Marcia Morris, MD

Twenty-one years ago, when I started working at the University of Florida providing clinical care to college students, it was rare for a student to mention having suicidal thoughts, and even more rare for me to involve parents in their care. Today, students are more likely to describe the presence of suicidal ideation, necessitating a more thorough safety assessment with potential outreach to parents for increased support. Surprisingly, suicidal ideation and suicide attempts in college students have not gone up drastically in the last 15 years.

The 2014 American College Health survey found that 8.3% of college students had seriously considered suicide, and 1.3% had attempted suicide, which is similar to the results from 2000 that showed 9.4% of college students seriously considered suicide and 1.6% attempted suicide.

 Perhaps I am hearing more students describe suicidal thoughts and behaviors because they are now more willing to talk about and get help for these experiences. Concurrently, many counseling centers describe a growing demand for services. Unfortunately, completed suicide rates have increased for the 15 to 24 age group, last measured in 2013 at 12.6/100,000 versus 10.4/100,000 in 2000.

[[{"type":"media","view_mode":"media_crop","fid":"41261","attributes":{"alt":"Â© Larisa Lofitskaya/shutterstock.com","class":"media-image media-image-right","id":"media_crop_9561132822533","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4325","media_crop_rotate":"0","media_crop_scale_h":"119","media_crop_scale_w":"185","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â© Larisa Lofitskaya/shutterstock.com","typeof":"foaf:Image"}}]]Suicide rates tend to be lower for college students than non-students of a similar age, at 6.5 to 7.5/100,000 for college students versus 12.1 to 15.0/100,000 for non-students, according to data from 1980 to 2009.

 Nevertheless, the rates are remarkably high at certain colleges. A 

 report reviewed data from MIT and Harvard, which showed suicide rates for college students in the past decade of 12.6/100,000 and 11.8/100,00, respectively.

, there have been high-profile suicides of high school and college students who seemed to have everything going for them. Consequently, there is growing concern about the financial and academic pressures students face that may be contributing to this phenomenon.

A 2009 study among college students identified multiple independent risk factors associated with suicidal ideation that include depressive symptoms, low social support, and affective dysregulation.

 Factors that may make students particularly vulnerable to suicidal ideation include the transition to greater independence from family, changing peer relationships, and access to drugs and alcohol. In this study, increased social support from parents and peers was associated with a reduced risk of suicidal ideation, confirming the necessity of increasing social support.

Because of the high rate of suicidal thinking in college students, psychiatrists face multiple tasks. A suicide risk assessment is needed followed by a decision about what actions to take, which can range from prescribing medication, to calling parents, to hospitalization. As part of a clinical standard of care of the suicidal patient, one would want to involve family members, but this becomes very difficult if the student is far from home and his or her family lives a few hundred or a thousand miles away.

I am not aware of any research that has examined how often parents are contacted by a health care professional when a college student is contemplating suicide, and whether this is done with a student’s consent. FERPA (Family Education Rights and Privacy Act) and HIPAA (Health Insurance Portability and Accountability Act) generally prohibit parent contact without student consent except in the case of a life-threatening emergency. Congress is considering a bill, Helping Families in Mental Health Crisis Act, that would provide more latitude for psychiatrists and administrators to contact parents without consent, for safety or health reasons.

 It is best to obtain consent, and most students when asked are willing to give consent, although it may take a few requests.

The JED Foundation, founded by parents of a college student who committed suicide, encourages schools to develop an emergency contact notification protocol, posting on its website: “Good practice suggests that a student be encouraged to notify, or allow the IHE (Institute of Higher Education) to notify, his/her emergency contact (eg, parent, spouse) under certain circumstances, such as when a student expresses thoughts of suicide.”

In my practice, I will speak with about two parents per month, for about 2% of my patients, usually because a student is having suicidal ideation, possibly with self-destructive actions. Contacting parents can serve a variety of purposes: (1) it can help with a suicide assessment by providing family history and patient psychiatric history; (2) it can increase social support for the patient; (3) it can help with the decision-making process regarding treatment; and (4) it can educate parents about an illness to allow them to more effectively help their child.

There are times when there is no family that can be contacted, for example, when parents have been abusive. Fortunately, this situation is rare, but when it does happen, the college psychiatrist is stuck between a rock and a hard place. It may be unsafe to send a patient home, and the college environment is not a safe place, but the patient does not meet full hospitalization criteria.

Many campuses are hiring case managers and creating peer support systems to help students in distress who lack family support. However, in most acute situations where suicide risk is elevated, one can and should turn to parents, who can be an important part of the treatment plan in more seriously ill patients.

The following case illustrates how psychiatrists can collaborate with parents to improve students’ safety.

Three weeks after starting school, Lisa was brought to the college counseling center by her roommate. An 18-year old freshman, Lisa had been up most nights for the past 2 weeks, trying to study but unable to concentrate. Her roommate became concerned because she’d hear Lisa mumbling to herself, as if hearing voices.

When I met with Lisa, she looked away as we talked. She admitted that she had thoughts of killing herself. She started to cry, saying she was scared because she thought her room was bugged and had stopped eating because she believed her food was poisoned.

After talking with Lisa, I believed she wouldn’t be safe in an outpatient setting. I wanted her to be evaluated in a hospital to see if medical issues were causing her distress, or whether she was having a strong emotional reaction to being away from home for the first time. Lisa didn’t agree to hospitalization; she said she would not hurt herself and just needed to go back to her room and sleep.

I asked Lisa if we could get her mother to help make the decision. Lisa signed a release form allowing me to speak with her mother. Her mother was surprised to hear from me. She had spoken with Lisa a few days ago and thought she sounded mildly depressed but didn’t think it was serious. Lisa had gone through an episode of depression in high school and had taken fluoxetine for 6 months with good response. Her mother revealed that Lisa’s grandmother had had bipolar disorder and had been treated with medication.

Lisa’s mother wanted to avoid hospitalizing her daughter-she lived about 600 miles away with her elderly father who was disabled, but she could be there in a couple of days to discuss the issue and make a decision. In the meantime, we tried to come up with a safety plan because I felt that Lisa was at an elevated risk of self-harm and needed to be evaluated and treated in an inpatient setting. Lisa’s mother advised her to follow my recommendations.

After the call with her mother, Lisa and I continued to discuss treatment options. She seemed frozen and unable to decide what to do, and she was scared to leave my office. In the end, unable to identify a plan that would keep her safe, I committed her to a 72-hour hold.

I called Lisa’s mother and talked with her about first episode psychosis, letting her know that it was hard to predict the long-term outcome. Some people recover; others require ongoing medication. I told her the key issue was to get a thorough medical and psychiatric evaluation, and pursue treatment with a therapist and psychiatrist. I also advised that after hospitalization, it would be best if Lisa remained home for the rest of the semester to recover fully with the support of her family and to receive care from an outpatient psychiatrist and therapist.

Lisa was evaluated and treated for psychotic disorder NOS as well as mood disorder NOS in the hospital. Her drug screen was negative; laboratory results were normal. After 10 days, her suicidal thoughts subsided and there was some decrease in paranoid thinking. She was discharged with a daily regimen of 10-mg escitalopram and 10-mg aripiprazole.

Lisa’s mother called me 2 weeks later to say that Lisa had come home for a week but felt better and returned to school with a reduced course load. She asked if I would be able to continue working with Lisa. I agreed but had reservations about Lisa being back in school. Lisa’ mother and I decided that I would meet with Lisa weekly and would call with any concerns. I referred Lisa’s mother to the National Alliance on Mental Illness website, which had helpful information on first episode psychosis.

Initially, Lisa seemed well with no psychotic or depressive symptoms. However, over a month, Lisa became depressed with passive suicidal thoughts and inability to focus; she also had trouble sleeping. She feared that her condition would worsen, and she would want to kill herself. We agreed it was best that she return home to continue care with a local psychiatrist and therapist.

Together we called her mother who reassured her daughter and said that she would be there the next day to take her home. Lisa felt immediate relief. She had no intent or plan to harm herself and was hopeful she would feel better once she got home. Lisa spent the night with a close friend until her mother arrived the next morning.

This case illustrates an important principle of working with suicidal college students and their parents. Although there might not always be an immediate agreement on the treatment plan, if the lines of communication remain open and dialogue is respectful, eventually all parties will come together with the goal of improved well-being for the patient. (The 

 provides guidelines for working with college students who are experiencing suicidal thoughts or behaviors.)

In this example, Lisa was reluctant to admit to her mother that she was struggling, which is a common experience for students trying to achieve independence. A third party, the psychiatrist, can “break the ice” to begin the discussion. Lisa’s mother also exhibited some denial about the seriousness of Lisa’s symptoms, but eventually a common understanding of the situation was reached. Denial is a frequent reaction from parents whose child is in distress; parents fear the impact of the illness on their child’s life.

Most importantly, develop a rapport with both the student and the parents, if you decide to contact them. You can do the most thorough suicide assessment in the world, checking off all the appropriate boxes, but it is essential the patient feel your empathy. This is critical as you make decisions with the patient and his parents about the best possible safety measures you can follow. Good doctor-student and doctor parent relationships are essential in the care of the suicidal college student.

Dr Morris is a Psychiatrist at the University of Florida Counseling and Wellness Center in Gainesville, FL. She reports no conflicts of interest concerning the subject matter of this article.

 American College Health Association National College Health Assessment II. Executive Summary; Spring 2014. 

http://www.acha-ncha.org/docs/NCHA-II_WEB-PAPER_SPRING2014_UNDERGRAD_REFERENCEGROUP_EXECUTIVESUMMARY.pdf

 American College Health Association National College Health Assessment. Executive Summary; Spring 2000. 

http://www.acha-ncha.org/docs/ACHA-NCHA_Reference_Group_ExecutiveSummary_Spring2000.pdf

 American Foundation for Suicide Prevention. Facts and Figures; 2013 

https://www.afsp.org/understanding-suicide/facts-and-figures

 Suicide Prevention Resource Center. Suicide among college and university students in the United States. 

http://www.sprc.org/sites/sprc.org/files/library/SuicideAmongCollegeStudentsInUS.pdf

 Rocheleau M. Suicide rate at MIT higher than the national average. 

http://www.bostonglobe.com/metro/2015/03/16/suicide-rate-mit-higher-than-national-average/1aGWr7lRjiEyhoD1WIT78I/story.html?s_campaign=8315

 Riba M, Tasman A. Suicide in college students: a call to action. 

 Arria AM, O’Grady KE, Wish ED. Suicide ideation among college students: a multivariate analysis. 

https://www.insidehighered.com/news/2014/01/07/potential-loosening-parental-notification-laws-students-mental-health-problems

 The JED Foundation. Student mental health and the law: a resource for institutions of higher education. 

https://www.jedfoundation.org/professionals/programs-and-research/legal-resource

10. American Psychiatric Association Practice Guidelines. Assessing and Treating Suicidal Behaviors. 

http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide-guide.pdf

Articles

Twenty years ago, it was rare for college students to mention suicidal thoughts, and even more rare to involve parents in their care. Today, students are more likely to describe suicidal ideation, necessitating a more thorough safety assessment with potential outreach to parents. 

Marcia Morris, MD

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Clinical Care of the Suicidal College Student: When and How to Involve Parents