An 18-year-old freshman college student, “A.B.,” was handsome, athletic, and artistically gifted. A.B. seemed to have everything going for him. Yet, he actually had few close friends, had always seemed a bit aloof, and was considered a “worry-wart.” He had a brief period of psychotherapy for depression and social anxiety when he was in junior high school. He had otherwise never been treated for depression and was in good physical health. His maternal grandmother had died by suicide, and his mother had chronic and recurrent depression. At school, A.B. often felt isolated and alone. During their weekly phone calls, he told his parents how lonely and unhappy he felt; he listened to them when they encouraged him to “push on.” After barely passing his first mid-term examination, he became preoccupied with failing, worried incessantly, and felt increasingly overwhelmed by the demands of studying for other examinations while attempting to keep up with daily work. To increase his concentration and energy, he began experimenting with stimulants during the day, which was soon followed by alcohol at night to help him relax and fall sleep. At his mother's urging, he visited the student counseling center. He made it clear that he did not want medications, and his therapist complied by not requiring a psychiatric assessment. Still, he did not feel comfortable with his therapist, failed to show up for his third appointment, and never called to reschedule.

During a 10-day holiday break, A.B. returned home and almost immediately began to feel less depressed, anxious, and withdrawn. His parents were heartened to hear of his enthusiasm to return to school and to switch from a premedical to an art history major. One week after returning to school, he was found dead from hanging in his dormitory room. The case vignette above is not an actual case, but is an amalgam of several tragic instances of college students who have died by suicide. It illustrates several points about suicide among college students, including risk factors and missed opportunities for prevention. Drawing upon A.B.'s history, course of illness, and outcome, this commentary will discuss college student suicide in terms of epidemiologic risk factors and the roles of academic psychiatry and psychiatric intervention in preventing suicide.

A.B. is not alone. The estimated global burden of suicide is one million deaths per year (1), making suicide the tenth-leading cause of death worldwide. Tragically, in the United States, suicide is the third-leading cause of death among college-age individuals and may even surpass homicide as the second-leading cause of death on college campuses (2, 3). In a national survey of over 20,000 college students, on 39 campuses, over 10% had seriously considered attempting suicide; 8% had made a plan; and almost 2% had actually attempted suicide in the previous year (4). Another recent survey of over 1,000 college students at a large mid-Atlantic university reported that 12% of students had pondered killing themselves at least once, 25% of whom said they thought about it repeatedly; 1% had made specific plans or carried out full-fledged attempts (5). Why are the rates of suicidal thoughts and behaviors so high among college students? “College and the transition to adulthood are a time of infinite possibilities; but, for students struggling with unaddressed mental health problems, those possibilities fade” (6). As during other phases of life, mental illness, particularly un- or undertreated mood disorders, are the most robust risk factors. Major depression affects individuals of all ages, ethnicities, and socioeconomic groups, and the age at onset of depression most often is during adolescence and early adulthood (7, 8). When depression occurs early in life, it is a particularly virulent disease associated with even higher rates of suicidal thoughts and behaviors throughout life than later-onset depression (8).

In addition to depression, bipolar disorders, anxiety disorders, eating disorders, and schizophrenia often first manifest themselves during college-age years and are associated with increased risk of suicide. Complicating the college years, alcohol and drugs become more available. When co-occurring with other mental illnesses, abuse of alcohol and other drugs exacerbates depressive symptoms, increases impulsivity, diminishes normal inhibitions against self-destructive impulses, and may lead to social isolation. A.B. manifested many of these risks: depression (especially, untreated, at the time of his suicide), anxiety (worry), and substance use. Also, A.B.'s family history of mood disorder, and, especially, of suicide, added to his risk. An important contributing factor to the approximately 1,100 deaths by suicide each year among U.S. college students (6) is the lack of treatment for students with serious mental disorders. One recent study (9) reported that although almost half (47%) of college-aged individuals met criteria for a psychiatric illness in the past year, fewer than one-quarter (20%) sought treatment. Almost two-thirds (65%) of those with mood disorders did not seek treatment. Also, college students were less likely to receive treatment for an alcohol- or drug-related illness than their age-matched peers. These results are strikingly similar to a national survey of 39 college campuses that found that only 24% of the students who reported “feeling so depressed it was difficult to function” received therapy for depression, and only 36% received antidepressant medication (4). Adding to the burdens of mental illnesses are the myriad developmental transitions and psychosocial stresses occurring during college and young adulthood: moving away from home, parents, and friends; social anomie; sexual identity and orientation conflicts; for some, developing (and losing) intimate relationships; and academic and social challenges (10–12).

A.B., like so many other college students, struggled with many of these same challenges. College life can be an impersonal and seemingly overwhelming milieu for even the healthiest of students; but for some students also burdened with mental illness, these developmental storms may be impossible to weather. Although we can identify many risk factors for suicide in college-age young adults, on an individual basis, it is unusual for survivors or clinicians to satisfactorily answer the question “Why?” A.B.'s family was shocked by the timing of his suicide. He had “turned the corner,” was feeling good, and making plans for the future. His family allowed themselves to feel hopeful. We can speculate on why he killed himself when he did, or whether his sudden burst of well-being may have been the result of knowing that the end was in sight, but, ultimately, we will never know. Such uncertainty is the rule, rather than the exception, and often is one of the most difficult burdens for the surviving loved ones to overcome (13).

Can suicide be prevented? Preventing suicide is at the core of what psychiatrists do. Every time we accurately diagnose major depression and provide effective treatment, we are doing exactly what APA Practice Guidelines recommend as the most effective way to prevent suicide (14, 15). Also, because major depression is a chronic and generally recurring illness, long-term maintenance treatment frequently is an essential component. No single antidepressant has been found more effective in lowering suicide risk than others (16), but the predominance of available evidence strongly points toward the salutary effects of treating depression (17). Lithium salts for patients with mood disorders (18), clozapine for those with schizophrenia or schizoaffective disorder (19), and possibly electroconvulsive therapy for patients with very severe or psychotic depression (20) have documented anti-suicide effects. Also, a variety of psychotherapies, such as interpersonal psychotherapy (21) and cognitive-behavioral therapy for suicide attempts (22) or dialectical behavioral treatment for impulsivity (23) and other psychosocial interventions to modify known risk factors play important roles in the treatment of individuals with suicidal thoughts and behaviors (14, 15, 24).

One issue that bears special attention is whether antidepressants increase suicide risk. A review of 372 placebo-controlled antidepressant trials and nearly 100,000 patients demonstrated an age-related increase in suicidal ideation and behaviors, as compared with placebo medications, and this finding led to a “black-box” warning for children, adolescents, and young adults (16). Yet these same data do not provide evidence that antidepressants actually increase rates of completed suicide. In contrast, there is a great deal of indirect evidence that antidepressants lead to decreases in suicide rates: 1) the greatest risk for suicidal attempts is just before treatment is initiated, and attempts begin decreasing within weeks of beginning treatment (25); 2) a review of 9 antidepressant drugs studied in 251 randomized, controlled trials with major depression and various anxiety disorders found no increased risk of completed suicide associated with assignment to either active drug or placebo (26); 3) a number of ecological studies comparing trends in suicide rates and antidepressant-prescribing suggest that antidepressant use is associated with decreasing rates of suicide (27–30); and 4) one study specifically looking at the relationship between serious suicide attempts and antidepressant treatment in young adults between the ages of 18 and 25 reported a protective effect of treatment, with lower rates of suicide attempts after treatment versus before treatment, and, likewise, as compared with patients who received no treatment (28). One particularly informative study (31) showed that after educating general practitioners on the Island of Jämtland about depression and its treatment, the use of antidepressants increased more in Jämtland than in Sweden, as a whole. Also, in Jämtland, the number of suicides decreased more steadily than in the rest of Sweden.

What can academic psychiatrists do? There are a number of places where academic psychiatrists can intervene.

• For the research-minded psychiatrist, prevention of college student suicide is an understudied public health problem ripe for further investigation. Research focused on the genomics of suicide risk and prevention, neural substrates, and maladaptive cognitions is rich with possibilities (32–34). Research targeting familial and other social-cultural factors that impede access to care in particularly vulnerable groups, such as international and transfer students (35), and possibly even premedical students (36), is another area worth pursuing. Some research can itself provide aid to high-risk students. A screening program developed by the American Foundation for Suicide Prevention, for example, offers an anonymous online screen for stress and depression that connects “at risk” students to a counselor, who then dialogues with the student to engage him/her to come for an evaluation and perhaps receive a direct referral (37, 38). Using the AFSP screening program, one large southern university found high rates of suicidal ideation among college students and found that the vast majority of students with suicidal ideation were not receiving any psychiatric treatment. Nineteen percent of those who screened positive for moderate or high suicide risk attended an in-person evaluation session with the counselor, and 14% entered treatment (39). Research assessing the effectiveness of these innovative screening and referral programs in actually reducing suicide rates on college campuses would be a valuable, although challenging, next step. Finally, promising studies like one that found a reduction in suicidal ideation among medical students after a program of faculty education, a specialized curriculum, and enhanced access to individual counseling should be replicated and perhaps extended to other graduate and college students (40). It takes only one life saved to make these efforts well worth the effort.

• For the psychiatrist-teacher, educating the public, mental health providers, students, psychiatry and other specialty residents, primary-care physicians, and other psychiatrists about mental illness, and, specifically, the assessment and treatment of suicide risk, is highly rewarding and can be very effective. When presented with depressed patients, many physicians do not ask questions about suicide, an inquiry that should be automatic in almost any clinical situation. A survey of primary-care residency training directors found that fewer than half reported that teaching about suicide was adequate (41). More robust training about these vital mental health concerns in primary care could reduce morbidity and mortality. Programs aimed at educating primary-care physicians in detecting and managing depression have had promising initial impact on reducing rates of suicide attempts (42) and completed suicides (43, 44). Even psychiatry residents often feel unprepared to assess and manage suicidal patients (45). Experts could provide standardized curricula, along with audio, video, and web-based learning resources for both primary-care and psychiatry residencies in the recognition and management of suicide and depression. Also, academic psychiatrists and psychiatry residents on college campuses need to spend time educating their colleagues, both other M.D.s and non-M.D. mental health specialists, about the fatality of depression, how to ask about suicide, and what to do if the answers are positive. Student health counselors and physicians need to know that depression can be a fatal illness and that the best ways to prevent suicide are prompt diagnosis, vigorous treatment, and vigilant follow-up. Had A.B. been better educated about depression and its treatment, he might have been more willing to engage in treatment; had his therapist at the counseling center been better educated and equipped with the correct tools, she might have been more prepared to provide effective treatment and/or complete a referral to a psychiatrist; had the Dean of the University been better educated, a campus-wide campaign could have encouraged faculty and staff to detect the warning signs for distress and to act as a caring community. Since recent events of campus violence, U.S. college campuses have improved their systems of communication concerning distressed students. The interpretation of the Family Educational Rights and Privacy Act (FERPA) law has evolved such that publically observed behaviors, or ones that could threaten safety, are able to be communicated appropriately and efficiently between faculty and administrators, with the goal of getting the distressed student appropriate help.

• And for the psychiatric clinician, treating mood and other psychiatric disorders vigorously, using not only optimal dosing and duration of pharmacologic agents, but also targeted psychotherapies and other psychosocial interventions is the bedrock of suicide prevention (14). Reminding ourselves that providing a caring ear, a timely assessment, and either appropriate treatment or referral may salvage a life and help generate much-needed outreach. Since many students are skeptical of psychiatric diagnosis or treatment (46), the clinician must take the initiative, to convince the student that his or her problems are “real” and generate a shared confidence in the treatment, which will help the student feel and perform better. Overcoming other barriers to treatment, such as perceived stigma and concern about family-member responses to psychiatric treatment (47), also bear attention. After the initial contact, prompt and regular follow-up, including follow-up of “no-shows,” may pay huge dividends. Too often, family, friends, and even seasoned clinicians are lulled into a false sense of security when a suicidal person perks up, announces some optimism, and begins to make plans for the future. Even when such proclamations are sincere, an imminent risk may remain. We have all been fooled, with tragic outcomes, by patients who seem to have “turned the corner,” yet remain vulnerable to suicide's compelling call. A.B. was one such example. Knowing that depressed patients who survive suicide attempts remain at suicide risk for years, if not for a lifetime—particularly in the period immediately after hospitalization or during future depressive episodes—provides roadmaps to suicide-prevention strategies. These strategies include prompt follow-up and close monitoring after hospitalization, continuation- and maintenance-care, and working with families to enlist their support and participation in care. Finally, participation in programs aimed at de-stigmatizing mental illness and treatment, firearms safety, or working with the media to ensure responsible coverage—although beyond the general duties of clinical practice—may provide life-saving rewards. Working with suicidal youths can be incredibly rewarding; but losing a young adult to suicide is a tragedy that can devastate even the most seasoned clinician. The academic psychiatrist can help prepare clinicians and residents for the awesome responsibility of caring for students at risk for suicide as well as assisting them in responding to the heart-rending loss (48–52).

This commentary summarizes the roles of academic psychiatrists in addressing the many vexing issues surrounding suicide among college students. Suicide is the second-leading cause of death in college students and it represents an early and fatal outcome potential for most mental disorders, which often surface during late adolescence or early adulthood. Suicide and suicidal behaviors among college students directly and profoundly affect college campuses, surrounding neighborhoods, and the individuals who study, work, and live in these communities. As members of these communities, academic psychiatrists are uniquely trained and positioned to affect outcomes via efforts directed toward basic and clinical research, psycho-education, mentoring, and outreach. Although many academic programs are already active participants in college mental health programs, increased involvement by psychiatry's leaders, academic institutions, and funding agencies would likely ensure a better future in this critical area.

At the time of submission, the authors reported no competing interests.

Other Resources:

http://www.suicide.org/college-student-suicide.html

http://www.jedfoundation.org/

http://www.afsp.org/

http://mentalhealth.samhsa.gov/SuicidePrevention/