Care of the College Student

 


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Am Fam Physician. 2013 Nov 1;88(9):596-604.

This version of the article contains supplemental content.

Author disclosure: No relevant financial affiliations.

There are approximately 20 million students in U.S. colleges and universities. Although this population is characterized as having good health, 600,000 students report some form of disability or some type of medical problem, including attention-deficit/hyperactivity disorder, learning disabilities, psychiatric disorders, and chronic illnesses, among others. Physicians can enhance youth transition to an adult model of health care; the use of self-care skills checklists is one recommended method to assist with the transition. Stimulant medications are effective for treating adults with attention-deficit/hyperactivity disorder, but physicians should use caution when prescribing stimulants to college students because of the high rates of medication diversion in this population. Depression, anxiety, posttraumatic stress disorder, sleep problems, and eating disorders are common in college students and can significantly impact performance. Emphasis on immunization of students for influenza, meningococcus, and pertussis is necessary because of the low rates of compliance. Screening and interventions for obesity, tobacco use, and substance abuse are important because of the high prevalence of these problems in college students. Screening for alcohol abuse facilitates identification of students with problem drinking behaviors. Students who are war veterans should be monitored for suicidal ideation and posttraumatic stress disorder. Lesbian, gay, bisexual, transgender, and questioning students are at risk of harassment and discrimination. Caution should be exercised when prescribing medications to college athletes to avoid violation of National Collegiate Athletic Association eligibility rules.

There are approximately 20 million full- and part-time students enrolled in American colleges and universities. Of these, 12 million are younger than 24 years, 56% are women, and 35% are minorities. Although this population is characterized as having good health, approximately 600,000 students report some form of disability or some type of medical problem, including attention-deficit/hyperactivity disorder (ADHD), learning disabilities, psychiatric disorders, and chronic illnesses, among others.1  Meeting the needs of the college student involves management of not only common illnesses and chronic conditions, but of behaviors and stressors that are unique to students. Common medical conditions in college students, which are treated in the same manner as in the general population, are addressed in Table 1.2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A structured, coordinated health care transition from the child health care model to the adult health care model will optimize the care of college students.

C

3

Pharmacologic and cognitive behavior therapy demonstrate effectiveness in the treatment of attention-deficit/hyperactivity disorder in adults.

A

1216, 18

Additional time on classroom tests and examinations is commonly encouraged for persons with attention-deficit/hyperactivity disorder or learning disabilities.

C

19

Tobacco use screening and cessation interventions are recommended for college students.

B

36

Alcohol use and misuse counseling is recommended for college students.

B

3941


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A structured, coordinated health care transition from the child health care model to the adult health care model will optimize the care of college students.

C

3

Pharmacologic and cognitive behavior therapy demonstrate effectiveness in the treatment of attention-deficit/hyperactivity disorder in adults.

A

1216, 18

Additional time on classroom tests and examinations is commonly encouraged for persons with attention-deficit/hyperactivity disorder or learning disabilities.

C

19

Tobacco use screening and cessation interventions are recommended for college students.

B

36

Alcohol use and misuse counseling is recommended for college students.

B

3941


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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Table 1.

Common Self-Reported Medical Conditions in College Students

ConditionFrequency (%)Comment

Acute or chronic conditions

Allergies

22

Usual care generally applies to these conditions

Independent management of these conditions or self-care may be a new experience for students

Sinus infection

17

Back pain

12

Strep throat

11

Asthma

9

Urinary tract infection

9

Broken bone/fracture/sprain

8

Ear infection

7.5

Migraine

7

Bronchitis

6

Disabling conditions

Attention-deficit/hyperactivity disorder

6

May manifest as academic problems, mood changes, sleep disruption, or substance abuse

May require educational accommodations

Learning disability

4

May manifest as depression, sleep disruption, attention-deficit/hyperactivity disorder, metabolic (thyroid) problems, or substance abuse

Psychiatric condition

4

Depression and anxiety are common among students; a minority of students seek care

Suicidal ideation is common

Chronic illness (e.g., cancer, diabetes mellitus, autoimmune disorders)

3.5

Knowledge and self-care abilities/strategies should be assessed

Deaf/hard of hearing

1.5

Partially sighted/blind

1.5

Mobility/dexterity disability

1

Speech or language disorder

1

Other disability

2


NOTE : 94% of male students and 91% of female students describe their health as good, very good, or excellent.

Information from reference 2.

Table 1.

Common Self-Reported Medical Conditions in College Students

ConditionFrequency (%)Comment

Acute or chronic conditions

Allergies

22

Usual care generally applies to these conditions

Independent management of these conditions or self-care may be a new experience for students

Sinus infection

17

Back pain

12

Strep throat

11

Asthma

9

Urinary tract infection

9

Broken bone/fracture/sprain

8

Ear infection

7.5

Migraine

7

Bronchitis

6

Disabling conditions

Attention-deficit/hyperactivity disorder

6

May manifest as academic problems, mood changes, sleep disruption, or substance abuse

May require educational accommodations

Learning disability

4

May manifest as depression, sleep disruption, attention-deficit/hyperactivity disorder, metabolic (thyroid) problems, or substance abuse

Psychiatric condition

4

Depression and anxiety are common among students; a minority of students seek care

Suicidal ideation is common

Chronic illness (e.g., cancer, diabetes mellitus, autoimmune disorders)

3.5

Knowledge and self-care abilities/strategies should be assessed

Deaf/hard of hearing

1.5

Partially sighted/blind

1.5

Mobility/dexterity disability

1

Speech or language disorder

1

Other disability

2


NOTE : 94% of male students and 91% of female students describe their health as good, very good, or excellent.

Information from reference 2.

Preparing for the Transition to College

HEALTH CARE INDEPENDENCE

College students often are assuming primary responsibility for their education and health for the first time. Promoting health care independence involves more than the provision of the medical record and immunization history. A structured, coordinated health care transition plan from the child to the adult health care model will optimize the care of college students.3 Figure 1 is a health care transition planning algorithm developed by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics, and American College of Physicians.3

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Health Care Transition Planning for Youth and Young Adults

Figure 1.

Health care transition planning algorithm for all youth and young adults within a medical home interaction.

Adapted from Cooley WC, Sagerman PJ; American Academy of Pediatrics; American Academy of Family Physicians; American College of Physicians; Transitions Clinical Report Authoring Group. Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics. 2011;128(1):185–186. Copyright © 2011 by the AAP.

Health Care Transition Planning for Youth and Young Adults


Figure 1.

Health care transition planning algorithm for all youth and young adults within a medical home interaction.

Adapted from Cooley WC, Sagerman PJ; American Academy of Pediatrics; American Academy of Family Physicians; American College of Physicians; Transitions Clinical Report Authoring Group. Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics. 2011;128(1):185–186. Copyright © 2011 by the AAP.

The “sending” medical practice should ensure that the departing student has a transition plan, and that the family and student are ready for the transition. A transition checklist for clinicians is provided in Table 2. A health care skills checklist (eFigure A) is one recommended method to assess the needs of the patient and to develop goals for the transition to a health care model that expects assumption of adult responsibilities. Group visits to complete the clinical and educational activities for transitioning students could be considered to enhance counseling efficiency. “Receiving” practices should assess the developmental readiness of the student and respond accordingly, orienting the student to the clinical practice and adult health care model. Ideally, some students would benefit from direct coordination of care with the college or university student health service.

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Table 2.

Clinician Checklist for Transitioning College Students

Meet privately with the patient for part of the visit

Encourage assumption of increased responsibility for his/her health care management:

Ensure that the patient understands his/her health conditions and medications

Send copies of reports, letters, and tests to the patient and his/her family

Provide anticipatory guidance:

Nutrition and fitness

Sexuality and relationships

Substance abuse and smoking

Specific health condition(s):________________

Health insurance

Sports/athletics

Functional independence

College/work plans

Functional independence and community inclusion (for patients with disabilities)

Medical decision making/privacy at age of majority (state specific)

Legal matters (e.g., advance medical directive, power of attorney)

Voting/selective service

Assess patient and family readiness for transfer to a new physician:

Initiate discussion about transfer to adult health care model

Identify possible physician

Initiate communication with the physician selected

Implement the transfer to the new practice:

Transfer medical records

Discuss nuances of care with the selected physician or clinic

Follow-up after the transfer

Assess the patient's ability to make independent decisions regarding health care, finances, and other adult concerns to determine whether there is a need for guardianship or conservatorship

Provide a pocket card of conditions and medications

Table 2.

Clinician Checklist for Transitioning College Students

Meet privately with the patient for part of the visit

Encourage assumption of increased responsibility for his/her health care management:

Ensure that the patient understands his/her health conditions and medications

Send copies of reports, letters, and tests to the patient and his/her family

Provide anticipatory guidance:

Nutrition and fitness

Sexuality and relationships

Substance abuse and smoking

Specific health condition(s):________________

Health insurance

Sports/athletics

Functional independence

College/work plans

Functional independence and community inclusion (for patients with disabilities)

Medical decision making/privacy at age of majority (state specific)

Legal matters (e.g., advance medical directive, power of attorney)

Voting/selective service

Assess patient and family readiness for transfer to a new physician:

Initiate discussion about transfer to adult health care model

Identify possible physician

Initiate communication with the physician selected

Implement the transfer to the new practice:

Transfer medical records

Discuss nuances of care with the selected physician or clinic

Follow-up after the transfer

Assess the patient's ability to make independent decisions regarding health care, finances, and other adult concerns to determine whether there is a need for guardianship or conservatorship

Provide a pocket card of conditions and medications

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Health Care Skills and Supplies: A Checklist for the College Student

eFigure A.

A health care skills checklist is one recommended method to assess the needs of the patient and to develop goals for the transition to a health care model that expects assumption of adult responsibilities.

Health Care Skills and Supplies: A Checklist for the College Student


eFigure A.

A health care skills checklist is one recommended method to assess the needs of the patient and to develop goals for the transition to a health care model that expects assumption of adult responsibilities.

Health care independence is also fostered by availability of medical self-help books and online resources, such as FamilyDoctor. org (http://familydoctor.org), and by basic medical supplies to handle common medical problems and injuries. The Centers for Disease Control and Prevention provides useful health resources for college students and their families at http://www.cdc.gov/family/college.

HEALTH CARE COVERAGE

Most college students (64%) have health insurance through their parents' plan, and another 13% are covered by college/university-sponsored plans. Approximately 9% are uninsured.4 Although student health insurance coverage requirements under the Affordable Care Act provide certain protections to the college student, there is still diversity among available plans. It is incumbent on students to have a working knowledge of their insurance plan, coverage, and claims process. Coverage of vaccinations and contraceptives varies by plan.5 A health care insurance toolkit for young adults is available at http://www.gettingcovered.org/Toolkit.

Common Learning and Mental Health Concerns

LEARNING ISSUES

Attention-Deficit/Hyperactivity Disorder. The prevalence of ADHD among college students is estimated to be 2% to 8%6,7; 50% of students receiving accommodative services in college demonstrate ADHD.8 Students with symptoms of ADHD are at increased risk of psychosocial and substance use problems.9

Adolescents and young adults who have ADHD demonstrate less hyperactivity, but report more mental restlessness, anxiety, irritability, and academic, social, mood, and sleep problems compared with children who have ADHD.10,11 Higher demands on executive function and less direct social support from family contribute to struggling and the need for pharmacologic and nonpharmacologic interventions in students who were previously undiagnosed.

Pharmacotherapy, including amphetamines, methylphenidate (Ritalin), bupropion (Wellbutrin), and atomoxetine (Strattera), is effective in adults.1215 Stimulant medications are more effective than nonstimulant medications for treating adult ADHD.16 Few studies have examined the effectiveness of these medications specifically in college students.

Cognitive behavior therapy for ADHD focuses on teaching patients ways to adapt their thinking and behaviors to increase daily functioning. When used in conjunction with medication, cognitive behavior therapy improves functioning and ADHD symptoms in adults17; it is unknown whether these findings can be generalized to college students.

In treating ADHD, an additional concern specific to college students is stimulant misuse; 5% to 35% of college students misuse or divert their ADHD medications.18 Those with a history of substance abuse or conduct disorder may be more likely to misuse or divert their medications.18 Educating recipients of prescribed stimulants and remaining vigilant for misuse among high-risk students may be helpful.6

Learning Disabilities. About 3% of college students surveyed report having a learning disability.7 Physicians may discover learning disabilities when evaluating students for other conditions, such as depression, sleep disorders, ADHD, and thyroid disease. There is no consensus regarding how to assess learning disabilities in college students,19 and the lack of agreement on the definition of a learning disability has resulted in few evidence-based treatment strategies. Given the difficulties associated with treatment of learning disabilities, educational accommodations are important to consider. Allowing students with ADHD or learning disabilities more time on classroom tests and examinations is commonly encouraged, and physicians may be approached to write medical statements requesting this accommodation on behalf of the patient.19 However, there are limited data suggesting that such accommodations significantly improve performance. Students with learning disabilities typically have their condition comanaged by their physician, psychologists, and educators.

SELECTED MENTAL HEALTH AND BEHAVIORAL PROBLEMS

Physicians should be alert for depression, anxiety, suicidal ideation, posttraumatic stress disorder (PTSD), and sleep and eating disorders, because they are highly prevalent in college students. Detailed information about treatment is widely available and does not differ from that for the general population.

Anxiety and Depression. Anxiety and depression, which can have a significant impact on academic performance, are the most common mental health problems reported by college students.7 Within the previous 12 months, 30.7% felt so depressed that it was difficult to function and 48.4% experienced overwhelming anxiety. Less than one-half of students experiencing depressive and anxiety symptoms seek care.20

Suicidal Ideation. Recent data suggest that suicide is the most common cause of death in college students.21 Suicidal ideation is reported in nearly 7% of students; about 2% report having a plan, and 0.5% report making an attempt in the previous year.22 Of those with suicidal ideation, approximately 50% seek help. Depression, low social support, parent-student conflict, affective dysregulation, and alcohol use disorders are risk factors for suicidal ideation.23 Systematic reviews conclude that there is insufficient evidence regarding psychosocial and pharmacologic treatments for suicide-related behaviors.24 Family physicians should be particularly vigilant for suicidal thoughts and behaviors in college students, and should direct students to outpatient care if there is no immediate risk. Information and resources about suicide are available at http://www.sprc.org/collegesanduniversities.

Posttraumatic Stress Disorder. Most students report experiencing a traumatic event in their lifetime.25 Probable PTSD is most commonly associated with sexual assault.25,26 Although it has not been tested in college settings, the Primary Care PTSD Screen, a four-item screening tool, may be useful for identifying students experiencing PTSD symptoms.2729

Sleep Disorders. Studies suggest that as many as 60% of college students report poor sleep quality,30 and sleep difficulties impact academic performance in 20% of college students.7 Sleep deprivation is associated with impaired cognitive functioning, mood problems, somatic symptoms, and decreased life satisfaction, and is a risk factor for illicit substance and alcohol use and motor vehicle crashes.31 Inadequate sleep hygiene, delayed sleep phase disorder, and insomnia are the most common sleep disorders in college students.31

Eating Disorders. About 1% of surveyed college students report that an eating disorder affected their performance.7 Self-help programs, cognitive behavior therapy, and interpersonal therapy have good evidence for treating bulimia nervosa and binge eating disorder. Antidepressants may be a primary treatment for bulimia nervosa, and anorexia nervosa should be treated in a tertiary care setting.32

Preventive Measures

IMMUNIZATIONS

College entrance physical examinations and routine visits provide opportunities for updating and administering immunizations. The 2010 National College Health Assessment indicated that only 40% of college students report receiving influenza vaccinations, and only 55% report receiving meningococcal vaccinations.4 Adequate pertussis immunization has also received national emphasis.

Current immunization schedules for adolescents and adults are provided by the AAFP (http://www.aafp.org/patient-care/immunizations/schedules.html) and the Advisory Committee on Immunization Practices (http://www.cdc.gov/vaccines/acip/recs/index.html).33

EVIDENCE-BASED PREVENTIVE RECOMMENDATIONS

The AAFP and the U.S. Preventive Services Task Force have general recommendations that are applicable to college students. The focus of these recommendations is on counseling to reduce the risk-taking behaviors more common in young adults. Additionally, U.S. Preventive Services Task Force guidelines focus on lifestyle choices related to diet, exercise, and healthy relationships that are amenable to counseling and modification when intervention occurs before obesity, inactivity, and unhealthy relationships become habits.

Obesity is an epidemic on college campuses.3 During the first year of college, students gain an average of 3.9 lb (1.8 kg).34 Systematic approaches to target obesity on college campuses are fragmented and have not been reviewed. Physicians should refer students to student health centers offering weight control services.35

Tobacco use is also common in this population.4 Evidence-based recommendations for targeting tobacco use among adolescents, including tobacco use screening and cessation interventions, apply to college students.36

Alcohol use and abuse are common in college students.4 Among those who consumed alcohol, 51% reported that within the previous 12 months they experienced some negative consequence associated with their alcohol consumption.4 Two primary subsets of college students are at greatest risk of problem drinking. The first subset consists of white, male, sensation-seeking students engaged in a social environment with a high drinking norm (e.g., Greek organizations). The second subset consists of female students who were more likely to experience negative affect and respond to distress by drinking.37

Screening for alcohol abuse facilitates identification of students with problem drinking behaviors. The first three consumption items of the Alcohol Use Disorders Identification Test (AUDIT-C ; Table 3) are recommended for identifying at-risk drinking among college students, using a cutoff score of 7 for males and 5 for females.38 Effective intervention programs increase motivation to change drinking habits, change expectations about the effects of alcohol, provide face-to-face or computer-based feedback on student-based norms of drinking behavior, emphasize cognitive behavior skills training, and offer a plan for reducing alcohol use.39,40 Ineffective programs include efforts to increase basic awareness and provide education.39,40 Mailed feedback, social marketing, and group feedback are also not effective.41 The website College Drinking–Changing the Culture (http://www.collegedrinkingprevention.gov) provides updated, evidence-based information about the prevention, assessment, and treatment of alcohol abuse in college settings.

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Table 3.

AUDIT-C for At-Risk Drinking

QuestionsPoints
01234

How often do you have a drink containing alcohol?

Never

Monthly or less

2 to 4 times a month

2 or 3 times a week

4 or more times a week

How many drinks containing alcohol do you have on a typical day when you are drinking?

1 or 2

3 or 4

5 or 6

7 to 9

10 or more

How often do you have five or more drinks on one occasion?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily


NOTE: A score ≥ 7 in male college students and ≥ 5 in female college students indicates at-risk drinking.

AUDIT-C = Alcohol Use Disorders Identification Test–Consumption items.

Information from reference 38.

Table 3.

AUDIT-C for At-Risk Drinking

QuestionsPoints
01234

How often do you have a drink containing alcohol?

Never

Monthly or less

2 to 4 times a month

2 or 3 times a week

4 or more times a week

How many drinks containing alcohol do you have on a typical day when you are drinking?

1 or 2

3 or 4

5 or 6

7 to 9

10 or more

How often do you have five or more drinks on one occasion?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily


NOTE: A score ≥ 7 in male college students and ≥ 5 in female college students indicates at-risk drinking.

AUDIT-C = Alcohol Use Disorders Identification Test–Consumption items.

Information from reference 38.

Use of illicit substances can complicate the diagnosis and treatment of academic or behavioral health conditions. Marijuana is the most commonly used illicit substance on college campuses.3  Other common illicit substances are listed in Table 4.42 Guidelines for providing drug education and administring drug testing are published by the American College Health Association (http://www.acha.org/Topics/atod.cfm).

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Table 4.

Illicit Substances Commonly Used on College Campuses

Drug nameStreet nameFormPsychoactive effectAdverse effects

Cocaine

Blow, snow, king's habit, coke

Snorted, injected, smoked

Stimulant

Hypertension, tachycardia, anosmia, rhinorrhea, bloody nose, paranoia, stroke, seizures

Flunitrazepam (Rohypnol)

Roofies, rophies, roche, Mexican valium, forget-me pill

Pill (taken orally or ground up and snorted)

Central nervous system depressant

Sedation, amnesia

Gamma-hydroxybutyrate (GHB)

Liquid X, liquid ecstasy, soap, easy lay, Georgia home boy, grievous bodily harm, G, goop

Liquid or powder (often mixed with alcohol and other beverages)

Central nervous system depressant

Sedation, euphoria, loss of consciousness, hallucinations, amnesia

Ketamine

Special K, vitamin K, cat valium

Snorted, intramuscular injection

Dissociative anesthetic

Hallucinations, psychosis, nausea, vomiting, hypertension, tachycardia

Marijuana (delta-9-tetrahydrocannabinol [THC])

Pot, ganja, weed, grass, reefer, Mary Jane (MJ)

Smoked (joints, water pipes, bongs, blunts), swallowed

Cannabinoid

Euphoria, palpitations, impaired cognition, sedation, increased appetite

Methamphetamine

Speed, meth, ice, chalk, crystal, glass, crank, fire

Powder (orally, snorted, injected), crystals(heated and smoked)

Stimulant

Palpitations, tachycardia, restlessness, insomnia, anorexia, gastrointestinal upset, seizures, headaches

Methylenedioxymethamphetamine (MDMA)

Ecstasy, E, XTC, X Adam, hug, beans, clarity, lover's speed, love drug

Pill, tablet, or capsule, often of different colors and with cartoon-like images

Multiple

Stimulant, hallucinogen, depression, anxiety, sleep problems


Information from reference 42.

Table 4.

Illicit Substances Commonly Used on College Campuses

Drug nameStreet nameFormPsychoactive effectAdverse effects

Cocaine

Blow, snow, king's habit, coke

Snorted, injected, smoked

Stimulant

Hypertension, tachycardia, anosmia, rhinorrhea, bloody nose, paranoia, stroke, seizures

Flunitrazepam (Rohypnol)

Roofies, rophies, roche, Mexican valium, forget-me pill

Pill (taken orally or ground up and snorted)

Central nervous system depressant

Sedation, amnesia

Gamma-hydroxybutyrate (GHB)

Liquid X, liquid ecstasy, soap, easy lay, Georgia home boy, grievous bodily harm, G, goop

Liquid or powder (often mixed with alcohol and other beverages)

Central nervous system depressant

Sedation, euphoria, loss of consciousness, hallucinations, amnesia

Ketamine

Special K, vitamin K, cat valium

Snorted, intramuscular injection

Dissociative anesthetic

Hallucinations, psychosis, nausea, vomiting, hypertension, tachycardia

Marijuana (delta-9-tetrahydrocannabinol [THC])

Pot, ganja, weed, grass, reefer, Mary Jane (MJ)

Smoked (joints, water pipes, bongs, blunts), swallowed

Cannabinoid

Euphoria, palpitations, impaired cognition, sedation, increased appetite

Methamphetamine

Speed, meth, ice, chalk, crystal, glass, crank, fire

Powder (orally, snorted, injected), crystals(heated and smoked)

Stimulant

Palpitations, tachycardia, restlessness, insomnia, anorexia, gastrointestinal upset, seizures, headaches

Methylenedioxymethamphetamine (MDMA)

Ecstasy, E, XTC, X Adam, hug, beans, clarity, lover's speed, love drug

Pill, tablet, or capsule, often of different colors and with cartoon-like images

Multiple

Stimulant, hallucinogen, depression, anxiety, sleep problems


Information from reference 42.

Table 5 lists common educational and behavioral health issues for college students, and primary care assessment tools that can be used for examination.4,6,7,20,23,25,26,2931,38,4348

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Table 5.

Selected Educational and Behavioral Health Issues in College Students

IssuePrevalenceAssessment toolsComments

ADHD

2% to 8%6,7

Adult ASRS (ADHD Self-Report Scale) Symptom Checklist version 1.1

Educational accommodations (e.g., more time on classroom tests and examinations)

Available at http://www.hcp.med.harvard.edu/ncs/asrs.php

Alcohol use and abuse

Approximately 65%4

AUDIT-C (Alcohol Use Disorders Identification Test–Consumption items)38

One-half of students who drink alcohol binge drink Binge drinking is associated with sexual assault

Anxiety

19%7

GAD-7 (seven-item Generalized Anxiety Disorder) scale Available at http://www.phqscreeners.com

Less than one-half of students with anxiety seek care20

Depression

12%7

PHQ-9 (nine-item Patient Health Questionnaire)

Less than one-half of students with depression seek care20

Available at http://www.phqscreeners.com

Drug abuse

Approximately 21% (of any illicit drug)4

Direct questioning

Includes illicit drug use, inappropriate prescription drug use, and diversion of prescription drugs

Eating disorder

Less than 1%7

SCOFF* Questionnaire44

Only 43% of patients with both bulimia nervosa and anorexia nervosa seek treatment for their conditions43

Learning disability

Approximately 3%7

Multidisciplinary assessment

Educational accommodations (e.g., more time on classroom tests and examinations)

Obesity

Approximately 35%4

Routine measures

Persons with obesity often develop chronic diseases

PTSD

8% to 12%25,26

PC-PTSD (Primary Care PTSD Screen)29

Approximately 50% of persons with PTSD receive treatment45

Sleep disorder

20% to 60%7,30

Insomnia Severity Index46

Common sleep disorders include inadequate sleep hygiene and delayed sleep phase disorder31

Suicidal ideation

6% have thoughts; 1% have made an attempt7

Suicidal Behaviors Questionnaire

Risk factors for suicidal ideation include depression, low social support, parent-student conflict, affective dysregulation, and alcohol use disorders23

Tobacco use

16% (overall)

Routine measures

Long-term health risks associated with tobacco use include lung and heart disease and cancer

Violence

4% (overall)

Partner Violence Screen47

Nonstrangers commit approximately 75% of sexual assaults48

15% to 20% of females and 5% to 15% of males have been raped; 25% are injured, but only 60% were treated48


ADHD = attention-deficit/hyperactivity disorder; PTSD = posttraumatic stress disorder.

*—SCOFF (Do you make yourself sick when you feel uncomfortably full?; Do you worry you lost control over how much you eat?; Have you recently lost more than 14 lb within three months [one stone's worth of weight]?; Do you believe you are fat when others say you are too thin? Would you say that food dominates your life?).

Information from references 4, 6, 7, 20, 23, 25, 26, 29 through 31, 38, and 43 through 48.

Table 5.

Selected Educational and Behavioral Health Issues in College Students

IssuePrevalenceAssessment toolsComments

ADHD

2% to 8%6,7

Adult ASRS (ADHD Self-Report Scale) Symptom Checklist version 1.1

Educational accommodations (e.g., more time on classroom tests and examinations)

Available at http://www.hcp.med.harvard.edu/ncs/asrs.php

Alcohol use and abuse

Approximately 65%4

AUDIT-C (Alcohol Use Disorders Identification Test–Consumption items)38

One-half of students who drink alcohol binge drink Binge drinking is associated with sexual assault

Anxiety

19%7

GAD-7 (seven-item Generalized Anxiety Disorder) scale Available at http://www.phqscreeners.com

Less than one-half of students with anxiety seek care20

Depression

12%7

PHQ-9 (nine-item Patient Health Questionnaire)

Less than one-half of students with depression seek care20

Available at http://www.phqscreeners.com

Drug abuse

Approximately 21% (of any illicit drug)4

Direct questioning

Includes illicit drug use, inappropriate prescription drug use, and diversion of prescription drugs

Eating disorder

Less than 1%7

SCOFF* Questionnaire44

Only 43% of patients with both bulimia nervosa and anorexia nervosa seek treatment for their conditions43

Learning disability

Approximately 3%7

Multidisciplinary assessment

Educational accommodations (e.g., more time on classroom tests and examinations)

Obesity

Approximately 35%4

Routine measures

Persons with obesity often develop chronic diseases

PTSD

8% to 12%25,26

PC-PTSD (Primary Care PTSD Screen)29

Approximately 50% of persons with PTSD receive treatment45

Sleep disorder

20% to 60%7,30

Insomnia Severity Index46

Common sleep disorders include inadequate sleep hygiene and delayed sleep phase disorder31

Suicidal ideation

6% have thoughts; 1% have made an attempt7

Suicidal Behaviors Questionnaire

Risk factors for suicidal ideation include depression, low social support, parent-student conflict, affective dysregulation, and alcohol use disorders23

Tobacco use

16% (overall)

Routine measures

Long-term health risks associated with tobacco use include lung and heart disease and cancer

Violence

4% (overall)

Partner Violence Screen47

Nonstrangers commit approximately 75% of sexual assaults48

15% to 20% of females and 5% to 15% of males have been raped; 25% are injured, but only 60% were treated48


ADHD = attention-deficit/hyperactivity disorder; PTSD = posttraumatic stress disorder.

*—SCOFF (Do you make yourself sick when you feel uncomfortably full?; Do you worry you lost control over how much you eat?; Have you recently lost more than 14 lb within three months [one stone's worth of weight]?; Do you believe you are fat when others say you are too thin? Would you say that food dominates your life?).

Information from references 4, 6, 7, 20, 23, 25, 26, 29 through 31, 38, and 43 through 48.

Special Populations

On college campuses, approximately 8% of students describe their sexual orientation as lesbian, gay, bisexual, transgender, or “unsure.” 7 These students report more harassment and discrimination, and have more negative perceptions of campus climates compared with heterosexual men and women.49 The Gay and Lesbian Medical Association published guidelines for caring for lesbian, gay, bisexual, transgender, and questioning patients, which can be found at http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageId=1037&parentID=568&nodeID=1.

Students who are war veterans demonstrate high levels of suicidal ideation (46%), and many report having a plan (20%) and think that they are likely or very likely to commit suicide (approximately 4%).50 Student veterans with PTSD were more likely to report being in in a physical fight during the previous 12 months, and were more likely to participate in high-risk drinking.51 Student veterans should be monitored for suicidal ideation and PTSD. The Primary Care PTSD Screen is available at http://www.ptsd.va.gov/professional/pages/assessments/pc-ptsd.asp.29 Organizations such as the Student Veterans of America (http://www.studentveterans.org) may help student veterans connect with resources and students with similar backgrounds. eTable A lists resources for student veterans.

View/Print Table

eTable A.

Resources for College Students Who Are War Veterans

ResourceDescriptionWebsite

American Council on Education

Information on academic credit for military experience

http://www.acenet.edu/higher-education/topics/Pages/College-Credit-for-Military-Service.aspx

eBenefits

Benefits and services available to veterans

https://www.ebenefits.va.gov/ebenefits-portal/

Iraq and Afghanistan Veterans of America

Provides health, employment, education, and community resources

http://iava.org/

Post 9/11 GI Bill

Educational benefits provided by the VA

http://www.gibill.va.gov/

Posttraumatic stress disorder treatment program locator

Provides a list of specialized programs available in each state

http://www2.va.gov/directory/guide/ptsd_flsh.asp

Servicemembers Opportunity Colleges

Educational opportunities available to service members

http://www.soc.aascu.org/

Student Veterans of America

Resources and support for student veterans to thrive in postsecondary education and beyond

http://www.studentveterans.org/

Toolkit for Veteran Friendly Institutions

Information to help institutions of higher education build effective programs for veteran students

https://vetfriendlytoolkit.acenet.edu/Pages/default.aspx

ULifeline

Resource center with information on emotional health

http://www.ulifeline.org/

Vet centers*

Information on helping veterans and their families with readjustment counseling and outreach services

http://www.vetcenter.va.gov/

Veterans Crisis Line

Connects veterans in crisis and their family/friends with qualified VA responders through a confidential toll-free hotline (800-273-TALK [8255]), online chat, or text

http://www.veteranscrisisline.net/

Veterans Health Administration†

Information on health benefits, medical centers, social services, long-term care, and more

http://www.va.gov/health/

Veterans of Operations Enduring Freedom, Iraqi Freedom, and New Dawn

Benefits and programs offered by the VA

http://www.oefoif.va.gov/


VA = U.S. Department of Veterans Affairs.

*—Vet centers are available to anyone who served in a combat zone and who received a combat/campaign ribbon.

†—Health care services are available to returning veterans for five years for service-related injuries or illnesses.

eTable A.

Resources for College Students Who Are War Veterans

ResourceDescriptionWebsite

American Council on Education

Information on academic credit for military experience

http://www.acenet.edu/higher-education/topics/Pages/College-Credit-for-Military-Service.aspx

eBenefits

Benefits and services available to veterans

https://www.ebenefits.va.gov/ebenefits-portal/

Iraq and Afghanistan Veterans of America

Provides health, employment, education, and community resources

http://iava.org/

Post 9/11 GI Bill

Educational benefits provided by the VA

http://www.gibill.va.gov/

Posttraumatic stress disorder treatment program locator

Provides a list of specialized programs available in each state

http://www2.va.gov/directory/guide/ptsd_flsh.asp

Servicemembers Opportunity Colleges

Educational opportunities available to service members

http://www.soc.aascu.org/

Student Veterans of America

Resources and support for student veterans to thrive in postsecondary education and beyond

http://www.studentveterans.org/

Toolkit for Veteran Friendly Institutions

Information to help institutions of higher education build effective programs for veteran students

https://vetfriendlytoolkit.acenet.edu/Pages/default.aspx

ULifeline

Resource center with information on emotional health

http://www.ulifeline.org/

Vet centers*

Information on helping veterans and their families with readjustment counseling and outreach services

http://www.vetcenter.va.gov/

Veterans Crisis Line

Connects veterans in crisis and their family/friends with qualified VA responders through a confidential toll-free hotline (800-273-TALK [8255]), online chat, or text

http://www.veteranscrisisline.net/

Veterans Health Administration†

Information on health benefits, medical centers, social services, long-term care, and more

http://www.va.gov/health/

Veterans of Operations Enduring Freedom, Iraqi Freedom, and New Dawn

Benefits and programs offered by the VA

http://www.oefoif.va.gov/


VA = U.S. Department of Veterans Affairs.

*—Vet centers are available to anyone who served in a combat zone and who received a combat/campaign ribbon.

†—Health care services are available to returning veterans for five years for service-related injuries or illnesses.

Student athletes are not only at higher risk of sports-related injuries, but also of loss of eligibility because of inadvertent violation of National Collegiate Athletic Association (NCAA) rules related to the use of supplements, over-the-counter medications, and prescription drugs. Current rules and standards are available at http://www.ncaa.org/wps/wcm/connect/public/ncaa/ssi/policy/drug+testing+landing+page. eTable B lists banned drugs, restricted drugs, and drugs that can be used after a formal medical exception is processed with the NCAA. Athletes should be counseled to clear the use of all dietary supplements and over-the-counter medications with their team medical staff or a physician so as not to inadvertently violate NCAA rules.

View/Print Table

eTable B.

NCAA Banned and Restricted Drugs

DrugStatus

Anabolic agents

Banned

Antiestrogens (aromatase inhibitors)

Banned

Possible medical exception: permitted if required for treatment of specific endocrinopathy

Beta2 agonists

Banned

Possible medical exception: permitted for inhalation to treat asthma

Beta blockers

Banned for rifle only

Caffeine

Concentrations in urine cannot be greater than 15 mcg per mL

Diuretics

Banned

Possible medical exception: if no appropriate alternative available

Glucocorticoids

Prohibited in competition

Possible medical exception: permitted for specific short-term indication

Hormones (growth hormone and erythropoietin)

Banned

Stimulants

Banned

Possible medical exception: for attention-deficit/hyperactivity disorder treatment (strict enforcement)


NCAA = National Collegiate Athletic Association.

Information from National Collegiate Athletic Association. NCAA banned drug list. http://www.ncaa.org/wps/wcm/connect/public/ncaa/health+and+safety/drug+testing/resources/ncaa+banned+drugs+list. Accessed March 20, 2012.

eTable B.

NCAA Banned and Restricted Drugs

DrugStatus

Anabolic agents

Banned

Antiestrogens (aromatase inhibitors)

Banned

Possible medical exception: permitted if required for treatment of specific endocrinopathy

Beta2 agonists

Banned

Possible medical exception: permitted for inhalation to treat asthma

Beta blockers

Banned for rifle only

Caffeine

Concentrations in urine cannot be greater than 15 mcg per mL

Diuretics

Banned

Possible medical exception: if no appropriate alternative available

Glucocorticoids

Prohibited in competition

Possible medical exception: permitted for specific short-term indication

Hormones (growth hormone and erythropoietin)

Banned

Stimulants

Banned

Possible medical exception: for attention-deficit/hyperactivity disorder treatment (strict enforcement)


NCAA = National Collegiate Athletic Association.

Information from National Collegiate Athletic Association. NCAA banned drug list. http://www.ncaa.org/wps/wcm/connect/public/ncaa/health+and+safety/drug+testing/resources/ncaa+banned+drugs+list. Accessed March 20, 2012.

Data Sources: Specific, evidence-based research on college students is relatively limited. We used PubMed as the primary literature search engine. Key words: college student and university student, plus the selected content (e.g., alcohol, tobacco). Key sources of data: American College Health Association, Essential Evidence, review articles in American Family Physician, federal reports on selected content, Cochrane reviews. Search dates: April 2011 through March 2012, and August 2012 through October 2012.

The Authors

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BRIAN K. UNWIN, COL (RET.), MC, USA, is section chief for geriatrics and palliative medicine, Carilion Clinic, Roanoke, Va. At the time this article was written, he was an associate professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

JEFFREY GOODIE, CDR, USPHS, is a board-certified clinical health psychologist, and is an assistant professor in the Departments of Family Medicine and Medical and Clinical Psychology at the Uniformed Services University of the Health Sciences.

BRIAN V. REAMY, COL (RET.), USAF, MC, is associate dean for faculty, and a professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

JEFFREY QUINLAN, CAPT, MC, USN, is an assistant professor in the Department of Family Medicine, and the clinic director of the University Family Health Center at the Uniformed Services University of the Health Sciences.

Author disclosure: No relevant financial affiliations.

Address correspondence to Brian K. Unwin, MD, Center for Healthy Aging, 2001 Crystal Spring Ave., Suite 302, Roanoke, VA 24014 (e-mail: bunwin55@gmail.com). Reprints are not available from the authors.

The authors thank Joshua Girton, associate general council, Uniformed Services University of the Health Sciences, Bethesda, Md., for his assistance with the content on campus violence.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army, Navy, or Air Force Medical Departments or the U.S. Army, Navy, Air Force, or Public Health Service.

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