How to be a Successful College Student

It's Labor Day and kids are getting ready to go back to school.  The Shrink Rap duck pictured here is getting in his last moments of holiday relaxation, and I am so happy to be up and running on my new Macbook pro.

Here at Shrink Rap, we don't offer medical advice, so this is not medical advice.  It's not based on anything even vaguely resembling evidence-based medicine, but I have treated many college students over the years and I have been impressed by those things that seem to make or break the college experience.  Back-to-School, but none of us treat the under-18 crowd, so my bullet point suggestions are limited to college students.  If you're a parent, feel free to send this to your college student, and if you're a student, feel free to ask "Who are those blogging shrinks with the duck? They must be quacks." 

Here are my quick & dirty pointers for how to succeed in college:

1) Show Up.
Being present in class, on time, in a state that vaguely resembles conscious is most of the battle.
If you don't go to class, with the exception of the unanticipated onset of a febrile or gastrointestinal illness, then you should know well in advance that you're not going to go and have a strategy for how you are going to make up the work.  By these criteria, "I don't want to get out of bed" doesn't work.  But "The professor doesn't speak English and lectures straight from the book, so it's a better use of my time to read the book and get notes from my roommate who takes great notes," may be a valid reason to skip class.

2) Don't smoke weed.
This is a tricky one-- many college students smoke weed (or at least those who end up my office almost all do).  Some people smoke marijuana regularly and still seem to live fully productive lives.  Some people seem to find it very "beneficial" to them even though it appears to be killing their motivation and decreasing their anxiety to the point where they have no ambition, barely move,  and don't do the things it's necessary to do in order to succeed, for example #1 above: Show Up.  Oddly enough, marijuana smokers do not see the connection between their  low motivational level and their low success status and they are absolutely sure their consumption of marijuana has nothing to do with their problems.  They become very skilled at telling others why weed isn't part of the problem and many are quite well versed on the rhetoric of NORML and how the it's a political agenda to keep marijuana illegal.   If you're not successful and you smoke weed, stop and see if your life gets better.  Oh, and by the way, two weeks off is not a 'trial.'  Don't smoke at all, ever, for 6-12 months and see if you're in a better place.  If you are successful and you smoke weed, you're probably not reading this article, but even in the best scenarios, it increases your risk of lung cancer and it causes the munchies which can make you fat, and if you get caught and arrested it's a lot of explaining to do for a very long time.   

3) College Students and Drinking.
This is even trickier because while there are college students who don't smoke weed, the role of alcohol in college life is huge and the pressure to drink is immense.  It's not legal if you're under 21, it seems to lead to all sorts of problems, but it seems to be an impossible sell to college students, so let me make suggestions based on the assumption that there is nothing I can say that would stop anyone from drinking:
--Don't drink on any night when you need to be somewhere the next morning.
--Don't drink enough that you vomit, pass out, or black out.
--Don't drive after you've had anything to drink: being dead is a lot worse than not finishing college.
--Keep your total consumption under 15 drinks a week for a man and 8 drinks a week for a woman.
--If you can't keep abide by the above suggestions, you have a problem and should get help.
NPR had an interesting show on Why College Students Drink So Much and Party So Hard about a book by Thomas Vander.
Add to the How to Stay Alive Issue :  Before you go out drinking, Eat.  If your friends pass out, roll them on their side and don't ever leave someone who is passed out alone.  If they really can't be aroused to at least push you away and groan, call an ambulance.  Don't do shots.  Beer pong is more fun and much safer. Don't drink in settings where you may be sexually vulnerable.

4) Get enough sleep.
If this means not scheduling early classes or taking naps during the day, then consider those things when you set your schedule, but sleep is really important.

5) If you have a psychiatric disorder, don't stop your treatment.
It's not unusual for kids to try this when they go off to college and don't have the 'rents handing them medications or driving them to therapy appointments.  It's a really bad idea.  Particularly bad times to cease treatment are first semester Freshman year and any year during mid-terms or finals.    I'll add: if you have a psychiatric disorder, don't drink, it makes everything worse.

6) Take a large, heavy brick and throw it through your Nintendo/PlayStation/XBox.
  Ditto for online fantasy games.  Anything outside of school work or employment that captures you for more than two hours a day may be a problem.  Reading psychiatry blogs is fine.

7) If you're a sensitive or problem child, don't have a roommate who shares the same bedroom with you, it adds to the stress of college and it's helpful to have space you can escape to.

8) If you're having a rough time, get help.
If you're struggling in class, talk to the professor and consider getting a tutor.  If you're very depressed, call the counseling center.  If you're feeling sick, go to the health center.  College is not the time to suffer alone.

9) Know the final drop date for your classes and if you're failing, drop the class.  Remember to turn in the form.

Anyone want to add to the list?
Best wishes for a happy, fun, and educational school year.

Go to iTunes U and Become a Psychiatrist

An interesting convergence of themes occurred today, from three separate threads. From this remarkable thematic convergence, I have come to the conclusion that one can become a psychiatrist just by sleeping.  Please, follow along.

I couldn't fall asleep last night and could no longer focus on writing a chapter for our book, and so was cruising iTunes U, looking to see what sort of interesting lectures they had there.  (Yes, it is ironic that, despite my above-stated conclusion, I was already a psychiatrist yet could not sleep.)

If you aren't familiar with iTunes U, they make audio and video podcasts of

 college lectures from MIT, Yale, Stanford, and other participating universities, available for free. No enrollment fee. No 8am lectures. No uncomfortable chairs. Alas, no credit, but you get to learn for free.

Believe it or not, I spent 45 minutes watching a Stanford engineering course on Fourier transforms -- and didn't fall asleep!  At 3:00 AM!!  Thank you, Brad Osgood (iTunes link HERE).  I did not take any notes, btw.

So, that was the first thread.  

After a fitful four hours of sleep, dreaming of wavelengths and lambda, I begin my Sunday morning with blueberry and ginger pancakes.  Since this is 2009 and all, I am reading -- not the Sunday paper -- but the Sunday blogs and news on the computer.  I come across a post by a fellow psychiatrist blogger in the Netherlands, DrShock, about a just-published article from Computers & Education, entitled "iTunes University and the Classroom: Can Podcasts Replace Professors?", and written by SUNY psychologist, Dani McKinney et al.  This was a very interesting second thread, which related to the first.  What Dr McKinney did was have two different groups of psychology students receive a lecture on "perception."  One group attended a traditional class lecture and the other received the lecture as a podcast.  They were later tested on their recall of information from the lecture.  Alas, there was no random group assignment, which is a relative weakness of the study design.  

But the findings suggest that a podcast lecture provided more opportunity to re-listen and take notes than the live lecture, as the podcast group scored significantly higher than the live lecture group.  Of those students who took an average amount of notes, the podcast students scored an average letter grade (10 points) higher than the classroom students.  (If you'd like a copy of the entire article, you may write Dr McKinney at mckinneyATfredoniaDOTedu.)

Most of the podcast students listened to the lecture more than once, so they had more opportunity to learn the material.  This is one of the benefits of having a recording of the lecture.

Here's what made me go "Hey, wait a minute, this is quite a coincidence!" -- I have had dinner with Dani McKinney before.  She is, in fact, a close friend of one of my close friends.

So, the third thread of this convergence of ideas hits me when I go to Shrink Rap and see that the Google ad on the right sidebar says,

"Be a Psychiatrist.  Advance your career - earn a degree in Psychiatry completely online."

Well, I can see the handwriting on the wall.  THIS is the 7th future trend in Psychiatry.  Online medical degrees.  You don't even need to go to class.  Just listen to the podcast (at least twice for better retention) and take notes while you listen, and you can advance your career in no time.  I suppose if you are really lazy, you could play the podcasts while you sleep.  I'm not sure if there would be adequate retention to pass the tests under this condition, but Dani assures me that she will be testing out this hypothesis with the next group of psychology students.  Wake me up when we get there.  In the meantime, I'm heading over to iTunes U to take some neurosurgery classes.  Reimbursement for procedures is much better than for cognitive services.

Psychiatry Stuff in the New York Times.

Has anyone seen my co-bloggers? I think they've vanished.

I'm still here. Life feels a little weird lately-- my oldest teen, the one who makes all the noise-- went away to college a few weeks ago, and younger teen started at a new school. Things feel a little off-kilter, like there's an odd void. It's more peaceful, and college kid sounds very happy. It's all good, just a little unsettling, and I feel like I need to figure myself out all over again.

With that as an aside, two interesting articles in the New York Times:

In The Bipolar Kid, Jennifer Egan explores the increase in the number of children diagnosed with bipolar disorder, the struggles their families face, the maze of treatments and medications these families explore, and how little we know about this disorder. As a parent, I found it a sad read. As a psychiatrist, well, there's this awareness that some people have stories of really horrendous childhood behaviors and grow up to be just fine. Egan writes:

Most clinicians say they believe that there will eventually be clear “biological markers” of bipolar disorder: ways to see and measure the disease as we can seizures, cancer or hypertension. Scientists are working to identify the genes (there appear to be many) involved in creating a predisposition for bipolar disorder. Brain imaging, still in its infancy, can already detect broad differences of size, shape and function among different brains. The hope is to know early on who is at risk so their condition can be diagnosed and treated as early as possible. Mental illness wreaks brutal damage on a life, crippling decision-making, competence and self-esteem to the point where digging out from under years of it can be next to impossible. And there is also a biological theory for why going untreated might worsen a bipolar person’s long-term prognosis. Epilepsy researchers have found that by electrically triggering seizures in the brains of animals, they can prompt spontaneous seizures, a phenomenon known as “kindling.” Simply having seizures — even artificially generated ones — seems to alter the brain in such a way that it develops an organic seizure disorder. Some scientists say that a kindling process may happen with mania, too — that simply experiencing a manic episode could make it more likely that a particular brain will continue to do so. They say this explains why, once a person has had a manic episode, there is a 90 percent chance that he will have another.

And our former guest blogger, Dr. Ronald Pies, had a short piece in Tuesday's NYTimes: Redefining Depression as Sadness. Dr. Pies talks about the difficulties psychiatrists face in differentiating bereavement from normal sadness, the risks of under-diagnosis and the implications of over-diagnosis. He writes:

Let’s say a patient walks into my office and says he’s been feeling down for the past three weeks. A month ago, his fiancée left him for another man, and he feels there’s no point in going on. He has not been sleeping well, his appetite is poor and he has lost interest in nearly all of his usual activities.

Should I give him a diagnosis of clinical depression? Or is my patient merely experiencing what the 14th-century monk Thomas à Kempis called “the proper sorrows of the soul”? The answer is more complicated than some critics of psychiatric diagnosis think.

My quicky take on his partial vignette, without my usual 2hour psychiatric evaluation, is that it's unusual for someone to seek psychiatric treatment for the first time because of a recent loss-- people generally cry on the shoulders of their friends, talk to their religious leaders, grieve and don't consider this unusual. The subset of people who present to a psychiatrist maybe having a more severe response, or another concern. With the little we know, it sounds to me like this patient has an Adjustment Disorder with Depressed Mood (is it okay if venture a guess based on on a few sentences?) and the patient should be seen often for psychotherapy. I'd give him medications if: 1) he has a history of depression and this looks like a recurrence 2) he's suicidal or unable to function/work 3) he's really insists that he needs a medication and he's intolerably miserable 4) he got no relief after a few weeks of therapy. Oh, and actually, if any of those things were going on, I'd call it Major Depression and not Adjustment Disorder. I just thought I'd stick in my unrequested opinion here, sort of silly given how little we know, but the issue of understandable reactions versus psychiatric illness is one we like talking about here at Shrink Rap.

Virginia Tech Shooting: Final Report

The final report on the investigation of the Virginia Tech tragedy was released in September (see also Washington Post story).

Some of the Recommendations:

11 recommendations by the panel (go to past 2 pages of the pdf), including:

• short- and long-term counseling to affected individuals
• crisis-management training for colleges

7 recommendations about changing privacy laws (last 3 pages), including:

• exempting university clinics from FERPA, so medical treatment info can be released without student's consent;
• adding good faith, safe harbor provisions for certain disclosures;
• reducing privacy rights for "troubled students";
• deeming law enforcement and medical personnel to be "school officials", which permits greater access to students' records;
• consider making all commitment hearing results public information

12 recommendations [.pdf] about changes in college mental health services (beg on pg 53), including:

• system of linking "troubled students" to counseling services on and off campus;
• adequate, culturally-competent community MH services for children and adolescents;
• requirements that professors and resident hall staff report all "aberrant" behaviors to the dean;
• repeated incidents of aberrant behavior be reported to the counseling center and to parents;
• counseling center report all students in court-ordered treatment to the threat assessment team;
• expansion of outpatient MH services statewide to meet community needs

14 recommendations [.pdf, same as above link] for changes (pg 60) in Virginia laws, including:

• extension of time period for temporary detention on an Emergency Petition (EP); allowing ER docs to do EPs (weird, they can do them in Maryland);
• lowering the "imminent danger" standard;
• increase the # of crisis stabilization beds to reduce waiting in ERs;
• assuring the "independent evaluator" has access to "necessary reports and collateral info" prior to the independent commitment eval;
• setting certain standards for the commitment hearings (ones I think Maryland already meets);
• reducing privacy rights for anyone going thru commitment proceedings;
• tightening up involuntary outpatient commitment procedures;
• "the sanction(s) to be imposed on the no-compliant [sic] person who does not pose an imminent danger to himself or others";
• requiring providers to report noncompliance with involuntary outpatient orders

15-minute Med Checks

I noted in today's Northern Star that Dr. Diana Kraft, Northern Illinois University's psychiatrist for 15 years, has retired after being told she must cut back on the amount of time she spends evaluating patients. The side bar in the paper indicates:

"On March 8, Kraft was notified by her supervisor that the time allotted for her to see patients would be reduced from 60 minutes for a new patient to 45 minutes, and 20 minutes for a return patient down to 15 minutes. Incorporating paperwork and dictation, Kraft would only be allotted 30 minutes of face time for a new patient and 10 minutes for a return patient, she said."

I hate it when administrators see patient care as an assembly line which can get speeded up when demand or profits require more efficient widget production. People are not widgets.