Tracking Student Health

BOSTON -- If American universities are spending millions of dollars a year on health services for students, shouldn't they at least know what they're dealing with?

Duh: yes, says James C. Turner, director of student health services at the University of Virginia.

"We have no aggregate data on either the health trends of college students or their utilization of health services," Turner said here at the annual meeting of the American College Health Association. That's why, last year, Turner started the College Health Surveillance Network, which compiles data from volunteer institutions to track how many students are visiting campus health centers, how often and why.

This year and last, Turner's data generated considerable interest at the ACHA conference. The CHSN is a unique project; the only other tool universities have at their disposal is ACHA's National College Health Assessment, which relies on students' self-reporting. CHSN data comes straight from institutional records, which do not rely on memory -- although they do probably understate diagnoses because of variations in the procedures and attentiveness of staff when it comes to coding (the process by which health center staff record student visits and diagnoses).

One attendee from a CHSN institution said he took issue with the validity of Turner's data -- not because the aggregation is faulty, but because the health center staff don't always take the time to assess and document deeper issues like anxiety when a student comes in with a primary complaint that only takes two minutes to address.

"I know that perhaps the reason they came in with the ear pain and the knee pain may have more to do with anxiety," the health official said, "but addressing issues of anxiety may take more time.... I think those of us who supply the data may really significantly under-represent what we do when the diagnoses are there."

Another problem: anxiety might be an issue for the student, but not necessarily meet the criteria for a diagnosis.

But as one attendee posited, perhaps perfect coding isn't the point of this project.

"I think one of the great values of CHSN is building a database so we can look at these trends," she said. "Maybe it's not about the exact incidents or prevalence, maybe it's about building this database that we'll be able to follow over time."

In its second year, the CHSN has grown slightly to include 22 universities (almost entirely four-year research institutions) accounting for 702,000 students. Representation skews slightly East, with eight universities situated in the South, six in the Northeast, and four each in the West and Midwest. The demographic make-up of the students attending those universities, by age, ethnicity and gender, closely mirrors that of their peers nationwide.

CHSN universities reported 289,299 individuals (about 33 percent of the general student population, similar to last year's findings) visiting their health centers 879,787 times in 2011-12.

By category, the most common reasons for visits were respiratory symptoms (89,409 students), birth control (52,852), physicals (21,319) and screenings for sexually transmitted infections (19,899). The only mental health categories on the 20-item list -- anxiety and depression -- rank at 12th and 14th, respectively. (The data include counseling center visits only for those universities where counseling and health services are integrated -- eight of the 22 -- which could result in an under-estimate of mental health diagnoses.)

Looking at the number of visits per patient, however, reveals that mental health issues may require more resources than the above numbers suggest. Despite ranking relatively low in terms of diagnoses per student, those students with mental health disorders accounted for 18 percent of total health center visits.

The top seven diagnoses of students who visited their health centers more than once were all mental health related: eating disorders, adjustment reaction, attention deficit hyperactive disorder, depression, bipolar/psychosis, anxiety disorder, and alcohol.

And, 34 percent of mental health cases are serious illnesses putting students at risk of self-harm or suicide (including depression, eating disorders and bipolar/psychosis).

"Because of better management of mental health conditions, we impact the rest of the campus by minimizing disciplinary problems, improving retention and helping the campus environment," Turner said. "But I worry, can we keep up with the profound demand? The demand for mental health services just seems to be growing almost exponentially."

In addition to documenting the workload mental health issues cause for staff, the CHSN findings reinforced well-documented patterns about the students seeking treatment: they are significantly more likely to be women and/or white.

But Turner noted some findings that surprised him: prevalence of every problem except non-alcohol drug abuse was more common among older students. For anxiety, depression and ADHD/ADD in particular, 22- 24-year-olds were significantly more likely to demonstrate symptoms.

"I think that's probably a pretty significant finding," Turner said. "Maybe older students are a little bit more savvy about seeking appropriate care. Younger students may go back home to seek appropriate care."

Or, an audience member speculated, seniors may be seeking treatment more because they're stressed out about graduation and job searches.

The CHSN data also allows for cross-referencing of different problems, and Turner decided to explore a personal interest. People with certain mental health disorders are more likely to contract an STI because of high-risk behavior, Turner said, but the impact of STIs on mental health is less well-understood.

So Turner pulled data on students with human papilloma virus, the most common STI among students and one that had a potential link to mental health because of its potential to cause cervical cancer.

The sample comprised more than 532,000 students who sought treatment from January 2011 through March 2013. Turner compared the group of students with HPV symptoms (abnormal pap smears, viral warts) seeking mental health treatment to a control group of students with conjunctivitis, ear disorders or routine physicals who also sought mental health treatment.

Turns out, students with an HPV diagnosis are 1.5 to 3 times as likely to be diagnosed with anxiety, depression or an adjustment disorder. Risk also increases by gender (HPV-positive females are 1.4 to 1.6 times more likely to be diagnosed with a mental health disorder), age (students over 21 are 1.6 to 2 times more likely), and locale (students at Western universities were 1.3 to 1.6 times more likely).

"All I can do is share the data; I can't explain why," Turner said of that geographical finding. But of the HPV-mental disorder relationship in general, he said, "I guess that might cause us to ask what other medical conditions we see in our students that might predispose them to mental health disorders."

Findings like that can shed light on effective approaches to therapy and the importance of collaboration between staff, Turner said.

The CHSN data more broadly, particularly the findings related to mental health, could help institutions project their staffing needs, Turner said. Staff from any university -- CHSN member or not -- can explore the data trends by region, age group, gender and ethnicity on the CHSN website.