Mental Health Issues and the University Student

20. Models of Treatment

Carrie, a 21-year old Southeast-Asian (Indian) American junior, comes in complaining of depressive symptoms and declining academic performance. She begins sheepishly with “I did something stupid. I stopped my medicine.” She was seen for similar complaints a year ago and treated with an antidepressant , which helped; however, she’d discontinued the medicine after two months because she’d felt better, and when summer began, she did not follow through with the therapy that had been recommended. Many of her depressive symptoms are triggered by complex conflicts within her family, from whom she was mostly apart over the summer. In the fall she was abroad. There were times when she felt depressed, and she drank more heavily while abroad, but overall she felt stable. Lately she’s getting drawn into her parents’ ongoing discord as well as severe family financial problems. The record reveals that she attended two sessions of therapy at the counseling center the previous year and two medication management visits and that she was improving but then stopped coming to either therapy or medication management and was lost to follow-up. Many of the models of psychiatric treatment in which most of us psychiatrists were trained meet challenges in working with college students. It’s not Chapter 20 Models of Treatment 198  Clinical Challenges uncommon for students to discontinue their medication earlier than recommended , or to avoid or prematurely terminate therapy. Often it’s not out of resistance or a desire to be noncompliant. Shifting our focus from a pathologybased model to a developmental framework, we can better understand that emerging adults are just beginning to learn to take responsibility for their own health and wellness. They may equate mental health treatment with being mentally ill, and thus, at the first signs of feeling better, they flee treatment in the hope that discarding it also discards the possibility that something is wrong. They may attribute feeling better to a misdiagnosis in the first place and question the need for ongoing care. Or something as simple as the academic year calendar, with its multiple hiatuses—vacations, breaks, and study abroad—may disrupt their resolve to engage in ongoing treatment. A core developmental task of emerging adulthood is managing the change from “dependency on one’s parents and other older adults to independence,”1 and this comes in conflict with traditional models of mental health care, including long-term but even briefer forms of regular psychotherapy and ongoing medication management. These can seem to encourage dependence. Even though today’s generation of students is more connected with their parents, keeping in closer touch and relying on them for advice, their trajectory through college still involves developing healthy autonomy, and this may play out in a student’s attitudes toward treatment. The fact is that many students do well even without ongoing long-term treatment. Those dealing with recurrent conditions, such as major depression or an anxiety disorder, will find themselves needing continued treatment. It’s important for the psychiatrist they see not to shame them for their treatment interruption and to remain flexible regarding the modes of treatment that will fit students’ needs. Psychologist Richard Eichler, who is director of Columbia’s counseling center, also recommends meeting many students’ abrupt cessation of counseling with an invitation to return when and if the student likes, noting that allowing them to use counseling intermittently actually supports their efforts at individuation.2 He suggests that college students are better able to make forays into the wider world with the knowledge of a secure base to which they can return in a crisis; most of us working in university settings have experienced this firsthand. As psychiatrists recommending a medical treatment, though, we must walk a fine line between understanding the developmental perspective and informing students about the recommended duration of medication treatment and Models of Treatment  199 risks of early discontinuation. At the same time, we must normalize their experiences with premature discontinuation as these arise. A student presenting with Carrie’s concerns, who may have had a depressive disorder with good response to an antidepressant, is likely to respond again, and we can easily resume medication. In my experience, some students meet full criteria for a mood or anxiety disorder while on campus, but do seem to do much better, even without treatment, at other times in other settings. Whether this implies that the original diagnosis was incorrect, or...