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THE ASSESSMENT OF SUICIDE RISK IN COLLEGE STUDENTS.

You are listening to Reach MD, the channel for medical professionals. Every suicide leaves heartache for family, friends and community. For detecting the warning before suicide and taking effective actions to prevent a suicide are not always easy. One program that is attempting to find and help college students who are considered high risk for suicide attempts is the college-screening project, a web-based outreach program. Welcome to the Clinician’s Roundtable. I am Dr. Cathleen Margolin and joining me from Atlanta, Georgia is psychiatrist Steven Garlow.

DR. CATHLEEN MARGOLIN:

Welcome Dr. Garlow.

STEVEN GARLOW:

Thank you. It is a pleasure to be here.

DR. CATHLEEN MARGOLIN:

Dr. Garlow, in your recent article published in the Journal of American College Help, you and your colleagues studied an interactive web-based method of outreach to college students at risk for suicide. Tell us about the college-screening project.

STEVEN GARLOW:

This was a noble program developed by American Foundation for Suicide Prevention in conjunction with a number of psychiatrists with the goal of reaching out to college students to identify students at risk for depression and for suicide, and to encourage them to come into treatment and what we utilized was a technology method of communication that is very comfortable to modern college students and that was e-mail and web-based interaction, so how the system work is all students or the undergraduates would receive an e-mail inviting them to participate in this program, as the tag line or ask are you depressed and then it would explain what is the method and explain the details. They could go to a secure website setup in their own account essentially and complete a screening questionnaire that included symptoms of depression, suicidal ideation, strong emotional state and things like that. That was then transmitted in a secure way anonymously, which I think the anonymity is one of key elements in it, anonymously to a therapist. We then do a review and communicate the results back to the students.

DR. CATHLEEN MARGOLIN:

So, it was more than just a simple online survey where they get some kind of score and there was a human element there.

STEVEN GARLOW:

The difference between this and other types of computerized assessment tools is that this involve every case was reviewed by a therapist, by a trained therapist who review their scores from this questionnaire and the responses and had a method specifically targeted to each individual and the other unique aspect of this system is that there was anonymous dialogue feature that the student could then communicate back to the therapist anonymously and that there was a live interaction. It is a different thing selling out a form and the computer telling you, you looks like you are depressed, you should seek treatment or something like that, I am there is a real life interaction between the students and the therapist.

DR. CATHLEEN MARGOLIN:

And, what did you find?

STEVEN GARLOW:

We found that well, 8% of the students participated responded and surprisingly in all of these students there was a very high degree of untreated depression, 16% of them had made a previous suicide attempt, about 8% were currently suicidal and expressed current suicidal ideation. We find a number of relationships, some of which were obvious so that the more severely depressed a person was the more likely they were to have suicidal ideation, but the other thing we found that there was an association between the strong emotional state, a sense of desperation in particular, a sense of question with do you feel out of control or desperate, anxious or stressed, angry, all of these types of strong emotional states related to but not exactly depression, they all also were highly associated with the students who are having the most significant suicidal ideation.

DR. CATHLEEN MARGOLIN:

Tell us about the diagnosis that the students did meet criteria for.

STEVEN GARLOW:

Depression, major depressive disorder was the main one and versions of depression without having clinical diagnostic interviews, it is hard to give exact diagnosis for many of these students, but certainly the PHQ9 which was the central element in the questionnaire, a score of 15 and above is a high likelihood of diagnosing depression and tell this question was initially developed and so those students most likely made a diagnosis of major depressive disorder.

DR. CATHLEEN MARGOLIN:

And major depressive disorder is a pretty serious condition who walk around untreated.

STEVEN GARLOW:

Correct and of those students had the most severe depression 85% were not in any supportive treatment whatsoever. The other remarkable thing about this was that these students were suffering in silence, these students were suffering alone, and you can read this in some of the dialogues that they thought that this was just unique to them or there was not any help, there was not any way him understanding this. They're very reluctant to seek out treatment, to come in for treatment, to admit that they're in pain, to admit that they are suffering. The most important part of this method of this way of reaching out to student is it takes away the onus of coming in for some kind of face-to-face meeting, at least initially and saying some that may be embarrassing or may be painful to say to some other person. By doing it through the computer that in anonymity, I think in some ways freed these students to be more open and honest and were forthright with the clinician.

DR. CATHLEEN MARGOLIN:

Where these numbers and the severity of symptoms a surprise to the researchers?

STEVEN GARLOW:

Yeah, they were definitely surprised. To us the severity, the frequency of previous suicide attempts, the frequency of current suicide ideation, severity of the depression, untreated depression, all these things were certainly surprising to me and my discussions with research team. It has been very sobering. It is very humbling to think that there is this degree of pain and suffering and would just barely enough to figuring out ways to majority of these students and bring then into treatment.

DR. CATHLEEN MARGOLIN:

Yes, that also must be validating what you are trying to do is obviously worthwhile.

STEVEN GARLOW:

And there is some other research that says that the most at risk students are the other ones that feel socially isolated, that are less likely to come into treatment and so through this computer message that comes to them where they're it overcomes that social embarrassment, the social awkwardness, the social stigma, the social inhibition to come in for treatment by coming through this communication method that college students now probably universally utilize e-mail and text messaging and web messaging and things like that. It is a way of overcoming social isolation and getting at those most in need.

DR. CATHLEEN MARGOLIN:

It is not necessarily as though they were waiting though for someone to ask. A lot of these students reported significant depression, but denied that it was interfering with their day-to-day functioning and that has to be surprising?

STEVEN GARLOW:

That is surprising, but but that's you know, invincibility of youth and in some of the dialogues, and some of the interactions, they would say, well, this is just normal, right? There would be some quote like that and people until it is pointed out, until it is explained to many people that how their feeling isn't normal and it is not okay to feel this way, you do not have to feel this way, people will ascribe it to, well I am under a lot of stress because I have to work and go to school, my classes are very hard, I am pre-med, I am pretty alone, I have to do well and my parents have all these expectations or people will ascribe how they're feeling to some external cause but in fact it is really internal to them and but because they have done that, because they said well I am under all this pressure because of my classes, they tolerate how they're feeling because, well that is just how everybody feels in this circumstance and that is one of things with this communication, the therapist can actually can let that student know, no, this is not the way you should feel. You do not have to feel this way.

DR. CATHLEEN MARGOLIN:

If you have just joined us, you are listening to ReachMD, the channel for medical professionals. I am Dr. Cathleen Margolin and my guest is psychiatrist, Steven Garlow and we're discussing the assessment of suicide risk in college students.

Dr. Garlow, so when these students have normalized these feelings and dismissed them and they're not seeking treatment, if they do go for a checkup or find themselves in the company of a physician, this makes it very difficult for the physician to try to make an assessment. Doesn't it?

STEVEN GARLOW:

Right, and this is where we have to be available open and forthright in asking the students about this, asking young people about this, ask about depression, ask how they're feeling, and be willing then to deal with what the answer is. We have to be prepared for that, but if we do not ask people about, if we do not ask students about it, the student comes in for something that might see minor, it is worth asking a sleep disturbance, a chronic headache, something like that. It is absolutely in their interest to ask about depression, ask explicitly about signs of depression, ask explicitly about suicide risks, ask explicitly have you been thinking about killing yourself? If we do not ask these questions explicitly, who are not comfortable as physicians asking these questions, we will never get the information from our patients and if we're forthright about it, it makes it easier then for our patients, for our students to be forthright back with us.

DR. CATHLEEN MARGOLIN:

And back to the study, what kind of response was given to the students who were medium-to-high risk for suicide and did not participate in evaluation and treatment.

STEVEN GARLOW:

Repeated messages came from the study therapist to this anonymous e-mail service encouraging them to come into treatment, trying to dialogue with them, trying to engage them one way or another. We had to follow up on some, some actually had sought treatment elsewhere, some had gotten better just in the process of interacting with the therapist online, so we never knew what acutely happened with, that is the nature of this kind of study, but the therapist would send multiple messages, encouraging messages, to try to get that person into treatment.

DR. CATHLEEN MARGOLIN:

So, would you think that the online dialogue itself was therapeutic?

STEVEN GARLOW:

There seem to be for some of these students something in their interaction with the clinician, somebody who is listening to them, somebody who is paying attention to them, not just a computer, not just a computer questionnaire, but somebody on the other end who was responding to them and addressing their needs, and responding to their concerns and if one reads some of the dialogues, it is very clear there is something like a therapeutic process going on where there is relief of anxiety, where there is relief of stress, where there is some resolution on the part of the student.

DR. CATHLEEN MARGOLIN:

Let us talk about the sex differences that were found. More women participated and sought treatment, but males are at a much greater risk to die from suicide. Aren't they?

STEVEN GARLOW:

Yes, that is absolutely correct. When women are more likely to have depression, women are more likely to seek treatment than men. This is one of the unmet need, this is what discontinuities in this that we're trying to overcome, trying to find other ways of engaging the male students into getting into treatment, and so we have actually been considering different ways as we move forward with this method of changing the approach, changing the questions we ask to try to may be move the language into so that we're more comfortable or more familiar to the male students that might help them come into treatment. Ultimately, coming into psychiatric treatment or not is at least in part about perception, about their perception stigma, about individuals who have an idea what it means to see a psychiatrist, they have an idea of what it would mean to their career, what it would mean to their status and to school, what it would mean to their relationships with their friends and their family and overcoming those kinds of issues that is one of the places where the dialogue would, I think, had some impact with being able to address some of those issues. It has been thought that the suicide risk in males is in part due to the reluctance to seek treatment, to reluctance to admit to being in pain, to admit to needing help. So, that is one of the challenges to male health practitioners in a college setting, but actually everywhere.

DR. CATHLEEN MARGOLIN:

This outreach program seems like a great idea. What does the future look like? Will it become a routine intervention on college campuses, do you think?

STEVEN GARLOW:

What we're trying to develop in at AFSP, The American Foundation for Suicide Prevention, are we're actually moving it up to have it, we're going to sort of widen the implementation to aide institutions including a couple of medical schools coming up. We will sort of add a tipping point to try to enlarge it and bring it to, to like you said to try to make it more of a routine part of the mental health program at any school and expand it and generalize it to more institutions, that is my goal, that is the right thing I think we need to take it, that being said it is not the only solution. Any university needs to have a multilayered, a multi-model approach to suicide prevention. There needs to be anti-stigma campaigns, there needs to be multiple avenues of outreach. There needs to be something like the college screening project that provides the door into the e-mail, internet-based process. That is going to get some students at risk, but there are other kinds of outreach methods, other kinds of anti-stigma campaigns that are going to contact and touch other students and bring other students in the treatment, but it is definitely a part of a comprehensive suicide prevention program on a college campus.

DR. CATHLEEN MARGOLIN:

Well, it sounds very promising and it is a very creative approach. I wish you luck with it.

STEVEN GARLOW:

Thank you.

Thank you for listening to the Clinician’s Roundtable on ReachMD, the channel for medical professionals. I am Dr. Cathleen Margolin and my guest has been psychiatrist, Steven Garlow of the Department of Psychiatry and Behavioral Sciences at Emory University School of Medicine. Thank you for joining me, Dr. Garlow.

STEVEN GARLOW:

Thank you.

You are listening to Reach MD, XM160, the channel for medical professionals.