One day in late January, the University of Kentucky’s president sent an email to the campus with a clear message: Get help if you need it.
Two students had recently died by suicide, and the president, Eli Capilouto, encouraged anyone processing grief to make use of the university’s mental-health resources.
Those resources are under strain. The university has 16 counselors — clinicians trained to help patients work through the symptoms and root causes of mental illness — to serve about 30,000 students.
Kentucky is hardly unique in being stretched thin. Stanford University recently added four clinicians to its counseling center as its provost called student mental health the “single highest priority and most compelling need” on the campus. Students’ wait times to see counselors on campuses across the country can be notoriously long — a persistent frustration as colleges try to battle what the University of California at Berkeley researchers have called “the new epidemic.”
But counseling is just one major prong of treatment for mental illness, and the most appropriate one for people first experiencing mild symptoms of depression, according to psychologists. The other major prong is medication.
Antidepressant prescriptions at a U. of Kentucky pharmacy, 2016-18
Source: U. of Kentucky
In that respect, campuses are well stocked. Records obtained by The Chronicle from dozens of universities unveil the immense volume of antidepressants stocked in campus-run pharmacies. At any given time, universities can have tens of thousands of pills on hand.
And it is fairly easy, experts say, to get prescribed, which often involves one visit to a campus clinic. That ease, combined with a growing demand for treatment, has resulted in a high volume of prescriptions written in recent years, according to the records obtained by The Chronicle. At Kentucky, for instance, 3,249 prescriptions for antidepressants were received by the campus pharmacy in 2018, an increase of 67 percent from just two years earlier.
There’s nothing wrong with the antidepressants’ availability. They can be a critical piece of treatment for students in the throes of mental illness. But what appears to be an increasing reliance on prescriptions, combined with an ever-present shortage of counselors, suggests that many students may not have ready access to the recommended treatment for depression in many cases: a combination of counseling and medication.
A Potential for Lopsided Treatment
It is generally accepted that the most effective treatment for medium to severe depression is a mix of therapy and medication. But on most college campuses, it’s easier to get the latter than the former.
A student experiencing symptoms of depression who wants to see a counselor may have to wait weeks. The average wait for a first-time appointment among all college counseling centers is about seven business days, according to a report by the Association for University and College Counseling Center Directors. And nearly two-thirds of counseling directors whose centers offer psychiatric services say they need “more hours of psychiatric services than they currently have to meet student needs,” according to the same report.
On many campuses the path to a prescription is simpler. A student can walk into a campus clinic where a medical employee can administer an evaluation called the PHQ-9, a nine-question rubric, commonly used across medicine, that assesses the patient’s well being with questions like “Have you been feeling blue for the last two weeks?” and “Have you experienced thoughts of suicide?”
Based on the student’s evaluation score, psychologists can direct them toward medication or therapy, or both, based on the severity of the symptoms. Some students are seeking mental-health resources with a driving force of “instant relief,” said Gregory Eells, executive director of Counseling and Psychological Services at the University of Pennsylvania and president-elect of the counseling-center directors’ group. So they tell their physician what they want, Eells said, rather than inquiring about what they need.
It’s common, experts say, for a patient to leave the first visit with a prescription for an antidepressant.
“Most students come in knowing one thing: They want help,” said William E. Neighbor, a clinical professor of family medicine at the University of Washington’s Hall Health Center. “They are interested in medications because most have friends who have been on them.”
Students may hesitate to start taking antidepressants because of the perceived stigma, Neighbor said. But if they do express interest, said Gabe Yeamans, a staff psychiatrist at the University of Texas at Dallas’ clinic, he’ll write them a paper prescription and leave them with the decision of whether to fill it.
Selective serotonin reuptake inhibitors, or SSRIs, are beneficial, Neighbor said, but for mild symptoms of depression, therapy is more effective. And across the spectrum of severity of depression, therapy is recognized as an effective treatment. “The benefits of therapy don’t end when the therapy ends, but the benefit of the medication stops when you stop taking it,” said Matthew Neltner, chief psychologist at the University of Kentucky’s Behavioral Health Clinic.
That benefit can, in some cases, save lives. But it can also carry side effects. Antidepressants, if taken for longer than four to six weeks, can be extremely difficult to wean off, according to psychologists. Insomnia, headaches, dizziness, worsened depression symptoms, flu-like symptoms, and electric-shock sensations may follow the abrupt end of a prescription.
And a psychiatrist who writes a prescription and urges a student go to therapy has no way of ensuring that he or she does either. But filling that prescription takes only a visit to the campus pharmacy, maybe in the same building as the clinic.
Therapy — admitting there is a problem, making an appointment, and showing up — is hard work, Neltner said. Some students don’t want to spend the time and energy when they know of others who’ve had success with antidepressants. That view alone could lead students to lopsided treatment.
Prescriptions by the Numbers
There is little, if any, data or research on how lopsided that treatment is across higher education. But a Chronicle analysis of pharmacy records obtained through requests to more than 100 colleges and universities reveals that the supply of SSRI prescriptions is quite high.
3-year total of unique persons prescribed SSRIs though a campus student health center (2016-18), pegged to one year’s on-campus enrollment (2017)
Source: Records obtained by The Chronicle from the named institutions
A handful of universities provided data on the number of unique patients who were prescribed antidepressants through the main campus pharmacy over a three-year period. At Indiana University, for example, nearly 3,000 unique patients’ prescriptions were sent to the pharmacy from 2016 to 2018. Indiana enrolled around 41,000 on-campus students in 2017. Meanwhile, the University of Alabama at Tuscaloosa, which enrolled around 34,000 on-campus students in 2017, saw roughly the same number.
More universities provided data on total prescriptions than on unique patients. At the University of Washington, which enrolled around 45,000 on-campus students in 2017, the campus pharmacy reported about 13,500 prescriptions written from 2016 to 2018 — an average of 101 prescriptions per 1,000 students. Fifty-nine percent of patients who received diagnoses of depression between the age of 18 and 24 were on antidepressants, and in the same age group, 10 percent of all patients — regardless of their diagnosis — were taking antidepressants, according to university data provided to The Chronicle.
Patients at the roughly dozen universities who provided day-by-day logs from their pharmacies were more likely to get a prescription for an antidepressant during final-exam months than at any other time period, according to data obtained by The Chronicle. (The stress of college cannot be left out of the conversation when looking at the pathway to treatment, said Neltner, who added that a rise in prescriptions during exams was consistent with his experience.)
Antidepressant prescriptions written at a campus student health center per 1,000 students enrolled on campus, 2017
Source: Records obtained by The Chronicle from the named institutions
The data do not capture the full range of students’ prescriptions. For instance, the data do not include prescriptions filled through any pharmacy but the campus pharmacy where the data originated.
Helping a Student in Pain
Campus psychologists and experts link high levels of prescriptions to a variety of factors, including the elevated conversation around mental health and the increase in young adults who go to college already on medications, said Jennifer L. Hartstein, a psychologist and member of the Active Minds network.
The marketing of the medications is also concerning, said Eells, of the University of Pennsylvania, because a majority of patients struggling with depression or anxiety do not have symptoms severe enough to require antidepressants.
When solving any problem, Neltner said, medical professionals have to look at the big picture of a patient’s situation to understand what has gone awry. Some complications, although easily fixed with medication, can be addressed with natural solutions too, Hartstein said. For example, headaches can be simply resolved with Advil, but hydration, food, and rest should be the immediate answer.
Therapy is the go-to treatment for a majority of students with depression and anxiety, many experts said, but it’s not always the first inclination of a patient in pain, Hartstein said.
“I’m sure there is some truth to it,” Neltner said, “but I don’t think [prescribing antidepressants as a Band-Aid] is the most common experience.” He said part of the crisis is limited on-campus therapy, but his staff takes care to direct students to counseling.
A task force has formed at Kentucky to better understand students’ experiences with mental illness and the resources available. In time the group’s members hope to learn more about the students lost to suicide on campuses and find commonalities that could lead them to better prevention.
But Capilouto, the university’s president, is conscious of the complexity surrounding the issue. There is no “this is good” and “this is bad” answer, he said. The “silver bullet” in this fight doesn’t exist, he said, because universities are not only trying to respond to a huge problem; they’re doing it in individual cases, thousands of times over.
“You can’t simply add more counselors and expect this problem to be solved,” Capilouto said.
Dan Bauman contributed reporting.
Follow Lily Jackson on Twitter at @lilygjack, or email her at lily.jackson@chronicle.com.
About the Data
The Chronicle identified more than 100 colleges and universities with a single campus pharmacy that reported its population served was no less than 60 percent college students. Of those campuses we requested the then-current inventory of SSRIs in that pharmacy, as well as the number of prescriptions of SSRIs written for that pharmacy in the years 2016 to 2018. Some campuses differentiated name-brand SSRIs from their generic counterparts; for purposes of analysis, we combined those numbers. The data have obvious limitations. Because the statistics focus on a single campus pharmacy, and because they cannot capture whether a prescription was filled, among other reasons, they do not provide a full picture of students’ use of SSRIs on the named campuses.
