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Turning Violence Inward: Understanding and Preventing Campus Suicide Morton M. Silverman, M.D. Senior Advisor, Suicide Prevention Resource Center Senior.

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Presentation on theme: "Turning Violence Inward: Understanding and Preventing Campus Suicide Morton M. Silverman, M.D. Senior Advisor, Suicide Prevention Resource Center Senior."— Presentation transcript:

1 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

2 THE BIG PICTURE

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4 Trends in Suicidal Behavior vs National Comorbidity Survey and Replication Suicide /100k /100k Ideation2.8%3.3% Plan.7%1.0% Gesture.3%.2% Attempt.4%.6% 9708 respondents, face-to-face survey, aged Queried about past 12 months No significant changes Kessler, et al., Trends in Suicide Ideation, Plans, Gestures, and Attempts in the United States, to JAMA May 25, 2005, Vol 293, No 20.

5 National Comorbidity Study ( ; yrs; 5877 respondents) LIFETIME IDEATION: 13.5% LIFETIME PLAN: 3.9% LIFETIME ATTEMPT: 4.6% Kessler, et al.; AGP 56: , 1999

6 Median Age of Onset (percentiles) (Kessler, et al., 2005) DISORDER 25th 50th 75th Major Depressive Disorder Bipolar I-II Panic Disorder Generalized Anxiety Disorder PTSD Obsessive-Compulsive ADHD Alcohol Abuse/Dependence18/19 21/23 29/31 Substance Abuse/Dependence17/18 19/21 23/28

7 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)

8 COLLEGE and GRADUATE STUDENTS SPEAK

9 ACHA-NCHA Findings Within the last school year have you……………… Felt Very Sad80.6%82.0%80.9% Felt Depressed44.4%44.8%45.1% Been Dx’d with Depression10.3%11.8%14.9% Seriously Considered Attempting Suicide 9.5%10.0%10.1% Attempted Suicide1.5%1.6%1.4%

10 ACHA-NCHS Findings Within the last school year have you…Fall, 2006 Felt Very Sad77.8% Felt so Depressed it was difficult to fxn42.2% Been Diagnosed with Depression14.5% Seriously Considered Attempting Suicide 9.4% Attempted Suicide1.4% Source: American College Health Association (2007)

11 ACHA-NCHA Survey: Fall 2006 American College Health Association. American College Health Association - National College Health Assessment (ACHA-NCHA) Web Summary. Updated August Available at

12 ACHA-NCHA Survey: Fall 2006 American College Health Association. American College Health Association - National College Health Assessment (ACHA-NCHA) Web Summary. Updated August Available at

13 ACHA-NCHA Survey: Fall 2006 American College Health Association. American College Health Association - National College Health Assessment (ACHA-NCHA) Web Summary. Updated August Available at

14 ACHA-NCHA Survey: Fall 2006 American College Health Association. American College Health Association - National College Health Assessment (ACHA-NCHA) Web Summary. Updated August Available at

15 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

16 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

17 Chris Brownson, Ph.D. The University of Texas at Austin >26,000 undergraduate and graduate students 70 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

18 Undergrad N=910 Recent family problems41.96 Recent academic probs37.57 Recent loss of romantic relationship Recent financial problems34.53 Intentional self-harm (non- suicidal) Recent loss of friendship27.56 Recent death of friend/family16.42 Sexual Assault9.22 Recent Trauma8.32 Recent conflict regarding sexual orientation 6.75 Recent suicide of friend/family5.74 Relationship violence5.62 Graduate N=411 Recent financial problems35.64 Recent academic probs30.45 Recent family problems27.97 Recent loss of romantic relationship Recent loss of friendship15.84 Intentional self-harm (non- suicidal) Recent death of friend/family12.13 Recent Trauma6.93 Relationship violence4.95 Recent conflict regarding sexual orientation 4.46 Sexual Assault3.96 Recent suicide of friend/ family3.47 Which of the following occurred before seriously considering a suicide attempt in the past 12 months

19 Undergrad N=910 Emotional / physical pain64.72 Romantic relationship problems Impact of wanting to end my life School problems43.17 Friend problems43.00 Family problems42.51 Financial problems31.10 Showing others the extent of my pain Punishing others13.61 Alcohol / drug problems10.13 Sexual assault7.82 Relationship violence5.60 Graduate N=411 Emotional / physical pain65.26 Romantic relationship problems Impact of wanting to end my life School problems45.38 Financial problems34.38 Family problems34.30 Friend problems28.12 Showing others the extent of my pain Punishing others8.29 Alcohol / drug problems6.56 Relationship violence5.85 Sexual Assault5.80 Events rated as having a large impact on seriously considering suicide in the past 12 months

20 WHAT THE EXPERTS SAY

21 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

22 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 % were former/current clients Post VTU: 30.5% report policy revisions re: communicating with parents about students in crisis

23 Mental Illness on Campus Contributing 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

24 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)

25 Foreign Students May be at increased risk if: - shy - lacking social skills - lacking a support network - having language/communication problems - having financial/academic difficulties

26 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

27 WAIT A MINUTE! ARE CAMPUSES TOXIC?

28 Suicidal ideation and behavior among high school students by category and sex*,U. S., 2005 Source: CDC Youth Risk Behavior Survey * During the 12 months preceding the survey ^One or more times

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30 What is the greatest precipitating factor among youth suicide? Among all 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]

31 What do we know about impulsiveness of youth suicide? Among all 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]

32 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

33 Best Practices for Campus Prevention Programs

34 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

35 Suicide is an outcome that requires several things to go wrong all at once Suicide is an outcome that requires several things to go wrong all at once Biological Factors Familial Risk Serotonergic Function Neurochemical Regulators Demographics Pathophysiology Immediate Triggers Access To Weapons Severe Defeat Major Loss Worsening Prognosis Proximal Factors Hopelessness Intoxication Impulsiveness Aggressiveness Negative Expectancy Severe Chronic Pain Predisposing Factors Major Psychiatric Syndromes Substance Use/Abuse Personality Profile Abuse Syndromes Severe Medical/ Neurological Illness Public Humiliation Shame

36 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 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.

37 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 Center For Health Services Research. Univeristy of North Carolina at Chapel Hill

38 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 Center For Health Services Research. Univeristy of North Carolina at Chapel Hill

39 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 programs 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 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.

40 What Changes Need to Happen on Campus to Protect and Save Lives?

41 Five minutes before the party is not the time to learn to dance! Snoopy 1964

42 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)

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44 Far Side by Gary Larson Duty and Liability

45 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

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47 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

48 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

49 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

50 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 4 th 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.

51 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.

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53 Comprehensive Prevention Approach

54 Jed Foundation/SPRC Comprehensive Approach

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57 National Suicide Prevention Lifeline National toll free number 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

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59 THANK YOU

60 Another Truism Suicide Prevention is Violence Prevention

61 Jed Foundation/EDC Comprehensive Approach

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

63 Promote Social Networks Reduce student isolation and promote feeling of belonging Encourage the development of smaller groups within the larger campus community

64 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

65 Develop Life Skills Improve students’ management of the rigors of college life Equip students with tools to recognize and manage triggers and stressors

66 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

67 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

68 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 quantitative and qualitative research commissioned by The Jed Foundation and mtvU

69 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

70 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

71 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

72 Provide Mental Health Services Goal: To accurately diagnose and appropriately treat students with emotional problems, including assessing and managing suicide risk

73 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

74 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

75 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

76 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.

77 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

78 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

79 Restrict Access to Lethal Means Goal: To limit access to potential sites, weapons, and other agents that may facilitate dying by suicide

80 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

81 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

82 Building Campus Safety 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 Distress Reduce Suicidal Behavior TJF

83 Comprehensive Framework: Mental Health and Suicide Prevention Areas of Strategic Intervention IndividualGroupInstitutionCommunity 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)

84 Contact Information Joanna Locke, MD, MPH Program Director, The Jed Foundation 583 Broadway, Suite 8B New York, NY


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