College students and suicide risk: prevention and the role of academic psychiatry

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 During a 10-day holiday break, A.B. returned home and almost immediately began to feel less depressed, anxious, and withdrawn.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 unor 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 Received November 3, 2010; revised March 1, 2011; accepted March 18, 2011. From the Dept. of Psychiatry, Univ. of California, La Jolla, CA. Correspondence: s.zisook@ucsd.edu (email). Copyright © 2012 Academic Psychiatry