Assessing mental health and violence on college campuses using the vulnerability model

Lisa R. Ponsford, DNP, RN, FNP-BC (Assistant Professor)

Journal of the American Association of Nurse Practitioners


Abstract

Background and purpose: Violence on college campuses has become increasingly more common than in previous years. Nearly 73% of students with a mental healthcondition living on campus experience a mental health crisis. College students arriving on campuses today come with different needs, expectations for services, and with different risk factors than in previous years. Advanced practice registered nurses (APRNs) in college health settings have the ability to recognize these changing trends and assist with improving the mental health of this population.

Methods: A critical analysis of an exemplar college campus is explored using the vulnerability model to assess risks that can lead to unnecessary and preventable violence on college campuses. The vulnerability model is a comprehensive approach utilized to guide an assessment to identify both individual and community risk factors influencing health and healthcare environments.

Conclusion: The use of the vulnerability model illustrated in this article reveals its usefulness in identifying the risk and needs for this population.

Implications for practice: APRNs and student health centers are positioned well to utilize the vulnerability model in assessing the needs of college campuses to improve outcomes of students.


Introduction

The Virginia Tech massacre, Kent State shootings, Xin Yang murder, UT tower shootings, CSU Fullerton shooting, Northern Illinois University shooting, Orangeburg massacre, Oikos University shooting, the murder of Jeanne Ann Clery at Lehigh University, and the most recent, Umpqua Community College shooting, are among the top violent crimes that have occurred on college campuses. The Virginia Tech massacre was one of the most profound violent acts by a college student in recent years. The perpetrator gunned down 32 people and wounded 17 others before killing himself (Campus Violence and Mental Health, n.d.). His mental history has since been well documented: he had suffered severe mental illness and depression since adolescence and was later diagnosed with “selective mutism,” an anxiety disorder with characteristics of social withdrawal and fear of social embarrassment (Campus Violence and Mental Health, n.d.). During his years at Virginia Tech, he displayed an increasing pattern of antisocial and disruptive behavior prior to committing this violent act (Campus Violence and Mental Health, n.d.).

Vulnerable populations, according to de Chesnay and Anderson (2012), “are those with a greater-than-average risk of developing health problems by virtue of their marginalized sociocultural status, their limited access to economic resources, or their personal characteristics such as age and gender” (p. 5). Individuals with mental health disorders are a vulnerable population. Many times, violence seen on college campuses is exacerbated by mental illness in this vulnerable population and is indicative of a nationwide college crisis (de Chesnay & Anderson, 2012). Attending college can be overwhelming for many students and college attendance can trigger previously undetected mental health issues. According to the National Alliance on Mental Illness (NAMI), the primary mental health diagnoses among college students are depression, anxiety, eating disorders, self-harm disorder (cutting), substance abuse, insomnia, and learning disorders (www.nami.org).

Seventy-five percent of all chronic mental illnesses begin at age of 24, when a person may still be seeking opportunities of higher education. According to the American Psychological Association (2014), depression has increased 10% over the last 10 years across campuses. Suicide is the third leading cause of death for ages 15–24 and more than 90% of individuals who die by suicide had one or more mental disorder (www.nami.org). Sadly, U.S. college campuses report more than 1100 suicides each year (American Psychological Association, 2014).

Nearly 73% of students with a mental health condition living on campus experienced a mental health crisis on campus (www.nami.org). Sixty-four percent of college students with mental health conditions drop out of, or leave, school; this represents the highest attrition rate of any disability group (www.nami.org). The implications of an individual with mental health issues withdrawing from education are observed in the individual's ability to develop the skills and experiences necessary to lead independent and productive adult lives. Mental disorders were recently identified as the leading cause of disability in the United States for ages 15–44 and were estimated to cost the United States $193.2 billion a year in lost wages (www.nami.org).

College students today are arriving on campuses with different needs, expectations for services, and with different risk factors than in previous years. Advanced practice registered nurses (APRNs) in college health settings must recognize these changing trends. Publically available data from an exemplar college campus will be explored to demonstrate the vulnerability of college students in relation to mental illness and poor social and health outcomes. The vulnerability model is used to explore community and individual risk factors affecting these health outcomes.

Critical analysis of college campuses using the vulnerability model

The vulnerability model was developed from previous foundational works that delineated risk factors from the individual or community contributing to poor health and healthcare access (Shi & Stevens, 2010). The vulnerability model is a comprehensive approach utilized to guide an assessment to identify both individual and community risk factors influencing health and healthcare involvements (Shi & Stevens, 2010). The comprehensive approach developed by Shi and Stevens (2010) examines the contributions of many risk factors and allows one to assess the collective impact of the risk as it relates to health (see Figure 1). According to Shi and Stevens (2010), “vulnerability is closely affected by individuals’ predisposing, enabling, and need attributes and is influenced by the same risk factors at a community level” (p. 21). These factors each independently influence vulnerability, and then converge to determine one's vulnerability status (Shi & Stevens, 2010).

Assessing the community of college students utilizing the vulnerability model assists in identifying risk factors, therefore goals can then be developed to improve the individual and community outcomes. The individual predisposing risk factors are identified as race/ethnicity of college students, multicultural beliefs on mental illness, stigma of mental illness, and alcohol/drug use. A research study involving 2843 college students found that frequent binge drinking was negatively associated with major depression and positively associated with generalized anxiety disorder (Cranford, Eisenberg, & Serras, 2009). Additionally, 67% of the students with both frequent binge drinking and mental health problems perceived a need for mental health services, yet only 38% received services in the prior year (Cranford et al., 2009).

Enabling risk factors include being underinsured and having a cultural barrier with providers. Often, resources are lacking on college campuses to fully treat mental health conditions. Many students are underinsured for these conditions, leading to a cost barrier to seeking treatment (www.nami.org). Individual need attributes include decreasing stress levels associated with college.

According to Shi and Stevens (2010), the surrounding environment influences individuals living within a community. In 2006, the UC Student Mental Health Committee reported that mental healthtrends nationally were negatively affecting college campuses, and three areas of concern were identified: (a) In alignment with national trends, college students were presenting with mental health issues with increased complexity and frequency; (b) budget trends within the college system were limiting resources available to students, which then manifested into longer wait times and difficulty retaining staff; (c) increasing demands and declining capacity pose a threat to the learning environment because of the significant adverse impacts on faculty and students (UC Student Mental Health Committee, 2006). The committee also recognized that graduate students were a higher-than-average risk population secondary to the level of stress magnified by family isolation, intense academic pressures of advanced studies, and increased pressures of family and financial obligations (UC Student Mental Health Committee, 2006).

The American College Health Association-National College Health Assessment (Committee on Educational Policy, 2009) found that 1 in 10 college students seriously considered attempting suicide, and 1.4% attempted suicide; both findings are consistent with the national average. The study also found that psychiatric hospitalizations increased a staggering 79% in 2007–2008, with an overall increase of 70% in college students receiving mental health services since 2000 (12,384–21,076), which is four times greater than the rate of enrollment growth of 17% (Committee on Educational Policy, 2009). Among three college campuses, there was an increase from 37 to 193 registered students with psychiatric disabilities (Committee on Educational Policy, 2009).

Continuing with the vulnerability model, there is a need to improve access to care by improving student insurance plans to cover mental health, the student-to-specialist ratio, and timeliness to care without delays in appointments. Quality of care will be provided according to national guidelines including establishing a single provider for continuity of care to develop a trusting relationship. These guidelines in turn will improve individual health outcomes by increasing awareness of mental illness, and improving management of symptoms and student-learning outcomes. Community health outcomes will be improved by decreasing attrition rates and the number of crimes and violent acts, and an improved awareness and acceptance of mental health conditions.

Vulnerable population of college students: An exemplar college campus

College students represent a vulnerable population, at risk for poor outcomes and the negative consequences at the intersection of health and social issues. In the Fall of 2011, exactly 236,691 students were enrolled in southern California universities (Selegean & Iannucci, 2011). Collectively, this number represents an average size metropolis in California and factors affecting the health and wellbeing of this vulnerable population need close scrutiny.

In one exemplar campus, a total of 27,889 students were enrolled, with 52% of this campus’ undergraduate population being Asian, and 21% from the underrepresented minority groups of African American, Chicano, Latino, and Native American. Ninety-four percent of the students were previous California residents, and 24% were from Orange County, 32% from Los Angeles County, and 36% previously resided outside California. Additionally, 47% were first-generation college attendees and/or came from low-income families. Financial aid was received by 73% of undergraduate students and 64% received need-based financial aid. Both financial aid and need-based financial aid have increased nearly 10% in the last 5 years on college campuses (Selegean & Iannucci, 2011).

Crime, while lower than the national or state average per 100,000, does exist within this college community (UC Student Mental Health Committee, 2006). Two hundred sixteen arrests were made on this campus in 2013 with 166 of those involving alcohol and 25 of those related to larceny. In addition, there were 10 weapon-related cases and 32 domestic violence incidents. There were two documented suicides, one attempted suicide, and 87 arrests for mentally disordered, nondrug-related incidents. Furthermore, five bias-motivated cases involving race, religion, and sexual orientation were documented. The trend of violent crimes on this southern California campus has been on an incline since 2007 with 10.15 cases per 100,000 and in 2013, 24.74 per 100,000 documented. However, these numbers remain lower than the overall California crime statistics of 503 per 100,000 in 2008 (last reported).

Mental health care on the exemplar college has limited resources to fully serve the students and is unable to manage and support after-hour care. The identified college has a lower student/specialist ratio than recommended by the International Association of Counseling Services. The campus has a 1:2536 psychologist-to-student ratio and a 1:17,846 psychiatrist-to-student ratio. Yet, the International Association of Counseling Services recommends one mental health professional per 1000 students (UC Student Mental Health Committee, 2006). Additionally, students not identifying themselves as in an immediate crisis could wait up to 6 weeks for an appointment with a psychiatrist (UC Student Mental Health Committee, 2006). Budget cuts have resulted in increased caseloads for their mental health providers, reduced department morale, and higher staff turnover rates related to increased pressures of complex cases and noncompetitive salaries (UC Student Mental Health Committee, 2006). These findings are significant, which put the student population at risk for poor mental health outcomes.

A student health plan is required for all college students to purchase at a rate of $466.00 per semester with a deductible of $300 and maximum out-of-pocket expense of $3000. Co-insurance coverage is 10% if the provider is in network and 40% if out of network. The student will pay $15 per primary care visit and $30 for specialty visits. Prescription co-payments are $10 for generic, $35 for formulary, and $50 for nonformulary. The plan covers preventative and wellness services, medical visits, urgent and emergent expenses, and surgery. The Student Health Center on the exemplar college campus offers a variety of services including General Medicine, Women's Health, Dermatology, ENT, Orthopedics, and Psychiatry. There are three psychiatrists and three senior psychiatry residents available to see students for mental healthconcerns. The center is open Monday through Friday from 8:00 a.m. to 5:00 p.m. with no availability on the weekends or holidays.

The exemplar collage campus assessed using the vulnerability model

The vulnerability model developed by Shi and Stevens (2010) provides a framework for examining vulnerable populations and has been used for the purpose of studying an exemplar college (Figure 2). In the exemplar college, the community predisposing risk factors of this vulnerable population are the demographics of the campus: 52% Asian, 21% other underrepresented minority group. Additionally, it was noted that crime and violence on the campus is on the incline. Enabling factors include the socioeconomic status of the students: 73% are receiving financial aid and 64% are receiving need-based financial aid. This leads to the assumption that many students do not have the extra funds to purchase prescriptions or cover the co-payments for mental health visits. Further, the lack of mental health providers and increased wait times for appointments puts the students at risk. Need factors include educating the students on mental health behaviors and strategies to improve mental health.

 

Overall, the exemplar college campus lacks resources to fully manage the number of students requiring mental health care, although it is acknowledged that individual college campuses have differing circumstances, strengths, and weaknesses. According to the American Psychological Association (2013), 95% of college counseling center directors agreed that college campuses were lacking the necessary resources to manage students with mental health needs.

Limitations and strengths of available resources on the exemplar campus

The most profound limitation identified on the exemplar campus was the lack of mental healthresources as described. The student-to-specialist ratio was severely deficient according to the national standards, thereby placing students with mental health issues and those around them at risk for potential harm. Another limitation identified was the lack of information the college campuses can provide to faculty about students of concern. College campuses attempt to implement safeguards to protect all students while maintaining privacy protections for those individuals with mental health concerns. The Americans with Disability Act gives the students with mental illness the right to enroll in college courses unless they become disruptive to the environment (Campus Violence and Mental Health, n.d.). However, according to the National Association of College and University Attorneys, “the Family Educational Rights and Privacy Act, permits the disclosure of information from student education records to appropriate parties in connection with an emergency if knowledge of the information is necessary to protect the health or safety of the student or other individuals” (Campus Violence and Mental Health, n.d., p. 5).

A strength identified on the exemplar campus was the participation in a nationally recognized Mental Health Awareness Week and Depression Screening Day. During this time Each Mind Matters joined the exemplar campus in supporting mental health. Individuals were made aware that they could become involved by taking a pledge against stigma and show commitment by becoming a change agent. Individuals also demonstrated their support online by adding a lime green ribbon to their profile pictures and followed Each Mind Matters on Facebook and Twitter. Additionally, supporters wore lime green ribbons to show support around campus.

An additional strength identified on this campus was the presence of a police department with 24-h patrol in both marked and unmarked vehicles. Also available to students was an emergency alert system using cell phone text messaging to notify the college community of an emergency. The system does require a student to sign up providing their contact information and cellular phone number. The police department website provides daily crime reports, active shooter information, and fulfills requests for safety escorts along with a plethora of other useful safety information.

The APRN role in health promotion on college campuses

Access to behavioral health for the underinsured and uninsured is often a challenge for individuals seeking mental health care. A shortage of qualified mental health providers and insurance coverage limits are often contributing factors to this challenge. Telehealth is becoming acceptable among other specialties to provide access to care to those in need. Telehealth is defined as “the use of technology to deliver care through techniques like videoconferencing” (U.S. Department of Health and Human Services, Health Resources and Services Administration [HHS, HRSA], 2013, p. 2). TeleMental Health consultations can be the first line for identifying emergent psychiatric needs and triaging according to priority by a behavioral health specialist such as a Psychiatric-Mental Health Nurse Practitioner. Implementation of care via Telehealth provides a cost effective, efficient, healthcare delivery system, while providing an expanded network of healthcare providers to patients with mental healthcare needs (HHS, HRSA, 2013).

College campuses could benefit from TeleMental Health implemented by the APRN. The University of Maryland, Department of Psychiatry established a TeleMental Health program to provide cost effective care with flexibility, rapid communication, and culturally competent care, and has proved to be successful (University of Maryland School of Medicine, n.d.). In a literature review conducted by Hilty et al., (2013), TeleMental Health was found effective for diagnosis and assessment across many populations including: adults, children, geriatric, and various ethnicities. TeleMental Health was additionally found beneficial for multiple mental health disorders in many settings and comparable to in-person encounters (Hilty et al., 2013). TeleMental Health is currently being explored by the HRSA to provide grant funding for clinics willing to provide mental healthcare services to low-income populations (HHS, HRSA, 2013). TeleMental Health could potentially be widely accepted by the present-day, technologically savvy generation of students on campus, and ultimately prove beneficial to their learning outcomes.

Conclusion

In the past decade, college student mental health issues and violence have been on the rise, illustrating a tremendous need to address mental health issues in this important age group. Evidence suggests that college students are experiencing greater levels of stress, anxiety, and psychopathology than ever before, regardless of campus location or size, leading to unhealthy outcomes. Utilization of a vulnerability model populated with publically available data of an exemplar college campus detected a lack of mental health resources available on the campus. Multiple studies have clearly shown that early identification and intervention, with mental and behavioral health support systems, can improve student life and potentially prevent a significant proportion of violence and crime seen on college campuses today. The most recent survey of college counseling center directors found that 59% of students who had received treatment indicated that therapy had a significant impact on remaining students in school and improved their academic performance (American Psychological Association, 2014). Despite the complexity of mental health issues on college campuses, the overall picture is clear. Today's college students are facing a serious mental health crisis and changes should occur to improve student health and safety on campus. APRNs and student health centers are well positioned to utilize the vulnerability model in order to assess and improve the outcomes of college students. Furthermore, APRNs should consider using such a model to assess their own campus and communicate findings with university administration.


References

American Psychological Association. (2014). The state of mental health on college campuses: A growing crisis. Retrieved from http://www.apa.org/about/gr/education/news/2011/college-campuses.aspx

Campus Violence and Mental Health. (n.d.). Campus violence and mental health. Retrieved from http://www.csg.org/knowledgecenter/docs/ MentalHealth-CampusSafety.pdf

Committee on Educational Policy. (2009). Report of the Student Mental Health Oversight Committee. Retrieved from http://regents.universityofcalifornia. edu/regmeet/mar09/e3pp.pdf

Cranford, J., Eisenberg, D., & Serras, A. (2009). Substance use behaviors, mental health problems, and use of mental health services in a probability sample of college students. Addictive Behaviors, 34(2), 134–145. doi: 10.1016/j.addbeh.2008.09.004

de Chesnay, M., & Anderson, B. A. (2012). Caring for the vulnerable (3rd ed.). Burlington, MA: Jones & Bartlett Learning.

Hilty, D., Ferrer, D., Parish, M., Johnston, B., Callahan, E., & Yellowlees, P. (2013). The effectiveness of telemental health: A 2013 review. Telemedicine Journal and E-Health, 19(6), 444–454. doi: 10.1089/tmj.2013.0075

Selegean, J., & Iannucci, A. (2011). UCI undergraduate student data Fall 2011. Retrieved from http://www.assessment.uci.edu/undergraduate/documents/ UCIUndergraduateStudentDataandTrendsF11.pdf

Shi, L., & Stevens, G. (2010). Vulnerable populations in the United States (2nd ed.). San Francisco, CA: Jossey-Bass.

UC Student Mental Health Committee. (2006). Student Mental Health Committee: Final Report [report]. Retrieved from http://regents.universityofcalifornia.edu/regmeet/sept06/303attach.pdf

University of Maryland School of Medicine. (n.d.). TeleMental Health. www.medschool.umaryland.edu

U.S. Department of Health and Human Services, Health Resources and Services Administration [HHS, HRSA]. (2013). Increasing access to behavioral health care through technology. Retrieved from http://www.hrsa.gov/publichealth/ guidelines/behavioralhealth/behavioralhealthcareaccess.pdf

 
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