Students often and perhaps increasingly experience mental health crises during college (1,2). Less understood is how colleges intervene in response to student psychiatric emergencies (3,4). Several highly publicized incidents of violence by college students—most recently, the shooting of a congresswoman and the killing of several others by a student at Pima Community College in Tucson, Arizona (5)—have heightened public and legislative concern about the adequacy of colleges' responses to students believed to have a mental illness.
This article presents the results of a statewide survey of colleges in Virginia, where issues of college student mental health have received prominent media and political attention since April 16, 2007. That day a student at Virginia Polytechnic Institute and State University, known as Virginia Tech, who had been placed on outpatient commitment 16 months earlier, killed 32 students and faculty and then shot himself (6,7). This study is the first, to our knowledge, to comprehensively examine the range of precautionary interventions taken by colleges to prevent students in crisis from harming themselves or others, including making continued matriculation contingent on participation in mental health treatment. We examine policies that authorize such interventions and the frequency with which these policies are invoked.
A survey was administered by e-mail in the spring of 2010 to directors of counseling centers or administrators with functionally analogous responsibilities at all public (N=15) and private (N=25) four-year colleges in Virginia. A survey was also sent to the central office of the Virginia Community College System because Virginia's community colleges (N=23) do not have counseling centers and to a two-year residential college. Findings from these institutions are reported separately.
Respondents were informed that the survey was sponsored by the Virginia General Assembly's Joint Commission on Health Care in coordination with the state's Commission on Mental Health Law Reform. They were also informed that the survey was voluntary and confidential and that its purpose was to gather information about the adequacy of students' access to mental health services and the ways in which colleges respond to students' mental health crises. Data were requested for the 2008–2009 academic year. The survey was reviewed and approved by the institutional review board of the University of Virginia.
Surveys were completed by all 40 directors of counseling centers at four-year colleges except one, who was at a private college. The survey was also completed by staff at the Virginia Community College System and the two-year residential college. The total number of students enrolled during 2008–2009 in the 63 colleges responding to the survey was 460,211.
Public four-year colleges reported eight student suicides and private colleges reported one student suicide during the 2008–2009 academic year (Table 1). Rates of suicide per 10,000 students were .39 and .13, respectively, for public and private schools. Public colleges reported 67 attempted student suicides, a rate of 6.11 per 10,000 students. Private colleges reported 17 attempted student suicides, a rate of 5.90 per 10,000 students. These, no doubt, are lower-bound estimates, given that they reflect only incidents that came to the attention of campus administrators.
Two colleges reported that a student had been arrested for killing someone. The counseling centers at most public and private colleges had no information on nonlethal or attempted violence by students.
A total of 11,117 students (543.95 per 10,000 students) accessed care at the counseling centers of public colleges, and 2,800 students (846.43 per 10,000 students) accessed care at the counseling centers of private colleges. These figures did not include students receiving care off campus from private providers. Suicidal ideation was reported by 1,025 students (1,208.44 per 10,000 students) who accessed care at the counseling centers of public colleges and 181 students (975.74 per 10,000 students) who accessed care at private colleges. Ideation of violence to others was reported by 334 students (403.54 per 10,000 students) who accessed care at the counseling centers of public colleges and by 17 students (110.61 per 10,000 students) who accessed care at private colleges.
Parents have a strong interest in being involved in their children's health care—in some cases even when the child is legally an adult (8). In the wake of the killings at Virginia Tech, the state General Assembly enacted a statute (Virginia Code Sec. 23.9.2:3.C) requiring every public college to establish policies and procedures requiring the notification of the parent of a student who is claimed as a dependent on the parent's federal tax return and who receives mental health treatment at the institution's student health or counseling center. The condition for which the student is being treated must be serious enough to qualify for civil commitment under the applicable state statute, and notification may be withheld if the student's treating physician or treating psychologist has placed in the student's record a statement that in the exercise of his or her professional judgment, the notification would be reasonably likely to cause substantial harm to the student or another person.
Parents were notified about a child who had caused self-harm in 68 cases at public colleges and in 70 cases at private colleges, for rates of 6.29 and 24.59 per 10,000 students, respectively. Four parents of students at public universities were notified about concerns about a student's overall mental health, independent of a concern about the student's becoming harmful to himself or herself or to others, a rate of 2.09 per 10,000 students. Eighty parents of students at private colleges were notified about overall mental health concerns, a rate of 41.72 per 10,000 students. Two-thirds (63%) of all colleges reported having a policy of attempting to obtain a release from students before contacting their parents, although it is likely that most of these disclosures were legally permissible without the student's consent.
A total of 107 students at public colleges and 48 students at private colleges were admitted to a psychiatric hospital, either voluntarily or involuntarily, in 2008–2009 (6.82 and 18.04 hospitalizations per 10,000 students, respectively). The average length of stay was approximately four days. A total of 58 students (4.97 per 10,000 students) at public colleges and 14 students at private colleges (2.06 per 10,000 students) were admitted to a psychiatric hospital under either a college-initiated emergency custody order (authorizing a maximum period of detention for evaluation of four hours) or a college-initiated temporary detention order (authorizing a maximum period of detention for evaluation of 48 hours).
Medical withdrawal and readmission
A total of 278 students at public colleges and 60 students at private colleges were granted a voluntary medical withdrawal from college for mental health reasons during the study period, rates of 28.67 and 25.18 per 10,000 students, respectively.
Nine (47%) public colleges and 20 (91%) private colleges reported having procedures authorizing involuntary medical withdrawal for mental health reasons. According to one such policy, the college “reserves the right to require a medical withdrawal if the student presents an ongoing, clear, and present danger to self and/or others or shows potential for presenting a clear and present danger and refuses to cooperate with treatment recommendations.” Involuntary withdrawals almost always required that the student receive a medical or psychological examination and that the results be reported to the dean of students.
Four students at public colleges and ten students at private colleges were subject to an involuntary medical withdrawal for mental health reasons during the study period, rates of 1.15 and 3.23 per 10,000 students, respectively. Readmission after medical withdrawal was almost always contingent on verification by the student's clinician that the student was adherent to prescribed inpatient or outpatient treatment during the period of medical withdrawal. It should be noted that five (36%) public colleges and 12 (52%) private colleges reported having procedures barring a student from residing in campus housing for mental health reasons, even if the student had not been subject to voluntary or involuntary medical withdrawal.
Mandated outpatient treatment
Thirty colleges (81%) reserve the right to require college students to adhere to outpatient mental health treatment as a condition of remaining a student in good standing upon readmission after a medical withdrawal or after a disciplinary violation related to a mental health condition. During the 2008–2009 academic year, 20 students at public colleges and 38 students at private colleges were required to continue in treatment as a condition of readmission.
A total of 12 public colleges (86%) and 20 private colleges (87%) reported having required a student to participate in mental health treatment as part of a disciplinary sanction for a violation that could lead to suspension or expulsion and that was determined to be related to a mental health condition. A total of 168 students at public colleges and 251 at private colleges were receiving treatment at the schools' counseling centers as part of a disciplinary sanction, rates of 302.05 and 1,704.01 per 10,000 students, respectively.
In the wake of the killings at Virginia Tech, the Virginia General Assembly passed a statute (Virginia Code Sec. 23-9.2:10) requiring public colleges to establish a threat assessment team that includes members from law enforcement, the mental health system, and university administration. The teams are authorized to obtain criminal history record information and health records for a student who upon a preliminary determination is deemed to pose a threat of violence to self or others or exhibits significantly disruptive behavior or need for assistance. In addition, the threat assessment team and any mental health professional treating a student of concern to the team are advised to agree on the kind of information that the mental health professional will disclose to the team on a routine basis so that it can monitor the student's attendance or compliance with treatment (9).
Threat assessment teams were in existence during the 2008–2009 academic year at all public colleges, as required by law, and at 17 (77%) private colleges, even without a statutory mandate. A total of 204 students at public colleges and 83 students at private colleges were monitored by a threat assessment team during that year, rates of 15.31 and 51.26 per 10,000 students, respectively. Mental health issues were a significant factor in 162 (56%) of the active cases of the threat assessment teams.
Virginia Community College System Policy 6.4.0 states that community colleges do not provide mental health services. Without access to a counseling center on campus, students at two-year community colleges seeking treatment must avail themselves of services at public mental health centers or seek care with private providers if they have sufficient financial resources or insurance.
Without on-campus mental health services, community colleges have a limited capacity to respond to mental health crises. For example, only six (27%) community colleges reported having procedures for involuntary medical withdrawal, compared with seven (47%) public colleges and 20 (91%) private colleges. Only one emergency custody or temporary detention order was initiated by a community college during the survey period. No student who had withdrawn for medical reasons from a community college was required to continue in outpatient mental health treatment as a condition of readmission. Eighteen (75%) community colleges, however, reported having a campus threat assessment team; the 11 community colleges that provided information about the number of students currently being monitored by a threat assessment team reported a mean of approximately six active cases.
Only nine suicides were reported among the almost 300,000 students enrolled at Virginia's four-year colleges during the 2008–2009 academic year. Attempted suicide, occurring 84 times, was much more prevalent (10). Only two of the 40 four-year colleges surveyed reported that a student had killed another person, but few colleges had information about students' nonlethal or attempted violence to others.
The overall annual rates at which students at four-year colleges in Virginia accessed care at the counseling center—approximately 5% of the student body at public colleges and 8% at private colleges—are roughly in accord with national data (8). Suicidal ideation among students who accessed care at the counseling center was common (12% at public colleges and 10% at private colleges). Ideation of violence to others among students who accessed care at the counseling center was much less prevalent (4% at public colleges and 1% at private colleges).
The procedures most frequently relied upon by both public and private colleges to obtain student adherence to mental health treatment were voluntary medical withdrawal, treatment at the counseling center as part of a disciplinary sanction (in lieu of being suspended or expelled from college), and monitoring by a threat assessment team. Rates of voluntary medical withdrawal at public and private colleges were comparable, but the rate of receiving treatment at the counseling center as part of a disciplinary sanction was five times higher and the rate of monitoring by a threat assessment team was three times higher at private than at public colleges. In addition, private colleges were much more likely than public colleges to notify parents of concerns about students' harming themselves or others or about students' mental health more generally.
Survey responses not reported in this article indicate that differences in rates of intervention are related to differences in service capacity of public and private colleges: On average, staff-to-student ratios in student affairs offices are three times higher in private colleges than in public colleges. Similarly, the ratio of clinicians to students in counseling centers is about twice as high in private colleges as in public colleges. Differences in rates of intervention may also reflect a greater willingness by private colleges to take a hands-on, protective stance toward the well-being of students.
The lack of a counseling center at all two-year community colleges severely limits their capacity to respond to concerns by faculty, administrators, or students about the mental health of possibly troubled students (11). Community colleges lack not only ready access to treatment providers but also on-site expertise in evaluating students in need of treatment and making appropriate referrals. Given the shortage of professional resources, it is unlikely that they have sufficient capacity to carry out the task of threat assessment with the requisite skill, notwithstanding a statutory mandate to do so.
Most four-year colleges in Virginia, both public and private, occasionally invoke a variety of protective interventions to respond to apparent mental health crises experienced by their students, but the number of students annually affected by these policies is generally small. The main value of procedures to mandate or leverage treatment in college may be to motivate students with mental illness to seek treatment voluntarily. Aside from sporadic use of threat assessment teams in extreme instances, community colleges lack the capacity to undertake any of these interventions. Anecdotal evidence suggests that these patterns are not limited to Virginia (12).
The survey was sponsored by the Joint Commission on Health Care of the Virginia General Assembly in coordination with the Virginia Commission on Mental Health Reform and supported by the John D. and Catherine T. MacArthur Foundation's Research Network on Mandated Community Treatment. The authors gratefully acknowledge the assistance of Jennifer Allman, M.S., Patricia Lunt, Ph.D., Natalie Morris, M.P.P., Kim Snead, B.S.W., M.P.A., and Michael Turner, M.Ed.
The authors report no competing interests.