ADDRESSING A CRITICAL ISSUE
In this new millennium, suicide clusters among college students have drawn media attention, have heightened concern and, occasionally, have resulted in lawsuits, but nothing has reduced the suicide rate in this population. Hovering around 7 per 100,000, this rate is actually about half as low for students as for age-matched, non-student emerging adults.1,2 Some studies have reported a slight recent decrease, but those fluctuations are usually attributed to the greater proportion of women (who have a lower suicide rate) in current university cohorts. Because there is no mandatory reporting of deaths as suicides on campus and because some students kill themselves while at home, on leave, or after failing out of school—and CDC data do not specify student status—the numbers may be less accurate than in other populations.
Even so, suicide remains the second leading cause of death for college students, as it has been since the 1950s. With mushrooming college attendance, however—enrollment between 1997 and 2007 grew by 26%, compared with a 14% rise in the preceding decade—higher numbers of promising young people are dying of what in many cases are treatable problems.3 Although completed suicide is an uncommon tragic event, suicidal thoughts are quite common. According to the Jed Foundation, half of college students have had suicidal thoughts at some point. Pooling available data suggests that only 1 of every 1000 students with suicidal ideation will commit suicide, so efforts to decrease deaths must also focus on the broader pool of students in distress.4 And, although most of the suicide risk factors in the general population apply on campus, there are some unique characteristics in the college group that require attention and a better understanding.
Surveys suggest an increase in overall student emotional distress in recent years. The American Freshman: National Norms Fall 2014 survey reported that among more than 150,000 first-year students from more than 200 universities, only about half—the lowest number since the survey began—rated their emotional health as “above average or highest 10%.” Almost 10% reported “frequently feeling depressed in the past year,” 3.4 percentage points higher than 5 years ago.
Problems persist beyond the first year. The American College Health Association’s 2014 National Health Assessment, which captured nearly 80,000 students at 140 schools, found that more than half felt “overwhelming anxiety” and more than a third felt “so depressed it was hard to function” in the past 12 months. In this sample, the percentage of students who had had a diagnosis of or had been treated by a professional for anxiety, depression, or two or more mental health diagnoses other than anxiety or depression were 14.3%, 12%, and over 6%, respectively. These numbers are all higher than in 2009, when, for example, only about 1 of 10 students reported treatment for anxiety or depression. This survey also suggests an increase in the preceding year’s rate of both serious suicidal ideation and suicide attempts: 8% of students in 2014 compared with 6% in 2009 reported serious ideation, and 1.3% attempted suicide, compared with 1.1%.
As in the general population, psychiatric illness and personality factors play a large part in predisposing some students to suicidal thinking. Alcohol use often precedes suicidal behaviors. There is a strong association between proximal alcohol use and increased suicide attempts, but among college students, the acute alcohol effect appears stronger for infrequent drinkers.5 This is troubling because the majority of problematic drinking on campus is binge drinking; many students are infrequent drinkers. Similarly, most student suicidal ideation is intense and brief, with crisis symptoms lasting a day or less and recurring throughout the year.6
A number of studies have highlighted depressive symptoms, impulsivity, hopelessness, low self-esteem and, in particular, previous suicidal behavior as risk factors, but among college students, “cross-gender behavior,” such as depression in men (who typically have lower depression rates than women) or recent alcohol consumption in women (who generally have lower alcohol abuse rates than men) can also signal heightened risk.7 Academic failure and relationship difficulties, including dating violence, are frequent environmental triggers, but for women, interpersonal events are more commonly associated with suicidal behaviors, while for men, achievement events are.7
Loneliness, and especially social hopelessness, is an additional risk factor. Social hopelessness refers to a negative cognitive style about relationships, including fears of never fitting in or finding intimacy. In college students, this better distinguishes those at risk for suicide than does a focus on general hopelessness.8 The American Freshman: National Norms Fall 2014 survey found freshmen arrive at college with less experience socializing in person and more time spent online with social media. How this might affect mental health remains to be seen.
Millennial generation students have been raised with high expectations both of their own performance and of success, and for most, a great deal of parental involvement. There is growing recognition that certain aspects of perfectionism cause significant distress. Social perfectionism, or the attempt to live up to extremely high standards that one believes others have set while fearing extreme criticism from others for failures, seems particularly damaging. When combined with high measures of self-criticism, doubt, and excessive concern over mistakes, social perfectionism is linked with depression and increased suicide risk.9 Perfectionism may be amplified in this social media age, in which students curate their on-line presences to project success and happiness while their lived experience may be widely divergent.
We are just beginning to systematically study other demographic factors that may predict student suicide, including the impact of race and ethnicity, minority status in terms of sexual orientation or gender identity, and the challenges of first-generation or low-socioeconomic status students. Existing research on these is sparse, but it is clear that the college years, with their focus on identity development for all students, may present particular challenges for students also dealing with discrimination or trying to reconcile warring worldviews within themselves. For example, some have suggested that within the African American community, religious beliefs can protect against suicide or, conversely, drive suicidal ideation underground.10
Black gay males may experience more suicidal behaviors because of discriminatory attitudes that are additively destructive. According to one study, 1 of 5 gay college students has attempted to kill himself; another study found that half of transgender youths in a sample of 55 adolescents had serious suicidal ideation, and a quarter had made at least one suicide attempt.11 Combat veterans may experience similarly elevated rates of suicidal thoughts and behaviors. One study of over 600 student veterans found elevated rates of depression, anxiety, and PTSD in this group and, alarmingly, nearly half reported suicidal thoughts and 7.7% reported having made an attempt.12
What is especially frustrating regarding the lack of progress in reducing college suicide is that we know what might help. There is ample evidence that those who engage in treatment have lowered odds of hurting or killing themselves, and that most completed suicides are by students who have never participated in counseling services.6 Many students remain unaware of the availability of campus counseling resources.
Stigma surrounding seeking psychiatric help persists, especially within campus cultures that amplify perfectionism. And unfortunately, the availability of campus mental health services varies widely across the country. Especially limited is access to psychiatric care: according to the 2014 National Survey of College Counseling Center directors, only 7% of 2-year institutions and 58% of 4-year colleges have on-campus psychiatric consultation. Referring students for off-campus care is often thwarted by inadequate financial resources, minimal or absent mental health insurance, limited means of transportation off-campus and, often, restricted availability of care even in the community.
Given the complexity of factors that affect student suicide, the most effective prevention efforts for college students must incorporate a population-based, public health approach rather than a crisis intervention model.13 Since most suicidal students do not seek counseling, it cannot be left to the counseling center alone to identify those at greatest risk. The Jed Foundation and other suicide prevention groups stress the importance of creating a campus culture of caring.
Psychiatrists can contribute to experiential campus programs focused on topics such as stress management or relationship improvement; these may benefit a broad range of students, including those who are potentially suicidal. Many campuses have created multidisciplinary behavior intervention teams that meet regularly to systematically review “students of concern.” Collaborating with all campus constituencies is essential, yet psychiatrists must also continually balance their patient’s right to best clinical care and confidentiality with the university community’s wish to create safety for all.
In the wake of lawsuits after a student suicide, some universities have instituted policies to remove students from dorms or place them on leave after they have expressed suicidal ideation. This is problematic because the vast majority of students with suicidal thoughts will not go on to commit suicide, and the perception that the university is acting to protect its own interests may not only invite other litigation but, more importantly, may deter students from seeking help for fear of being dismissed from school.
Unfortunately, not all efforts at prevention will be successful. How a campus responds after a student’s suicide has the potential to not only alleviate community distress but also prevent additional crises. Here again, there is significant variability in how universities respond. Most counseling centers are not guided by regulatory oversight, which in other clinical settings would require incident reporting and a careful review of the factors leading to a critical incident. When the student was not even a patient of the center, it is particularly unclear who might be responsible for a morbidity and mortality style review that might shed more light on best practices in suicide prevention.
Many universities avoid reporting on student deaths as suicides, either out of fear of contagion effects, which have been documented in a number of studies and especially in adolescents, or because of family wishes to protect the student’s privacy. Yet according to both CDC and NIMH guidelines, contagion effects can be mitigated by the way that details of a suicide are reported. Furthermore, some studies show that among youths, any death of a peer, even if not self-inflicted, can increase suicidal thinking and even attempts. Secrecy may thus not be the best solution, but rather informed sensitivity to how information about suicide is shared. The Jed Foundation has compiled a postvention guide for campuses, which is a very useful resource.14
The fact that student suicide rates are lower than general population rates is largely attributed to the relative dearth of access to firearms on campus. Guns are the leading method of suicide for men and the second leading method for women in the general population; guns are also the leading method of suicide for male students, but their use is one-third as common among students.15
In the wake of recent suicide-massacres on campus, however, many states have introduced legislation that strikes down university bans on concealed weapons. Seven states now allow concealed weapons on public university campuses, and as I write this, Texas awaits governor approval of a bill allowing concealed weapons at all its public universities.16 With more access to the most widely used method of suicide, other efforts at suicide prevention may become even more critical in the years ahead.