turning violence inward: understanding and preventing campus suicide morton m. silverman, m.d....

Turning Violence Inward: Understanding and Preventing

Campus Suicide

Morton M. Silverman, M.D.Senior Advisor, Suicide Prevention Resource Center

Senior Medical Advisor, The Jed Foundation

Clinical Associate Professor of Psychiatry, The University of Chicago

Violence on Campus: Prediction, Prevention, and Response

Columbia University Law School

New York, NY

April 4, 2008

THE BIG PICTURE

Trends in Suicidal Behavior1990-1992 vs. 2001-2003

National Comorbidity Survey and Replication

Suicide

1990-1992

14.8/100k

2001-2003

13.9/100k

Ideation 2.8% 3.3%

Plan .7% 1.0%

Gesture .3% .2%

Attempt .4% .6%

•9708 respondents, face-to-face survey, aged 18-54•Queried about past 12 months•No significant changes

Kessler, et al., Trends in Suicide Ideation, Plans, Gestures, and Attempts in the United States, 1990-1992 to 2001-2003- JAMAMay 25, 2005, Vol 293, No 20.

National Comorbidity Study(1990-92; 15-54 yrs; 5877 respondents)

• LIFETIME IDEATION: 13.5%

• LIFETIME PLAN: 3.9%

• LIFETIME ATTEMPT: 4.6%

Kessler, et al.; AGP 56: 617-626, 1999

Median Age of Onset (percentiles) (Kessler, et al., 2005)

DISORDER

25th

50th

75th

Major Depressive Disorder 19 32 44

Bipolar I-II 17 25 42

Panic Disorder 15 24 40

Generalized Anxiety Disorder 20 31 47

PTSD 15 23 39

Obsessive-Compulsive 14 19 30

ADHD 7 7 8

Alcohol Abuse/Dependence 18/19 21/23 29/31

Substance Abuse/Dependence 17/18

19/21 23/28

Campus Suicide

• Suicide is the 2nd leading cause of death among campus students

- more teenagers and young adults die from suicide than from all medical illnesses combined

– 18 million enrolled students (over 9 million are ages 18 – 24)• Estimated 1,350 suicides annually (3 per day)

COLLEGE and GRADUATE STUDENTS SPEAK

ACHA-NCHA Findings

Within the last school year have you……………… 2000 2002 2004

Felt Very Sad 80.6% 82.0% 80.9%

Felt Depressed 44.4% 44.8% 45.1%

Been Dx’d with Depression 10.3% 11.8% 14.9%

Seriously Considered Attempting Suicide

9.5% 10.0% 10.1%

Attempted Suicide 1.5% 1.6% 1.4%

ACHA-NCHS Findings

Within the last school year have you… Fall, 2006

Felt Very Sad 77.8%

Felt so Depressed it was difficult to fxn 42.2%

Been Diagnosed with Depression 14.5%

Seriously Considered Attempting Suicide

9.4%

Attempted Suicide 1.4%

Source: American College Health Association (2007)

ACHA-NCHA Survey: Fall 2006

American College Health Association. American College Health Association - National College Health Assessment (ACHA-NCHA) Web Summary. Updated August 2007. Available at http://www.acha-ncha.org/data_highlights.html. 2007.

ACHA-NCHA Survey: Fall 2006

American College Health Association. American College Health Association - National College Health Assessment (ACHA-NCHA) Web Summary. Updated August 2007. Available at http://www.acha-ncha.org/data_highlights.html. 2007.

ACHA-NCHA Survey: Fall 2006

American College Health Association. American College Health Association - National College Health Assessment (ACHA-NCHA) Web Summary. Updated August 2007. Available at http://www.acha-ncha.org/data_highlights.html. 2007.

ACHA-NCHA Survey: Fall 2006

American College Health Association. American College Health Association - National College Health Assessment (ACHA-NCHA) Web Summary. Updated August 2007. Available at http://www.acha-ncha.org/data_highlights.html. 2007.

UC Berkeley Graduate Student Survey - April, 2004

In the last 12 months:

• 45.3% experienced an emotional stress-related problem that significantly affected their well-being and/or academic performance

• 67% felt overwhelmed; 54% felt so depressed that it was difficult to function; 9.9% seriously considered suicide

• females were more likely to report feeling hopeless, exhausted, sad, or depressed

Why Don’t Students in Need Seek Help?

> 25% of depressed young adults express “intent not to accept a diagnosis of depression” due to:

• Negative beliefs and attitudes toward depression causation and treatment

• Beliefs that depression should be hidden from family, friends, employers

• Lack of past helpful treatment experiences

Van Voorhees et al., Annals of Family Medicine, 2005

Chris Brownson, Ph.D.cbrownson@mail.utexas.edu

The University of Texas at Austin

>26,000 undergraduate and graduate students70 colleges & universities

Web-based, anonymous, 25% response rate

Selected Data from National Research Consortium of

Counseling Centers in Higher Education’s Study on The Nature of College Student

Suicidal Crises

Undergrad

N=910

Recent family problems 41.96

Recent academic probs 37.57

Recent loss of romantic relationship

36.00

Recent financial problems 34.53

Intentional self-harm (non-suicidal)

27.67

Recent loss of friendship 27.56

Recent death of friend/family

16.42

Sexual Assault 9.22

Recent Trauma 8.32

Recent conflict regarding sexual orientation

6.75

Recent suicide of friend/family

5.74

Relationship violence 5.62

Graduate N=411

Recent financial problems 35.64

Recent academic probs 30.45

Recent family problems 27.97

Recent loss of romantic relationship

26.98

Recent loss of friendship 15.84

Intentional self-harm (non-suicidal)

13.86

Recent death of friend/family

12.13

Recent Trauma 6.93

Relationship violence 4.95

Recent conflict regarding sexual orientation

4.46

Sexual Assault 3.96

Recent suicide of friend/ family

3.47

Which of the following occurred before seriously considering a suicide attempt in

the past 12 months

Undergrad

N=910

Emotional / physical pain

64.72

Romantic relationship problems

58.81

Impact of wanting to end my life

49.37

School problems 43.17

Friend problems 43.00

Family problems 42.51

Financial problems 31.10

Showing others the extent of my pain

30.05

Punishing others 13.61

Alcohol / drug problems

10.13

Sexual assault 7.82

Relationship violence 5.60

Graduate

N=411

Emotional / physical pain

65.26

Romantic relationship problems

52.63

Impact of wanting to end my life

46.56

School problems 45.38

Financial problems 34.38

Family problems 34.30

Friend problems 28.12

Showing others the extent of my pain

27.03

Punishing others 8.29

Alcohol / drug problems

6.56

Relationship violence 5.85

Sexual Assault 5.80

Events rated as having a large impact on seriously considering suicide in the past 12

months

WHAT THE EXPERTS SAY

2006 AUCCCD Survey (367 campuses)

• 9% of enrolled students seen

• 25% are on psychiatric medications (17% in 2000; 9% in 1994)

• 40.1% of clients had severe psychological problems, 8.3% have impairments so severe that they can’t remain in school or can only do so with extensive psychological help

• 2,368 hospitalizations for psychological reasons• 142 suicides - only 10% current/former clients

2007 AUCCCD Survey(272 campuses)

• 8.5% of enrolled students seek counseling

• 91.5% believe greater # of students with severe psychological problems

• 49% of clients have severe psychological problems

• 1,981 hospitalizations for psychological problems• 105 suicides - 21.8% were former/current clients

• Post VTU: 30.5% report policy revisions re: communicating with parents about students in crisis

Mental Illness on CampusContributing Factors to Increased Demand for Services:

– early diagnosis; better treatment

– overall lessening of social stigma re: mental illness

– greater adjustment stress of diverse student population

– limited access to off-campus services (high cost of private care; insufficient insurance)

– increased stress associated with the 24/7 pace of campus life (academic, social, etc.)

– adjusting to a world of terrorism; economic uncertainty; political instability

Campus Suicide• Suicide is the 2nd leading cause of death among

college students– Majority of students who die by suicide (≈80%) have never

been seen by the counseling service– Only ~14% of students report receiving suicide prevention

information from their colleges

• Students at risk: - Those with pre-existing mental illness - Those that develop mental illnesses while in college - Those who lack coping and other life skills (or stop their treatments

while away from home)

Foreign Students

• May be at increased risk if:

- shy

- lacking social skills

- lacking a support network

- having language/communication problems

- having financial/academic difficulties

Student Challenges - Summary

• Finances - living expenses; health insurance

• Social Life - dating; partnerships

• Marital Life - spousal job; postponing children?

• Race/Ethnicity/Gender Issues - inequalities; “glass ceiling”

• Developmental Issues - separation; individuation; ethical & moral principles; commitments; being self-reliant; working alone

• Social/Coping Skills - working closely with faculty; peers

• Dissertation Woes• Transitioning Into/Out of School - support; identity

• Career Identity - academia vs. “real world”

• Getting a Job• Acculturation/Assimilation - international students; language

• Psychiatric Illnesses - including substance use and abuse

WAIT A MINUTE!

ARE CAMPUSES TOXIC?

Suicidal ideation and behavior among high school students by category and sex*,U. S., 2005

0

5

10

15

20

25

Seriously consider suicide Suicide plan Attempted suicide^ Suicide attempt withmedical

Category

Percentage of all students

FemaleMaleTotal

Source: CDC Youth Risk Behavior Survey* During the 12 months preceding the survey^One or more times

What is the greatest precipitating factor among youth suicide?

Among all 18-24 year olds who died by suicide:• Almost 50% were due to intimate partner problems• Other reasons included:

– legal/criminal (20%), – financial (12%), – relationship problem with friend or family (13%)

• Important to attend to youth who have had a recent life event (relationship problem), who are depressed, and a tendency towards impulsiveness, especially within 2 weeks of life event

[Source: Harvard NVISS Pilot 2001]

What do we know about impulsiveness of youth suicide?

Among all 18-24 year olds who died by suicide:

• 1 in 5 occurred on the same day as an acute life crisis• 1 in 4 occurred within 2 weeks

• Approx. 46% occurred either on the same day or within 2 weeks of a life crisis

• Important because impulsiveness of suicide– Crucial to provide immediate help– Develop means for students in crisis to cope, provide safe

haven, ensure support system in place

[Source: Harvard NVISS Pilot 2001]

Truisms

Campuses are not therapeutic communities

-therefore must acknowledge limits on services and resources

You can’t treat a public health problem out of existence

- therefore solution is not just to increase counseling center staff and campus police force ad infinitum

Best Practices for Campus Prevention Programs

What Are We Trying to Do?

• Disease Prevention

prevent self-injurious behaviors • Health Promotion

promote resiliency promote life-enhancing skills promote health maintenance

DIFFERENT GOALS REQUIRE DIFFERENT APPROACHES

Suicide is an outcome that requiresseveral things to go wrong all at onceSuicide is an outcome that requiresseveral things to go wrong all at once

BiologicalFactors

FamilialRisk

SerotonergicFunction

NeurochemicalRegulators

Demographics

Pathophysiology

ImmediateTriggers

Access To Weapons

SevereDefeat

MajorLoss

WorseningPrognosis

ProximalFactors

Hopelessness

Intoxication

ImpulsivenessAggressiveness

NegativeExpectancy

Severe Chronic Pain

PredisposingFactors

Major PsychiatricSyndromes

SubstanceUse/Abuse

PersonalityProfile

AbuseSyndromes

Severe Medical/Neurological Illness

Public HumiliationShame

Evidence-based Interventions • Community education/awareness

– Safety is an issue

• Community collaboration around suicide prevention

• Social marketing– Destigmatizing help-seeking for mental health problems– Increasing social support– Strengthening social networks– Honor and support responsible help-seeking

Guild PA, Freeman VA, Shanahan E. Promising Practices to Prevent Adolescent Suicide: What We Can Learn From New Jersey. Cecil G Sheps Center For Health Services Research. Univeristy of North Carolina at Chapel Hill. 2004.

Knox, K, et al., Risk of Suicide and related adverse outcomes after exposure to a suicide programme in the US Air Force:cohort study. British Medical Journal, December 13, 2003.

Evidence-based Interventions

• Gatekeeper training

• Peer helper programs

• Resiliency/coping/problem solving skill building programs– Juvenile justice– Homeless youth

Guild PA, Freeman VA, Shanahan E. Promising Practices to Prevent Adolescent Suicide: What We Can Learn From New Jersey. Cecil G Sheps CenterFor Health Services Research. Univeristy of North Carolina at Chapel Hill. 2004.

Evidence-based Interventions

• Restricting availability of means

• Improved surveillance

• Postvention for the bereaved

• Domestic violence prevention

• Training the media

Guild PA, Freeman VA, Shanahan E. Promising Practices to Prevent Adolescent Suicide: What We Can Learn From New Jersey. Cecil G Sheps CenterFor Health Services Research. Univeristy of North Carolina at Chapel Hill. 2004.

Evidence-based Interventions

• Access to effective treatment of mental health problems– Training for primary care providers– Training for mental health providers– Increased availability of mental health treatment– Increased affordability of mental health treatment– Linking suicide prevention programs with treatment

services– Appropriate follow-up after ED treatment

• Alcohol and substance abuse programsGuild PA, Freeman VA, Shanahan E. Promising Practices to Prevent Adolescent Suicide: What We Can Learn From New Jersey. Cecil G Sheps Center for Health Services Research. Univeristy of North Carolina at Chapel Hill. 2004.

Knox, K, et al., Risk of Suicide and related adverse outcomes after exposure to a suicide programme in the US Air Force:cohort study. British Medical Journal, December 13, 2003.

What Changes Need to Happen on Campus to

Protect and Save Lives?

Five minutes before the party is not the time to learn to dance!

Snoopy 1964

Major Barriers To Progress• Lack of awareness and support among senior administrators

• Stigma (lack of help-seeking culture)

• No single person in charge of wellness

• Departmental and programmatic “silo effect”

• Lack of urgency in dealing with highest risk students

• Legal “blurs” - FERPA; HIPAA

• Fears around liability

• Insurance policy weaknesses (lack of parity; discrepancies; inadequacies)

Far Side by Gary Larson

Duty and Liability

Issues to Consider Relevant to Effective Prevention

• Knowledge of Effective Prevention Programs

• Comprehensive Needs Assessment – Community Readiness and Support – Resources for implementation – Investment in current practice– Population needs and access issues

• Fear of Evaluation

• Sustainability

Building an Effective Safety Net

• Create a new, senior-level administrative position to oversee student health and well-being

• Ensure coordination and communication across various departments and organizations on campus

• Prioritize mental health promotion and suicide prevention when allocating resources

Building an Effective Safety Net II

• Organize a cross-institutional mental health task force or committee, which includes students, to examine mental health issues and services

• Survey all students to understand the landscape of mental health issues on campus, including students’ knowledge and perception of campus mental health services (needs assessment)

• Ensure that policies and procedures emphasize the best interests of the students

Building an Effective Safety Net III

• Clarify and/or institute transparent policies regarding parental notification and leave of absence/re-entry

• Ensure appropriate training regarding exceptions to confidentiality

• Address perceived legal barriers that may affect how to approach students with emotional issues

• Encourage the creation and involvement of a student mental health advocacy group

Policy Implications

• Judicial: Removal for serious suicidal ideation – be prepared to remove a lot of people.

• Importance of academics: Recent academic problems is second most likely event to precede SI, “school problems” ranked 4th in contributing to SI.

Therefore, provide motivation to follow through on treatment in exchange for continuing/returning to school.

• Need to find a way to help students without punishing them academically.

Take Home Messages

• Suicidal ideation is not uncommon.

• Develop educational campaigns to encourage help-seeking for those with mental health issues and suicidal thinking.

• Educate peers in addition to others on campus about how to respond to those with mental disorders and suicidal ideation.

• Professional services must get word out that they are helpful and available and confidential.

• Focus on life skills and community responsibilities.

Comprehensive Prevention Approach

Jed Foundation/SPRCComprehensive Approach

National Suicide National Suicide Prevention LifelinePrevention Lifeline

• National toll free number 1-800-273-TALK

• Calls routed automatically to the closest of 125 networked crisis centers

• Partners with NASMHPD, Rutgers & Columbia Universities

• Evaluation studies published June, 2007 in Suicide and Life-Threatening Behavior

QuickTime™ and a decompressor

are needed to see this picture.

THANK YOU

msilverman@edc.org

Another Truism

Suicide Prevention is Violence Prevention

Jed Foundation/EDCComprehensive Approach

Promote Social Networks

Goal: To promote relationship-building between students and a sense of community on campus

Promote Social Networks

• Reduce student isolation and promote feeling of belonging

• Encourage the development of smaller groups within the larger campus community

Develop Life Skills

Goal: To promote the development of skills that will assist students as they face various challenges in both school and in life

Develop Life Skills

• Improve students’ management of the rigors of college life

• Equip students with tools to recognize and manage triggers and stressors

Increase Help-Seeking Behaviors

Goal: To educate students about mental health and wellness, encourage seeking appropriate treatment for emotional issues, and reduce the stigma surrounding mental illness and seeking help for suicidal thoughts and behaviors

Increase Help-Seeking Behaviors

• Stimulate campus-wide cultural change that de-stigmatizes mental health problems and removes barriers to getting help

• Enhance accessibility of mental health services

• Educate students about the signs and symptoms of suicide and mental illness and where to go to get help

• Provide online self-assessment tools

Groundbreaking pro-social campaign with mtvU launched in November 2006

Seeks to reduce stigma and increase help-seeking through on-air, online and

on-campus components

Campaign built on original quantitativeand qualitative research commissioned by

The Jed Foundation and mtvU

Identify Students At Risk

Goal: To identify those students who may be at risk for suicide through the use of outreach efforts, screening, and other means

Identify Students At Risk• Include questions about mental

health on medical history form• Provide gatekeeper training to

recognize/refer distressed or distressing students

• Create interface between disciplinary process and mental health service

• Screen to identify high-risk or potentially high-risk students

• Establish cross-department case management committee

Transition Years

• Partnering with the American Psychiatric Foundation (philanthropic arm of the American Psychiatric Association)

• Outreach project to high school seniors, college freshmen, and their parents

• Promote the smooth, safe, and healthy transition from high school to college

• Key components will include a literature review, survey of parents, media campaign, parents resource guide, and student “survival” guide

Provide Mental Health Services

Goal: To accurately diagnose and appropriately treat students with emotional problems, including assessing and managing suicide risk

Provide Mental Health Services

• Utilize internal university resources to complement existing services

• Engage in prevention/outreach• Create linkages to community

resources• Train mental health providers

to identify/treat suicidal risk• Refer cases as appropriate• Institute policies and

procedures • Train personnel on

confidentiality, notification, and other legal issues

UDBD

• Understanding Depressive and Bipolar Disorders (www.UDBD.org)

– Free Web site designed to help college counseling and other healthcare professionals learn to better distinguish between unipolar depression and bipolar disorder

– Provides information about these disorders and the key questions to ask when evaluating students

– Includes useful tools such as tips for differentiating among types of depression and case studies

Clinical Training Workshops

• Assessing and Managing Suicide Risk tailored for college mental health professionals– Originally developed by AAS and SPRC– One-day training includes in-depth discussion, journal

writing, video clips, and small group exercises; participants also assigned pre-workshop reading

– Delivered by an expert trainer

• Hundreds of college mental health professionals have been trained so far

• Currently undergoing formal evaluation

Crisis Management Procedures

Goal: To develop policies that promote the safety of distressed or suicidal students and respond to crises, including suicidal acts, using institutionalized processes.

Crisis Management Procedures

• Establish and follow policies (e.g., parental notification, medical leave/re-entry) and protocols that respond to suicide attempts and other high-risk behavior

• Respond with a comprehensive postvention program

Framework

Document guides the process

of creating campus-wide

protocols that address:– Safety for at-risk students

– Emergency contact notification

– Leave of absence/re-entry

www.jedfoundation.org/framework.php

Restrict Access to Lethal Means

Goal: To limit access to potential sites, weapons, and other agents that may facilitate dying by suicide

Restrict Access to Lethal Means

• Limit access and/or erect fences on roofs of buildings

• Replace windows or restrict size of window openings

• Restrict access to chemicals

• Prohibit guns on campus

• Control access to alcohol and other drugs

Legal Roundtable

• Fear of liability is affecting decision-making around students in distress or at risk for suicide

• Need for a clear, concise resource for college health/mental health professionals, administrators, and legal counsels

• One-day roundtable held in Spring 2007 brought together leading experts in higher education law, as well as campus personnel, to discuss issues of law and liability as they relate to mental health

Build

ing

Campu

s Saf

ety

Net

Increase Evidence Base Pilot Program ● Framework ● ULifeline Clinical Workshop

Strengthen Campus Services ULifeline ● Framework ● CampusCare Clinical Workshop ● UDBD.org

Raise Awareness & Decrease Stigma ULifeline ● mtvU Pro-Social Campaign

APA Collaboration ● Outreach

Promote Help-Seeking ULifeline ● mtvU Pro-Social Campaign APA Collaboration

Decrease Emotional DistressReduce Suicidal Behavior

TJF

Comprehensive Framework: Mental Health and Suicide Prevention

Areas of Strategic Intervention Individual Group Institution Community

State/Federal Policy

Identify students at risk

Increase help-seeking behaviors

Provide mental health services

Establish and follow crisis management procedure

Restrict potentially lethal means

Develop life skills

Promote social networks

Adapted from Potter et al, 2004 and DeJong & Langford, 2002

Program and Policy Levels (social ecological framework)

Contact Information

Joanna Locke, MD, MPHProgram Director, The Jed Foundation

583 Broadway, Suite 8BNew York, NY 10012

212.647.7544jlocke@jedfoundation.org

www.jedfoundation.org