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College Psychiatry as Public Health PsychiatryClifford B. Reifler MD , Myron B. Liptzin MD & J. Thomas Fox MDPublished online: 06 Aug 2010.

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College Psychiatry as PublicHealth Psychiatry

Clifford B. Reifler, MD; Myron B. Liptzin, MD; J. Thomas Fox, MD

Abstract. This ten-year survey of the use of student mentalhealth services offered by the University of North Carolina sug-gests that increased usage over time has been due to greater avail-ability of staff and a broadening of services offered rather than toan increase of the prevalence of mental illness among the studentbody. The authors believe that college psychiatry, as one of theearliest examples of the provision of mental health services to acommunity, can be used as a model for other aspects of publichealth psychiatry.

ublic health is the scientific diagnosis and treatmentof the community.22 The community, not just theindividual, is the patient. Public health psychiatry is

concerned with the scientific diagnosis and treatment of themental health status and needs of the community. As intreatment of an individual, the treatment of the communityshould be based upon knowledge of the nature and distrib-ution of the illness, upon understanding of the assets andliabilities of the patient, and upon evaluation of the efficacyof the intended treatment. It is our purpose to look at col-lege psychiatry as one of the earliest examples of the treat-ment of a community and to begin to identify ways in whichour therapeutics can move from a theoretical basis to onemore related to specific knowledge and understanding ofthe patient, the illness, and the treatment.

From the time of the first mental health program in a stu-dent health service at Princeton in 1910,29 college psychia-try has been focused as much upon the treatment of thecommunity as upon those few individuals who have devel-oped psychiatric problems. As early and vocal proponentsof the possibility of primary prevention,11(p26–55) collegepsychiatrists have had continuing interest in the relation

P

between the individual patient and the collective patient,particularly those factors in the latter which have relevanceto the production of distress and disease in the former. Theinvolvement of the psychiatrist in aspects of the collegecommunity beyond his consultation room has been an earlyhallmark of campus psychiatry.16,19

Initially the focus was on the dissemination of generalmental hygiene principles and attitudes. In all these discus-sions it was assumed that the university community hadsome effect not only upon the intellectual development ofthe individual but also upon his emotional growth and mat-uration. It was felt that this influence could be modifiedtoward a more healthy development, and one of the firstpublished papers with this interest, “The Responsibilities ofthe Universities in Promoting Mental Hygiene,” was writtenby Macfie Campbell in 1919.10

According to Farnsworth,18 Smiley Blanton was workingwith students at the University of Wisconsin from 1914 to1924. In 1920 Karl Menninger developed a mental hygienecourse and a counseling system at Washburn College, Tope-ka, and Harry Kerns was appointed to what was perhaps thefirst full-time position as campus psychiatrist in the U.S.Military Academy at West Point. Dartmouth (in 1921), Vas-sar (in 1923), and Yale (in 1925) soon developed psychiatricprograms in their health services.19 By 1927 when the Com-monwealth Fund sponsored a meeting of “college mentalhygienists,” 21 schools were represented, including threepreparatory schools.24

The early publications in the area focused on the particu-lar problems of this age group and their amelioration andprevention by appropriate mental hygiene practices.Descriptions of the social setting, the academic stresses,and the institutional demands were quite frequent, as werediscussions of appropriate mental health program policiesand operating philosophies.

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Copyright © 1967 American Psychiatric Association. Reprintedfrom Am J Psychiatry. 1967;124:5, with permission.

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In 1925 in one of the earliest papers Smiley Blanton, thenat Minnesota, cited a study of 1,000 unselected juniors andseniors of whom “fully half had emotional difficulties whileten percent had emotional maladjustments serious enoughto warp their lives.”8 This is probably one of the first quan-titative estimates of the prevalence of psychiatric disordersamong college students based upon actual study, and tenpercent has subsequently been used as a convenient figurein many discussions of college mental health needs by suchwriters as Angell3 and Farnsworth,17 and by the Group forthe Advancement of Psychiatry.19

Unfortunately there has been only limited corroborationof these figures. Most of the succeeding papers, and therehave been many, are primarily descriptions of operatingpolicy and/or philosophy with descriptions of the particularfeatures of their programs and problems, often illustrated bycase examples and usually pointing at areas where furtherwork, both therapeutic and investigative, was necessary.While these papers have provided many unanswered ques-tions and often gave valuable clinical standards and operat-ing guidelines, there has been a notable lack of informationupon which to base valid comparisons. A number of thesereports do describe some characteristics of the patient pop-ulation. When this is done without reference to the base“population at risk,” this type of data is more descriptive ofthe problems the clinic faces than of the problems the stu-dent body faces.

The epidemiological study of Smith, Hansell, and Eng-lish32 on a small church-affiliated metropolitan liberal artscollege can serve as a model for the kind of work that needsto be done at other institutions. The finding of a prevalenceof “clinical disturbance” among 12 percent of their malefreshman sample is quite consistent with previous expecta-tions and with several other epidemiological surveysreviewed by Segal.31

While some information about clinic usage, such as diag-nosis or number of visits, can only be referred to the patientpopulation, other data such as age, living arrangements,group membership, sex, and academic and marital statushave already referents in the general student population.(Figures are usually available from the appropriate univer-sity office.) In the absence of some standardization in termsof percent of student population or rate per thousand, thedata are more useful for comparisons of operating clinicsthan for comparisons between different schools and studentbodies or for aid in identifying some of the factors influ-encing illness.

In some reports sufficient data are given to allow sec-ondary computation of rates for specific groups and in a fewinstances the conclusions drawn are explicitly derived fromvalues standardized to specific populations. In this paper wewill report a portion of such standardized data obtainedfrom a retrospective analysis of the last ten years of experi-ence at the Student Health Service at the University ofNorth Carolina.

Where appropriate, data will be compared to the infor-mation available in the literature about student health.

These data from the literature represent reports from col-leges and universities differing in size, sex distribution, geo-graphic representation, and source of support, and spanninga 30-year period. Consistent findings can be assumed torepresent problems of the college student group. Wherethere are divergences it would seem that some factor or fac-tors in the social system of the individual institution shouldhave first priority for study.

THE SETTING

The University of North Carolina is the oldest state-sup-ported university in the county, having first received stu-dents in 1795. It is a large coeducational liberal arts institu-tion located in Chapel Hill. The total population of thetown, including university students, has grown fromapproximately 19,000 in 1956 to approximately 30,000 per-sons in 1965. During the ten-year period under study, thestudent body population increased from about 7,000 stu-dents to 12,500 students, and of the total student population,consistently about one-fourth have been in the graduate orpost-baccalaureate professional schools. Male studentshave always outnumbered female students, but the over-allmale:female ration has gradually declined from 4.7:1 in1956 to 3.3:1 in 1965. Because the university accepts manyfemale transfer students after they have completed twoyears of college elsewhere, there are proportionally fewerfemale students in the freshman and sophomore classes (forinstance, in 1964 the ratio was 7.4:1) than in the junior andsenior classes (in 1964 the ration was 2.3:1).

The director of the Student Health Service has theresponsibility for student health at the university. He has astaff of seven full-time physicians and a well-equipped 65-bed infirmary which is attached to a wing of North Caroli-na Memorial Hospital, the primary teaching hospital for theUniversity of North Carolina School of Medicine.

The psychiatric section of the Student Health Service isstaffed by members of the faculty in the Department of Psy-chiatry who devote the major portion of their clinical timeto the area of student health. In addition, second- and third-year psychiatric residents spend varying amount of timethere as a required part of their training and are supervisedby the staff psychiatrists. Prior to 1962 residents providedover 90 percent of the direct clinical services. All profes-sional services of the infirmary, including psychiatric con-sultation, are provided without additional charge as part ofthe student’s health fee.

Except for a service which provides solely vocational andeducational testing and counseling, the student health psy-chiatry section represents the only formal psychologicalcounseling service available to students. Students may bereferred by others, such as physicians, deans, chaplains, res-idence hall advisors, or teachers, but approximately three-fourths come without such formal referral. Students withprevious psychiatric history who are applying for admissionto the university may be seen for a clearance interview inorder to assess the degree of their current adjustment and toacquaint them with the available facilities.

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Psychiatric treatment in the infirmary is primarily char-acterized by a “conservation” approach directed towardcrises intervention and treatment for the acute problem.Consequently, students are usually seen for relatively fewvisits and the psychiatrists generally limit themselves toevaluation, immediate therapeutic intervention, and referralwhen necessary. If longer-term out-patient therapy is indi-cated, the patient is referred to either the staff or privateclinics of the North Carolina Memorial Hospital Depart-ment of Psychiatry. If hospitalization other than a brief stayin the university infirmary is indicated, the inpatient serviceof North Carolina Memorial Hospital is available, as areseveral other nearby state and private hospitals.

METHOD

All patient records since 1952 were reviewed for suchdemographic information as age, sex, race, citizenship, andacademic and marital status and for clinical informationincluding diagnosis, number of visits, and recommendationat last visit. When no diagnosis was explicitly made thechart was reviewed by the authors. If appropriate data wereavailable, the patient was classified by one of the majordiagnostic categories (psychosis, neurosis, character disor-der, or transient situational reaction) or it was determinedthat the contact was solely for screening or other adminis-trative purposes.

A final category of “unclear, unclassifiable, or unknown”was used only when the information in the record was miss-ing or of such brevity that no intelligent guess could bemade. This was the case in such a large proportion of therecords prior to 1956 that only the data since that time areconsidered to have any validity, and analysis was restrictedto patients seen since 1956.

Data from the clinic population were then related to thecomparable data available on the entire UNC student popu-lation for the fall semester of the corresponding academicyear (June through May).

Patients were categorized by college class rather than agebecause of the close correlation between class and age forthe undergraduate population. Post-baccalaureate students,however, have a much greater age range—from 21 to over50. Nationality is not reported here because of the relativeinfrequency of foreign students (less than two percent of thestudent body), who will be the subjects of a later study. Racewas not studied because no university statistics are availableas to the categorization of the student body by race.

Consistently throughout this paper we will use the con-vention of stating proportions in terms of “rate per 1,000students” when the reference population is the student bodyand in terms of “percent” when we refer back to the clinicpopulation.

LIMITATIONS OF THE DATA

There is much discussion about the applicability of thetraditional psychiatric nosology to subadult cases. This isnot a new problem. In 1923 F. E. Williams commented thatthe student “cannot be classified in the usual sense, and

there would be no advantage in so doing. The psychiatrist isfaced with an acute situation in the emotional life of hispatient. The question before the psychiatrist is not what ishe, but rather why is he.”36

In 1942 Anthonisen,4 describing the diagnostic categoriesseen among the student population at Wellesley College, cat-egorized over 50 percent of her patients as “concern states.”These are described as a situation in which “some specifictopic has become a focus for uncomfortable preoccupation”and would probably correspond to the diagnosis of “transientsituational reaction.” Monks and Heath23 at Harvard Univer-sity felt that the usual accepted classifications of disease andinjury were inadequate in dealing with a college population.In 1954 they devised a whole new system of classification ofacademic, social, and personal problems for use in a collegestudent health service. These, too, would probably best cor-respond to “transient situational reactions” if one decided, aswe did, to categorize diagnostically wherever possible.

Although the APA Diagnostic and Statistical Manual2 isfar from ideal in categorizing psychiatric disorders amongcollege students, it was used in this study as the commonunifying principle behind the diagnoses of the many differ-ent psychiatrists, both staff and residents, who saw studentsin the health service. We felt that by utilizing the broad cat-egories contained in this manual the differences of empha-sis inevitable in dealing with the diagnostic criteria of alarge number of psychiatrists would be minimized and thereliability of the categorization increased.

Another limitation is the fact that one patient may appearin the statistics more than once if he was evaluated by thepsychiatrists during different years of the study. Except forpatients diagnosed as having psychoses or those seen forscreening interviews, this represents a relatively small per-centage of the clinic population and may correspond to theindeterminate number of individuals in the population atrisk who are counted in successive years. It is for this rea-son that all data are considered by “year” as the unit of com-parison and averages are of yearly rates.

The population-at-risk figure was taken to be the numberof students enrolled for the fall semester. This numberdeclined gradually throughout the school year and is nottherefore an accurate representation but rather a maximumfor the academic year. Additionally, the number of “summersession only” students is not taken into account in the basepopulation figures. While there is no way of assessing thedegree to which these factors alter our figures, they appearto operate in opposing directions and tend to partially com-pensate for each other. It is felt that the degree of error intro-duced by these factors is minimal for our purposes.

The possibility of the use of additional psychiatricresources other than the health service is another indetermi-nate factor in our analysis. Presumably some students doobtain private psychiatric treatment or are seen in the out-patient department of a neighboring institution withoutbeing evaluated at the health service. Although this is prob-ably increasing over the years as the availability of privatepsychiatrists in the community has increased, informal

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communication with a number of the local psychiatrists hasindicated this figure is still extremely low.

RESULTS

The number of patients being seen has regularlyincreased faster than the growth of the university (Table 1).The yearly usage of our facility has grown from 18 per1,000 students in 1956 to over 44 per 1,000 in 1965. This isan average increase of 9.73 percent per year (95 percentconfidence limit is ±3.22 percent). The particularly largeincrease in the last two years relates in part to the increaseduse of our service by the university administration forscreening of presumably high-risk groups or for evaluationof a particular student whose behavior has brought him topublic attention and concern. This now accounts for 18 per-cent of our patients, whereas in the three previous years itwas only nine percent (an increase of approximately fourpatients per 1,000 students).

This large increase over a decade raises the inevitablequestion of whether the actual prevalence of psychiatric ill-ness is increasing in the student population.

Comparisons over a 30-year period of the published stu-dent mental health service usage rates (mostly midwesternand northeastern schools) show range of usage from 15 per1,000 to 99 per 1,000 (Table 2). It would be a serious error,however, to confuse this usage rate with an illness rate.

Not all students who present themselves as patients arediagnosed as sick and, of course, not all nonpatients are

healthy. Thus we are unable to say from these figures muchabout true incidence or prevalence of psychiatric illness. Wefeel, however, that at UNC the vast majority of psychoticreactions are brought to our attention either by the studenthimself or by the university administration. The more acuteor more severe the illness, the greater is the probability ofthe individual’s behavior bringing him to the eye of the pub-lic and to the psychiatrist for evaluation. We would expectthat this holds true at other campuses where a psychiatrist isavailable.

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320 JOURNAL OF AMERICAN COLLEGE HEALTH

TABLE 1. University of North Carolina StudentMental Health Service Usage by Year

Rate perUNC Students 1,000

Year enrollment seen students

1956 6,971 125 17.91957 7,038 147 20.91958 7,513 167 22.21959 7,959 152 19.11960 8,592 210 24.41961 9,082 230 25.31962 9,604 270 28.11963 10,887 308 28.31964 11,303 466 41.21965 12,419 550 44.3

TABLE 2. Mental Health Facility Usage and Rate of Psychosis at Selected Colleges

Approximate Period PsychoticCollege Reference Years enrollment reported Usage rate† patients‡

Michigan 27 1930–34 11,600 four years 50 1.328 1930–37 12,200 seven years 77 1.8

Wellesley 4 1934–40 1,500 six years 84 2.2Harvard 34 1935–36 8,000 first year 16 4

14 1961 11,000 ? 2.51 1963–64 13,000 one year 78

New Hampshire 13 1944–45 1,700 one year 70 3Kansas 35 1951–52 one year 25 3

35 1959–60 9,400 one year 36Vasar 25 1951–59 1,450 eight years 86 ?99 colleges 20 1953 varies one Year 52 ?Northwestern 12 1955 7,000 unspecified 86 1“Midwestern coed” 26 1955–60 2,200 five years 20 2Clark 6 1953–63 2,250 eight years 71 ?Cornell 9 1959–60 10,600 one year 59 ?Yale 5 1960–66 8,500 five years 99 2British Columbia 30 1962–63 13,600 first year 15 2.1Massachusetts 1 1962–64 8,000 two years 63 2.6Indiana 15 1964–66 22,400 two years 34 2.7Over-all 1930–66 1,700–22,400 one–eight years 15–99 1.0–4.0

median 63 median 2.2North Carolina 1956–65 7,000–12,500 ten years 18–44 1.86 ± 0.14

†Per 1,000 students per year.‡Calculated by CBR.

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A comparison of reported rates of psychotic diagnosesappears in the last column of Table 2. It would appear thatalmost any college or university at any time can expect, ashas been previously estimated by Farnsworth,17 that abouttwo students in every 1,000 will have a psychotic illness eachyear. The implications for universities and colleges in termsof planning, at least in regard to the most severe illnesses, areclear. This is not just a matter of writing the individuals off,however; a preliminary follow-up of from two to eight yearsof the 170 students at UNC who comprise our average rate ofpsychotic reactions of almost two per 1,000 per year showsthat at the time of investigation at least one-third had receivedtheir degree or were currently enrolled and making satisfac-tory progress toward it. This proportion is even less then thefigure of 50 percent in studies summarized by Farnsworth.18

Another piece of evidence against the idea that the increas-es usage is a measure of general increase in morbidity is thatif this were true the percentage of serious illness in the clinicpopulation would tend to remain constant. Analysis of theproportion of patients in each diagnostic category (Figure 1)demonstrates a trend toward less serious diagnoses.

Perhaps the best single index of degree of illness, however,cutting across diagnostic categories, is the impression of theinterviewer as to the necessity of further treatment. Recom-mendations for referral, while obviously representing a con-tinuum of opinion, fall into three general categories: hospital-ization, outpatient treatment, and no further treatment. How

these recommendations have changed over the decade is por-trayed in Figure 2. For clarity we have omitted the relativelyconstant yearly figure of approximately 17 percent of patientsfor whom the recommendation was unclear, unknown, orwho did not show up for further appointments.

While the absolute number in all categories has gone upas a function of the greater usage, an increasing percentageof the patients are being classified as “referral not indicat-ed.” This is primarily at the expense of the “outpatient treat-ment recommended” group. In contrast to the “hospitaliza-tion” group, where almost all the recommendations wereimmediately followed, no information is available as to theextent to which the OPD recommendation was implement-ed. As most of these recommendations were in the form ofreferrals to the university hospital psychiatric outpatientdepartment (both private and staff clinics), a follow-upstudy is feasible and planned.

Is the level of student mental illness greater now than itwas ten years ago? This cannot be answered from our data,but they suggest that the common experience of increasedusage over time is due not so much to any increased mor-bidity as it is to greater availability of staff and a more freelyutilized consultation for lesser conditions, perhaps at a timewhen interventions are more effective and less costly.18,19

In keeping with the findings of both student health clin-ics and general clinics,9,21 our female population used thepsychiatric facilities consistently more than did the malestudents (Figure 3). Although the rate of increased usageover the ten-year period was the same for both sexes, thefemale usage rate significantly exceeded the male usagerate by a constant proportion of approximately one and one-third to one (p < .01).

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Neurotic ReactionsPersonality DisordersPsychotic Reactions

504540353025201510

56

Perc

ent o

f Pa

tient

s

FIGURE 1. Diagnostic category by year. Amer. J.Psychiat. 124: 5, November 1967.

50

57 58 59 60 61 62 63 64 65

Situational ReactionsScreening and AdministrativeUnclear or unknown

3025201510

56

50

57 58 59 60 61 62 63 64 65

Hosp.OP RxNo further Rx indicated

50

40

30

20

10

1956

Perc

ent o

f Pa

tient

s

FIGURE 2. Termination recommendations exp-ressed as percentage of clinic population, byyear.

57 58 59 60 61 62 63 64 65

60

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Year

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Contrary to the experience of almost all other collegehealth services,1,7,9,13,21,27,33 we have found a consistentlylower usage of our facility by freshmen and sophomores (p< .01) (Figure 4). Other health services have explained theiroverrepresentation of these younger students in terms ofimmaturity, lack of experience, and difficulty in adjusting tocollege life. Undoubtedly these terms characterize ouryounger students as well, and it is necessary to go beyondthe characteristics of the age group and look at the charac-teristics of the particular university social system. Does thisuniversity offer special support to its younger students? Arethere factors in the social system which act differentiallyupon students in their first years?

One such factor acting differentially upon students in thefirst two years of college is the academic structure. Thisuniversity groups these two years together in an undifferen-tiated core curriculum program prior to the student’s choos-ing a departmental major in his junior year. One of the char-acteristics of this program is the provision of a constant andgenerally available faculty advisor who is concerned withand knowledgeable about the academic behavior of the stu-dent. There is even an early warning network whereby theadvisor receives reports from the several instructors the stu-dent may have and discusses with the student his over-allprogress. There are many complaints about this system, butwe believe it gives the student a constant name and personwith whom to relate—something which is not always avail-able in the last two years.

Another possible explanation is the strong advisor pro-gram in the residence halls in which the majority of fresh-men and sophomores live. The University of North Carolinacurrently requires all undergraduate women to live in uni-versity-controlled housing—either residence halls or sorori-ties. This is not true for men, who after the freshman year areallowed to move out of the residence halls if they wish.Approximately two-thirds of the sophomore men remain in

the residence halls, whereas about the same proportion ofmale upper classmen elect to obtain other lodgings.

If living in the residence halls has some relationship topsychiatric service usage, one would expect that theincreased usage of our facilities by upper classmen wouldbe a primarily male phenomenon. Analysis of the usagerates by class and sex (Figure 5) strengthens this line ofthought. Although the rate of usage by male upperclassmen

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322 JOURNAL OF AMERICAN COLLEGE HEALTH

MalesFemales

50

40

30

20

10

1956

Rat

e/10

00

FIGURE 3. Student mental health service usageby year and sex.

57 58 59 60 61 62 63 64 65

60

Year

Freshmen and SophomoresJuniors and SeniorsGraduate Students

50

1956R

ate/

1000

FIGURE 4. Student mental health service usage byacademic class and year.

57 58 59 60 61 62 63 64 65

45

40

35

30

25

20

15

10

5

Year50

1956

Rat

e/10

00

57 58 59 60 61 62 63 64 65

45

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Year

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is significantly higher than that by male freshmen andsophomores (p < .01), there is no difference between thecorresponding groups of female students.

DISCUSSION

It appears that over the years the limiting factor on studentusage of health service psychiatric facilities has been relatedmore to availability of staff than to exhaustion of the numberof students needing consultation. Usage rates remain consid-erably lower than estimates of prevalence in all but the oldestand most active university mental health facilities. Our owndata over a ten-year period reflect the increasing usage asmore services are made available. This increased usage appar-ently represents an increasing representation of less severeproblems, as it seems that the yearly rate for psychotic illnessamong college students has remarkable stability.

While there is no indication that morbidity is increasingamong college students, differential usage rates among

various categories of students give some clues to factors inthe college which influence the state of student mentalhealth. It is our supposition from the data presented thatfactors relating to community organization at both acade-mic and social levels influence the mental health of thestudent and his usage of available facilities. Studies arecurrently being undertaken to assess the effects of resi-dence hall living and the characteristics of those who leaveit as well as those who stay.

Our preliminary explorations have demonstrated a high-er psychiatric usage rate among those students living offcampus. This is consistent with our supposition from thedata presented here that residence hall living provided a“protection” for out younger students. Three years ago, infact, we found such an unusually high proportion of seriousillness among freshmen males who lived off campus thatthe administration decided to requite all freshmen to live inthe residence halls. Since that time we have continued to

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Freshmen and SophomoresJuniors and Seniors

50

1956

Rat

e/10

00

FIGURE 5. Student mental health service usage among undergraduates by academic class and sex.

57 58 59 60 61 62 63 64 65

45

40

35

30

25

20

15

10

5

Year

55

60

65

70

75

80

1956 57 58 59 60 61 62 63 64 65Year

Male Female

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work closely with the residential advisors and the offices ofthe deans of men and of women in order to provide mentalhealth consultation of the several types described byCaplan.11(p212–231)

We obviously believe that this “protection” is useful toour younger students. Whether it has similar utility for ourolder students is open to question. We are, after all, dealingwith an age group which is not static but rather one whosemembers are undergoing considerable change and matura-tion. Conditions appropriate to allow a 17-year-old studentto develop his capacities to their fullest potential may beuseless or indeed detrimental to that same student three orfour years later. Conversely, situations which may be stress-ful to one group may be irrelevant to another. Our interest isaimed at the identification and evaluation of such differen-tial vulnerability in the college population.

We have focused on several small areas which we feel areimportant, not so much substantively but in relation todeveloping a model for the scientific diagnosis and treat-ment of the community—in this case a university. Some ofthe advantages of utilizing a college community for thesepurposes are: its known population, its relative circumscrip-tion geographically, and the relative homogeneity of suc-cessive classes entering into the system. The latter is partic-ularly important in that it allows the effects of interventionsto be evaluated within a relatively short time, complete gen-erations passing within four-year periods.

The possible implications of successful interventions inthis critical portion of our population are exceeded in noother group. The establishment of base-line data and ofexpected frequencies allows comparisons to be made andfactors isolated that may serve to delineate high-risk groupsor situations. The identification and further study of suchfactors allow a rational approach toward community treat-ment with a principal emphasis on primary prevention.

Communities, like men, are in some ways like all others,in some ways like some others, and in some ways like noothers. College communities, despite the characteristicswhich make them unique, also have characteristics fromwhich generalizations can be made. As college psychiatrybegins a second decade at UNC and a second half-centurynationally, it is essential that the diagnosis and treatment ofcommunity mental health be as soundly based upon scien-tific data and principle as is our diagnosis of individualhealth states. The college health service can in this areaserve as a model and a laboratory for many aspects of pub-lic health psychiatry.

NOTE

Read at the 123rd annual meeting of the American PsychiatricAssociation, Detroit, Mich., May 8–12, 1967. The authors are withthe Department of Psychiatry, School of Medicine, and with theStudent Health Service, University of North Carolina, Chapel Hill,N. C. 27514. This paper is adapted from a dissertation submittedby the senior author to the faculty of the University of North Car-olina in partial fulfillment of the degree of Master of Public Healthin the Department of Epidemiology of the School of PublicHealth.

ACKNOWLEDGMENT

The authors wish to thank Mr. Michael Hogan for his assistancein the statistical analysis.

REFERENCES

1. Allen, A. D., and Janowitz, J. F.: A Study of the Outcome ofPsychotherapy in a University Health Service, J. Amer. Coll.Health Ass. 13:361–378, 1965.

2. American Psychiatric Association: Diagnostic and Statisti-cal Manual: Mental Disorders. Washington, D. C.: American Psy-chiatric Association, 1952.

3. Angell, J. R.: Mental Hygiene in Colleges and Universities,Ment. Hyg. 17:543–547, 1933.

4. Anthonisen, M. R.: Practice of a College Psychiatrist, Dis.Nerv. Syst. 3:175–184, 1942.

5. Arnstein, R. L.: personal communication.6. Baker, R. W.: Incidence of Psychological Disturbance in

College Students, J. Amer. Coll. Health Ass. 13: 532–540, 1964.7. Baker, R. W., and Nidoff, L. J.: Pattern of Occurrence of

Psychological Disturbance in College Students as a Function ofYear Level, J. Clin. Psychol. 20:530–531, 1964.

8. Blanton, S.: A Mental Hygiene Program for Colleges, Ment.Hyg. 9:478–488, 1925.

9. Braaten, L. J., and Darling, C. D.: Mental Health Services inCollege: Some Statistical Analyses, Student Med. 10:235–253, 1961.

10. Campbell, C. M.: The Responsibilities of the Universities inPromoting Mental Hygiene, Ment. Hyg. 3:199–209, 1919.

11. Caplan, G.: Principles of Preventive Psychiatry. New York:Basic Books, 1964.

12. Carlson, H. B.: Psychiatric Casualties in College. Educ.Admin. & Supervision 41:270–276, 1955.

13. Carroll, H. A., and Jones, H. M.: Adjustment Problems ofCollege Students, School and Society 59:270–272, 1944.

14. Coon, G. P.: “Acute Psychosis, Depression, and Elation,” inBlaine, B. D., Jr., and McArthur, C. C., eds.: Emotional Problemsof the Student. New York: Appleton-Century-Crofts, 1961.

15. Coons, F.: Annual Report, Psychiatric Division of StudentHealth Service, Indiana University, Bloomington, Indiana, June1966.

16. Farnsworth, D. L.: Psychiatry and Higher Education, Prac-tical Applications of Psychiatry in a College Setting, Amer. J. Psy-chiat. 109:266–271, 1952.

17. Farnsworth, D. L.: Social and Emotional Development ofStudents in College and University, Part 1, Ment. Hyg.43:358–367, 1959.

18. Farnsworth, D. L.: Psychiatry, Education, and the YoungAdult. Springfield, Ill.: Charles C Thomas, 1966.

19. Group for the Advancement of Psychiatry: Report #17,“The Role of Psychiatrists in Colleges and Universities.” NewYork: Group for the Advancement of Psychiatry, 1957.

20. Gundle, S., and Kraft, A.: Mental Health Programs inAmerican Colleges and Universities, Bull. Menninger Clin.20:57–69, 1956.

21. Landfield, A. W., Nawas, M. M., and O’Donovan, D.: AQuarter of a Century in the Life of a University Mental HygieneClinic, J. Amer. Coll. Health Ass. 12:202–207, 1963.

22. McGavran, E. G.: Scientific Practice of Public Health,Texas J. Med. 54:776–779, 1958.

23. Monks, J. P., and Heath, C. W.: A Classification of Acade-mic, Social, and Personal Problems in a College Student HealthDepartment, Student Med. 2:44–62, 1954.

24. Morrison, A. W.: A Further Discussion of College MentalHygiene, Ment. Hyg. 12:41–54, 1928.

25. Nixon, R. E.: A Challenge for the College Mental HealthService, Student Med. 8:340–343, 1959.

26. Peabody, G. A.: Campus Psychiatry, Curr. Psychiat. Ther.1:1–7, 1961.

REIFLER ET AL

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27. Raphael, T.: The Place and Possibilities of the MentalHygiene Approach on the College Level, Amer. J. Psychiat.92:855–873, 1936.

28. Raphael, T., and Gordon, M. A.: Psychoses Among CollegeStudents, Amer. J. Psychiat. 95:659–675, 1938.

29. Raycroft, J. E.: History and Development of Student HealthPrograms in Colleges and Universities, J. Lancet 61:375–381, 1941.

30. Schwarz, C. J.: A Psychiatric Service for University Stu-dents, Canad. Psychiat. Ass. J. 9:232–238, 1964.

31. Segal, B. E.: Epidemiology of Emotional DisturbanceAmong College Undergraduates: A Review and Analysis, J. Nerv.Ment. Dis. 143:348–362, 1966.

32. Smith, W. G., Hansell, N., and English, J. T.: PsychiatricDisorder in a College Population, Arch. Gen. Psychiat. 9:351–361,1963.

33. Stogdill, E. L.: A Survey of Case Records of a Student Psy-chological Consultation Service Over a Ten Year Period, Psychol.Exch. 4:129–133, 1936.

34. Tillotson, K. J.: Psychiatric Work in the Hygiene Depart-ment of Harvard University, New Eng. J. Med. 216:9–11, 1937.

35. Whittington, H. G.: Evaluation of a Treatment Program in aCollege Psychiatric Clinic, Compr. Psychiat. 2:329–377, 1961.

36. Williams, F. E.: Discussion of Kerns, H. N.: Cadet Prob-lems, Amer. J. Psychiat. 80:555–563, 1924.

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