Evidence to Support Routine Mental Health Screening and Intervention in Graduate Health Sciences Students

Purpose: The prevalence of depression and anxiety is growing in the United States and it is estimated that depression will be the leading cause of illness globally by 2030. Anxiety disorders are the most prevalent of the mental disorders in the U.S. Suicide is the second leading cause of death among people ages 15-34. Many of these mental disorders begin during the adolescent and early adult years with increasing pressure during transition periods, such as the college years and graduate school years, as particularly stressful times. College is a critical time to intervene for young adults facing mental health conditions. According to the National Alliance on Mental Illness (NAMI), more than 75% of all mental health conditions begin before the age of 24. College students face many challenges that may lead to conditions like depression and self-harm thoughts. College students have access to alcohol and drugs, are on their own for the first time, and have several rigorous academic demands. There are long waiting lists for mental health treatment. Despite the United States Preventive Services Task Force (USPSTF) recommendation for depression screening, it is generally not offered due to a lack of resources/mental health treatment for follow-up. Less than 25% of young adults with mental health problems receive treatment and of the college students no longer attending college 64 percent are not attending college because of a mental health related reason.

Methods: The Ohio State University Wellness Onboarding Program for health sciences students across seven colleges was launched four years ago to improve the mental health outcomes, healthy lifestyle behaviors and physical health. A randomized controlled study was completed in 2016-2017 to evaluate the effects of the wellness onboarding intervention. First year graduate health sciences’ students were randomized to receive either an 8 session evidenced-based, cognitive behavioral skills building program delivered by a trained nurse practitioner (NP) student or completion of a wellness plan and wellness resources. The Transtheoretical Model was used to guide this study design. A total of 201 health sciences and social work students participated in the study and 31 Nurse Practitioner (NP) students served as wellness coaches. Valid and reliable measures were assessed with study participants at baseline and two weeks after completing the intervention (Patient Health Questionnaire-9 for depression, Generalized Anxiety Disorder-7 for anxiety, Brief Intervention for Perceived Stress for stress, and Healthy Lifestyle Beliefs and Healthy Lifestyle Behaviors Scales). Descriptive statistics were used to summarize sample characteristics, overall and stratify by intervention groups. Bivariate tests were used to check the balance in sample characteristics between the two randomized groups using t-test for continuous variable (age) and Chi-square statistics for categorical variables. Paired t-tests were used for within-group comparison. The mixed-effects linear modeling for repeated measures were used for between-group comparison. All tests were two-sided with a significance level of 0.05. SAS version 9.4 (SAS Institute®, Cary, North Carolina) was used for all the analyses.

Results: Cohorts 1 (2015-2016, n=93) and Cohort 2 (2016-2017, n=201) consisted of students with a mean age of 24.5 years (SD=4.9) and a majority aged 21-24 years (70.6%), non-Hispanic White (73.6%), never married (86.6%), and no children (94.5%), in good to excellent health (84.6%), and having seen a consistent healthcare provider (58.2%).

Baseline screening results demonstrated Cohort 1(41%) and Cohort 2 (32%) had elevated depressive symptoms; Cohort 1 (28%) and Cohort 2 (45%) had elevated anxiety; 37% in both cohorts were overweight/obese; and Cohort 1 (19%) and Cohort 2 (12%) had elevated cholesterol. Overall seven students reported suicidal ideation on the PHQ-9 question 9.

The students who were randomized to the intervention group had significant increase in healthy lifestyle behaviors (P<0.001) and decrease in anxiety (P<0.001) at 3-month follow-up compared to baseline, while such changes were not observed in the control group. Compared to the control group, the students who were randomized to the intervention had significantly higher healthy lifestyle behaviors (mean difference = 3.56, P<0.05). Although not statistically significant, the students who were randomized to intervention tended to have higher healthy lifestyle beliefs, lower depression score, lower anxiety, and lower stress, compared to the control group. Health coaching at least once a week resulted in healthier lifestyle behaviors and decreases in depressive symptoms and stress.

Conclusion: Using NP students as wellness coaches to deliver cognitive-behavioral healthy lifestyle interventions in institutions of higher learning can improve the health, lifestyle behaviors and well-being of other health sciences’ students. Wellness coaching provides NP students with an opportunity to practice and to gain experience delivering an evidence-based cognitive-behavioral skills building program, which is gold standard evidence-based treatment for mild to moderate depression and anxiety. More large scale clinical trials are needed with health sciences students to provide screening for depression and determine the most effective interventions to improve their health, lifestyle behaviors and well-being, which will equip them with necessary skills to cope with the demands of “real-world” clinicians upon graduation.