By 8:45 a.m. on a Tuesday in April, six patients had already started appointments at the Mental Health Clinic on campus.

The small front room of the fourth-floor office in Boynton Health Service buzzes each day with phone calls and check-ins.

Just a week shy of finals, the clinic is booked solid. The earliest date to see a therapist is two weeks out. For a medication assessment, it’s four.

Antidepressant prescriptions are second only to birth control on campus, and national trends show more college students come to campus with serious mental illnesses.

At Boynton, increasing one therapist’s hours to full time last year and adding a psychiatrist have shortened the waiting list, and the clinic has seen marked increases in the number of students it serves. But the clinic director says space and staff have hit a ceiling while students’ needs keep increasing.

When the worst happens, and clinic staff hears about a student committing suicide, there’s a shared worry that the clinic’s physical and personnel limitations prevented them from helping.

Vetris Pate leads a team of three front desk workers who serve as the first and last points of contact with patients. She anticipates 60 to 90 appointments each day, plus students who come in person to the clinic to set a date for their first session, as required.

Pate has seen students cry or just walk out when they learn two to four weeks stands between them and a time slot with a therapist or psychiatrist. But the wait is better than most other area mental health clinics, and the waiting list has shrunk since last year, clinic director Gary Christenson said.

In January 2011, before staff hours were added, 35 students were on the waiting list. It grew to 40 in the fall, but there are only three or four students on it this semester. The clinic has seen a 2.5 percent increase in the number of patients  and  5.6 percent more appointments compared to last year.

Setting appointments and offering chairs

Pate describes working at the clinic as “intense.” She spends her day “taking in a lot of people’s emotions.” When she first started in 2007, she often took the job home with her, but she’s learned to let things go. She takes a walk down by the river over her lunch break to decompress.

“It can be a challenge. I think it’s manageable,” she said. “We all do a good job de-stressing.”

She and the other front desk staff are trained to observe nonverbal cues. If a student seems distressed, staff might bring them to a more private room to wait.

“Generally a lot more students are coming in with anxiety or depression. You never really know how that person’s going to react,” she said.

As receptionists, Pate and her co-workers are the go-betweens for patients and doctors. She takes a lot of questions over the phone and works to make sure students receive the right kind of care in the right time frame.

She acknowledges that “usually people wait until it’s pretty bad” to seek help, which is why she’s thankful for a triage nurse and an urgent counselor that she calls “backup.”

Depending on the time of year, between one and five students walk in each day for an urgent appointment. Pate can always tell when finals are approaching because the number is on the higher end.

Anyone setting the first appointment has to go into the clinic, which gives the front desk staff a chance to vet concerns and ensure the student is in the right place.

A student is put on the waiting list if the next available appointment is more than two weeks out. It’s hard on staff when a waiting list accumulates, Pate said. They feel like they’re not doing enough.

The numbers have gone down, but it still builds up occasionally, and she knows it’s stressful for students.

“I almost start to feel like I’m deceiving people, in a way,” Pate said. “We make people come all the way in here. So they come all the way in here, and then they don’t get an appointment.”

The clinic has started listing the wait time on its website so students have an idea before they go in to schedule a time.

But the volume of patients and the wait aren’t the only problems Pate has to troubleshoot. Some days, it’s the size of the waiting room.

When all the providers work, the small waiting room fills, and, on occasion, the clinic runs out of chairs. At least one time, Pate has offered her own.

It’s a sign of how Pate wants to help students as much as she can.

“We’re thinking on our feet,” she said. “I wouldn’t want anyone to leave without having anything.”

‘We had to make the choice’

Michele Sullivan, a therapist and social worker, said she tries to keep her office clean and detached from her personal life because she knows that, when she’s not there, another therapist will use it to see patients.

“We are really bursting at the seams here,” she said.

Therapist Pearl Barner II has been at Boynton for 21 years and has seen the benefits of added staff. He said the clinic used to have only two psychiatrists (physicians qualified to diagnose patients and prescribe medication), and now there are four psychiatrists and a nurse practitioner dedicated to medication management.

Adding one staff member opens six appointment slots in a single day. From September through March, 2,284 students visited the mental health clinic 8,078 times.

To make room for as many of the University’s more than 52,500 students as possible, Boynton sets an appointment cap at 11 sessions per 12-month period. Fees-paying students get the first session with no out-of-pocket charge and pay just a $10 co-pay per session after that. There is no limit on the number of visits with psychiatrists who manage medications.

“In order to be open and available, we somehow have to look at accessibility of the clinic,” Barner said.

The cap was instated more than a decade ago, but most students visited the clinic fewer than five times a year, said Christenson, the clinic director. At the same time, a small number of patients were taking up the majority of space.

“We had to make the choice,” Christenson said. “For students who need weekly sessions, there are therapists in the community.”

Sullivan works with patients to find resources in the community if the clinic’s services don’t suffice. She refers out patients when their schedules or insurance don’t match up with Boynton.

Patients who need more than the clinic can provide, like food shelf assistance, an Attention Deficit Disorder assessment or help with a complicated eating disorder that requires a team of doctors, are also referred to an outside agency.

On campus, other agencies overlap with the mental health clinic. University Counseling & Consulting Services also has walk-in crisis counseling but goes beyond Boynton in its academic and career counseling. It doesn’t perform medication evaluations, but it has more options in group therapy.

Increasing needs

In their experience, Boynton therapists and psychiatrists said student problems range from adjustment issues that stem from first experiences of independence to more serious mental illnesses, like depression and anxiety.

College counseling services across the country have experienced a collective influx of students with greater mental health needs. The conversation over how to serve changing student needs has been ongoing for at least a decade.

Back in 2003, the Chronicle of Higher Education reported a sharp rise in the number of college students taking psychiatric medication and the number diagnosed with depression and other psychological issues.

A study published that same year showed that rates of depression in students at Kansas State University had doubled between 1989 and 2001. The proportion of students taking psychiatric medication increased from 10 percent to 25 percent.

In a 2011 national survey of counseling center directors, which did not include the University of Minnesota, 91 percent reported continued increases in the number of students on campus with “severe psychological problems.”

Student needs have changed over the years, as more people with serious conditions have gone to college because of improvements in medication and resources, said Brian Van Brunt, the immediate past president of the American College Counseling Association and the director of counseling at Western Kentucky University.

More students go to college already diagnosed and, if required, taking medication, studies show.

“Earlier if you had these conditions, you didn’t go to college,” Van Brunt said. “You did something else. You never dreamed you’d go to college.”

The 2011 national survey showed 23 percent of clinic clients are on psychiatric medication. That proportion rose from 9 percent in 1994.

From September to March, Boynton filled 4,643 prescriptions for mental health-related medications, according to Boynton data. Many patients are prescribed more than one medication, and that number includes refills over the time period.

Almost three-quarters of those prescriptions are for antidepressants, which treat depression and anxiety, Christenson said.

“We’re not just prescribers of medication,” Christenson said of the clinic’s psychiatrists. He was the second one when he joined the staff 17 years ago.

The first session with a psychiatrist is a medication evaluation, which includes recording symptoms and family history, as well as a person’s context. Christenson has heard too often from patients that have been given a prescription in the past but never filled it because they didn’t think the doctor took enough time to understand their story.

Boynton places no cap on the number of times a student can visit a psychiatrist because individuals on medication will be on it for a long time and require regular monitoring.

“It’s not like taking an antibiotic,” Christenson said.

Solving the space problem

Christenson said the clinic has added capacity almost every year, mostly in the form of increased staff hours.

Most staff members work four days per week, so administrators got creative and hired a nurse practitioner who jumps from office to office to take advantage of free space.

Christenson calls it creating “an office out of thin air.”

The clinic also made its records electronic to convert a room filled with files into two offices. A hallway was cut down to make another office.

Because mental health services don’t include performing procedures, the clinic doesn’t generate a profit, which makes it difficult to fund, the director said.

But the stress of school and the economy, and the transitional nature of college life, put pressure on the existing staff to do more for their patients.

“Students have additional issues,” Christenson explained. “Students have a clock that’s running faster, and the semester clock doesn’t stop for them.”

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Campus mental health resources can be found at mentalhealth.umn.edu