After numerous hospitalizations, electroconvulsive therapy and a battery of drug trials, a college senior remained suicidal. Looking for advice on her patient, a psychiatrist brought the case to a team meeting, only to be told by a senior colleague, "You can't save them all."
"That kind of attitude is one I feel strongly can't exist in any counseling center or outpatient clinic," the psychiatrist said, her voice still filled with anger and disgust. "It's a ridiculous attitude."
The psychiatrist did not give up on the patient, who has been symptom-free for over five years and is now happily married and employed. "Hopelessness is the biggest predictor of suicide," the psychiatrist told Psychiatric Times. "As a parent of someone who will one day go to college, I empathize with all the parents and have the expectation that the people they go to will not give up on them."
Faced with a steep rise in the suicide rate among adolescents and young adults, U.S. colleges and universities are trying to remain hopeful while redoubling efforts to identify and treat at-risk students.
Suicide rates among males between the ages of 15 and 24 years have tripled over the past 60 years, while the rate among females in the same age group has grown nearly twofold over the same time period (National Mental Health Association [NMHA] and the Jed Foundation, 2002). The overall rate of completed suicide among college students is roughly 7.5 per 100,000, making it the second leading cause of death within that cohort (The Jed Foundation, 2000).
In an attempt to reach vulnerable college students who may initially be more comfortable with the anonymity of cyberspace, Emory University and the American Foundation for Suicide Prevention (AFSP) are collaborating on an online screening project that assesses students for suicidal ideation and/or behavior. Students logon to the site anonymously to fill out the survey, which also screens for a variety of other psychiatric disorders. The questionnaire takes approximately 10 minutes to complete and is reviewed by a licensed clinician. Students who report suicidal ideation or behavior are contacted electronically within 24 hours by a clinician and are urged to come in for a face-to-face evaluation with a psychiatrist. If the students are unwilling to do so, clinicians remain available for electronic correspondence, with the goal of gradually persuading them to come in for treatment.
"We thought prevention on college campuses was a neglected area," AFSP medical director Herbert Hendin, M.D., told PT. "A lot of the kids who kill themselves are not in treatment at the services that are provided by the colleges. There are a lot of people who get information and communicate more easily on the Internet than one would ever have thought 10 years ago, and we're trying to take advantage of that."
To date, 220 out of approximately 1,250 Emory freshmen have completed the survey. Of that number, six have required and received emergent follow-up, which, in keeping with project guidelines, is provided by a campus psychiatrist. The survey will be sent to all undergraduates this fall.
"It seems like the majority of people we've seen are people who probably would never have seen a psychiatrist," said J. David Moore, M.D., assistant professor in the department of psychiatry and behavioral sciences at Emory University School of Medicine and co-principal investigator of the project. "If they do have a positive reaction to myself or the study, whether they're in college or 10 years from now, they'll be able to seek help without feeling ashamed. The majority have been thankful and surprised that it wasn't as big a deal as they thought it would be. One student said, 'This is just like a doctor's appointment.'"
The strength of the Emory/AFSP project may be its assumption that at-risk students do not fall into a single category. Some students enter college with a diagnosed psychiatric disorder, while others develop difficulties after they arrive (NMHA and the Jed Foundation, 2002). "It is impossible to pick out which kids are going to actually complete suicide," said Michael Craig Miller, M.D., in an interview with PT. Miller, editor-in-chief of The Harvard Mental Health Letter, added: "The issue really becomes what kind of mental health services are appropriate for a college health service to provide for its student bodyThe only thing that's going to work is to treat the whole population appropriately."
While most would agree with Miller's conclusion, the question of what constitutes appropriate care varies considerably from college to college and is not unrelated to mounting pressure over how to treat more students with the same or fewer resources. According to the 2001 National Survey of Counseling Center Directors, 73% of respondents reported using a brief treatment model to manage growing caseloads, while 68% of respondents said they saw students in therapy less than once a week to facilitate effective caseload management (Gallagher et al., 2001). In addition, 44% of directors polled in the 274-school survey reported that increasing external referrals was another way to maximize limited resources, yet nearly 60% expressed concern over the need to locate better referral sources for students who need long-term treatment.
While American colleges and universities are trying a host of strategies to get at-risk students into treatment, what happens once they have succeeded is anything but certain. Margaret Chisolm, M.D., a Baltimore-based psychiatrist, is extremely worried about the lack of uniform clinical standards on college campuses and believes that many students are not receiving appropriate treatment. "You can't develop a treatment plan and recommend a treatment if you don't know what you're treating," Chisolm said. "A significant number of counseling centers do not do a diagnostic evaluation, at least not a structured one."
Chisolm said she believes any clinician can be trained to do a proper diagnostic evaluation, although psychiatrists tend to have greater expertise in terms of the variety and severity of patients seen. "You don't want someone who has to look up in a book what the signs and symptoms of mania are," she said.
Chisolm sees college students who have been referred from a variety of university counseling centers as well as local community-based clinics and said many clinicians make the mistake of basing their diagnostic impressions solely on the patient's self-report.
She remembers one student who needed to take a leave of absence for what the college deemed an adjustment disorder in the wake of a family death. A careful diagnostic workup by Chisolm revealed euphoric symptoms and a family history of psychiatric disorder that had been missed by previous treaters. She diagnosed bipolar disorder and the student improved after treatment with lithium.
"If you don't ask, you really don't know," said Chisolm. The patient "didn't recognize the euphoria as a problem and didn't volunteer thatShe only talked about the depressive symptoms," said Chisolm. Unfortunately, previous treaters did not adequately probe, assuming that the family death was the obvious cause of the patient's difficulties. "It's a very common trap people fall into when they're doing evaluations. When there's been some sort of crisis or [external] event that triggers the [psychiatric] event, they can describe that event as being the reason for how they're feeling."
Chisolm recalled treating a depressed college student at an elite Southern university who languished for a year before being started on an antidepressant. The student had arrived at the university's counseling center stating that he was depressed and wanted to see a psychiatrist for a medication evaluation; he instead received psychotherapy exclusively. "This is a highly sophisticated student who comes in asking for something and is told that's not what they need," said Chisolm. "They ended up suffering with their illness much longer than they needed to. You can imagine someone who isn't [sophisticated] and doesn't ask to see a psychiatrist. They may never get to see one."
Clinicians at University of Arizona do not use a structured evaluation (i.e., mental status exam), but they do make formal DSM-IV diagnoses, according to Ken Marsh, Ph.D., director of the university's counseling and psychological services. Campus clinicians see 5% to 7% of the student body each year. The university, which has an enrollment of approximately 35,000 students, stopped scheduling intake appointments in the late 1980s and moved to a walk-in system so that students could be seen the same day. A triage system allows clinicians to determine the severity of student distress and to respond with the appropriate speed and level of care.
Like many other colleges and universities, clinicians at Emory University work with residential life staff, representatives from fraternity and sorority organizations, athletic teams, and academic departments to promote awareness of mental health issues and resources. While distress arising from interpersonal problems has been linked to suicidal ideation, academic failure has been more frequently linked to suicidal behavior and completed attempts (Meilman et al., 1994), underscoring the need for a team approach in recognizing students at risk.
Two or three students commit suicide at University of Arizona annually, and the rate has held constant over the years, Marsh said. One of those students, sophomore Jed Satow, committed suicide in 1998 and is the namesake of the Jed Foundation, a public nonprofit charity committed to youth suicide prevention. The foundation recently launched the Ulifeline Web site www.ulifeline.org, an Internet clearinghouse that connects students to a variety of mental health sites. Links range from an in-depth mental health and drug information library to a site that enables students to get answers to psychiatric questions at any hour. The Ulifeline site also enables students to access the Duke Diagnostic Psychiatry Screening Program. Developed by Duke University, the program screens students for a variety of DSM-IV diagnoses. While not intended as a substitute for an in-per-son evaluation, the screening program can be an anonymous, nonthreatening "first step" for students, who also can access information about the mental health services available at their respective colleges and universities.
In New England, Massachusetts Institute of Technology is spending $838,000 to improve access to counseling services and to increase awareness of campus mental health resources. The institute also is planning to hire four additional clinicians and two health education staff members. In April, campus officials instituted a plan whereby students and MIT Health Plan members seeking mental health services for the first time can get a same-day 15- to 20-minute phone consultation with a senior campus clinician; emergent cases will be seen immediately. Improved access was the biggest priority cited by students surveyed as part of MIT's Mental Health Task Force in late 2001. Creation of the task force followed the April 2000 suicide of MIT sophomore Elizabeth Shin and the ensuing $27 million suit brought against the institute by Shin's parents.
Good psychiatric care may have saved the life of Harvard University senior Dave Canose. Looking back, Canose believes his depression began during his last year in high school but was not diagnosed until he arrived at Harvard as a transfer student in the fall of 2000. "I didn't recognize it for what it was," said the Pittsburgh native, who is treasurer of the Harvard-based Mental Health Awareness and Advocacy Group. "After a while, you start to feel that there's nothing you can do to make it better. I remember thinking about death and suicide a lot." Canose went to see a clinical social worker at the college's counseling center, who quickly referred him to a psychiatrist for a medication consult. He was impressed with the directness of his psychiatrist, who explained that he met diagnostic criteria for major depression and urged him to consider medication.
"There's been a gradual shift and commitment to get myself out of this," said Canose, whose condition improved with antidepressant medication and regular psychotherapy. "You're not going to just wake up and find yourself happy and healthy. It's going to take months and even years of waking up every day to get out of bed, get yourself ready, go out into the world and do your best. At some point, you realize you can go out and be a productive person and contribute something to your college campus, a workplace, your family. You feel like what you're doing is valuable and nobody is going to take that away from you."
1.Gallagher RP, Sysko HB, Zhang B (2001), National Survey of Counseling Center Directors. Alexandria, Va.: International Association of Counseling Services Inc.
2.Meilman PW, Pattis JA, Kraus-Zeilmann D (1994), Suicide attempts and threats on one college campus: policy and practice. J Am Coll Health 42(4):147-154.
3.NMHA and The Jed Foundation (2002), Safeguarding Your Students Against Suicide-Expanding the Safety Net: Procceedings from an Expert Panel on Vulnerability, Depressive Symptoms, and Suicidal Behavior on College Campuses. NMHA: Alexandria, Va.
4.The Jed Foundation (2000), Suicide and America's Youth. Available at: www.jedfoundation.org/suicide.html. Accessed July 2, 2002.