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