Suicide Prevention on Campus

(This is the second of two articles on suicide among college students. The first article ran in August, p1 -- Ed.)

College students are far less likely to kill themselves than are nonstudent peers, according to a 10-year research study examining suicide rates at 12 Midwestern campuses.

The Big Ten Student Suicide Study (Silverman et al., 1997) found an overall student suicide rate of 7.5 per 100,000, compared to the national average of 15 per 100,000 in a sample matched for age, race and gender. Forty-six percent of student suicides occurred in the 20-year-old to 24-year-old age group. Graduate students were found to be at greatest risk, comprising 32% of campus suicides.

"The finding that the suicide rate on campus is lower than in the general population didn't surprise me," said Morton Silverman, M.D., study co-author and director of the Student Counseling and Resource Service at University of Chicago. "The whole infrastructure of a campus is geared toward providing support, feedback, caring and assistance toward self-actualization, growth and maturation. As a result, students who are struggling get attention faster, get treated faster and, as a result, function better."

Campus prohibitions against firearm possession also are credited for the lower observed rate, Silverman told Psychiatric Times. According to statistics from the Centers for Disease Control and Prevention (CDC, undated), 57% of suicides in 1998 were carried out with a gun. Students who commit suicide are more likely to hang themselves, jump from unprotected buildings or ingest lethal chemicals commonly found in campus labs, said Silverman, adding that these findings offer campus administrators important and practical help with prevention efforts.

The Big Ten study, which looked at nearly 350,000 students per year over a 10-year period, analyzed 261 suicides. "Even if we missed a few [suicides] every year, that number is still, when you do the calculations, way below the national figures," Silverman said.

When asked about the higher rate of suicide among graduate students, he responded, "We're not sure if it's a question of later onset of the major psychiatric disorders or whether it takes a number of years of having these illnesses untreated that [eventually] puts you in the danger zone." Silverman added that pressure to make decisions about a career or the future might also be a factor.

Despite encouraging statistics suggesting that college may be protective against suicide, campus administrators and clinicians who treat students still are losing sleep over how best to spot and treat at-risk students.

Suicide rates have been rising steadily among the young and nearly tripled between 1952 and 1995 (CDC, undated). Suicide now ranks as the second leading cause of death for American college students (Jamison, 1999; Silverman, 1993). In 1998, suicide killed more teen-agers and young adults than AIDS, cancer, heart disease, pneumonia, birth defects, stroke, influenza and chronic lung disease combined (CDC, undated).

According to the National Survey of Counseling Center Directors, 85% of counseling center directors surveyed reported an increase in severe psychological problems among students over the past five years (Gallagher et al., 2001). More than half of counselors polled in the 2001 survey of 274 colleges and universities said the prevalence of self-injury had increased over the same period.

For every completed suicide, there are untold numbers of suicide attempts and an even larger pool of individuals who have considered suicide. According to the National College Health Risk Behavior Survey, 10.3% of college students had seriously considered ending their own lives during the preceding 12 months (CDC, 1997). Even more chilling, 6.7% of students actually made suicide plans. Yet only 17.6% of college students nationwide reported that they had received information on suicide prevention from their institution.

The transition to college life can be challenging under the best of circumstances. Students, many of whom may be leaving home for the first time, are being exposed to new freedoms and new responsibilities simultaneously. Academic and social pressures can be overwhelming.

"I think there is that pressure, especially in the freshman year, when there's initial anxiety that's going to settle out," Michael Craig Miller, M.D., assistant professor of psychiatry at Harvard Medical School and editor-in-chief of The Harvard Mental Health Letter, told PT. "They need help with the transition and once they make it, it's quite successful."

Unfortunately, not every student makes the transition successfully. Severe psychiatric disorders such as bipolar disorder and schizophrenia typically first manifest themselves between the ages of 18 and 24 years and can easily derail the lives of students. Major depression, posttraumatic stress disorder and personality disorders also can be extremely disruptive.

Sleep deprivation is a hallmark of the college experience. It is also a major trigger of mania, which increases the odds of depression, mixed states and suicide (Jamison, 1999). Unfortunately, the boundless energy and creativity that often accompany mania are sought-after qualities by many colleges and universities. Consequently, students may be in serious, if not life-threatening, crisis before they or others recognize the need for psychiatric intervention.

"People assume that many behaviors that are, in fact, symptomatic of serious mental illness are part and parcel of normal adolescence," said Kay Redfield Jamison, Ph.D., in an interview with PT. "This is understandable but potentially dangerous," said Jamison, who has bipolar disorder and attempted suicide at age 28, years after beginning to struggle with symptoms of the disease.

Jamison believes that parents and prospective students should inquire into the availability of good mental health care services, regardless of whether a student has a diagnosed mental illness. "People should be well-informed when they apply," she said. "It's a high-risk time."

Substance abuse, an unfortunate fact of life on many U.S. campuses, can also make the difference between suicidal ideation and a lethal attempt. Researchers at the CDC are among those who see a link between substance abuse and increased vulnerability to suicide. In one study, researchers found that students with a history of suicidal ideation were more likely to use tobacco, alcohol and illegal drugs (Brener et al., 1999). While study design did not allow researchers to determine whether suicidal ideation preceded substance use, data were robust enough to warrant recommendations that substance abuse screening be integrated into suicide prevention efforts.

In a separate study, CDC researchers found that 18-year-old to 24-year-old college students who reported suicidal ideation were significantly more likely to engage in "injury-related risk behaviors" (Barrios et al., 2000). Specifically, this group was more likely to drive while intoxicated, ride with an intoxicated driver, swim or boat after drinking alcohol, engage in a physical fight, carry a weapon, and fail to wear seatbelts regularly if at all.

A freshman survey on a health center intake form "would be a perfect place to ask these questions, especially since alcohol is so closely related to both suicidal ideation and completion and to these other risk behaviors," Lisa Cohen Barrios, Dr.P.H., told PT. "Again, the asking of the questions is pretty simple. What takes more effort is preparing the staff to deal with the answers. When you're talking about suicide they really don't want to know the answer because they have to talk about this difficult problem," said Barrios, study co-author and CDC health scientist. "It's not comfortable."

Today's colleges and universities also are drawing many more students who arrive on campus with diagnosed mental illnesses. Thanks to advances in medication, many students with major depression, bipolar disorder and even schizophrenia are able to attend college. "We are the recipients of our own success stories," said University of Chicago's Silverman. "The degree to which we have been successful as mental health practitioners in identifying and successfully treating disorders that appear in adolescence [is the degree to which] we have been successful in giving these adolescents the opportunity to continue pursuing academic training." Silverman cautioned that while many can and do thrive, there is still a segment of this population that may be particularly vulnerable to the stressors inherent in college.

There is considerable debate as to whether a school's selectivity increases the likelihood of student suicide. The latest round of the debate is being played out in Cambridge, Mass., where Massachusetts Institute of Technology (MIT) is in the midst of a $27 million wrongful death suit over the death of a troubled sophomore in April 2000. Media reports have painted a portrait of an institution in the midst of a suicide epidemic. In fact, MIT's suicide rate is below the national average if one adjusts figures for the school's overwhelmingly male student body (American Foundation for Suicide Prevention, 2002). Regardless of student status, suicide rates for men continue to be significantly higher than for women, despite the fact that women are more likely to attempt suicide.

"You enter an environment like Harvard or MIT or Stanford or Yale and that may, for a variety of reasons, not be a good match for you, yet it's painful and disappointing to realize that," said Miller. "Most of us would push through it, some of us put our hands up in the air, some feel trapped and don't know what to do," he said. The pressure engendered by the demands of an elite college does not in and of itself cause suicidality but can tip the scales in vulnerable individuals. "The important thing is that there is a place for the student to go to discuss these things."

Silverman disagreed with the notion that elite colleges breed the kind of stress that can fuel suicidality. "Kids who end up at pressure-cooker schools tend to thrive on that kind of stress. I don't think stress, in and of itself, or the academic calendar, in and of itself, accounts for this."

Students' perceptions of achievement -- and failure -- may be far more important than their choice of alma mater. "A different but not uncommon profile of an adolescent suicide is that of a high-achieving, anxious or depressed perfectionist," wrote Jamison in Night Falls Fast. "Setbacks or failures, either real or imagined, can sometimes precipitate suicide. It may be difficult to determine the extent of such a child's psychopathology and mental suffering, due to the tendency to try to appear normal, to please others, not to call attention to oneself. The real reasons for suicide remain fugitive."

Concern over confidentiality -- and potential litigation -- further complicates the issue of suicide prevention on campus. "The issue is that there are two competing values," said Miller. "One is guarding somebody's confidentiality and the other is about doing something that may be helpful and potentially life-saving. From time to time, those decisions have to be made ... you don't want to do it frivolously. You should approach these decisions systematically, be reasonably clear in your own mind what your system is for doing this and do it consistently."

Miller believes there's been a trend toward greater documentation among psychiatrists in general but cautions that standardized forms, such as those used during intake interviews, are only as good as the information they contain. "I think that the fear of being sued has been on people's minds for decades, and I don't know that it's any different on college campuses," he said. "If there have been highly publicized cases, people take note of that and they do what they can to put systems in place to deliver the care more effectively. I don't think that necessarily has an impact on the number of suicides, but it may have an impact on people's comfort in giving the care and may make the delivery of care more rational in the sense that you have a better sense of why you're doing what you're doing."

References:

References

1.

American Foundation for Suicide Prevention (2002), Media advisory: experts offer media suggestions for coverage of campus suicide. April 4.

2.

Barrios LC, Everett SA, Simon TR, Brener ND (2000), Suicide ideation among US college students. Associations with other injury risk behaviors. J Am Coll Health 48(5):229-233 [see comment].

3.

Brener ND, Hassan SS, Barrios LC (1999), Suicidal ideation among college students in the United States. J Consult Clin Psychol 67(6):1004-1008.

4.

CDC (undated), Suicide in the United States. National Center for Injury Prevention and Control. Available at: www.cdc.gov/ncipc/factsheets/suifacts.htm. Accessed June 27, 2002.

5.

CDC (1997), Youth Risk Behavior Surveillance. National College Health Risk Behavior Survey -- United States, 1995. MMWR 46(SS-6).

6.

Gallagher RP, Sysko HB, Zhang B (2001), National Survey of Counseling Center Directors. Alexandria, Va.: International Association of Counseling Services Inc.

7.

Jamison KR (1999), Night Falls Fast. New York: Vintage Books.

8.

Silverman MM (1993), Campus student suicide rates: fact or artifact? Suicide Life Threat Behav 23(4):329-342.

9.

Silverman MM, Meyer PM, Sloane F et al. (1997), The Big Ten Student Suicide Study: a 10-year study of suicides on midwestern university campuses. Suicide Life Threat Behav 27(3):285-303.