excellence in the delivery of integrated medical and mental health services. Most recently, UNLV was one of only 30 universities in the country to receive an award for providing comprehensive mental health services and suicide prevention programming from the Jed Foundation.

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Mind, Body and Sport: The psychologist perspective

# data[].attributes.attachment_link.description
Intercollegiate athletics embodies a unique and demanding culture. The pressures and demands on 18- to 21-year-old student-athletes are great. Their wins and losses are seen by many, questioned by many, and often criticized publicly.

# data[].attributes.headline
Correlations between injury, physical and mental exhaustion in college athletes.

# data[].attributes.subject
Correlations between injury, physical and mental exhaustion in college athletes.

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This article talks about how college athletes are just tired all the way around, and how they have impacts with the high work load.

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Introduction

Enhancement of competitive athletic performance while avoiding injury has been a major goal of training programs. Thus, the pursuit of an optimal physical training program for competitive athletes has been a focus of exercise science researchers for decades. Improved physical performance has resulted from more effective training practices involving the manipulation of intensity (), frequency ( 5,7,12,16,17,22,30 ), and volume (), and mode (), periodization (), and taper () models.

To illuminate the optimal amount of training intensity, volume, and frequency, Peterson et al. () found via a meta-analysis using 37 studies, the best strength gains among athletes resulted by training muscle groups twice weekly at a mean of 85% one repetition maximum (1RM) for 8 sets per muscle group; no mention was made concerning the number of repetitions per set. They also noted decreases in strength when using more than 8 training sets. In addition, they found minimal strength gains when training with 1-3 sets of intensities at 50-70% of a 1RM.

Rhea and Alderman's () meta-analysis involving periodized and nonperiodized strength and power training programs elicited that periodized training programs enhanced strength and power better than nonperiodized training programs. Periodized training allowed for strength and power gains elicited from "...higher intensities and volumes without overtraining" (p. 416). This meta-analysis also showed the greatest moderating factors were the age in populations ≤55, the training status of untrained vs. trained or elite athletes, and the program length. To further support the argument for periodized training models, Buford et al. () compared 3 periodization models, linear progression, daily undulating periodization (DUP), and weekly undulating periodization (WUP), in recreationally trained male and female participants. The training program lasted 9 weeks, and everyone trained 3 times weekly with volume and intensity equated across the duration of the study. All groups increased bench press and leg press strength over the 9 weeks; however, DUP had lower percent changes and higher rating of perceived exertion (RPE) values, and the WUP had slightly greater strength gains and lower RPE scores.

Manipulation of the intensity, frequency, and volume training variables in tapering models has been observed (). Bosquet's () meta-analysis elicited a tapering strategy for decreasing intensity and volume 41-60% over a 2-week period. These studies offer information toward designing training programs that may enhance mental and physical functions by forestalling fatigue, which leads to decreased performance and increases of chronic injury.

Although research has been conducted to ascertain the optimal amount for each training variable, there has been a paucity of studies linking information from the research to what is actually practiced among collegiate sports programs. Thus, the primary purpose of this research was to obtain information concerning injury incidence, and perceptions of training intensities and fatigue levels among college athletes via a survey study. A second purpose was to illuminate correlations between the collected data.

Methods

Experimental Approach to the Problem

This study employed an original survey instrument, designed by the current investigators. The survey instrument was divided into the following sections: (a) demographic information, (b) training frequency, (c) training intensity, (d) injury incidence, and (e) feelings of physical exhaustion, mental exhaustion, and disinterest or apathy ( Table 1). Height, weight, and age were collected as continuous data. The remaining questions on the instrument used categorical responses.

Subjects

The subjects for this study were student athletes at an NCAA Division II cooperating institution sponsoring 16 sports ( Table 2). The 411 students coded as athletes in the institution's data management system were invited to participate in the study.

Procedures

The instrument was electronically administered in the fall of 2007 by an independent third party on the campus of the cooperating institution. Subsequently, those student athletes not initially responding were sent follow-up notification and a second invitation to participate. Data from the survey were returned to the investigators in summary format by the third party before analyses. These procedures protected the anonymity of, and allowed for the voluntary participation of, the respondents. All procedures were approved by the Institutional Review Board.

Statistical Analyses

Both descriptive and Pearson product-moment correlation data analysis techniques were employed. The significance level was established at 0.05.

Results

A total of 411 electronic surveys were sent to student athletes. Completed instruments totaled 149 for a return rate of 36.25%. Data analyses began by collecting the demographic profile of the respondents ( Table 2). Investigators then compiled and analyzed descriptive statistics among 3 themes from the survey: injury incidence, training intensity, and mental and physical exhaustion ( Table 3). Next, investigators examined correlations between the same 3 themes ( Tables 4 and 5). Collected data revealed several slight to moderate statistically significant correlations.

Descriptive Analyses

Descriptive statistics were compiled in the study for training frequencies, leisure time physical activity hours, and the intensity of training sessions ( Table 3). Both male (mean = 5.56) and female (mean = 5.10) college athletes at the cooperating institution trained a similar number of days per week during the competition season. Men (mean = 4.98) and women (mean =4.31) also trained a comparable number of days per week during the noncompetition seasons. During the competition season, athletes in both genders trained a similar number of hours per day (male mean = 2.51; female mean = 2.93). Furthermore, men trained an average of 2.14 hours per day, and women trained an average of 2.93 hours per day during the noncompetition season. In addition to scheduled training times, both male athletes (mean = 3.78) and female athletes (mean = 4.43) spent a similar number of hours per week participating in leisure-time physical activity. The number of competitions for men and women in crosscountry and outdoor track was 8 and 14, respectively.

Thirty-eight women (56%) reported experiencing a chronic injury in the past 12 months, whereas 26 (38%) experienced an acute injury during the same time frame. Of the men in the study, 36 (44%) reported a chronic injury in the past year, whereas 37 (46%) experienced an acute injury.

Furthermore, the self-reported intensity type of training sessions was reported by athletes. Intensity type was categorized into light intensity, moderate intensity, and vigorous intensity ( Table 3).

Next, the investigators compiled the reports of physical and mental exhaustion for male and female athletes during both the competition and noncompetition seasons ( Table 6). Physical and mental exhaustion responses were converted to percentages by the investigators ( Table 7).

Negative Correlations

Among women, data analyses revealed a statistically significant negative relationship between chronic injury incidence and noncompetitive season physical exhaustion, r (66) = −0.33, p < 0.01. For men, incidence of acute injury was negatively related to vigorous intensity training r (79) = −0.22, p < 0.05. No other statistically significant correlations for injury incidence were uncovered ( Tables 4 and 5).

Light-intensity training was negatively related to 3 other variables in the study ( Tables 4 and 5). A negative relationship existed between light-intensity training and noncompetitive season physical exhaustion, r (66) = −0.32, p < 0.01, among women. For men, negative relationships existed between light-intensity training and vigorous-intensity training, r (79) = −0.23, p < 0.05. A relationship between light-intensity training and competitive season physical exhaustion was also revealed for male athletes, r (79) = −0.40, p < 0.01.

Moderate-intensity training was negatively related to 3 variables in the study, 3 for men and 1 for women ( Tables 4 and 5). The moderate-intensity relationships for men were between (a) vigorous intensity, r (79) = −0.25, p < 0.05, (b) competitive season physical exhaustion, r (79) = −0.23, p < 0.05, and (c) noncompetitive season physical exhaustion, r (79) = −0.34, p < 0.01. Women displayed a relationship between moderate-intensity training and vigorous-intensity training, r (66) = −0.48, p < 0.01.

Noncompetition season mental exhaustion was negatively related to chronic injury for women, r (66) = −0.379, p < 0.01, and to light-intensity training for men r (79) = −0.245, p < 0.05. Competition season mental exhaustion was also negatively correlated to acute injury for men r (79) = −0.315, p < 0.01 ( Tables 6 and 7).

Positive Correlations

Vigorous-intensity training was positively correlated to competitive season physical exhaustion for men, r (79) = 0.57, p < 0.01, and noncompetitive season physical exhaustion for women, r (66) = 0.24, p < 0.05. Noncompetition season physical exhaustion was positively correlated to competition season physical exhaustion for men, r (79) = 0.43, p < 0.01 ( Tables 6 and 7).

Competition season mental exhaustion was positively correlated to 3 variables for men: vigorous-intensity training, r (78) = 0.421, p < 0.01, competition season physical exhaustion, r (78) = 0.456, p < 0.01, and noncompetition physical exhaustion, r (78) = 0.268, p < 0.05. Among women in the study, competition mental exhaustion was related to competition season physical exhaustion, r (66) = 0.666, p < 0.01 ( Tables 6 and 7).

Finally, noncompetition season, mental exhaustion was positively correlated to 3 variables in the study, 1 for women and 2 for men. Women with higher levels of mental exhaustion during their noncompetition season also indicated higher levels of competition season mental exhaustion, r (66) = 0.335, p < 0.01. Men with higher levels of noncompetition season mental exhaustion indicated higher levels of noncompetition physical exhaustion, r (78) = 0.488, p < 0.01, and competition season mental exhaustion, r (78) = 0.302, p < 0.01 ( Tables 6 and 7).

Discussion

The 2 purposes of this research were to obtain information concerning injury incidence, and perceptions of training intensities and fatigue levels among college athletes in efforts to illuminate correlations between the collected data. Through the researcher-designed survey, the investigators collected information for demographics; training frequencies; perceived intensities; injury incidence; and feelings of physical exhaustion, mental exhaustion, and disinterest or apathy. Much of the collected information seems like common sense when viewed through the lens of previous research involving intensity, frequency, and volume.

Both male and female athletes in the current study reported training frequencies of 5-5.5 days per week during competition season and 4.5-5 days during noncompetition season. Hoffman et al. () studied training frequency among football players, and their findings indicate that 5 days per week produced upper and lower body strength gains, running endurance, and body composition better than the 3- or 6-day groups; improvements in the 4-day group were similar to the 5day group except that no significant improvement in bench press occurred. They also concluded that lack of significant improvements over the 10-week study in the 3- and 6-day groups indicated evidence of overtraining, because these groups performed a greater volume than the 4- or 5-day groups. Wirth and Schmidtbleicher () found strength increased 2.7, 7.3, and 12.8% in athletes training 1, 2, and 3 days per week, respectively. These investigators suggested that 2 training sessions were optimal because of other training components included in a weekly program. The current study did not differentiate day-to-day training activities within the survey questions.

Men in the current study reported performing 1.46, 2.19, and 2.48 days of light-, moderate-, and vigorous-intensity training weekly, respectively. The women trained, respectively, 1.31, 2.32, and 2.22 days with light-, moderate-, and vigorous-intensity weekly. In relation to the results of the following studies, perhaps the men and women in the current research used more high-intensity training rather than moderate zones. Gonzalez-Badillo et al. () studied strength gains in competitive weightlifters after 10 weeks of training 4-5 days per week. They found that moderate volumes of high relative intensity (78-79%) produced greater performance gains than the low (77-78%) and high (80-81%) volumes of similar relative intensity; high intensity consisted of 182 repetitions with resistance greater than 90% of 1RM, moderate intensity used 91 repetitions with weight greater than 90% of 1RM, and low-intensity performance included 4 repetitions with resistance greater than 90% 1RM. High was less effective than low. Esteve-Lanao et al. () compared 2 5-month endurance training programs involving low-intensity zone 1 (below ventilatory threshold) and moderate-intensity zone 2 (between ventilatory threshold and respiratory compensation threshold) and high-intensity zone 3 (above respiratory compensation threshold; ≥ 90% O ₂ max). During competition, both groups performed high intensity 2 times weekly, and the remaining training was either in zone 1 or zone 2, dependent on their assigned group. Also, both groups included 1 weight training session per week with 1-2 sets of 60% 1RM. Posttraining performance time improved significantly for both groups but was greater for the group spending more time in zone 1. Their results indicated that training intensity was critical when volume and load were constant; a faster racing pace was elicited among trained endurance athletes with 80% of training in zone 1, 12% in zone 2, and 8% in zone 3. Thus, according to research, it appeared that a greater proportion of moderate intensity in either aerobic or anaerobic training produced enhanced performance; of particular interest noted concerning intensity was the fact that the high anaerobic and high aerobic groups were less effective than the moderate- and low-intensity groups.

Athletes in the current study reported perceived physical and mental exhaustion for both the competition and noncompetition seasons: rarely, sometimes, or frequently ( Tables 6 and 7). Growing concern exists about the lack of time off or significantly reduced training, the related levels of exhaustion, and the ultimate impact on performance and burnout. Sport psychology authors have noted both mental and physical exhaustion as signs of overtraining and burnout and causes for decreases in athletic performance (). Moreover, related research exists regarding the unexplained underperformance syndrome, which contains physical and mental exhaustion components (). Also, implementing systematic recovery periods to maximize performance or developing balance between training and recovery has also been a topic of discussion (). The findings of the current study echo previous research, because statistically significant relationships were uncovered related to mental exhaustion, both during the competition and noncompetition seasons to injury, training intensity, and physical exhaustion.

Systematic protocols using taper strategies offer methods to avoid overuse syndromes that may lead to injury. Results from taper research indicate that changes in training intensity produce the greatest differences in training results, and alterations in volume and frequency play a lesser role in performance maintenance or improvement. Mujika and Padilla () state the optimal tapering strategies to minimize fatigue and maximize performance among athletes involve a 60-90% volume reduction, no intensity changes, and frequency should be maintained above 80% within a nonlinear individualized program design. In the current study, 56 and 44% of the women and men, respectively, experienced chronic injuries within a 12-month period. Chronic injuries can be a result of overuse leading to overreaching or overtraining that may take days, weeks, or months for recovery.

The male athletes in this study reported physical exhaustion during both the competition (59.26% sometimes, 30.86% frequently) and the noncompetition season (55.56% sometimes, 19.75% frequently). The men also trained in the moderate- or vigorous-intensity range 2.20 (±1.47) and 2.48 (±1.59) days per week. Given that 44% of the men reported chronic injuries, one might question whether overreaching or overtraining was occurring even though there were insignificant correlations between exhaustion and injury, and physical intensity and injury ( Table 5).

Similarly, 56% of the female athletes reported chronic injuries with physical exhaustion occurring 66.18% sometimes and 23.53% frequently during competition and 66.18% sometimes and 17.65% frequently during noncompetition ( Tables 4 and 7). Thus, once again, even though there was actually a negative correlation, one might assume the intensity of training added to injury and then the training lessened or ceased.

Periodized training program designs have also been used to enhance performance gains and diminish fatigue levels, which leads to overreaching or overtraining over time. In general, Rhea and Alderman () found no differences between genders, ages 55 and younger experienced greater responses than older populations, and untrained populations had greater responses than athletes and trained populations. Their meta-analysis also revealed that training periods less than 8 weeks resulted in lower adaptation responses; training 9-20 weeks was optimal with apparent plateaus for programs lasting more than 20 weeks. The research of Buford et al. () indicated a WUP model that modified volume or intensity on a weekly basis was most beneficial for strength development and lowering perceived exertion; RPE was examined throughout their study as a valid measure to quantify intensity as related to "...impending overtraining syndrome." (p. 1246). The current research did not address whether or what type periodization was used.

One manner periodization was used was to reconfigure the resistance loads within a program. Brandenburg and Docherty () found the reduced load protocol produced greater fatigue, as measured by maximal isometric force and lactic acid, than the constant load protocol. The constant intensity load used 77.8% of 1RM for each set, whereas the reduced load went from 81% intensity for set one down to an average of 74.2% across all sets, which enabled more repetitions to be completed for the reduced load protocol. Both protocols produced similar strength gains after the 8-week program. No effort in the current research was made concerning specific daily training activities.

Several limitations with the current study exist. One limitation to the current study is a lack of specificity in identifying the training components of weight training, aerobic conditioning, and sport specific activities. Of particular interest for designing training programs is noting the cause of the greatest fatigue over the course of a week. If a particular program component is cited as a main cause for fatigue then that variable could be further modified by periodization or tapering protocols. Another limitation is the generalization of training information with regard to intensities and volumes. Knowledge of intensities and numbers of sets and repetitions during daily weight training, or the amount of time in active sport specific practice is important for ascertaining specifics related to fatigue.

In summary, the primary purpose of this research was to obtain information concerning injury incidence and perceptions of actual training intensities and fatigue levels among college athletes via a survey study. A second purpose was to illuminate correlations between the collected data.

Among both men and women approximately 4.5 days per week in training is spent performing moderate and high levels of intensity. First-hand experience with any athlete on campus reveals that these individuals are frequently tired. As one might expect with college athletes, frequency of training occurs roughly 5 days per week, not to mention any leisure time spent participating in physical activity.

It is felt by the investigators that the injury prevalence is high with 50% of the total number of athletes who responded to this survey reporting chronic injury. This is of importance because the causes of chronic injury are complex and individualized, varying from overuse, overreaching and overtraining to rehabilitation issues post-acute injuries and during chronic injury.

Perceived physical exhaustion occurred "frequently" 30.86 and 23.53% of the time with men and women, respectively, during the competition season. Only 19.75 and 17.65% of the time was physical exhaustion "frequently" experienced during noncompetition among men and women, respectively.

In conclusion, the investigators found significant negative correlations between chronic injury incidence and noncompetitive season physical exhaustion among women. For men, acute injury incidence was negatively related to vigorous-intensity training. Light-intensity training was negatively related to noncompetitive season physical exhaustion among women and vigorous-intensity training for men. A relationship between light-intensity training and competitive season physical exhaustion was also revealed for male athletes. Moderate-intensity training for males was negatively related to vigorous-intensity training, competitive season physical exhaustion, and noncompetitive season physical exhaustion. Moderate-intensity training for females was negatively related to vigorous-intensity training. Significant positive correlations included vigorous-intensity training and competitive season physical exhaustion for men and between noncompetitive season physical exhaustion for women. Finally, noncompetition season physical exhaustion was positively correlated to competition season physical exhaustion for men.

Practical Applications

Coaches and trainers could plan more moderate zoned training time each week during competition season because the current investigators found the training was predominantly 2-3 hours of moderate to high intensity 4.5 days per week both during competition and noncompetition. Especially for highly active participants during competition season, where the competition event elicits higher intensity than the weekly training days, moderate training levels in the 77-80% () intensity with tapering of 60-90% () is recommended. Because there does not seem to be a real "off season" because athletes train almost 12 months during the year, tapering, periodization, and rest are extremely important to help avoid overreaching and overtraining leading to excessive physical and mental exhaustion and injury.

One way to avoid overuse, overreaching, and overtraining is through the daily training log. Daily RPE for each exercise and activity can be recorded and tracked to forestall the onset of overtraining. Of particular interest would be to note the intensity, volume, and related RPE of each exercise or activity. Acute mental and physical fatigue levels and delayed onset soreness and mood states provide information for individualization. With the ultimate goal of performance enhancement and injury prevention, it is important to consider daily to weekly to monthly fluctuations in training components for individual athletes.

Future research collecting specific data on each athlete's daily training activities involving the intensities, volumes, frequencies, sport-specific exercise, and the RPE scores related to each daily activity can further facilitate both generalized and individualized training protocols. Also, recognizing the onset of chronic injury within each training season could illuminate the patterns of activities leading up to chronic injury for that individual; this might help the person avoid those same patterns in the future.

Acknowledgments

We would like to thank Mr. Paul Klute for electronically administering the survey used for this research study.

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Correlations Between Injury, Training Intensity, and... : The Journal of Strength & Conditioning Research

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aining intensities and fatigue levels among college athletes via a survey study. A second purpose was to illuminate correlations between the collected data. This study employed an investigator-designed survey instrument administered to 411 NCAA Division II male and female athletes, with 149 completed responses.

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College Students and Mental Health Problems and Treatment Considerations

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College Students and Mental Health Problems and Treatment Considerations

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This article talks about different ways to get help, treatment options and even how to talk to the parents.

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Abstract

Attending college can be a stressful time for many students. In addition to coping with academic pressure, some students have to deal with the stressful tasks of separation and individuation from their family of origin while some may have to attend to numerous work and family responsibilities. In this context, many college students experience the first onset of mental health and substance use problems or an exacerbation of their symptoms. Given the uniqueness of college students, there is a need to outline critical issues to consider when working with this population. In this commentary, first, the prevalence of psychiatric and substance use problems in college students and the significance of assessing age of onset of current psychopathology are described. Then, the concerning persistent nature of mental health problems among college students and its implications are summarized. Finally, important aspects of treatment to consider when treating college students with mental health problems are outlined, such as the importance of including parents in the treatment, communicating with other providers, and employing of technology to increase adherence. It is concluded that, by becoming familiar with the unique problems characteristic of the developmental stage and environment college students are in, practitioners will be able to better serve them.

Keywords: College, Mental health, Treatment considerations

Mental health problems are very common among college students [ 1]. This may be due to the fact that attending college corresponds to a challenging time for many traditional and non-traditional undergraduate students. Traditional college students start college after completing high school, are typically younger, depend on parents for financial support, and do not work or work part-time [ 2]. Thus, in addition to stress related to academic load, these students may have to face the task of taking on more adult-like responsibilities without having yet mastered the skills and cognitive maturity of adulthood. For example, many traditional college students may face potentially stressful experiences for the first time including working, being in a significant relationship that may lead to marriage, or having housemates with cultures and belief systems different from their own [ 3]. Non-traditional college students are often employed full-time, older, and may have dependents other than their spouses [ 3]. Thus, this group of students may have to cope with meeting work and family demands in addition to academic requirements. In these contexts, many college students may experience the persistence, exacerbation, or first onset of mental health and substance use problems while possibly receiving no or inadequate treatment. With the increasing recognition of child mental health issues and the use of more psychotropic medications, the number of young adults with mental health problems entering college has significantly increased. For example, in a survey of 274 institutions, 88 % of counseling center directors reported an increase in "severe" psychological problems over the previous 5 years including learning disabilities, self-injury incidents, eating disorders, substance use, and sexual assaults [ 4]. Thus, there is an increase in demand for counseling and specialized services. However, the increase in demands has not always corresponded to an increase in staff [ 4]. In particular, counseling centers are in need of psychiatrists with expertise in treating traditional as well as non-traditional college students, two groups with specific age-related characteristics and challenges. In this commentary, the prevalence of psychiatric and substance use problems in college students, as well as their common onset, will be described. Next, the worrisome persistent nature of mental health problems among college students and its implication will be discussed. Finally, important treatment considerations for traditional and non-traditional college students will be outlined.

Prevalence of Mental Health Disorders

Most mental health disorders have their peak onset during young adulthood. Kessler et al. [ 5] observed that by the age of 25 years, 75% of those who will have a mental health disorder have had their first onset. Among traditional students, the significant disruptions associated with attending college may exacerbate current psychopathology that first manifested in childhood and/or trigger its first onset. Similarly, non-traditional students who may have to attend to the demands of their numerous roles (work and family) may experience an exacerbation of their symptoms or a relapse.

Anxiety disorders are the most prevalent psychiatric problems among college students, with approximately 11.9 % of college students suffering from an anxiety disorder [ 1]. Among the anxiety disorders, social phobia has an early age of onset (median age of onset between 7-14 years), while panic disorder, generalized anxiety disorders (GAD), and post-traumatic stress disorder (PTSD) have somewhat later onsets [ 6]. Giaconia et al. [ 7] found that in a community sample of adolescents the peak risk period for developing PTSD was between the ages of 16 to 17 years, with approximately one third of the sample developing the disorder by the age of 14 years [ 7]. Through a national mental health survey, Vaingankar et al. [ 8] examined 6,616 respondents and reported that the mean age of onset for obsessive-compulsive disorder (OCD) was 19 years of age and 20 years of age for GAD. Thus, many traditional students with PTSD may have experienced symptoms before college, whereas those with GAD and OCD may start experiencing symptoms while in college.

Another common mental health problem among college students is depression, with prevalence rates in college students of 7 to 9 % [ 1, 9]. Zisook et al. [ 10] found that over half of all cases of depression had a first onset during childhood, adolescence, or young adulthood. Similarly, others have shown an elevated risk for mood disorders beginning in the early teens increasing with age in a linear fashion. In the National Comorbidity Survey-Replication study, Kessler et al. [ 6] reported that one out of every five individuals with depression had their first episode by the age of 25 years. The onset of bipolar disorder (BAD) appears to follow a similar trend. Approximately 3.2 % of college students meet the criteria for BAD [ 1]. An emerging literature has shown that the majority of adults with BAD have the onset of their disorder in child and adolescent years, with at least a third of adults with BAD having their onset before the age of 12 years [ 11].

Suicide, although not a specific diagnosis, is the third leading cause of death among young adults and is a significant problem among college students [ 12]. A large survey reported that among 8,155 students, 6.7 % reported suicidal ideation, 1.6 % reported having a suicide plan, and 0.5 % reported making a suicide attempt in the past year [ 13]. Given that many students with suicidal ideation do not seek treatment, it is critical to implement screening strategies to identify them and engage them in treatment [ 14, 15]. Among the major risk factors for suicide in this age group are depression [ 16], hopelessness [ 17, 18], and substance use [ 19, 20].

Eating disorders such as bulimia, anorexia, and binge eating are common and often have their onset during adolescence with a rapid increase in risk during early adulthood [ 21]. For instance, a survey of 2,822 college students reported that 9.5% of students screened positive for an eating disorder with a greater proportion of females relative to males (13.5 vs. 3.6 %, respectively) [ 22]. Stice et al. [ 23] found that peak periods of risk for onset was between 17 and 18 years of age for bulimia nervosa and binge-eating disorder, and was between 18 and 20 years for purging behavior (feeding or eating disorder not elsewhere classified). They also found that sub-threshold eating disorders are even more common than full criteria-eating disorders, with both full and subthreshold disorders associated with significant impairment [ 23].

Attention-deficit/hyperactivity disorder (ADHD) onsets during childhood and persists into adulthood in approximately one half of cases and negatively affects many critical areas in young adults. Between 2 and 8 % of college students suffer from ADHD and approximately one fourth of students receiving disability services have ADHD [ 24]. ADHD is associated with poor academic performance [ 25], social difficulties, and an increased risk for alcohol and drug use [ 26] that further exacerbate difficulties in college.

There is a paucity of literature regarding the prevalence of schizophrenia among college students; however, it appears that symptoms in the psychotic spectrum are not uncommon among college students. Studies have described the course of schizophrenia as having its beginning in early adolescence and persisting into young adulthood. Sham et al. [ 27] studied 270 schizophrenic probands in an older Swedish study and found that for both males and females there was a rapid increase in the onset of schizophrenia in late teens and early twenties followed by a lower risk of onset in the late twenties. Similar results were found by Hafner et al. [ 28], who studied 267 patients with schizophrenia and found that the initial onset of the disorder showed an early and steep increase in young adulthood until the age of 25 years. Furthermore, they found that 47% of females and 62% of males in the sample had their first symptoms of schizophrenia before the age of 25 years. Thus, young adults in college may experience the prodromal or early manifestation of a first onset of a psychotic disorder.

Autism spectrum disorders (ASDs) include a group of related complex and chronic neurodevelopment disorders, which are generally characterized by a variable presentation of problems with socialization, communication, and behavior [ 29]. Although ASDs are typically considered very disabling, a number of young people with ASDs do not have co-occurring intellectual impairment or language speech impairment (i.e., high functioning autism spectrum disorder and Asperger's disorder) and are able to attend college. Interestingly, a sample of 667 college students at a single university was used to diagnostically and dimensionally assess the rate of high functioning ASD in college populations. The study found that depending upon the ascertainment method between 0.7 and 1.9 % of college students could meet the criteria for high-functioning ASD [ 30]. Although the severity of ASD may decline during the adult period, individuals continue to have poor social functioning and often continue to require services [ 31- 34]. Thus, to enable people with ASD to succeed in college, providers should ensure that specific accommodations regarding academics, independent living, and social and vocational counseling are implemented [ 35].

Substance Use Among Young Adults in College

The use of alcohol and illicit drugs peaks during young adulthood and slowly declines with age [ 36]. Therefore, it is not surprising that the most prevalent problem among college students is the presence of substance use disorders. Approximately one in five college students meet the criteria for alcohol use disorder (AUD) in the previous year (12.5 % alcohol dependence and 7.8 % alcohol abuse) [ 37]. Another hazardous behavior common among college students is binge drinking, defined as consuming four standard drinks for women and five for men in a 2-h period [ 38]. Nearly half (44 %) of college students binge drink, and one in five engages in this behavior frequently [ 39, 40]. Binge drinking is considered the number one public health hazard and the primary source of preventable morbidity and mortality for college students in the USA. Among college students, alcohol consumption is associated with motor vehicle accidents, another leading cause of death in this age group [ 41], accidental injuries, unsafe sex, sexual assaults, and poor classroom performance, as well as impairments in prefrontal cortex functions such as memory and attention [ 39, 40, 42, 43]. Furthermore, many college students who are heavy drinkers continue to exhibit substance use-related problems after college [ 44, 45] and later develop an AUD [ 46]. Nicotine use is also very common, with 22-40 % of adolescent and young adult smokers meeting the criteria for dependence [ 47- 49]. Drug use disorders are less common, with approximately 1 in 20 students meeting the criteria (4.2 % drug abuse and 1.4 % drug dependence) [ 1]. Marijuana use is very prevalent in this population. A study by Suerken et al. [ 50] found that 30 % of those entering college admitted to using marijuana before college entry. Furthermore, according to the most recent 2012 data from the National Survey on Drug Use and Health [ 36], approximately 23.5 % of male full-time college students and 16.1 % of female full-time college students are current marijuana users. Cannabis use has been shown to negatively influence cognitive performance, memory, and achievement motivation, all of which can deleteriously impact educational achievement and lead to higher risk of school dropout, lower occupational attainment, and workforce failure [ 51- 53]. Among college students, binge drinking and cannabis use often co-occur. College students who drink heavily are approximately ten times more likely to use marijuana than those that are light drinkers [ 54]. Data from the National College Health Risk Behavior Survey shows that binge drinking students are nine times more likely to report lifetime use of marijuana than their non-binge drinking peers [ 55]. The increased risk for using illicit substances among binge drinkers has serious implications, given that alcohol use in combination with drug use is known to increase substance-related negative consequences [ 56], even when controlling for level of drinking [ 57].

In addition to substance use and hazardous alcohol use, college students often engage in non-medical use (or misuse) of prescription medications, namely taking prescription medications without a prescription or taking more than prescribed. Although in the past 2 years, the rates of non-medical use of pain relievers among young adults have decreased, they continue to be high [ 58]. According to the National Survey on Drug Use and Health, approximately one in ten young adults reported non-medical use of pain relievers in the past year [ 59]. Data suggest that the most commonly misused medications among college students include opioids, benzodiazepines (sedative/hypnotics), and amphetamine/methylphenidates (stimulants), with 5-35 % of college students having misused stimulants [ 60]. In a nationwide representative sample of 10,904 college students, McCabe et al. [ 61] found that the rates of non-medical use of prescription stimulants were highest among Caucasians, males, members of fraternities and sororities, and those who have lower grade point averages. In a study by Garnier-Dykstra et al. [ 62], assessing 1,253 college students, they found that by year four 61.8 % of students were offered prescription stimulants at least once and approximately one third had used them non-medically. They found that subjects endorsed friends as the most common source of prescription stimulants and the most common reason for use was to study [ 62]. Of concern is that over the past 20 years the rates of overdoses involving prescription drugs in the USA have reached epidemic proportions, with increased risk of overdosing for those using opioid analgesics or benzodiazepines and who have multiple prescriptions [ 63]. Nonmedical use of prescription medications often co-occur with heavy alcohol use [ 64], a worrisome occurrence given that alcohol taken in combination with analgesic opioids may further inhibit activity in the central nervous system, increasing the risk of oversedation, respiratory depression, and death. Regrettably, college students do not appear to view prescription drug abuse as problematic [ 64]. Practitioners should communicate with college students about the ethical, medical, psychological, addictive, and legal issues of prescription drug abuse. College students should be advised to take their medications as prescribed and not give or sell their medications to others. Safe storage of controlled substances such as benzodiazepines or stimulants is important.

Implications of Age of Onset on Trajectory of Psychopathology

When assessing college students, it is critical to determine the age of onset of current psychopathology. Specifically, early age of onset of any mental health disorder is associated with poorer outcome and may be associated with a different presentation from that of later onset. For example, several studies have found that early-onset anxiety disorders are associated with greater severity and chronicity than adult-onset [ 65]. Childhood onset anxiety appears to increase the likelihood for the development of other subsequent psychiatric comorbidity [ 66, 67]. Early age of onset of obsessive-compulsive disorder is associated with more symptomatology [ 68], higher rates of comorbid tic disorders [ 69], and higher frequency of tic-like compulsions [ 70]. Multiple studies have shown that childhood onset mood disorders are linked to longer episode duration, a higher number of depressive episodes among women, increased suicidality and need for hospitalization, and increased risk for other co-occurring mental health problems in adulthood [ 71- 73]. Similarly, an earlier onset of bipolar disorder is more problematic as it is associated with higher risk for co-occurring psychiatric and substance use disorders, less lithium responsiveness, more mixed presentations, and increased illness burden [ 74- 79]. Likewise, studies suggest that the onset of schizophrenia before the age of 18 years may correspond to a more chronic form of the disorder [ 80- 82] with studies reporting an overall lower psychosocial functioning and poorer long-term outcome related to early-onset schizophrenia [ 81, 83, 84]. Finally, among college students, age of first alcohol use is associated with heavier use and worse alcohol-related problems [ 85].

In summary, mental health problems are prevalent in college students, with substance use, anxiety, and mood disorders being the most common. Traditional college students are in a transitional age, young adulthood, which is associated with numerous stressors and during which many mental health problems often first occur. Non-traditional college students also face numerous stressors associated with having multiple roles, demands, and financial obligations. College students who have their first onset of mental illness or initiate substance use during childhood or adolescence appear to have a more pernicious trajectory and course of illness. Early identification of college students with mental health problems and thorough assessments are critical in order to provide adequate services and to ensure better outcomes, such as graduation.

Significance of Early Identification of Mental Health Problems and Outreach Strategies

Among college students, mental health problems not only are common, but they often persist for several years. Zivin et al. [ 86], through longitudinal data on 763 students, observed that 60 % of those who had a mental health problem at baseline continued to report at least one mental health problem 2 years later. The rate of persistence differed among disorders. For example, eating disorders were reported as most persistent, with 59 % of those reporting an eating disorder at baseline still having it at follow-up. Of the students with depression at baseline, 27 % continued to have it 2 years later. Self-injury behavior and suicidal thoughts also persisted. Approximately 40 % of students continued to report self-injury behavior and 35 % continued to report suicidal thoughts 2 years after baseline [ 86].

Lack of identification or acknowledgement (denial) of mental health symptoms and/or lack of or inadequate treatment are common problems among college students and may contribute to the persistence of mental health problems in this population. For instance, in a study by Zivin et al. [ 86], less than half of the college students with mental health problems persisting over 2 years received mental health treatment during that time period [ 86]. Other studies have also shown that the rates of treatment in college students are very low. For example, in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a national survey on adults including 2,188 college students, data showed that only 18 % of students with past year mental health diagnoses had received treatment in the previous year [ 1]. Specifically, 34 % of stder, 15 % of students with a diagnosis of anxiety disorder, and only 5 % of those with an alcohol or drug disorder received treatment. Similarly, the Healthy Minds study, a large online survey of college mental health, found that only 36 % of students who screened positive for a mental health problem including depression, panic disorder, GAD, suicidal ideation, or self-injury received treatment in the previous year [ 87]. A few reasons have been proposed for the low rates of help seeking in this population including fear of personal stigma, not perceiving treatment as urgent or essential, and lack of time [ 88, 89]. The Healthy Minds study also showed that more women receive treatment than men (39 vs. 30 %) [ 87]. It is concerning that even when students receive treatment it appears that often it is inadequate. Eisenberg et al. [ 87], on the basis of the Healthy Minds study, outlined that approximately only half of the students with depression received adequate care, defined as receiving 2 months of an antidepressant medication or at least eight sessions of counseling or therapy.

The early identification and treatment of psychopathology and substance use disorders impact the ultimate trajectory and sequelae of the disorder(s). With regard to bipolar disorder, it has been shown that the recurrence of episodes is associated with progressive loss of brain volume, that with the progression of the disease patients respond less to both pharmacotherapy and psychotherapy and that early intervention may be neuroprotective [ 90]. It has, therefore, been suggested to implement an "energetic broad-based treatment" during the first onset of bipolar disorder to change its trajectory [ 90]. Similarly, the Treatment and Intervention in Psychosis (TIPS) project showed that early detection and delivery of standard treatment for psychosis including antipsychotic medication, individual psychosocial treatment, and psychoeducational multifamily groups had positive effects on long-term functional outcome [ 91]. Moreover, it was shown that the duration of untreated psychosis has long-term negative effects on the course of the illness [ 91]. The presence of psychiatric and substance use problems during college is associated with a wide range of negative outcomes from unemployment, serious social and educational impairment [ 46, 92, 93], and obesity [ 94]. Together these studies underline the importance of prompt and adequate treatment of psychopathology to prevent neurocognitive and functional decline.

The problem of low treatment seeking in college students may be addressed by the use of technology. As noted previously, traditional as well as non-traditional students report that they do not seek help because of limited time or because they worry about what others may think [ 87, 95]. Technology-based programs for screening as well as for treatment would have the advantage of providing anonymity and could be available at any time and may be cost-effective. Escoffery et al. [ 96] found that 74 % of the students acknowledged having ever received health information online, and more than 40 % reported that they frequently searched the Internet for health information, suggesting that college students regularly use the Internet as a health resource. Several studies explored the use of Web-based surveys of depression and anxiety to screen for mood problems among college students [ 97]. Hass et al. [ 98] tested a Web-based method to perform screening for depression and other suicide risk factors, and respondents were provided personalized assessment and online communication with a clinical counselor. They reported that such an approach increased the rate of help-seeking behavior among at-risk students. Our team at the Massachusetts General Hospital Depression Clinical and Research Program showed that the use of emails and social networking sites, such as Facebook, is feasible and cost-effective for reaching out to college students and for depression screening [ 99]. Taken together, these studies support using Web-based programs with college students as a strategy to enhance treatment seeking. Moreover, it may be advisable to offer computer-based treatments to students who may be afraid of stigma or have limited time. For example, numerous Internet-based cognitive-behavioral therapy approaches are available that have been found effective for treating a range of mental health problems [ 100- 102].

Many students who present at college health centers have mental health problems [ 103]. Thus, a collaborative relationship between university health centers and behavioral health services may lead to an increase in identification and referrals for behavioral health treatments of students with mental health problems. A collaborative relationship between university health centers and behavioral health services can be categorized in several ways [ 104]. In the integrated model, medical and behavioral health services are delivered in an integrated manner as part of a team program. In this model, the team members have a treatment plan that includes medical as well as behavioral aspects [ 104]. Alternatively, medical and behavioral health services can be co-located, and services are coordinated as a result of medical and behavioral health staff sharing resources and being in the same location. Finally, when medical and behavioral health services are delivered at different locations, the services can be coordinated. In this model, information between health centers and behavioral health centers are exchanged in a formalized and established way [ 104]. In the last two models, the clinicians delivering medical care and those delivering behavioral health services are not part of the same team. An important aspect of coordination of services is the use of electronic medical records (EMRs). Specifically, the adoption of the use of EMRs may be associated with better care for college students because its use may enhance communication between providers, coordination, measurement, and decision support [ 105].

Treatment Considerations

Upon completion of thorough evaluation, evidence-based practice (EBP) interventions should be employed for the treatment of this population. Given that numerous resources are available outlining EBP for mental health problems, this commentary will not review them. The American Psychiatric Association (APA) provides evidence-based recommendations for the assessment and treatment of psychiatric disorders online ( http://psychiatryonline.org/guidelines.aspx), and the Substance Abuse and Mental Health Services Administration (SAMHSA) has a National Registry of EBP available online as well ( http://www.samhsa.gov/ebpWebguide/). The latter also provides links to other resources including the National Guideline Clearinghouse™ (NGC) ( http://www.guideline.gov/index.aspx), which is a comprehensive database of evidence-based clinical practice guidelines and related documents maintained by the Department of Health and Human Services. Clinicians may also consult several books, including A Guide To Treatment That Works [ 106]. Given that low adherence is a common problem among college students, providers may opt to enhance EBP with Motivational Interviewing (MI) [ 107]. MI has been shown to enhance engagement and adherence to psychosocial as well pharmacological treatments [ 108, 109], and thus, it could be useful to address these problems with college students. When treating college students, several issues ought to be considered related to the developmental stage as well as the context college students are in. Some considerations are relevant for the treatment of both traditional and non-traditional students and some are specific to each group. When treating traditional students, it is important to consider that most of them are still dependent on their parents, thus parental involvement in treatment is advisable. Parents could be invited to attend some of the treatment meetings with their children to address problems involving them or to be enlisted as a support source to facilitate improvement. When communicating with parents, it is important to educate them on what to expect during the early stages of symptom abatement and recovery, enhancing their ability to support the college student in coping with the cycles of both partial and full remissions and relapses over time. Allowing feedback and providing access in a proactive, mutually agreeable manner will not only enhance safety, but also facilitate support and treatment of the college student. Moreover, given the negative effect that parents' mental health problems have on children [ 110, 111], providers may consider offering referrals for mental health services to the parents who may need them. Services can be offered to parents even if their offspring are not willing to engage in the treatment. For example, the Community Reinforcement and Family Training (CRAFT) has been shown to help parents facilitate seeking treatment of family members who are substance users [ 112]. With regard to prevention interventions, Turrisi et al. [ 113, 114] have developed a parent-based intervention (PIB) that has been shown to be associated with reduction of binge drinking in the children of those who received it. Parents' involvement can be beneficial even when they live away from where the students are currently attending college as they could provide, even if remotely, critical information about the patient's history or they could ensure/facilitate continuity of care during school breaks. While the involvement of the parents can be beneficial, given that most young adults in college are over 18 years of age, the patient's consent is required. When conducting mental health evaluations of young adults in college, providers should routinely discuss the pros and cons of parental involvement and encourage it. Ideally, parents could be involved at a minimum as a resource for information and to ensure continuity of care.

Issues to consider with non-traditional college students relate to the fact that most of them have to juggle academic responsibilities as well as work and/or family commitments and demands. Thus, to ensure that these students receive adequate services, providers should have extended and flexible hours and even child care options. These students may need additional and different types of services than traditional students such as case management to deal with financial, housing, relational, and child rearing issues. Moreover, to address their family needs, they may be more likely to need couple counseling or family therapy.

One important issue to consider for all college students relates to the problem of continuity of care during school breaks. Providers should ensure continuity of care by establishing services during school breaks or by identifying strategies for maintaining mental health during this period. Care for college students may occur in different ways, and college providers must examine each situation carefully to ensure continuity of care. Some students may have a primary provider where they reside with their parents, may be followed remotely, and may need intermittent support while in college. In this case, the college providers should communicate with the provider at home to be aware of whether the student may be at risk for safety and their needs. Vice-versa, some students may have a primary provider at their college and may need a provider for either medication management or psychotherapy during breaks. In this scenario, the college's providers should ensure that the student will continue to receive adequate care while away. Not having insurance coverage may be a barrier to continuity of care. However, with the new healthcare reform, allowing US patients up to 26 years to be covered by their parent's insurance, college students may be able to have more options for care during breaks. In addition to ensuring continuous care, college providers may have to pay special attention to students whose needs cannot be addressed by the services provided on campus. Therefore, health centers or counseling centers should develop an extensive referral system easily accessible to their students with severe mental illness or in need of higher level of care. Lastly, some students may receive services from providers at their college as well as from outside their institution; therefore, it is critical that all providers coordinate care.

Conclusion

In this commentary, we aimed at illustrating critical issues to consider when treating college students with mental health problems. This commentary did not aim to be exhaustive and it includes a selected number of references. Therefore, the conclusions drawn are not the results of a systematic assessment. Moreover, our illustration refers to issues typical of undergraduate students, and we have not discussed problems present among graduate or medical students. The latter differ from undergraduate students in a number of important ways including academic responsibilities, campus life, and relationships with academic advisors. These limitations withstanding, we believe that mental health providers working in college campuses should enhance their training and knowledge by becoming familiar with the topics reviewed here.

In summary, mental health problems are common among college students. Academic pressure together with stressors typical of starting and attending college may precipitate the first onset of mental health and substance use problems or an exacerbation of symptoms. Often the nature of psychopathology is chronic due to low rate of treatment seeking and low adherence to treatment. Thus, it is critical to employ outreach programs and implement strategies to ensure treatment retention. Given that many traditional students continue to depend on their family while in college, parental involvement in treatment is important. Finally, given the effect that the academic calendar may have on continuity of care, it is critical for clinicians to ensure that college students receive treatment throughout the year and to coordinate with other clinicians that may be involved in the students' care. Thus, expertise in developmental psychopathology, family dynamics, specific college issues, and systems of care is critical to conduct clinical treatment to college students.

​

Acknowledgments

This research was supported by NIH K24 DA016264 to Timothy Wilens and in part by NIAAA K23AA020064-012 to Paola Pedrelli. Timothy Wilens receives/d research support from or is/has been on the advisory board for the following Pharmaceutical Companies: National Institute on Drug Abuse (NIDA), Euthymics, Shire, Theravance, and TRIS. Dr. Timothy Wilens is or has been a consultant for Euthymics, Major League Baseball, Minor League Baseball, the National Football League, and Shire. Dr. Timothy Wilens has a published book with Guilford Press: Straight Talk About Psychiatric Medications for Kids.

Footnotes

Disclosure Drs. Pedrelli, Nyer, and Yeung as well as Ms. Zulauf have no conflicts of interest to report.

Contributor Information

Paola Pedrelli, Massachusetts General Hospital, Boston, MA, USA.

Maren Nyer, Massachusetts General Hospital, Boston, MA, USA.

Albert Yeung, Massachusetts General Hospital, Boston, MA, USA.

Courtney Zulauf, Massachusetts General Hospital, Boston, MA, USA.

Timothy Wilens, Massachusetts General Hospital, Boston, MA, USA.

References

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College Students: Mental Health Problems and Treatment Considerations.

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Attending college can be a stressful time for many students. In addition to coping with academic pressure, some students have to deal with the stressful tasks of separation and individuation from their family of origin while some may have to attend to numerous work and family responsibilities.

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Technology and College Students Mental Health 

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Technology and College Students Mental Health 

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This article talks about how some technology has important effects on some college students mental health

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Technology and College Student Mental Health: Challenges and Opportunities

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In recent years, there has been an increase in symptoms of depression, anxiety, eating disorders, and other mental illnesses in college student populations. Simultaneously, there has been a steady rise in the demand for counseling services. These trends…