turning violence inward: understanding and preventing campus suicide morton m. silverman, m.d....
TRANSCRIPT
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Turning Violence Inward: Understanding and Preventing
Campus Suicide
Morton M. Silverman, M.D.Senior Advisor, Suicide Prevention Resource Center
Senior Medical Advisor, The Jed Foundation
Clinical Associate Professor of Psychiatry, The University of Chicago
Violence on Campus: Prediction, Prevention, and Response
Columbia University Law School
New York, NY
April 4, 2008
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THE BIG PICTURE
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Trends in Suicidal Behavior1990-1992 vs. 2001-2003
National Comorbidity Survey and Replication
Suicide
1990-1992
14.8/100k
2001-2003
13.9/100k
Ideation 2.8% 3.3%
Plan .7% 1.0%
Gesture .3% .2%
Attempt .4% .6%
•9708 respondents, face-to-face survey, aged 18-54•Queried about past 12 months•No significant changes
Kessler, et al., Trends in Suicide Ideation, Plans, Gestures, and Attempts in the United States, 1990-1992 to 2001-2003- JAMAMay 25, 2005, Vol 293, No 20.
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National Comorbidity Study(1990-92; 15-54 yrs; 5877 respondents)
• LIFETIME IDEATION: 13.5%
• LIFETIME PLAN: 3.9%
• LIFETIME ATTEMPT: 4.6%
Kessler, et al.; AGP 56: 617-626, 1999
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Median Age of Onset (percentiles) (Kessler, et al., 2005)
DISORDER
25th
50th
75th
Major Depressive Disorder 19 32 44
Bipolar I-II 17 25 42
Panic Disorder 15 24 40
Generalized Anxiety Disorder 20 31 47
PTSD 15 23 39
Obsessive-Compulsive 14 19 30
ADHD 7 7 8
Alcohol Abuse/Dependence 18/19 21/23 29/31
Substance Abuse/Dependence 17/18
19/21 23/28
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Campus Suicide
• Suicide is the 2nd leading cause of death among campus students
- more teenagers and young adults die from suicide than from all medical illnesses combined
– 18 million enrolled students (over 9 million are ages 18 – 24)• Estimated 1,350 suicides annually (3 per day)
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COLLEGE and GRADUATE STUDENTS SPEAK
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ACHA-NCHA Findings
Within the last school year have you……………… 2000 2002 2004
Felt Very Sad 80.6% 82.0% 80.9%
Felt Depressed 44.4% 44.8% 45.1%
Been Dx’d with Depression 10.3% 11.8% 14.9%
Seriously Considered Attempting Suicide
9.5% 10.0% 10.1%
Attempted Suicide 1.5% 1.6% 1.4%
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ACHA-NCHS Findings
Within the last school year have you… Fall, 2006
Felt Very Sad 77.8%
Felt so Depressed it was difficult to fxn 42.2%
Been Diagnosed with Depression 14.5%
Seriously Considered Attempting Suicide
9.4%
Attempted Suicide 1.4%
Source: American College Health Association (2007)
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ACHA-NCHA Survey: Fall 2006
American College Health Association. American College Health Association - National College Health Assessment (ACHA-NCHA) Web Summary. Updated August 2007. Available at http://www.acha-ncha.org/data_highlights.html. 2007.
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ACHA-NCHA Survey: Fall 2006
American College Health Association. American College Health Association - National College Health Assessment (ACHA-NCHA) Web Summary. Updated August 2007. Available at http://www.acha-ncha.org/data_highlights.html. 2007.
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ACHA-NCHA Survey: Fall 2006
American College Health Association. American College Health Association - National College Health Assessment (ACHA-NCHA) Web Summary. Updated August 2007. Available at http://www.acha-ncha.org/data_highlights.html. 2007.
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ACHA-NCHA Survey: Fall 2006
American College Health Association. American College Health Association - National College Health Assessment (ACHA-NCHA) Web Summary. Updated August 2007. Available at http://www.acha-ncha.org/data_highlights.html. 2007.
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UC Berkeley Graduate Student Survey - April, 2004
In the last 12 months:
• 45.3% experienced an emotional stress-related problem that significantly affected their well-being and/or academic performance
• 67% felt overwhelmed; 54% felt so depressed that it was difficult to function; 9.9% seriously considered suicide
• females were more likely to report feeling hopeless, exhausted, sad, or depressed
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Why Don’t Students in Need Seek Help?
> 25% of depressed young adults express “intent not to accept a diagnosis of depression” due to:
• Negative beliefs and attitudes toward depression causation and treatment
• Beliefs that depression should be hidden from family, friends, employers
• Lack of past helpful treatment experiences
Van Voorhees et al., Annals of Family Medicine, 2005
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Chris Brownson, [email protected]
The University of Texas at Austin
>26,000 undergraduate and graduate students70 colleges & universities
Web-based, anonymous, 25% response rate
Selected Data from National Research Consortium of
Counseling Centers in Higher Education’s Study on The Nature of College Student
Suicidal Crises
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Undergrad
N=910
Recent family problems 41.96
Recent academic probs 37.57
Recent loss of romantic relationship
36.00
Recent financial problems 34.53
Intentional self-harm (non-suicidal)
27.67
Recent loss of friendship 27.56
Recent death of friend/family
16.42
Sexual Assault 9.22
Recent Trauma 8.32
Recent conflict regarding sexual orientation
6.75
Recent suicide of friend/family
5.74
Relationship violence 5.62
Graduate N=411
Recent financial problems 35.64
Recent academic probs 30.45
Recent family problems 27.97
Recent loss of romantic relationship
26.98
Recent loss of friendship 15.84
Intentional self-harm (non-suicidal)
13.86
Recent death of friend/family
12.13
Recent Trauma 6.93
Relationship violence 4.95
Recent conflict regarding sexual orientation
4.46
Sexual Assault 3.96
Recent suicide of friend/ family
3.47
Which of the following occurred before seriously considering a suicide attempt in
the past 12 months
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Undergrad
N=910
Emotional / physical pain
64.72
Romantic relationship problems
58.81
Impact of wanting to end my life
49.37
School problems 43.17
Friend problems 43.00
Family problems 42.51
Financial problems 31.10
Showing others the extent of my pain
30.05
Punishing others 13.61
Alcohol / drug problems
10.13
Sexual assault 7.82
Relationship violence 5.60
Graduate
N=411
Emotional / physical pain
65.26
Romantic relationship problems
52.63
Impact of wanting to end my life
46.56
School problems 45.38
Financial problems 34.38
Family problems 34.30
Friend problems 28.12
Showing others the extent of my pain
27.03
Punishing others 8.29
Alcohol / drug problems
6.56
Relationship violence 5.85
Sexual Assault 5.80
Events rated as having a large impact on seriously considering suicide in the past 12
months
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WHAT THE EXPERTS SAY
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2006 AUCCCD Survey (367 campuses)
• 9% of enrolled students seen
• 25% are on psychiatric medications (17% in 2000; 9% in 1994)
• 40.1% of clients had severe psychological problems, 8.3% have impairments so severe that they can’t remain in school or can only do so with extensive psychological help
• 2,368 hospitalizations for psychological reasons• 142 suicides - only 10% current/former clients
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2007 AUCCCD Survey(272 campuses)
• 8.5% of enrolled students seek counseling
• 91.5% believe greater # of students with severe psychological problems
• 49% of clients have severe psychological problems
• 1,981 hospitalizations for psychological problems• 105 suicides - 21.8% were former/current clients
• Post VTU: 30.5% report policy revisions re: communicating with parents about students in crisis
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Mental Illness on CampusContributing Factors to Increased Demand for Services:
– early diagnosis; better treatment
– overall lessening of social stigma re: mental illness
– greater adjustment stress of diverse student population
– limited access to off-campus services (high cost of private care; insufficient insurance)
– increased stress associated with the 24/7 pace of campus life (academic, social, etc.)
– adjusting to a world of terrorism; economic uncertainty; political instability
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Campus Suicide• Suicide is the 2nd leading cause of death among
college students– Majority of students who die by suicide (≈80%) have never
been seen by the counseling service– Only ~14% of students report receiving suicide prevention
information from their colleges
• Students at risk: - Those with pre-existing mental illness - Those that develop mental illnesses while in college - Those who lack coping and other life skills (or stop their treatments
while away from home)
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Foreign Students
• May be at increased risk if:
- shy
- lacking social skills
- lacking a support network
- having language/communication problems
- having financial/academic difficulties
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Student Challenges - Summary
• Finances - living expenses; health insurance
• Social Life - dating; partnerships
• Marital Life - spousal job; postponing children?
• Race/Ethnicity/Gender Issues - inequalities; “glass ceiling”
• Developmental Issues - separation; individuation; ethical & moral principles; commitments; being self-reliant; working alone
• Social/Coping Skills - working closely with faculty; peers
• Dissertation Woes• Transitioning Into/Out of School - support; identity
• Career Identity - academia vs. “real world”
• Getting a Job• Acculturation/Assimilation - international students; language
• Psychiatric Illnesses - including substance use and abuse
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WAIT A MINUTE!
ARE CAMPUSES TOXIC?
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Suicidal ideation and behavior among high school students by category and sex*,U. S., 2005
0
5
10
15
20
25
Seriously consider suicide Suicide plan Attempted suicide^ Suicide attempt withmedical
Category
Percentage of all students
FemaleMaleTotal
Source: CDC Youth Risk Behavior Survey* During the 12 months preceding the survey^One or more times
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What is the greatest precipitating factor among youth suicide?
Among all 18-24 year olds who died by suicide:• Almost 50% were due to intimate partner problems• Other reasons included:
– legal/criminal (20%), – financial (12%), – relationship problem with friend or family (13%)
• Important to attend to youth who have had a recent life event (relationship problem), who are depressed, and a tendency towards impulsiveness, especially within 2 weeks of life event
[Source: Harvard NVISS Pilot 2001]
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What do we know about impulsiveness of youth suicide?
Among all 18-24 year olds who died by suicide:
• 1 in 5 occurred on the same day as an acute life crisis• 1 in 4 occurred within 2 weeks
• Approx. 46% occurred either on the same day or within 2 weeks of a life crisis
• Important because impulsiveness of suicide– Crucial to provide immediate help– Develop means for students in crisis to cope, provide safe
haven, ensure support system in place
[Source: Harvard NVISS Pilot 2001]
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Truisms
Campuses are not therapeutic communities
-therefore must acknowledge limits on services and resources
You can’t treat a public health problem out of existence
- therefore solution is not just to increase counseling center staff and campus police force ad infinitum
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Best Practices for Campus Prevention Programs
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What Are We Trying to Do?
• Disease Prevention
prevent self-injurious behaviors • Health Promotion
promote resiliency promote life-enhancing skills promote health maintenance
DIFFERENT GOALS REQUIRE DIFFERENT APPROACHES
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Suicide is an outcome that requiresseveral things to go wrong all at onceSuicide is an outcome that requiresseveral things to go wrong all at once
BiologicalFactors
FamilialRisk
SerotonergicFunction
NeurochemicalRegulators
Demographics
Pathophysiology
ImmediateTriggers
Access To Weapons
SevereDefeat
MajorLoss
WorseningPrognosis
ProximalFactors
Hopelessness
Intoxication
ImpulsivenessAggressiveness
NegativeExpectancy
Severe Chronic Pain
PredisposingFactors
Major PsychiatricSyndromes
SubstanceUse/Abuse
PersonalityProfile
AbuseSyndromes
Severe Medical/Neurological Illness
Public HumiliationShame
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Evidence-based Interventions • Community education/awareness
– Safety is an issue
• Community collaboration around suicide prevention
• Social marketing– Destigmatizing help-seeking for mental health problems– Increasing social support– Strengthening social networks– Honor and support responsible help-seeking
Guild PA, Freeman VA, Shanahan E. Promising Practices to Prevent Adolescent Suicide: What We Can Learn From New Jersey. Cecil G Sheps Center For Health Services Research. Univeristy of North Carolina at Chapel Hill. 2004.
Knox, K, et al., Risk of Suicide and related adverse outcomes after exposure to a suicide programme in the US Air Force:cohort study. British Medical Journal, December 13, 2003.
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Evidence-based Interventions
• Gatekeeper training
• Peer helper programs
• Resiliency/coping/problem solving skill building programs– Juvenile justice– Homeless youth
Guild PA, Freeman VA, Shanahan E. Promising Practices to Prevent Adolescent Suicide: What We Can Learn From New Jersey. Cecil G Sheps CenterFor Health Services Research. Univeristy of North Carolina at Chapel Hill. 2004.
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Evidence-based Interventions
• Restricting availability of means
• Improved surveillance
• Postvention for the bereaved
• Domestic violence prevention
• Training the media
Guild PA, Freeman VA, Shanahan E. Promising Practices to Prevent Adolescent Suicide: What We Can Learn From New Jersey. Cecil G Sheps CenterFor Health Services Research. Univeristy of North Carolina at Chapel Hill. 2004.
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Evidence-based Interventions
• Access to effective treatment of mental health problems– Training for primary care providers– Training for mental health providers– Increased availability of mental health treatment– Increased affordability of mental health treatment– Linking suicide prevention programs with treatment
services– Appropriate follow-up after ED treatment
• Alcohol and substance abuse programsGuild PA, Freeman VA, Shanahan E. Promising Practices to Prevent Adolescent Suicide: What We Can Learn From New Jersey. Cecil G Sheps Center for Health Services Research. Univeristy of North Carolina at Chapel Hill. 2004.
Knox, K, et al., Risk of Suicide and related adverse outcomes after exposure to a suicide programme in the US Air Force:cohort study. British Medical Journal, December 13, 2003.
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What Changes Need to Happen on Campus to
Protect and Save Lives?
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Five minutes before the party is not the time to learn to dance!
Snoopy 1964
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Major Barriers To Progress• Lack of awareness and support among senior administrators
• Stigma (lack of help-seeking culture)
• No single person in charge of wellness
• Departmental and programmatic “silo effect”
• Lack of urgency in dealing with highest risk students
• Legal “blurs” - FERPA; HIPAA
• Fears around liability
• Insurance policy weaknesses (lack of parity; discrepancies; inadequacies)
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Far Side by Gary Larson
Duty and Liability
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Issues to Consider Relevant to Effective Prevention
• Knowledge of Effective Prevention Programs
• Comprehensive Needs Assessment – Community Readiness and Support – Resources for implementation – Investment in current practice– Population needs and access issues
• Fear of Evaluation
• Sustainability
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Building an Effective Safety Net
• Create a new, senior-level administrative position to oversee student health and well-being
• Ensure coordination and communication across various departments and organizations on campus
• Prioritize mental health promotion and suicide prevention when allocating resources
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Building an Effective Safety Net II
• Organize a cross-institutional mental health task force or committee, which includes students, to examine mental health issues and services
• Survey all students to understand the landscape of mental health issues on campus, including students’ knowledge and perception of campus mental health services (needs assessment)
• Ensure that policies and procedures emphasize the best interests of the students
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Building an Effective Safety Net III
• Clarify and/or institute transparent policies regarding parental notification and leave of absence/re-entry
• Ensure appropriate training regarding exceptions to confidentiality
• Address perceived legal barriers that may affect how to approach students with emotional issues
• Encourage the creation and involvement of a student mental health advocacy group
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Policy Implications
• Judicial: Removal for serious suicidal ideation – be prepared to remove a lot of people.
• Importance of academics: Recent academic problems is second most likely event to precede SI, “school problems” ranked 4th in contributing to SI.
Therefore, provide motivation to follow through on treatment in exchange for continuing/returning to school.
• Need to find a way to help students without punishing them academically.
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Take Home Messages
• Suicidal ideation is not uncommon.
• Develop educational campaigns to encourage help-seeking for those with mental health issues and suicidal thinking.
• Educate peers in addition to others on campus about how to respond to those with mental disorders and suicidal ideation.
• Professional services must get word out that they are helpful and available and confidential.
• Focus on life skills and community responsibilities.
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Comprehensive Prevention Approach
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Jed Foundation/SPRCComprehensive Approach
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National Suicide National Suicide Prevention LifelinePrevention Lifeline
• National toll free number 1-800-273-TALK
• Calls routed automatically to the closest of 125 networked crisis centers
• Partners with NASMHPD, Rutgers & Columbia Universities
• Evaluation studies published June, 2007 in Suicide and Life-Threatening Behavior
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QuickTime™ and a decompressor
are needed to see this picture.
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Another Truism
Suicide Prevention is Violence Prevention
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Jed Foundation/EDCComprehensive Approach
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Promote Social Networks
Goal: To promote relationship-building between students and a sense of community on campus
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Promote Social Networks
• Reduce student isolation and promote feeling of belonging
• Encourage the development of smaller groups within the larger campus community
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Develop Life Skills
Goal: To promote the development of skills that will assist students as they face various challenges in both school and in life
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Develop Life Skills
• Improve students’ management of the rigors of college life
• Equip students with tools to recognize and manage triggers and stressors
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Increase Help-Seeking Behaviors
Goal: To educate students about mental health and wellness, encourage seeking appropriate treatment for emotional issues, and reduce the stigma surrounding mental illness and seeking help for suicidal thoughts and behaviors
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Increase Help-Seeking Behaviors
• Stimulate campus-wide cultural change that de-stigmatizes mental health problems and removes barriers to getting help
• Enhance accessibility of mental health services
• Educate students about the signs and symptoms of suicide and mental illness and where to go to get help
• Provide online self-assessment tools
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Groundbreaking pro-social campaign with mtvU launched in November 2006
Seeks to reduce stigma and increase help-seeking through on-air, online and
on-campus components
Campaign built on original quantitativeand qualitative research commissioned by
The Jed Foundation and mtvU
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Identify Students At Risk
Goal: To identify those students who may be at risk for suicide through the use of outreach efforts, screening, and other means
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Identify Students At Risk• Include questions about mental
health on medical history form• Provide gatekeeper training to
recognize/refer distressed or distressing students
• Create interface between disciplinary process and mental health service
• Screen to identify high-risk or potentially high-risk students
• Establish cross-department case management committee
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Transition Years
• Partnering with the American Psychiatric Foundation (philanthropic arm of the American Psychiatric Association)
• Outreach project to high school seniors, college freshmen, and their parents
• Promote the smooth, safe, and healthy transition from high school to college
• Key components will include a literature review, survey of parents, media campaign, parents resource guide, and student “survival” guide
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Provide Mental Health Services
Goal: To accurately diagnose and appropriately treat students with emotional problems, including assessing and managing suicide risk
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Provide Mental Health Services
• Utilize internal university resources to complement existing services
• Engage in prevention/outreach• Create linkages to community
resources• Train mental health providers
to identify/treat suicidal risk• Refer cases as appropriate• Institute policies and
procedures • Train personnel on
confidentiality, notification, and other legal issues
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UDBD
• Understanding Depressive and Bipolar Disorders (www.UDBD.org)
– Free Web site designed to help college counseling and other healthcare professionals learn to better distinguish between unipolar depression and bipolar disorder
– Provides information about these disorders and the key questions to ask when evaluating students
– Includes useful tools such as tips for differentiating among types of depression and case studies
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Clinical Training Workshops
• Assessing and Managing Suicide Risk tailored for college mental health professionals– Originally developed by AAS and SPRC– One-day training includes in-depth discussion, journal
writing, video clips, and small group exercises; participants also assigned pre-workshop reading
– Delivered by an expert trainer
• Hundreds of college mental health professionals have been trained so far
• Currently undergoing formal evaluation
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Crisis Management Procedures
Goal: To develop policies that promote the safety of distressed or suicidal students and respond to crises, including suicidal acts, using institutionalized processes.
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Crisis Management Procedures
• Establish and follow policies (e.g., parental notification, medical leave/re-entry) and protocols that respond to suicide attempts and other high-risk behavior
• Respond with a comprehensive postvention program
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Framework
Document guides the process
of creating campus-wide
protocols that address:– Safety for at-risk students
– Emergency contact notification
– Leave of absence/re-entry
www.jedfoundation.org/framework.php
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Restrict Access to Lethal Means
Goal: To limit access to potential sites, weapons, and other agents that may facilitate dying by suicide
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Restrict Access to Lethal Means
• Limit access and/or erect fences on roofs of buildings
• Replace windows or restrict size of window openings
• Restrict access to chemicals
• Prohibit guns on campus
• Control access to alcohol and other drugs
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Legal Roundtable
• Fear of liability is affecting decision-making around students in distress or at risk for suicide
• Need for a clear, concise resource for college health/mental health professionals, administrators, and legal counsels
• One-day roundtable held in Spring 2007 brought together leading experts in higher education law, as well as campus personnel, to discuss issues of law and liability as they relate to mental health
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Build
ing
Campu
s Saf
ety
Net
Increase Evidence Base Pilot Program ● Framework ● ULifeline Clinical Workshop
Strengthen Campus Services ULifeline ● Framework ● CampusCare Clinical Workshop ● UDBD.org
Raise Awareness & Decrease Stigma ULifeline ● mtvU Pro-Social Campaign
APA Collaboration ● Outreach
Promote Help-Seeking ULifeline ● mtvU Pro-Social Campaign APA Collaboration
Decrease Emotional DistressReduce Suicidal Behavior
TJF
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Comprehensive Framework: Mental Health and Suicide Prevention
Areas of Strategic Intervention Individual Group Institution Community
State/Federal Policy
Identify students at risk
Increase help-seeking behaviors
Provide mental health services
Establish and follow crisis management procedure
Restrict potentially lethal means
Develop life skills
Promote social networks
Adapted from Potter et al, 2004 and DeJong & Langford, 2002
Program and Policy Levels (social ecological framework)
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Contact Information
Joanna Locke, MD, MPHProgram Director, The Jed Foundation
583 Broadway, Suite 8BNew York, NY 10012
www.jedfoundation.org