Suicidality in Graduate School: Part 1

AMHC team member Sara writes on the very difficult topic of suicide and mental illness among graduate students, including her own experiences.

November, 2003:  I’m an undergraduate going into my first semester at the University of Wisconsin-Madison after yet another stint in the hospital for anorexia. That seems not to matter now.  Every morning, I trudge up Bascom Hill on my way to Spanish, early sunrise glinting off the grassy slope.  Malnourished, depressed, and guilt-ridden after witnessing a friend’s suicide attempt in the hospital, I check out every book on suicide I can get my hands on.  My mood gets progressively worse, and then one night I decide that somehow, my friend’s decision becomes the thing I must also do.  I upend my pills on the kitchen counter. Lift my journal off my bedside table, and scribble a few lines. Is this how it’s done?  I suppose this is how it’s done Don’t think, just do it. Don’t think, just do it. Whoa. Don’t think….

Against a backdrop of grey skies, a person wearing a light brown coat and sunglasses faces away from the camera with their head down. They are standing in a field with long stalks of light brown grasses all around.

It’s been over ten years since my overdose and subsequent three days I spent in the ICU, and I still can’t piece everything together.  That time and place will forever be lost. And yet. Although it remains my sole attempt, I would be remiss if I denied that the thoughts haven’t lingered.

Now a clinical psychology graduate student, I spend moments and sometimes days reasoning with my intrusive thoughts about death and a desire to abscond from life.  I’ve been depressed; had months on end when getting out of bed and walking down my street to the corner Starbucks took all the effort I could muster.  And I’m not the only one.  A significant proportion of graduate and postdoctoral students consistently report that emotional or stress-related problems negatively impact their well-being and/or academic performance, and many report symptoms that would appear to be indicators of clinically significant mental illness (e.g., chronic anxiety and depression; for a recent review, see Tsai & Muindi, 2016). Although more research is needed in this area (for a review of the status of mental illness research among graduate students, see the AMHC post on the status of research in this area), up to half of all graduate students may be affected by these issues. Alarmingly, in one survey, 10% admitted to having made a prior suicide attempt (Garcia-Williams, Moffitt, & Kaslow, 2014). These attempters are many of the same students who are struggling with the aforementioned mental health problems. Nevertheless, it’s important to recognize that several individuals who think about or attempt suicide have no pre-existing mental illness (Cao et al., 2015).

Now let’s think about these stats.  In a graduate cohort of 10 incoming students, this means that at least one person may have attempted suicide, and that up to half of the cohort is likely to be struggling with mental health concerns — many of which are linked to suicidality. These are alarming percentages, especially knowing that previous suicide attempts are among the most significant unique predictors of future attempts (Joiner et al., 2005; May, Klonsky, & Klein, 2012).

 

Mental illness and suicide

By the time I entered graduate school, I had already been diagnosed with anxiety, anorexia, and had a serious suicide attempt behind me. There is a clear link between mental illness and suicide risk: over 90 percent of those who die by suicide are known to have a diagnosable psychiatric illness (Harris & Barraclough, 1997). A relatively recent study (Garcia-Williams, Moffitt, & Kaslow, 2014) found that graduate students endorsing recent suicidal behaviour reported elevated rates of depression, anxiety, disordered eating, and substance abuse. Moreover, co-occurring disorders — i.e., having more than one mental illness — increases vulnerability (Henriksson et al, 1993), and in some cases reliably differentiates those with suicidal ideation from those who attempt suicide (Asarnow et al., 2008; Gould et al., 1998). Not surprisingly, mental illness compounds the challenges faced by graduate students, and graduate school may engender mental health difficulties (Tsai & Muindi, 2016).

 

The dark side of competition in graduate school

Graduate school is notorious for the toll it takes on its students. Among other strains, students face challenges such as an extended training period and strenuous hours, financial hurdles, tension with supervisors, lab members, or departmental committees, research or internship difficulties, balancing serious relationships and children, and the reality of a grim post-academic job market. These unique stressors have been known to precede many graduate student suicide attempts (You & Chen, 2012).

In preparing for this piece, I reached out to several of my friends and colleagues — many of whom are also in the field of psychology, and who had personal experience with suicide — to get a better sense of how these issues affect them.

Bridget(1), a Master’s Student in School Psychology, describes how the overwhelming stress and pressure placed upon students in her field to succeed due to competition in the job market contributed to her two suicide attempts:

“…“[The] main trigger for [my attempts] was the high competition for jobs in my field after graduation.   … I knew that in order to get a job, I needed to do whatever I could to make myself stand out. And that is when I started overworking myself: instead of completing one specialization like everyone else, I decided to complete three… Instead of completing one internship, I decided to do five. I took a position as an instructor for undergrad classes, and one as a graduate research assistant, I became the president of my graduate program’s student organization, I started doing a weekly volunteer shift for the local crisis line to improve my resume, I began publishing and presenting at local and national conferences, I became an executive board member and graduate student representative for the statewide chapter of my field’s professional organization… Feeling overwhelmed and inadequate [as a result of this stress] let me to consider suicide…”

Additionally and somewhat ironically, the very qualities that make us successful as graduate students — for instance, our perfectionism, meticulousness, self-criticism, and unswerving motivation — may also predispose some of us to suicide (see this New York Times article describing the link between perfectionism and suicide on campus). Graduate school’s hypercompetitive environment, known to foster self-doubt and the infamous “imposter syndrome” (Clance & Imes, 1978), often exacerbates these traits (for more on the imposter syndrome phenomenon, check out this link from the American Psychological Association and this one from Slate).

Yolanda, a clinical psychology doctoral student who has battled depression and suicidality, recalls how competition with other graduate students (“who’s more miserable and has more work..?”) results in an unsupportive environment that facilitates her depression. She notes how detrimental it is “[to have] those same individuals enable my ineffective coping and joking about it instead of encouraging me to care for myself.”

Bridget notes that her “need for perfectionism and control in life … [led] to spending way too much time on school-related things.  Nevertheless, she knew she was “in over [her] head”, but

“I believed that if I took any sort of step back I would ruin my chance at ever getting a job. It felt too hard to compete with everyone and too hard to keep up. Finally, at the end of my first year of grad school, the stress got to me, and I checked out.”

As individual who has long struggled with obsessive-compulsive personality features — the prevalence which appears to be elevated among graduate students (e.g., Hunt & Gable, 2013; Toews et al., 1997) — I have also found the driven and often cutthroat mentality so normative among my peers adversely affects my mental health. There is often an inexplicable yet palpable pressure to out-do the next student, especially those with similar interests. For me, this climate has discouraged collaboration, engendered extreme individualism and paranoia, isolated me, and thwarted the development of supportive connections among those in my cohort and larger program. Such feelings of social isolation are ubiquitous among graduate students (Hadjioannou, Shelton, Fu & Dhanarattigannon, 2007; Hartnett & Katz, 1977; Jairam & Kahl Jr, 2012), a troubling fact, as alienation is one of the most robust predictors of suicidality (Van Orden et al., 2010).

 

Overworking and lack of adequate self-care in graduate school: A deadly combination 

In my second year of graduate school, I stayed awake for three days straight two weeks in a row.  Assignments were due, so I stayed awake drinking coffee and matcha tea and popping anti-congestants that had amphetamine (aka, speed) –like qualities.  My weight plummeted. I felt like the protagonist in Haruki Murakami’s short story, Sleep, written from the perspective of a 30-year-old housewife who comes to a tragic end on her 17th day without sleep.

But who among us hasn’t pulled a few all-nighters, skipped meals, or had one too many cocktails to deal with the stress of a heavy semester?  Smith and Brooks (2015) found that most graduate students reported a decline in their physical health after starting graduate school, which is potentially linked to losing sleep, poorer eating habits and worse exercise routines. Not only do these factors increase our vulnerability to emotions, but they also simultaneously reduce our judgement and ability to cope adaptively. Although correlational, poor diet (Li, Zhang, & McKeown, 2009) and exercise (Davidson et al., 2013) have been linked to previous suicide attempts, while insomnia is a recently identified component of acute suicidal affective disturbance (ASAD), a dangerous condition distinct from mood disorders (i.e., mental illnesses such as depression or bipolar that are characterized by underlying mood-related dysfunction) depression, bipolar) known to trigger a rapid onset of suicidal intent (Tucker et al., 2016; Stanley et al., 2016). ASAD is a time-limited state (usually lasting only a few hours in duration) also marked by extreme social withdrawal, self-disgust, irritability, agitation, and/or nightmares, and is thought to precipitate 15-20% of all suicide attempts and put individuals at serious risk for death (Joiner, 2015).

Bridget notes “I was so incredibly stressed out that I was barely sleeping, could barely bring myself to eat, I was so focused on school and work I never made time to see or talk to my friends anymore or do anything I enjoy… The stress had torn me down and I had lost my motivation completely.”

And yet some of us try to cope by working even harder.  As her depression increased, Yolanda took on more work to distract herself from her feelings — a strategy that ultimately backfired:

“Taking on more work (especially busywork) when I’m already stressed out meant I was spending less time on activities that looked like self-care… also because I was spreading myself so thin, I wasn’t producing quality work, which made me disappointed in myself [and] feel like a failure. It’s like a vicious cycle where I’m reinforcing the thought that I suck.”

On a long concrete-brick staircase, a person wearing black sits near the bottom with their knees up. The photo is black and white.

Learning how to destroy ourselves: the role of acquired capacity in suicide

For graduate students, an additional and critical (yet oft-overlooked) component exists in the transition from suicidal ideation to action. Suicidologists posit that suicidal behaviour arises from the joint influences of desire – a combination of psychological pain and hopelessness compounded by alienation – coupled with the capability for lethal self-injury (Joiner, 2005; Klonsky & May, 2015). The latter, termed “acquired capacity”, can be dispositional (e.g., having a high pain tolerance), acquired (e.g., from exposure to painful and provocative experiences), and/or practical (e.g., possessing knowledge or means necessary to make a suicide attempt; Klonsky & May, 2015).  So how might acquired capacity factor into the graduate school equation?

Some areas of training can also increase acquired capacity via exposure to painful and provocative events (e.g., nursing and medical students learning and practicing medical procedures). Many graduate students also possess the practical knowledge and means (e.g., chemical, mechanical) for suicide that others of us may not necessarily be able to access. For instance, as part of my junior psychology assessment practicum, I obtained training to evaluate the lethality of deliberate self-harm. As result, I gained knowledge about combinations of medications that are more likely to result in death — knowledge that could prove dangerous if I were to become imminently suicidal.

Finally, the persistence and grit that is so common among those who have reached an advanced level of education might transfer over to capability for suicide because of that willingness to persist through distress and pain in the pursuit of that certain goal, in this case death (Pennings et al., 2015; Law et al., In Press). Preliminary researcher supports the notion that acquired capacity may be elevated and contribute to suicide rates among those pursuing advanced degrees (e.g., medical school; Downs et al., 2014 and Fink-Miller, 2015; veterinary school; Witte, Correia, & Angarano, 2013).

 

Multiple pathways to suicide

It’s easy to see how various aspects of the graduate school experience confer risk for core emotional states (e.g., loneliness, hopelessness, desperation) known to precipitate suicide in graduate students (Garcia-Williams et al., 2014; Joiner, 2005; Klonsky & May, 2015). Nonetheless, consideration of and respect for unique experiences is also necessary, as diverse vulnerability factors cutting across numerous domains – e.g., individual, social, systemic — and their interactions contribute to suicide.

For instance, Yolanda describes how comparing herself to others leads to thoughts (“I’m a failure… a hypocrite, and a liar”), emotions (misery, shame), and behaviours (avoidance) which aggravate her depression and trigger suicidal ideation. Likewise, receiving unfavourable feedback from my supervisor never fails to send me into a tailspin; I get a panicky, sinking feeling in my stomach and the world immediately takes on a darker cast. If I’m unable to keep my ruminations in check, these thoughts can spiral into existential brooding: What am I doing here? He’s sorry he took me on as a graduate student. I’m different than everyone else. Who am I kidding – I don’t belong. At such times, escaping from my distress becomes paramount, and the notion of suicide can be comforting.

Although our proximal experiences appear similar, unique personality, environmental, and contextual dynamics are responsible for our experiences.  Just as multiple pathways to graduate school exist, there is no single suicidal profile for graduate students (or anyone, for that matter).

Summary 

Academia can be a relatively unforgiving environment, especially for those vulnerable to or already struggling with mental health issues. Although I’ve discussed variety of unique risk factors that can increase susceptibility for suicide in this population, numerous others exist — especially among minority groups (i.e., women, international students, etc). The alarming magnitude of this problem demands more effective prevention and intervention efforts. Hence, in the upcoming post, I will discuss issues related to stigma, service access/utilization, policy change, and treatment.  Stay tuned!

*          *         *

(1) Names were changed to protect the privacy of each individual

References

1. Cao, J., Chen, J. M., Kuang, L., Ai, M., Fang, W. D., Gan, Y., … & Lv, Z. (2015). Abnormal regional homogeneity in young adult suicide attempters with no diagnosable psychiatric disorder: a resting state functional magnetic imaging study. Psychiatry Research: Neuroimaging, 231(2), 95-102.
2. Clance, P. R., & Imes, S. A. (1978). The imposter phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychotherapy: Theory, Research & Practice, 15(3), 241.
3. Davidson, C. L., Babson, K. A., Bonn‐Miller, M. O., Souter, T., & Vannoy, S. (2013). The impact of exercise on suicide risk: examining pathways through depression, PTSD, and sleep in an inpatient sample of veterans. Suicide and life-threatening behavior, 43(3), 279-289.
4. Downs, N., Feng, W., Kirby, B., McGuire, T., Moutier, C., Norcross, W., … & Zisook, S. (2014). Listening to depression and suicide risk in medical students: the Healer Education Assessment and Referral (HEAR) program. Academic Psychiatry, 38(5), 547-553.
5. Fink-Miller, E. L. (2015). Provocative work experiences predict the acquired capability for suicide in physicians. Psychiatry Research, 229(1-2), 143-147.
6. Garcia-Williams, A. G., Moffitt, L., & Kaslow, N. J. (2014). Mental health and suicidal behavior among graduate students. Academic psychiatry, 38(5), 554-560.
7. Hadjioannou, X., Shelton, N. R., Fu, D., & Dhanarattigannon, J. (2007). The road to a doctoral degree: Co-travelers through a perilous passage. College Student Journal, 41(1), 160.
8. Harris, E. C., & Barraclough, B. (1997). Suicide as an outcome for mental disorders. A meta-analysis. The British Journal of Psychiatry, 170(3), 205-228.
9. Hartnett, R. T., & Katz, J. (1977). The education of graduate students. The Journal of Higher Education, 646-664.
10. Heikkinen, M., Aro, H., & Lönnqvist, J. (1994). Recent life events, social support and suicide. Acta Psychiatrica Scandinavica, 89(s377), 65-72.
11. Henriksson, M. M., Aro, H. M., Marttunen, M. J., Heikkinen, M. E., Isometsa, E. T., Kuoppasalmi, K. E. E. A., & Lonnqvist, J. K. (1993). Mental disorders and comorbidity in suicide. American journal of psychiatry, 150, 935-935.
12. Hunt, K., & Gable, K. N. (2013). Prevalence of depressive symptoms and obsessive–compulsive personality traits among pharmacy students. Currents in Pharmacy teaching and learning, 5(6), 541-545.
13. Hyun, J. K., Quinn, B. C., Madon, T., & Lustig, S. (2006). Graduate student mental health: Needs assessment and utilization of counseling services. Journal of College Student Development, 47(3), 247-266.
14. Hyun, J., Quinn, B., Madon, T., & Lustig, S. (2007). Mental health need, awareness, and use of counseling services among international graduate students. Journal of American College Health, 56(2), 109-118.
15. Jairam, D., & Kahl Jr, D. H. (2012). Navigating the doctoral experience: The role of social support in successful degree completion. International Journal of Doctoral Studies, 7, 311-329.
16. Joiner, T. (2015, April). Acute Suicidal Affective Disturbance (ASAD): A New and Needed Diagnostic Entity.  Paper presented at the 48th annual conference of the American Association of Suicidology, Atlanta, GA.
17. Joiner, T. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.
18. Klonsky, E. D., & May, A. M. (2015). The three-step theory (3ST): A new theory of suicide rooted in the “ideation-to-action” framework. International Journal of Cognitive Therapy, 8(2), 114-129.
19. Law, K.C., Khazem, L.R.,  Jin, H.M., & Anestis, M.D., (In Press). Non-suicidal self-injury and frequency of suicide attempts: The role of pain persistence. Journal of Affective Disorders.
20. Li, Y., Zhang, J., & McKeown, R. E. (2009). Cross-sectional assessment of diet quality in individuals with a lifetime history of attempted suicide. Psychiatry Research, 165(1), 111-119.
21. May, A. M., Klonsky, E. D., & Klein, D. N. (2012). Predicting future suicide attempts among depressed suicide ideators: a 10-year longitudinal study. Journal of psychiatric research, 46(7), 946-952.
22. Smith, E., & Brooks, Z. (2015). Graduate student mental health 2015. National Association of Graduate-Professional Students (NAGPS) & University of Arizona Graduate Professional Student Council Survey.
23. Stanley, I. H., Rufino, K. A., Rogers, M. L., Ellis, T. E., & Joiner, T. E. (2016). Acute Suicidal Affective Disturbance (ASAD): A confirmatory factor analysis with 1442 psychiatric inpatients. Journal of psychiatric research, 80, 97-104.
24. Toews, J. A., Lockyer, J. M., Dobson, D. J., Simpson, E., Brownell, A. K., Brenneis, F., … & Cohen, G. S. (1997). Analysis of stress levels among medical students, residents, and graduate students at four Canadian schools of medicine. Academic Medicine, 72(11), 997-1002.
25. Tsai, J. W., & Muindi, F. (2016). Towards sustaining a culture of mental health and wellness for trainees in the biosciences. Nature biotechnology, 34(3), 353-355.
26. Tucker, R. P., Michaels, M. S., Rogers, M. L., Wingate, L. R., & Joiner, T. E. (2016). Construct validity of a proposed new diagnostic entity: Acute Suicidal Affective Disturbance (ASAD). Journal of affective disorders, 189, 365-378.
27. Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner Jr, T. E. (2010). The interpersonal theory of suicide. Psychological review, 117(2), 575.
28. Witte, T. K., Correia, C. J., & Angarano, D. (2013). Experience with euthanasia is associated with fearlessness about death in veterinary students. Suicide and Life-Threatening Behavior, 43(2), 125-138.
29. You, F., & Chen, Z. (2012). Impacts of academic stress, self-efficacy and optimism on suicide ideation of doctoral students. Chinese Journal Of Clinical Psychology, 20(5), 662-665.

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