Prevalence of Mental Health
Conditions in a Cohort of 700,000
College Students
James C. Turner, MD
Adrienne Keller, PhD
Department of Student Health
and the National Social Norms Institute
University of Virginia
1
Funding Sources
UVa Department of Student Health
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Federal:
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Anheuser-Busch Foundation
Foxfield Racing Association
National Center for Drug Free Sport
National Collegiate Athletics Association
National Organization for Youth Safety
(NOYS)
– The BACCHUS Network
– The Gordie Foundation
– The Network: Addressing Collegiate
Alcohol and Other Drug Issues
Virginia Alcoholic Beverage Control Board
Virginia Department of Health
UVA:
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–
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Office of the Vice President for Student
Affairs
Student Health fee paid by all UVa
students to Department of Student Health
Laboratory and pharmacy revenues shared
with UVa Health System.
U.Va. Parents Committee
Youth-Nex Grant
Private/Non-profit
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CDC
National Institute on Alcohol Abuse and
Alcoholism
U.S. Department of Education
State:
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•
•
•
Salary 100% from UVa Student
Health. No personal conflicts of
interest.
2
College Health Surveillance Network
(CHSN)
3
College Health Surveillance Network
(CHSN)
Why a surveillance network?
Paucity of data on health trends among college students.
• 19 M individuals in college. 54% of population attends college.
• Health care utilization patterns not reported.
– Billions spent on health services for students
• No clinical data on student populations.
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Infectious disease outbreaks
Substance use/abuse, depression, eating disorders
Chronic diseases (diabetes, asthma) and common acute problems
Syndrome surveillance
Injuries
• Prevention strategies.
– Vaccine uptake
– Substance abuse education
– STI education
4
College Health Surveillance Network
(CHSN)
• Funded by CDC grant and UVa (SH and NSNI).
• Established a 22 school network using EMR
uploads of depersonalized data to central
server.
• Each school IRB approval or institutional data
sharing agreement.
5
College Health Surveillance Network
(CHSN)
•
•
•
•
702,000 currently enrolled students 2011/12
22 four-year public and private not-for-profits
21 of 22 are Research Universities Very High
Census region representation:
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Northeast:
South:
Midwest:
West:
6
8
4
4
• Demographics similar to 2011 DOE data on
Research Universities Very High.
3
Gender
7
Student level
8
Age
9
Race and ethnicity
10
Epidemiology
Academic Year 2011-2012
(n=879,787 visits)
Most common categories of visits*
1.
URI, pharyngitis, other respiratory
symptoms
2. Contraceptive management
3. Anxiety
4. Injuries (all categories)
5. Depression
6. General symptoms (e.g. fatigue,
sleep disorders, fever)
7. STI screenings
8. Joint pain
9. Urinary symptoms including UTI
10. Digestive system symptoms
(nausea, vomiting, diarrhea, GERD)
11. Follow-up care
12. Back & other musculoskeletal
13. Menstrual & other gynecologic
disorders
14. Physicals
15. Adjustment reaction
16. ADHD & ADD
17. Ear Disorders
18. Viral infections
19. Eating Disorders
20. Vaginitis and vulvovaginitis
* (excludes vaccines, allergy shots, administrative visits, TB screening)
11
Epidemiology
Academic Year 2011-2012
(n=879,787 visits)
Most common categories of visits*
1.
URI, pharyngitis, other respiratory
symptoms
2. Contraceptive management
3. Anxiety
4. Injuries (all categories)
5. Depression
6. General symptoms (e.g. fatigue,
sleep disorders, fever)
7. STI screenings
8. Joint pain
9. Urinary symptoms including UTI
10. Digestive system symptoms
(nausea, vomiting, diarrhea, GERD)
11. Follow-up care
12. Back & other musculoskeletal
13. Menstrual & other gynecologic
disorders
14. Physicals
15. Adjustment reaction
16. ADHD & ADD
17. Ear Disorders
18. Viral infections
19. Eating Disorders
20. Vaginitis and vulvovaginitis
* (excludes vaccines, allergy shots, administrative visits, TB screening)
12
Epidemiology
Academic Year 2011-2012
(n= 289,299 individuals)
Most common categories of patients*
1.
URI, pharyngitis, other respiratory
symptoms (N=89,409)
2. Contraceptive management
(N=52, 852)
3. Physicals (N=21,319)
4. STI screenings (N=19,899)
5. Injuries (all categories)
6. General symptoms (e.g. fatigue,
sleep disorders, fever)
7. Urinary symptoms including UTI
8. Digestive system symptoms
(nausea, vomiting, diarrhea, GERD)
9. Joint pain
10. Menstrual & other gynecologic
disorders
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Back & other musculoskeletal
Anxiety
Ear disorders
Depression
Viral infections
Contact dermatitis & eczema
Conjunctivitis
Vaginitis and vulvovaginitis
Neurological disorders
Abdominal pain
* (excludes vaccines, allergy shots, administrative visits, TB screening)
13
Epidemiology
Academic Year 2011-2012
(n= 289,299 individuals)
Most common categories of patients*
1.
URI, pharyngitis, other respiratory
symptoms (N=89,409)
2. Contraceptive management
(N=52, 852)
3. Physicals (N=21,319)
4. STI screenings (N=19,899)
5. Injuries (all categories)
6. General symptoms (e.g. fatigue,
sleep disorders, fever)
7. Urinary symptoms including UTI
8. Digestive system symptoms
(nausea, vomiting, diarrhea, GERD)
9. Joint pain
10. Menstrual & other gynecologic
disorders
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Back & other musculoskeletal
Anxiety
Ear disorders
Depression
Viral infections
Contact dermatitis & eczema
Conjunctivitis
Vaginitis and vulvovaginitis
Neurological disorders
Abdominal pain
* (excludes vaccines, allergy shots, administrative visits, TB screening)
14
Utilization of Resources
Visits per Patient by Diagnosis
2011/2012
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Eating Disorders
Adjustment Reaction
ADHD
Depression
Bipolar/psychosis
Anxiety Disorder
Alcohol
Diabetes
Hypertension
HPV
5.37
3.44
3.37
3.36
3.25
3.02
2.89
2.27
2.01
1.79
11)
12)
13)
14)
15)
16)
17)
18)
19)
20)
Back Disorder
Drug abuse
Injury
Asthma
Respiratory Disorder
Contraceptive Mgmt
Menstrual Disorder
UTI
Ear Disorder
General Symptoms
1.75
1.51
1.50
1.46
1.42
1.40
1.32
1.29
1.21
1.19
15
Utilization of Resources
Visits per Patient by Diagnosis
2011/2012
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Eating Disorders
Adjustment Reaction
ADHD
Depression
Bipolar/psychosis
Anxiety Disorder
Alcohol
Diabetes
Hypertension
HPV
5.37
3.44
3.37
3.36
3.25
3.02
2.89
2.27
2.01
1.79
11)
12)
13)
14)
15)
16)
17)
18)
19)
20)
Back Disorder
Drug abuse
Injury
Asthma
Respiratory Disorder
Contraceptive Mgmt
Menstrual Disorder
UTI
Ear Disorder
General Symptoms
1.75
1.51
1.50
1.46
1.42
1.40
1.32
1.29
1.21
1.19
16
Mental Health Disorders
College Health
• August 2011-May 2012
– Total provider visits (excl. RN, vaccines, nutrition):
638,526
– Total mental health provider visits:
117,083 (18% all schools; 30% CC, 7.8% non-CC)
– Proportion of group seen for mental health visit:
• Male
• Female
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•
•
•
41,952 (12.8%)
75,086 (21.7%)
White
62,548 (14.8%)
Af. Am
5,108 (12.5%)
Asian
5,708 (10.7%)
Hispanic 3,994 (8.5 %)
17
Mental Health Disorders
Academic Term 2011/12
3.36
3.44
3.37
5.37
1.51
3.25
2.89
18
Cases per 10K Enrolled per Academic Year 2011/12
Gender (all male/females differences significant at p<.05)
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Cases per 10K Enrolled per Academic Year 2011/12
Ethnicity (*p<0.05 compared to white)
*
*
*
*
*
*
*
**
**
*
**
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Cases per 10K Enrolled per Academic Year 2011/12
Counseling vs. Non-counseling (*p<0.05)
*
*
*
*
*
*
21
Cases per 10K Enrolled per Academic Year 2011/12
Age 18-24 years old (*p<0.05 compared to 18-19)
*
*
*
*
*
*
*
*
**
*
*
22
Mental Health Disorders
CHSN
• Seven disorders lead the list of visits per
patient per year, an eighth in top twenty.
• Alcohol disorders low (co-morbidity).
• Demographic groups have varying
prevalence-age, gender, ethnicity
(utilization or other factors).
• Health programs with no counseling
services see significant proportions of
mental health disorders.
23
Mental Health Disorders
CHSN
• Mental health disorders comprise 18% of all
visits to college health services (30 % vs.
7.8% if data is integrated).
• 34% cases (depression, eating disorders,
bipolar/psychosis) are serious disorders at
risk of self-harm or suicide.
• Case rates permit calculation of potential
clinical demand for services on campuses
and benchmarking with other schools.
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STI’s association with mental health
disorders.
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STI’s associated with mental health
disorders.
• Adolescents with certain mental health
disorders have an increased rate of STI’s
due to high risk behaviors.
• Impact of STI’s on mental health is less well
understood.
26
Is Human Papillomavirus (HPV)
diagnosis associated with increased
risk of having a mental health
diagnosis?
DATA SOURCE
• College Health Surveillance Network
• Data from Jan. 1, 2011 thru March 31, 2013
• 532,059 students used Student Health
Services during those 27 months
Diagnostic Definitions
• HPV: 9,608 patients with ICD9 codes for
– HPV
– Abnormal Pap Smear
– Viral warts
• Mental Health: 41,476 patients with ICD9 codes for
– Unipolar depression
– Adjustment reaction disorders
– Anxiety disorders
• Comparison group: 89,367 patients with ICD9 codes for
– Conjunctivitis
– Ear disorders
– Routine & required physicals
How to compute risk?
• Simple Chi Square: Odds Ratio for a two-bytwo table
• But that does not take into account different
lengths of time AT RISK
• And it does not control for demographic
differences
• For that we need a statistical technique called
Cox regression survival analysis
Relative Risk* with 95% C.I. of a Mental Health
Diagnosis following an HPV Diagnosis compared to
Three Other Diagnoses (n=90,192)
*Controlling for age, gender, region
31
Demographic Variables
Risk of mental health diagnosis after HPV is increased by:
• Female gender: 1.4 to 1.6 times greater
• Age over 21:
1.6 to 2 times greater
• School in West: 1.3 to 1.6 times greater
• Relative risk for Female, over 21, in the West, with HPV
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3 months:
6 months:
9 months:
12 months:
27 months:
4.54
3.44
2.9
2.61
2.27
(3.03, 6.78)
(2.3, 5.15)
(1.94, 4.33)
(1.75, 3.9)
(1.52, 3.4)
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Conclusion: Over 26 months, controlling for age,
gender & race, compared to 3 other diagnoses.
• HPV Diagnosis
– Increases odds of having diagnosis of anxiety, depression
or an adjustment disorder by 1.5 to 3 times.
– Women over age 21, attending school in West have
much greater odds.
• What other medical conditions associated
with development of mental health
disorders?
• One example of the importance of
collaborative care models for campuses.
Public Portal
http://www.collegehealthsurveillancenetwork.org/
Home | Data | Flu | Pertussis | NSNI
Welcome to the College Health Surveillance Network
The information presented here, abstracted from the College Health Surveillance Network (CHSN), provides a current glimpse into
the health concerns of students attending 4-year universities in the United States. CHSN, a project supported by the CDC and the
University of Virginia, provides the first national database specific to the epidemiologic trends and health service utilization for
college students. To view an overview with CHSN's
34
ACHA College Student
Mortality Rates
35
ACHA College Student
Mortality Rates
• No published study of college student mortality
rates among multiple institutions since 1939.
• No existing data regarding leading causes of
mortality among 19 million college students.
• Student deaths uncommon, tragic, newsworthy.
• NIAAA: 1700-1900 deaths per year alcohol.
• ACHA conducted a survey of 1154 institutions
regarding deaths Aug 1, 2009-May 31, 2010.
• Sources of death information: dean of students, student
health/counseling services, campus security, registrar, central
administration, public affairs.
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Results
• Sample of 157 schools and 1.361M students
18-24 year olds students (academic term
09/10).
• Sample has similar gender and ethnicity
characteristics of national population of 18-24
year old college students in four year
institutions.
Ref: Turner, Leno, Keller. Causes of Mortality Among American College Students:
A Pilot Study. J. of College Student Psychotherapy. 2013. 27(1):31-42 .
37
Summary of Mortality Rates
18-24 years old
4-Year institutions
Leading causes
– Vehicular injury
• Alcohol related vehicular
• Non-alcohol related vehicular
– Non-vehicular injury
• Alcohol related
• Non-alcohol related
– Suicide
– Homicide
Rate /100K
95% CI
Predicted
6.88
(5.6-8.15)
29.21
14.1
3.37
3.51
(2.48-4.26)
(2.6-4.41)
3.88
(2.9-4.83)
1.49
2.39
(0.90-2.09)
(1.64-3.13)
6.18
0.53
(4.97-7.38) 7.0, 11.72
(0.18-0.88) 0.32, 15.78
14.71
4.9
Ref: Turner, Leno, Keller. Causes of Mortality Among American College Students:
A Pilot Study. J. of College Student Psychotherapy. 2013. 27(1):31-42.
38
Summary of Mortality Rates
18-24 years old
4-Year institutions
Leading causes
– Vehicular injury
• Alcohol related vehicular
• Non-alcohol related vehicular
– Non-vehicular injury
• Alcohol related
• Non-alcohol related
– Suicide
– Homicide
Rate /100K
95% CI
Predicted
6.88
(5.6-8.15)
29.21
14.1
3.37
3.51
(2.48-4.26)
(2.6-4.41)
3.88
(2.9-4.83)
1.49
2.39
(0.90-2.09)
(1.64-3.13)
6.18
0.53
(4.97-7.38) 7.0, 11.72
(0.18-0.88) 0.32, 15.78
14.71
4.9
Ref: Turner, Leno, Keller. Causes of Mortality Among American College Students:
A Pilot Study. J. of College Student Psychotherapy. 2013. 27(1):31-42.
39
Summary of Mortality Rates
18-24 years old
4-Year institutions
Leading causes
– Vehicular injury
• Alcohol related vehicular
• Non-alcohol related vehicular
– Non-vehicular injury
• Alcohol related
• Non-alcohol related
– Suicide
– Homicide
Rate /100K
95% CI
Predicted
6.88
(5.6-8.15)
29.21
14.1
3.37
3.51
(2.48-4.26)
(2.6-4.41)
3.88
(2.9-4.83)
1.49
2.39
(0.90-2.09)
(1.64-3.13)
6.18
0.53
(4.97-7.38) 7.0, 11.72
(0.18-0.88) 0.32, 15.78
14.71
4.9
Ref: Turner, Leno, Keller. Causes of Mortality Among American College Students:
A Pilot Study. J. of College Student Psychotherapy. 2013. 27(1):31-42.
40
Campus Protective Effect
• Suicide 47% lower than same aged general population
(no change in 30+ years).
– Can we do better?
• Alcohol related deaths 60-76% lower than same-aged general
population and those repeatedly predicted for college
students by NIAAA.
– What are we doing right?
– Morbidity still a critical public health issue.
• Homicide 97% lower than predicted rate for general
population.
– What are we doing right?
41
Mental Health Disorders
Common and Critically Important
• Despite highly prevalent mental health disorders
– Student mortality rates due to alcohol, suicide, and homicide are
lower than same-aged non-college peers.
•
•
•
•
Effective identification and management.
Effective education for substance use and help-seeking behavior.
Less driving on residential campuses.
Campus security and gun restrictions.
– Opportunity to refocus attention on suicide prevention.
– The gun control debate might focus on campus successes.
• Many students enjoy ready access to a wide range of services
on campuses.
– Resource intensive. Better management of mental health
impacts other services.
– Making a huge difference but can we keep up with demand??
– Robust utilization but varies by demographic group.
• Analyzing patterns affords opportunities to develop outreach.
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Thank you
Questions
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