College Students and Suicide Prevention – Administrators and Staff

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 20’s • 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 don’t seek help, and our friends and family don’t 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 Gatekeeper Training- Dr. Ellen Anderson 10

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 Gatekeeper Training- Dr. Ellen Anderson 11

12. What Is Mental Illness? We know that illnesses like epilepsy, Parkinson's and Alzheimer’s 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 Gatekeeper Training- Dr. Ellen Anderson 12

13. 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 General’s Report on Suicide, 1999) Is Suicide Really a Problem? Gatekeeper Training- Dr. Ellen Anderson 13

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 Women’s risk rises until midlife, then decreases Men’s risk, always higher than women’s, 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? Gatekeeper Training- Dr. Ellen Anderson 14

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) Gatekeeper Training- Dr. Ellen Anderson 15

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 General’s call to Action, 1999) Gatekeeper Training- Dr. Ellen Anderson 16

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) Gatekeeper Training- Dr. Ellen Anderson 17

18. Depression Is An Illness • Our current cultural view of suicide is wrong - invalidated by current understanding of brain chemistry and it’s 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 coward’s 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 General’s Call To Action, 1999,Stoff & Mann, 1997, The Neurobiology of Suicide) Gatekeeper Training- Dr. Ellen Anderson 20

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 Gatekeeper Training- Dr. Ellen Anderson 23

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 D’Amasio 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 MRI’s 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) Gatekeeper Training- Dr. Ellen Anderson 28

29. What Happens If We Don’tTreat 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 General’s Call To Action, 1999) Gatekeeper Training- Dr. Ellen Anderson 29

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 today’s 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 person’s 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 don’t 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 • Don’t 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 Depressionhttp://www.ncaa.org/news/2004/20040412/active/4108n32.html • Pavela, G. (2006) College Student Suicide: Legal Issues • President’s 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 General’s 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-behavioral therapy for depression”. Journal of Consulting and Clinical Psychology 67: 894-904.