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2. The Healthy Minds Network Webinar Series Session #22, September 2017
Understanding and Addressing Suicide on College and University Campuses
The Healthy Minds Network Webinar Series
Session #22, September 2017

3. Welcome and About The Healthy Minds Network
The Healthy Minds Network Research-to-practice network based at University of Michigan Public health approach to mental health among young people HMN Research-to-Practice Objectives: (1) produce knowledge (research) (2) distribute knowledge (dissemination) (3) use knowledge (practice)

4. HMN Announcements Currently enrolling schools for HMS 2017-18
healthymindsnetwork.org/participate
Next Webinar: Mindfulness pt. 2
Later Fall—stay tuned!

5. Today’s Webinar
September 2017: Healthy Minds Campus Suicide Awareness Series
Understanding and addressing suicide on college and university campuses
Presenters
Sarah Ketchen Lipson, PhD, EdM
Maggie Mortali, MPH
Marian Trattner, MSW
Nycole Fassbender

6. Population-Level Data on Suicidal Thoughts and Behaviors
Sarah Ketchen Lipson, PhD, EdM
The Healthy Minds Study

7. HMS Data About HMS 2007-2017 2016-2017 academic year >160 campuses
>175,000 students
academic year
54 campuses
~48,000 students

8. Prevalence of Suicidal Ideation, Plans, & Attempts

9. Suicidal Ideation & Comorbidities

10. Suicidal Ideation Over Time
No SI, time 2 (2 years later)
SI, time 2 (2 years later)
No SI, time 1
94% 6%
SI, time 1
65%
35%
Zivin, K., Eisenberg, D., Gollust, S., & Golberstein, E. (2009). Persistence of mental health problems and needs in a college student population. Journal of Affective Disorders.

11. Academic Impairment
Eisenberg et al. (2007). Prevalence and correlates of depression, anxiety, and suicidality among university students. American Journal of Orthopsychiatry.
Missing academic obligations because of mental health, past 4 weeks = 18% undergraduates, 14% graduate students
Mental or emotional health difficulties affected academic performance, past 4 weeks = 44% undergraduates, 41% graduate students

12. Suicidal Ideation by Gender & Sexual Identity
NO SIGNIFICANT VARIATIONS BY RACE/ETHNICITY

13. Past-Year Suicidal Ideation, Plans, & Attempts: Undergraduate vs
Past-Year Suicidal Ideation, Plans, & Attempts: Undergraduate vs. Graduate Students

14. How do rates of suicidal ideation vary across academic disciplines?

15. Variations across HMS Campuses
Explore other variations, risk, and protective factors related to suicidality at the HMN Data Interface: data.healthymindsnetwork.org

16. Past-Year Mental Health Service Use among Students with Suicidal Ideation

17. Where do students with suicidal ideation seek mental health services?

18. Treatment Adequacy
Eisenberg, D., & Chung, H. (2012). Adequacy of depression treatment among college students in the United States. General Hospital Psychiatry.
Among students with depression and suicidal ideation 
Any antidepressants, past year = 37%
Any counseling, past year = 47%
Antidepressants + counseling, past year = 29%
Antidepressants or counseling, past year = 55%
Minimally-adequate treatment (antidepressants for 2+ months, 7+ counseling sessions) = 34%

19. Barriers to Help-Seeking
Downs, M., & Eisenberg, D. (2012). Help seeking and treatment use among suicidal college students. Journal of American College Health.
“I prefer to deal with issues on my own,” endorsed by ~75% of suicidal students may indicate a propensity toward self-reliance, discomfort talking about personal problems, or other factors
Top 10 barriers all pertained to personal attitudes or circumstances and most structural or institutional factors (e.g., convenience and perceptions about services) ranked in bottom half

20. Facilitators of Help-Seeking
Downs, M., & Eisenberg, D. (2012). Help seeking and treatment use among suicidal college students. Journal of American College Health.
Those with any past year treatment use asked to check any “important reasons” why they received services
67% of suicidal respondents said that they sought services on their own
Among the one-third who did not say they “decided on their own”, 89% reported they received help due to influence from others
8% mandated to treatment by campus staff, suggesting that campus policies designed to identify at-risk students may be important factors in service use for some individuals

21. Past-Year Informal Help-Seeking for MH among Students with Suicidal Ideation

22. Maggie Mortali, MPH Director, Interactive Screening Program (ISP)
American Foundation for Suicide Prevention

23. Reducing Barriers to Mental Health Care among College Students
Maggie G. Mortali, MPH
Director, Interactive Screening Program (ISP)

24. Scope of the Problem
Undocumented and Untreated Mental Health Conditions
Only 26.6% of college students with major depression receive mental health treatment1
Only 4% of college students with a substance use disorder receive treatment2
Over 50% of college students who seriously consider attempting suicide do not receive professional help3
Over 85% of college students who die by suicide had not sought help at their college counseling center4
Suicide is a leading cause of death among college and university students in the United States. Each year, it is estimated that approximately 1,100 college students die by suicide. In addition, many other college and university students have suicidal thoughts and attempt suicide.
Research shows that each year, 1 in 3 college students report “feeling so depressed that it was difficult to function,” and 1 in 10 said they had “seriously considered attempting suicide” That same study found that despite the availability of free or low-cost mental health services on most college and university campuses, only 27% of depressed students were receiving any type of mental health treatment
Because untreated or inadequately treated mental health conditions are the leading cause of suicide in adolescents and young adults, these findings point to college students as an at-risk population for intentional self-harm behavior. So regardless of the frequency with which college students die by suicide, there is convincing evidence that those who are most at risk for suicide have low rates of utilizing campus mental health services.
References:
(American College Health Association [ACHA], 2015)
(Gallagher, 2014)
Eisenberg, Hunt, & Speer (2012); ACHA (2015)
Eisenberg, Hunt, Speer, & Zivin (2011)
Drum (2009)
Gallagher (2015)

25. Scope of the Problem Significant Barriers to Help-Seeking
Ambivalence about treatment need or effectiveness1
Fear of involuntary removal or mandatory leave-of-absence policies2
Perceived stigma or discrimination of mental health conditions3
Negative attitudes toward mental health treatment (sometimes rooted in past experiences)4
Cultural beliefs that equate mental health problems with weakness5
1. Arria et al. (2011)
2. Appelbaum (2006); Haas (2010)
3. D'Amico, Mechling, Kemppainen, Ahern, & Lee (2016)
4. Haas (2010)
5. Haas (2010)

26. Interactive Screening Program
ISP is an online screening program utilized by college and university counseling centers to connect students to available mental health services before crises emerge.
To implement the program, each counseling center receives a customized ISP Website where students anonymously:
Take a questionnaire for stress, depression, and other mental health concerns
Receive a personalized response from a campus counselor
Exchange messages with the counselor about available resources and services.
ISP serves as a convenient and safe way for individuals to connect with an experienced, caring mental health professional provided by the organization. Offering individuals a way to anonymously communicate with a counselor about available service options allows them to address their mental health concerns before they escalate. Reach individuals who are not engaging in mental health services – provide a safe & secure way for individuals to connect with available services - Connect with individuals in a way that reduces barriers to care

27. Key Principles of ISP
The following principles reduce barriers to care and encourage students to engage in available mental health services  
Participant Anonymity
Personalized Contact with campus counselors
Connection to Participants’ Experience
Interactive Engagement
The following principles reduce barriers to care and encourage people to engage in available mental health services
Participant Anonymity: Participants feel more comfortable admitting their concerns and asking questions.
Personalized Contact with Counselors: Instead of computerized feedback, participants receive a response to their questionnaire from a mental health professional.
Connection to Participants’ Experience: Counselors make participants feel validated by responding to their experience rather than suggesting diagnoses or emphasizing the “need” for treatment.
Interactive Engagement: Participants and counselors work together to lessen participants’ concerns about seeking services.
“ …If it weren’t for the anonymity in this process, I probably wouldn’t be considering any type of help right now.”

28. How the Program Works
1. ISP Website home page outlines the program procedures
2. Participants create a website login allowing for complete anonymity.
3. Participants take the Questionnaire.
4. Counselors review the participants’ Questionnaire and post a response on the ISP website.
5. Participants exchange messages with the counselor – ask questions, get recommendations and support for engaging in mental health services
1. ISP Welcome Page describes the program, provides mental health resources, and emergency contact information
2. User ID/PW gives individual a safe and secure way to connect and learn about services
3. The Questionnaire is based on the PRIME-MD Patient Health Questionnaire and contains the nine-item Patient Health Questionnaire (PHQ-9);
Measures of intense emotional distress (i.e., anxiety, hopelessness)
Alcohol and drug use;
Current suicidal thoughts/behaviors/plans and past suicide attempts;
Current mental health treatment;
The Questionnaire is not a tool for diagnosis, rather place to begin conversation
Gives counselor a sense of what individual is currently going through
Gives individual opportunity for reflection and way to begin considering getting help for indicated problems
After participant submits their questionnaire...
System classifies participants’ risk status using a defined algorithm based on their answers.
System generates notification to designated ISP counselor/s with participant’s tier and link to ISP website
4. Counselors review and respond to the participants’ questionnaires. Offers empathy, connection, care, concern using a personalized response using the tier-specific template
5. Participant replies to Counselor’s Response by submitting a message on ISP’s Dialogue platform - Opportunity to get questions answered and receive specific recommendations for services and resources
Reassurance, guidance, support from caring mental health professional
“…I was finally able to let someone know how badly I was feeling without any judgment and in a confidential manner.”

29. Participant Level of Distress
16,285 (N=16,285) undergraduate students submitted a questionnaire
Based on participants questionnaire answers:
11,620 (71.4%) indicated high levels of distress
52.5% indicated suicidal thoughts, plans and/or behaviors
4,620 (28.4%) indicated moderate levels of distress
45 (0.3%) indicated low levels of distress

30. Participant Engagement
14,435 (88.6%) of participants logged back in to the ISP website to view the counselors’ response
5206 (32.0%) of those participants exchanged dialogue messages with the counselor
Of the participants indicating high levels of distress:
10,502 (90.3%) logged back in to the ISP website to view the counselors’ response
4214 (40.1%) of those participants exchanged dialogue messages with the counselor

31. Conclusion
Proactive approach to offering help to students who experience barriers to care
Encourages and offers personalized support for students to connect to mental health services
Adaptable to counseling center’s goals, mission, and resources
Part of comprehensive suicide prevention and mental health promotion strategy
“ …validated my feelings of being overwhelmed/burnt out, and made me feel more ok with seeking help”

32. Bystander Intervention Specialist The University of Texas at Austin
Marian Trattner, MSW
Bystander Intervention Specialist
The University of Texas at Austin

33. September 2017
Understanding and addressing suicide on college and university campuses
Healthy Minds Network
Marian e. Trattner, MSW
Bystander Intervention Specialist, The University of Texas at Austin

34. About Us UT Austin Counseling and Mental Health Center (CMHC)
52,000 students
Flagship university in Texas
Top 6% rule
Counseling and Mental Health Center (CMHC)
Housed in Division of Student Affairs
Short term counseling, multidisciplinary staff
See about 5,600 students/year (53% increase in past 5 years)
Prevention and Outreach Department
Voices Against Violence Program (14 years)
Be That One. Promote Mental Health. Prevent Suicide (9 years)
BeVocal: The Bystander Intervention Initiative of UT Austin (3 years)
Well-being in Learning Environments Initiative (2.5 months - Grant funded)

35. Public Health Approach
The Strategic Planning Approach
SPRC’s strategic planning approach to suicide prevention includes the following six steps.
Step 1. Describe the problem and its context. Use data and other sources to understand how suicide affects your community and describe the problem and its context.
Step 2. Choose long-term goals. Identify a small set of long-term goals (e.g., reduce the suicide rate among a particular group).
Step 3. Identify key risk and protective factors. Prioritize the key risk and protective factors on which to focus your prevention efforts.
Step 4. Select or develop interventions. Decide which combination of strategies (e.g. increase connectedness, increase access to evidence-based treatments) best address your key risk and protective factors and will be a part of your comprehensive approach to suicide prevention. Then find and review existing programs and practices to select approaches that have evidence of effectiveness and are a good fit for your settings, populations, needs, and resources. If you can't find a program that meets your needs, you may need to adapt a program or create a new one (see Evidence-Based Prevention).
Step 5. Plan the evaluation. Use your evaluation plan to track progress toward your long-term goals, show the value of your suicide prevention efforts, and decide how to expand them.
Step 6. Implement, evaluate, and improve. Implement and evaluate your activities, using your evaluation data to monitor implementation, solve problems, and enhance your prevention efforts.

38. Mission: To foster a campus community that empowers students to manage the ups and downs of college life. Vision: Every student thrives inside and outside the classroom
Values:
Student centered
Population approach
Systems thinking
Social justice
Data informed
Campus partnerships
Priority areas:
Resilience
Means reduction
Distress
Mindfulness
Social connections

39. Mental Health Promotion Sample Activities

40. Suicide Prevention Sample Activities
Discuss 24/7 Behavior Concerns Advice Line Too…….
Suicide prevention through peer education, outreach and support
Full time public health outreach program
Gatekeeper training workshops
Media consultation and training
Relationship building
Referral services
Environmental interventions
Consultation to campus stakeholders
Empowering students to be mental health allies
Means Reduction and Environmental Strategies:
Awnings installed on two campus garages to deter potential jumpers
Conducted environmental scan to identify targets for means restriction
Awnings
Parking garage signs
Site of repeated deaths from jumping
Install light fixtures to block path for jumping
24/7 crisis line number
24/7 emergency information on Student ID Cards

41. Innovation and Future Trends
Multidisciplinary
Increase in tailored programming for students of color and other marginalized identities
Race-based trauma
Campus climate
Multi-issue bystander intervention initiatives
Student centered non-clinical peer support groups
Technology
Mental Health Promotion Initiatives
More timely data around suicide attempts and deaths
The above list are non-clinical trends…
Below are clinical approaches…
Integrated health program
Counseling or in Academic Residence (CARE) Program

42. National Resources and 24/7 Support

43. https://cmhc.utexas.edu/
For more information:

44. President, Student Advisory Committee
Nycole Fassbender
Student
Marquette University
President, Student Advisory Committee
Active Minds, Inc.

45. A Student Perspective What can be done? Nycole Fassbender
Active Minds- Student Advisory Committee President

46. Brief Introduction
Nycole Fassbender, I study Criminology and Psychology at Marquette University in Wisconsin.
I have been involved with Active Minds for almost 4 years now.
Currently serve as the Student Advisory Committee President for Active Minds National.
This is a topic close to my heart, I lost my sixteen year old brother to suicide in May of this year.

47. Prevention Available Resources:
QPR Training- Question Persuade and Refer
“Just as people trained in CPR and the Heimlich Maneuver help save thousands of lives each year, people trained in QPR learn how to recognize the warning signs of a suicide crisis and how to question, persuade, and refer someone to help. Each year thousands of Americans, like you, are saying "Yes" to saving the life of a friend, colleague, sibling, or neighbor”
Red Watch Training
Peer to Peer training (new initiative happening on my campus right now)
Source:

48. Prevention Through Active Minds
Send Silence Packing:
A traveling exhibit through Active Minds
Oct University of Michigan -- Ann Arbor, MI Oct Saginaw Valley State University -- Saginaw, MI
1,100 backpacks to represent the number of college students each year that die by suicide
Powerful and impactful
Increase in counseling outreach after MU hosted this in Fall 2015
Resources also provided at this exhibit

49. Send Silence Packing Options
Some other options if you aren’t on the touring path or unable to host Send Silence Packing.
This was a great alternative event put on by the Active Minds chapter at the University of Rochester
PC: Anaclare Sullivan

50. End the Silence Sharing mine and my brother’s story has been impactful
It was a difficult decision, but my parents and I decided to not hide behind how my brother lost his battle with mental health.
With sharing stories, Be Mindful!
Know the language you are using, don’t use further stigmatizing language.
“Died by suicide” instead of “committed suicide”
Be aware of the social media around popular portrayals of mental health (ex. 13 Reasons Why Netflix Series)
Be inclusive!
Active Minds provides an amazing online story workshop for our chapters or organizations on a contract basis.

51. Available Resources
One of the best ways to help someone is to know the resources available. If you are unable to help, knowing can point them in the right direction.
Counseling Center: most Universities have on call counselors after hours
National Suicide Awareness Hotline:
Veteran’s Crisis Line: Press “1”

52. Post-vention
Again, be open that this occurred but also be mindful of the family.
Active Minds recently released a post guide for chapters
This goes over resources and how to talk about it on campus.
Make sure your university recognizes that this is an important thing to address after.
More counseling tabling, resource posters, counselors available.

53. Questions? Thank you to our amazing presenters!
Maggie Mortali,
Marian Trattner,
Nycole Fassbender,
Sarah Ketchen Lipson, and the Healthy Minds Team,
Slides & Recording will be available at healthymindsnetwork.org/events/webinar-series

54. Follow Up Questions
1. The 85% statistic - was that specific to their campus? (85% of college students who die by suicide had not sought help at their college counseling center)
The 85% statistic is from the National Survey of College Counseling Centers 2014 Report. The National Survey of College Counseling Centers (formerly the National Survey
of Counseling Center Directors) has been conducted since 1981 and has included data provided by the administrative heads of four-year college and university counseling centers in the United States and Canada. The purpose of the survey has been to stay abreast of current trends in college counseling and to provide counseling center directors with ready access to the administrative, ethical, and clinical issues faced by their colleagues in the field. The 2014 report can be downloaded from this link:
Does the questionnaire include substance use?
Yes, the questionnaire includes four items related to substance use. Using a likert scale ranging from “not at all”, “some of the time”, “a lot of the time”, and “most or all of the time”, students are asked, “During the last 4 weeks have you experienced any of the following? Drinking alcohol (including beer or wine) more than usual; Feeling like you were drinking too much; Feeling that your work or school attendance or performance was affected by your drinking; Using drugs other than alcohol (marijuana, cocaine, etc.) or taking prescription medications without medical supervision?”
Are counseling centers also using ISP to triage mental health needs on their campuses? Ensuring students with the most severe needs get more immediate care?
Yes, ISP serves as a great way to triage students to ensure that students in distress – students with the most severe needs – get more immediate care. The ISP system scores each questionnaire and based on the student’s answers, the questionnaire is categorized into 4 tier levels, Tier 1A, 1B, 2, and 3, ranging from highest to lowest risk. The tier generates a specific response template for the counselor to use in responding to the questionnaire, which is further customized for each student. Counselors utilize the response to communicate with students what services are available based on the needs of the student at that time, whether it’s scheduling an appointment with the counselor or getting a referral to off-campus services, for example. In this way, ISP can also be used to help refer students who may be better served by off-campus or community based mental health services.

55. Follow Up Questions
4. Since the survey is anonymous, what is the liability involved should students disclose high risk issues?
Guided by legal professionals with specific experience in working with issues related to college suicide, AFSP designed ISP to ensure the fullest possible measure of safety and protection for the colleges/universities who utilize the program as well as for the students themselves. Specifically, program procedures include:
Emphasizing in the introduction of the program to students that the program is not a crisis intervention service and that there will be a time delay between their submission of the Questionnaire and the counselor’s response.
Underscoring from the outset that students’ anonymity is maintained throughout their use of the online services.
Clearly indicating that beyond the counselor’s written response to every student who submits a questionnaire. no program services will be provided unless the student requests them.
These procedures comply with recommendations made by a panel of legal experts assembled by the Jed Foundation (see Student Mental Health and the Law: A Resource for Institutions of Higher Education at  We strongly recommend this resource to all colleges and universities.
Lastly, it is important to note that over the last decade, as it has been increasingly recognized that many at-risk students do not avail themselves of available mental health services, colleges and universities have been taking more proactive approaches to identifying and offering help to those in need. Because such programs do not create the need, but rather reflect the institution’s awareness of it – as well as its willingness to take extra steps to meet it – providing programs like ISP are often considered to mitigate institutional liability, rather than increase it.

56. Follow Up Questions
5. What types of system(s) need to be in place for those who report immediate distress or suicidal ideation, plan, and intent?
Because ISP does not serve as a crisis intervention service, crisis resources must be available to students through the ISP website. This can be the national suicide prevention lifeline, the crisis text line, or local services like a mobile crisis unit or 24/7 after hours care team.
Are there counselors designated to responding to students or do staff psychologists respond to these students in addition to their case load?
There are many different ways that the ISP can be staffed. Based on your counseling center staff’s available time and resources, any number of clinicians can be appointed to serve in the role of communicating with students via the ISP website. ISP has been successfully managed by a single counselor or multiple counselors with each counselor devoting a limited number of hours to this effort.
Staff responsibilities include administrative duties to coordinate outreach and planning efforts; time communicating with students through the ISP website; and clinical time for students who choose to make appointments. Most counseling centers find it helpful to appoint one staff member to serve as coordinator of all ISP activities and serve as the main point of contact to AFSP Staff.