What a medical school dean of students learns about young adults in crisis

I have two jobs that look unrelated and are not. In one, I am a child and adolescent psychiatrist who sees young people and their families in Lexington and across South Carolina. In the other, I am Associate Dean for Student Affairs at the University of South Carolina School of Medicine Columbia, where I have been on the faculty since 2006 and where, before the dean's office, I directed the course that teaches first-year students how to talk to patients. Earlier in my career I was a psychiatrist at the university's counseling service. Between those roles I have spent close to two decades watching high-achieving young adults reach their limit. Here is some of what I have learned, and how it changes the way I practice.

Crisis almost never arrives suddenly

When a student ends up in my office in real trouble, the family and sometimes the student describe it as coming out of nowhere. It almost never did. When I go back through the record, there is a pattern: a missed assignment in September, a request for an extension in October, a skipped small-group session, an email that went unanswered for a week. Each one was explainable alone. Together they were a trajectory.

In the clinic, this has made me a believer in tracking small things. I ask my teenage and young adult patients about attendance, not just mood. I ask whether they are answering messages from friends. I ask parents of my younger patients to tell me when the homework stops coming home, not when the report card arrives. The report card is three months late.

The best students hide it best

Medical students are selected for their ability to perform under pressure and to keep performing when they feel terrible. That skill, which will serve them as physicians, is also what lets a depressive episode go unseen for a semester. A 2016 meta-analysis in JAMA found that roughly a quarter of medical students worldwide screened positive for depression and about one in ten reported suicidal thinking, and that a minority of those who screened positive had sought treatment. In my own experience the students in greatest distress are often the ones with the best grades and the warmest smile at the end of a long day.

I carry this into practice with my young adult patients, many of whom are also high performers. I do not take "I'm fine" as data. I ask about sleep, appetite, concentration and hopelessness in specific terms. I ask what they are not telling the people around them. Competent people are good at reassuring the adults in their lives, including their psychiatrist, and I have learned to be harder to reassure.

Help-seeking is blocked by fear, not ignorance

Every medical student knows what depression is. Knowing is not the barrier. The barriers I hear most often are fear that a diagnosis will follow them onto a licensing application, fear that a dean will find out, fear that classmates will see them walk into the counseling center, and fear that needing help means they do not belong in medicine. Some of these fears are outdated and some are not entirely irrational, and both kinds keep people from care.

What has worked, in my experience, is removing the friction and separating the roles. A student needs to be able to see a clinician who is not their evaluator, and needs to know exactly how confidentiality works and where its limits are. As a dean I do not treat students I am responsible for evaluating; that line is not negotiable. As a psychiatrist I explain confidentiality to every teenager and young adult in the first visit, in plain language, including the specific situations in which I would involve a parent. Young people engage when they know the rules. They disengage when they have to guess.

Transitions are where people break

The students who struggle most are rarely struggling in the middle of a stable year. It is the first semester of medical school, the first clinical rotation, the move from a structured classroom to an unstructured ward, the first time they are evaluated by someone who does not know them. The same is true of the patients I see at every age. The move to middle school. The first year of high school. The first semester of college. The first job after graduation. Each one strips away a structure that was quietly holding things together.

So I plan for transitions in advance. If I am treating a high school senior for anxiety, we start talking about college in the spring, not in September when the first panic attack has already happened. We arrange the prescription handoff if the school is in a state where I am not licensed. We talk about the disability services office and what documentation they will need. For a college senior, we talk about the first job before the offer letter arrives. Anticipating a transition does not prevent every crisis, but it changes the odds.

Structure is treatment

In the dean's office, one of the most effective interventions I have is not clinical at all. It is helping a student in distress reduce the chaos: a modified schedule, a leave of absence taken before failure rather than after, a plan for the next six weeks written down and shared. The relief is often immediate, because much of the suffering was the feeling of being out of control.

In the clinic this shows up as my insistence on sleep schedules, on keeping one commitment going even when motivation is gone, and on school and workplace accommodations as part of the treatment plan rather than an afterthought. Medication can lift a mood. It cannot build a day. The patient and the people around them have to do that, and my job is to make sure it is part of the plan.

Recovery is the rule, and it takes longer than anyone wants

The students I have worked with through a serious episode have, overwhelmingly, gone on to graduate and practice. Most of them say later that the crisis changed how they take care of themselves and how they treat their own patients. That is the most hopeful thing I know, and I say it to the families of my teenage patients in the worst week of their lives, because it is true.

What I also say is that recovery is slower than the crisis. A semester off is not a defeat. A second medication trial is not a failure. A young adult who needs six months of therapy to get back to baseline is not weak. The pressure to get back to normal quickly is itself a symptom of the culture that produced the crisis, and part of my job, in both of my jobs, is to push back against it.

More from Dr. Williams

• How I evaluate a child for ADHD, and why I will not diagnose from a questionnaire alone2026-06-09
• Teen depression: what parents see first and what to do in the first two weeks2026-07-07
• College students and anxiety: a psychiatrist's guide to the first semester2026-08-04

Educational content and not a substitute for evaluation. If you are in crisis, call or text 988.