Suicide Clusters on College Campuses: Risk, Prevention, Management
Suicide contagion and clusters are more likely among young people in contained communities such as college campuses.
TABLE 1. Examples of media coverage that may trigger suicide contagion
TABLE 2. The JED Foundation and Suicide Prevention Resource Center framework for suicide prevention
[[{"type":"media","view_mode":"media_crop","fid":"44876","attributes":{"alt":"suicide on campus","class":"media-image media-image-right","height":"244","id":"media_crop_924463477494","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5239","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"©Photographee.eu/ Shutterstock","typeof":"foaf:Image","width":"162"}}]]Suicide is the 2nd leading cause of death among 18- to 24-year-olds.1 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 suicide clusters on college campuses have created significant distress and disruption for students, clinicians, and administrators at these institutions.2 Suicide contagion and clusters are more likely among young people in contained communities such as college campuses.3
The Substance Abuse and Mental Health Services Administration partnered with the Jed Foundation to develop a webinar course focused on college suicide clusters.4 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).
College student suicide
The rates of college student suicide are estimated to be between 6.5 and 7.5 suicides per 100,000 students.5,6 This is significantly lower than the rate among 18- to 24-year-olds in general, which is approximately 12 to 13 suicides per 100,000.7 Among college students, rates of suicide ideation and suicide attempts are between 6% and 8% and 1% and 2%, respectively.8 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.9,10
Definitions
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 colleagues11 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.
Media and suicide
A direct impact on suicide rates by media reporting has been recognized for nearly 40 years and is called the “Werther effect.”12 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 Table 1 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.”12 Media reports that avoid the pitfalls listed in Table 1, 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 lower the risk of suicide contagion.13
Preventing suicide clusters
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.14 The Jed Foundation and Suicide Prevention Resource Center developed a framework, based on the Air Force Model, for suicide prevention on college campuses (Table 2).
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.15[PDF] 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 sequences of suicides in the past.16,17 Suicides have been limited at Cornell and NYU by taking steps 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.
Postvention as prevention
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.
Communication after a campus suicide
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 very clear guidelines for communicating about suicide, which can be used in these situations.18 It can be helpful to point out to campus journalists that media reporting guidelines have been endorsed by leading journalism programs as well as suicide prevention specialists.19
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.20[PDF]
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 services
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 Hall20 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.
Conclusion
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.
Disclosures:
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.
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