Abstract
The suicide rate remains the second leading cause of death for young adults and increased by 33 percent between 1999 and 2019.1 Also, it is the fourth leading cause of death among people ages 35-44 and the fifth leading cause among people ages 45-54, making suicide a problem not unique to only the university community; it is problem all across the country.2 The 2021-2022 academic year will also be mentally challenging to students returning to campus and those taking online classes due to COVID-19. The World Health Organization Situation Report published August 1, 2020, reported 4,456,389 confirmed cases and 151,265 deaths.3 However, most universities reopened their campuses in the fall of 2021. As universities may have limited social events, some students, particularly freshmen, may feel isolated. Social distancing can also cause stress levels among students to increase. This research investigates the perception of students about the need and use of telehealth and virtual appointments to provide students additional opportunities to receive the care they need. Most students were born in the information age and welcome technology as a tool to solve problems.4 The authors determined that providers can use mobile platforms to solve health problems. Regarding the full-scale replacement of health services with telehealth, the participants did not believe this was helpful and efficient. The authors determined that if healthcare providers implement telehealth, particularly in remote university campuses and rural areas, it will help to improve behavioral health on university campuses.
Keywords: telehealth, behavioral health, students, COVID-19
Introduction
Nature of the Problem
Within the United States, there has been a mental health crisis going on for years, and we continue to see its prevalence every day. The National Alliance on Mental Illness reports that approximately one in five adults experiences mental illness each year, equating to about 51.5 million people in 2019; the prevalence rate for young adults was the highest.5 Even though nearly 13.1 million of the adult population suffers from severe mental health illness, 8.6 million received treatment, which is about 65 percent.6 The implication is that not having access to care is a significant cause of not receiving the necessary treatment. In fall 2021, many schools are reopening, and some students will go back to campus. Most students may feel isolated while on campus. The older teens and young adults who are transitioning from their inherited families to their chosen families are mostly affected.7 The isolation can lead to difficulty concentrating and decision-making because students may not have the needed face-to-face interaction with their instructors and peers. Some students may increase the use of substances, including tobacco, because they may believe in using such substances as a solution to their problems. Students with existing mental health conditions may experience worsened situations due to limited interactions. Healthcare stakeholders must make it possible for students to receive mental health treatment as colleges observe social distancing.
Purpose of the Research
This research aims to explore various health information and technology approaches and strategies to pursue high-quality medical care delivery for isolated and rural areas, particularly in college towns. Providers can create behavioral health facilities that will use telehealth platforms to help students access the mental health services they need. Telehealth services can be timely and cost-effective and still be able to administer high-quality behavioral healthcare. The primary reason for focusing on isolated colleges is because of a lack of accessibility to a continuum of care. Healthcare providers may not invest in establishing robust facilities in isolated areas where they cannot generate revenues for their investments. Technology, salaries, and other related costs drive facility location strategies. Telehealth might be economical to use in such areas.
COVID-19 can worsen mental health problems across all ages. The World Health Organization (WHO) Situation Report published on August 9, 2021, reported a global 202,138, 110 confirmed COVID-19 cases, and 4,285,299 associated deaths.8 Many colleges and universities plan to have face-to-face lectures starting in fall 2021. Unfortunately, such a mode of delivery requires students to be on campus. Due to social distancing and strict rules to reduce the spread of the coronavirus, many students may feel isolated from friends and families. Mental health issues on campus can increase. This research investigates students’ perceptions regarding the need and use of telehealth, particularly in the coronavirus pandemic period.
Hypothesis and Significance to Healthcare Providers
The null hypothesis is as follows: College students express no support for the use of telehealth for behavioral health care services. Due to legislative changes over the past few years, more people are being treated with telehealth and have insurance to help them receive the treatments they need. However, suicidal ideation and youth depression rates are still rising.9 One of the reasons is due to a shortage of mental health professionals. The Health Resources and Service Administration reported 6,010 mental health professional shortage areas, and 6,849 practitioners are still needed.10 While the amounts of uninsured have dropped, there is still limited access. Thus, the utilization of telemedicine can make a difference.
Background and Literature Review
Overview
A National Institute of Mental Health report shows that nearly half of all mental health illnesses begin by age 14 and 75 percent by age 24. The implication is that college students and young adults are the most likely age group affected by severe mental illness in the United States.11 When the institute used demographic groups to classify mental health, the percentage of mental health patients in the lesbian, gay, or bisexual group was as high as 44.1 percent.12 In 2018, the second leading cause of death for the age group 14-25 was suicide, which can happen due to mental illness.13
Current Environment on Campuses
Mental Health on College Campuses. Research conducted by the University of Michigan on nearly 65000 students at 81 universities and colleges suggests that 35.5 percent of undergraduate students met the criteria for at least one mental health problem. Of that population, only 39.4 percent have received treatment in the past year.14
Research conducted at Franciscan University concluded that of their student participants, 11 percent had severe or extremely severe depression, and 15 percent had severe or highly severe anxiety.15
Many factors cause suicidal ideation on campuses. Research suggests that there is an association between low social support and suicidal ideation. A feeling of hopelessness has a strong association with suicidal ideation.16
Ways to Combat Mental Health
Mobile applications. Current trends within behavioral health are showing that the use of telehealth and telepsychiatry is promising. Results of a study conducted by Hubley, Lynch, Schneck, Thomas, and Shore concluded that patients show satisfaction with telepsychiatry. Also, telepsychiatry is more cost-effective.17
The accessibility of mobile devices allows patients and providers to change the way behavioral health is delivered. The addition of human support on the back end of these applications expands access to care to those who previously could not do so.18 In a review of 21 articles by Lui, Marcus, and Barry, findings suggest that the use of applications and mobile games focused on attention bias is associated with a significant anxiety reduction compared to controlled groups as well as a reduction in depressive symptoms. The review also suggests a substantial decrease in comorbid symptoms.19 In a large-scale empirical research study, evidence suggests the use of mobile or internet-based care increases access to patients. Such mobile devices are a viable treatment for depression and anxiety and become more cost-effective as more patients use them.20 Research conducted on the usability and willingness to suggest an online tool found that those in the treatment group would recommend the service to a friend. The authors found that participants were satisfied with the program, and it helped them deal with their issues.21
Methodology
The authors used a survey as the primary method to collect data on university students who reside on university campuses. The survey was anonymous and randomized. However, it was specifically delivered to college students in colleges isolated from cities. The survey was not tested prior to the distribution. However, the authors believe college students have adequate knowledge to respond to the survey questions correctly for the results to be valid and reliable. The survey focused on personal exposure to mental and behavioral health, usage and knowledge of existing services provided, and comfortability with a telehealth option if provided. The primary data gathered focused on the student perspective of undergraduate and graduate students. Five colleges from three states participated. Of the 200 targeted students, 72 students participated. The response rate was 36 percent. To assure the sample reflects the population, students who consented to participate in the survey provided their school email that was used. However, the survey was anonymous, and the participants’ names and colleges were deidentified.
Students age 18 to 34 could participate. The survey was administered electronically to increase student participation, and the authors sent reminders. Age and gender are asked to be able to get population data of those that completed the survey. Questions about insurance coverage and knowledge on telehealth were helpful to determine the health literacy and insurance coverage of the students on campus.
Results
Seventy-two students randomly participated. Of the responses, 48 were female, and 24 were male, making a 2:1 ratio. The age range of the majority of the respondents was 19 to 21 years old at 55.6 percent. When asked about health insurance, 95.8 percent of respondents marked yes. Freshmen and sophomores made up the majority with 27.8 percent and 30.6 percent, respectively. The next largest group was graduate or nontraditional students at 18.1 percent. Getting into the survey information, 22.2 percent of students had heard of telehealth. Respondents answered that 12.5 percent (nine of 72) had been diagnosed with depression or anxiety (Figure 1).
When asked if someone close to them had problems regarding mental health in the last two years, the authors found that the majority of students, 52.8 percent, have had a friend or family member with mental or behavioral health problems in the last two years. Also, 30.6 percent had personally experienced a mental health issue within the past two years (Figure 2).
When asked if they had ever seriously considered harming themselves, 18.1 percent responded yes, and when asked about taking one's life, 6.9 percent answered yes. These results are represented in Figure 3 and Figure 4.
Regarding knowledge of the services on campus available to students, they responded strongly at 69.4 percent that they knew what services were available, and 15.3 percent had attempted to schedule an appointment at the counseling center. The final questions were to look at the likeliness of speaking to someone at the center or virtually. When asked if they felt comfortable talking to someone at the counseling center, students responded at 37.5 percent for “yes,” 41.7 percent for “maybe,” and 20.8 percent for “no” (Figure 5). When asked about speaking to someone virtually, the “yes” answers increased to 38.9 percent, “no” increased to 30.6 percent, and “maybe” dropped to 30.6 percent (Figure 6).
The final question revolved around the students’ view on a mobile application to intervene with self-harm behaviors. The respondents answered “yes” for the majority at 65.3 percent, followed by “maybe” at 20.8 percent, and 13.9 percent at “no” (Figure 7).
Discussion
Of the responding students, we had 66 percent female and 33 percent male who participated. The result suggests that female students might be interested in solving health issues more than males. When we removed graduate students from the calculation, the ratio remains the same. However, further research and a larger sample size across campuses are needed to ascertain this research finding. When asked if they had heard of telehealth, the majority of students that had were graduate students. Only four of those who responded were undergraduate students. The outcome suggests graduate students are more knowledgeable about treatment options than undergraduate students. When asked if they had been diagnosed with depression, the nine “yes” responses comprised eight females; seven of those eight were either freshmen or sophomores. This population is most likely to be living on campus, so they will be the most critical population to monitor their mental health status. Besides, the outcome suggests some freshmen and sophomores have not yet been fully independent after graduating from high school. The academic rigor and research requirements from instructors might challenge these groups.
When asked about mental health within the last two years, nearly 64 percent have been around someone dealing with mental health problems or have personally had problems with mental health in the previous two years. Though students may know more about mental health, it is ideal for counselors to expose them to react appropriately to mental health situations they experience.
The following two questions were concerning self-harm and suicidal ideation. When asked about serious thoughts about self-harm, 18 percent of the students responded “yes,” and for just undergraduate students, it was 17 percent. This percentage is very close to the 19 percent reported by the National Alliance on Mental Illness. When asked about suicidal ideation, the percentage was 7 percent, which is two percentage points higher than the NAMI reporters of 4.6 percent and lower than the reported age group number of 11 percent for people ages 18 to 25. This lower percentage might be due to the nature of students who participated. Female students participated twice as much more than male students, and the suicide rate for females in the age group is lower than that of males.
When asked about willingness to talk to someone at the counseling center for behavioral health issues, there were 27 responses for “yes,” 15 for “no,” and 30 for “maybe.” That leads to a nearly 2:1 ratio for yes to no. The response demonstrates the desire for students to solve mental health problems when diagnosed. If colleges and universities plan to implement mental health counseling, it must be robust enough to attract most students’ attention. When asked if they felt the need to speak with someone about their mental health virtually when needed, it was split much more evenly at 38.5 percent “yes,” 30.5 percent “no,” and 30.5 percent “maybe.” This result is not very encouraging for the use of therapy sessions on a mobile application, but the result was much different when looking at crises. Students were very responsive to the use of virtual means to intervene in crisis situations, with 65 percent responding “yes” and 14 percent “no.” The response demonstrates that the students believe that virtual means can help someone considering self-harm.
Conclusion
While we do not know for sure that telehealth services would prevent suicide, it was evident that students will be interested in the services. However, some students are unsure about how telehealth will help improve behavioral health. If possible, colleges and universities could include a freshman class on mental health to help students become well-educated on this issue A limitation of the research consists of the low number of participants. The authors plan to increase the sample size to have more reliable findings. Including other colleges from many states could help make future research more valid and dependable. For future research, the authors plan to explore how students’ majors and fields of study influence their desire to use telehealth services.
We propose funding telehealth mobile technology to be a significant portion of federal budgets. Such budgets include those for improving public health informatics and technology. The results may vary as we expand the scope of our future research in other regions of the country.
Third-party payers, particularly the Centers for Medicare and Medicaid Services, could continue to reimburse telehealth providers even after the COVID-19 pandemic. However, government agencies must regulate such services to ensure they are similar to typical provider visits. The authors propose that colleges, universities, and providers could give preferences and more attention to the young adults in the lesbian, gay, bisexual, transgender, and queer group. As noted in the literature review, this group has a higher chance of having mental health issues. In addition to the telehealth treatment options, this group may need counseling and guidance, even on college campuses. The data provided by the National Alliance on Mental Illness was significantly high. If they experience isolation and intimidation on campuses, they risk having mental health issues.
There is also a need to exclude certain patients from participating in the services based on the need for thorough mental health assessments. Though any HCPCS or CPT code can safely and appropriately be rendered at a distance, the authors suggest the following services be excluded from telehealth services: G0425-G0427: Initial Telehealth Consultations
It is also ideal for universities to improve mental health counseling to reduce suicidal rates on campuses. The majority opinion showed that they believe that a crisis situation could be mitigated by using this type of service. We hope that the use of telehealth remotely will improve the treatment of behavioral health issues on isolated college campuses. The authors hope that patients and providers will eventually use telehealth intensively in healthcare if third-party payers approve reimbursements. If students embrace its use in remote areas, it can also become easier for their parents to embrace the services. The authors hope to expand the research by involving more young adult population.
Notes
1. Centers for Disease Control and Prevention. “Facts About Suicide.” Retrieved August 11, 2021. https://www.cdc.gov/suicide/facts/index.html.
2. Ibid.
3. World Health Organization. “Weekly operational update on COVID-19 - August 9 2021.” Retrieved August 10, 2021. https://www.who.int/publications/m/item/weekly-operational-update-on-covid-19---9-august-2021.
4. Pew Research Center. “Millennials stand out for their technology use, but older generations also embrace digital life.” https://www.pewresearch.org/fact-tank/2019/09/09/us-generations-technology-use/
5. National Institute of Mental Health. “Mental Health by the Numbers.” Retrieved August 11, 2021. https://nami.org/mhstats.
6. National Institute of Mental Health. “Mental Illness.” Retrieved August 10, 2021. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml#part_154788.
7. Weissbourd, R. “Young adults hardest hit by loneliness during pandemic.” The Harvard Gazette. 2021.
8. World Health Organization.
9. Lamis DA, Ballard ED, May AM, Dvorak RD. “Depressive symptoms and suicidal ideation in college students: The mediating and moderating roles of hopelessness, alcohol problems, and social support.” Journal of Clinical Psychology. 2016; 72(9):9 19-932.
10. Health Resources & Services Administration. “Shortage Areas." Retrieved December 28, 2021. https://data.hrsa.gov/topics/health-workforce/shortage-areas.
11. National Institute of Mental Health. “Mental Health by the Numbers.”
12. Ibid.
13. Suicide Prevention Resource Center. “Suicide by Age” Retrieved August 10, 2021. http://www.sprc.org/scope/age.
14. Lipson, S K., S Zhou, B Wagner, K Beck and D Eisenberg. “Major differences: Variations in undergraduate and graduate student mental health and treatment utilization across academic disciplines.” Journal of College Student Psychotherapy 30 (2016): 41.
15. Beiter, R, R Nash, M McCrady, D Rhoades, M Linscomb, M Clarahan and S Sammut. “The prevalence and correlates of depression, anxiety, and stress in a sample of college students.” Journal of Affective Disorders (2015): 96.
16. Lamis DA.
17. Hubley, S, S B. Lynch, C Schneck, M Thomas and J Shore. “Review of key telepsychiatry outcomes.” World Journal of Psychiatry 6 (2016): 282.
18. Jonathan, G K., L Pivaral and D Ben-Zeev. “Augmenting mHealth with human support: Notes from community care of people with serious mental illnesses.” Psychiatric Rehabilitation Journal 40 (2017): 338.
19. Lui, J. H. L., Marcus, D K., and C T. Barry. “Evidence-based apps? A review of mental health mobile applications in a psychotherapy context.” Professional Psychology: Research and Practice 48 (2017): 210.
20. Bashshur, R L., G W. Shannon, N Bashshur and P M. Yellowlees. “The empirical evidence for telemedicine interventions in mental disorders.” Telemedicine and E-Health 22 (2016): 113.
21. McCall, H C., C G. Richardson, F D. Helgadottir, and F S. Chen. “Evaluating a web-based social anxiety intervention among university students: Randomized controlled trial.” Journal of Medical Internet Research 20 (2018)
Author Biographies
Joseph Ollio is the first graduate of the Master’s in Health Information Management program from Slippery Rock University.
Abel Gyan is an associate professor and the director of health information management in the School of Business at Slippery Rock University.
Edith Gyan is a registered nurse at the U.S. Department of Veterans Affairs where she works in the psychiatric unit.