Eight Colleges Collaborate to Improve Depression Care

Across the nation, a strong need to safeguard college students' mental health has been hindered by campus health systems that are overburdened and sometimes ill equipped to deal with students with serious mental health problems.

Now, campus-based primary care and mental health clinic staffers are participating in a collaborative pilot project involving eight university health centers to ensure that students with depression do not slip through the cracks.

Through the project, called “Using the Collaborative Care Model to Improve Depression Care on College Campuses,” clinicians are screening students systematically using the nine-item depression scale known as the Patient History Questionnaire 9 (PHQ-9). They then refer students who are diagnosed with depression to clinics that offer specialty services either on campus or in the community if the schools lack counseling services.

The PHQ-9 is based on the nine diagnostic criteria for major depressive disorder listed in DSM-IV.

The scores, which range from 0 (no depression) to 27 (severe depression), can help clinicians determine the most suitable treatment milieu for patients.

The schools are tracking the students' outcomes while they are in treatment for depression. In addition, each school is using an interactive Web-based program that is designed to help students achieve healthy lifestyle goals that will enable them to combat depression between clinician visits.

Students' Mental Health Needs Growing

“The need for mental health services among college students is growing,” Henry Chung, M.D., told Psychiatric News. Chung is the principal investigator for the project and assistant vice president of student health at New York University, one of the participating schools.

The other participating schools are Cornell University, Princeton University, Hunter College, Baruch College, Case Western Reserve University, Northeastern University, and St. Lawrence University. The Aetna Foundation, New York Community Trust, and New York City Department of Health and Mental Hygiene provide funding for the project; the American Psychiatric Institute for Research and Education provides expertise.

Chung cited data from the American College Health Association showing that 10.3 percent of college students were diagnosed with depression in 2000. That number had increased to 15 percent by 2004.

The survey findings were based on responses from 47,202 students at 74 campuses across the country.

“We know that campus counseling centers have experienced an increased demand for their services, and many have waiting lists” for students needing mental health treatment, Chung noted. He also pointed out that an increasing number of students entering college are taking psychotropic medications.

In the collaborative project, staff at campus health centers, which chiefly treat students for flu, colds, sprains, and other routine health problems, began screening students for depression in summer 2006.

Students with a PHQ-9 score greater than 15, which suggests major depression, are referred to campus counseling services for treatment, which may include antidepressants, psychotherapy, or a combination of both. Students with mild depression are usually either re-evaluated within one or two weeks or referred for further evaluation and treatment.

Measurements Target Quality of Care

Chung explained that using the PHQ-9 not only standardizes the evaluation process but facilitates communication and cooperation between primary care and mental health clinicians on campus.

“Measurement is essential to proper treatment,” he said.

A small group of clinicians from each participating school meets a few times a year at “learning sessions” featuring presentations on the PHQ-9 and treatment algorithms, including evidence-based approaches to depression treatment.

The algorithms are designed to be used by psychiatrists and primary care physicians who treat students with depression.

Practice teams also learn about the results of Sequenced Treatment Alternatives to Relieve Depression (STAR^*D) study funded by the National Institute of Mental Health, which included 2,876 participants with depression across 18 primary care sites.

The results of the first phase of the four-phase STAR^*D study were published in the January American Journal of Psychiatry. The study was designed to enhance understanding of how best to treat individuals who do notrespond to the first antidepressant they were prescribed (Psychiatric News, January 20).

One of the most useful aspects of the learning sessions is the opportunity to learn how other schools transformed their health systems to implement the collaborative project, according to Chung. He emphasized that the process of screening and evaluating students under the collaborative project is flexible enough to be adapted to each student health center with minimal disruption of therapy.

Minority Outreach Key Goal

Daniel Silverman, M.D., chief medical officer at Princeton University and executive director of Princeton University Health Services, told Psychiatric News that one of the major goals of the study is to help improve recognition and treatment of depression among minority students.“ They are less likely to seek help for depression than are other students,” he noted.

Silverman, who is also a co-investigator on the project, pointed out that mental health problems tend to be the most serious ones in student populations.

“An increasing number of students arrive on college campuses with diagnosed depression, bipolar disorders, eating disorders, stress-related disorders,” he said. “We believe in integrating medical and psychological services and in a more evidence-based and rigorous approach to mental health care than one typically finds on college campuses to improve detection and treatment of depression on college campuses.”

About 100 students from eight schools are enrolled in the project. Ultimately, however, each school hopes to track about 50 students who have depression.

Another of the project's goals is to reduce depressed students' PHQ-9 scores by at least five points over an eight-week period or to below 10 in a 12-week period.

The project is designed to allow clinicians to continue screening, treating, and referring students with depression at each school.

Students Receive Treatment More Quickly

Some may wonder whether increasing referrals to campus counseling centers, which are often overburdened with students in need of treatment, may only exacerbate that problem.

But this is not the case, according to Silverman, who said that standardizing the evaluation and referral of students allows those who need depression treatment to receive it more quickly as part of a more efficient process.

“When a student has an elevated PHQ-9 score in the primary care setting, we now have the ability to get the student treatment more quickly,” he explained. At Princeton, for example, students with a score of 15 or more can be seen the same day by a mental health clinician on campus.

The project is also improving access to care for students at St. Lawrence University, near the Canadian border in New York, noted Patricia Ellis, R.N., director of health and counseling there.

Campus clinicians have screened nearly 90 percent of student walk-ins for depression, and those with elevated PHQ-9 scores get immediate referrals to a clinician in the same building. “We've met our goal for optimizing screening and treatment of our students for depression,” Ellis said.

In one common scenario, students might go to the health center complaining of reduced appetite, sleeping problems, and general malaise before they are identified as suffering from depression. But many struggle with these symptoms without seeking help at all.

Standardized screening and referral “has helped us to be proactive in treating depression before it becomes a bigger issue,” she noted.

Jerald Kay, M.D., chair of APA's Corresponding Committee on College Mental Health, said “given the increasing national concern over the mental health of college students, this project is timely and creative.”

He noted that the potential “to enroll thousands of college students in the project and utilize best practices for depression” will provide valuable data and improve the mental health of college students across the country. ▪