Prevalence of Mental Health Conditions in a Cohort of 700,000

College Students

James C. Turner, MDAdrienne Keller, PhD

Department of Student Health and the National Social Norms Institute

University of Virginia

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Funding SourcesFunding SourcesUVa Department of Student HealthUVa Department of Student Health

• Federal:– CDC– National Institute on Alcohol Abuse and

Alcoholism– U.S. Department of Education

• State:

– Virginia Alcoholic Beverage Control Board– Virginia Department of Health

• UVA:– 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 – 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

• Salary 100% from UVa Student Health. No personal conflicts of interest.

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College Health Surveillance NetworkCollege Health Surveillance Network(CHSN)(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.

– 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

College Health Surveillance NetworkCollege Health Surveillance Network(CHSN)(CHSN)

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•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.

College Health Surveillance NetworkCollege Health Surveillance Network(CHSN)(CHSN)

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• 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:

– Northeast: 6– South: 8– Midwest: 4– West: 4

• Demographics similar to 2011 DOE data on Research Universities Very High.

College Health Surveillance NetworkCollege Health Surveillance Network(CHSN)(CHSN)

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Gender

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Student level

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Age

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Race and ethnicity

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EpidemiologyAcademic Year 2011-2012

(n=879,787 visits)Most common categories of visits*

1. URI, pharyngitis, other respiratory symptoms

2. Contraceptive management3. Anxiety4. Injuries (all categories)5. Depression6. General symptoms (e.g. fatigue,

sleep disorders, fever)7. STI screenings8. Joint pain9. Urinary symptoms including UTI10. Digestive system symptoms

(nausea, vomiting, diarrhea, GERD)

11. Follow-up care12. Back & other musculoskeletal13. Menstrual & other gynecologic

disorders14. Physicals15. Adjustment reaction16. ADHD & ADD17. Ear Disorders18. Viral infections19. Eating Disorders20. Vaginitis and vulvovaginitis

11* (excludes vaccines, allergy shots, administrative visits, TB screening)

EpidemiologyAcademic Year 2011-2012

(n=879,787 visits)Most common categories of visits*

1. URI, pharyngitis, other respiratory symptoms

2. Contraceptive management3. Anxiety4. Injuries (all categories)5. Depression6. General symptoms (e.g. fatigue,

sleep disorders, fever)7. STI screenings8. Joint pain9. Urinary symptoms including UTI10. Digestive system symptoms

(nausea, vomiting, diarrhea, GERD)

11. Follow-up care12. Back & other musculoskeletal13. Menstrual & other gynecologic

disorders14. Physicals15. Adjustment reaction16. ADHD & ADD17. Ear Disorders18. Viral infections19. Eating Disorders20. Vaginitis and vulvovaginitis

12* (excludes vaccines, allergy shots, administrative visits, TB screening)

EpidemiologyAcademic 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 UTI8. Digestive system symptoms

(nausea, vomiting, diarrhea, GERD)9. Joint pain10. Menstrual & other gynecologic

disorders

11. Back & other musculoskeletal12. Anxiety13. Ear disorders14. Depression15. Viral infections16. Contact dermatitis & eczema17. Conjunctivitis18. Vaginitis and vulvovaginitis19. Neurological disorders20. Abdominal pain

13* (excludes vaccines, allergy shots, administrative visits, TB screening)

EpidemiologyAcademic 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 UTI8. Digestive system symptoms

(nausea, vomiting, diarrhea, GERD)9. Joint pain10. Menstrual & other gynecologic

disorders

11. Back & other musculoskeletal12. Anxiety13. Ear disorders14. Depression15. Viral infections16. Contact dermatitis & eczema17. Conjunctivitis18. Vaginitis and vulvovaginitis19. Neurological disorders20. Abdominal pain

14* (excludes vaccines, allergy shots, administrative visits, TB screening)

Utilization of ResourcesVisits per Patient by Diagnosis

2011/2012

1) Eating Disorders 5.372) Adjustment Reaction 3.443) ADHD 3.374) Depression 3.365) Bipolar/psychosis 3.256) Anxiety Disorder 3.027) Alcohol 2.898) Diabetes 2.279) Hypertension 2.0110) HPV 1.79

11) Back Disorder 1.7512) Drug abuse 1.5113) Injury 1.5014) Asthma 1.4615) Respiratory Disorder 1.4216) Contraceptive Mgmt 1.4017) Menstrual Disorder 1.3218) UTI

1.2919) Ear Disorder 1.2120) General Symptoms 1.19

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Utilization of ResourcesVisits per Patient by Diagnosis

2011/2012

1) Eating Disorders 5.372) Adjustment Reaction 3.443) ADHD 3.374) Depression 3.365) Bipolar/psychosis 3.256) Anxiety Disorder 3.027) Alcohol 2.898) Diabetes 2.279) Hypertension 2.0110) HPV 1.79

11) Back Disorder 1.7512) Drug abuse 1.5113) Injury 1.5014) Asthma 1.4615) Respiratory Disorder 1.4216) Contraceptive Mgmt 1.4017) Menstrual Disorder 1.3218) UTI

1.2919) Ear Disorder 1.2120) General Symptoms 1.19

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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 41,952 (12.8%)• Female 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 %)

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Mental Health DisordersAcademic Term 2011/12

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3.373.44

3.36

5.37

1.51 3.25 2.89

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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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* *

*

*

*

***

** * **

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*

*

*

**

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Cases per 10K Enrolled per Academic Year 2011/12 Counseling vs. Non-counseling (*p<0.05)

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Cases per 10K Enrolled per Academic Year 2011/12 Age 18-24 years old (*p<0.05 compared to 18-19)

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*

*

**

* *

* *

*

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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.

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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.

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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-by-two 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)

31*Controlling for age, gender, region

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

– 3 months: 4.54 (3.03, 6.78)– 6 months: 3.44 (2.3, 5.15)– 9 months: 2.9 (1.94, 4.33)– 12 months: 2.61 (1.75, 3.9)– 27 months: 2.27 (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 NetworkThe 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

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ACHA College StudentACHA College StudentMortality RatesMortality Rates

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ACHA College StudentACHA College StudentMortality RatesMortality 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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ResultsResults

• 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 .

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Summary of Mortality RatesSummary of Mortality Rates18-24 years old 18-24 years old

4-Year institutions4-Year institutions

Leading causes Rate /100K 95% CI Predicted– Vehicular injury 6.88 (5.6-8.15) 29.21

• Alcohol related vehicular 3.37 (2.48-4.26) 14.1• Non-alcohol related vehicular 3.51 (2.6-4.41)

– Non-vehicular injury 3.88 (2.9-4.83) 14.71• Alcohol related 1.49 (0.90-2.09) 4.9 • Non-alcohol related 2.39 (1.64-3.13)

– Suicide 6.18 (4.97-7.38) 7.0, 11.72– Homicide 0.53 (0.18-0.88) 0.32, 15.78

Ref: Turner, Leno, Keller. Causes of Mortality Among American College Students: A Pilot Study. J. of College Student Psychotherapy. 2013. 27(1):31-42.

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Summary of Mortality RatesSummary of Mortality Rates18-24 years old 18-24 years old

4-Year institutions4-Year institutions

Leading causes Rate /100K 95% CI Predicted– Vehicular injury 6.88 (5.6-8.15)

29.21• Alcohol related vehicular 3.37 (2.48-4.26) 14.1• Non-alcohol related vehicular 3.51 (2.6-4.41)

– Non-vehicular injury 3.88 (2.9-4.83) 14.71• Alcohol related 1.49 (0.90-2.09) 4.9 • Non-alcohol related 2.39 (1.64-3.13)

– Suicide 6.18 (4.97-7.38) 7.0, 11.72– Homicide 0.53 (0.18-0.88) 0.32, 15.78

Ref: Turner, Leno, Keller. Causes of Mortality Among American College Students: A Pilot Study. J. of College Student Psychotherapy. 2013. 27(1):31-42.

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Summary of Mortality RatesSummary of Mortality Rates18-24 years old 18-24 years old

4-Year institutions4-Year institutions

Leading causes Rate /100K 95% CI Predicted– Vehicular injury 6.88 (5.6-8.15) 29.21

• Alcohol related vehicular 3.37 (2.48-4.26) 14.1• Non-alcohol related vehicular 3.51 (2.6-4.41)

– Non-vehicular injury 3.88 (2.9-4.83) 14.71• Alcohol related 1.49 (0.90-2.09) 4.9 • Non-alcohol related 2.39 (1.64-3.13)

– Suicide 6.18 (4.97-7.38) 7.0, 11.72– Homicide 0.53 (0.18-0.88) 0.32, 15.78

Ref: Turner, Leno, Keller. Causes of Mortality Among American College Students: A Pilot Study. J. of College Student Psychotherapy. 2013. 27(1):31-42.

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• 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?

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Campus Protective EffectCampus Protective Effect

Mental Health DisordersMental Health DisordersCommon and Critically ImportantCommon 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. 42

Thank you

Questions

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