INTEGRATIVE REVIEW
SILVA, Carina Felix da [1], SABÓIA, Vera Maria [2], SOUZA, Sônia Regina de [3], SANTIAGO, Adriana da Silva [4]
SILVA, Carina Felix da et al. Universities facing the potential risk for student suicide: an integrative review. Revista Científica Multidisciplinar Núcleo do Conhecimento. Year 09, Ed. 07, Vol. 02, pp. 05-24. July 2024. ISSN: 2448-0959, Acess link: https://www.nucleodoconhecimento.com.br/health/universities-facing, DOI: 10.32749/nucleodoconhecimento.com.br/health/universities-facing
Introduction. Suicide is linked to socio-economic, socio-cultural, and age-related circumstances. When people cannot find solutions to their problems, they must be monitored closely and effectively. The university campus can become a welcoming and powerful environment to develop actions that prevent risk factors for suicide. Objective. To describe the synthesis of knowledge about actions developed in universities to minimize the risk for suicide. Method. An integrative review was carried out in August 2020 in the Virtual Health Library, Pubmed Central, Cochrane Library, and Web of Science. Results. Two thematic categories emerged: “Suicide prevention: the campus as a shelter” and “Suicide prevention and mental health promotion: other strategies”. Publications in the United States of America predominated (63.63%). The promotion of mental health as a strategy to reduce suicide was little addressed, and it was found that the demands of university students are met through psychology services, counseling centers, campaigns, training, and support groups. Discussion and conclusion. The university contributes to the construction of values, concepts, and ways of exploring the world. It is a privileged place, with a unique potential for applying strategies on the subject of suicide, training subjects capable of identifying and understanding the signs of risk to intervene or activate help.
Keywords: Health promotion, Student health services, Suicide, Universities.
Academic life involves situations that can raise levels of tension/anxiety and stress. Some students bring conceptions when they enter the university that fade over time. This fact and the lack of social and family life can trigger psychological problems and suicidal thoughts (Santa; Cantilino, 2016).
Suicide is the second leading cause of death between the ages of 15 and 29, a high rate for this type of death (classified as preventable and a public health priority). However, suicides can be prevented timely, using evidence-based and low-cost interventions (Organização Pan Americana de Saúde, 2018).
Suicide has multiple associated factors, complex contexts, intertwined socio-economic circumstances, socio-cultural diversity, gender, and age. When the individual is unable to develop solutions to their problems at this stage, they need to be closely and effectively monitored. Thus, the university campus in which the individual is inserted can become a rich, welcoming, and powerful environment for developing actions that promote health and prevent risks related to suicide.
Based on scientific evidence, this study aims to describe the synthesis of knowledge about actions developed in universities to minimize the risk for suicide.
An integrative review was carried out. This research method aims to synthesize results obtained in research on a particular topic in a systematic, orderly, and comprehensive way, allowing a critical evaluation of available evidence on a given subject in a qualitative manner (Ercole; Melo; Alcoforado, 2014).
The research question was determined in the 1st stage of the review, using the Population, Interest, Context (PICo) framework, as follows: Population (P): university students, Interest (I): actions to manage suicide, Context (Co): Universities. Then, the following research question was formulated: What actions are developed in universities to manage suicide among students?
The following inclusion criteria were established in the 2nd stage of the review: full-text articles, published in the last 10 years, in Portuguese, English, or Spanish, directly related to the research theme, and articles with results that answer the research question. Reviews, duplicates, articles that do not address the theme of suicide or mental health promotion in the university environment, articles that do not present interventions for undergraduate students, and articles that do not contribute to the particular research question were excluded.
The search strategy was conducted using tools that allowed the combination of descriptors, inclusion, and exclusion criteria. The study selection process was carried out in August 2020 through online access of articles indexed in the Virtual Health Library (VHL), Pubmed Central (PMC), Cochrane Library, and Web of Science (WoS). The research question was addressed by combining the following descriptors indexed in the Health Sciences Descriptors (DeCS): “Universidades”, “serviços de saúde para estudantes”, and “suicídio”. In addition, the following MeSH terms were used: “universities”, “student health services”, and “suicide”. The terms were combined with the Boolean operators “AND” and “OR” (Table 1). The descriptors and terms were used in different languages according to the chosen databases.
Table 1 Search strategies for each database
The 3rd stage of the review process consisted of identifying the studies by applying the inclusion and exclusion criteria, screening the titles and abstracts, screening the full-texts, and deeply analyzing the articles selected for the review.
Initially, 186 records were found; however, after inserting the inclusion criteria, this number was reduced to 62. Then, the titles and abstracts were screened, and 28 articles were excluded due to lack of conformity with the theme and research question.
In the full-text screening stage, of the 34 selected publications, 19 were excluded for the following reasons: (1) articles related to practices and activities developed by undergraduate students in population assistance, and (2) assessment of the incidence and prevalence of suicide in Universities without the prospect of implementation of a program or intervention.
About the findings in more than one Database, one article was present in the four search sites used, and two appeared in two databases. Thus it was necessary to exclude 4 productions per repetition. The identification flowchart presents the study selection process (Figure 1).
Figure 1. Flowchart of identification, screening, and selection process
After the selection process, an exhaustive reading of the eleven eligible articles was carried out, providing a greater understanding of the theme and its dimensions, enabling the analysis, interpretation, and categorization of the studies (4th stage of the integrative review) (Table 2). According to each category raised, the 5th stage of the review was conducted, the interpretation and discussion of results (Souza, Silva; Carvalho, 2010).
Table 2. Characteristics of selected studies
A total of 63.63% of the studies were originated in the United States, 18.18 (18%) in the United Kingdom, 9.09% in Spain, and 9.09% in Italy. Concerning the interventions, 90.90% of the results found in the studies discussed suicide prevention, while interventions aimed at the treatment or assistance were cited in 54.54% of the articles. Mental health promotion was addressed in 27.27% of the studies, campaigns in 27.27%, training in 27.27%, and group-related activities in 18.18%. Counseling centers on college campuses were mentioned in 36.36% of the studies and specialized care in 45.45%.
The scientific productions were grouped by content similarity, and the activities involved training programs, counseling, and group meetings. The results were summarized in two thematic categories: “Suicide prevention: the campus as a shelter” and “Suicide prevention and mental health promotion: other strategies”.
This category, “Suicide prevention: the campus as a shelter”, consisted of six articles and deals with indirect strategies to prevent suicide, including training for campus employees and human resources designed to meet the needs of university students at risk for suicide.
The Gatekeeper training was the choice of studies by Cimini et al. (2014) and Pasco et al. (2012). The study by Shannonhouse et al. (2017) explored Applied Suicide Intervention Skills Training (ASIST), while Blasco et al. (2016) sought data for the University and Mental Health (UNIVERSAL) project. Moutier et al. (2012) aimed to increase knowledge about depression and destigmatize help- seeking to prevent suicide, like King et al. (2015) adopted screening schemes in their invitations and recruitment processes.
The authors are presented in the following order: Cimini et al. (2014), Pasco et al. (2012), Shannonhouse et al. (2017), Blasco et al. (2016), Moutier et al. (2012), King et al. (2015). The case study by Cimini et al. (2014) evaluated the effectiveness of a small- group, single-session, audience-specific interactive gatekeeper training program conducted at a large public university in the northeastern United States.
Participants in this case study were faculty, campus staff, and students. The training provided information on identifying suicide risk and coping strategies and included a simulation with the participation of actors.
Another study by Pasco et al. (2012) used gatekeeper training to improve communication and relational skills beyond the didactic focuses gatekeeper training. This study builds on the existing literature by demonstrating the positive impact of experiential exercises and role-playing practices. In this type of training, participants receive information about warning signs, strategies for identifying students at-risk, and strategies for making appropriate referrals (Pasco et al., 2012; Cimini et al., 2014).
The study by Shannonhouse et al. (2017) investigated an Applied Suicide Intervention Skills Training (ASIST). This training is already taking place and trains caregivers to employ the Pathway for Assisting Life (PAL) model for suicide first aid, an intervention that helps a person at-risk choose to restore his/her safety in the moment of risk. The guardian and the person at-risk identify unique protection and risk factors, immediate and long-term needs, and available resources to create a customized safety plan.
Regarding studies on program development and implementation, Blasco et al. (2016) and Moutier et al. (2012) performed data collection through the web to gather useful information for the development of suicide prevention programs. The study by Blasco et al. (2016) describes the UNIVERSAL project, an international initiative created to expand scientific knowledge about suicidal behavior among university students worldwide. The objective is to assess the prevalence and incidence of suicidal thoughts and behavior in Spanish students.
Moutier et al. (2012) described the development and implementation of a campus-wide medical school program that aims to increase knowledge about depression and destigmatize help-seeking to prevent suicide. This study focuses on medical students, residents, and faculty physicians. The program consists of a dual approach: (1) screening, assessment, and referral and (2) education. The program beings with a face-to-face approach with target groups about burnout, depression, and suicide. The screening process is anonymous, confidential, and web-based using custom software created by the American Foundation for Suicide Prevention (AFSP).
The study by King et al. (2015) deals with evaluating a screening program, also developed by the AFSP and disseminated in colleges at various universities in the United States. This initiative identifies students at risk for suicide through an email invitation, offering them the opportunity to participate in an online screening program like the one used by Moutier et al. (2012).
According to King et al. (2015), in this interactive approach, a trained counselor reviews student responses and posts a confidential, personalized assessment message on the website. Students can participate in an online dialogue with the advisor and are encouraged to schedule a personal assessment.
The gatekeeper training used by Cimini et al. (2014) and Pasco et al. (2012) showed that there was a statistically significant increase in knowledge and comfort after the completion of the training among teachers, staff, and students, reinforcing the benefits associated with this model of training.
The benefits identified in the study by Shannonhouse et al. (2017) reinforce that the intentional interaction between the guardian and the person-at-risk can reduce the risk for suicide, even without referral and mental health services. The results support that ASIST training increases feelings of comfort, competence, and confidence in working with an at-risk person and in the skills to carry out interventions.
Moreover, in the study by Moutier et al. (2012), of the 48 individuals referred for treatment, the majority (71%) stated that they would not have presented themselves without the encouragement and knowledge that the school provided through the educational component and the web-based screening program.
One of the challenges mentioned by Blasco et al. (2016) is the potential low participation or loss of subjects during follow-up. In comparison, Pasco et al. (2012) state that the major challenge faced by gatekeeper professionals is the limited time generally allocated for its completion.
This category, “Suicide prevention and mental health promotion: other strategies”, comprised five articles on activities directly offered to students to supply their demands, including outpatient services, campaigns, and meetings addressing specific themes. The researchers Sagar-Ouriaghli et al. (2020) explored the construction of focus groups, while Silk et al. (2017), and Biasi et al. (2017) investigated psychological counseling services. Jacob et al. (2020) addressed counseling services and specialized care through the Student Mental Health Service Clinic. Shepardson and Funderburk (2014) conducted a study in a University Health Center.
The authors are presented in the following order: Sagar-Ouriaghli et al. (2020),
Silk et al. (2017), Biasi et al. (2017), Jacob et al. (2020), and Shepardson and Funderburk (2014).
A study of male university students explored barriers to seeking help, how an appropriate intervention should be planned, and how to disseminate this intervention to male students. Five contents were identified: (1) protecting male vulnerability, (2) providing a male narrative of seeking help, (3) differences in the intervention format, (4) difficulties in knowing when and how to seek help, and (5) strategies for engaging male students. These themes represent important considerations that can be used, along with the existing literature on male help-seeking, to develop male friendly interventions (Sagar-Ouriaghli et al., 2020).
A University Counseling Center (UCC) developed a social norms campaign on a university campus to promote help-seeking among students as a suicide prevention strategy and made conventional care materials available to students to encourage them to seek help.
The study by Silk et al. (2017) evaluated the results of this campaign, showing that students who said they had seen messages from university counseling centers reported greater effects than those who did not. Biasi et al. (2017) compared data from students who sought professional psychological help at the university’s counseling service with data from students who have never asked for psychological help. The results confirm the specificity of university counseling services that should address psychological difficulties and specific areas of academic and interpersonal functioning.
The University of Cambridge School of Clinical Medicine supported the Clinical Student Mental Health Service (CSMHS) development to provide expert advice to medical students, which are considered a vulnerable group. The Jacob et al. (2020) study assessed the efficiency and effectiveness of this type of service, which aims to provide easy and quick access to support from psychiatrists and clinical psychologists.
Students have access to Behavioral Therapy, Interpersonal Therapy, or Cognitive Analytical Therapy. For therapies that are not available within the CSMHS, routine National Health Services (NHS) referrals are also available. A significant proportion of medical students who attended the service scored high on validated scales that measure emotional distress, suicide, and mental illness (Jacob et al., 2020).
The article by Shepardson and Funderburk (2014) describes the process of implementing behavioral health analysis in a university health center and the results of universal screening for depression, suicidal ideation, alcohol misuse, tobacco use, and sleep problems in students. Behavioral health services on college campuses can help identify students with behavioral health problems and increase access to mental health care.
Regarding benefits, Sagar-Ouriaghli et al. (2020) provide a detailed account of suggestions from current students on how to improve mental health initiatives for male students. Jacob et al. (2020) state that participants benefited from timely information from mental health experts, showing improvements in mental well-being and functioning. The study by Silk et al. (2017) informs that the campaign had benefits such as increased intention to seek help and talk to others about the usefulness of the University Counseling Center.
It is necessary to think of different ways to produce scientific knowledge on university students mental health promotion, as the university campus is where students spend a considerable part of their daily lives. However, the absence of Brazilian studies demonstrates the need for encouragement of research on the subject and highlights the importance of implementing health promotion and illness prevention interventions.
According to the American College Health Association (ACHA), the suicide rate among young adults from 15 to 24 years of age has tripled since the 1950s (Rosiek, Rosiek-Kryszewska, Leksowski, and Leksowski, 2016), and suicide is one of the leading causes of death among young people of university age (Silk et al., 2017).
This relationship between young age/academic life and suicide can be explained by the inaccuracy of entering the labor market – which is one of the several factors associated with suicide – conveyed to the excessive use of narcotics, loss of sleep quality, family pressures, lack of interaction with friends, mood swings, and anxiety, leading to suicidal thoughts or suicide itself (Miranda et al., 2018).
Studies show that students exposed to campaign messages under experimental conditions are more likely to refer a friend to the University Counseling Center, and they are also more likely to seek help due to mental issues. In this way, the support provided by University Counseling Centers (for example, through suicide awareness campaign materials) has positive effects on university students perceptions and behaviors (Silk et al., 2017).
Biasi et al. (2017) highlight the importance of evaluating students psychological functioning and difficulties because, along with these difficulties, students may have a low ability to keep up with the demands of the University.
Students with a history of attempted suicide, current suicidal ideation, depression, and alcohol abuse are classified as at particularly high risk for suicide. Combined, some of these behaviors provide a greater risk for suicide than when they occur singularly (King et al., 2015).
The vulnerability of young people increases with the consumption of alcohol and illicit drugs due to the freedom to be away from parental controls (Santos et al., 2017).
Suicide risk screening at university centers can facilitate the early identification and treatment of common mental health issues among students (King et al., 2015; Shepardson and Funderburk, 2014).
Training campus helpers in a comprehensive suicide intervention may be the best way to provide the most immediate help to students at-risk for suicide. University counseling services should design and implement programs to promote interpersonal skills and facilitate friendship networks within the university community (Biasi et al., 2017; Shannonhouse et al., 2017).
In studies that used the gatekeeper method, improvements in the self- perception of faculty employees about students at-risk for suicide were evidenced and their abilities to carry out interventions. Moreover, the participants confidence in dealing with a person-at-risk increased, and their skills in simulated interventions improved (Pasco et al., 2012; Cimini et al., 2014; Shepardson and Funderburk, 2014).
With the transition of medical students to hospital and community training, they can become more vulnerable to mental illness. Commonly reported stressors at this stage include difficulties relating to supervisory consultants, exposure to patient distress or people facing terminal illnesses/death, compromised sleep patterns, and the pressure to develop a professional character (Jacob et al., 2020).
In the study by Jacob et al. (2020), eighty percent of students sought mental health support services before joining the Student Clinical Mental Health Service under investigation. Given the above, it is understood that frequent or intense exposure to stressors involved in the university context can contribute to the mental illness of students (Santos et al., 2017).
Regarding the gender-related issues, Sagar-Ouriaghli et al. (2020) study show that male students accounted for 69% of college suicides, generally associated with lower help-seeking rates. According to that study, 69% of UK university students who committed suicide in 2015 were male.
Sagar-Ouriaghli et al. (2020) also state that men tend to have a more stigmatizing view of mental health than women, and this stigma associated with seeking help has been shown to influence students willingness to talk about their health concerns.
When joining the university, young adults usually get away from home. They live with strangers, removed from their support systems and working under intense pressure, especially when depression or other mental health issues come into play (Rosiek et al., 2016).
Students reported the need to establish trust, confidentiality, and a good relationship so that the fear of being judged or having their intimacies revealed to others dissipates, with the possibility of asking for help. Furthermore, they highlighted the preference for a fun and informal environment (Sagar-Ouriaghli et al., 2020).
The study by Santos et al. (2017) emphasizes the relevance of activities that promote actions related to the prevention and confrontation of problems related to the stage of youth and academic life, such as the importance of health professionals working in the academic environment.
Suicide has multiple associated factors, complex contexts, intertwined socio- economic circumstances, socio-cultural, gender, and age diversity. When individuals cannot develop solutions to their problems at this stage, they need to be closely and effectively followed up. The university campus can become a rich, welcoming, and powerful environment for developing actions that promote health and prevent risks.
Suicide is a preventable death, and it is necessary to talk about this issue to perpetuate adequate information that generates destigmatization, innovative care technologies, and their applications in various fields of society. The University environment is one of the most important factors influencing different levels of individuals lives.
The joint work between university students and campus professionals can bring new meanings to mental health protection networks. As the University is a place that contributes to the construction of ways of exploring the world, it is seen as a privileged place, with unique potential for the application of strategies that favor the promotion of mental health, destigmatization, and education on the subject of suicide.
It is also a particularly conducive place to train subjects capable of identifying and understanding signs of risk, becoming able to intervene or call for help. The recognition of the needs of undergraduate students is essential for starting the planning and development of actions with a positive impact on their lives.
Although suicide prevention is considered a priority for research and intervention, longitudinal investigations are needed to identify the risk and protective factors associated with suicidal behavior. A preliminary survey before starting any action is essential, as socio-economic, environmental, and cultural differences may influence the demands of each institution.
In addition to enabling the development of new research, this investigation represents an instrument that supports reflection on the theme of “suicide” and its impacts on student’s lives. We expect that this study will increase awareness on suicide and suicide prevention among university students, disseminate information on preventive strategies that already exist, and encourage the development of new interventions.
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[1] PhD at the Institute of Psychiatry (IPUB – UFRJ) (In progress); Master’s degree in Health Care Sciences from UFF; Degree in Nursing (bachelor’s and licentiate’s degree) from Universidade Federal Fluminense (UFF). ORCID: 0000-0003-2824-2389. Currículo Lattes: http://lattes.cnpq.br/8834915683718461.
[2] Advisor. Post-doctorate in the Postgraduate Program at the Faculty of Nursing at the State University of Rio de Janeiro (UERJ); PhD in Nursing from UFF; Master’s degree in Nursing from UFF; Degree in Nursing and Obstetrics from UFF. ORCID: 0000-0003-0382-5078. Currículo Lattes: http://lattes.cnpq.br/2886146961212444.
[3] Postdoctoral in the Academic Program in Health Care Sciences (PACCS)
by UFF; PhD in Nursing from UFRJ; Master’s degree in Nursing from UFRJ; Degree in Nursing and Obstetrics from UFF. ORCID: 0000-0001-7981-0038. Currículo Lattes: http://lattes.cnpq.br/8543534166970830.
[4] PhD in Health Care Sciences from UFF; Master’s degree in Nursing from UFRJ; Degree in Nursing and Midwifery from the Anna Nery School of Nursing at UFRJ. ORCID: 0000-0003-4404-4024. Currículo Lattes: http://lattes.cnpq.br/0749560160526441.
Material received: 29 de fevereiro de 2024.
Peer-approved material: 05 de abril de 2024.
Edited material approved by the authors: 17 de julho de 2024.
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