College Students and Suicide Prevention

1
College Students and Suicide Prevention
Administrators and Staff

• Ellen J. Anderson, Ph.D., SPCC

2
College Student Suicide

• Suicide is the second leading cause of death for
  college students
• The number one cause of suicide for college
  student suicides (and all suicides) is untreated
  depression

3
Despair At A Young Age

• Unlike most disabling physical diseases, mental
  illness begins very early in life. Half of all
  lifetime cases begin by age 14 three quarters
  have begun by age 24. Thus, mental disorders are
  really the chronic diseases of the young,
  (National Institute of Mental Health)
• Anxiety disorders often begin in late childhood
• Mood disorders in late adolescence
• Substance abuse in the early 20s
• Unlike heart disease or most cancers, young
  people with mental disorders suffer disability
  when they are in the prime of life, when they
  would normally be the most productive

4
Despair At A Young Age

• Many young people who come to college have not
  yet been diagnosed with Depression,
  Schizophrenia, or Bi-Polar Disorder
• We are seeing an increase in suicidal ideation
  and behavior on campus as more people with severe
  mental illness attend college
• Improved treatment has allowed many young people
  to continue a normal life despite the development
  of severe mental illnesses

5
Despair At A Young Age

• In general, non-college young adults complete
  suicide at about twice the rate as college
  students
• Foreign students may have a higher risk for
  suicide
• Suicide is not more frequent in any of the four
  years of college, but it does occur more often in
  students who take more than four years to earn
  their degrees

6
High Levels Of Stress

• Going to college can be a difficult transition
  period in which students may experience high
  levels of stress, which can lead to Clinical
  Depression
• Many college students also use higher levels of
  alcohol and drugs than at earlier times in their
  lives, increasing the risk of suicidal ideation
• A hallmark of diagnosis for clinical depression
  is the presence of suicidal thinking
• Yet our lack of knowledge about this illness
  means that we dont seek help, and our friends
  and family dont push us to get help

7
Unwilling To Seek Help

• Stigma about treatment means that very few people
  with suicidal ideation actually seek treatment
• Additionally, a survey indicates that one in five
  college students believe that their depression
  level is higher than it should be, yet only 20
  say they would go to the campus counseling center
• Those whose symptoms improve when they activate a
  suicide plan may be especially resistant to
  seeking help
• Nearly half of suicidal students present for some
  medical treatment in the months before completing
  suicide although they may not acknowledge
  suicidal thoughts

8
Awareness

• Teachers, coaches, and residence hall counselors
  should focus not only on disruptive students, but
  also on those who are quietly withdrawn or whose
  dormitory discussions or classroom essays
  disclose hopelessness and suicidal thinking
• Training in awareness about depression and
  suicidal thinking is important for all staff
• Policies should be in place to discover students
  with suicidal ideation and help them to recover

9
How common is suicide among teenagers and young
adults?

• Suicide is the 3rd largest killer of young people
  between the ages of 10 and 25, and the 2nd
  largest killer of young adults
• Suicidal ideation is admitted by about 25 of
  adolescents at some time during high school
• Suicide attempts are more frequent among the
  young than the old, although completions are less
  likely
• About 4,000 young people die from suicide every
  year in the US
• Teen suicide tripled between 1950 and 1980, but
  has dropped somewhat in the past 25 years
• Around the world, adolescent suicide declined in
  industrialized nations with the increase in use
  of anti-depressant medication, despite fears that
  meds will increase suicidal behavior in teens

10
What Is Mental Illness?

• Prior to our understanding of illness caused by
  bacteria, most people thought of any illness as a
  spiritual failure or demon possession
• Contamination meant spiritual contamination
• People were frightened to be near someone with
  odd behavior for fear of being contaminated

10
Gatekeeper Training- Dr. Ellen Anderson
11
What Is Mental Illness?

• What do we say about someone who is odd?
• Looney, batty, nuts, crazy, wacko, lunatic,
  insane, fruitcake, psycho, not all there, bats in
  the belfry, gonzo, bonkers, wackadoo, whack job
• Why would anyone admit to having a mental
  illness?
• So much stigma makes it very difficult for people
  to seek help or even acknowledge a problem

11
Gatekeeper Training- Dr. Ellen Anderson
12
What Is Mental Illness?

• We know that illnesses like epilepsy, Parkinson's
  and Alzheimers are physical illness in the brain
• Somehow, clinical depression, anxiety, Bi-Polar
  Disorder and Schizophrenia are not considered
  physical illnesses requiring treatment
• We confuse brain with mind
• Talking about suicide is taboo

12
Gatekeeper Training- Dr. Ellen Anderson
13
Is Suicide Really a Problem?

• 87 people complete suicide every day
• 32,466 people in 2005 in the US
• Over 1,000,000 suicides worldwide (reported)
• This data refers to completed suicides that are
  documented by medical examiners it is estimated
  that 2-3 times as many actually complete suicide
• (Surgeon Generals Report on Suicide, 1999)

13
Gatekeeper Training- Dr. Ellen Anderson
14
The Gender Issue

• Women perceived as being at higher risk than men
• Women do make attempts 4 x as often as men
• But - Men complete suicide 4 x as often as women
• Womens risk rises until midlife, then decreases
• Mens risk, always higher than womens, continues
  to rise until end of life
• Are women more likely to seek help? Talk about
  feelings? Have a safety network of friends?
• Do men suffer from depression silently?

14
Gatekeeper Training- Dr. Ellen Anderson
15
What Factors Put Someone At Risk For Suicide?

• Biological, physical, social, psychological or
  spiritual factors may increase risk-for example
• A family history of suicide increases risk by 6
  times
• Access to firearms people who use firearms in
  their suicide attempt are more likely to die
• Social Isolation people may be rejected or
  bullied because they are weird, because of
  sexual orientation, or because they are getting
  older and have lost their social network
• (Goleman, 1997)

15
Gatekeeper Training- Dr. Ellen Anderson
16

• A significant loss by death, separation, divorce,
  moving, or breaking up with a boyfriend or
  girlfriend can be a trigger
• The 2nd biggest risk factor - having an alcohol
  or drug problem
• Many with alcohol and drug problems are
  clinically depressed, and are self-medicating for
  their pain
• (Surgeon Generals call to Action, 1999)

16
Gatekeeper Training- Dr. Ellen Anderson
17

• The biggest risk factor for suicide completion?
• Having a Depressive Illness
• Someone with clinical depression often feels
  helpless to solve his or her problems, leading to
  hopelessness a strong predictor of suicide risk
• At some point in this chronic illness, suicide
  seems like the only way out of the pain and
  suffering
• Many Mental health diagnoses have a component of
  depression anxiety, PTSD, Bi-Polar, etc
• 90 of suicide completers have a depressive
  illness
• (Lester, 1998, Surgeon General, 1999)

17
Gatekeeper Training- Dr. Ellen Anderson
18
Depression Is An Illness

• Our current cultural view of suicide is wrong -
  invalidated by current understanding of brain
  chemistry and its interaction with stress,
  trauma and genetics on mood and behavior
• Suicidal thinking is a severe symptom of the way
  depression is altering the brain causing
  changes in thinking, mood and body regulation
• Suicide has been viewed for centuries as
• a moral failing, a spiritual weakness, a mortal
  sin
• an inability to cope with life
• the cowards way out
• A character flaw
• This view must be replaced by more current
  understanding of brain disorders as treatable,
  physical illnesses
  (Anderson, 1999)

19

• The research evidence is overwhelming -
  depression is far more than a sad mood. It
  includes
• Body Regulation Problems
• Weight gain/loss
• Sleep problems
• Sense of tiredness, exhaustion
• Mood Regulation Problems
• Sad or angry mood
• Loss of interest in pleasurable things, lack of
  motivation
• Irritability
• Thinking and Memory Problems
• Confusion, poor concentration, poor memory,
  trouble making decisions
• Negative thinking
• Withdrawal from friends and family
• Often, suicidal thoughts
• (DSMIVR, 2002)

20

• 20 years of brain research teaches that these
  symptoms are the behavioral result of
• Changes in the physical structure of the brain
• Damage to brain cells in the hippocampus,
  amygdala and limbic system
• Depressed people suffer from a physical illness
  what we might consider faulty wiring
• (Braun, 2000 Surgeon Generals
  Call To Action, 1999, Stoff Mann, 1997, The
  Neurobiology of Suicide)

20
Gatekeeper Training- Dr. Ellen Anderson
21
Faulty Wiring?

• Literally, damage to certain nerve cells in our
  brains - the result of too many stress hormones
• Cortisol
• Adrenaline
• Testosterone hormones activated by our
  Autonomic Nervous System to protect us in times
  of danger
• Chronic stress causes changes in the ANS, so that
  high levels of activation occur with very little
  stimulus
• Constant activation in the ANS causes changes in
  muscle tension, imbalances in blood flow patterns
  - leads to asthma, IBS and depression, increased
  risk for death from heart disease
• (Goleman, 1997, Braun, 1999)

22
Faulty Wiring?

• Every time something upsets us it causes the ANS
  to activate stresses accumulate and keep us in
  a state of high arousal stress hormones build
  up
• People with genetic predispositions, placed in a
  highly stressful environment will experience
  damage to brain cells from stress hormones
• As damage occurs, thinking changes in the
  predictable ways identified in our list of 10
  criteria (Goleman, 1997 Braun, 1999)

23
One of Many Neurons

• Neurons are special cells that make up the brain
  and their united, networked action is what causes
  us to think, feel, and act
• Neurons must connect to one another (through
  dendrites and axons)
• Stress hormones damage dendrites and axons,
  causing them to shrink away from other
  connectors
• As fewer and fewer connections are made, more and
  more symptoms of depression appear

23
Gatekeeper Training- Dr. Ellen Anderson
24
How Can We Stop Brain Damage?

• As damage occurs, thinking changes in the
  predictable ways identified in our list of 10
  criteria
• Four things can reduce this brain damage
• Stress reducing mental exercises - meditation
• Exercise
• Antidepressant medication
• Cognitive/Behavioral Psychotherapy

25

• Many cultures have developed stress reduction
  rituals/mental exercises Yoga, Tai Chi, Qi
  Jong, meditation, prayer these millennia old
  methods work well to reduce stress hormone
  production
• Exercise can help burn off high stress hormone
  levels and even reduce production
• Antidepressants can counter the effects of stress
  hormones
• We know now that antidepressants stimulate genes
  within the neurons (turn on growth genes) which
  encourage the growth of new dendrites
• New dendrites reconnect neurons and symptoms are
  reduced
• It can take longer than six weeks for the brain
  to repair itself enough that people feel better
• (Braun, 1999)

26
How Does Therapy Help?

• Medications may improve brain function, but do
  not change how we interpret stress
• Cognitive or interpersonal therapy helps people
  change the (negative) patterns of thinking that
  lead to depressed and suicidal thoughts
• Changing our inaccurate beliefs and thought
  patterns alters our response to stress we are
  not as reactive or as affected by stress at the
  physical level
• Research shows that cognitive therapy is as
  effective as medication in reducing depression
  and suicidal thinking (Lester, 2004)

27
How Does Therapy Help?

• The Talking Cure as Freud originally called it
  turns out to have a scientific basis for success
• Daniel Goleman, Daniel Siegal, Antonio DAmasio
  and others are explaining how social interaction
  with others physically alters our neuronal paths,
  allowing different ways of thinking to change the
  chemical, electrical and thought pattern flow in
  our brains
• We know that people raised in highly abusive
  homes have visibly different brains than people
  from normal homes, as seen on MRIs and CAT scans
• We also know that healing relationships, changed
  perspectives (reframing) and altered self-beliefs
  change how people react to stress, and what they
  react to

28
Possible Sources Of Depression

• Genetic a predisposition to this problem may be
  present, and depressive diseases run in families
• Predisposing factors Childhood traumas, car
  accidents, brain injuries, abuse and domestic
  violence, poor parenting, growing up in an
  alcoholic home, chemotherapy
• Immediate triggers violent attack, illness,
  sudden loss or grief, loss of a relationship, any
  severe shock to the system
• (Anderson, 1999, Berman Jobes, 1994, Lester,
  1998)

28
Gatekeeper Training- Dr. Ellen Anderson
29
What Happens If We DontTreat Depression?

• Significant risk of increased alcohol and drug
  use
• Significant relationship problems
• Lost work days, lost productivity (up to 40
  billion a year)
• High risk for suicidal thoughts, attempts, and
  possibly death
• (Surgeon Generals Call To Action, 1999)

29
Gatekeeper Training- Dr. Ellen Anderson
30
Can Suicide Be Predicted?

• No
• That said, there are Practice Guideline standards
  for assessment that should be followed
• Be aware of the Impulsive nature of most suicides
• Responsibility for knowledge of risk factors for
  suicide
• Dangers of misusing risk assessment scales-may
  not account for todays danger

31
College Mental Health Professionals

• What are ethical obligations for college mental
  health professionals?
• As with any mental health professional, a duty to
  warn and a responsibility to students with
  suicidal ideation to treat and keep safe
• Responsible to assess risk and help students
  manage symptoms,
• Responsible to seek medical assistance and
  hospitalization as needed
• Need for a fully documented risk assessment
• Dangers of abandonment, negligent referral, and
  fragmented care
• Maintain standards of care

32
What Are "Best Practices" In Staff Training And
Educational Programming

• The United States Air Force model
• Develop a campus-wide commitment to suicide
  prevention
• Reducing stigma against seeking professional help
• Depression screening programs and online
  resources Jed Foundation, American Foundation
  For Suicide Prevention

33
What Are My Responsibilities?

• We should not be looking at student suicide
  primarily from a risk-management perspective
• College administrator responses to students
  become defined by the law and not through primary
  responsibility as educators
• As educators, we have to take some risks. That
  means working harder to keep students at risk of
  suicide enrolled, working with them, giving them
  the help they need, and not finding faster and
  more creative ways to remove them. (Gary
  Pavela, 2006, The Chrone)

34
A Protective Environment

• Mandatory-removal policies carry legal risks of
  their own - ADA
• Office for Civil Rights within the U.S.
  Department of Education has been called upon to
  issue letter rulings pertaining to these policies
  students with documented mental health
  diagnoses may win a lawsuit
• The risk of liability for suicides is low most
  cases focus on high risk immediate suicidality
• College administrators, may err on the side of
  under-reaction, in terms of notifying parents, in
  terms of hospitalization
• Decisions in some recent cases do not define the
  law nationally and do not mean your proper
  response as an administrator is to find a quick
  way to get rid of the student
• What the cases would point to is that you must
  react promptly and appropriately to a student who
  is manifesting signs of imminent risk of suicide
  (Pavela, 2006)

35
Parental Notification

• Should colleges notify parents of students at
  risk of suicide?
• Previously, a strong bias not to notify parents
  about problems a student was having
• In recent years a shift toward more parental
  notification
• FERPA Family Educational Rights and Privacy Act
  amended able to notify parents in certain
  alcohol incidents
• Who should notify parents and under what
  conditions?
• Mental-health professionals will have a legal and
  ethical obligation to breach confidentiality in
  an emergency, when a person is at imminent risk
  of harming themselves
• Parents would have to be notified by the
  hospital. When students enroll, it should be part
  of their file Who do you want notified in case
  of emergency?

36
Parental Notification

• My role of an administrator
• Administrators have more latitude than
  mental-health professionals to notify parents
• Err on the side of treating suicidal statements
  as a genuine suicide threat or gesture,
• Arrange for immediate evaluation of that student,
  
• Ask the student about needing to involve the
  parents immediately,
• Listen to arguments about why that wouldn't work,
  and I would
• Talk to a mental-health professional.
• Once there is a suicide threat or gesture -
  notify parents, even when it isn't a full-blown
  emergency

37
Should Colleges Withdraw Students Who Threaten Or
Attempt Suicide?

• Rate of young-adult suicide for people going to
  college is about one-half of the rate for young
  adults who are not going to college
• Campus environments, human connection, and
  limited access to firearms are protective
• College campuses do a good job of limiting
  firearms, the most dangerous choice of a suicide
  weapon
• Sending kids home means taking them out of a
  protective environment and putting them where
  they may be more likely to hurt themselves
• policies can use the threat of removal as
  "leverage" to get students help they need.
• Use the administrative process as a lever to get
  the student help
• We are a community that can't tolerate violence,
  including violence to self, and we have a
  mechanism to help you, and if not, we can remove
  you
• Both are using discipline as a threat, but one is
  carrying through immediately, and the other is
  doing everything possible not to use it.

38
Empowering Students To Help Prevent Suicides
Among Peers

• Often peers know about potentially suicidal and
  depressed behavior and comments
• Increase discussion with students about the
  responsibility of friendship
• A higher loyalty is to save a person's life, not
  keep a persons secret
• Friends don't let depressed students handle their
  problem alone, and they get help for that
  student, even if they have to break
  confidentiality
• Teach when to get help and where to get it this
  goes beyond the ability of friendship to manage

39
Help Faculty React Appropriately

• Training is needed so that faculty will not
  under-react to suicidal references
• Training to understand what depression is and how
  it can lead to suicide
• Realizing that relationship and support is not
  enough we dont simply offer kindness when
  someone is having a heart attack

40
Mentoring and Connection

• One of the triggering factors to depression is
  isolation, the feeling of not being a part of a
  community
• College students still need adult support and
  someone to talk with
• Faculty and students alike need training in these
  issues, but stigma makes it difficult for people
  to talk about
• Try a stress-management seminar
• Talk about relationship issues, as many suicidal
  thoughts come up as a response to relationship
  loss
• Dont be afraid to bring up suicide in any
  appropriate discussion setting

41
After A Suicide

• Schools should prepare postvention plans in case
  a suicide does occur on the campus
• The plans should focus on outreach to survivors
  and on preventing suicide contagion by managing
  the information that is presented to the press
  and public
• Opportunities to talk should be made available to
  students and staff
• Connections should be maintained with other
  students who are known to have suicidal thoughts,
  and on friends of the person who died

42
Jed Foundation Prevention Model
43

• If one cannot state a matter clearly enough so
  that even an intelligent twelve-year-old can
  understand it, one should remain within the
  cloistered walls of the university and laboratory
  until one gets a better grasp of one's subject
  matter
• Margaret Mead

44
A Brief Bibliography

• American Foundation for Suicide Prevention (AFSP)
  has launched the College Screening Project - a
  pilot program aimed at identifying college
  students at risk for suicide and encouraging them
  to get help they need
• Anderson, E. The Personal and Professional
  Impact of Client Suicide on Mental Health
  Professionals. Unpublished Doctoral dissertation,
  U. of Toledo, 1999
• Berman, A. L. Jobes, D. A. (1996) Adolescent
  Suicide Assessment and Intervention.
• Blumenthal, S.J. Kupfer, D.J. (Eds) (1990).
  Suicide Over the Life Cycle Risk Factors,
  Assessment, and Treatment of Suicidal Patients.
  American Psychiatric Press.
• Jacobs, D., Ed. (1999). The Harvard Medical
  School Guide to Suicide Assessment and
  Interventions. Jossey-Bass.

45

• Jamison, K.R., (1999). Night Falls Fast
  Understanding Suicide. Alfred Knopf 
• Lake, P. (2002). The Emerging Crisis of College
  Student Suicide Law and Policy Responses to
  Serious Forms of Self-Inflicted InjuryStetson
  Law Review, Vol. 32, No. 1, 2002
• Lester, D. (1998). Making Sense of Suicide An
  In-Depth Look at Why People Kill Themselves.
  American Psychiatric Press
• Oregon Health Department, Prevention. Notes on
  Depression and Suicide ttp//www.dhs.state.or.us/
  publickhealth/ipe/depression/notes.cfm
• Putukian, M. Wilfert, M, 2004. Student Athletes
  Also Face Dangers From Depression
  http//www.ncaa.org/news/2004/20040412/active/4108
  n32.html
• Pavela, G. (2006) College Student Suicide Legal
  Issues
• Presidents New Freedom Council on Mental Health,
  2003
• Quinnett, P.G. (2000). Counseling Suicidal
  People. QPR Institute, Spokane, WA
• Schneidman, E.S. (1996). The Suicidal Mind.
  Oxford University Press.
• Schwartz AJ and Whitaker LC. Suicide among
  college students Assessment, treatment and
  intervention. In SJ Blumenthal DJ Kupfer (Eds)
  Suicide over the life cycle Risk factors,
  assessment, and treatment of suicidal patients.
  (pp. 303-340). Washington DC American
  Psychiatric Press, 1990.

46

• Signs of Depression in Youth. Oregon State Dept.
  of Health. http//www.dhs.state.or.us/publichealth
  /
• ipe/depression/signs.cfm
• Stoff, D.M. Mann, J.J. (Eds.), (1997). The
  Neurobiology of Suicide. American Academy of
  Science
• Styron, W. (1992). Darkness Visible. Vintage
  Books
•  
• Surgeon Generals Call to Action (1999).
  Department of Health and Human Services, U.S.
  Public Health Service.
•  
• Tang, T.Z. De Rubeis, R.J. ((1999). Sudden
  Gains and critical sessions in cognitive-behaviora
  l therapy for depression. Journal of Consulting
  and Clinical Psychology 67 894-904.