Written By: Jeffrey Hayes, Psy.D.
Suicide represents a significant public health concern. More than 45,000 people in the United States die by suicide each year (Centers for Disease Control and Prevention (CDC), 2018). Approximately 7% of U.S. citizens have experienced the death of a friend or family member due to suicide (Berman, 2011). In addition to the obvious emotional toll of suicide for individuals, families, and communities, suicide behavior (i.e., any action intended to take one’s own life) results in more than $70 billion in medical and work-related costs in the U.S. every year (CDC, 2018).
Suicide is the second leading cause of death among traditionally-aged college students in the U.S., with a prevalence of approximately 14 deaths per 100,000 persons (CDC, 2018). Some studies, however, indicate that death by suicide is less common among college students than similarly-aged peers (Schwartz, 2013), due in part to lower rates of gun ownership. Research suggests that, each year, 10% of college students seriously consider suicide and roughly 1.5% engage in suicide behavior (Wilcox et al., 2010); these rates have increased slightly every year since 2010 (Center for Collegiate Mental Health, 2019). Fortunately, effective programs have been developed whose goal is to direct at-risk college students to campus counseling centers to receive psychological help (Garlow et al., 2008; Haas et al., 2008). Inherent in such efforts is the recognition that university counseling centers serve high-risk students. Students attended more than a million sessions of psychotherapy on U.S. campuses during the 2016-2017 academic year (LeViness, Bershad, & Gorman, 2017), and compared with students in general, those who seek psychotherapy are more depressed, hostile, and anxious. They are also three times more likely than their classmates to report high levels of suicide ideation and five times more likely to have made a previous suicide attempt (McAleavey et al., 2012). A survey of counseling center directors indicated that, on average, four clients per year in each center engage in suicidal behavior (LeVinnes et al., 2017). It has been estimated that the relative risk of suicide for counseling center clients is 18 times greater than for students at large (Schwartz, 2006).
Although many studies have identified factors associated with suicide ideation among college students, fewer studies have examined actual suicide behavior in this population, and virtually no research has investigated specific risk factors for students receiving psychotherapy. The difficulties associated with accurate prediction of low frequency health events such as suicide have been well-documented (e.g., Kessler, Borges, & Walters, 1999). Nonetheless, given the serious consequences of suicide behavior, we believe that empirical data that help psychotherapists determine which clients possess elevated risk for suicide behavior would be of value to prevention and intervention efforts. It may be most efficient, clinically, to identify single, readily observed variables associated with suicide behavior. Identifying only individual variables, however, may obscure less obvious types or classes of clients who present with suicidal thoughts but have varying degrees of risk for subsequent suicide behavior while in treatment.
Risk factors for suicide behavior may be classified in terms of current psychological distress, chronic mental health problems, and demographic factors. In terms of current psychological distress, prevalent theories regarding suicide behavior implicate factors such as hopelessness, perceived burdensomeness to others, and feelings of marginalization and loneliness (Chu et al., 2017). In addition, research suggests that disorders that are characterized by highly affective, impulsive, and aggressive symptoms tend to be positively associated with suicide behavior in the general population. Specifically, anxiety disorders, including generalized anxiety disorder and social phobia, have been found to be predictive of suicide behavior (Bernal et al., 2007; Glenn & Nock, 2014; Kessler et al., 1999; Sareen et al., 2005). Depression is also linked to higher rates of suicide behavior (Baalbaki, 2016), and it is typically the leading risk factor for suicide behavior among all mental health diagnoses (Bernal et al., 2007). Substance abuse also is predictive of suicide behavior (Johnson, Oxendine, Taub, & Robertson, 2013). Additional current distress-related risk factors among college students, in particular, include academic concerns (Baalbaki, 2016), hostility (Brent & Melhem, 2008), hopelessness (Kisch, Leino, & Silverman, 2005), interpersonal problems, and family concerns (Westefeld et al., 2005).
With regard to chronic mental health problems, suicide behavior is more common among college students who have been hospitalized for psychological reasons (Qin & Nordentoft, 2005), who have engaged in suicide behavior previously (O’Connor et al., 2013), or who have engaged in non-suicidal self-injury (Klonsky, May, & Glenn, 2013). It may be that young adults whose previous psychological problems were serious enough to warrant psychiatric hospitalization, along with those who have a history of self-harming behavior, experience an increased desperation, or numbness, that leads them to engage in more extreme self-injurious behavior in the form of suicide attempts.
In terms of demographic variables, gender, race, and sexual orientation have been found to be associated with suicide risk in the general population. In particular, males die by suicide more often than women, although women engage in suicide behaviors more frequently than men (Nock et al., 2008). Furthermore, non-Hispanic Whites (Nock et al., 2008) and non-heterosexuals (Figueiredo & Abreu, 2015) have been identified as having elevated risk for suicide behavior. The extent to which cultural factors predict suicide behavior in college students is not known, although research has demonstrated that students with disabilities tend to have more suicide ideation than students without disabilities (Coduti, Hayes, Locke, & Youn, 2016).
In addition to identifying risk factors, research points to several protective factors that decrease the risk of suicide behavior. In the general population, these include the importance of religion or spirituality in an individual’s life (Simonson, 2008), and among college students, living with other people rather than alone (Schweitzer, Klayich, & McLean, 1995).
