Suicide and deliberate self-harm in Oxford University students over a 30-year period

Suicidal behaviour among the university students in the UK: A systematic review

Introduction

Identifying risk factors would help consider suicide prevention in any specific population. We aimed to assess suicidal behaviour among university students in the UK.

Methods

An extensive keyword search was conducted through PubMed, Cochrane, CINHAL Plus, PubMed Central, Web of Science, Trip database, and Science Direct, following the PRISMA guidelines to identify different publications. The search strategy for the literature review was based on the Population Exposure Outcome framework. Critical appraisal utilised the CASP tool for cohort studies and the AXIS tool for cross-sectional studies, resulting in 14 included studies. A narrative synthesis was performed.

Results

Postgraduate and undergraduate students used different suicidal methods such as poisoning, jumping, hanging, drowning, and suffocating, with jumping most preferred by male students. The predisposing factors of suicide among university students included: mental health problems (depression, psychological stress, psychosis, mania, neuroticism, financial anxiety, imperfect parents' connection with students), sexual orientation with risk of suicide among non-heterosexual students due to lowered self-esteem from feeling disregarded, disrespected and insufficient attention from the surrounding. Suicidal behaviour was high among unmarried students, male and unemployed female students, and students with childhood experiences such as physical abuse, family violence, emotional abuse, neglect, and physical punishment-gender, with females seeking more services from general hospitals with more suicide attempts in older females. High risk was also noted in males, with increased risk in white students compared to black students.

Conclusion

The review highlighted that students with previous mental health problems, a history of experiencing sexual abuse in childhood, bad relationships with their mother, disrespect and disregard in the community due to sexual identity are the major contributing factors for suicide among university students in the UK.

Self-harm in university students: A comparative analysis of data from the Multicentre Study of Self-harm in England

BACKGROUND

Increases in poor mental health and suicide have been identified among university students in the UK. However, little is known about self-harm in this group.

AIMS

To describe and identify care needs of university aged-students who self-harm via comparisons with an age-equivalent non-student group who self-harm.

METHODS

Observational cohort data from The Multicentre Study of Self-harm in England were used to investigate students aged 18 to 24 years who presented to emergency departments for self-harm, 2003 to 2016. Data were collected via clinician reports and medical records from five hospitals in three English regions. Characteristics, rates, repetition, and mortality outcomes were investigated.

RESULTS

The student sample included 3491 individuals (983, 28.2 % men; 2507, 71.8 % women; 1 unknown) compared to 7807 (3342, 42.8 % men; 4465, 57.2 % women) non-students. Self-harm increased over time in students (IRR 1.08, 95%CI 1.06-1.10, p < 0.01) but not in non-students (IRR 1.01, 95%CI 1.00-1.02, p = 0.15). There were differences in monthly distribution of self-harm with more presentations by students in October, November, and February. Characteristics were broadly similar, but students reported more problems with studying and mental health. Repetition (HR 0.78, 95%CI 0.71-0.86, p < 0.01) and mortality (HR 0.51, 95%CI 0.33-0.80, p < 0.01) were lower in students than non-students.

CONCLUSIONS

Self-harm in students may be directly related the student experience, such as academic pressure, relocation, and the transition to independent living. Wellbeing initiatives targeting these factors, alongside mental health awareness training for academic and non-academic staff may help to support students at risk.

Alcohol and the Risk of Railway Suicide

Suicide is one of the ten most common causes of death in the world. Of all deaths from suicide, 22% can be attributed to the use of alcohol, which means that every fifth suicide would not occur if alcohol were not consumed by the population. People under the influence of alcohol choose more radical and effective methods of dying by suicide, e.g., throwing themselves under a moving vehicle, such as a train. The presented analysis aimed to determine important risk factors affecting railway suicide in Poland and their relation to the state of alcohol intoxication of the victims, and the relationship between ethyl alcohol consumption and the phenomenon of suicide. Documentation obtained from the Department of Forensic Medicine at the Medical University of Warsaw, in the form of death registers and forensic medical records concerning examination and autopsy, was analyzed. This made it possible to identify suicide victims from among pedestrian victims of railway accidents recorded during the period under study. The research was carried out using unidimensional and multidimensional statistical analyses with IBM SPSS Statistics, version 25. Sober suicide victims were statistically significantly older than victims under the influence of alcohol; alcohol concentration was correlated with the age of the victims-the older the victims were, the higher the alcohol concentration. A significantly higher number of deaths attributed to suicide by sober victims was observed in autumn compared to other seasons. Multidimensional analysis showed a statistically significant effect of age and season on the probability of dying by suicide under the influence of alcohol-this probability decreases with the age of the victims and is also significantly lower in autumn. The observed relationship between age and the presence of alcohol in suicide victims can be the cause of railway suicides. Knowledge of the mechanisms of seasonal variability of suicidal behavior can help to develop effective strategies to prevent railway suicides. It is necessary to improve the system of reporting railway suicides, as only reliable statistics provide the possibility of assessing both the scale of the problem and the effectiveness of actions taken.

The long-term mental health of Australia's tertiary students

PURPOSE

The objective of the current study was to quantify the extent to which Australia's tertiary students have reported poorer mental health in comparison with the general community between 2001 and 2017.

METHODS

Data were derived from the Household, Income and Labour Dynamics in Australia Survey, a longitudinal household-based panel study. There were 29,124 participants who provided at least one observation over the study period. On average, participants provided 7.4 observations. Mental Health was assessed with the SF-36 mental health and vitality subscales.

RESULTS

There was little evidence for differences in mental health and vitality between those studying at tertiary levels and those not in tertiary education. Age-stratified analyses revealed that any differences were reported by older students. Interactions between education level and time revealed that the association between tertiary study and mental health outcomes has been consistent over time.

CONCLUSION

There were very few differences between those in and those not in tertiary education. The magnitude of any differences was very small and does not necessarily reflect substantial poor mental health outcome. Overall, the most consistent finding was that there was little risk for poor mental health outcomes attributed to tertiary study.

Suicide Deaths in University Students in a UK City Between 2010 and 2018 - Case Series

Background: There are longstanding concerns over the mental health and suicide risk of university students in the UK and internationally. Aims: This study aimed to identify risk factors for suicide among students attending universities in a UK city. Method: Suicide deaths between January 2010 and July 2018 were identified from university records. An audit tool was used to collate data from university records and coroners' inquest files. Results: A total of 37 student deaths were identified. Only 10.8% of the students had disclosed a mental health issue at university entry. There was strong statistical evidence that students who died by suicide were more likely to have been male, experiencing academic difficulties (repeated years, changing course, and suspension of studies were all associated with a 5-30-fold increased risk), and in need of financial support compared with other students. Limitations: The coroners' records were only available for around half of the deaths. Healthcare records were not available. Conclusion: Markers of academic and financial difficulty should be considered as flags to identify students at heightened risk. Whilst the relative risk associated with academic difficulties is high, the absolute risk is low. Improved disclosure of mental health issues at university registration could facilitate targeted support for vulnerable students.

The incidence of suicide in University students in England and Wales 2000/2001-2016/2017: Record linkage study

BACKGROUND

There are growing concerns about the mental health and risk of suicide amongst university students.

AIM

To investigate trends in the incidence and characteristics of university student suicides in England & Wales for the academic years 2000/01 to 2016/17.

METHOD

Record linkage between Office for National Statistics mortality data and Higher Education Statistics Agency data for England and Wales. Poisson regression and chi-squared tests were used to investigate secular trends and the characteristics of students dying by suicide.

RESULTS

There were 1330 student suicide deaths from 2000/01 to 2016/17; the annual incidence in 2015/16-2016/17 was 4.7 per 100,000 students. There was evidence of a rise in incidence since 2009/10 (incidence rate ratio per year 1.04 ((95%CI 1.00-1.07) p = 0.029). Incidence in 2012/13 to 2016/17 was less than half the rate in the general population of a similar age. Incidence was higher in males than females and amongst undergraduates vs. postgraduates. There was some evidence of a reduced risk amongst black compared to white students (RR 0.53 (95%CI 0.32-0.88). Incidence was highest in January and lowest during the summer holidays (July-September).

LIMITATIONS

There was no age/sex or sociodemographic breakdown of the overall student population for 2000/01 to 2011/12.

CONCLUSION

Rates of suicide are considerably lower amongst students than the general population. In keeping with trends in young people in the wider population, the incidence of student suicide has increased since 2009/10. To inform prevention, research is needed to understand reasons for the rise in suicide in young people.

Ongoing university studies and the risk of suicide: a register-based nationwide cohort study of 5 million young and middle-aged individuals in Sweden, 1993-2011

OBJECTIVES

To investigate the risk of suicide, unnatural death and all-cause death in university students compared with non-students, taking previous educational attainment into account.

DESIGN

Open cohort study of all residents aged 18-39 and living in Sweden at any time between 1 January 1993 and 31 December 2011.

SETTING

We linked data from national registers and calculated person-years during university studies for three time periods (1993-1999, 2000-2005 and 2006-2011). Time as non-student was calculated and categorised according to attained educational level. Incidence rate ratios (IRR) with 95% CIs were calculated with Poisson regression models, controlling for age and period.

PARTICIPANTS

The cohort consisted of 5 039 419 individuals, 51% men and 49% women.

MAIN OUTCOME MEASURES

Incidence of suicide (International Classification of Diseases (ICD)-9: E950-E959, ICD-10: X60-X84) or death with undetermined intent (ICD-9: E980-E989, ICD-10: Y10-Y34), unnatural death (ICD-9: E800-E999 and ICD-10: V01-Y99) and all-cause death.

RESULTS

A total of 7316 deaths due to suicide were identified, of which 541 were registered among university students. The risk of suicide was twofold during ongoing university studies compared with when having attained university education, IRR 2.37 (95% CI 2.07 to 2.72) in men and IRR 2.15 (95% CI 1.77 to 2.61) in women.

CONCLUSIONS

Having ongoing university studies was associated with a higher risk of suicide compared with having attained university-level education. This finding highlights the importance of achieving a deeper understanding of suicidal behaviour during years at university. Further studies should assess risk factors for suicide and suicidal behaviour in university students.

Suicide in a National Student Mental Health Patient Population, 1997–2012

Abstract. Background: Entering higher education is a time of transition that coincides with the typical age of onset of serious mental illness. Awareness of the distinguishing characteristics of students with mental illness who die by suicide may inform clinical management. Aim: We aimed to compare the characteristics of mental health patients who died by suicide as students with other young people who died by suicide. Method: UK data were analyzed for individuals aged 18–35 years in contact with mental health services who died by suicide from 1997 to 2012. Univariate analyses examined the sociodemographic, behavioral, and clinical features of those who died as students. Backward stepwise regression analysis identified factors independently associated with student deaths. Results: In all, 214 university students died by suicide within 12 months of mental health service contact. Factors associated with student deaths were: being younger, female, from an ethnic minority group, and a primary diagnosis of affective disorder. Medication nonadherence was less likely to be associated with student deaths. Conclusion: Deaths by suicide are split almost equally between male and female students, unlike the predominance of male suicide in the general population. There are clear differences in the characteristics of the student and nonstudent groups, although causation could not be established.

Tweens feel the burn: "salt and ice challenge" burns

PURPOSE

To review our institution's experience with frostbite injury secondary to "salt and ice challenge" (SIC) participation.

METHODS

We conducted a retrospective analysis of intentional freezing burns from 2012 to 2014. Demographics, depth and location of burn, total body surface area of burn, treatment, time to wound healing, length of stay, complications, and motives behind participation were analyzed.

RESULTS

Five patients were seen in the emergency department for intentional freezing burns that resulted from SIC (all females; mean age: 12.3 years; range age: 10.0-13.2 years). Mean total body surface area was 0.408%. Salt and ice was in contact with skin for >10 min for two patients, >20 min for two patients, and an unknown duration for one patient. Complications included pain and burn scar dyschromia. Four patients cited peer pressure and desire to replicate SIC as seen on the Internet as their motivation in attempting the challenge.

CONCLUSION

SIC has become a popular, self-harming behavior among youths. Increased public education, and provider and parent awareness of SIC are essential to address this public health concern.

Management of common behaviour and mental health problems

Behavioural problems are usually influenced by both biological and environmental factors. Disruptive behavioural problems such temper tantrums or attention deficit hyperactivity disorder are displayed during the first years of childhood. Breath-holding attacks are relatively common and are an important problem. Although the attacks are not serious and the prognosis is usually good, parents often fear that their child may die during an attack. Parents therefore require explanation and reassurance from health professionals. Conduct disorders (often referred to as antisocial behaviours), such as aggression to others or theft, are more serious as they tend to be repetitive and persistent behaviours where the basic rights of others are violated. Emotional problems, such as anxiety, depression and post-traumatic stress disorder tend to occur in later childhood, and are often unrecognised because young children often find it difficult to express their emotions, or it may go unnoticed by the child's parents. This article briefly discusses the most common behavioural problems, including autism, that affect children of all ages.

Confronting death from drug self-intoxication (DDSI): prevention through a better definition

Suicide and other self-directed violence deaths are likely grossly underestimated, reflecting inappropriate classification of many drug intoxication deaths as accidents or unintentional and heterogeneous ascertainment and coding practices across states. As the tide of prescription and illicit drug-poisoning deaths is rising, public health and research needs would be better satisfied by considering most of these deaths a result of self-intoxication. Epidemiologists and prevention scientists could design better intervention strategies by focusing on premorbid behavior. We propose incorporating deaths from drug self-intoxication and investigations of all poisoning deaths into the National Violent Death Reporting System, which contains misclassified homicides and undetermined intent deaths, to facilitate efforts to comprehend and reverse the surging rate of drug intoxication fatalities.

Promising strategies for advancement in knowledge of suicide risk factors and prevention

Suicide is an important public health problem. Although there have been advances in our knowledge of suicide, gaps remain in knowledge about suicide risk factors and prevention. Here, we discuss research pathways that have the potential to rapidly advance knowledge in suicide risk assessment and reduction of suicide deaths over the next decade. We provide a concise overview of the methodologic approaches that have the capacity to rapidly increase knowledge and change practice, which have been successful in past work in psychiatry and other areas of medicine. We suggest three specific pathways to advance knowledge of suicide risk factors and prevention. First, analysis of large-scale epidemiologic surveys and administrative data sets can advance the understanding of suicide. Second, given the low base rate of suicide, there is a need for networks/consortia of investigators in the field of suicide prevention. Such consortia have the capacity to analyze existing epidemiologic data sets, create multi-site cohort studies of high-risk groups to increase knowledge of biological and other risk factors, and create a platform for multi-site clinical trials. Third, partnerships with policymakers and researchers would facilitate careful scientific evaluation of policies and programs aimed at reducing suicide. Suicide intervention policies are often multifaceted, expensive, and rarely evaluated. Using quasi-experimental methods or sophisticated analytic strategies such as propensity score-matching techniques, the impact of large-scale interventions on suicide can be evaluated. Furthermore, such partnerships between policymakers and researchers can lead to the design and support of prospective RCTs (e.g., cluster randomized trials, stepped wedge designs, waiting list designs) in high-risk groups (e.g., people with a history of suicide attempts, multi-axial comorbidity, and offspring of people who have died by suicide). These research pathways could lead to rapid knowledge uptake between communities and have the strong potential to reduce suicide.

Measurement of perceived functions of non-suicidal self-injury for Chinese adolescents

Due to the lack of validated assessment tools for motives of non-suicidal self-injury behaviors in the Chinese contexts, this study aims to evaluate the psychometric properties of the Chinese version of the Functional Assessment of Self-Mutilation (C-FASM). A total of 345 secondary school students (mean age = 11.41 years), who reported non-suicidal self-injury in the past year, voluntarily participated in the questionnaire survey. Confirmatory factor analysis results supported a second-order model of 4 motivational factors. The overall scale scores had significant correlations with depression, anxiety, impulsiveness, self-esteem, social support, and suicidal ideation. The internal consistency of the scale was also satisfactory. The C-FASM is a valid and reliable instrument for assessing non-suicidal self-injury among nonclinical Chinese adolescents.

Adolescent non-suicidal self-injury (NSSI) in German-speaking countries: comparing prevalence rates from three community samples

PURPOSE

Non-suicidal self-injury (NSSI) has been recognized as a significant mental health problem in adolescence with high prevalence rates. To date, there are few studies that compare rates of adolescent NSSI between different countries. Thus far no prevalence rates of adolescent NSSI have been reported for Austrian or Swiss community samples.

METHODS

This study aimed to assess and compare rates of adolescent NSSI in school samples from Austria, Germany and Switzerland using the same assessment instrument (Ottawa Self-Injury Inventory; OSI).

RESULTS

Within these countries, 6-month prevalence rates between 7.6 and 14.6% were found, with rates showing significant differences between countries (χ² = 16.54, p = 0.02).

CONCLUSIONS

These results demonstrate with some variability the significant rates of NSSI in youth in a cross-country study.

Method choice in nonfatal self-harm as a predictor of subsequent episodes of self-harm and suicide: implications for clinical practice

OBJECTIVES

We examined time-varying and time-invariant characteristics of nonfatal intentional self-harm episodes in relation to subsequent episodes of self-harm and suicide.

METHODS

We conducted a follow-up cohort study through 2007 of 3600 patients discharged from hospitals in New Jersey with a primary diagnosis of intentional self-harm in 2003. We determined repetition of self-harm from hospital records and suicide from state registers.

RESULTS

Use of methods other than drug overdose and cutting in self-harm events, greater medical severity of nonfatal episodes, and a history of multiple self-harm episodes increased the risk of suicide. However, most suicides occurred without these risk factors. Most suicides took place without intervening episodes of self-harm, and most persons used a low-lethality method (drug overdose or cutting) in their index episode, but switched to a more lethal method in their fatal episode.

CONCLUSIONS

Our findings suggest that preventing suicide among persons with a history of self-harm must account for the possibility that they will adopt methods with higher case-fatality ratios than they previously tried.

Coping with job stress by hospital doctors: a comparative study

BACKGROUND

Currently only few studies exists focusing on cross-cultural differences in job stress and stress management. The present study aimed to examine and compare job stress and coping behaviour of Australian and German physicians.

METHODS

The present study was designed as a cross-sectional comparison using questionnaire data of 310 German and 256 Australian hospital doctors. The questionnaires contained items on demography and self-rated subjective coping strategies. The Perceived Stress Questionnaire (PSQ) and the Brief COPE Questionnaire were used to analyze national differences in coping behaviour.

RESULTS

According to the comparison, German physicians perceived higher values of job stress. Coping behaviour differed significantly between the two doctor samples.

CONCLUSIONS

This study demonstrated a number of similarities, but also some unexpected differences in Australian and German doctors' job stress and coping strategies. These findings may help direct further research on cross-cultural investigations and health promotion interventions in both countries.