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Advance directives help students experiencing a mental health crisis

By Susan White

Results from a UNC School of Social Work study suggest that college students diagnosed with a mental illness would support the use of psychiatric advance directives to ensure their needs are met during a mental health crisis. The endorsement was among the findings from a recent feasibility study that gauged student views on the creation of advance directives for crisis prevention and management.

According to the study, students agreed that having some form of legal document that outlines their wishes for treatment and care would enable them to maintain some control over their illness.

“Overall, the results were very positive,” said Anna Scheyett, the project’s lead investigator and the School’s associate dean for academic affairs. “The students liked the idea of being able to be in control of something when they really feel out of control, especially when they first come to college and are far away from people who know them.”

The study, which was funded by the School’s Armfield-Reeves Innovations Fund, involved a small sample size – 40 UNC students – and Scheyett noted the project’s limitations and the need for further research. Still, the study demonstrates that psychiatric advance directives “may be a creative and well-received intervention,” that addresses the specific needs of university students with mental health issues, she said.

Those needs are prevalent among college campuses nationwide. According to the Center for the Study of Collegiate Mental Health (CSCMH), 19 percent of college students in 2008 had experience with counseling services before enrolling in college; 10 percent had used psychiatric medications and 5 percent had spent time in a psychiatric hospital.

Furthermore, an annual survey conducted by the American College Health Association (ACHA) found that more than 18 percent of students in 2006 reported experiencing some form of depression. In 2009, nearly 46 percent of students reported feeling so hopeless at least once within the past year that they were unable to function.

Although suicides are rare among college students, they remain a concern. CSCMH’s study found that 11 percent of college students in 2008 seriously considered suicide prior to enrollment, while 5 percent attempted suicide. UNC is not immune to such tragedies. The campus was shaken last year by the death of a 25-year-old law student who killed himself in his on-campus apartment. According to media reports, family members said the student had been depressed since the death of his father two years earlier.

Because of confidentiality laws, university administrators often struggle with the legal and ethical dilemmas of how to respond when a student shows symptoms of mental illness. Advance directives could help colleges act more responsively to students, Scheyett said.

Advance directives function much like a living will and enable individuals to include in writing as much or as little information as they choose to share about their specific needs and their desires for treatment during a crisis. This information may include symptoms or signs that illustrate a person is having a problem, medication to avoid or the name of a therapist to call. Individuals generally designate who has access to the advance directives, such as hospitals, police departments, friends or family.

“Simply knowing that there is somebody on campus who, in a confidential way, kind of has your back can be comforting, helpful and stress reducing,” Scheyett said. “I think having to actually think about what you would put in one of these documents can be therapeutic because it makes you think about what are my triggers? What do I look like? So the self-reflection and self-awareness are helpful.”

Advance directives have been used in North Carolina since 1997, but Scheyett said she knows of no college or university that has used them to encourage students to proactively address their mental health needs. For her initial study, Scheyett said she was most interested in learning participants’ thoughts on what an advance directive for college students should look like.

“I needed to know what college students concerns would be, what would be the advantages for them and how to tailor it in a specific way to meet their needs,” she said.

Overwhelmingly, study participants agreed that advance directives are “potentially beneficial interventions,” but most also worried about being stigmatized and discriminated against if a violation of confidentiality occurred. Others worried they would encounter problems if they needed to change any instructions on their documents.

Scheyett said those concerns can partly be addressed with technology by enabling students to create electronic versions of their advance directives using a password protected website. That access information could then be stored on a bracelet or tag that students wear and that could readily be available in the case of an emergency. A mental health professional could also contact students regularly to see if any changes need to be made to their advance directives, ensuring that the documents are up-to-date, Scheyett concluded.

With the first phase of her study done, Scheyett is now pursuing grant funding so that she can conduct a randomized trial. In this study, she would recruit students specifically willing to create psychiatric advance directives for themselves. Scheyett would then track their progress for at least one year or longer if there is enough funding to support the study.

“Obviously, you would look at crisis events, but I think I also want to look at things that are a little more proximal,” she said. “For example, there is evidence that shows that advance directives strengthen the alliance between the client and the mental health system in general, and I’d want to look at that. Do students feel better about mental health care and about treatment in general? Do they feel better about their mental health provider? Do they feel more or less stigmatized because of having an advance directive?”

There is also evidence that suggests that people who use advance directives are more adherent with their medication, she added. In tracking these details and the outcomes, Scheyett said she ultimately hopes to learn if having an advance directive could potentially prevent a crisis situation from occurring or at least, decrease its severity.