College Psychiatry

[clement]

What are some pluses and minuses of a gig being a psychiatrist for a college campus? Other than low pay likely.
Minuses off the top of my head (and I have a bias against the outpatient world):
1. Likely a fair amount of reading up on adhd and psychostimulant seeking (this is actually in line with my exposure to this cohort w/in a more general adult population and outpatient settings).
2. Higher risk age group for suicide

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[dl2dp2]

The low pay issue is becoming more extreme to the point that they are having difficulty recruiting.

I suspect that college psychiatry as an in-house service will end soon. Multiple startup companies are taking contracts now to do this, and colleges cannot afford to hire quality psychiatrists on their own with very high turnover rates. Some wealthy top colleges will continue to have these services and will benefit from the fact that some psychiatrists like these jobs for personal preferences, but overall these jobs are on the chopping block IMO.

 

[Celexa]

I like treating adults because they are adults and are allowed to and expected to make their own decisions.

Treating from within the college as part of student services always struck me as potentially being the worst of all worlds--patients who are technically adults, but with the additional headaches of the in loco parentis issues that swirl around colleges and universities.

I fully admit whatever biases were instilled in me by the fact that without question, the page I most dreaded getting overnight as a resident was "suicidal student from [big name local university]".

 

[clement]

I like treating adults because they are adults and are allowed to and expected to make their own decisions.

Treating from within the college as part of student services always struck me as potentially being the worst of all worlds--patients who are technically adults, but with the additional headaches of the in loco parentis issues that swirl around colleges and universities.

I fully admit whatever biases were instilled in me by the fact that without question, the page I most dreaded getting overnight as a resident was "suicidal student from [big name local university]".

I agree with the biases instilled and the dreaded, “…From X university” line… At least back in my ER days…Very often this was a post doc from abroad who was under geographically distant parental financial pressure and immigration status pressures…With hard to gather collateral, poor local supports, difficult-to-tease-apart cultural biases favoring minimization of sx.

I do think the college student arena is in many ways better suited for CAP folks despite technically being adult patients.
I’m just noticing a trend in such jobs being posted even by state universities. I always skip over them and wondered what gives?

 

[Sushirolls]

They do what CMH agencies do... Hire an ARNP. Then have their unique twist, the Psych depart has their students do "testing" and once they have a report, the ARNP shells out the stimulant.

 

[calvnandhobbs68]

At least in my experience the ADHD issue didn’t even come up because the university just had a blanket policy that you had to have a neuropsych eval before you even scheduled a psych appointment if there was any question about ADHD. Weeded out a lot of stimulant seeking.

I didn’t get the sense that their psychology department was particularly eager to do this testing though in regards to the above post.

But yeah I’ve always heard that the pay is terrible.

 

[clement]

They do what CMH agencies do... Hire an ARNP. Then have their unique twist, the Psych depart has their students do "testing" and once they have a report, the ARNP shells out the stimulant.

I worked in a county setting where there was an informal understanding that one didn’t need to prescribe stimulants w/o testing but some pressure to make the referrals to the local academic center (which only took private insurance incidentally). The vast majority of college kids w/ no prior hx of such would aggressively seek out the testing, even paying cash. What I found is that some private practice phds (who weren’t burdened with the prescribing) would have a suspiciously low threshold for diagnosing adulthood adhd (the variety which has a decidedly high incidence before the bar exam or mcat).

 

[Sushirolls]

Yep. I'm currently in an environment with a robust PhD/PsyD "testing" and going to PCP to get stims. Don't get me started on that topic.

 

[clausewitz2]

I worked in a county setting where there was an informal understanding that one didn’t need to prescribe stimulants w/o testing but some pressure to make the referrals to the local academic center (which only took private insurance incidentally). The vast majority of college kids w/ no prior hx of such would aggressively seek out the testing, even paying cash. What I found is that some private practice phds (who weren’t burdened with the prescribing) would have a suspiciously low threshold for diagnosing adulthood adhd (the variety which has a decidedly high incidence before the bar exam or mcat).

To be fair, since the idea of neuropsych testing to diagnosis ADHD is nonsense on stilts, insurance rarely pays for it and it is really only happening for people paying cash in general.

 

[clement]

To be fair, since the idea of neuropsych testing to diagnosis ADHD is nonsense on stilts, insurance rarely pays for it and it is really only happening for people paying cash in general.

I guess I was giving some private insurance credence to the academic centers but even then…the testing culture for adults can be akin to methadone mills in ideology.

 

[nexus73]

Broadly speaking, I've had mixed results with psychological testing. Mostly it's been useful in adults to identify intellectual disability diagnosis that was missed for whatever reason in childhood (often good verbal skills and growing up in a small town where everyone just got passed in school). However, I've seen IQ testing results much lower than I expected. For example, someone with a score of 55 who was navigating living on the streets and selling meth, not just delivering etc, but actually a drug dealer, and I suspect this individual's effort on testing was extremely low but the psychologist did not include any sort of validity testing in the IQ test.

I saw a patient with blatant BPD, but who herself wanted an autism diagnosis get said diagnosis from a psychologist after hours of testing. She did not meet diagnostic criteria for ASD, but certainly screamed extremely loudly when you tried to explain that to her.

Also a patient with BPD, anxiety, depression who was adamant she was "psychotic" because she felt like people at work were always judging her; well she sought psych testing on her own and they diagnosed her with psychotic depression based on her self-report of feeling judged in social settings.

I've also seen defense experts in competency evaluations seemingly ignore obvious personality disorders (typically antisocial) and diagnose bipolar disorder, when the person's symptoms were clearly better explained by their antisocial symptoms and they never had anything close to a manic episode (outside of meth use). And they completed and billed for several hours of psych testing to reach their conclusions.

All this to say that psych testing generates a seemingly quantifiable result, but that actually requires the qualitative interpretation by a psychologist. So on the surface some people may get the impression that psych testing provides "the truth" or is somehow the gold standard for diagnosis when the psychiatric clinical interview is unclear, but that's really not true.

Not to dog on all psychologists here. But the qualitative nature of the evaluations provides wiggle room to draw potentially questionable conclusions, like a person with ADHD (who just happens to be paying me cash) does in fact have ADHD, when maybe they don't. But wouldn't it be great to just keep getting super easy cash referrals for ADHD evals?

 

[whopper]

The biggest issues I see ith college students and mental health...
1-substance abuse
2-1% of these students will go schizophrenic, about 4% will go manic for the first time
3-several already had a psych disorder well treated, but are moving out of state so their psychiatrist at home can't treat the person in the state where the college resides.
4-first episode depression especially if the college is in an area with horrendous weather.

 

[clausewitz2]

In my experience if you do FEP work your caseload will be about 40% college psychiatry if that is an enriched enough sample for you, albeit not entirely representative.

 

[clement]

Broadly speaking, I've had mixed results with psychological testing. Mostly it's been useful in adults to identify intellectual disability diagnosis that was missed for whatever reason in childhood (often good verbal skills and growing up in a small town where everyone just got passed in school). However, I've seen IQ testing results much lower than I expected. For example, someone with a score of 55 who was navigating living on the streets and selling meth, not just delivering etc, but actually a drug dealer, and I suspect this individual's effort on testing was extremely low but the psychologist did not include any sort of validity testing in the IQ test.

I saw a patient with blatant BPD, but who herself wanted an autism diagnosis get said diagnosis from a psychologist after hours of testing. She did not meet diagnostic criteria for ASD, but certainly screamed extremely loudly when you tried to explain that to her.

Also a patient with BPD, anxiety, depression who was adamant she was "psychotic" because she felt like people at work were always judging her; well she sought psych testing on her own and they diagnosed her with psychotic depression based on her self-report of feeling judged in social settings.

I've also seen defense experts in competency evaluations seemingly ignore obvious personality disorders (typically antisocial) and diagnose bipolar disorder, when the person's symptoms were clearly better explained by their antisocial symptoms and they never had anything close to a manic episode (outside of meth use). And they completed and billed for several hours of psych testing to reach their conclusions.

All this to say that psych testing generates a seemingly quantifiable result, but that actually requires the qualitative interpretation by a psychologist. So on the surface some people may get the impression that psych testing provides "the truth" or is somehow the gold standard for diagnosis when the psychiatric clinical interview is unclear, but that's really not true.

Not to dog on all psychologists here. But the qualitative nature of the evaluations provides wiggle room to draw potentially questionable conclusions, like a person with ADHD (who just happens to be paying me cash) does in fact have ADHD, when maybe they don't. But wouldn't it be great to just keep getting super easy cash referrals for ADHD evals?

In one high acuity setting where I worked, a lot of adolescent bpd’s wanted to have undiagnosed asd. It was almost a fad even among some adult bpds there.

 

[Candidate2017]

The biggest issues I see ith college students and mental health...
1-substance abuse
2-1% of these students will go schizophrenic, about 4% will go manic for the first time
3-several already had a psych disorder well treated, but are moving out of state so their psychiatrist at home can't treat the person in the state where the college resides.
4-first episode depression especially if the college is in an area with horrendous weather.

Plus everyone endorses "ADHD", "bipolar", "SI" after every breakup, and/or "HI" and shooting up the campus.

In addition to low pay, there's a reason universities, even those affiliated with a psychiatry residency, have trouble filling psychiatry jobs at the campus psych clinic.

 

[Stagg737]

In one high acuity setting where I worked, a lot of adolescent bpd’s wanted to have undiagnosed asd. It was almost a fad even among some adult bpds there.

I saw this in residency on our CAP unit and in the ER where I work frequently and I think it’s more than just a fad. I very often see budding borderlines and young borderlines that claim to be ASD along with a couple other diagnoses/labels. If you delve into it they’ll almost always tell you they think that because they watched TikTok videos or YouTubers and feel like they describe them. Imo, the internet, and specifically social media, has been so harmful for young individuals with certain personality traits and identity disturbances.

 

[clement]

Plus everyone endorses "ADHD", "bipolar", "SI" after every breakup, and/or "HI" and shooting up the campus.

In addition to low pay, there's a reason universities, even those affiliated with a psychiatry residency, have trouble filling psychiatry jobs at the campus psych clinic.

I completely forgot about campus shoot up threats as a potential con.

 

[clement]

yes typically some kind of social media influence and often pathognomonic of bpd in the budding ones (who incidentally tend to live in psych er’s for months). After a while it gets to be too much when you have a shelf of razors stacked in your bra and claim to be asd w/ a straight face. Yes, ego dystonic.

 

[theduderino]

You don't need to work directly for a university to see college/grad students. I work at a private practice and about 25% of my patients are college students. I built relationships with a college health clinic and they send me referrals. They are happy to refer students to the community because they do not have the capacity to do longitudinal care. Some of my practice is psychotherapy and I enjoy the developmental challenges that come with this age group. Many college students have a "baked in" sense of future orientation/goals around their education/career which is a useful anchor when things get tough.

I agree with @dl2dp2 that it doesn't make sense to do this in-house. You'll be part of a huge bureaucratic apparatus that sees you simultaneously as an ancillary cost center and as a liability meat shield in the case of a suicidal/violent/difficult student.

 

[clement]

You don't need to work directly for a university to see college/grad students. I work at a private practice and about 25% of my patients are college students. I built relationships with a college health clinic and they send me referrals. They are happy to refer students to the community because they do not have the capacity to do longitudinal care. Some of my practice is psychotherapy and I enjoy the developmental challenges that come with this age group. Many college students have a "baked in" sense of future orientation/goals around their education/career which is a useful anchor when things get tough.

I agree with @dl2dp2 that it doesn't make sense to do this in-house. You'll be part of a huge bureaucratic apparatus that sees you simultaneously as an ancillary cost center and as a liability meat shield in the case of a suicidal/violent/difficult student.

+1 meat shield 🥩