Commentary
annascheyett.jpg RooksAdrienne[1].jpgby Anna Scheyett* and Adrienne Rooks**

Fear of stigma and discrimination has discouraged many college students from sharing information about their mental illness with university administration, advisors, or other faculty. Rates of mental illness in college students are high and are rising. An estimated 15% of university students experience clinical depression, rates of psychiatric hospitalization in college students have increased 35% in the past five years, and suicide is the second leading cause of death in college students Unlike these high rates of self-harm, recent campus violence such as the shootings at Virginia Tech and Northern Illinois University are rare, but have heightened awareness about mental illness in students. Despite all this, many students struggle alone and do not know where to turn for support

When a student shows symptoms of a mental illness, legal and ethical dilemmas, inexperience, and a lack of policy have confounded administrators. Unless there is a significant risk of harm, confidentiality laws create barriers to conversation between university staff and students' family or mental health care providers. The university is unable to respond to help the student, symptoms may prevent them from asking for help, and a psychiatric crisis -- often resulting in school drop out, sometimes resulting in hospitalization, and occasionally leading to tragedy -- may occur.

At our university this situation was seen with a graduate student we'll call Laura (not her real name). Laura began missing classes and not handing in assignments. After a few weeks she disappeared from classes altogether. Her responses to professors' calls were brief and cryptic; she refused to accept help and support from faculty or other students. Without any information about prior treatment Laura had received, and without permission to speak with a family member, we were forced to simply watch, while contacting her frequently, but wait until she reached a crisis and threatened self-harm, when we could facilitate her hospitalization. Following this crisis, Laura was afraid to return to classes and dropped out of school.

Psychiatric Advance Directives (PADs) are legal documents that allow individuals, when well, to document their wishes for treatment during times of psychiatric crisis when they are no longer capable of saying what they need or making competent decisions regarding their care. PADs have been used by adults with mental illness who wish to direct their care as symptoms reappear and/or a crisis occurs. There is some form of legal advance directive for mental health treatment in 46 states, though the specifics vary from state to state. Research indicates high demand for PADs among individuals with serious mental illnesses.

PADs, tailored to a college student's experience, could be a powerful intervention to support university students with a mental illness. With PADs, students can identify and document things such as:

  • early warning signs of relapse;
  • interventions that are most helpful;
  • people to contact if a student begins to relapse;
  • permission for specific medications they know are helpful, or refusal of medications they know are not helpful.

Additionally, students could identify and give permission for the university to communicate with care providers and relevant support people (family, partners, and friends). For example, Laura could have used a PAD to document that her beginning relapse symptoms included increased isolation and inability to complete tasks. She could have indicated that calling her therapist and her brother would help if she gets depressed. She could have given us permission to contact them so they could reach out to her. With this PAD, we would have been able to more quickly recognize what was happening and spoken with her therapist, who could have intervened to get Laura the help she needed, and avert a crisis.

How exactly would PADs work for students at colleges and universities? Every school has a different configuration of supports for students--a health center, disability office, dorm counselors, advising system. By using the existing infrastructure schools can indicate they are able to work with students who have a mental illness and offer them the opportunity to create a PAD. They can use this same infrastructure to educate the university community about mental illnesses and the value of PADs, thus creating a support system for students with mental illnesses and decreasing the stigma of these disorders. With a commitment and a focus, schools could develop creative ways to spread the word about PADs, even including information on PADs in all enrollment packets, orientation materials, and campus health care information. This would also promote inclusion.

One test of the feasibility of PADs is being explored at the School of Social Work at the University of North Carolina at Chapel Hill. In our project, students can obtain information about PADs through multiple people in offices that generally provide information about student life or health -- Office of Disability Services, Dean of Students Office, Counseling and Wellness clinic. A student interested in a PAD can be connected with a trained facilitator, who helps them develop the document. Part of the discussion includes identifying specific people, doctors, relatives, teachers, roommates or classmates the students wants to have a copy of the PAD so they can act if there is a need or pending crisis. At UNC in Chapel Hill, this could also include formal service providers such as the emergency room of the local hospital, or the local police social work unit. We then distribute copies of the PAD to these providers.

Recipients of the PAD need to be educated about what a PAD is and how it works, such as requirements for confidentiality, explaining what a PAD is and talk about their role in helping the student if they see specified early signs of relapse in the PAD. For some, it could be decreased need for sleep, fast speech, change in appetite. Whatever the symptoms, they know it is the trigger to talk about going to a mental health provider. And if the student refuses, they then know to call the Counseling and Wellness clinic for help. Throughout we emphasize the importance of confidentiality and of respecting the student, along with some basic education about mental illnesses.

Our hope is that this project will have several positive effects. First, clearly we hope the PAD will help students with a mental illness get help earlier, to avoid a crisis; or if one goes into crisis, to get the mental health care he or she prefers and knows is best. Second, we hope that creating a PAD will help students feel supported, so the university can become a partner with them in ensuring a successful educational experience. Third, we hope that by reflecting on their experiences with mental illnesss, as they create a PAD, students will increase their self-awareness regarding warning signs and symptoms of relapse and strategies for supporting their mental health. Finally, we hope that simply having conversations about PADs with offices and departments on campus, as well as with informal supports such as faculty and friends, we will educate people about mental illness and decrease the stigma.

PADs could be a way to communicate clearly that students with mental illnesses belong on campuses, that universities want them there, and that universities are willing to provide them with supports to increase their chance of success. The could be a way to promote stability and recovery in students with mental illnesses. If we can demonstrate effectiveness, PADs could become a standard intervention in campuses across the nation, providing universities with a way to ensure that students get the mental health care they need well before a crisis occurs.

*Dr. Anna Scheyett is the Associate Dean of Academic Affairs at the School of Social Work, University of North Carolina, Chapel Hill. In addition to research about psychiatric advance directives, she is engaged in research about serious mental illnesses, consumer rights and criminal justice.

**Adrienne Rooks is a graduate student at the University of North Carolina at Chapel Hill School of Social Work with research interests in health care and psychiatric advance directives.

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