Marjorie MalpiedeThe World Health Organization’s program shows new thinking aimed at the campus behavioral health crisis
A recent study published by the American Psychological Association found that one-third of freshmen from 19 colleges in eight countries report symptoms consistent with a diagnosable psychological disorder. The concerning “1 out of 3” statistic was widely reported in the news media as further evidence of a global mental health epidemic among college students. The study, however, is only part of a much larger effort to apply data analytics and precision medicine to identify students at risk and provide the time-sensitive interventions that, in some cases, may save their lives.
The new findings are from the World Mental Health International College Student Initiative, (WMH-ICS) a longitudinal study with an innovative twist led by the World Health Organization (WHO). Its primary instrument is a web-based self-report student questionnaire that has been administered in surveys to young people in over 25 countries on five continents since it was first introduced six years ago. The questionnaire evaluates a number of common mental disorders, such as major depression, generalized anxiety disorder and panic disorder among college students.
The initiative is led by Dr. Randy P. Auerbach, an Associate Professor at Columbia University, along with an international team of collaborators. In addition to providing prevalence data, Auerbach and his team analyze the large datasets of the participating universities in ways to help schools identify the profiles of students with a wide range of behavioral health problems (e.g., insomnia, substance use, eating disorders). As the effort has evolved, the researchers have begun to introduce an online intervention in the form of I-CBT (Internet-based, cognitive behavioral therapy) to survey respondents screening positive for clinically significant mental disorders.
In addition to embedding a randomized treatment effectiveness trial into their surveys, the WMH-ICS collaborators are developing statistical models based on artificial intelligence methods to help clinicians decide which students are most likely to be helped by I-CBT. Such “precision treatment” models might well change the status quo in college behavioral health and help solve the campus behavioral health crisis in the process.
These models are based on recognition of the fact shown in much previous mental health treatment research that not all treatment paths are right for all patients; as well as the hypothesis that systematic predictors of such differences can help select the right treatment for the right patient right away. If this hypothesis turns out to be true, as it is proving to be in a number of other areas of medicine where precision treatment models are being developed, the results could help colleges and universities reduce the trial and error approach that characterizes much current mental disorder treatment planning. This, in turn, will increase the efficiency of treatment and reduce the number of students who drop out of treatments that are not right for them.
WHO is behind this
The WMH-ICS is the “brain child” of Dr. Ronald C. Kessler, an epidemiologist and the McNeil Family Professor of Health Care Policy at Harvard Medical School. The initiative’s population-based approach to mental health is a familiar concept, sourced in the philosophy of its originator, the World Health Organization. What is novel about this work is its application to college students within the campus ecosystem. The backdrop for the WMH-ICS came from another WHO program, the World Mental Health Survey Initiative which brought together a dream team of investigators from around the world including Dr. Kessler.
Kessler’s work studying the social determinants of mental illness was instrumental in the cross-national study that involved face to face interviews over a span of twenty years. The study, which continues today, helped determine treatment efficacy by factors such as population group and culture and is credited with raising global awareness of mental illness and its cost on the world economy.
“There is no illness category that has as high a cost to society, as high a cost effectiveness of treatment, but as low a level of investment in terms of funding from the government as mental disorders,” said Kessler.
One of the factors that Kessler and the WMH-ICS investigators studied in their research on the societal costs of untreated mental disorders was education level. They found that mental disorders, which are much more likely than chronic physical disorders to begin in childhood or adolescence, are powerful risk factors for low educational attainment. This is especially important in poorer countries, where the percentages were low and the expectations on the student were very high. “Only a tiny proportion of young people in many low and middle income countries go to college,” said Kessler. “Most of these kids are first-generation college students who face enormous pressures for success from their extended families. But the schools have little in the way of resources to help students cope with these pressures and the emotional problems they often create.”
In 2010, Kessler met Auerbach, who, at the time, was a junior faculty member at Harvard Medical School with a research focus on adolescent disorders and suicide. Auerbach was particularly interested in college student mental health and believed there was a gap in analysis and methodology in this area given the importance of the population group. Auerbach took on the significant hours and effort to get the initial grant for the initiative from the World Mental Health Survey to create the instrument and begin recruiting schools. Follow-on grants have subsequently come from a variety of sources including participating countries.
Also joining the team was Stephanie Pinder-Amaker, Director of McLean’s College Mental Health Program and the former Associate Dean of Students and Chair of the Mental Health Work Group at the University of Michigan. Pinder-Amaker is a key link to the colleges and provided a bridge to early adopters like Harvard and Boston University.
ICSI was soon off the ground with a web site stating its purposes: “The Initiative is designed to: generate accurate epidemiological data on unmet need for treatment of mental, substance, and behavioral disorders among college students worldwide; implement and evaluate web-based interventions for both the prevention and treatment of these disorders; and disseminate the evidence-based interventions found to be effective.”
A Critical Point in Time
Just as Kessler, Auerbach and Pinder-Amaker began recruiting schools for the WMH-ICS, the rise in the demand for mental health resources on college campuses skyrocketed. According to the Center for Collegiate Mental Health 2016 report, while college enrollment has increased by just 5 percent over the past five years, the number of students seeking behavioral health services has risen by 29.6 percent or six times enrollment.
“When we started doing the first waves of this study, we were seeing that rates were alarmingly high, treatment access was relatively low, and universities were coming to us saying, ‘What do we do?’ said Auerbach.
The team focused on data analytics as their primary contribution to their participating schools. The initiative began in Belgium and now has 20 schools collecting data, including more than 10 in the United States. But as Auerbach says, it is the messages within the data that can help schools address their unmet service needs.
“Our thinking was, if we are going to study these really large populations, can we start to develop predictive algorithms to identify these potential risk groups in order to help universities provide more targeted care?” he said.
As they continued to work on identifying risk groups, they considered how an intervention, triggered by certain scores on the survey, could provide an immediate response for students who might be suffering while also helping schools with their capacity problems. Currently, most college counseling centers provide some number of traditional therapy sessions, a model that can become unsustainable, given the increase in, and inconsistency of, the demand.
“Counseling centers are able to fill only so many mental health requests by mid-semester, and invariably, a wait list begins to form,” said Auerbach. “The people who are less severe, wait in line, much like an emergency room. The problem is the people who are experiencing what we call ‘sub-threshold symptoms’ are often impaired enough that it is affecting their quality of life and their ability to perform at school.”
With the goal of providing students the care they need in as timely a way as possible, the team met with experts in e-health about college-specific tools that can be accessed online. The first innovation is a product called “ICare,” developed in Germany, that provides online cognitive behavioral therapy designed specifically for college students. The seven-week course includes intermittent coaching to help keep students stay engaged. When students report a certain level of distress on the behavioral health assessment, they can receive a message saying “because you reported some elevated levels of depressive symptoms, you might benefit from this online treatment. If you’re interested, click here.”
One of the strongest arguments for these online tools is their potential to reach students who are not likely to show up at the counseling center. According to the WMH-ICS data, only about 15 to 20 percent of students who need treatment actually receive it on campus. Their evidence shows that for many students, particularly those who are impacted by stigma, or feel so depressed they become powerless, online tools can help, even as a first step.
“For hundreds of years, we have been doing one to one, face to face counseling and that is effective for a lot of people, but we also know from recent analysis, that online interventions, in certain circumstances, can be comparatively effective,” said Auerbach who notes this is particularly true of young people whose native language involves technology.
The way of the future
Randy Auerbach recently moved to New York where he continues to co-lead the WMH-ICS effort while in his new roles at Columbia University and the Sackler Institute for Developmental Neuroscience. There, Auerbach runs a research lab to better understand risk for disorders and suicidal behaviors in young people and to guide processes that help determine which interventions work best for certain patients.
Auerbach, Kessler and their colleagues from WMH-ICS are continuing to publish their prevalence findings and chronicling the ongoing worldwide crisis in college student mental health. They are also looking at a range of new technologies and online tools; anything, Kessler says, that “adds to a coordinated system where you can provide the right stuff to the right people in the right way.”
Their exploration spans both ends of the behavioral health spectrum. The group is interested in developing a broad-based tool kit for issues like stress management, general worry, perfectionism, and sleep management. Meanwhile, they are feeling good about their initial results and hoping that through a combination of precision medicine, data analytics and technology, they may even prevent some students from dying by suicide – now the second leading cause of death among college students.
“We’re trying to use complex precision medicine models to help increase our ability to select treatments that are optimal for a meaningful subset of students and make sure those students get those treatments,” said Kessler. “This will inevitably be an iterative process, but we’re in it for the long haul and our goal is to keep working until we find helpful treatments for every student with a meaningful emotional problem.”
