Psychiatric Annals

CME Article 

Suicide Among College Students: Risk and Approaches to Prevention and Management

Victor Schwartz, MD

Abstract

College campuses are a unique setting for the delivery of mental health care. Approximately 20 million people attend institutions of higher education in the United States. There has been growing recognition in recent years that a community/public health approach to suicide prevention on college campuses can be effective. Psychiatrists can play an important role in supporting suicide prevention on college campuses. [Psychiatr Ann. 2017;47(8):406–411.]

Abstract

College campuses are a unique setting for the delivery of mental health care. Approximately 20 million people attend institutions of higher education in the United States. There has been growing recognition in recent years that a community/public health approach to suicide prevention on college campuses can be effective. Psychiatrists can play an important role in supporting suicide prevention on college campuses. [Psychiatr Ann. 2017;47(8):406–411.]

As of 2014, there were more than 20 million students attending degree-granting postsecondary institutions in the United States.1 Although enrollment in colleges and universities has grown substantially in recent decades, there has been a small drop in those numbers in recent years, which may be linked to rising tuition rates, a sluggish economy, and less government support of public institutions.1

Having a college education has wide-ranging personal and professional benefits;2 however, the college years can be stressful. For some college-age students, major psychiatric illnesses may emerge during this time frame. There are significant personal and psychological developments occurring during this period, which can be stressful for many people.

The College Mental Health Picture

There are several reliable sources of information about problems and trends regarding the mental health of college students. These include information from counseling center director's surveys,3 counseling center patient intake data,4 and surveys of random samples of college students.5,6 These surveys all paint a fairly concerning picture of the mental health of college students. For many years, 90% to 95% of directors of counseling centers have reported greater numbers of students with serious mental health concerns presenting for service.3 In 2015, over 20% of students who visited counseling services reported suicidal concerns as their reason for coming in for care.3 Nationally, over 10% of students are seen individually by their campus counseling services.3

Among college students in general, when asked about factors that negatively affected their academic performance, 33.8% reported stress, 24.4% anxiety, 22.2% sleep difficulties, and 16.2% depression.7 In the same survey, when asked about their experiences at any point in the prior year, 51% reported feeling hopeless, 60.8% felt very lonely, 66% very sad, and 37.5% so depressed it was difficult to function. Furthermore, 32.6% of undergraduates reported an alcohol binge in the prior 2 weeks and 17.4% reported driving after having had alcohol in the prior month.7

Suicidal Behaviors

Suicidal behaviors are unfortunately common among college students. In the spring of 2016, 7.3% of undergraduates reported nonsuicidal self-injury (a significant risk factor for suicide), 10.5% reported serious thoughts of suicide, and 1.6% reported a suicide attempt in the prior year.7 Although these rates had been holding steady for many years, they have increased in the past 2 to 3 years.7

Determining the rates of how many deaths actually occur because of suicide on college campuses is more difficult. Although the Centers for Disease Control and Prevention collect data on causes of death sorted by age and various demographic factors, they do not determine student status at the time of death. There is also no organized system for colleges to report student deaths, and although counseling center directors are asked about student suicides and deaths on their campus in the prior year in the Association of University and College Counseling Center Directors survey,3 these reports only reflect the deaths that directors are aware of. For example, they may not know of deaths that have occurred off campus, during school breaks, or among students who have taken a leave.

The most careful reviews of college student suicide rates were completed many years ago. Silverman et al.8 published the “Big 10 Study” of suicide among college students in 1997 based on data collected during the 1980s. Schwartz9 reported on suicide rates in college students between 1990 and 2004 and again between 2004 and 2009. In both reviews, annual rates were found to be approximately seven suicides per 100,000 students. It is important to note that annual suicide rates among people age 20 to 34 years who are not attending college (12 to 14 per 100,000 people) are significantly higher than for their peers who do attend college.10

In fact, current suicide rates among college students are not yet defined. For 2009, the annual suicide rate among people age 20 to 34 years was 12 to 13 per 100,000 people. Since that time, however, as of 2015, the annual rate increased to 15.5 per 100,000 people.10 Thus, it is possible that the suicide rates among college students have also increased during this time. There has been an uptick in suicidal ideation and attempts among college students in recent years.7

Why has suicide among college students received heightened attention if the rates are lower than for people age 20 to 34 years who are not college students? Part of this is due to the nature of college communities. For example, if one or two suicide deaths of young adults occur in a town of 40,000 people, they will not likely be thought of as connected events. However, if the same two suicide deaths occurred on a college campus with a similar student body population as the small town, they will likely be viewed as connected and newsworthy. This is not just a matter of perception. The self-contained nature of college campuses increases the risk of suicide contagion on campus when one occurs.11

An Approach to Prevention and Management of College Student Suicide

Although college campuses present challenges in relation to suicide contagion, the boundaries and organized nature of them can also present opportunities to prevent suicide and manage suicide risk. In 2006, The Jed Foundation and Suicide Prevention Resource Center (SPRC) worked together to adapt a public health driven model previously developed by the US Air Force12 to address suicide risk on college campuses.13 This model had been shown to lower rates of suicide, homicide, domestic violence, and accidental death among service members when implemented by the US Air Force.12

The JED/SPRC Model for Comprehensive Mental Health Promotion and Suicide Prevention for Colleges and Universities provides an approach to campus (or community) suicide prevention and management through a comprehensive public health lens (Figure 1). The Model consolidates the extant information about effective suicide prevention interventions14,15 and addresses prevention, early identification and intervention for those at risk, clinical care/crisis management/postvention, and restricting access to means for self-harm. The two core elements of prevention are supporting life skills and enhancing connectedness.

The Jed Foundation's comprehensive approach to emotional and behavioral health. Used with permission from The Jed Foundation.

Figure 1.

The Jed Foundation's comprehensive approach to emotional and behavioral health. Used with permission from The Jed Foundation.

Supporting Life Skills

Young people with poor life skills are at increased risk for substance abuse and suicidal behaviors.16 Life skills can be thought of as including both basic activities like managing nutrition, sleep, money, possessions, and time; these skills are typically acquired in the process of growing up and being encouraged to take more responsibility for self-care and self-management. More impactful and more challenging to correct are the social and emotional skills that typically develop through the maturation process. Basic social and emotional skills include17 (1) the ability to be aware of one's emotional state; (2) the ability to manage and cope with emotional distress; (3) the ability to be aware of the feelings and needs of others; (4) the ability to establish and maintain friendships and relationships with others; and (5) the ability to establish and articulate life values and goals.

Colleges are trying to build opportunities to enhance basic life and social and emotional skills activities into their student life programming. Many schools offer time and stress management workshops, dialectical behavior therapy, and relationship groups and programming in residence life that can promote self-awareness and self-efficacy.

Connectedness

In a study of suicidal thinking among college students, Drum et al.18 found evidence of the critical role of connectedness in periods of suicidality. Among students seriously considering suicide, the most prominent contributing antecedents were romantic problems, academic problems, family problems, and friend problems, illustrating the strong association between connectedness and suicidality—be it romantic, social, or familial. Relationships with family, friends, romantic partners, and even pets are among the most potent factors preventing suicide attempts. Students cite not wanting to hurt or disappoint their loved ones as well as the support obtained from them as powerful protective factors.18

Programs and activities on campus directed at creating a sense of community and identifying and supporting connections for lonely and isolated students are widely implemented but should be done in a strategic and deliberate way.19 Participation in Greek organizations (sororities and fraternities), intramural sports, religious and other identity communities, art and music groups, student clubs, and government are all activities that can support a sense of connectedness on campus.

Early Intervention: Identifying Students At Risk and Increasing Help-Seeking Behavior

It is both intuitively obvious, and recently has been empirically demonstrated, that interventions that help to identify those at risk for suicide, increase help-seeking behavior and promote early intervention can lower the risk of suicide.20 These activities can be promoted through several means.

Gatekeeper trainings and community education activities are focused on alerting people in a community likely to be positioned to help or support someone in a crisis. Gatekeepers are those in a community likely to encounter those who are struggling. On-campus gatekeepers include (among others) academic advisers, residence life staff, chaplains, coaches and trainers, and student services staff. Gatekeepers must know their role in supporting student mental health and should be well-informed about how to access essential services. Furthermore, students can receive simple training to learn how to recognize friends at risk and how to access the necessary care. Student access to mental health information, screening tools, as well as campus wide mental health promotion days can help to increase the likelihood of a student seeking help.21

Mental Health Services and Crisis Management

Campuses should provide access to a full range of mental health care either on campus or through referral arrangements with off-campus resources. Most colleges do provide primary care mental health services for students with ongoing care needs. Backup and help to manage mental health accommodations should also be available for students. It is also important for students with a history of mental health treatment who are moving away from home to attend college to develop a continuity of care plan with their home care team, family-, and campus-based clinicians.22

Crisis management includes services to handle daytime and after-hour emergencies as well as access to a crisis phone/text line. Furthermore, campuses must be prepared to manage the aftermath of suicide death,23 since a robust postvention plan not only helps the campus manage what happens afterwards, but can lower the risk of suicide contagion.

Means Restriction

Preventing people with suicidal ideation or impulses from getting access to the means for self-harm is a strongly significant factor in lowering the risk of suicide.24 Because suicidal crises are often brief and self-limited, creating a delay between impulse and action can be life-saving. Means restriction activities on campus can include (1) firearm restrictions or safe storage options; (2) safe storage of dangerous chemicals in laboratories; (3) secured roofs and windows; and (4) restricting access or safeguarding bridges and other high places on campuses.

The JED Campus Program provides ongoing technical assistance to colleges in assessing, enhancing, and implementing this model.25

The Role of Psychiatrists in Campus Suicide Prevention and Mental Health Care

Psychiatrists have traditionally played a peripheral role in college mental health systems.26 Fewer than 1% of college counseling services are directed by psychiatrists, nearly 40% of colleges have no access to psychiatry/medication prescribing services on campus, and in many cases when there are psychiatrists on campus they are located in health service rather than the counseling service.3 For colleges that have adequately integrated psychiatry and counseling services, psychiatrists can play a valuable role in supporting campus mental health and suicide prevention activities.

Assessment and Management of Crisis Cases

Psychiatric training is unique among other mental health disciplines in requiring a broad range of experience working with patients who have mental health and substance-related crises as well as being capable of assessing and managing their treatment options.27 As such, psychiatrists are particularly well placed to evaluate and care for students who experience mental health crises. Although staff psychiatrists are primarily responsible for medication management in campus mental health systems, they can also play an important role in assessing and managing the care of seriously ill and suicidal students. By virtue of managing psychopharmacology options, psychiatrists have most likely had clinical contact with those students who have more significant levels of psychopathology, which is the population most likely to present in a crisis.

Student At-Risk Teams

In the 10 years since the mass shooting tragedy at Virginia Tech, many colleges have established student at-risk teams.28 These teams aim to identify and intervene nimbly with students who may be at risk for suicide, emotional distress, or who may present a danger to their campuses. Again, given their experience in evaluating and treating serious mental illness and suicide risk, it is sensible for campus psychiatric staff to serve as members or consultants to campus behavioral intervention/at-risk teams.

Leave of Absence Protocols

As noted above, up to 10% of students report having experienced serious thoughts of suicide in the prior year. Although many students can be safely treated at school, some students request a leave of absence to receive care in a more structured setting or closer to home. It is recommended that schools have flexible policies allowing students to take time off to receive care in a supportive setting when necessary.29 Staff psychiatrists can play a useful role in assessing these student requests and working with the student, their family, and the university to build a safe treatment and activity plan that will help in preparing the student for return to school.

Other Roles for Psychiatrists on Campus

Although not directly connected to suicide prevention, psychiatrists can play two other important roles on campus. Of course, the primary role served is to prescribe psychiatric medication or to supervise the prescribing when handled by a medical doctor who is not a psychiatrist, physician assistant, or nurse practitioner. Having ready access to medications when needed is a significant step in preventing smaller problems from evolving into major crises. So ultimately, having ready access to prescribing on campus is an important component of a full-scale mental health and suicide prevention system.

College counseling services are an excellent setting for training senior psychiatry residents and child/adolescent fellows. As most training occurs in hospital-based services, many of the patients to whom trainees are exposed are severely and often persistently ill. The range of students presenting to college counseling services and the frequency with which they are highly responsive to both psychotherapy and medication management can be instructive for residents.30

Conclusion

Although a unique and often underrecognized area of concern, college counseling services are charged with offering treatment to 6% to 7% of the US population. It is estimated that approximately 1,500 college and university students die by suicide each year with suicide being the second leading cause of death for this group.9

College campus mental health services and organizations like The Jed Foundation have made important strides in developing systems of care and programming to support students and prevent campus suicides.31 Psychiatrists can and should play an important role in these activities and over time will hopefully become more integrated into and provide more leadership for campus mental health systems.

References

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Authors

Victor Schwartz, MD, is a Clinical Associate Professor of Psychiatry, NYU School of Medicine; and the Chief Medical Officer, The Jed Foundation.

Address correspondence to Victor Schwartz, MD, Department of Psychiatry, NYU School of Medicine, 550 First Avenue, New York, NY 10016; email: vschwartz@jedfoundation.org.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/00485713-20170706-01

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