Finding Our Lanes: A Roadmap for Collaboration Between Academic Medical Centers and Behavioral Telehealth Companies.

ABSTRACT: Outpatient mental health care in the United States is delivered by an uncoordinated patchwork of public and private entities that struggle to effectively differentiate the care they provide. The COVID-19 pandemic catalyzed transformative changes in this space, including rapid adoption of telehealth and escalating private sector investment to provide services for individuals wishing to obtain care through insurance. In this article, we briefly review the current landscape of ambulatory mental health care. Utilizing Kissick's Iron Triangle model of health care delivery, we compare the relative strengths and weaknesses of academic medical centers and the growing private sector, entities potentially positioned to synergistically foster a mental health ecosystem with improved quality, access, and cost-effectiveness. A roadmap for strategic integration is presented for how academic centers-institutions frequently overwhelmed by patient volume-might leverage partnerships with a private sector eager to utilize novel technology to improve access, demonstrate data-driven outcomes, and advocate for improved reimbursement from payers. We also assess the potential risks and pitfalls of such collaboration. In return, academic institutions can refocus on their strengths, including research, systems knowledge, quality-improvement initiatives, education and training, and specialty clinical care.

Microaggression and discrimination exposure on young adult anxiety, depression, and sleep.

BACKGROUND: Increasing research examines social determinants of health, including structural oppression and discrimination. Microaggression - subtle/ambiguous slights against one's marginalized identity - is distinct from discrimination, which typically presents as overt and hostile. The current study investigated the comparative effects of each exposure on young adult anxiety, depression, and sleep. Race-stratified analyses investigated patterns across groups. METHODS: Young adults (N = 48,606) completed the Spring 2022 American College Health Association-National College Health Assessment III. Logistic regressions tested odds of anxiety symptoms, depressive symptoms, and sleep disturbance in association with microaggression and discrimination exposure. RESULTS: Microaggression and discrimination equally predicted increased likelihood of anxiety symptoms (ORMicro = 1.42, ORDiscrim = 1.46). Discrimination more strongly predicted depressive symptoms (OR = 1.59) and sleep disturbance (OR = 1.54) than did microaggression (ORDepress = 1.24, ORSleep = 1.27). Race-stratified analyses indicated stronger associations between the each exposure and poor mental health in Whites than Asian American, Black/African American, and Hispanic or Latino/a/x respondents. LIMITATIONS: Microaggression and discrimination exposure were each assessed using a single item. The outcome measures were not assessed using validated measures of anxiety, depression, and sleep (e.g., GAD-7, MOS-SS); thus results should be interpreted with caution. Analyses were cross-sectional hindering our ability to make causal inferences. CONCLUSIONS: The findings provide preliminary evidence that microaggression and discrimination exposure operate on health in distinct ways. Racially marginalized individuals may demonstrate a blunted stress response relative to Whites. Treatment approaches must be tailored to the particular exposures facing affected individuals to maximize benefits.

Suicidality associated with decreased help-seeking attitudes in college students: Implications for identifying and treating at-risk students.

Suicide is a leading cause of death in college-aged youth, yet only half of all college students report engaging in professional mental health help-seeking. We examined how the various aspects of young adults' suicidality were associated with their openness to pursue professional mental health care in the future (i.e., "future help-seeking intentions"). Multilevel binary logistic regressions were tested in a sample of 24,446 U.S. college undergraduates with suicidality. The moderating effect of past service utilization on future help-seeking intentions was also tested. Strikingly, young people reporting past-year suicidal ideation, past-year suicidal attempts, and self-reported likelihood of a future suicide attempt demonstrated decreased likelihood of future help-seeking intentions, while those reporting prior diagnosis of a mental health condition and/or past service utilization demonstrated an increased likelihood. Past service utilization also significantly moderated the effect of suicide disclosure, such that youth reporting prior disclosure and prior professional treatment-seeking demonstrated greater odds of future help-seeking intentions relative to those who had disclosed suicidality but never utilized professional services. In order to mitigate the mental health crisis facing youth, further exploration is necessary to understand why students with suicidality do not report openness to seek help. It is also imperative to develop and implement novel strategies to identify at-risk students, understand and alleviate relevant barriers to treatment, and promote positive help-seeking attitudes and behaviors.

Long COVID and psychological distress in young adults: Potential protective effect of a prior mental health diagnosis.

BACKGROUND: Although young adulthood is a period characterized by marked psychological vulnerability, young adults are typically considered to be in good physical health and are therefore understudied with respect to the effects of COVID-19 infection and long COVID. The present study examined associations between post-acute sequelae of COVID-19 (PASC) and serious psychological distress during young adulthood, and tested whether prior mental health diagnosis moderated this association. METHODS: Participants were 44,652 young adults who completed the Spring 2022 administration of the American College Health Association-National College Health Assessment III (ACHA-NCHA). Blockwise logistic regressions tested the odds of meeting the clinical threshold for serious psychological distress. RESULTS: PASC was associated with 53 % increased likelihood of meeting the clinical threshold for serious psychological distress. Among young adults with a prior mental health diagnosis, PASC predicted 36 % increased odds of serious psychological distress; among those without a diagnosis, PASC predicted 81 % increased odds. LIMITATIONS: PASC was assessed using a single self-report item rather than a clinical diagnosis of specific symptomatology. The analyses were cross-sectional and relied on concurrent reports of PASC and psychological distress which precluded us from making claims regarding directionality of the associations. The outcome of generalized psychological distress limited us from generating targeted treatment recommendations. CONCLUSIONS: PASC may confer elevated psychological distress among young adults. The association of PASC to serious psychological distress was stronger in young adults without a mental health diagnosis than those with a diagnosis. Prior experience with mental illness may mitigate the psychological burden of long-term symptomatology.

COVID-19-related direct and vicarious racial discrimination: Associations with psychological distress among U.S. college students.

BACKGROUND: The COVID-19 pandemic has been accompanied by a myriad of racist incidents targeting minorities in the U.S. Young adults are susceptible to direct and vicarious (indirect) pandemic-related racial discrimination. We sought to examine associations between both types of discrimination experiences and psychological distress among college students across different racial groups. METHODS: We analyzed self-reported data from 64,041 undergraduate students from the Spring 2021 American College Health Association-National College Health Assessment. Logistic regression examined odds of severe distress based on self-reported exposure to direct and vicarious racial discrimination. RESULTS: Even after controlling for sociodemographic characteristics and prior mental health diagnoses, there was a significant association between direct discrimination and distress among Asian (AOR: 1.3, p < 0.001), Hispanic (AOR: 1.6, p < 0.001), and Multiracial (AOR: 1.4, p < 0.001) students. Vicarious discrimination was significantly associated with distress among White (AOR: 1.4, p < 0.001), Asian (AOR: 1.4, p < 0.001), Hispanic (AOR: 1.5, p < 0.001), and Multiracial (AOR: 1.3, p < 0.001) students. Further analysis considering distress as a continuous measure revealed a significant association between vicarious discrimination and distress for Black participants (ß = 0.9, p < 0.001). LIMITATIONS: Self-reported variables are susceptible to recall bias. Minority racial group analyses may be underpowered. CONCLUSIONS: Our findings reveal an overall link between both direct and vicarious racial discrimination and distress across several racial groups. Further studies should examine effective mental health interventions and anti-racism initiatives to support students who have experienced direct or vicarious discrimination due to COVID-19.

Strategies for Naming and Addressing Structural Racism in Immigrant Mental Health.

Immigrants account for 13.7% of the US population, and the great majority of these individuals originate from Latin America or Asia. Immigrant communities experience striking inequities in mental health care, particularly lower rates of mental health service use despite significant stressors. Structural barriers are a significant deterrent to obtaining needed care and are often rooted in racist policies and assumptions. Here we review and summarize key pathways by which underlying structural racism contributes to disparities in immigrant mental health, including anti-immigration policies, labor and financial exploitation, and culturally insensitive mental health services. Significant accumulated research evidence regarding these barriers has failed to translate into structural reform and financial investment required to address them, resulting in pronounced costs to both immigrant populations and society at large. We propose specific strategies for addressing relevant structural inequities, including reforming economic and financial policies, community education initiatives, and task-sharing and strengths-based interventions developed in partnership with immigrant communities to promote access to mental health care for populations in dire need of culturally appropriate services. (Am J Public Health. 2023;113(S1): S72-S79. https://doi.org/10.2105/AJPH.2022.307165).

Prevalence and Correlates of Prescription Stimulant Misuse Among US College Students: Results From a National Survey.

Objective: There is a high prevalence of prescription stimulant misuse (PSM) among college students in the United States (US). Preventing and identifying PSM requires an understanding of risk factors and correlates, but large-scale surveys regarding this issue have been lacking. We present the largest multi-institution study to date on the correlates of PSM among US college students.Methods: We performed a secondary analysis of the 2017 American College Health Association-National College Health Assessment (ACHA-NCHA), an annual national survey on the demographics, health, and academic experiences of US college students. Logistic regression models examined associations between past-year PSM in 40,645 undergraduate college students and hypothesized risk factors.Results: PSM was reported in 8% of college students. PSM was associated with past-year diagnosis or treatment of depression (adjusted odds ratio [AOR] = 1.16; 99% CI, 1.01-1.33), anorexia (AOR = 1.44; 99% CI, 1.02-2.03), attention-deficit/hyperactivity disorder (AOR = 1.66; 99% CI, 1.41-1.95), and substance use disorder/other addiction (AOR = 1.79; 99% CI, 1.30-2.46). The odds of PSM were 5.5 times higher for students who endorsed past-month use of "Legal drugs" and 8 times higher for students who endorsed past-month use of "Illegal drugs" than for those who did not. Other factors associated with PSM included academic difficulty, daytime sleepiness, fraternity or sorority involvement, White race, and cis-male gender.Conclusions: This study identifies many potential risk factors for PSM among US undergraduate college students. Targeted outreach, prevention, and clinical management are discussed. As the COVID-19 pandemic has exacerbated psychiatric distress, sleep difficulties, substance use, and attentional challenges among college students, this study may serve as a baseline for future studies examining the impact of COVID-19 on PSM among college students.

Association Between College Course Delivery Model and Rates of Psychological Distress During the COVID-19 Pandemic.

Importance: College students in the US have been heavily affected by the COVID-19 pandemic. In addition to increased rates of depression and anxiety, college students have faced unprecedented stressors, such as geographic relocation and abrupt conversion from in-person classes to online classes. Objective: To study the association between course delivery model and psychological distress among US college students. Design, Setting, and Participants: This cross-sectional analysis used national data from the American College Health Association-National College Health Assessment III data set. Data were gathered from a web-based survey administered from January to early June 2021 to full-time US college students attending 4-year programs. Exposure: Course delivery model was self-reported. Main Outcomes and Measures: Psychological distress was measured using the Kessler Screening Scale for Psychological Distress. Results: This study evaluated 59 250 full-time undergraduate students (68.1% women; 51.5% White students; mean [SD] age, 21.2 [4.3] years); 3.5% attended fully in-person classes, 61.2% attended fully online classes, and 35.3% attended a mixed format of in-person and online classes. Students who attended classes fully online reported higher levels of psychological distress than those who attended a mix of online and in-person classes (b = 0.76 [99% CI, 0.64-0.88]; P < .001). This association remained significant after controlling for geographic region, year in school, gender, race and ethnicity, food security, current anxiety and/or depressive disorders, COVID-19 concerns, and residence (living on campus, off campus with family, or other off-campus arrangements) (b = 0.18 [99% CI, 0.04-0.31]; P = .001), as well as time spent socializing with friends (b = 0.13 [99% CI, 0.002-0.26]; P = .009). Conclusions and Relevance: The findings of this study suggest that mental health professionals may wish to consider the association of course delivery models with mental health outcomes when working with college students. Colleges should be aware of the mental health burden associated with attending fully online classes and consider possible in-person components and supports for students.

A phase I dose escalation, dose expansion and pharmacokinetic trial of gemcitabine and alisertib in advanced solid tumors and pancreatic cancer.

PURPOSE: Aurora Kinase A (AKA) inhibition with gemcitabine represents a potentially synergistic cancer treatment strategy via mitotic catastrophe. The feasibility, safety, and preliminary efficacy of alisertib (MLN8237), an oral AKA inhibitor, with gemcitabine was evaluated in this open-label phase I trial with dose escalation and expansion. METHODS: Key inclusion criteria included advanced solid tumor with any number of prior chemotherapy regimens in the dose escalation phase, and advanced pancreatic adenocarcinoma with up to two prior chemotherapy regimens. Four dose levels (DLs 1-4) of alisertib (20, 30, 40, or 50 mg) were evaluated in 3 + 3 design with gemcitabine 1000 mg/m2 on days 1, 8, and 15 in 28-day cycles. RESULTS: In total, 21 subjects were treated in dose escalation and 5 subjects were treated in dose expansion at DL4. Dose-limiting toxicities were observed in 1 of 6 subjects each in DL3 and DL4. All subjects experienced treatment-related adverse events. Grade ≥ 3 treatment-related adverse events were observed in 73% of subjects, with neutropenia observed in 54%. Out of 22 subjects evaluable for response, 2 subjects (9%) had partial response and 14 subjects (64%) had stable disease. Median PFS was 4.1 months (95% CI 2.1-4.5). No significant changes in pharmacokinetic parameters for gemcitabine or its metabolite dFdU were observed with alisertib co-administration. CONCLUSIONS: This trial established the recommended phase 2 dose of alisertib 50 mg to be combined with gemcitabine. Gemcitabine and alisertib are a feasible strategy with potential for disease control in multiple heavily pre-treated tumors, though gastrointestinal and hematologic toxicity was apparent.

Testing positive, losing a loved one, and financial hardship: Real-world impacts of COVID-19 on US college student distress.

BACKGROUND: The COVID-19 pandemic has taken a particularly heavy toll on U.S. college students. In addition to facing academic-related stress and social pressures, these individuals are now increasingly susceptible to experiences such as contracting the virus, losing loved ones to COVID-19, or facing financial hardship due to the pandemic. The effects of such personal, pandemic-related experiences on young adult mental health - and the inherent racial disparities within these outcomes - remain largely understudied. METHODS: We analyzed 65,568 undergraduate students from the Spring 2021 American College Health Association-National College Health Assessment (ACHA-NCHA). RESULTS: The rates of the aforementioned COVID-19-related stressors were unevenly distributed across racial groups. A logistic regression analysis to identify predictors of moderate and serious psychological distress revealed that participants who had experienced the death of a loved one had 1.14 times greater odds of developing psychological distress (p < 0.0001). Those who experienced financial hardship had an odds ratio of 1.78 (p < 0.0001). Surprisingly, testing positive for COVID-19 was associated with an odds ratio of 0.82 of psychological distress (p < 0.0001). LIMITATIONS: Self-reported measures are susceptible to recall bias and misinterpretation. Exposure and outcome variables were measured simultaneously in this cross-sectional study which limits inference on causality. CONCLUSIONS: Financial burdens and bereavement are especially impactful stressors among college students during the pandemic, whereas contracting COVID-19 seemingly exhibits less impact on distress levels. When addressing student wellbeing, institutions should consider prioritizing the implementation of resources to support individuals affected by pandemic-related financial and familial losses.

International student stressors and mental health during the COVID-19 pandemic: a qualitative study.

OBJECTIVE: To identify stressors affecting international students' mental health during the COVID-19 pandemic. PARTICIPANTS: Twenty-two international students from 10 countries and 17 US institutions participated. METHODS: Participants were recruited from a larger study examining the wellbeing of young adults during the pandemic. RESULTS: Four main stressors were identified: (1) Uncertainty and anxiety induced by decisions and policies in response to COVID-19; (2) Fears regarding xenophobia; (3) Limited understanding by educators and school staff of international students' unique challenges; (4) Greater awareness of racial and cultural identity. CONCLUSION: The pandemic has contributed to additional stressors for international students. Educators and mental health professionals may help support international students' mental health by gaining basic knowledge about common stressors and directly acknowledging the challenges, educating international students on race and racism and supporting anti-racism efforts, and encouraging the creation of shared affinity spaces and increasing psychoeducation to promote resilience.

Implementing Multidisciplinary, Team-Based Care in an Academic Outpatient Psychiatry Department.

This column describes the implementation of a multidisciplinary, team-based model of care within an outpatient psychiatry practice at a large urban academic medical center. The authors outline the process by which the innovative team-based care model was selected, funded, and implemented to address long patient wait times, lack of clinical supports, and dissatisfaction of clinical providers. This column also describes the organizational norms that had to be adjusted or sustained to achieve the intended outcomes of reduced intake wait times and financial sustainability, while ensuring that patients continued to receive high-quality care.

Prevalence and correlates of mental health symptoms and disorders among US international college students.

Objective: This study assessed the prevalence and correlates of mental health (MH) symptoms and diagnoses in international college students in the United States. Participants: The sample included 44,851 degree-seeking undergraduate students (42,428 domestic students and 2,423 international students). Methods: Logistic regression analyses were conducted using international student status to predict MH symptoms and diagnoses from the Spring 2017 administration of the ACHA-National College Health Assessment (ACHA-NCHA). Results: International students were less likely than domestic students to report a diagnosis of anxiety, comorbid depression and anxiety, or other psychiatric diagnoses. International students were more likely to report suicide attempts and feeling overwhelmingly depressed. Conclusions: Among international students studying in the US, lower rates of MH diagnoses despite higher rates of depressive symptoms and suicide attempts mirror similar trends seen in American-born minority students. University campuses should consider culturally sensitive and targeted psychoeducation, mental health services, and outreach programming.

Preexisting Depression and Daytime Sleepiness in Women and Men.

BACKGROUND: Sleep problems can persist following the treatment of depression and remission of symptoms. The extent to which having a previous history of depression may be associated with current daytime sleepiness is largely unknown. METHODS: Data were obtained from the spring 2017 American College Health Association-National College Health Assessment (ACHA-NCHA) survey (92 institutions) which assessed self-reported health in U.S. college students (n = 41,670). Among the sample, 93.5% were 18-24 year of age, and 69.6% women. Logistic regression estimated the association between reported prior lifetime diagnosis of depression and daytime sleepiness from the past 7 days, while adjusting for depressive symptoms and antidepressant use from the past year. Unadjusted and adjusted logistic regression models stratified by gender were performed. RESULTS: Among those who reported problems with sleepiness, 31.6% women and 19.4% men had a preexisting depression diagnosis. Individuals with preexisting depression were more likely than those without this diagnosis to report sleepiness problems (women: OR = 1.4, CI = 1.3-1.6, p < .001; men: OR = 1.2, CI = 1.0-1.4, p < .01). However, this association differed significantly by gender, with women with a preexisting depression diagnosis having a 13.0% greater likelihood of sleepiness compared to men. CONCLUSIONS: Those with a preexisting depression diagnosis, and specifically women, may be at risk for daytime sleepiness even in the absence of current depressive mood-related symptoms. Given that many individuals are at risk for daytime sleepiness, mental health initiatives, including those on college campuses, should incorporate sleep hygiene within their programming.

Priorities for addressing the impact of the COVID-19 pandemic on college student mental health.

The COVID-19 pandemic has already produced profound impacts on college students, with unprecedented directives for student relocation from their college campuses and dormitories mid-semester and coursework that took place through virtual learning. The current disruptions and anticipated potential long-term changes call for immediate prioritization regarding next steps for addressing college mental health and well-being. This viewpoint article highlights two urgent priorities for addressing current college mental health needs: the development of strategies for ensuring mental health service access, and intentional outreach to college students with special circumstances. The current crisis also represents an opportunity for campus administrators, mental health professionals, researchers, and policymakers to leverage innovative models of care as well as identity-related student assets, strengths, and resilience-promoting factors to support students' eventual return to campus and to respond more effectively to future massive disruptions.

Binge drinking and sexual risk behavior among US sexual and gender minority college students.

BACKGROUND AND OBJECTIVES: Binge drinking and sexual risk behaviors have historically been associated with lesbian, gay, bisexual, and transgender (LGBT) adults; however, few studies have described this association among broader sexual and gender minority (SGM) students, who often identify outside of LGBT (e.g., asexual, queer). This study examined the relationship between binge drinking and sexual risk behaviors among SGM versus non-SGM college students. METHODS: A retrospective analysis was conducted with cross-sectional data from the Spring 2017 American College Health Association-National College Health Assessment (ACHA-NCHA) survey among US undergraduates (n = 47,821) across 92 institutions. Binge drinking was measured as more than five drinks consumed the last time the student socialized; sexual risk behavior was measured as the number of sexual partners in the past 12 months. RESULTS: Numerous undergraduates nationally identify as SGM (19.9%), with bisexual (32.7%), other SGM (26.1%), and asexual (25.4%) students comprising the largest subgroups. Prevalent among both SGM (28.1%) and non-SGM (29.6%) students, binge drinking had a significant main effect on the number of sexual partners. A significant interaction effect was observed between SGM identity and binge drinking on the number of sexual partners, such that this association was stronger in SGM versus non-SGM students. This effect remained significant across multiple SGM subgroups. DISCUSSION AND CONCLUSIONS: SGM students are more prevalent and diverse than previously reported. While prevalent overall, binge drinking may be uniquely sexualized among SGM students. SCIENTIFIC SIGNIFICANCE: In the first large-scale study assessing drinking among disaggregated SGM college students, data suggest tailoring alcohol interventions to SGM students, particularly those identifying outside of LGBT.

Perceived COVID-19-related anti-Asian discrimination predicts post traumatic stress disorder symptoms among Asian and Asian American young adults.

OBJECTIVE: This study investigates the prevalence of COVID-19-related discrimination and the extent to which COVID-19-related discrimination is associated with mental health symptoms among Asians and Asian American (A/AA) young adults during the first three months of the COVID-19 pandemic. METHODS: We used data from the COVID-19 Adult Resilience Experiences Study (CARES), a cross-sectional online survey conducted in the U.S. Out of 1,001 respondents, 211 A/AA young adults were analyzed for this study. RESULTS: Sixty-eight percent of A/AA young adults reported that they or their family have experienced COVID-19-related discrimination and approximately 15% of respondents reported verbal or physical assaults. After controlling for covariates including predisposing factors, lifetime discrimination, and pre-existing mental health diagnoses, COVID-19-related discrimination was significantly associated with an increased level of symptoms of posttraumatic stress disorder (PTSD), but not of anxiety or depression. Our study results suggest that COVID-19-related discrimination may contribute to PTSD symptoms among A/AA young adults. LIMITATIONS: This was cross-sectional data which was collected through online and self-report rather than clinical evaluation. CONCLUSION: This finding adds greater urgency to develop and implement policy- and individual-level interventions to reduce race-based discrimination among A/AA.

Clinical profiles of college student patients in a psychiatric hospital.

College students represent a significant portion of patients in a psychiatric hospital. However, limited previous research has examined the clinical profiles of this unique population, especially across both inpatient and outpatient settings. To better understand college student mental health, the current study explored the potentially heterogeneous groups of students admitted to inpatient or treated in outpatient units in a large psychiatric hospital. Latent profile analysis (LPA) was used to identify latent clusters based on mental health-related struggles, measured by the Counseling Center Assessment of Psychological Symptoms-34, a measure specifically designed to assess college students. LPA results identified five underlying clusters: 1) negative affect (NA); 2) NA/alcohol struggles; 3) NA/eating concerns; 4) general distress; and 5) low clinical scores. Students who reported comorbid alcohol-related struggles or eating concerns with negative affect showed the greatest overall distress. The NA/alcohol struggles group was more likely to be inpatient than outpatient. Notably, the NA/eating concerns group, one of the most distressed groups, did not significantly predict higher levels of care, indicating that outpatient students may struggle as greatly as inpatient students. The current study provides new insights into the clinical profiles of the important, yet traditionally understudied, population of college students in both inpatient and outpatient psychiatric hospital settings. Future research on college student patients is imperative to better understand college student mental health from both hospital and university perspectives.

Moving from Cultural Competence to Cultural Humility in Psychiatric Education.

Given the significant, persistent health care inequities encountered by minority populations, health care organizations and training programs have sought to incorporate cultural competency training initiatives. However, the variety of pedagogical models demonstrate the current lack of a uniform standardized curriculum. Limitations of knowledge-based cultural competence initiatives have resulted in a shift toward attitude- and behavior-based "cultural humility." Cultural humility, the ability to maintain an interpersonal stance that is open in relation to aspects of cultural identity that are most important to the patient, expands on cultural competence, which is essential to improving patient care in mental health care settings.