But this framing might not provide a complete picture of this particular mental-health problem on college campuses. When I meet Wallack again in his office just after the new year, he provides a few examples of how the statistics involving suicide and college students get muddled. For one thing, if a student dies on campus, the university usually will know the cause of death. But if they die away from campus — perhaps at their parent’s home — university representatives may never know the cause of death. So when considering the number of suicide deaths for college students, he says, it has to be a number that is inherently underreported because institutions can only count those deaths that occur on campus. And as Locke himself points out to me, many colleges don’t even track their student body’s suicide rates to begin with.
Self-harm and Suicidal Ideation Diagnoses
The Healthcare Cost and Utilization Project (HCUP) produced a 2017 Nationwide Emergency Department Sample (NEDS) as a database for suicide diagnoses in emergency rooms across the country. This report shows the number of suicide-related ER visits per 100k population of each age group, revealing that the number of suicide-related cases spikes for people aged 18 to 24, the typical age of college students. This value was a 100.3% increase from 2007.
Wallack also sees significance in the fact that the number one cause of death in the college population is accidental death, and the largest subgroup of those deaths is alcohol related accidents. He suggests that mental-health issues often inform those students’ alcohol consumption, and that although alcohol might be identified as the primary contributing factor in a death, the substance abuse could be the way the student treated the mental-health problem. He says that at some level, there may be a self-awareness of what one is doing when one drinks themself to death, but that death is never recorded as a suicide. Carruthers backs up Wallack’s point, adding that short of finding a suicide note or other circumstantial evidence, coronors are more likely to declare a death an accident if it could easily be seen as one. Ultimately, Wallack says, “It’s not necessarily that we are just undercounting the number of suicide deaths. We’re undercounting the number of deaths that are caused by mental-health problems.”
When unraveling the causes and contributing factors to suicide, it’s a challenge to consider both the hard data presented to us on paper and the lived experiences heard from people who struggle with mental illness and those who treat them. Though the numbers show that attending college may be a protective factor against suicide, aspects of college life present risk factors to mental health too. During a week in March when universities across the country start to shutter for COVID-19, Leah Wentworth, Ph.D., the director of student wellness for the entire State University of New York (SUNY) system, somehow manages to find time to speak with me over the phone. “It’s fairly easy to say, ‘Well, the stats say this thing and so this group isn’t at the same risk, or whatever,’” Wentworth says. “But there’s the information that we all know from the statistics, and then there’s the likelihood and the reality that people are feeling less mentally healthy in some really important ways on campus.”
“Students seem to be very willing to endorse items that reflect things being talked about in the culture at levels that are far above what a professional would evaluate to be the problem.”
It’s clear that students face a number of concerns such as financial problems during school, the anxiety of paying off loans after graduation, and the stressful workloads necessary to secure part-time work, professional experience, and academic achievements. Students also face macro-level problems and stressors such as climate change, a divisive presidency, and now COVID-19 and its resulting economic downturn. These big events leave their marks on individual minds. Locke tells me that after 9/11, anxiety surpassed depression as the primary reason students sought treatment, and anxiety continues to increase today as the primary concern when students seek treatment.
CCMH data shows that in the 2018-2019 school year, 40% of students who sought services at counseling centers reported having thoughts of ending their life in the two weeks prior to their visits. But relying solely on student-self reports may be contributing to the alarming suicide rates we see in the media. Because when you look at the same data set, the counselors who actually work with those students report that suicidality is only a real presenting concern in 10% of them. Locke sees that discrepancy as a 75% reduction in the prevalence of suicidal ideation. “Students seem to be very willing to endorse items that reflect things being talked about in the culture at levels that are far above what a professional would evaluate to be the problem,” he says.
But that’s not necessarily a bad thing. In one sense, these high self-report rates are likely a positive reflection of 15 years of suicide prevention efforts that helped drive a greater cultural acceptance of seeking treatment for mental-health struggles. In 2003, the son of former Senator Gordon Smith from Oregon died by suicide in college. The next year, President George W. Bush signed the Garret Lee Smith Memorial Act, which provided $82 million in funding for college campus and tribal community suicide prevention efforts. Those efforts fall into three buckets: reducing the stigma surrounding suicide, increasing help-seeking behaviors, and training community members to identify people at risk and refer them for treatment. “If you look at it from a prevention perspective, if you spent 15 years trying to convince people at risk to seek help, and we didn’t see an increase, that would be concerning because it would mean all of those dollars were wasted and we’re not catching anybody new,” Locke says. “On the other hand, if you do see an increase in those numbers, maybe that means that you’re catching people who might possibly be at risk and getting them into treatment.”
Carruthers says that in suicide prevention, there are so many dots to connect that it’s like trying to drive at night without lights. But his territory, the state of New York, boasts the lowest suicide rate in the country. That’s partly to do with demographic factors: suicide rates are higher in states with larger rural populations, and New York inculdes a big urban one. New York City also benefits from the strictest gun laws. Half of all suicide deaths nationwide are by guns, but in New York, it’s less than a third. The fact that the state places 50th is also owed to his Suicide Prevention Office’s activities, which are up against structural challenges. “Health and behavioral healthcare systems — even mental-health services — have never been explicitly designed to reduce suicide deaths,” says Carruthers. “They’ve been designed to provide services for depression, or college students with depression or anxiety. And so it requires a whole reorientation for health and behavioral healthcare systems to systematically think, ‘Okay, how can we reduce deaths?’”
“Health and behavioral healthcare systems — even mental-health services — have never been explicitly designed to reduce suicide deaths.”
In the college prevention space, the New York Suicide Prevention Office is partnering with SUNY to figure out the unique needs of college students. That’s where Wentworth comes in. She says that on campuses, meaningful differences exist in health-seeking behaviors across demographic factors. For example, first-generation students who are people of color or from a lower socio-economic status, or both, start their four years with a certain level of anxiety about the college experience, but may be less likely to seek treatment because they already feel they’re being judged differently on campus. Also, as part of an online telecounseling initiative, Wentworth found that 40% of students who utilized the services identified as something other than heterosexual. “That is an opportunity for our clinicians to ensure that they are inclusive. Talking about romantic relationships with somebody that is asexual, that may not be part of the training of a typical counselor, but it is an opportunity for us to identify and understand that our population needs to be supported exactly as it is,” she says.
Telecounseling is a huge asset for the college-aged population. The New York Suicide Prevention Office and SUNY both promote the use of Crisis Textline, which is a free, confidential, 24/7 texting service for emotional crisis support, and can be reached by texting “HOME” to 741741. Carruthers says that more than 75% of its users are under 24 years old, 20% identify as Hispanic, and 12% identify as Black. “You would think people, if they’re in distress, would want to hear a human voice, or would want to have eye contact. But obviously young people — that’s kind of in their wheelhouse and their comfort zone,” he says. “The beauty of a text-based platform is you eliminate bias. No one’s judging you based on your looks and it may be a safe space for them to seek help.”
The Garret Lee Smith grants still serve as the primary mechanism for prevention funding for SUNY. The grants are awarded to fund six areas of prevention: educational seminars, crisis hotlines, informative materials for students, educational materials for their families, campus-community training to effectively respond to students with emotional difficulties, and infrastructure creation to link institutions with healthcare providers. But Wentworth says that not all campuses in the country possess the bandwidth to write or implement these grants. She once worked on a successful grant in Iowa and can attest to the fact that even if things go well, it can run its course for about three years, or whatever the grant period may be, and then the activities can dwindle and disappear. Though there’s robust evidence that these grants really do lower suicide rates, it’s difficult to sustain strategies and retain people to work on them with short-term funding solutions that fail to build or sustain long-term programmatic solutions.
Meanwhile, students seeking treatment continue to overwhelm counseling centers, and more are on their way. During my conversation with Locke, Brett Scofield, Ph.D., the associate director of the CCMH who joins our conversation, adds that students who display threat-to-self characteristics — such as having suicidal thoughts in the last two weeks — utilize 20% to 30% more counseling center services than students without those characteristics. And because one bucket of suicide prevention is identifying and refering students to services, more and more of them are coming in. As these centers try to serve more people, who represent more risk, who require more services, it becomes harder to serve the people who just need basic support and don’t represent risk yet. But while those students who only needed basic support wait in line, their mental-health challenges possess the potential to develop into crises. Locke calls it “The perfect storm.” As they explain this conundrum, I picture a snowball growing as it rolls down a hill. Then I think again of Wallack’s river, and it looks like it’s headed toward a waterfall.
Then, Locke tells me, the real problem is not that we have a suicide crisis on campuses. It’s that thanks to 15 years of suicide prevention efforts, more people than ever before are seeking services that have failed to grow with the demand. “If you spent 15 years trying to tell people to seek services, it would have been really smart to have grown services at the same time,” he says. “The new reality is we have been so successful at convincing people to seek services that now we need to respond and grow capacity. There’s really no way around it.”
“The new reality is we have been so successful at convincing people to seek services that now we need to respond and grow capacity. There’s really no way around it.”
Though that river looks daunting, I find comfort in knowing that there are people working to get to the top of it — to stand on that bridge and help the many students who struggle to find effective treatment before they reach a point of crisis. But people like Wallack and Carruthers and Locke are not the only ones standing on that metaphorical bridge. “Being human means that you experience distress. That’s a shared human experience,” Locke tells me. “So in a way, we’re literally in this together. We have to begin a process of de-pathologizing the experience of human distress so that we can all support each other, and then make sure the people who really need the treatment are able to get it.”
Back at the coffee shop in February, in my seat by the door, I wipe the last of my latte foam from my top lip. A man pulls off his wet beanie hat and places it on the counter while he orders. In the back, the industrial milk steamer screams. Two girls in the corner loudly discuss their shampoo and conditioner preferences, and an employee comes by to vacuum the Persian rug beneath our feet. Carruthers leans over our table to break through the noise and asks me to report on one more thing. “People are not alone,” he says. I watch as he stands, pulls on his dark winter coat, and heads back out into the pelting winter rain. I write that down. And circle it.
The spring 2020 “Reporting on Social Justice with Data” class at Syracuse University contributed Nationwide Emergency Department Sample (NEDS) data analysis.
