Promoting a health-centered approach to acute mental health crises on college campuses: The case for collegiate-based emergency medical services

Abstract

As college and university campuses re-open during the COVID-19 pandemic, there is increased concern for mental health crises. Current trends in campus mental health care emphasize providing quality care in a safe, non-judgmental, and non-punitive manner. Collegiate-based emergency medical services organizations are well-positioned to respond to acute mental health crises on college campuses. Campus health professionals and administrators seeking to promote a health-centered approach toward mental health crises should support the growth and development of collegiate-based emergency medical services organizations.

Keywords:

• College-aged populations
• emergency medical services
• healthcare administration
• mental health
• student health

Introduction

Mental health challenges on college and university campuses are increasingly common and well documented.^1–3 College represents a challenging period for many students’ mental health, with notable stressors including academic performance, interpersonal dynamics, and living away from home. Concerns for student mental health have been even greater during the COVID-19 pandemic, which has dramatically altered daily life and limited social support structures.⁴ Recent studies suggest that the pandemic has precipitated an increase in stress, anxiety, and depressive thoughts among some college students.^5–9 The (ACHA) National College Health Assessment, a national research survey, reported an increase from 27% in fall 2019 to 32% in fall 2020 in students that rated overall stress experienced in the last 30 days as high.^6,7 Similar increases were seen with regard to loneliness and suicidal behaviors.^6–9

Acute mental health crises – e.g., panic attacks, severe depressive or manic episodes, self-harm, and suicidal ideation/attempts – necessitate special consideration by campus policy makers as effective care may require immediate intervention. In the campus environment, mental health emergencies have historically been handled by a combination of law enforcement, campus safety, and local emergency medical services (EMS) personnel. There is a growing recognition, however, that mental health issues should be viewed primarily in a medical, rather than law enforcement, context. Calls for change to emphasize the delivery of medical care to those in mental health crises have been especially strong on college campuses.¹⁰ Responding to student voices, college administrations have looked for creative ways to promote student health and safety outside of traditional law enforcement methods. At Stanford University, a new policy was instituted that relies on EMS providers from the Palo Alto Fire Department to transport most students on psychiatric holds to the hospital; previously, students had typically been transported by police officers.¹¹ The greater focus on college mental health is encouraging, but there remains room for innovation in on-campus response to mental health emergencies.

We advocate that on-campus mental health crises should be addressed primarily through a medical lens while acknowledging the important role served by law enforcement and campus safety officers in protecting the safety of patients, healthcare providers, and bystanders. To promote effective crisis response, we advocate for greater consideration of collegiate-based emergency medical services (CBEMS) organizations in the discussion on effective response to on-campus mental health emergencies.

Collegiate-based emergency medical services: an alternative option

There are currently over two hundred CBEMS organizations at colleges and universities across North America.¹² At many institutions, CBEMS organizations are staffed by student volunteers who respond to on-campus medical emergencies. CBEMS organizations are well situated to respond to mental health emergencies for several reasons. CBEMS organizations that respond to emergencies are staffed by fully trained and licensed medical providers, including emergency medical technicians (EMTs) and/or paramedics (EMT-Ps). Student-providers are subject to the same national and state licensing exams, continuing education requirements, and standards as their traditional, non-collegiate-based EMS counterparts. CBEMS providers at the EMT level or higher are trained to perform an initial evaluation of a psychiatric patient, engage in de-escalation techniques, and transport (or arrange for transport) to an appropriate facility for a higher level of care. Importantly, CBEMS providers at the EMT level or higher are also qualified to identify and provide initial treatment for life-threatening medical comorbidities – a capability that is not typically held by law enforcement or campus safety personnel.

Relative to traditional, non-collegiate-based EMS organizations, CBEMS organizations offer distinct advantages for on-campus mental health crisis response. In our experience, we have noted that CBEMS organizations often place special emphasis on training and initiatives related to mental health emergencies and promotion. Perhaps this is reflective of an emerging interest in mental health and wellness amongst young adults.^13,14 Logistically, CBEMS providers are often located on-campus and can arrive at the scene faster, a crucial factor in emergency medical care. Student-providers have intimate knowledge of campus geography and are less likely to get lost in dense college campuses.

Of particular importance for mental health crisis calls, college students may feel more comfortable talking to a CBEMS provider as opposed to local EMS providers. Student EMS providers can leverage their status as peers to create a trusting and productive patient-provider relationship. In addition, CBEMS providers often experience and can identify with many of the same stressors as their patients (e.g. final exams, navigating the college social scene, lack of money, etc.), and are at a similar life stage. We have seen how this common ground can allow student-providers to relate to and connect with their peers, leading to better healthcare delivery. Peer support groups are used in mental health care plans for this same reason, and their use has been shown to reduce symptoms in cases of depression.¹⁵

Lastly, local EMS systems may benefit when CBEMS organizations are available to respond to on-campus mental health emergencies. CBEMS organizations can reduce responses to campus for over-burdened local EMS agencies. When additional care is needed, CBEMS organizations are capable of referring the patient to alternative destinations such as the health center or transporting the patient to an appropriate medical facility.

Concern for student involvement in mental health care

Notwithstanding the advantages of involving CBEMS organizations in on-campus mental health emergency response, there are legitimate concerns about students responding to care for fellow students. Health professionals and administrators may be concerned about the privacy of students. However, in meeting licensing and certification requirements, student-providers receive the same patient confidentiality and HIPAA training and are bound to the same legal guidelines as their non-campus-based EMS counterparts. In our experience, student-providers hold these ethical and legal responsibilities in due regard, meeting their professional expectations.

Beyond privacy, some may argue that traditional, non-campus-based EMS organizations or mental health professionals are better suited to respond to on-campus mental health crises given their level of experience and training. We are not advocating the elimination of either. However, we argue that CBEMS organizations can be an additional, augmenting resource. For cases requiring knowledge outside of their scope of practice, CBEMS providers may consult with physician medical control and mental health professionals, or call advanced life support EMS.¹³

Lastly, there may be concerns for safety in having student-providers respond to mental health emergencies. We maintain that law enforcement and campus safety officers play crucial roles in promoting safety and security in emergency situations. Responding in conjunction with their law enforcement and/or campus safety partners, CBEMS providers can focus on the health and safety of the patient and ensure that the situation is viewed appropriately as a medical issue. Moreover, on-scene collaboration between CBEMS organizations and law enforcement/campus safety can foster meaningful relationships and lead to bidirectional training during which best practices are shared for the compassionate, ethical, and safe care of a patient experiencing a mental health crisis.¹³

Supporting CBEMS organizations as a mental health resource

Many institutions have been reluctant to allow the formation of new organizations or to fully support existing CBEMS organizations.¹⁶ Accordingly, we offer the following recommendations to promote CBEMS organizations as an emergency mental health resource.

Institutions should encourage new CBEMS agencies to form and allow organizations to respond to campus emergencies when licensed and appropriate. Additionally, sufficient funding should be allocated to CBEMS groups to enable them to train more students as licensed providers, expand operational hours, and attend continuing education and mental-health-focused training. In addition, colleges should support advanced training through courses such as QPR Suicide Prevention and Mental Health First Aid.^17,18 Importantly, college health professionals and administrators should provide dedicated time for mutually beneficial training between CBEMS agencies, campus safety, local EMS agencies, police, on-campus mental health resources, local psychiatric emergency resources, and physician support. Harnessing recent developments, colleges and universities should also consider supporting innovative programs in mental health crisis care. Emerging concepts include telemedicine connections to physicians or mental health professionals for in-field consultations, alternate destination programs (e.g., patient transport to a psychiatric center instead of an emergency department), and direct connection to remote or in-person on-campus mental health resources.^19,20

Lastly, administrators should also consider the toll responding to mental health crises may take on the student-provider. Student-providers consistently demonstrate the utmost resiliency and courage when confronted with challenging situations. Resources should be offered to support their mental health. For example, Santa Clara University reserves appointments at their on-campus counseling center for student-EMTs.

Conclusion

In summary, the COVID-19 pandemic has heightened concerns about the mental health of students. Concurrently, there are increasing calls for mental health crises to be viewed in a medical/health-centered context as opposed to a law enforcement one, requiring health professionals and administrators to rethink traditional mental health emergency response. CBEMS agencies are uniquely positioned to offer mental health crisis care, as an additional or augmenting resource, and should be incorporated into crisis response.

Conflict of interest disclosure

Authors have no conflict of interest to declare.

Additional information

Funding

The authors declare no financial support for the research, authorship, or publication of this article.