Mental Health Issues and the University Student

17. Emergency Situations on Campus

An economics professor brings 19-year-old Marissa for an urgent counseling center evaluation, concerned because she broke into tears in his office after he’d called her in to discuss a failing grade. He reports that she’d been a strong student at the beginning of the semester but lately had been skipping class and not responding to e-mails, and now she’d failed an exam. Marissa told the professor that she’d been having personal problems and was in counseling. The record confirms that Marissa met twice with a psychology intern to discuss a flailing romantic relationship; there were no signs of high risk at that time. She no-showed to subsequent appointments and had not responded to the therapist’s attempt to contact her. During this evaluation, Marissa is initially reluctant to divulge much, saying, “This is so stupid. I’ll be fine. I’m not crazy.” She eventually admits that her boyfriend broke up with her two weeks ago, and she’s felt unable to complete schoolwork since. She endorses multiple symptoms of depression but is ashamed, seeing everything as a sign of having been too dependent on her boyfriend. Her closest friend is on leave this semester, and she’s felt isolated. This particularly bothers her since she already feels different from her peers due to the insulin-dependent diabetes she’s had to manage since age 10. She admits, “Life is just too hard sometimes, and really doesn’t seem worth it” Chapter 17 Emergency Situations on Campus 164  Clinical Challenges and mumbles that she’s thought about giving herself extra doses of insulin. She has been deterred by thoughts of how it would affect her mother. On the other hand, she says, “It would be easier on her to not have to figure out how to pay my tuition, now that I can’t even get school right.” Her parents went through a contentious divorce several years ago, and her father refuses to contribute to college expenses, “though financial aid is calculated based on both their incomes.” Emergency Assessment and Hospitalization Psychiatrists assessing students in the midst of a crisis, whether in the counseling center or in other settings, must determine whether in addition to a high level of distress the student also is at risk of imminent harm, either to self or others. This is an imprecise science, made more difficult in the setting of work with emerging adults who may avoid fully disclosing symptoms for fear of being hospitalized, or simply because the achievement-oriented culture on many campuses actively discourages admitting or articulating vulnerability in general. A variety of rating scales and assessment instruments have been studied in college populations, but none can in isolation predict risk. One of the more widely used scales, Beck’s Scale for Suicidal Ideation (SSI), can be administered in about 10 minutes and has documented predictive validity for completed suicide.1 When there’s time, and if the student is willing to complete it, the SSI can be a helpful tool in risk assessment. The Counseling Center Assessment of Psychological Symptoms (CCAPS) scale, normed on college counseling center populations, also provides a helpful distress index and a hostility subscale in addition to symptom-related subscales;2 norms are continually updated, and the instrument is available free of charge to university counseling centers (contact the Center for Collegiate Mental Health at Penn State). Many counseling centers use the CCAPS as an initial and a termination measure for all students seen there, and it can rapidly flag especially worrisome presentations. Marissa presents several factors that elevate our concern for risk. She has insulin-dependent diabetes, considered one of the most psychologically challenging chronic medical conditions and one that doubles the risk of depression compared with the general population.3 She has suicidal thoughts, articulates a plan, and has ready access to a potentially lethal means of self-harm (insulin overdose). She didn’t adhere to treatment even before reaching crisis and did not seek help as she felt worse. She still lacks insight into the need for help. If she’s suffering from untreated depression, her ability to adequately manage her Emergency Situations on Campus  165 diabetes may be compromised even in the absence of suicidal thoughts. Hospitalization would address both her mental and physical health needs. When the psychiatrist suggests hospitalization to Marissa, she starts to weep and says, “It hasn’t...