The first time Bob Lamb thought of alcohol as an escape, he was standing in a hospital emergency room. A friend of his had collapsed and Lamb, then a sophomore at the University of the Sciences, had performed CPR. "I kept him alive long enough for his dad to see him," Lamb recalled.

After his friend died, Lamb thought, "I need to get out of here, to get drunk and forget everything that I'm feeling."

Until then, Lamb drank occasionally, like many college students, but that night was the beginning of a downward spiral. He became a daily drinker, missed classes, and failed courses. He took several leaves from school to get mental-health and substance-use care.

Now more than six years in recovery, and a recent graduate of Temple University's master of public health program, Lamb, 30, recognizes that  his alcohol-use disorder stemmed from the trauma of his friend's death. But the realization caught him off guard.

As a teenager, he'd been told not to drink and drive. To match every alcoholic beverage with a glass of water. To never go to college parties alone. But none of the warnings he'd received about alcohol mentioned mental health.

As millions of freshmen arrive on college campuses this month and next, they are warned of binge drinking, alcohol poisoning, and sexual assault. Parents dropping their children off may have thought about episodes such as the death of 19-year-old Tim Piazza after a night of alcohol-fueled hazing at Pennsylvania State University. But for most, there likely was little discussion of the relationship between alcohol and mental health, or how drinking can exacerbate anxiety and depression — increasingly common diagnoses among incoming students.

"We have a major alcohol problem that has never really been properly addressed," said Pascal Scoles, director of Community College of Philadelphia's collegiate recovery program.

Bob Lamb, a recent graduate from Temple’s master of public health program, has been in recovery from alcohol use disorder for more than six years.
Courtesy Bob Lamb
Bob Lamb, a recent graduate from Temple’s master of public health program, has been in recovery from alcohol use disorder for more than six years.

The national conversation about addiction has been focused on opioids, which college recovery experts say is appropriate. But they worry that alcohol will continue to be overlooked. "Alcohol is often the forgotten issue," said Devin Reaves, executive director of the Pennsylvania Harm Reduction Coalition.

Not only are more young people dying from alcohol-related liver disease, but excessive drinking also can worsen mental illness and has been linked to suicidal thoughts. Suicide is the second-leading cause of death among college students.

>>READ MORE: College students train to help peers at risk for suicide, depression and more

Despite these consequences, American society, and college campuses in particular, treat alcohol differently from other drugs, said Frank Greenagel, an addiction policy expert in New Jersey who works with college students. Many think it's harmless, he said, and the focus on opioids can further normalize that. "Now people with a drinking problem think, 'At least I'm not taking pills.' "

How alcohol affects mental health

When working with students in recovery at CCP, Scoles addresses substance use and mental health at the same time. "I've always felt that you can't really separate them out anyway," he said.

Research backs him up. About 20 percent of people with a history of substance use disorder suffer from at least one mood disorder and 18 percent suffer from at least one anxiety disorder, according to a federally funded study. Long-term alcohol use has been shown to decrease the brain's levels of serotonin, a neurotransmitter that contributes to feelings of happiness and plays a large role in depression. Drinking also lowers blood sugar and causes dehydration — conditions that can mimic symptoms of anxiety or trigger an episode. Alcohol consumption can also lead to a loss of inhibition, impaired judgment, and impulsiveness, which studies have linked to a higher risk of suicide.

To make matters worse, drinking can counteract the benefits of many psychiatric medications. Alcohol and antidepressants, for example, affect many of the same neurotransmitter pathways. If the medication is aimed at increasing levels of serotonin in the brain, extended alcohol use can slow that process. Sometimes the effects are more dire. Some antidepressants inhibit the body's ability to break down tyramine — an amino acid found in certain types of alcohol. Drinking while on those medications can lead to dangerous spikes in blood pressure.

Although it's clear that mental health and substance use are connected, Scoles said, the exact relationship varies. For some people, substance use leads to mental-health concerns as they lose jobs and friends, and suffer other consequences. Others will turn to alcohol and other drugs as a way of coping with pre-existing mental-health issues.

Gemmika Champion, a student at Drexel University, has been in recovery from alcohol use disorder for more than three years.
DAVID SWANSON / Staff Photographer
Gemmika Champion, a student at Drexel University, has been in recovery from alcohol use disorder for more than three years.

For Gemmika Champion, a 24-year-old from Overbrook, drinking was a way to self-medicate her social anxiety and deal with childhood trauma. She had her first drink at 12, started binge drinking at 16, and began drinking daily when she got to college.

"I had a lot of discomfort about how to fit in and whether or not I liked myself," Champion said. Alcohol helped with that, at least in the moment. "But in the morning, I'd feel that pang of anxiety, guilt, and shame," she said. "And I'd think, 'What's the solution for that? What worked last night? To drink.'"

It's easy for college students to get caught in that cycle, said Stephanie Ives, associate vice president and dean of students at Temple University. Many students drink to socialize or self-medicate, she said, but for some, that evolves into dependency.

Champion broke the cycle by going through detox, therapy, and a 12-step program. Now three years sober and a master's student at Drexel University, she continues therapy, recognizing that good mental-health care is just as important to her recovery as abstaining from alcohol. "Addiction is a chronic disease that requires constant maintenance," she said.

‘A holistic approach’

College recovery specialists say the goal of discussing alcohol is not to shift resources away from addressing opioids or other drugs.

Most students with a substance-use disorder have used multiple drugs, said Lisa Laitman, director of the alcohol and drug assistance program at Rutgers University. "We need to have a holistic approach with different substances, and also with mental health," she said. "It isn't one or the other."

A growing number of colleges are offering on-campus recovery programs that provide counseling, student support groups and sober activities. Some, such as the programs at Rutgers and Penn State, also offer sober dorms for students in recovery.

"A lot of people have this idea that if a student develops a substance-use disorder, that they should never go back to college because it's a high-risk environment," said Jason Whitney, program coordinator of Penn State's collegiate recovery community. "But in many cases, their odds are better if they come to a college with a recovery program than stay at home."

Mike Luna, student body president at CCP, has been in recovery from alcohol and opioid use disorder for more than two years.
DAVID MAIALETTI / Staff Photographer
Mike Luna, student body president at CCP, has been in recovery from alcohol and opioid use disorder for more than two years.

For Mike Luna, the recovery program at CCP has made all the difference. Luna, 29, left home in New Jersey at 21 to try to find independence and a job in Philadelphia. But when he struggled to make child-care payments and afford the trips back home, he lost partial custody of his son. That's what fueled his drinking. "It was to run from reality," he said, "from the emptiness and resentment I had for not being able to provide for my child."

He visited bars in the morning, spent the day selling pirated DVDs to finance his addiction, and returned to the bars at night. After being prescribed opioids for a gunshot wound, he got hooked on those, too.

Once he got clean, more than two years and 40 days ago — per the app on his cellphone that tracks his days, minutes and seconds in recovery — Luna knew he needed the structure of a recovery program to stay clean. "It's the real reason I came to CCP," he said.

Engaging with mentors and other students has helped him work through his anger and stay accountable. He was recently elected student body president and is on track to graduate with a degree in liberal arts in 2020.

"Going from a certificate from rehab to a college degree didn't seem realistic," he said, but "I was able to turn the psychological warfare of addiction into accomplishment."

At colleges that don't have recovery programs, there are still many ways to help students with substance-use disorder, experts say. It can involve employing a substance-use specialist in college counseling centers or increasing student awareness about the link between substance use and mental health. It's also important to confront the normalization of drinking culture, because fewer young people are drinking than most students assume.

It must be a constant conversation, Laitman said. "You don't do a one-hour session at the beginning of the year at orientation and that's it," she said. "Students are overwhelmed at orientation, so it needs to be an ongoing process."