Academic performance of students who underwent psychiatric treatment at the students’ mental health service of a Brazilian university

ABSTRACT CONTEXT AND OBJECTIVE: University students are generally at the typical age of onset of mental disorders that may affect their academic performance. We aimed to characterize the university students attended by psychiatrists at the students’ mental health service (SAPPE) and to compare their academic performance with that of non-patient students. DESIGN AND SETTING: Cross-sectional study based on review of medical files and survey of academic data at a Brazilian public university. METHODS: Files of 1,237 students attended by psychiatrists at SAPPE from 2004 to 2011 were reviewed. Their academic performance coefficient (APC) and status as of July 2015 were compared to those of a control group of 2,579 non-patient students matched by gender, course and year of enrolment. RESULTS: 37% of the patients had had psychiatric treatment and 4.5% had made suicide attempts before being attended at SAPPE. Depression (39.1%) and anxiety disorders/phobias (33.2%) were the most frequent diagnoses. Severe mental disorders such as psychotic disorders (3.7%) and bipolar disorder (1.9%) were less frequent. Compared with non-patients, the mean APC among the undergraduate patients was slightly lower (0.63; standard deviation, SD: 0.26; versus 0.64; SD: 0.28; P = 0.025), but their course completion rates were higher and course abandonment rates were lower. Regarding postgraduate students, patients and non-patients had similar completion rates, but patients had greater incidence of discharge for poor performance and lower dropout rates. CONCLUSION: Despite the inclusion of socially vulnerable people with severe mental disorders, the group of patients had similar academic performance, and in some aspects better, than, that of non-patients.


INTRODUCTION
Admission into university is indicative of certain capabilities among young adults, which allowed them to complete high school and pass the entrance examinations. Those conditions are not limited to cognitive traits, but also include access to information and an evolved state of internal and external mental organization and structures. On the other hand, this phase of life brings new challenges such as living away from family, making new friends and adapting to a new level of academic requirements. It is also an age at which outbreaks of various mental disorders frequently occur. [1][2][3] For such reasons, since the beginning of the twentieth century, a number of universities in the United States and Europe have created internal services for student mental health care. 4 Such concerns have also motivated several institutions in Brazil to establish their own services for the same purpose. 4 Campinas State University (Universidade Estadual de Campinas, Unicamp) is a Brazilian public university, founded in 1966. 5 In 2011, the university had 27,783 regular students, of whom 60.04% were undergraduates. 7 The university's Psychological and Psychiatric Service for Students (Serviço de Assistência Psicológica e Psiquiátrica ao Estudante, SAPPE), which is the mental health service on the campus, was created in 1987. The service is structured such that psychiatrists provide medical support for psychological treatment, thus attending to the most severe cases. During the survey period of the present study, psychiatric consultations accounted for around 15% of all attendance provided by the service. 6,7 A study conducted within SAPPE 8 reviewed the medical files of all students who sought the service between 1987 and 2003.
It found that students who were dependent on scholarships and those living in student housing belonging to the university were overrepresented in relation to the total number of university students. This indicated that mental care on the campus was more important to students whose economic conditions were unfavorable. Another study conducted in 2011 9 surveyed the group of students who sought the service for a second time after completing the initial treatment. It identified unfavorable economic situation, academic difficulties, early seeking of the service for first attendance and low self-esteem as the main factors associated with returning to the service.
In 2005, 6 the university debuted its Affirmative Action and Social Inclusion Program (Programa de Ação Afirmativa e Inclusão Social, PAAIS), a series of measures following federal government guidelines for expansion of social inclusion programs. Initially, it was intended to cover 30% of new undergraduate students, but was recently expanded to 50% of entrants. 10 In the light of previous studies, it is reasonable to expect that the resulting growth of the vulnerable university population will imply an expansion of the number of students who are dependent on healthcare services provided by the university.

OBJECTIVE
Our aim was to characterize the patients treated by psychiatrists at SAPPE, describing some of their socioeconomic and clinical attributes, and to compare some of their academic performance indicators with those of their colleagues who were not assisted by the service. Our purpose was to move a few steps further forward in gathering inputs for planning, not only of the mental health services themselves, but also of broader strategies that may be needed to address the ongoing changes affecting the student population. Therefore, we assessed those two education levels (undergraduate and postgraduate) separately and for postgraduate students, we analyzed only academic status.

The National Commission for Research Ethics (Comissão
With regard to establishing parameters for evaluating academic indicators, we asked DAC to set up a control group through random selection of at least two other students from the same course and from the same semester of enrollment for each patient of the service. They were also asked to preserve the same gender proportion found in the group of assisted students. Specifically for the undergraduate courses, we compared 769 assisted students with a control group of 1,514 students who did not receive assistance from SAPPE, and then, separately, 468 assisted postgraduate students with a control group of another 1,065 postgraduate students who did not attend this service. Within the control group, the proportions of students affected by mental diseases and of students already subject to mental health care outside of SAPPE are unknown to us. The reason for selecting a comparison group with twice the number of students was to mitigate the distortions that might have arisen from that factor. We performed the comparisons separately according to course level (undergraduates and postgraduates), using the chi-square test for categorical variables and the Mann-Whitney test for comparisons of APC.
The latter was calculated only for undergraduates. 11,12 The level of significance was 5%.

Sociodemographic data
The average age of the students when they were first assisted  Table 1 shows some of the sociodemographic attributes, as well as some general academic data such as the fields of study and the distribution between undergraduates and postgraduates.

Clinical data
When the students sought psychiatric care at SAPPE for the first time, 37.0% (n = 454) of them had undergone some prior psychiatric treatment and 2.8% (n = 34) had already gone through hospital psychiatric services. The data showed that 4.53% (n = 56) of the students had made suicide attempts before seeking the service. Among these, 19 (1.5%) had made more than one attempt. During the period of treatment at SAPPE, 1.78% (n = 22) attempted suicide. Six students made more than one attempt. The majority of the students assisted by psychiatrists (74.6%; n = 923) were also under simultaneous psychotherapeutic care ( Table 2).
Academic performance of the assisted students compared with that of those who did not attend the service  Table 3).
Among postgraduate students assisted over the surveyed period, only 17 students (3.7%) were still enrolled in their courses at the end of the first half of 2015. Just over two-thirds (69.0%; n = 321) had completed the course, while 6.7% (n = 31) had left the course before its conclusion. Among the latter, seven students did so because they transferred to another course. This number also accounts for direct progression from a master's to a doctoral course. Around one in five of the assisted postgraduate students (20.6%; n = 96) was clearly discharged for poor academic performance. Three were cut off from their programs but rejoined later on, solely to defend their dissertation or thesis, as allowed by Unicamp's master's and doctoral program statutes. In the postgraduate control group, the course completion rate was very similar (68.9%); the rate of drop-out was a little higher (9.13%) and the rate of discharge due to poor academic performance, a little lower, but no significant difference was found (chi-square test, P = 0.3538) ( Table 3).

DISCUSSION
To the best of our knowledge, this is the first study conducted in Brazil to address the academic performance of university students who underwent psychiatric treatment. This study also examined the association between psychiatric disorders in general and academic performance.
With regard to gender distribution at the university during the period 2004-2011, 6 men formed the majority (55%) of the total student population of the university. This indicates that there was female overrepresentation among the clientele served by SAPPE. This finding is consistent with other studies that correlated demand for mental health care and gender. 8 Admittance to campus halls of residence follows socioeconomic selection criteria and extends to only about 3.0% of the university students. 6 About 13% of the assisted students were resident there: a clear overrepresentation that is corroborated by previous studies carried out in this service. 8 The same applies to the overrepresentation of students whose main source of income was scholarships.
The inverse relationship between mental disorders and economic standard of living is one of the most consistent results from epidemiological population studies and studies on primary care, not only in Brazil but also internationally. However, the relationship between mental health/illness and social vulnerability is very complex and requires deep reflection and contextualization in order to be understood. A simplistic form of logic that correlates "madness" and "poverty", thereby reinforcing stigma and prejudice with regard to the least favored population, is a pitfall to be avoided. 13 The fact that a considerable number of students underwent psychiatric care before seeking the service for the first time is open to several interpretations. It could be an indication of greater severity, but could also be a consequence of reduction of stigma, which would stimulate an earlier search for care and might possibly have contributed towards success in being admitted into the university.
The most frequent diagnosis was depressive episodes, followed by anxious and phobic disorders. Among the studies conducted in Brazil, we did not find any centered on students who underwent psychiatric treatment that allowed us to establish direct comparisons regarding the prevalence of different mental disorders. The majority of the studies to which we had access screened either the general population or some specific group (mostly healthcare-related courses) for the prevalence of mental disorders. Some other published papers have pointed out that only a relatively small proportion of the students affected by mental disorders seek and receive clinical attention. [14][15][16][17] This applies especially to substance-related disorders 18  concerning dropout rates in comparison with their colleagues in the control group, might also be considered to be a good outcome, given that graduation from a university course can generally be considered to be an important achievement. It needs to be borne in mind, however, that at an individual level, academic dropout is not necessarily a bad outcome. For instance, although abandoning a course may seem to be an unfavorable event, if the student does this because he has the opportunity to enter another institution that is more aligned with his aspirations, this will indeed be a favorable outcome.
The course completion rate among the assisted postgraduate students was almost equal to that of the control group. Postgraduate courses have more stringent deadlines than undergraduate courses, ranging from 12 to 30 months for a master's degree and 24 to 48 months for a doctorate. Delayed completion of the course results in automatic discharge from the program. The dropout rate among the assisted postgraduate students was similar to that of their colleagues in the control group.
Our study design did not allow us to attribute the positive outcomes that we found solely or directly to the care provided by SAPPE or to any other known factor. Nonetheless, we consider that our results are encouraging with regard to the continuity of efforts towards providing mental health care and other forms of social assistance to university students.
All the limitations of the methods of retrospective medical record reviews need to be taken into consideration in this study. There is no standardization in completing the records, thus offering some room for the researcher's interpretation bias.
The academic data could not be directly assessed by the present researchers, but were collected by a professional from the Academic Board. The Academic Board provided data using their own categorization criteria, which were subsequently re-categorized by the researchers.

CONCLUSION
The students who underwent psychiatric treatment were the most severely affected group among the individuals who sought the campus mental health care service. They represented around 15% of the students who were assisted at the service, and included people diagnosed with severe mental disorders. The academic performance indicators found in this group did not differ radically from those of the control group. In the case of the undergraduates, their course completion rates were even somewhat better, which may suggest that there is a positive effect from care with regard to prevention of course abandonment.