Disorders Other Than Depression Pose Highest Dropout Risk

The association between having a psychiatric diagnosis and failing to graduate from college might seem obvious, but an analysis of national survey data indicates a pattern of diagnoses that departs from the common wisdom.

Depression is generally seen as a widespread problem on college campuses, for example, but the new study found that people with bipolar I disorder, antisocial personality disorder, and three types of substance use disorders were all less likely to graduate from college than those with depression.

The study provided fresh evidence that “psychiatric factors play a significant role in college academic performance,” wrote Justin Hunt, M.D., M.S., Daniel Eisenberg, Ph.D., and Amy Kilbourne, Ph.D., M.P.H., in the April Psychiatric Services. “[T]he benefits of prevention, detection, and treatment may therefore include higher graduation rates.”

Prior research by others found that mental disorders in young people were associated with shortened school careers at every level from primary school to college, with the greatest problem coming at the high-school level.

“It's very expensive when a kid drops out of school,” said Jerald Kay, M.D., professor and chair of psychiatry at the Boon-shoft School of Medicine at Wright State University in Dayton, Ohio.

On a practical level, the college loses the revenue that accompanies a student, said Kay, a former chair of APA's Corresponding Committee on Mental Health on College and University Campuses. Society at large loses the added productivity contributed by a college graduate compared with someone who never earned a college degree. Most important, the former student loses out on the personal benefits of having a college degree, he noted.

“You can't be lulled into a sense of complacency by thinking that [not having a college degree] does not have a dramatic effect on a young person's life,” said Kay in an interview.

Hunt and colleagues analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The survey was conducted in 2001-2002 by the National Institute on Alcohol Abuse and Alcoholism and included 15,800 adults over age 21 who had entered college but had never graduated.

Questions on the NESARC covered lifetime diagnoses of six psychiatric disorders (mania/bipolar I disorder, major depression, panic disorder with agoraphobia, social anxiety disorder, generalized anxiety disorder, and antisocial personality disorder) and four substance use disorders (alcohol, marijuana, amphetamine, and cocaine abuse or dependence).

“These diagnoses were selected because they represent some of the most common diagnoses among adolescents and young adults, and their symptoms have plausible effects on academic success,” said the researchers.

The study did not ask about other diagnoses common to young people such as attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, and psychotic disorders.

Major depression, generalized anxiety, and social anxiety presented some initial associations with failure to graduate, but were not significant after sociodemographic factors influencing college completion (such as racial or ethnic background and geographic region) were accounted for.

In contrast, bipolar I disorder, antisocial personality disorder, and marijuana, amphetamine, and cocaine use disorders were all “significantly and positively associated with failure to graduate from college,” they said.

Hunt and colleagues speculated on why bipolar I disorder might show a strong positive association with dropping out of college, while no such association was found with other serious conditions including major depression, generalized anxiety, or panic disorder with agoraphobia.

The general stress of college study, combined with drinking, poor sleep patterns, and the emotional ups and downs of interpersonal relationships might contribute to the development of bipolar disorder, they suggested.

One surprise to the researchers was the slightly negative and statistically insignificant association of alcohol use disorder with college completion. A previous study of mental disorders and educational attainment did find a significant role for alcohol abuse in limiting college careers.

Hunt and colleagues' finding that alcohol abuse did not contribute to college failure is also at odds with the experience of college health officials in the United States, said Kay. Heavy drinking is associated with a host of educational and personal problems, like missing classes, poorer schoolwork, increased unprotected sex, and trouble involving police.

“It's important not to underestimate the importance of alcohol use,” Kay emphasized.

Why use of cocaine, marijuana, or amphetamines but not alcohol might contribute to poor college outcomes posed another question.

“In the college population, it may be difficult to sort out recreational drinking from true problem drinking with DSM-IV diagnostic criteria alone,” the researchers said.

Disorders that did not show an association might have affected college students less because they created fewer problems for the students, said the authors. Perhaps the students with those conditions may simply be more resilient, or maybe some traits—such as anxiety—may actually push some students to work harder, they said.

Improved awareness and treatment may be having an effect, too, said Kay. “I think we've made a dent in the problem, and it may point to success in treating depression and anxiety on campus.”

“Consequences of Receipt of a Psychiatric Diagnosis for Completion of College” is posted at <http://psychservices.psychiatryonline.org/cgi/content/full/61/4/399>.