Download Background

Working with Transitional Age Youth
(TAY) and College Student Mental Health
(CSMH): Opportunities for Collaboration
and Integration in General and Child &
Adolescent Psychiatry Training
Elberg Z, Scharf M, Ruberman L, Kirsch DJ, Hanrahan
L, Kothavale S, Domakonda M, Baynes K
Disclosures
 Zhanna Elberg MD, University at Buffalo - none
 Michael Scharf MD, University of Rochester - none
 Louise Ruberman MD, Albert Einstein/Montefiore - none
 Daniel Kirsch MD, University of Massachusetts - none
 Laura Hanrahan MD, University at Buffalo – none
 Baynes, Kathleen MD, University of Rochester - none
 Supriya Kothavale DO, Albert Einstein/Montefiore- none
 Mirjana Domakonda MD, Columbia/Cornell - none
Workshop Objectives
After attending this workshop participants will be able to
 1. Define unique characteristics and mental health needs
of TAY/CSMH
 2. Identify challenges/barriers to creating didactic and
clinical experiences targeted at TAY/CSMH
 3. Describe currently existing training experiences in
CAP (Child and Adolescent Psychiatry) and General
Psychiatry training programs focused on TAY/CSMH
 4. Utilize material presented at the workshop to develop
TAY/CSMH experiences at participants' home
institutions
Background- Working with
Transition Age Youth and
College Student Mental Health
Scharf & Ruberman
Transitional Age Youth (TAY)
 TAY= Youth moving from adolescence to adulthood
 Developmental Tasks:
 Moving away from family
 Becoming independent
 Further developing identity,
 Learning to handle more complex relationships
 Typical challenges:
 adjusting to the start of college
 moving into the working world
 … or not
From Youth In Transition: Moving Into Adulthood Resource Center; www.aacap.org
Developmental Themes in
College Bound TAY
 Maturing relationships with parents, friends, significant
others as separation-individuation is reworked
 Readiness for college process in junior/senior year HS
 Sustained academic work with limited involvement from
parents important to success in transition
 Still potential for impulsivity and risk-taking in healthy
college bound teens secondary to ongoing brain
maturation and increased responsiveness to external
motivators*
* Casey et al., (2008). Annals of the NY Academy of Sciences
Need for clinical services during
TAY and college years
 Number of students who matriculate on meds or
with a pre-existing diagnosis on the rise
 Pathology in students who present to centers more
severe*
 The highest increase during this age range of any
medical illness is psychiatric (panic, depression, BD,
schizophrenia, substance abuse)
 Current depression and anxiety predict academic
difficulty and suicidality**
* Gallagher (2012). J of College Student Psychotherapy; **Corey et al., (2012). J of American College Health
Risk factors in entering college
freshman: pre-existing disorder
 TAY vulnerable to developmental increases in psychiatric
disorders
 Exacerbation of pre-existing psychiatric conditions can occur
with transition to college (e.g. ED)
 Substance Use can increase risk for other psychiatric disorders
 Learning issues & disorganization frequently associated with
ADHD can compromise academic adjustment
 Students with diagnosed psychiatric disorders must manage
their treatment with less support than high school
Challenges to providing mental
health care to college students
 Only 36% of students with diagnoses go for help on campus
with variation campus to campus*
 Of students who were recently suicidal, less than half got help
 More than ½ College Counseling Center Directors see demand
for service rising without increase in funding or staff
 78% of Directors reported increase in crises in 2011 survey**
 2/3 of directors have trouble finding long-term rx for
students***
*Eisenberg et al., (2011). Journal of Nervous and Mental Disease; * *Gallagher (2012). J of College Student Psychotherapy ***as
reported in Kay & Schwartz (2010). Mental Health Care in the College Community
Hx of Psychiatry Training in College
Mental Health Services (CMHS)
 Campus mental health & counseling: 1910 Princeton, 1932 U
Minnesota
 WWII vets to campus & Truman Commission on Higher
Education impact mental health treatment on campus
 Community mental health impact on CMHS: embedded care,
emphasis: well-being, early identification, prevention, education
 Social work & psychology training on campus; psychiatry
training and child psychiatry more recently
 Currently 56% Adult Psychiatry and 48% Child Fellowships have
either elective or required training experiences at CMHS**
*Iarovici, (2013); ** Kay & Schwartz, (2013). J of College Student Psychotherapy; Derenne & Martel “A Model CSMH Curriculum for
Child and
Adolescent Psychiatry Training Programs”, in press
Down the road: other issues in TAY for
psychiatry residency and fellowship
 High school transition to college
 Non-college bound TAY
 Management of severe mental illness (SMI)
in TAY
 Service relationships between child and
adult providers – integration of care
 Models for psychiatric care for TAY
Psychiatry Training and
TAY/CSMH Experiences
Elberg &Kirsch
Institute of Medicine & National
Research Council, 2014
“The transition from child to adult medical and
behavioral health care often is associated with poor
outcomes among young adults. Challenges include
discontinuities in care, differences between the
child/adolescent and adult health systems, a lack of
available adult providers, difficulties in breaking the
bond with pediatric providers, lack of payment for
transition support, a lack of training in childhood-onset
conditions among adult providers, the failure of pediatric
providers to prepare adolescents for an adult model of
care, and a lack of communication between pediatric
and adult providers and systems of care” (p 219)
“Investing in the Health and
Well-Being of Young Adults”
IOM/NRC (2014)
 The world has changed.
 Young adults (YA, youth 18-26) are a discrete group
distinguishable from adolescents and older adults,
with specific developmental needs.
 YA are surprisingly unhealthy – obesity, MI, SA
 Creates a legacy of morbidity, disability, chronicity
IOM Report
Key Themes
 Current policies and programs for YA’s are often
fragmented and uncoordinated.
 Policies and programs often are inadequately
focused on the specific developmental needs of this
population.
 Evidence base is limited.
IOM Report
 What does it do?
 Guidance on policies and programs to improve young
adults’ health, safety, and well-being.
 Priorities for research to inform these policies and
programs.
 To whom?
 Federal, state, and local policy makers and program
leaders. Employers, NPO’s, and other community partners.
 When?
 When the evidence indicates that young adults’ specific
needs are not being met.
Coming Fall 2015
Academic Psychiatry
Special Edition: College Mental Health

Topical Papers Published Online, Ahead of
Print:

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Fuchs: Multidisciplinary Treatment Planning: An
Educational and Administrative Tool for Resource
Management in a University Counseling Center
http://link.springer.com/article/10.1007/s40596-0140262-0
Garrick: The Calendar, Complementarity, Pacing, and
Service Delivery in the College Mental Health Setting
http://link.springer.com/article/10.1007/s40596-0140105-z
Hunt: Racial/Ethnic Disparities in Mental Health
Care Utilization among U.S. College Students:
Applying the Institution of Medicine Definition of
Health Care Disparities
http://link.springer.com/article/10.1007/s40596-0140148-1
Pedrelli: College Students: Mental Health Problems
and Treatment Considerations
http://link.springer.com/article/10.1007/s40596-0140205-9
Romero: Integrating a College Mental Health Track
into a Public Psychiatry Fellowship
http://link.springer.com/article/10.1007/s40596-0140272-y

Topical Papers Accepted and In Press –
Online Soon!

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
Derenne: A Model CSMH Curriculum for Child
& Adolescent Psychiatry Training Programs
Available online soon at
http://link.springer.com/article/10.1007/s40596-0150307-z
Shatkin: Psychiatry's Next Generation: Teaching
College Students about Mental Health Available
online soon at
http://link.springer.com/article/10.1007/s40596-0150305-1
Sondheimer: Ethics and Psychiatry Residency
Training in College Student Mental Health
Available online soon at
http://link.springer.com/article/10.1007/s40596-0150306-0
General Psychiatry Training
and CSMH Rotations
 56% had college counseling center rotation
 70% elective rotation
 Rotation: psychotherapy, med management, group therapy
 70% on site departmental supervisor
 70% rated experience as positive
 30% didactics focused on CSMH
 22% no formal didactics but subjects covered elsewhere in
curriculum
DeMaria et al. (2013). J of College Student Psychotherapy
Challenges to CSMH
Rotations
 Funding
 Adequate Supervision
 Proximity to University Counseling Center
 Departmental support
 Space in the curriculum
 Lack of interest
CAP and CSMH/TAY
 48% allow trainees to rotate in CSMH experiences
 39% do not offer
 CSMH rotations: 100% elective
 Settings: UCCC, student health centers, outpatient
clinics in academic centers
 TAY experience – trainees see patient up to 24 y/o
on inpatient, outpatient and emergency settings
Derenne & Martel “A Model CSMH Curriculum for Child and Adolescent Psychiatry Training
Programs”, in press
Barriers to CSMH/TAY
Experiences in CAP
 Lack of time
 Availability of Supervisors
 Clinical Sites
 Funding
 Lack of interest/not necessary for training
 Space in the curriculum
 Experiences already available/covered in general training
 ACGME requirement to work with <18 y/o
Didactics in CAP
 74% on normal development
 30% ethics of TAY
 31% transition planning
 35% legal issues
 7% models of mental health delivery on college
campuses
 4% systems of care on college campuses
Milestones and TAY
 Development through the life cycle – developmental
tasks of transitioning young adults
 System based practice – models of mental health
service delivery with higher education
 Professionalism – legal and ethical principles
 Somatic Therapies – stimulant diversion on college
campuses
University at Buffalo
General Psychiatry Residency Program
Laura Hanrahan, MD
County Hospital Community Mental
Health Clinic
 PGY 3 outpatient continuity clinic
 8-12 clinic hours, 1-2 supervision hours
 Population: Community Adults (>18yo) with broad range of
psychiatric diagnosis including psychotic disorders, affective
disorders, and adjustment disorders.
 Supervision: Direct by General and CAP Psychiatrists
 TAY referred by CAP Clinic as they age out
 Residents provide medication management
University at Buffalo Counseling
Center
 1-2 PGY 3 residents assigned as part of outpatient continuity clinic
(required rotation)
 4 hours of medication management
 Population: college students with range of psychiatric diagnosis
including affective disorders, adjustment disorders, substance
abuse disorders, less commonly psychotic disorders
 Supervision is onsite, indirect by General Psychiatrist Faculty
member
 Focus: exposure to diverse patient population
 Downside: supervision/didactics do not directly address issues
pertaining to college systems and college mental health
Buffalo State College Counseling
Center
 1-2 PGY 3 residents assigned as part of outpatient continuity clinic
(required rotation)
 4 hours of medication management
 Population: college students with range of psychiatric diagnosis
including affective disorders, adjustment disorders, substance
abuse disorders, less commonly psychotic disorders
 Supervision is onsite, direct and indirect by CAP Psychiatrist
Faculty member
 Focus: exposure to college systems of care/developmentally
appropriate care/transitional issues
CAP Community Mental Health
Clinic
 1-2 PGY 3 residents assigned as part of outpatient continuity clinic
(required rotation)
 4 hours of medication management , 1 hour of
supervision/didactics
 Population: children and adolescents (<18) with variety of
psychiatric diagnosis
 Direct supervision by CAP faculty psychiatrist
 Opportunity to address adolescents starting to transition to
adulthood; especially with transition to college
 Downside: TAY/college readiness not emphasized, depends on if
resident is exposed to patients with TAY needs
Other settings
 VA outpatient behavioral health clinic
 Adults > 18yo
 Onsite direct supervision by faculty and non faculty General psychiatrists
 Inpatient behavioral health units
 Adults (>18yo): onsite direct supervision by faculty, General psychiatrist
 Adolescent (12-17yo): onsite direct supervision by faculty, CAP psychiatrist
 C/L service
 Emergency Rotation (all ages) (onsite direct supervision with mix)
 Psychotherapy Clinic
 Take home: TAY are encountered on every rotation without
differentiating unique needs of this population
Patient Examples
 24yo male with new onset Schizophrenia. Working with
family systems for improved treatment.
 19 y/o male with Autism Spectrum Disorder and PTSD.
Issues related to transitioning from the child to adult
system of care and separation/individuation.
 21yo female college student. Borderline personality traits,
anxious attachment. Struggles with creating healthy
social supports and separation from her family.
Didactics
 Not specific to TAY
 Multiple lectures throughout General residency training
on normal development.
 Emphasis on development in psychotherapy didactics.
 CAP program has no formal curriculum on TAY or
transitions to college.
 Discussions of issues pertaining to TAY/CSMH are
usually done in clinical supervision.
In Development: First Episode Psychosis
Clinic (16-25) and TAY Clinic (18-25) –
tentative launch Fall 2015
Formal TAY curriculum in development to include:
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Normal development
Systems of care on college campuses
Legal issues Of TAY/CSMH population
Ethical issues of TAY/CSMH population
Transitioning from child to adult system of care
College readiness for HS students
Unique challenges of treating severe mental illness in TAY
Psychotherapy and TAY
University of Massachusetts
College Mental Health Elective
Mirjana Domakonda MD
Responsibilities
Prior to the start of the elective:
 Meet with 1-2 local college counseling center staff
 Review extant literature on TAY/CMH
 Become familiar with CMH clinical research project
and obtain IRB approval, as needed
Responsibilities
As part of each evaluation:
 Chart review
 Initial evaluation
 Collateral
 Follow-up appointments
Patient Demographics
Characteristic
Total Sample (n = 16)
Age (years)
Mean
19.6
Range
18 - 22
Male
8 (50)
Female
8 (50)
White Nonhispanic
12 (75)
African American
1 (6.25)
Hispanic
2 (13.5)
Other
1 (6.25)
Gender n (%)
Ethnicity n (%)
Colleges Attended
6
5
4
3
2
1
0
Becker
Clark
Holy
Cross
WPI
WSC*
Diagnoses
Mood
Anxiety
Childhood
Eating Disorder
MDD (9)
Anxiety d/ o
NOS (4)
ADHD (5)
Anorexia
Nervosa (1)
Depressive
d/o NOS (1)
Social Anxiety
d/o (2)
ASD (2)
NOS (1)
Adjustment
d/o (1)
Panic d/o (2)
Bipolar d/o
Type 1 (1)
PTSD (1)
Other
Mood d/o
2/2 Meds (2)
Unique Roles & Bridging
Adult and CAP
 Developmental perspective
 Psychoeducation
 Disorders of childhood onset
 Emerging illness
 Family work
 Systems management
Albert Einstein College of Medicine/
Montefiore Medical Center
Child and Adolescent Psychiatry Fellowship
Supriya Kothavale, DO
Fordham University
Counseling and Psychological Services
(CPS)
Elective rotation for 2nd Year Child and Adolescent
Psychiatry (CAP) Fellows
Schedule is as follows:
8 hrs weekly for six months:
7 patient hrs, 1 supervision hr
Population: undergraduates, graduate students
Roles of Trainees
Fellows are primary psychotherapy clinicians, hence they
do not prescribe psychotropic medications
Provide short term psychodynamic psychotherapy
Collaborate with CPS staff for referrals to Psychiatry
Resident or Part-time MD for pharmacological
management if clinically indicated
Individual supervision by staff PhD/PsyD
Treatment Modalities
Individual counseling (10 sessions)
Group counseling (no cap)
Emergency and crisis intervention services
Psychiatric Services
For continued psychotherapy, referral services to the
community are available, once individual therapy is
completed
http://www.fordham.edu/info/20031/counseling_and_psychological_services
The Experience
One case provided as an opportunity for
continuity
Supervision is provided individually for one
hour each week
A unique experience of relying entirely on
psychotherapy skills to a population that is
still transitioning into young adulthood
Patient Examples
18 yo female, freshman; difficulty transitioning into
college, leave of absence for the semester
19 yo female, sophomore; with binging and purging
habits
21 yo female, junior; depressive symptoms, diagnosed
with SAD, feeling lost about the future
19 yo male, sophomore; poor self-esteem, anxiety,
lack of close friendships with peers
Developmental Themes
Moving toward a more cohesive sense of identity and becoming more
self-reliant and independent
Becoming more concerned about the future and how actions of the
present may impact outcome; becoming familiar with delayed
gratification and moving away from impulse
Development of more serious relationships and becoming confident with
their sexuality
Having the capacity to use the insight gained from processing earlier
adolescent and childhood experiences
Examining inner experiences and striving toward emotional stability
AACAP Facts for Families on Normal Adolescent Development
University of Rochester
General Psychiatry Residency And Child and
Adolescent Psychiatry Fellowship
Kathleen Baynes MD
University of Rochester
University Campus Counseling
Required rotation for PGY3 General Psychiatry Residents
5 hrs weekly for full year:
3 patient hrs, 1 didactic hr, 1 supervision hr
Opportunity for additional elective time in 3rd and 4th
year
Population: undergraduates, graduate students, medical
students, music school students and their adult
spouses/family members
Psychotherapy
Historical influence of Carl Rogers, who wrote ‘The
Treatment of the Problem Child’ at U of R
Residents are primary psychotherapy clinicians - they
don’t prescribe!
Collaborate with University Health Service for
referrals to Psych NP/MD
Supervision by PhDs
Didactics with psychology PhD interns
Practical Details
Up to 10 *free* yearly sessions via student health
insurance
Referral to CMHC, private practice or resident
clinic!
Average # of sessions is bimodal:
1 session: crisis support/problem
solving/adjustment
8-9 sessions: 8-16 week brief psychotherapy
(psychodynamic, cbt, interpersonal)
All patients screened with PAI - personality
assessment inventory and selectively with MMPI.
Special Features
All sessions are videotaped as per clinic policy;
explicitly a teaching clinic
Supervision is focused and detail oriented;
rapport building, non-verbal communication,
phrasing of verbal interventions, transference
and countertransference
Unique experience of relying entirely on
psychotherapy skills in a population generally
very appropriate for psychotherapy
Patient Examples
18 yo female, undecided major; with adjustment
disorder, r/o depression, recent romantic break up
18 yo male, engineering major; with hx of narcissistic
traits, new onset panic attacks
19 yo female, trumpet major at music school; with
anxiety disorder, strong family hx of OCD
24 yo female, medical student*; hx of heroin abuse in
stable remission, referred for couples counseling
and ongoing substance abuse counseling
*procedure to prevent any overlap in future educational encounters
Transitional Issues
Collateral: Reluctance of college age patients to allow
communication with sources of collateral
Transference/Countertransference - overempathy,
reluctance to acknowledge ‘first break’/SPMI in this
promising, young, smart population
Continuity: Striking contrast between campus
counseling services and options for community
referrals, particularly when SPMI/substance services
needed or summer bridge care
The College at Brockport
State University of New York
Elective rotation for either General Psychiatry Residents or
Child and Adolescent Psychiatry Fellows
Counseling Center provides full range of short term and long
term services, including CD (“AOD”) services
UR CAP Division has contract to provide Psychiatrist
services, other clinicians employees of college
Lack of available resources for students in region have led to
functioning as a CMHC for many (an ongoing tension for
administration and clinicians).
Less affluent population compared to UR
The College at Brockport
State University of New York
Residents can focus on any aspect of services
provided, supervised by UR CAP faculty working at
Counseling Center
Including consultation and collaboration with
primary care providers in Health Center
Residents who have done elective thus far have
focused on psychopharm in TAY (particularly
emerging or early course of serious mental
disorders), as compliment to UR UCC experience.
Breakout Groups
• What do you think a rotation in
college mental health could add to
your child or adult training program?
• What are the potential obstacles to
starting such a program?
• What is the first step you would need
to take?
• What is the second step?
Take Home Points
• Increased need for psychiatric treatment of TAY
• Need to train adult and child psychiatrists to treat TAY
• Training Directors can introduce elective or mandatory training
experiences in college mental health
• Programs face time constraints, potential budget issues and mindset
barriers to college rotations
TASKS:
 Meet with local CMHS director
 Brainstorm with faculty about training needs
 Brainstorm with trainees about interest in college rotation
 Write up proposal to submit to faculty, chair
 Propose rotation to college, discuss challenges, supervision and
evaluation process; offer to have faculty do teaching for CMHS staff
 Pilot rotation, involve CMHS in joint evaluation, plan changes
Selected References
 Casey et al., (2008). The Adolescent Brain. Annals of the NY
Academy of Sciences, 1124: 111-124.
 Corey et al., (2012). The Relationship of Level of Positive Mental
Health With Current Mental Disorders in Predicting Suicidal
Behavior and Academic Impairment in College Students. J of
American College Health, 60(2) : 126-133.
 DeMaria et al. (2013). Psychiatry Resident Rotations in University
Counseling Centers: A Pilot Study of Rotation Types and Challenges.
J of College Student Psychopathology, 27: 337-344.
 Derenne J & Martel, A Model CSMH Curriculum for Child and
Adolescent Psychiatry Training Programs. in press.
 Eisenberg et al., (2011). Mental Health Service Utilization among
College Students in the United States. Journal of Nervous and Mental
Disease, 199(5): 301-308
Selected References
 Gallagher (2012). Thirty Years of the National Survey of
Counseling Center Directors: A Personal Account. J of College
Student Psychotherapy, 26(3): 172-184.
 IOM, NRC (2014). Investing in the Health and Well-Being of
Young Adults
 Iarovici D. (2014). Mental Health Issues and the University
Student. Baltimore: Johns Hopkins University Press.
 Kay J Schwartz V. (2010). Mental Health in the College
Community. NY: Wiley-Blackwell.
 Reetz. et al. (2013). The Association for University and College
Counseling Center Directors Annual Survey.
Resources
 Annual Survey of College Students by American College
Health Association (ACHA)
 National Survey of Counseling Center Directors by
Richard Gallagher, data since 1981
 AACAP Facts for Families on TAY
 Youth In Transition: Moving Into Adulthood Resource
Center, www.aacap.org
 http://healthymindsnetwork.org/
 The Jed Foundation :
https://www.jedfoundation.org/students/programs/tr
ansition-year; http://www.transitionyear.org/
Thank You!