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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: 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! 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: 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!