Today’s college students consistently report feeling overwhelmed and also report high levels of stress, depression, and hopelessness (American College Health Association [ACHA], 2007). Feelings of depression and hopelessness, in particular, are significant risk factors for suicide.

Among college students, suicide is the second-leading cause of death; an estimated 1,088 college students die by suicide each year (National Mental Health Association and the Jed Foundation, 2002). The rate of attempted suicide may be as high as somewhere between 100 and 200 for every completed suicide (American Association of Suicidology, 2004). According to the ACHA (2007), one in ten college students reported having seriously considered suicide in the last twelve months.

The National Strategy for Suicide Prevention (NSSP; U. S. Department of Health and Human Services Office of the Surgeon General and National Alliance for Suicide Prevention, 2012) has called for the recognition of suicide as a significant public health problem and for taking a public health approach to suicide prevention. For colleges and universities this means a comprehensive, multifaceted approach that is focused both on at-risk populations and the general population and that is not left solely to counselors and counseling centers to implement (Suicide Prevention Resource Center, 2004). Drum, Brownson, Burton Denmark, and Smith (2009) referred to this as a problem-focused (as opposed to an individual-focused) paradigm “that requires the entire campus community to share responsibility for reducing student suicidality” (p. 220).

Since 2005, 138 campuses have received funding under the Garrett Lee Smith Memorial Act to implement campus suicide prevention programs. (See www.sprc.org/grantees for more information about the grants and grantees.) These campuses have taken a variety of approaches to prevent, treat, and respond to suicide on their campuses. This sourcebook highlights successful strategies implemented by grantee campuses that can serve as models for suicide prevention on other campuses.

The first two chapters set the context for the book. Chapter One addresses the overarching landscape of college student mental health. Deborah Taub and Jalonda Thompson outline what has been called “the campus mental health crisis” (Kadison and DiGeronimo, 2004) and the need for a comprehensive approach to the complex problem of campus suicide prevention. In Chapter Two, Elizabeth Jodoin and Jason Robertson situate suicide prevention within a public health context, as called for by the NSSP. In this chapter, they present the National Mental Health Association and Jed Foundation model (2002) for suicide prevention.

The remaining five chapters address specific components of a comprehensive suicide prevention program with illustration from college campuses that have received Garrett Lee Smith grants. Chapter Three addresses gatekeeper training, an approach to early identification and referral of students at risk for suicide. Cory Wallack, Heather Servaty-Seib, and Deborah Taub provide guidance for instituting campus gatekeeper training programs, illustrated with a campus example. In Chapter Four, Julie Catanzarite and Myles Robinson examine the role of peer education in suicide prevention and describe the creation of a peer educator program focused on mental health and suicide prevention. In Chapter Five, R. Bradley Johnson, Symphony Oxendine, Deborah Taub, and Jason Robertson describe the nature of suicide among lesbian, gay, bisexual, and transgender (LGBT) students and prevention efforts for this community. Chapter Six explores the complex nature of suicide prevention within diverse communities and populations. Richard Shadick and Sarah Akhter describe the approach they took at Pace University, New York City campus. Finally, Dolores Cimini and Estela Rivero highlight the important role that postsuicide intervention—what you do after a tragedy—plays in campus suicide prevention efforts in Chapter Seven.

An important note about the evaluation of effectiveness of comprehensive suicide prevention efforts: suicide is a low-incidence event, that is, the number of suicides, or even suicide attempts, on a single campus in any given year is likely to be relatively small (Haas, Hendin, and Mann, 2003; Silverman, 1993). Therefore, it is not effective to attempt to evaluate prevention efforts using the number of suicides or suicide attempts on campus (Schwartz and Reifler, 1988). Instead, those working in suicide prevention have measured related variables including numbers of referrals to counseling and levels of knowledge and awareness about campus resources and suicide warning signs to evaluate the effectiveness of their efforts.

Suicide is a preventable cause of death (National Institute of Mental Health, 2010); former U.S. Surgeon General David Satcher identified it as the most preventable (U. S. Department of Health and Human Services Office of the Surgeon General and National Alliance for Suicide Prevention, 2012). Students who receive counseling are six times less likely to take their own lives (Schwartz, 2006) than those who do not receive counseling. The approaches outlined in this volume represent elements of an effective comprehensive approach to campus suicide prevention.

Deborah J. Taub
Jason Robertson
Editors

References

American Association of Suicidology. Youth Fact Sheet, 2004. Retrieved December 5, 2011, from www.suicidology.org

American College Health Association. American College Health Association—National College Health Assessment: Reference Group Executive Summary, Fall 2006. Baltimore: Author, 2007.

Drum, D. J., Brownson, C., Burton Denmark, A., and Smith, S. E. “New Data on the Nature of Suicidal Crises in College Students: Shifting the Paradigm.” Professional Psychology: Research and Practice, 2009, 40, 213–222.

Haas, A. P., Hendin, H., and Mann, J. J. “Suicide in College Students.” American Behavioral Scientist, 2003, 46, 1224–1240.

Kadison, R. D., and DiGeronimo, T. F. College of the Overwhelmed: The Campus Mental Health Crisis and What To Do About It. San Francisco: Jossey-Bass, 2004.

National Institute of Mental Health. Suicide: A Major, Preventable Mental Health Problem: Facts about Suicide and Suicide Prevention among Teens and Young Adults, 2010. Downloadable fact sheet. Retrieved October 8, 2012, from www.nimh.nih.gov/health/publications/suicide-a-major-preventable-mental-health-problem-fact-sheet/suicide-a-major-preventable-mental-health-problem.shtml

National Mental Health Association and the Jed Foundation. Safeguarding Your Students Against Suicide: Expanding the Safety Network. Alexandria, Va.: National Mental Health Association and the Jed Foundation, 2002.

Schwartz, A. “College Student Suicide in the United States: 1990–1991 through 2003.” Journal of American College Health, 2006, 54, 341–352.

Schwartz, A. J., and Reifler, C. B. “College Student Suicide in the United States: Incidence Data and Prospects for Demonstrating the Efficacy of Preventative Programs.” Journal of American College Health, 1988, 37(2), 53–59.

Silverman, M. M. “Campus Suicide Rates: Fact or Artifact?” Suicide and Life-Threatening Behavior, 1993, 23, 329–342.

Suicide Prevention Resource Center. (2004). Promoting Mental Health and Preventing Suicide in College and University Settings. Newton, Mass.: Education Development Center.

U.S. Department of Health and Human Services Office of the Surgeon General and National Alliance for Suicide Prevention. 2001 National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, D.C.: U.S. Department of Health and Human Services, September 2012.

U.S. Department of Health and Human Services Office of the Surgeon General and National Alliance for Suicide Prevention. 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, D.C.: U.S. Department of Health and Human Services, September 2012.

DEBORAH J. TAUB is professor of higher education and coordinator of the Student Personnel Administration in Higher Education program at the University of North Carolina at Greensboro. She was project director for Purdue University’s Garrett Lee Smith Grant and the project evaluator for UNCG’s Garrett Lee Smith Grant.

JASON ROBERTSON is an assistant professor at Averett University. Prior to this, he was the wellness coordinator for the Wellness Center at UNCG and served as the director of outreach and training on UNCG’s SAMHSA Garret Lee Smith Grant.

1

College Student Suicide*

Deborah J. Taub, Jalonda Thompson

Suicide is the second-leading cause of death among college students. College student suicide and suicide prevention are best understood within the larger context of contemporary concerns about college student mental health.

Suicide is the second-leading cause of death among college students, and it is estimated that 1,088 college students die by suicide each year (National Mental Health Association and the Jed Foundation, 2002). Estimates are that the rate of attempted suicide is somewhere between 100 and 200 for every completed suicide (American Association of Suicidology, 2004). According to the American College Health Association (ACHA; 2007), one in ten college students reported having seriously considered suicide in the previous twelve months. The Suicide Prevention Resource Center (SPRC; 2004) has called college suicide and attempted suicide only “the tip of the iceberg of a larger mental health and substance abuse problem among college students” (p. 5).

This chapter presents the context of college student mental health within which the problem of college student suicide is situated. Because it is estimated that 90 to 95 percent of those who die by suicide have some form of treatable mental disorder at the time of their deaths, frequently depression or substance abuse (Joiner, 2010; Moscicki, 2001), the state of college student mental health today is highly relevant to campus suicide prevention. Many campus suicide prevention efforts focus on the identification of students struggling with mental health concerns and the referral of those students to counseling resources available to them before their treatable problems reach the acute stage of suicide.

This chapter presents highlights of the data on college student mental health and suicide risk and protective factors. Next, we explore college students’ use of counseling services and patterns of help seeking among college students. Finally, the need for a comprehensive approach to campus suicide prevention is addressed.

College students at risk for suicide can be divided into two large groups: those who come to college with an already diagnosed mental health problem and those who develop mental health problems while in college (National Mental Health Association and the Jed Foundation, 2002). Many major psychiatric illnesses, including depression, bipolar disorder, and schizophrenia, often do not manifest themselves until the late teens or early twenties (Kessler and others, 2007). The Suicide Prevention Resource Center (2004) has speculated that leaving home and going to college “may exacerbate existing psychological difficulties or trigger new ones” (p. 9). Poor sleep habits or experimentation with or abuse of drugs and alcohol, combined with the academic and social stresses of college, may play a role in triggering or worsening mental health problems in college students.

What is the extent of the “campus mental health crisis” (Kadison and DiGeronimo, 2004)? In fall 2011, the ACHA conducted the National College Health Assessment. According to the results of the study, during the previous year, 86.1 percent of respondents reported they felt overwhelmed by all they had to do, 60.5 percent felt very sad, 57.2 percent felt very lonely, 49.9 percent felt overwhelming anxiety, 45.2 percent felt that things were hopeless, and 30.3 percent felt so depressed that it was difficult to function; 6.6 percent reported they had seriously considered suicide (American College Health Association, 2012).

The Healthy Minds Study of college student mental health found that 17 percent of students screened positive for depression (Hunt and Eisenberg, 2010). College counseling centers report increased demand for services (Kitzrow, 2003) and increasing number of students with severe psychological problems (Barr, Rando, Krylowicz, and Reetz, 2010; Benton and others, 2003).

Certain groups of students are considered to be more at risk for mental health difficulties than others. Research suggests that 10 percent of college student athletes struggle with issues serious enough to warrant counseling (Ferrante, Etzel, and Lantz, 1996; Watson, 2006). Social isolation may put international students at greater risk of mental health concerns (Mori, 2000). Although women are more likely than men to have considered suicide once or twice, men are more likely to have considered suicide three or four times (National Mental Health Association and the Jed Foundation, 2002); further, men are more likely than women to complete suicide. Students under age twenty-one are more likely to exhibit suicide ideation and to attempt suicide than those over age twenty-two (National Mental Health Association and the Jed Foundation, 2002); students in the early years of college have been found to be at greatest risk (Brener, Hassan, and Barrios, 1999; Davis and DeBarros, 2006; Kisch, Leino, and Silverman, 2005). One study (Silverman and others, 1997) found graduate students to be at higher risk than undergraduates.

Westefeld, Maples, Buford, and Taylor (2001) found higher rates of suicide among gay, lesbian, and bisexual students than among heterosexual students, and Russell and Joyner (2001) found increased suicide ideation and suicide attempts in adolescents with same-sex sexual orientations. In a meta-analytic study of twenty-four studies, Marshal and colleagues (2011) found significantly higher rates of suicidality and depression among sexual minority youth than among heterosexual youth.

In addition, research has identified a number of risk factors associated with suicide (Berman, Jobes, and Silverman, 2006; Suicide Prevention Resource Center, 2011). Risk factors are variables that are associated with suicide. Risk factors for suicide (Berman, Jobes, and Silverman, 2006; Suicide Prevention Resource Center, 2011) include mental illness, alcohol and other substance abuse, hopelessness, impulsiveness and/or aggressiveness, history of trauma or abuse, previous suicide attempt, a family history of suicide, some major physical illnesses, barriers to effective care, lack of social support, stigma associated with help seeking, access to lethal means, and media that glamorizes suicide (Suicide Prevention Resource Center, 2011). The SPRC suggests that college students with one or more risk factors have a greater potential for suicidal behavior.

Protective factors are variables that “dissuade a person from considering suicide as an option” (Rutter, Freedenthal, and Osman, 2008, p. 143). Protective factors “enhance resiliency and serve to counterbalance risk factors” (Berman, Jobes, and Silverman, 2006, p. 299). These protective factors include access to effective and appropriate care, access to clinical intervention and support for help seeking, restricted access to lethal means, family and community support, cultural and religious beliefs that discourage suicide, skills in problem solving and conflict resolution, and positive beliefs about the future (Berman, Jobes, and Silverman, 2006; Suicide Prevention Resource Center, 2011; U.S. Public Health Service, 1999). Because many risk factors are difficult to change, many suicide prevention efforts have been directed at promoting protective factors.

Despite the prevalence of mental health problems among college students, students at risk of suicide often do seek the help that is available to them on campus. Although most U.S. colleges and universities provide free or low-cost counseling services for students (Gallagher, 2006; Stukenberg, Dacey, and Nagi, 2006), only a minority of those at risk seek counseling (Furr, Westefeld, McConnell, and Jenkins, 2001; Kisch, Leino, and Silverman, 2005). Nationally, an average of only slightly more than 11 percent of students sought the mental health services that were available to them (Barr, Rando, Krylowicz, and Reetz, 2010). Among college students who screened positive for depression or anxiety, between 37 percent and 84 percent, depending on the disorder, did not seek services (Eisenberg, Goldberstein, and Gollust, 2007). Nearly 50 percent of those who die by suicide in the United States had never been in contact with mental health services (Hamdi and others, 2008), and 80 to 90 percent of college students who die by suicide had not sought help from their college counseling centers (Kisch, Leino, and Silverman, 2005).

The following section looks at the groups of college students with decreased utilization of mental health services, the barriers to use of mental health services for college students, and who college students are seeking for help.

Groups With Lower Rates of Use of Mental Health Services

Colleges and universities in the United States are attempting to meet the mental health needs of a diverse student population who are coming to college “overwhelmed and more damaged than previous years” (Kitzrow, 2003, p. 169). The 2008 Chronicle of Higher Education Almanac predicted that, by 2016, the minority enrollment at colleges and universities will reach 39 percent, and 46 percent by the year 2020 (Kitzrow, 2003; Van der Werf and Sabatier, 2009.). With this increase, services offered to diverse student groups and many counselors’ training are inadequate for the mental health needs of minorities, international students, students from lower socioeconomic backgrounds, and other underrepresented groups on college campuses (Kitzrow, 2003). In general, researchers suggest that students from underrepresented groups experience “higher levels of stress from social oppression and discrimination and hence have higher levels of psychological distress and, therefore, greater need for mental health services” (Rosenthal and Wilson, 2008, p. 62).

However, many of the groups with the highest need of services are the same groups seeking services at a lower rate than their counterparts (Rosenthal and Wilson, 2008). Among those who use counseling services at lower rates than risk factors might suggest are appropriate are international students (Nilsson, Berkel, Flores, and Lucas, 2004), racial and ethnic minority students (Brinson and Kottler, 1995; Davidson, Yakushka, and Sanford-Martens, 2004; Eisenberg, Golberstein, and Gollust, 2007), men (Gonzalez, Alegria, and Prihoda, 2005; Komiya, Good, and Sherrod, 2000), student athletes (Etzel, Watson, Visek, and Maniar, 2006), and graduate students (Hyun, Quinn, Madon, and Lustig, 2006).

Barriers to Utilization of Mental Health Services

Although Yorgason, Linville, and Zitzman (2008) found that students in distress were more likely to know about and use campus counseling services, they also found that there were students who were mentally distressed who “either did not know about services or knew about services but did not use them” (p. 173). Why do students not seek the help that is available? Researchers have identified several barriers to the use of mental health services by college students, including public and personal stigmas (Bathje and Pryor, 2011), lack of time (Hunt and Eisenberg, 2010; Yorgason, Linville, and Zitzman, 2008), privacy concerns, lack of emotional openness, lack of a perceived need for help, concerns about costs or insurance coverage, skepticism about treatment effectiveness (Hunt and Eisenberg, 2010), lack of knowledge of services (Yorgason, Linville, and Zitzman, 2008), and language barriers (Chu, Hsieh, and Tokars, 2011).

Who Are College Students Seeking for Assistance with Their Mental Health Needs?

In lieu of more formal sources of help, such as mental health professionals, college students seem more likely to turn to informal sources for help and support (Barksdale and Molock, 2008). Students are likely to turn to friends and family to talk about their problems (Davidson, Yakushka, and Sanford-Martens, 2004; Tiago de Melo and Farber, 2005); in one study (Oliver, Reed, Katz, and Haugh, 1999), 90 percent of students reported talking about problems to friends, and 80 percent to family.