As universities and colleges prepare to welcome students back to campus this fall, their counseling centers are already bracing themselves for the challenges to come. Facing a likely influx of students in crisis, campus mental health professionals will need new resources to support this vulnerable population. Telehealth, provided in the right way for the right patients, can be an important part of the student mental health solution.
Student mental health issues have long been common in higher education, and the pandemic has only exacerbated their vulnerability, as many struggled with feelings of fear, helplessness, grief, and resentment.
According to the CDC, one in four people aged 18-24 seriously contemplated suicide in June 2020, and a similar number increased their substance use; three-quarters faced at least one adverse mental health symptom. In recent research by the Center for Collegiate Mental Health (CCMH), students seeking services during the peak of the pandemic reported that it had negatively impacted their mental health, motivation or focus, loneliness and isolation, and academics.
As their need grew, their access to student mental health services actually decreased; the CCMH notes that college counseling centers served 32 percent fewer students during fall 2020 than fall 2020, as campus closures and the lack of private meeting spaces posed new barriers to care. Those who did manage to access care reflect increased need on an individual basis, with 20 percent more attended appointments per student. With nearly all centers offering online appointments starting in spring 2019, this trend may also reflect a decrease in no-show rates noted among students participating in telehealth appointments rather than conventional face-to-face meetings.
Combine rising need with constrained access to services over the past year, and the scale of the risk mitigation challenge over the coming academic year becomes clear, especially in light of the hurdles university health centers already face. Recruiting the providers needed to serve their population—in terms of sheer number as well as diversity and specialization—is a constant problem, especially in smaller towns and rural locations. With resources constrained, counseling centers are forced to limit the services they provide while somehow fulfilling their ethical duty.
Remote care models such as telehealth and telepsychiatry have been around for many years, attracting both interest and some amount of skepticism. When I joined the staff of Michigan State University Counseling and Psychiatric Services in 2019 to help create its first telepsychiatry clinic for students, I had questions of my own. With more than a decade of experience in campus psychiatric services, I knew firsthand the high bar such services would need to clear to be an effective part of the student counseling landscape. I wanted to be sure that telehealth could be done well, done safely, and truly meet the needs of these patients. I now believe that, with the right approach, it can. While it will never entirely replace in-person care, telehealth can be a vital complement to on-campus resources to meet the increased need for student mental health services.
Providing the right resources, in the right way, for the right patients
To serve their populations effectively, campus counseling centers need more than just additional resources–they need the right kind of resources for the right patients. For some students, that will always mean face-to-face care. Sometimes this is a matter of the individual’s personal preference or comfort level. In other cases, the provider may need to monitor the vital signs of a patient with alcohol use disorder or provide in-person care to an individual with a diagnosis such as schizophrenia, psychosis, or bipolar mania who may not be able to participate effectively in an online meeting. But when providers can safely identify students who might benefit from telehealth, this approach can become an important tool to be able to offer.
For some patients, telehealth can be not just more expedient, but also preferable to an in-person visit. This can be true for students from ethnic or racial groups with a particular stigma around mental health; an online provider in a remote location can feel safely distant from the local community. For others, telehealth can increase the possibility of finding a provider who fits a particular profile—someone with a similar background or gender, or a specialist in the challenges facing LGBTQ individuals, and so on. Maintaining an on-campus staff of sufficient diversity to reflect the whole student population simply isn’t realistic for many centers. A telehealth partner can help fill out that roster.
Medication management can be another valuable use case for telehealth. Both therapists and prescribing doctors recognize the importance of working in tandem with each other to achieve the best outcome; effective psychopharmacology depends on an understanding of the individual’s psychotherapy. A counseling center can be justifiably leery of sending a student off to an MD without being able to maintain an ongoing relationship. Similarly, a health center may have medical providers on campus but lack the therapist capacity needed for ongoing counseling. In either case, a telehealth provider embedded within the service can complete the therapist-prescriber-patient triad on an ongoing basis to achieve the best outcome for the student.
Complement and collaborate–don’t reinvent or replace
While telehealth can play an important role in campus mental health, it’s crucial to understand that it should never be seen as a replacement for an in-person counseling center. A university’s own campus-based staff will always have a more intimate understanding of the local community and culture within which students are embedded. Many students will do best with in-person treatment, and it should continue to be available to them. The same is true in cases where a telehealth patient needs in-person follow-up, or to transition completely to in-person care. Rather, the telehealth provider should be seen as a partner and a complement, integrated within your existing system and working with the resources you’ve already built on the ground. The goal is to extend and enhance your own service, not reinvent it.
Close collaboration is essential for a successful telehealth partnership. University health centers can be skeptical about telehealth out of concern that their students will be dropped into a digital black box where campus providers will lose all visibility into their case. That’s an unsettling prospect not only because they care about the student’s health and outcome, but also because of the continuity of insight into a student’s case needed to ensure a seamless transition back to campus services as needed in the future. On a population level, counseling centers also need to have a holistic picture of which students are at moderate risk, which are at high risk, which have been referred out, which are making progress, what types of diagnoses are being seen on campus, and so on. Done right, telehealth should increase visibility and understanding, not obscure it.
At the end of the day, telehealth should be seen as a way for counseling centers to provide better care for all of their students. By expanding the resources available to students for whom telehealth is a good fit, on-campus providers can more effectively meet the needs of students for whom in-person care is needed. By tapping into a broader range of providers–more specializations, more backgrounds—than they could realistically support on their own teams, even small counseling centers can offer more personalized care for a diverse population with equally diverse needs. And by expanding their mental health care capacity in absolute terms, colleges and universities can better address the growing needs of their community not just in post-pandemic times, but for the long term.
Nora has spent most of her career working in college mental health centers at Michigan State University and Colorado State University—including developing the first telepsychiatry clinic at MSU. Her deep understanding of telepsychiatry led her to her current role as Medical Director of the digital mental healthcare clinic, Mantra Health. In addition, Dr. Feldpausch is currently the Western USA/Western Canada representative to the APA affiliated Association for College Psychiatry, as well as a volunteer clinical faculty member at CU College of Medicine.
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