Taking an Integrated Approach to Suicide Prevention on Campus

This article on depression and suicide prevention is part
two of our Healthy Campus 2010 series, examining different
health indicators and discussing ways to help colleges and universities reach the targets set as part of the initiative’s
goals to eliminate health disparities and increase quality
and years of life.

College marks the beginning of a very different life for
most teens, with sudden autonomy and ever-increasing academic demands. While students are usually intellectually prepared for college, their emotional and social development
is not always so assured. In this context, it is perhaps not surprising that suicide is the second leading cause of death in college-aged students. The Healthy Campus 2010 initiative has several objectives related to depression and other aspects of students’ mental health, including reducing the rate of suicide attempts by college students from 1.5 percent to 0.5 percent.

At one time, the onus would probably have been on the campus counseling center to develop strategies to tackle this statistic. Yet recent figures show that relying on counseling centers to shoulder this burden alone would miss most of the students at greatest risk: more than 80 percent of students who commit suicide have never been to their college or university counseling center. Michael C. Klein, a clinical psychologist at New York University’s health center, and
co-principal investigator of the National College Depression Partnership, explains why this may be.

“I think it’s a combination of attitude and perceptions,” he states. “People’s ideas about what therapy is or does are
still shaped by stereotypes. You may realize that you have a problem but you may think there is a stigma attached to going to your counseling center. Additionally, a common mindset of depressed students is a generalized negative perspective –
the feeling ‘what’s the point, there’s nothing anyone can do to help’. It’s a very isolating experience.”

Klein believes that the best way to address depression on campus and be more successful at preventing student suicides is to focus on secondary prevention and take an integrated approach that involves the health center and student affairs working in tandem with the counseling center. The idea is to create gateways into the care system from services that are being used more frequently by students.

“We know for sure that students tend to come in for medical appointments at some point during the academic year,” Klein explains. “By instituting universal screening, we can identify
at-risk students in primary care and coordinate with a care manager at the counseling center.”

The College Depression Partnership recommends that these screenings are carried out at least once per academic year
to be effective, although if the system can tolerate it, there
is no reason why it cannot be integrated as part of every
visit. Their standard screen is the depression section of the Patient Health Questionnaire, or PHQ-9, originally published
by Pfizer, but freely available for use (subject to copyright restrictions) at http://www.phqscreeners.com. The advantage of using a standard measure is particularly clear when integrating services between departments: it gives a shared language that doesn’t rely on subjectivity, allowing health professionals to quickly explain the severity of a patient’s condition in one sentence.

Klein’s tips for starting an integrated approach to depression screening:

Get buy-in from senior leadership
Effective organizational change requires buy-in
from all involved departments at every level.
It’s not enough for clinical staff to see these changes as a priority; senior leadership need to understand its importance as well. This includes providing a health insurance requirement as a condition of enrollment and enforcing it.
Start small
Rather than saying “from tomorrow, we’ll screen
every student for depression”, administer the screen a couple of times, see the reaction and then if necessary change how you introduce it or when it’s performed and then try to implement it on a larger scale. Gradual change is much more likely to stick.
Recognize that screening doesn’t increase the prevalence of depression
Some health centers are concerned that if they start screening, suddenly they will have to manage scores of students diagnosed with depression in a short amount of time. “The prevalence of depression among students is between five to eight percent,” says Klein. “So if you screen a thousand people, there might be
50 that you need to do something about, and of those 50 maybe 10 or so you might have to do something about immediately.”
Establish a backup team for providers
Make sure there is a designated person from the counseling center or a psychiatric nurse who is available at all times as a consultant, so if there is someone who does need help immediately or the provider isn’t comfortable with handling a particular situation by themselves, the consultant can step in.
Ensure health promotions efforts feed back
into an integrated approach
Health promotions can be part of the mix, but raising awareness shouldn’t be the end goal – point students toward accessing care. www.ulifeline.org is an example of a great health promotions resource. It’s aimed solely at students and not only does it provide plenty of information, but students can complete an online self-evaluation and see the contact information for who they can talk to at their school right there on the screen.

The idea of an integrated approach to suicide prevention provides a good strategy to meeting the related Healthy Campus 2010 target of reducing student suicide by one percent. It also raises a bigger issue: that of cross-campus communication. "I think that one of the lessons learned from the Virginia Tech tragedy is the importance of communication between different parts of the school system," says Klein soberly. "Using an integrated approach and secondary prevention methods, you can identify someone with depression earlier in the syndrome and lower their mortality risk."

Michael C. Klein is Grants Administrator/Clinical Psychologist
at New York University’s health center, and co-principal investigator of the National College Depression Partnership (NCDP). You can read more about this national project at www.nyu.edu/shc/about/college_depression_partnership.html