Sept. 20, 2006

Using the Web to Prevent Suicide

As questions of institutional liability after student suicide have received much more attention in recent years, many health officials have called for improved suicide prevention strategies. But carrying out such efforts is not the easiest of tasks when no one knows for sure what will push one student instead of another to want to take his or her own life.

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Officials at the American Foundation for Suicide Prevention believe that colleges can do much more via the Web to help students contemplating suicide. For the past five years, the group has been fine-tuning a “College Screening Program” that uses the Internet to identify students at risk for suicide and to refer them for treatment. Through pilot tests that have reached thousands of students, officials believe they have the statistics to prove that the program works — and, in fact, more institutions have started using it this semester, based on that data. Still, some caution that questions of institutional liability and confidentiality concerns could prevent some campus officials from wanting to use it.

The program uses a screening instrument called the Student Health Questionnaire, which is sent to groups of instituion-selected students anonymously online through a secure Web site. “Unique to this screening tool is that the clinical evaluation is individually tailored to the student,” said Ann Haas, a research director with AFSP. “A clinically trained counselor writes a personalized assessment and offers the student the opportunity for online dialogue or encourages a face-to-face meeting.”

Pilot testing of the project began in the spring 2002 semester at Emory University, and, in spring 2004, a second pilot test site was created at the University of North Carolina at Chapel Hill. Both campuses are still using the program today. Officials chose to focus on different groups of students — at Emory, all freshmen have received the e-mail invitations; UNC Chapel Hill, meanwhile, focused on seniors.

In more than three years of the pilot testing, 14,500 students were invited to participate in the screening via campus e-mail. They all received an e-invitation to visit a secure Web site, register using a unique alias and password, and complete a Student Health Questionnaire, which asks them a variety of questions about their feelings and behaviors, including current psychiatric treatment or use of psychiatric medications, if any.

(AFSP officials provided this example of a hypothetical depressed student’s responses to the questionnaire and the online input that he or she would receive.)

Haas said that for every 1,000 students invited to participate, about 80 completed the questionnaire, about 20 engaged in online dialogues, and about 10 entered treatment. Over 50 percent of those completing the questionnaire had significant mental health problems with some kind of elevated suicide risk, she said, and few reported being in therapy or taking psychiatric medications.

“If you can get 10 or 15 more students to come in who have serious problems, you’ve done something radical to address campus suicide,” said Haas.

Health officials are quick to note that there is no typical suicide victim. It happens to both the rich and poor, to males and females, to gays and straights and among all the races. Several studies have shown that people who have sought treatment for mental disorders are more likely to kill themselves, but campus health officials rarely have access to a student’s mental health background until after he or she has committed or tried to commit suicide.

Still, campuses like George Washington University, which currently faces a lawsuit from a student who claims he was forced to leave the institution and threatened with criminal prosecution after he sought help for depression at the university’s counseling center, have tried to increase their prevention efforts. The Massachusetts Institute of Technology, for instance, started providing more campus-based therapy and depression screening programs after a student lit herself on fire in her dorm room and died in 2000. And many institutions nationwide have beefed up campus health center Web sites with information that point struggling students to places to seek help.

In those cases, however, its often up to a troubled student to initiate contact. With the AFSP model, the usual scenario is flipped.

“Over 90 percent of the students with whom I communicate face-to-face or via e-mail say they would not have sought help without having used this questionnaire,” said Jill Rosenberg, a licensed social worker at Emory who runs the program, reviewing all questionnaires at the institutions and contacting students based on their responses. “Students were uniformly enthusiastic about the university offering such a service.”

Rosenberg said that as a result of the pilot program, Emory was able to fine-tune the questionnaire and the timing of the e-mailings. “Currently, we mail the invitation to complete the online questionnaire to each class at staggered intervals during the academic year,” she said. “Students are advised that they can complete the questionnaire and avail themselves of the services that are offered at any time during the year.”

Gary Pavela, director of judicial programs at the University of Maryland at College Park who monitors student psychological legal issues, said that a potential benefit of such a program might be the added sense that some other person cares about them and is willing to offer support. “It’s usually preferable that such contact be in person,” he said, “but there is research showing that letters and – presumably – e-mail can also have good results.”

Richard Kadison, director of mental health services at Harvard University who has reviewed the program, believes its online application allows institutions to reach more at risk students who are reluctant to walk in the door of a counseling center. “I think anything that raises awareness and reduces stigma is a good thing,” he said. “I don’t think you can do effective psychotherapy on the Internet — maybe we will be able to someday, but not today – because the interpersonal relationship, nuances of body language, and sense of connection don’t really allow for that.”

Haas agrees that long-term treatment over the Internet is probably not in a patient’s best interest, but argues that such a program can help remove barriers from getting at risk people in to visit counselors. “We’ve got to find ways of doing more treatment online,” she said. “This is a mode that today’s students communicate through.”

Kadison said that many institutions already use an existing online screening program at mentalhealthscreening.org, which allows students to screen for problems and self refer. He believes that the AFSP model positively expands on that site’s abilities by providing personalized feedback from a counselor.

Haas said that despite the results thus far, some institutions might be wary about instituting the program due to liability and confidentiality issues.

“Tort lawyers do not lack creativity in filing new kinds of lawsuits,” Pavela said regarding the liability issue. “But strong public policy reasons support this initiative and I don’t think judges will be quick to expand the scope of potential liability. The key to minimizing liability risks will be explaining pertinent limits in advance, delivering on what is promised, and doing everything possible to obtain prompt local help from a qualified professional for a student determined to be at risk of suicide.”

“There are certainly concerns about liability for the college, but I think it is far better to try to help students who may be struggling than to not offer help because of fears of liability,” said Rosenberg.

Liability issues aside, Rosenberg said that one of the greatest challenges in students who have used the program involves confidentiality. “I have the opportunity to address this concern via the anonymous, online dialogue,” she explained. “I try to reassure students that the information they provide to me will be kept confidential except as required by law (i.e. if they are homicidal, suicidal or abusing a child or an elder person) and that my goal is to help, not to be punitive.”

The project is currently being expanded to be used by MIT, Morehouse College, the University of Pittsburgh and Vanderbilt University, and AFSP has had initial discussions with institutions that wish to focus specifically on graduate students or medical students.

— Rob Capriccioso

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