Tele-Psychiatry for College Students: Challenges, Opportunities, and Lessons Learned from the Pandemic

  • Journal of Medical Regulation
  • June 2023,
  • 109
  • (2)
  • 21-28;
  • DOI: https://doi.org/10.30770/2572-1852-109.2.21

ABSTRACT

College students are the human capital of a nation, and their college education lays the foundation for their success as future leaders of society. However, their ability to advance is often impeded by stress. Changes in lifestyle, increased academic workload, student debt, forming interpersonal relationships, and coping with new adult responsibilities may result in clinically significant anxiety and depression that require medical attention. Left untreated, these illnesses hinder academic progress and decrease graduation rates. College students constitute a highly mobile population frequently traveling for breaks and school-related activities and, as such, at increased risk of interruption and/or discontinuation of care.

The COVID-19 pandemic challenged our ability to offer consistent mental health care for students and forced us to implement public health measures that were long overdue. Temporary governmental policy changes allowing for the provision of remote care across state lines at the same reimbursement rate as in-person services were vital to student mental health recovery, retention in school, and graduation rates. The time-limited loosening of state-based medical licensure restrictions clearly demonstrated the feasibility, benefits, and dire need for widespread implementation of telehealth. These are important lessons that should inform future policies for student health.

In this paper, we advocate therefore, that the temporary loosening of the licensure restrictions and equitable reimbursement rates be codified into law. The current licensing regulations have not kept pace with the lived experience of college students or modern society in general. Given more mobile lifestyles, these restrictions result in frequent inevitable transitions of care which are highly undesirable. Even if providers outside metropolitan areas were readily available,1,2 these transitions of care are fraught with considerable risk for medical error. We also advocate for a national standardization of tele-psychiatry policy and procedures, including access to electronic health care records for providers taking care of matriculated students. To date, student mental health services are a patchwork of organizational models of varying funding and efficacy.

Keywords:

Introduction

Urgent appeals to offer tele-psychiatry as an option to access care for patients in the United States predate the COVID-19 pandemic by decades.3 In this paper, we focus predominantly on college and university students, a cohort of 17 million 18 - 28-year-old emerging adults representing a sizable portion of the US population. Contrary to popular misconception, they are not the “worried well,” but constitute a highly mobile, increasingly crisis-prone patient cohort with chronic psychiatric conditions. Even before the pandemic, 1 in 5 college students worldwide have experienced 1 or more diagnosable mental disorders.4 COVID-19 has increased this number and exacerbated collegiate mental health issues.5

Because of a lack of federal licensure that would allow college mental health physicians to extend care across state lines, these students suffer frequent discontinuities of treatment that may result in suboptimal clinical outcomes, academic underperformance, and decreased retention in school.6,7 The COVID-19 pandemic has brought this public health issue into sharp relief; it highlighted the need to re-evaluate the current model for delivering care to college students, who are the human capital of the nation. Investing in their well-being and mental health is vital to ensure their academic success in the service of creating a better future.

College Mental Health and the Pandemic

College students are at a developmental stage characterized by the challenges of individuating from their family, exploring their sexuality, coalescing their identity, establishing new relationships, asserting themselves in the world, succeeding academically, and taking the first steps towards career success.8 All of these developmental steps unfold with little to no support for the students who live away from home, in an academically, financially, and socially demanding environment. Many young adults have mortgaged their future to student debt they will need to pay back with entry-level salaries. Unsurprisingly, data show that college students report elevated levels of distress requiring medical and psychiatric care.9,10 Furthermore, colleges have a diverse, highly mobile, and financially distressed student body that is heavily reliant on on-campus care.

University counseling and psychiatric services have evolved from their historical roots in student academic advising in the 1930s. Because of clinical need, they have morphed into ambulatory, integrated, multidisciplinary health centers. The psychiatric providers attend to a multiculturally diverse student body with chronic conditions and acute mental health crises and must nimbly respond to public health emergencies and other disasters on campus.

Because of historical, financial, and local cultural reasons, there is no organizational standardization of university counseling services,11 and psychiatry straddles both the psychological and medical fields. In student health centers, psychiatric providers are either integrated in counseling or primary care, or psychiatric services are entirely outsourced to private practitioners off campus. According to the Center for Collegiate Mental Health 2021 report,12 only 34.3% of the 662 institutions polled offer in-house dedicated psychiatric providers, while 24.4% of institutions outsource psychiatric care. Recommendations are vague and colleges do not always implement them.10 Some institutions follow the 1:10,000 ratio of psychiatrist to general population, originated in 1962 in Canada,13 but most institutions do not have enough human and/or financial resources to implement this ratio.

The sudden onset of the COVID-19 pandemic in 2020 disrupted college life profoundly and created a parallel mental health crisis for many college students, both in the US and abroad.7,5,14 On short notice, colleges and universities switched to online learning and students were told to return home. Some students profited from the emotional support and logistical help their families provided; in other cases, they returned to homes that were dysfunctional, abusive, unwelcoming, or devastated by personal and economic losses caused by the pandemic. Even though the traumatizing effects of the pandemic were not experienced in a uniform way, loss of academic opportunities and missed milestones were widely reported.

A few informal surveys conducted during the initial stages of the pandemic7,15 noted worsening or relapse of mental health symptoms, medication discontinuation, increase in hospitalization, and heightened suicidal ideation among college and university students. Psychiatrists working most closely with students had to rectify in real time their lack of access to psychiatric care in their home states. Studies published since the pandemic confirm the initial data and confirm the trend.16,17 Similarly, a survey of college students conducted by Active Minds revealed that 20% experienced significant worsening of their mental health because of COVID-19.18 Moreover, 55% were not aware of the emergency mental health resources in their community.18 The above-described disruption of mental health care when away from campus is a well-known phenomenon to college psychiatrists. It occurs routinely during summer and winter breaks. Students typically lack the necessary literacy to navigate our overly complex healthcare systems.10 Furthermore, outside of college towns and major metropolitan areas there is a paucity of mental health providers who might be in-network of student health insurances, resulting in long wait times and/or complete lack of care for the students' acute and chronic conditions.

College students of color experienced the added burden of negotiating intensified racial tension in the context of tragic events that renewed public focus on longstanding systemic racism. The COVID-19 pandemic unleashed a wave of abusive behavior towards Asian Americans. College students reported numerous instances of verbal and physical abuse on campus.19 The public health crisis exposed the health and economic disparities that affect minority communities, both in general and on campus.20 In addition, the racial justice protests following the deaths of several Black individuals highlighted the daily terror this population lives with and underscored the need for culturally competent care. The social justice protests compelled colleges and universities to engage in a dialogue about racism.21,22 However, the potentially cathartic and empowering experience of sharing stories of microaggressions on college campuses (#blackintheivory) or demanding systemic change came at a price for the activists; they felt alienated and exhausted and found it difficult to take care of themselves resulting in, or exacerbating, poor functioning and clinical symptoms of distress.23–25

International students were uniquely threatened. Stranded far away from home and isolated from local support, they endured racially and ethnically motivated abuse. Additionally, they faced the terrifying prospect of having their visas invalidated by US Immigration and Customs Enforcement because they could not access in-person classes.5,14,25,26

At baseline, colleges and universities were already facing an increase in demand for mental health services and were struggling to add providers on-site to meet the demand.27 In mid-March 2020, the pandemic disrupted access to care for all students. Amidst the chaos, students needed more —rather than less—expert mental health care, especially by providers able to contextualize the impact of these specific social stressors on the students' college experience. College mental health services had to change overnight and pivoted to remote video or phone sessions for their suddenly displaced students. Despite the legal and insurance obstacles limiting the delivery of care when and where it was needed most, both staff and psychiatric providers did their best to maintain a lifeline for students. Since campuses reopened, college mental health clinics are struggling to provide access to an increasing number of students while dealing with provider shortages.2,27

Paving the Way for the Future of College Mental Health

Proposal for the development of standardized college tele-psychiatric care

Moments of crisis present an opportunity for a paradigm shift. Student health care is essential for student well-being and academic success. However, from unresolved legal aspects of offering services across state lines to high-speed internet availability, access remains a major obstacle. We gained significant knowledge about how to provide quality care beyond the in-person models to students during this challenging period.28 It behooves us to keep the momentum going and develop a plan to address the most important obstacles identified to date. Telehealth has immense potential to offset health inequities and allow students to blossom. Students who are under higher levels of social and/or economic stress depend on consistent mental health care to achieve academic success. To overcome the barriers to timely and expert care, we propose that tele-psychiatry be incorporated as a standard option for student health care, and that regulatory changes implemented during the pandemic become permanent.

Tele-Psychiatry

Telehealth offers potential advantages over in-person treatment.29 It often lowers the cost of care, removes barriers to treatment for students who lack transportation, and may facilitate greater access to multilingual and multicultural providers. Students with social anxiety, PTSD, agoraphobia, or other disabilities often prefer to attend sessions in the privacy of their homes. For these reasons, telehealth can advance the provision of a more socially just public health approach.

Despite clear benefits and wide acceptance29 the legal and practical aspects of telehealth have not been fully understood.3 Some of these issues are further discussed below, under the section “Digital Divide.” Physicians struggle with ethical and legal dilemmas attendant to the provision of care across state lines without a federal license. Navigating these dilemmas forces physicians into being “gatekeepers” of mental health services, contributing to physician burnout. During the public health emergency, the governors of many states issued temporary executive orders to ease licensure restrictions. This created the additional challenge of having to keep track of a complicated patchwork of state mental health laws and executive orders which continues to this date, even though there has been an increase in data suggesting that the continuation and expansion of telehealth are achievable and sustainable.30

Licensure

Psychiatrists who work in college settings typically see patients originating from many different states, as exemplified by the Choy survey7 and other data.31 Under current circumstances, most college providers operate under the limitations of the Interstate Medical Licensure Compact (https://www.imlcc.org), that 37 states, Washington, DC, and the Territory of Guam have joined. However, populous states such as California, Texas, Florida, and New York, where many institutions of higher education are located, either do not participate or are in the early stages of introducing legislation to join it. Even though the interstate compact streamlines the licensure process, individual physicians still must file an application for each state in which they wish to be licensed and be responsible for annual licensure fees. They may be subject to Maintenance of Certification regulations greater than their primary state of practice. Students who are temporarily located in a state in which their college mental health provider lacks licensure are unable to pursue telehealth care at their university's health center. This is clearly not an optimal situation. The students' frequent traveling for summer and winter breaks, study abroad periods, internships, or family visits, put physicians into potential legal jeopardy— they can be perceived as abandoning their patients or disregarding licensing restrictions.

Medicine, as all regulated professions in the US, is licensed at the state level. This creates an inherent difficulty providing care to a mobile population when psychiatrists remain stationary. We advocate for further attention to pathways that would allow them to continue to provide care to their mobile students.

“Digital Divide”

Even when restrictions were temporarily lifted in the early days of the pandemic, not all students were able to continue care because they lacked access to technology needed for telehealth visits. This “Digital Divide”32,33 predates the pandemic and disproportionately impacts those from lower socioeconomic status and rural areas and was further exposed and widened by the pandemic. It requires creative solutions, such as those implemented during the pandemic (eg, free internet access to students, increased bandwidth in rural areas, increased numbers of free WiFi hotspots) and listed on the Federal Communications Commission website.34 Successful strategies should be tracked, amplified, and used regularly.

We realize that the gap between the current delivery models and federal policies on telehealth is too wide to be tackled at once. One way to bridge it is to adapt and expand existing integrated care models, such as asynchronous and hybrid psychiatric consultation and facilitate the connection between in-person local primary care physicians with college psychiatrists.

Most patients are familiar with synchronous tele-psychiatry, or video-calls with their psychiatrist, when both parties participate at the same time, although they are at separate locations. However, since the introduction of electronic health records, patients have direct access to their personal provider via secure text messages and to their personal medical information in HIPAA-compliant patient portals. This facilitates the development of asynchronous health interventions—“store and forward”—that occur at various times independent of patient visits. For example, a recorded interview between a trained interviewer and the patient can be assessed later by a psychiatrist and utilized in triaging needs and creating a treatment plan. If the plan includes “homework” (such as independent activities, videos, and other resources), those can also be accessed asynchronously. This can improve access to culturally competent care and optimize physicians' time.35

Patients can text their mental health physician not only to ask questions, but also to express concerns, report side effects, seek clarifications, and upload documents. The physician will in turn answer these requests, depending on urgency, during business hours of the same day, or within a pre-agreed timeframe. In addition, physicians, or other members of their team, can use remote health apps to review test results, hospital discharge summaries, consult with other specialists, make necessary calls to pharmacies, forward clinical information to health insurance companies to obtain prior authorization for medication prescriptions, write letters of advocacy, or complete forms on behalf of the patient. Most patients appreciate this time-saving, efficient, and direct channel of communication with a physician who is most familiar with their case rather than seeking advice from an unfamiliar on-call physician. This can be particularly true for college students, who already spend a significant amount of time on their electronic devices and are technologically literate. Since before the pandemic there was a growing interest in utilizing mental health apps to facilitate access to mental health care and resources36 to college students.

On the other hand, despite efforts in improving and promoting mental health apps, research shows a continuous lag in utilization, driven by digital overload, cost, and privacy concerns.37–39 In addition, from a physician's perspective, asynchronous treatment intervention takes up increasing amounts of time that may not be remunerated by health insurance companies and state agencies whose billing policies are out of sync with contemporary health care delivery innovations.40

Reimbursement/Insurance

Lack of health insurance coverage predates the pandemic. It deserves special mention because it highlights health inequities that exist in college mental health. Student health fees often cover wellness and basic health services but not specialty care, such as psychiatry. College and university psychiatrists practice in a variety of settings7 and often bill for their services, which are considered specialty care. Data from the US Census Bureau's American Community Survey, reported by the Lookout Mountain Group in 2020,41 show that 1.6 million students were uninsured prior to the pandemic, despite gains in coverage after the Affordable Care Act (ACA) and Medicaid expansion that significantly benefited college students, especially college students of color.42

Preliminary data42 showed that ACA coverage allowed for access to outpatient services, as opposed to emergency services, potentially decreasing costs, and improving outcomes.

Lack of insurance coverage, especially for non-traditional students (older, married, attending college part-time) hampers access to care. In the post-pandemic recovery period, when colleges and universities are confronting budgetary cuts and considering reducing on-site and tele-mental health services, this could mean reduced access for a substantial percentage of students. Furthermore, if reimbursement is different for in-person and telehealth visits,43 college or university health services will feel compelled to prioritize better paid in-person visits whenever possible.

During the pandemic, federal regulations led the way for temporary changes in telehealth. We advocate for affordable health care coverage for this population, including mental health care parity and telehealth services like those codified by federal insurance. That should include receiving telehealth services, including audio-only services, for mental or behavioral health care in their homes in any part of the country if certain conditions are met; and continued coverage of video-based mental health visits for Student Health Centers located in designated Health Provider Shortage Areas, following the model of Federally Qualified Health Centers and Rural Health Clinics.

Crisis Management

Psychiatric patients in crisis require quick intervention. What happens if a patient becomes distressed during a telehealth session and hospitalization is needed? Since college students are highly mobile, how does one pinpoint their location and deploy assistance? Again, adaptation is key. In most college health centers, students are required to provide an emergency contact to be on file. If choosing to be seen via telehealth, students should be required to sign a consent form authorizing providers to notify the designated local emergency contact, a person most likely to know the student's location. At the beginning of each appointment, the physician should also confirm the student's location and be aware of the nearest emergency department's location. Students who do not meet the threshold for safety should be referred to in-person services in well-established integrated care locations. For example, attending a telehealth appointment with a psychiatric consultant in a private soundproof space in a primary care office.

Privacy

The use of technology also highlights privacy issues. Existing regulations are insufficient to provide strong privacy and risk protections for users.44 Cybersecurity aside, finding a quiet, secure environment to discuss sensitive mental health concerns may prove to be difficult when talking from a home shared with family and/or roommates. Private spaces in designated public places (libraries, community health centers, schools, and parking lots) equipped with complimentary WiFi hotspots are needed. A few examples already in use include hospitals (https://www.pikevillehospital.org/wifi-hotspot-for-patients-to-use-telehealth/) and office soundproof pods (https://www.frameryacoustics.com/en/products/?gclid=Cj0KCQjw7pKFBhDUARIsAFUoMDYwKn2qll-OtB2c2tzO5mDbxrGMr4km-HapjVENYlt-bK9fz6-iP7SoaAsHbEALw_wcB). Another option is utilizing integrated care practices that offer soundproof internet-enabled rooms (or pods), that will provide both privacy and immediate attention, if a crisis emerges.

Conclusion

College students are a highly mobile population, at risk of experiencing discontinuation of care due to frequent traveling across state lines. Telehealth has proven to be a viable and affordable way to deliver care to college students. Creative solutions for identified barriers could improve continuity of care for this population. The long overdue implementation of tele-psychiatry remains mired in a web of legal, malpractice, privacy, reimbursement and insurance regulations, and technological barriers, especially for disadvantaged students. We recognize the political and legal challenges attendant to creating a national standardization for providing psychiatric care to college students, including medical licensure legislation for psychiatrists employed by institutions of higher learning, but we feel compelled to advocate for it. With this in mind, we recommend the following:

  1. Standardization of telehealth use for college students and loosening of state-based licensure restrictions.

  2. Lobbying for improved WiFi infrastructure around the country, especially in areas considered “tech deserts” (places without technology), that is affordable and reliable, and increasing digital literacy.

  3. Developing models of collaborative care that meet the specific needs of college students that can improve delivery of specialized services in the primary care setting. This includes attending a telehealth appointment with a psychiatric consultant in a private soundproof space in a primary care office.

  4. Lobbying for affordable health care for college students that covers both in-person and telehealth services.

  5. Establishing designated public places (libraries, community health centers, schools, and even parking lots) fitted with technology and offer privacy for college students who live with family or roommates.

We recognize that these are complex and multifaceted issues, but we feel inspired and emboldened by the lessons learned during the pandemic as a starting point for change.

Acknowledgments:

The authors comprise the College Student Committee of the Group for the Advancement of Psychiatry.

Footnotes

  • Author contributions: Concept design and manuscript drafting (LDF); revision of content (all)

  • Funding/support: The authors are funded by their own institutions.

  • Other disclosures: N/A

  • Received June 14, 2021.
  • Revision received February 17, 2023.
  • Accepted March 28, 2023.

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In this Issue

Journal of Medical Regulation

Journal of Medical Regulation

Vol. 109, Issue 2

1 Jun 2023

Table of Contents Index by author

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Keywords

Tele-psychiatry, pandemic, mental health