Going to College With Bipolar Disorder - Part I

In 2011, the International Bipolar Foundation Foundation published the online book: Healthy Living with Bipolar Disorder. At that time, I contributed the chapter "Going to College With Bipolar Disorder." IBPF is currently in the process of publishing a second edition of the on-line book. It should be available on their website in early 2017.

At this point in late fall, the majority of high school students are in the process of submitting applications for their 2017-18 college enrollment. It thus seemed timely to offer the revised version of the IBPF book chapter through this blog. For those who have followed my blog writings, there isn't much in the material that has not been addressed elsewhere in this blog, but for new readers, it does represent a consolidation of many of the issues pertaining to the experience of university and college students with bipolar disorder.

The chapter has been divided into Part I and Part II and is reprinted below with permission of the International Bipolar Foundation.

The Desire to Leave the Diagnosis Behind

The transition from high school to college is an exciting time. For many, it’s their first extended time away from home; as well, the first big step towards adult identity where one is less defined as the child of Mr. and Mrs. Parent. This is a time of intense striving towards autonomy and individuality. It’s also a time of modifying existing identifications based on new attachments and group affiliations.

These new beginnings also give rise to hope for new outcomes. It’s not uncommon that a graduating high school senior will want to leave his or her mid-adolescent difficulties behind while getting a fresh start in a new college environment. Some of that intention is warranted. After all, college is one of the more striking “new beginnings” that most encounter in late adolescence. However, the big disappointment here is that the same kind of new beginning doesn’t apply to bipolar disorder.

While it is true that college students will gradually settle in to their new college student identity, it’s also true that students’ bipolar reality will accompany them into their college environment. It’s not something they get to leave behind. A fresh start with bipolar disorder really means revisiting one’s approach to treatment and deciding what’s most appropriate for the next stage of development.

Considering the Best Choices for a College or University

It’s important to note that smaller institutions of higher education, particularly those without large graduate programs, are often referred to as “colleges” whereas larger institutions with much broader ranges of academic programs and graduate schools are typically referred to as “universities.” Sometimes we see that these different terms are even used interchangeably. For simplicity sake, the remainder of this chapter will refer to the generic term “college.” It should also be noted that whether referring to a college or a university setting, the advice pertaining to higher education with bipolar disorder applies equally to both.

For the high school student who has already been diagnosed with bipolar disorder, selecting the right college is no simple matter. The choice doesn’t just reflect strength of the college’s reputation, its unique areas of study, or even whether the school provides adequate student aids and scholarships. Equally important, if not more so, is finding an environment that will be optimal for maintaining emotional and psychological stability.

Close to Home or a More Distant School?

When deciding near or far, we look to the student’s recent history of stability as an indicator of the kind of support network that will be necessary at college. If relatively stable for the last year or two without hospitalizations or frequent medication changes, then perhaps being close to home is not as important. With a good track record of sustained stability, attending schools that are a few hours or even a few states away from home are reasonable options. That said, bipolar disorder is also characterized by unpredictability. One can have a sustained period of stability and also find that things go off the rails without warning. Therefore, wherever one goes to school a “rapid- response support plan” involving family should always be in place.

If more recent management of bipolar symptoms has been difficult and the student is struggling with instability while applying for college, then perhaps a community college setting or a four-year school fairly close to home would be a better choice. The real issue here is the extent to which one may need to rely upon family support as part of his or her essential support network. If the best choice–home or away–is unclear, there's no reason why one couldn't begin attending a community college and then transition to school away from home once stability has been demonstrated. Besides, transfer acceptance to a four-year school becomes easier when one has shown a year or two of strong performance at the community college level.

Mental Health and Psychiatric Resources at Today’s Colleges

These days, most universities provide counseling and psychiatric services for their enrolled students. More commonly, these services are provided within the same department, usually named something like Counseling and Psychological Services. At some universities counseling and mental health may actually be split into different service units. There may be a university Counseling Center and a separate unit such as Student Health, Mental Health Services where psychiatrically oriented treatment is provided. However the latter configuration is typically not the norm.

Regardless of what the services are called it will be important to investigate what is offered and where it will be found. For purposes of this continued discussion, the generic phrase, “university counseling center,” will be referred to as if it were a full-service treatment setting.

For any student the choice of where to go to college is crucial. For students with bipolar disorder, it’s imperative to investigate the scope of services available through a college’s counseling center before making any commitment to attend. If those resources are minimal or without a clear psychiatric component, then one should also make sure good psychiatric services are accessible in the nearby community.

This isn’t to say that mental health treatment resources should be the primary criterion for college selection; but for bipolar students, it really should be high up on the list of priorities. Clearly a bad choice would be to attend a college where access to psychiatric services was limited, both at the college and in the local professional community. Excellent treatment resources should always be readily accessible for those with bipolar disorder.

One caution: University counseling centers are typically faced with higher student demand for services than they are easily able to provide. Therefore, it is common that university counseling centers primarily provide short-term counseling with focus upon stabilization and community referral for long-term help, if needed. Since bipolar disorder is typically an ongoing condition, students should not be surprised if counseling center professionals want to refer them into the local community for longer-term treatment. These practices will vary from one school to the next, but if counseling center professionals talk about a referral, this must not be taken as a rejection. It's simply the reality of limited resources that many counseling centers are facing today. There’s also an inherent benefit to a private referral. Given the brief treatment focus of many university counseling centers, a bipolar student may not be able to see the same provider over an extended period of time. If one is fortunate to obtain a good psychiatrist and psychotherapist in the local community, then this treatment team can be in place for the duration of college enrollment. Continuity of treatment is a good thing.

Important Preparatory Steps Before Arriving at School

Once a college has been selected there are a few more steps the bipolar student should take to assure a smooth transition. First, it is recommended that the student contact the university’s counseling center either before arriving on campus or shortly afterwards, and make an initial appointment to see a counselor, even if things are going fine. Another good strategy is to set up a meeting during the summer orientation prior to first year enrollment. By doing so, the student is able to establish a personal connection with a mental health professional which will enable rapid access to help if needed for future bouts of instability. It's also far easier to accomplish this at the beginning of the semester than two thirds of the way into the semester when counseling centers have become quite busy responding to the high volume of other students seeking help.

When transferring treatment the student should also sign a release allowing his or her previous treating psychiatrist to forward copies of medical records to the counseling center, new psychiatrist or community-based, mental-health professional. With this information in hand, any new psychiatrist or psychotherapist can easily review previous treatment history in order to best serve the student in the new location.

Students should be aware that their medical records do belong to them and they have a right to receive copies at any time. During late adolescence and young adulthood, when students are likely to be on the move, it’s actually recommended that they maintain a notebook of their medical records so that they’re able to bring copies of records with them when transitioning to college, graduate school, a first job, employment relocation, or whatever may come next.

Keeping Stress Manageable: Not Taking on Too Much Too Quickly

Sometimes the array of offerings at the outset of college can be like a cornucopia of new possibilities. Fascinating courses, social clubs and organizations, sports, student government, new recreation options, music and drama… the list goes on. Boredom will not likely be a part of the college experience.

While considering all these choices, strong feelings of anticipation and excitement are perfectly normal. Why not just dive in and fully immerse yourself? Simple - doing so activates a lot of intensity. And while intensity can feel pleasurable, it is nonetheless stressful. For students with bipolar disorder, the stress of intense engagement is not necessarily their friend. In fact, stress is often the most common trigger for mood destabilization.

First year bipolar students are strongly advised to step back and select from the cornucopia with a sense of moderation. What does moderation look like? Perhaps it’s signing up for 12 credits instead of 15 to 18. Perhaps extracurricular activity choices are delayed by one semester or at least not taken on with multiple concurrent commitments. And when a road trip is impulsively suggested by suitemates the second weekend of the semester… hopefully the bipolar student will choose wisely to remain on campus and stay focused upon building a stable foundation.

Keep in mind that starting college is an important juncture where many aspects of change are occurring simultaneously. Saying no to some things at the outset of school doesn’t mean they won’t remain available as future choices.

Approaching things gradually also does not equate with being left behind. For the bipolar student, figuring out moderation is far preferable than taking on too much too soon, becoming overwhelmed and having to bail out prematurely.

The Potential Pitfalls of University Life

If the symptoms of bipolar disorder did not emerge until sometime around age 35, the effective management of mild to moderate symptoms would be a much easier undertaking. Consider the reality that by middle-age, important maturational adjustments such as relying upon structured daily routines, employing good sleep hygiene, significantly limiting drug and alcohol use and more generally refraining from impulsive, risky behavior, are all choices that one has come to value in the broader context of a stable lifestyle.

But the middle-age onset of bipolar symptoms is mostly fantasy. Reality is, for many with bipolar disorder, their full symptom presentation generally emerges somewhere between the mid-teens and the mid-twenties. And instead of much needed balance, the accrual of structure, healthy routine and sobriety tend to become delayed due to the behavioral norms of late adolescence.

For many who are starting a four-year college much of their previous life experience has been defined by parental norms and rules. And while parental roles tend to ease up as one becomes older, it is still the case that by the end of high school, students are usually chomping at the bit to have a taste of freedom. At college, they're no longer being told what time to go to bed, what time they need to be home or even what they can or cannot do when they are out and about. Many of these life choices become their own and it absolutely makes sense that college students want to relish this freedom and throw away limitations that may feel “parental.”

The natural consequences to this progression are that during the college years, we usually see that 1) good sleep hygiene is discarded, 2) experimentation with psychoactive substances is common and 3) strategies for managing high work volume are far from being stress free. The good news is that for most in their late teens and early 20’s, their approaches to work and play will undergo significant modification over the next 10 to 15 years. But if you're bipolar and headed off to college, or even if you encounter your disorder while already attending school, you don't have that kind of time to make necessary adjustments.

Why not? For the individual with bipolar disorder, good stable sleep can be as effective (if not more so) than prescribed medicine. It's often the case that inadequate sleep and/or inconsistent sleep patterns are some of the most common precipitates of bipolar mood destabilization. Similarly, research is showing that frequent and excessive use of psychoactive substances is a potent destabilizing influence for those with bipolar disorder (Baethge, C., Hennen, J, Khalsa, H.K., Salvatore, P., Mauricio, T. and Baldessarini, R.J., 2008). If fact, it’s quite common that most college students with bipolar disorder report that substance use is something they have struggled with.

The third part of the terrible triad is stress. Stress usually worsens psychiatric disorders. Stress makes people feel worse even when they are free of any psychiatric diagnosis. For those with bipolar disorder the combination of high stress, substance use and poor sleep habits is quite simply like introducing a lit match to gasoline. The outcome isn't good.

So it makes sense that the freedom and opportunities of college life present the bipolar student with enormous challenges. The solution is simple: get good sleep, stay away from substances and become masterful at handling the stresses of college life. Ah, if only it were that simple! You see, there’s something else, quite significant, that’s wedged between the pitfalls of college life and effective solutions.

Continued in - Going to College With Bipolar Disorder, Part II

Copyright - Russ Federman, 2016

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Russ Federman, Ph.D., ABPP is in private practice in Charlottesville, VA (www.RussFederman.com). He is co-author of Facing Bipolar: The Young Adult’s Guide to Dealing with Bipolar Disorder (New Harbinger Publications).