Victor Schwartz, MD

, Sigmund Freud examined the difference between mourning-a natural and non-pathological process-and melancholia, what we would now call major depression or 

. Although the feelings of grief, sadness, and temporary disruptions in functioning (disturbed sleep, appetite, and concentration) experienced when we lose someone close to us or something we highly value, look very much like clinical depression, they arc towards return to our usual functioning. In clinical depression or melancholia, the disturbances are of course, more intense, prolonged. and continue to interfere with the ability to function over a longer time (are sometimes associated with thoughts or impulses to self-harm) and often with depression there is no obvious loss or precipitant.


	I’ve been thinking of this distinction recently in light of the challenges we are all facing in managing our fear, worry, stress, isolation, and for many of us potential and real loss as we face the 

 pandemic. There has been much written and said about the dire mental health impact of the pandemic. The feelings are real, natural, and sensible as well as disturbing and adaptive-similar to the feelings we experience during mourning. And, while they may increase our risk of exacerbations or new onset of mental illness, we should be careful not to label these natural feelings as themselves pathological or signs of mental illness.

Let’s consider an analogy. Imagine you are carrying a heavy package up a hill on a hot day. As you are walking along you may notice that you are breathing more heavily than usual, you might be sweating, your heart is likely beating faster and as you continue, your arms may start to ache. Is carrying this package harming your health? At this point, it would seem reasonable to suggest you are fine. Your body is reacting the way it ought to in order to compensate for the load you are carrying. Of course, if you have a history of heart problems or are dehydrated, or if you have arthritis in your knees, carrying this package can lead to or exacerbate a physical problem.

So, while the burdens we are all bearing right now are disturbing and might put us at higher risk for a mental health problem than is usual, we should not confuse our completely typical and normal feelings with illness. At the same time, it is sensible that we should remain alert enough for signs of a more concerning or pathological response to our burden (ie, severe, unrelenting anxiety and/or sadness, inability to cope or concentrate, sleep and/or find pleasure in anything at all, or thoughts or impulses of self-harm or harm to others).


	In addition to the importance of distinguishing illness from typical adaptive response, there is another valuable and relevant psychological lesson to be gleaned from the work of Sigmund Freud. One of Freud’s core (and rather remarkable) observations was that the people he treated in psychoanalysis would begin to relate to the analyst in ways and patterns that were similar to the ways they had interacted with parents and other important figures from their early lives. He called this phenomenon “transference.”


	The idea is that we all repeat our relationship patterns, our assumptions about people and situations; and the more vague, ambiguous, and stressful a situation is, the more we fill in the gaps of our understanding with old patterns. In his Pulitzer prize winning book 

, the social anthropologist Ernest Becker extended Freud’s idea of transference. He argued that we all carry the roots of our childhood psychological development with us and central to those childhood feelings are our inevitable feelings of fear and helplessness that every child feels. Becker claims that when we are faced with frightening situations, and especially one’s where we feel out of control and in which we may be in serious danger, it is natural and nearly inevitable to wish for a parental figure-a hero- to protect and save us. This is dangerous because when this occurs we may suspend or partly suspend our adult intellectual capacity to reason and think independently. This is how propaganda works and at its extreme how people can be brainwashed: when people fear for their life, they will grasp onto whoever might be in a position to keep them safe or help them-even if it is the person who might also harm them.

During the pandemic crisis, people fear for their safety and we are faced with a situation in which there is a lot of uncertainty about what is happening-both the exact nature of the risk and how to minimize it. This is precisely the type of situation during which the kind of transference-driven dependency Becker described, can emerge. It is easy to be confused, manipulated, or taken advantage of when we are fearful and feeling helpless.

While the current pandemic increases our risk of being manipulated or misled, the world of social media and the current tense and uncertain political environment amplify our uncertainty and can leave us grasping for anything and anyone who seems to have an answer. When we become aware of this natural human vulnerability, we can be on guard for people who might be trying to manipulate or take advantage. When there is so much unknown, we should be suspicious of anyone who claims to have too much certainty, to have “the solution,” especially if they tell you they’ll share it with you for the right price. At times like this, humility is core to truthful and valuable information.

Where does this leave us? We should accept that the past few weeks and the coming weeks will be difficult and that difficulty will apparently continue for a while, but people are working on science and evidence-driven responses and strategies. We should try to continue thinking carefully and critically about what we hear and read, we should do what we can to make sensible decisions about our safety and health and that of those around us, and most important, we should do what we can to stay connected as well as we can to those who provide us positive and real emotional support and do what we can to relieve our distress and the distress of those around us.

Hopefully we can all stay safe and healthy and help each other carry this burden. We can come out of these experiences more aware of ourselves and more sensitive and deeply connected.

is Clinical Associate Professor of Psychiatry, NYU School of Medicine and Chief Medical Officer, The Jed Foundation (JED), New York, NY. He reports no conflicts of interest concerning the subject matter of this article.

Articles

In his 1918 essay, “Mourning and Melancholia,” Sigmund Freud examined the difference between mourning and melancholia, what we would now call major depression or depressive disorder.

Thinking Clearly During COVID-19: Thoughts on Fear, Stress, and Mental Illness

Full disclosure: I do not know any of the details of these situations. Also, I was interviewed for this story, and several heavily edited and misleading snippets of my comments were included in the report.

 show ran a story, reported by Ronan Farrow, describing the travails of 22 students who were purported to have been forced out of their colleges after having presented for treatment at their school counseling/mental health services.

 Farrow’s report focused on 3 students.

In the most detailed account, a University of Chicago student reported that she had presented to the counseling service for treatment of depression and superficial cutting. She tells Farrow she had absolutely no suicidal intent but was taken to a hospital and kept there for 2 weeks-an extraordinary duration for someone in no apparent risk or danger. After a year’s leave, she is back at Chicago.

A Yale University student reported having been forced to withdraw from school when hospitalized for depression and made to reapply in order to return. She is back at Yale and is fighting this policy, which requires students to reapply to the university after taking a medical leave.

The other Chicago student reported having been forced to take a leave after a psychiatric hospitalization. Upon her discharge, in a meeting with campus administrators to discuss her situation, her mother described her as “going into a fetal position and sobbing, begging to be readmitted to school.” The student and her mother feel the school’s having her take a leave was reflective of a complete lack of empathy and compassion-rather than a sensible assessment of her level of distress and dysfunction at the time.

In any event, one would imagine from this report that psychiatrically ill and suicidal students are routinely being shipped off to hospitals and removed from their colleges without due process or discussion. Farrow suggests that the fear of this happening may very well be leading students in distress to avoid seeking help at their schools. He is correct about the danger of students having this impression. Unfortunately, it is reports like this one that are creating this impression, which is largely inaccurate.

Currently, there are approximately 20 million college and university students in the US.

 According to the National College Health Assessment, nearly 10% of students reported serious thoughts of suicide in the past year and 1.6% reported a past-year suicide attempt.

 Thus, about 2 million students had serious thoughts of suicide, and 300,000 made a suicide attempt in the prior year. College counseling services typically see slightly more than 10% of their school’s students in a year

; about one-third report having had serious suicidal ideation.

College counseling centers are treating vast numbers of students with suicidal ideation or past-year attempts. And yet, Farrow found 22 students who were reported to have been forced out of school because of suicidal behavior or ideation (or, as reported, for seemingly meaningless minor acts of self-harm).

The Americans With Disabilities Act (ADA) makes it very difficult for colleges to involuntarily remove students with psychiatric illness-even when they are suicidal. The ADA allows for complaints to be brought to the Office of Civil Rights of the US Department of Education, which provides an indicator of how many students feel they were unfairly or inappropriately forced out of school. The number of civil suits brought against colleges for impinging on students’ civil rights can also be tracked. In fact, there are very few complaints/lawsuits given the number of troubled students seen by college counseling services.

The best examples of a school overreacting may have been the Jordan Nott case and the Jane Doe vs Hunter case.

 In both cases, students were removed from college after voluntarily seeking inpatient treatment for depression with suicidal ideation. In each case the action was taken without any discussion with the student. In each case the university settled, and at least in the Nott case, George Washington University made substantial changes to its protocols for managing depressed students.

Moreover, it is important to recognize that after the Virginia Tech tragedy, some school administrators understandably became much more skittish about having students with suicidal ideation on campus. One can also find this heightened reactivity and push to remove potentially suicidal students when there has been a recent suicide or suicide cluster on a campus or prominently covered in the news.

There are also situations in which an individual administrator at a college has a particularly hard-nosed or anxious attitude about the risk of having a suicidal or potentially suicidal student on campus. But, all of these problems are quite rare. Most often a student who needs time away from school (and ideally his or her family) is cooperative with university clinicians and administrators, and a reasonable plan can be agreed on-if a leave occurs, it is fully voluntary.

Some schools have made the leave process more cumbersome or unwieldy by establishing policies that make students uneasy or hesitant to take a needed leave. For example, some schools require students who take a medical or mental health leave to stay out of school for a full year. Some schools do this because they don’t want students to take a leave to get out of bad academic performance. Other schools have rigid academic structures that make it difficult for a student to return the subsequent semester.

Others, such as Yale, require students who take a leave of absence to reapply to the college. While students are typically readmitted after they have received the necessary treatment and stabilized, this policy has led students to feel as if the school can arbitrarily choose to readmit them or not-in many cases increasing students’ hesitation to take needed leaves of absence.

What is the truth about involuntary leave?

While there are a few situations or policies that may lead to involuntary leave, there are large numbers of students with significant pathology and many with suicidal ideation and past or recent attempts who are being treated and kept in school. In fact, college clinicians and administrators (and campus at-risk teams) are managing many actively suicidal students.

 report as suggesting that colleges are concerned about their reputations and PR, this was only the beginning of my comment. The truth is that campus counselors and administrators primarily care about their students’ welfare and safety (this was the completion of the quote not included in the story) and they recognize that on balance, if a student can be kept in school, it is better for the student (and the system) to remain enrolled. College attendance may actually protect against suicide-the rate of suicide among college attendees is half that of young adults who do not attend college.

Furthermore, removing every student with suicidal ideation or a suicide attempt would remove many students who might be better off remaining in school.

 And consider that if a student is depressed but functioning, he or she will be more occupied, potentially better socially connected, and probably more hopeful by remaining in school.

Another incentive for colleges to work with students and their families in a cooperative way and arrive at mutually acceptable plans is highlighted in the Farrow report. In the past 20 years, colleges have made substantial strides in increasing student comfort with help-seeking. The number of students who receive treatment at college counseling centers and support through other campus offices (eg, residence life, disabilities) has grown steadily. This in some part accounts for the lower rates of suicide among college students.

 story or the sporadic reports in campus newspapers about forced leaves of absence appear, these may very well have a negative impact on student help-seeking and ironically (and tragically) make students less safe.

Farrow and the complaining students are correct that colleges need to be sensitive and sensible in managing suicidal students. They have, however, created a misimpression of a much larger problem than actually exists. They have also failed to explain how complicated many of these situations are. Students and families are sometimes not fully able to acknowledge the extent of pathology or risk, and college clinicians and administrators sometimes make mistaken or less than ideal decisions. More often than not, the student, family, clinicians, and administrators can mostly agree about the situation and an acceptable plan emerges. In the rare situation in which the student and the campus professionals cannot reach an agreement, it is best to treat these situations as a clinical impasse and work to understand the motivations and conflicts from a dynamic and therapeutic perspective. If an agreement cannot be reached, a mandated leave is possible and may be the leverage needed to get a student to seek needed treatment.

Dr. Schwartz is Clinical Associate Professor of Psychiatry, NYU School of Medicine; and Medical Director, JED Foundation, New York, NY. He reports no conflicts concerning the subject matter of this article.

 Mental health policies at universities draw increasing concern. Today. June 2016. 

http://www.today.com/news/mental-health-policies-universities-draw-increasing-concern-t99441

 National Center for Education Statistics. Fast Facts. 

http://nces.ed.gov/fastfacts/display.asp?id=372

 American College Health Association. National College Health Assessment. 

 Association for University and College Counseling Center Directors. Director Surveys. 

http://www.aucccd.org/director-surveys-public

 Center for Collegiate Mental Health. 2015 Annual Report.

 http://sites.psu.edu/ccmh/wp-content/uploads/sites/3058/2016/01/2015_CCMH_Report_1-18-2015.pdf

 Lannon OG Jr. Direct threat and caring for students at risk for self-harm: where we stand now. National Association of College and University Attorneys. 

http://www.higheredcompliance.org/resources/SelfHarm.pdf

 Apppelbaum PS. “Depressed? Get out!”: dealing with suicidal students on college campuses. Law & Psychiatry. July 2006. 

http://ps.psychiatryonline.org/doi/abs/10.1176/ps.2006.57.7.914

One would easily imagine from a recent TV report that psychiatrically ill and suicidal students are routinely being shipped off to hospitals and removed from their colleges without due process or discussion.

Mandatory Leave of Absence for College Students With Suicidal Behaviors: The Real Story

A. Friends or roommates of the deceased student

C. Students themselves who are currently depressed

D. Students in the early stages of a psychotic illness

Suicide contagion and clusters are more likely among young people in contained communities such as college campuses.

Campus suicide is a highly complex issue that evokes fear and anxiety among all involved, including students, administrators, family, first responders, and friends who themselves struggle with suicidal ideation, and action must be taken to mitigate risk. Managing suicides and suicide clusters on campus requires a combination of vigilance, flexibility and, ironically, the ability to accept our professional and clinical limitations.

Suicide Clusters on College Campuses: Risk, Prevention, Management

, by Victor Schwartz, MD, of The Jed Foundation.

1. Haw C, Hawton K, Niedzwiedz C, Platt S. Suicide clusters: a review of risk factors and mechanisms. 

Poll

After a campus suicide, who is at increased risk of suicide in the near future? The answer might surprise you (or not).

Mini Quiz: Is Suicide Contagious?

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 Although suicide occurs less frequently among college students than among the general population of similar age, suicides on college campuses often receive substantial media attention. Because more than 20 million young adults attend college, these suicides also represent a serious public health concern. In recent years several high-profile 

 on college campuses have created significant distress and disruption for students, clinicians, and administrators at these institutions.

 Suicide contagion and clusters are more likely among young people in contained communities such as college campuses.

The Substance Abuse and Mental Health Services Administration partnered with the Jed Foundation to develop a 

The goals were to review current knowledge about suicide contagion and clusters in college students and the interaction of media and suicide contagion, and to share clinical experience and wisdom about management and postvention. While it is uncertain how to prevent suicide contagion and clusters, thoughtful management of media and communications and well-handled postvention steps can mitigate the risk of subsequent suicides.

The following review of campus suicide clusters draws significantly from the content of this presentation by Madelyn Gould, PhD, MPH (Professor of Epidemiology in Psychiatry, Columbia University); Kerri Smith, LCSW, MPH (Senior Campus Prevention Specialist, Suicide Prevention Resource Center); Dolores Cimini, PhD (Assistant Director for Prevention and Program Evaluation; University Counseling Center; University at Albany, State University of New York); Greg Eells, PhD (Director, Counseling and Psychological Services, and Associate Director, Gannett Health Service, Cornell University) and Philip Meilman PhD (Director of Counseling and Psychological Services, Georgetown University).   

The rates of college student suicide are estimated to be between 6.5 and 7.5 suicides per 100,000 students.

 This is significantly lower than the rate among 18- to 24-year-olds in general, which is approximately 

 and suicide attempts are between 6% and 8% and 1% and 2%, respectively.

 These rates have remained relatively stable in this group over the past 10 to 20 years. Rates of suicidal ideation and attempts are reported to be significantly higher among student-veterans and LGBTQ students, although the actual rates of suicide among these students groups are unknown.

Suicide contagion is defined as the process by which knowledge of a suicide facilitates the occurrence of a subsequent suicide. While there is no clear evidence as to how contagion occurs, there are several compelling suggestions. Peoples’ emotions and behavior can be affected by the emotional state of those around them-empathy and identification. Emotional contagion can heighten distress in susceptible individuals and can increase their risk of suicide once a suicide has occurred. As with contagion in infectious illness, the proximity (both actual and psychological) can increase risk. Thus, people close to the person who has died (eg, residents in the same dormitory, teammates) are at higher risk, and those who feel psychologically closer to (identify with) the person who died are also at risk.

While it is uncertain how to prevent suicide contagion and clusters, thoughtful management of media and communications and well-handled postvention steps can mitigate the risk of subsequent suicides.

Suicide clusters are an excessive number of suicides occurring in close temporal and/or geographical proximity. Gould and colleagues

 analyzed data about 53 suicide clusters that occurred in the US from 1988 through 1996 and found that clusters were most likely to occur among teens and young adults. They estimated that between 1% and 5% of teen suicides occur as part of a cluster. Moreover, media reporting had a significant impact on the emergence of suicide clusters.

College students are mostly in the age group at risk for clusters and often live in close proximity to each other. Colleges also attempt to foster strong group and communal identity and connectedness; in fact, feeling strong connections to others can protect against mental illness and suicide. Nevertheless, the capacity to identify with and be influenced by others tends to be stronger among young people and in this instance may increase risk in a population when a suicide has occurred.

A direct impact on suicide rates by media reporting has been recognized for nearly 40 years and is called the “Werther effect.”

 There have been notable surges in suicide rates after prominent media reports of the suicide of celebrities. After the suicide of Marilyn Monroe, for example, suicides increased by 12% above expected rates in the subsequent month. (See

 for media coverage that may trigger suicide contagion.)

Conversely, we have learned that well-constructed media reports can actually lower the rates of suicide in a community. This has been termed the “Papageno effect.”

 Media reports that avoid the pitfalls listed in 

, convey that there are positive coping strategies and alternatives to suicide in the face of adversity, and refer at-risk individuals to crisis and treatment resources have been shown to 

Ideally, the best way to prevent suicide clusters on campus is to do everything possible to prevent a first suicide. While we do not currently have the ability to effectively predict and prevent suicides, there is substantial information about how suicide risk can be lowered (especially in closed communities). In the 1990s the US Air Force developed a suicide prevention model that reduced rates of suicide, homicide, accidental death, and domestic violence among service members.

 The Jed Foundation and Suicide Prevention Resource Center developed a framework, based on the Air Force Model, for suicide prevention on college campuses (

Several of these framework areas have particular relevance to suicide clusters and their prevention. For example, campus at-risk or behavioral intervention teams help identify students at risk and thus promote early intervention.

 Campus teams can be a powerful tool in identifying, tracking, and developing support for students who may be susceptible to mental health problems, crises, or suicide. These are among the students who are at heightened risk once a campus suicide has occurred.

Another important tool in preventing campus suicides and suicide clusters is restricting access to lethal means. There are strong suggestions that, similar to the experience with media and reporting, very public suicides may have an impact on the risk of suicide contagion, and locations where suicides have occurred may become iconic sites for suicide and thus increase the risk of clusters and subsequent suicides. Examples are the bridges at Cornell University and the library atrium at New York University (NYU), which have both experienced 

 Suicides have been limited at Cornell and NYU by 

 to safeguard these spaces with barriers. After a campus suicide, especially a public suicide, it is important to explore areas of physical risk on campus and/or areas of ongoing access to means of self-harm.

It is important for campus mental health experts to make certain that there are guidelines in place about safe communication and reporting on suicide.

An important element in preventing suicide clusters on campus is the development and implementation of a comprehensive suicide postvention plan and protocol. Recently, the Higher Education Mental Health Alliance (HEMHA)-an umbrella group of campus mental health, health, and student affairs organizations, and both APAs (the American Psychiatric Association and the American Psychological Association)-developed postvention guidelines for college campuses with the following goals: facilitate the grieving process, help stabilize the community and return to order and routine, and limit the risk of further suicides through contagion.

It is important for campus mental health experts to make certain that there are guidelines in place about safe communication and reporting on suicide. It is essential that campus administrators, communications officers, and school-based (and local) media understand that when they report on suicide, they not only convey information but also play a role in the ongoing health and safety of the community. The National Action Alliance for Suicide Prevention has developed 

 for communicating about suicide, which can be used in these situations.

 It can be helpful to point out to campus journalists that 

 have been endorsed by leading journalism programs as well as suicide prevention specialists.

Safe communication after a campus suicide demands substantial coordination, flexibility, and sensitivity. Often, information needs to be shared quickly because a death has occurred publicly or is already being publicized by social media before the full circumstances of the death are clear. Furthermore, information sharing needs to weigh the desires and sensitivities of the grieving family, since many families have religious or culturally based reticence about openly describing the death as a suicide. These discussions will obviously be difficult and painful for the newly bereaved family and campus administrators, and tact and sensitivity are essential. Sharing information with friends and others who are close to the deceased student also needs to occur differently than sharing information with the campus as a whole, especially on large campuses. The HEMHA Postvention Guide provides useful guidance on communication with the family and the campus community after a student suicide.

One of the central challenges in safe communication after a suicide is to balance the amount of information shared. Too little sharing might make students feel that the administration is hiding things and raise communal anxiety. Too much might flood students and raise the risk of identification and subsequent suicides. As a general rule, it is essential for the campus administration to convey a sense of control and confidence to reassure students and the community and help contain anxiety and a sense of helplessness.

Clinical interventions after a suicide overlap significantly with information sharing. Campus clinicians (often alongside campus administrators and potentially campus clergy) need to be prepared to meet with groups of students most closely affected by the suicide. Meilman and Hall

 developed a helpful protocol for processing grief in a productive way. These meetings help bring the campus community together and heal.

It is also essential that campus clinicians and student support personnel remain vigilant for other students who may be struggling in relation to a campus suicide, including students who are significantly depressed and/or have suicidal impulses or ideation or students who are talking a great deal about and potentially identifying with the student who died. It is important to note that students who might be in the early phase of psychotic illness are at heightened risk for suicide in general but may not present clinically in ways that are associated with suicide risk.

Campus suicide and suicide clusters are uniquely challenging tragedies that evoke fear and anxiety and can disrupt campus life and increase risk for the community. This is a highly complex issue we do not know enough about. We do know that suicides on campus increase risk, particularly for students who may themselves be struggling with suicidal ideation or impulses and for those close to the deceased student. We also know that actions taken may increase or mitigate risk. Managing suicides and suicide clusters on campus requires a combination of vigilance, flexibility and, ironically, the ability to accept our professional and clinical limitations.

We can help to some extent, and we can try not to make things worse. Strangely, there is an argument to be made that too much intervention (or too much specifically suicide-focused intervention) might actually make the campus community more anxious and might be counterproductive. Typically, clusters will eventually slow or extinguish, and over time the campus can return to a semblance of normal function. In this process, it is incumbent on clinicians to do all we can to keep the campus safe and help the community grieve and heal.

Dr Schwartz is Medical Director of The Jed Foundation in New York and Clinical Associate Professor of Psychiatry at New York University School of Medicine. He reports no conflicts of interest concerning the subject matter of this article.

 Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report; July 20, 2012. 

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6128a8.htm

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http://news.yahoo.com/mental-health-suicide-on-college-campuses-katie-couric-141742009.html

 Haw C, Hawton K, Niedzwiedz C, Platt S. Suicide clusters: a review of risk factors and mechanisms. 

 The Jed Foundation. Responding to Suicide Clusters on College Campuses. 

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

 Silverman MM, Meyer PM, Sloane F, et al. The Big Ten Student Suicide Study: a 10 year study of suicides on Midwestern university campuses. 

 Schwartz AJ. Rate, relative risk, and method of suicide by students at 4-year colleges and universities in the United States, 2004-2005 through 2008-2009. 

 American Foundation for Suicide Prevention. Facts and Figures; 2014. 

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

 American College Health Association. National College Health Assessment; 2015. 

http://www.acha-ncha.org/reports_ACHA-NCHAII.html

 Rudd DM, Goulding J, Bryan C. Student veterans: a national survey exploring psychological symptoms and suicide risk. 

 Johnson RB, Oxendine SM, Taub DJ, Robertson JO. Suicide prevention for LGBT students. In: Taub DJ, Robertson JO, eds. 

Preventing College Student Suicide: New Directions for Student Services

. San Francisco: Jossey-Bass; 2013:55-69.

 Gould MS, Wallenstein S, Kleinman MH, et al. Suicide clusters, an examination of age specific effects. 

 Niederkrotenthaler T, Voracek M, Herberth A, et al. Role of media reports in completed and prevented suicide: Werther v Papageno effects. 

 Kramer AD, Guillory JE, Hancock JT. Experimental evidence of massive-scale emotional contagion through social networks. 

http://www.pnas.org/content/111/24/8788.full.pdf

 Knox KL, Pflanz S, Talcott GW, et al. The US Air Force suicide prevention program: implications for public health policy. 

 Higher Education Mental Health Alliance. Balancing Safety and Support on Campus. 

http://www.jedfoundation.org/campus_teams_guide.pdf

 Cornell University Facilities Services. Means Restriction Study for Bridges; 2005. 

https://meansrestrictionstudy.fs.cornell.edu/

 Huffington Post. NYU installs aluminum screens to prevent suicides in Bobst Library; 2012. 

http://www.huffingtonpost.com/2012/08/20/nyu-bobst-library-suicides-aluminum-screens_n_1812743.html

 Action Alliance for Suicide Prevention. Action Alliance Framework for Successful Messaging; 2015. 

http://suicidepreventionmessaging.actionallianceforsuicideprevention.org/

 Dart Center for Journalism and Trauma. Suicide. 

 Higher Education Mental Health Alliance. Postvention Guide: A Guide to Response to Suicide on College Campuses. 

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 The Jed Foundation. Promoting Emotional Health and Preventing Suicide; 2016. 

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

In the past few years, college mental health issues have received increasing attention by the mental health community, the public, administrators, and legislators. Events such as the death of MIT student Elizabeth Shin and the subsequent legal battle, and the series of suicides at NYU a few years ago received prominent media coverage.

 In the aftermath of the tragic murders/suicides at Virginia Tech and Northern Illinois University, college student mental health issues and campus safety have become pressing public health and policy concerns.

Psychiatrists have historically played a peripheral role in most college mental health services and, thus, have not been well informed about the mental health challenges encountered on campus.

While the tragedies at Virginia Tech and Northern Illinois University riveted the nation’s attention, professionals within the college mental health world had been discussing the mental health crisis for years before these horrific events. Research in college mental health issues has not been well funded, and epidemiological information is scarce. The American College Health Association undertakes a yearly self-report survey of college students (nearly 95,000 respondents last year), which gathers general information about students’ health and mental health.

 Dr Robert Gallagher of the University of Pittsburgh surveys college counseling center directors yearly.

 The University of Michigan is al-so in the early stages of a multiyear study of the mental health of university students.7

What have these reports shown? There are currently approximately 17.5 million university students in the United States.

 Gallagher reported that in 2006, 8.5% of students sought counseling through their school service; another 29% were seen by college-based counselors in other settings. Voelker

 noted that visits to university counseling centers rose 42% between 1992 and 2002 at 11 large Midwestern universities.

For the past 10 years, Gallagher has consistently reported that about 90% of counseling center directors believe they are treating increasing numbers of students with severe pathology. In 1994, 9% of students seen at counseling centers were taking psychiatric medications. By 2006, this number had risen to 23.3%, and 7.5% of students had such serious impairments that they could not function in college settings or without extensive psychiatric/psychological support.

Students’ self-reports seem no more reassuring. According to the most recent American College Health Association survey, about 13% of students reported having symptoms of anxiety, and more than 18% reported depression symptoms.

 Almost 15% had received a diagnosis of depression sometime in their lives; 25% reported problems with their studies as a result of sleep problems; 33% acknowledged stress-related problems; 43% said they felt so depressed at some point in the academic year that it was difficult to function; 10% had seriously considered suicide; and 1.9% had attempted suicide.

National Institute on Alcohol Abuse and Alcoholism (NIAAA)

 has gathered data on alcohol use in colleges. The news is dire on this front as well: 31% of the surveyed students met criteria for alcohol abuse.

 Moreover, there were 1.3 million yearly alcohol-related injuries or assaults among college students. While there are estimated to be about 1100 suicides each year on college campuses, 1700 deaths are attributed to alcohol-related accidents and unintentional injuries.

Large numbers of students acknowledged that they had unsafe sex while intoxicated or did something they later regretted. Rates of assault and sexual assault related to alcohol and drug use are also alarmingly high. In 2005, 83% of campus arrests were alcohol-related.

Students who abused painkillers during the previous month increased from under 1% in 1993 to 3.1% in 2005.

 During the same period, daily marijuana use more than doubled from 1.9% to 4%; the use of illegal drugs other than marijuana, such as heroin and cocaine, increased from 5.4% to 8.2%.

When most college clinicians discuss the crisis in college mental health, they emphasize that the demands on ser-vices have dramatically outpaced the capacity and rate of growth of available mental health care systems. Most college counseling services provide free, short-term care for students and are usually funded by student services fees. Historically, the counseling centers were conceptualized as settings where students could be helped through a specific developmental challenge or adjustment problem (eg, homesickness, failure to establish a social network). The centers are frequently staffed by psychologists (more often counseling psychologists rather than clinical psychologists) and, until recently, often had little if any psychiatric staff.

Because many students have limited or no insurance coverage and many communities have limited options for low-fee care, colleges find themselves providing services for larger numbers of seriously ill students for longer periods. With the availability of effective treatment options, students with serious mental illness are now able to attend college. The need for clinicians equipped to care for these students has grown simultaneously. Colleges must decide whether to spend money hiring lower-salaried therapists (social workers and nurse practitioners) or psychiatrists.

Colleges are not in the business of providing health and mental health care. While the schools recognize the need to provide ample services, this is often done somewhat grudgingly and often after a crisis (such as a campus suicide).

Colleges have a complicated relationship with their students. Most students are legal adults and entitled to privacy and autonomy. However, colleges have some responsibility to oversee their students’ conduct and to provide in some general way for their safety and well-being.

 Parents expect to be part of the discussion if their child is having difficulties. College administrators, policy makers, legislators, and judges have all struggled to strike a balance between these values of privacy/autonomy and oversight/safety/ parental involvement.

The concerns around this conflict of values have been acutely heightened by the tragedies at Virginia Tech and Northern Illinois University. There have been calls from many corners to increase oversight of students, curtail their privacy and autonomy, and lower current legal thresholds for parental contact and mandatory leaves of absence.

These concerns have placed new pressures on college mental health services to keep campuses safe but sometimes without appropriate strategic planning. While there may be circumstances in which sharing clinical information or mandated medical leaves might be appropriate, these pressures have increased the challenge and conflict experienced by campus clinicians to keep patient care the primary goal of the clinical interaction. Lowering the threshold for communication is likely to erode the often fragile trust between a troubled student and the campus mental health systems and/or university administrators.

Currently, fewer than 1% of college counseling centers are directed by psychiatrists, and only 63% of schools provide psychiatric services on campus. The average weekly number of consultation hours is 17 per 100,000 students.

 [APA] president) convened a Presidential Task Force on College Mental Health to increase awareness and promote advocacy for college mental health in the psychiatric community. This group, now an APA committee, has become a “meeting place” (both real and virtual) for psychiatrists who work in college mental health settings. Many of these psychiatrists experience professional isolation.

College mental health services play an important role in promoting healthy and safe college communities and campuses. Having robust services available improves student retention and, thus, good services make good economic sense. With increasingly severe psychopathology of students, psychiatric services must be enhanced. Clinicians who support and treat the most troubled students and who can assess and manage psychiatric emergencies are needed. If an on-site psychiatrist is not economically feasible, referrals to accessible and affordable psychiatric services off-campus need to be provided.

Residency training and fellowship electives at college mental health ser-vices provide wonderful opportunities for residents to learn about college mental health issues (and to learn about short-term therapies and combined and split treatment). Experts in college mental health have begun to be invited to address grand rounds and professional meetings. The APA has established a college mental health area on its Web site (Healthy Minds. Healthy Lives

]) and there are a growing number of other Web sites devoted to college mental health and substance abuse.

While there are some efforts at careful epidemiological work, much more needs to be done to continue to understand and explain the growing number of increasingly troubled students presenting to college services and the best approaches for their care.

 The stigma associated with mental health problems on campus needs to be addressed, and integrated models of mental health care need to be put into practice.

The best college mental health services, while scrupulously maintaining the privacy of their patients, also find ways to educate their college communities about mental health issues. Tragedies on college campuses are more likely to be prevented by establishing open lines of communication and a strong collaboration among students, faculty, and administrators.

College mental health clinicians and administrators need to be well versed in the laws pertaining to college students but primarily should act in the “best interest of the student.” Relevant laws such as the Family Educational Rights and Privacy Act and the Americans with Disabilities Act provide a framework for decision making in complex cases. However, these laws do not, and should not, dictate case management in crisis situations; ultimately, clinicians should follow sound clinical judgment and appropriate consultation with colleagues in the decision-making process.

Despite all the problems and challenges that face college mental health services, work in this setting is generally quite rewarding. University students are usually intelligent, hard working, and resilient; and they often make substantial strides in treatment, however brief. Helping a student to remain in school, complete an education, and actualize his or her potential is a deeply gratifying professional experience.

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Author | Victor Schwartz, MD

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