Opening the Gate for Student Mental Health Needs

From the September 15, 2023 issue of the Transformational Times

Opening the Gate for Student Mental Health Needs

Kevin Bozymski, PharmD, BCPS, BCPP

Dr. Bozymski, a board-certified psychiatric pharmacist, discusses the mental health stressors faced by health care students, and shares his journey of training future pharmacists to become mental health “gatekeepers” for their peers (and themselves) …

Expanding beyond algorithms

When people ask me what I do for a living, it’s not as straightforward as saying teacher or pharmacist—or even the phrase, mental health pharmacist. It usually involves a back-and-forth dialogue, with me imperfectly describing my winding path as the audience inquires, prompts and clarifies. Upon reflection, the emphasis on one-on-one connections is what got me on my path. 

While healthcare practitioners and researchers value the scientific method (me included), I’ve often found algorithms too restrictive. That’s why psychiatry resonated with me as a student pharmacist, where the right pharmacologic choice cannot be made without considering an individual’s preferences, values, and environment.

It’s also why academia called to me as a resident pharmacist, where a “one-size- fits-all” teaching approach does not meet every learner’s preference, needs, and background. 

Unfortunately, it’s easy to fall into the algorithm trap as a teacher when discussing student mental health, especially when we aren’t taking care of our own mental health. We look back in our own life to how we handled stress as a learner, assuming our experience will translate well to another’s. We worry about finding time to dialogue, looking toward rating scales used in clinic appointments as a model for triaging student concerns. This solutions-first mindset shows in our health care learners, as a recent scoping review of medical student literature found fears of decreased career opportunities, nonconfidentiality and personal stigma as the top individual barriers to care.

Before walking in someone else’s shoes, it’s worth asking about their journey so far and how they find themselves now. 

From stress to burnout to on fire 

As the psychiatric pharmacist on faculty within Medical College of Wisconsin School of Pharmacy, I am invited to give perspective about student mental health on many interdisciplinary councils, committees and workgroups. The most impactful discussions, though, come in one-on-one discussions with my student pharmacist mentees. 

These quarterly meetings have a brief agenda,  and are open-ended for me to actively listen and ask: How is your quarterly session going? What has been a surprise since we last spoke? Where do you want your shoes to take you, and how can I help them do so?

It's no secret that the MCW PharmD curriculum is stressful, with students completing four years of traditional coursework in just three. And while it’s unclear to what extent stress correlates to burnout and mental health concerns, published U.S. student pharmacist surveys identify positive response rates of 19% to 40% for clinical depression (via PHQ-9) and 21% to 41% for clinical anxiety (via GAD-7). (see references 2-5)

Furthermore, the American Academy of Colleges of Pharmacy has released a statement encouraging pharmacy schools to proactively promote overall wellness and stress management techniques.

There’s no easy algorithm to determine who develops clinically significant concerns, but it is near-impossible to do so unless a student is connected enough to their academic community to be asked.

Who’s at the gate for mental health care?

Access and stigma are two driving barriers in psychiatry, and certainly student mental health is no exception. Therefore, gatekeeper training—programs teaching how to identify warning signs of mental crises and connect people to needed services—have been spreading across the globe. Such programs are not just for healthcare practitioners, but for anyone with a desire to improve mental health in their area. Thanks to funding from the Kern Institute, the MCW Pharmacy School, and Advancing a Healthier Wisconsin endowment, I’ve had the honor as a certified Mental Health First Aid instructor of teaching 60 first-year PharmD students (so far) how to open the gate for their peers, their communities, and themselves.

While students over the years have commented on its benefits, one anonymous comment from a course evaluation struck me the most:

“These skills were amazing to learn. It has helped with not only my family and friends but also has been used in practice with my peers. To have the ability to learn about what people go through and how to be able to approach and talk to people about a mental health crisis is something everyone should learn.”

If we cannot break down every systematic gate standing between an individual and mental health resources, we can at least ensure the keepers know how to help passersby. And even if my student pharmacist self from over a decade ago does not fully understand the unique stressors of this generation, I can at least dedicate myself to learning from and conversing with them in a non-algorithmic way - using the information gained to better appreciate, reassure, and connect.

After all, with mental health, an imperfect response is better than no response at all.

Take action:

Interested in becoming trained as a MHFA instructor (or just completing MHFA certification yourself)? Please contact Dr. Kevin Bozymski or Dr. Himanshu Agrawal for more information. 

For further reading:

1. Berliant M et al. Barriers faced by medical students in seeking mental healthcare: a scoping review. MedEdPublish (2016). 2022; 12:70.

2. Koutsimani P et al. The relationship between burnout, depression, and anxiety: a systematic review and meta-analysis. Front Psychol. 2019; 10:284.

3. Fischbein R et al. Pharmacy and medical students’ mental health symptoms, experiences, attitudes, and help-seeking behaviors. Am J Pharm Educ. 2019;83(10):7558.

4. DeHart RM et al. Prevalence of depression and anxiety among student pharmacists. Int J Med Pharm. 2020;8(2):1-8.

5. Shangraw AM et al. Prevalence of anxiety and depressive symptoms among pharmacy students. Am J Pharm Educ. 2021;85(2):8166.

6. American Colleges of Clinical Pharmacy. AACP Statement on Commitment to Clinician Well-Being and Resilience. Accessed https://www.aacp.org/article/commitment-clinician-well-being-and-resilience on September 5, 2023.

7. Suicide Prevention Resource Center. Choosing A Suicide Prevention Gatekeeper Training Program: A Comparison Table. Accessed https://sprc.org/wp-content/uploads/2022/12/GatekeeperMatrix6-21-18_0.pdf on September 5, 2023.

8. National Council for Mental Wellbeing. About MHFA: What is Mental Health First Aid? Accessed https://www.mentalhealthfirstaid.org/about on September 5, 2023.

Dr. Kevin Bozymski, PharmD, is an Assistant Professor with appointments in the MCW Pharmacy School Department of Clinical Sciences and the School of Medicine Department of Psychiatry & Behavioral Medicine. He is a certified Mental Health First Aid instructor, providing training through an Advancing a Healthier Wisconsin endowment. He also provides clinical services at both the MCW Tosa Health Center and Froedtert Hospital Complex Intervention Unit.

MCW's Seventh MedMoth Storytelling Evening

  

MCW's Seventh MedMoth Storytelling Evening

MCW MedMoth, a student-initiated and student-led storytelling event, was held on November 30, 2023. Over 100 appreciateive listeners came to support the ten storytellers as they shared tales on everything from the lifelong scars left after shoplifting to lessons learned from running a food pantry program to a death in the ICU. 

Some of the stories will soon be featured on the Medical Education Matters podcast. 

Thanks to the Kern Institute, the Kern Family Foundation, and the Charles E. Kubly Foundation for support of MCW MedMoth over the past four years. These events reflect human centered design principles and character. MedMoth supports students, staff, faculty, and health care professionals in human flourishing and resilience.

Big props to the MedMoth team: MCW students Meg Summerside, Linda Nwumeh, Amber Bo, Meghan Schilthuis, Corey Briska, and Maya Martin, and to Kern faculty/staff Shannon Majewski, Devarati Syam, Adina Kalet, Bruce Campbell, and Cassie Ferguson. 

Look for the next MCW MedMoth evening in Spring 2024!

MCW's Student Assistance Program: Build It, and They Shall Come

From the September 15, 2023 issue of the Transformational Times - Student Mental Health 

Take 3 with Dr. David Cipriano - MCW's Student Assistance Program: Build It, and They Shall Come

Dr. Himanshu Agrawal, co-editor-in-chief of the Transformational Times, converses with Dr. David Cipriano, Director of Student and Resident Behavioral Health at Medical College of Wisconsin, about student mental health services. 

 

As the director of student and resident behavioral health at MCW, what would you say has been the greatest accomplishment that MCW has made in the last five years? 

 

David Cipriano, PhD: I would say that one of the greatest successes we have achieved has been improved accessibility. We accomplished this through increasing the number of sessions that are available to each MCW student at no cost to them (from five sessions to ten sessions per academic year) and through bringing ComPsych, a Student Assistance Program onboard (to increase choices, flexible scheduling and out-of-network care options). This has coincided with an increase in utilization of mental health services by MCW students. Please be on the lookout for a detailed description of these results in an upcoming paper to be published in the Wisconsin Medical Journal. 

 

Our second biggest accomplishment is that we have seen a significant decrease in stigma around mental health in survey data that we have been collecting for several years now. This also undoubtedly contributes to increased utilization of our services.  

 

As the director of student and resident behavioral health at MCW, what will be your top priority for the next five years? 

 

David Cipriano, PhD: We have two top priorities: first, to ensure our clinical services are inclusive and welcoming for all students, including those underrepresented in medicine; secondly, we aspire to increase and improve group offerings. This will include general groups as well as specialty groups.  

 

 

As the director of student and resident behavioral health at MCW, what is the one thing that you wish to say to each student at MCW? 

David Cipriano, PhD: I've said this before and I will say it again — there does not need to be a major crisis or a major diagnosis for you to come to us, to seek help.

The stress of training, moving to a new city, leaving behind your old support system, or any of the myriad of personal situations is reason enough to talk to a therapist for a new perspective, more tools and better coping strategies.

David J. Cipriano, PhD, is a psychologist and an associate professor in the Department of Psychiatry and Behavioral Medicine at MCW. He also serves as the Director of Student and Resident Behavioral Health. 

Have you Heard About the Papageno Effect?

From the September 15, 2023 issue of the Transformational Times - Student Mental Helath

Have you Heard About the Papageno Effect? 

 

Himanshu Agrawal, MBBS, DF-APA 

 

A psychiatrist-psychotherapist shares how his own vulnerability came back to affect him... 

 

It started as a run-of-the-mill psychiatric intake on a Wednesday afternoon. The Milwaukee clouds were weeping outside, as I settled in to listen to a new story. A medical resident was telling me about growing up battling anxiety and depression.  

 

At one point, the resident stopped narrating their social history. I sensed a bit of hesitation and wondered if there was something on their mind that they wanted to share. 

 

“Err…yes, actually there is…. You may not remember this, but last year you wrote an article for Transformational Times (Being Human in Medicine: Fabulous Failures), where you talked about how you did very poorly on your (USMLE) Step 1 exam, and it devastated you. And you maybe were thinking of ending it all, and some random person helped you carry on. Do you remember the essay I’m talking about?” 

 

I bloody well did! Not only was it one of the most emotionally difficult “manuscripts” I had ever put on paper, having received little to no feedback after its publication, I had been left with a lingering sense of awkward embarrassment; that feeling you get when you realize you tried something out of your comfort zone, and it probably fell flat on its face. I had been consumed with doubt ever since — why did I write that piece?! It was inane and out of sync with my surroundings. It had not helped my imposter syndrome at all! 

 

My inner monologue was interrupted by my patient. 

 

“…well, to tell you the truth, I had done very poorly on a similar exam, and I had decided that I would kill myself that Saturday.” 

 

My heart sank as they carried on. 

 

“It’s so bizarre. I usually don’t read the Transformational Times, but for some reason, I ended up reading your article. And suddenly, I decided I wouldn’t kill myself. It was exactly what I needed to hear. As you can see, it took me a little bit longer to come and find actual help. This is such a coincidence that you ended up being the psychiatrist I was assigned!” 

 

I was stunned. The clouds were now weeping inside my office, too, in both ends of the room. Speechless, I am not certain what I mumbled in response.  

 

What I am certain about is that I will never doubt myself about writing something that feels so central to my authentic self. 

 

In scientific literature, we talk about a phenomenon called the Papageno effect, named after a character who loses his love and plans to end his life in Mozart’s opera, The Magic Flute. The suicide is prevented at the last minute by three boys who remind him that there are alternatives to dying.  

 

The reason this effect is named after Papageno is quite simple: For individuals in crisis, the way that the media reports on suicide could have either a positive or negative effect on the individual’s decision. What this complex phenomenon boils down to is this: If an individual struggling with suicidal thoughts and intents reads or hears about someone else who has gone through a similar struggle, but somehow continues living, this may have a positive effect on the individual who is struggling. The protective effect is even stronger if the individual can somehow relate to the person in the story (e.g., how my patient could relate to my story when I was a medical student).  

 

The Transformational Times essay, "Being Human in Medicine: Fabulous Failures," just happens to be a concrete example of this phenomenon in action. Who knows whether a life could be directly or indirectly saved by another essay in the Transformational Times.  

 

Please enjoy. 

 

And please live! 

 

[Please note — owing to the sensitive nature of this essay, the author heavily disguised the (former) patient described. Additionally, the author has the individual’s permission to share this story, which occurred several years ago.] 

 

For further reading: 

 

Hawley LL, Niederkrotenthaler T, Zaheer R, Schaffer A, Redelmeier DA, Levitt AJ, Sareen J, Pirkis J, Sinyor M. Is the narrative the message? The relationship between suicide-related narratives in media reports and subsequent suicides. Aust N Z J Psychiatry. 2023 May;57(5):758-766.  

doi: 10.1177/00048674221117072. Epub 2022 Aug 23. PMID: 35999688; PMCID: PMC10126449. 

 

Character and Caring: A Pandemic Year in Medical Education. Kalet, Adina, et al., eds. Ten16 Press (2021) 

 

Himanshu Agrawal, MBBS, DF-APA, is an associate professor in the Department of Psychiatry and Behavioral Medicine at Medical College of Wisconsin and sees patients for psychotherapy and medication management at the Tosa Health Center. He is a small group facilitator within the Kern REACH (Recognize, Empathize, Allow, Care, Hold) curriculum. He is co-editor-in-chief of the Transformational Times.