Depression and Suicide _ ______________________________________________________________________
College Students Suicide is the second most common cause of death among college students, with an estimated 1,000 students taking their lives on college campuses each year. More than 50% of college students report having had suicidal thoughts, and another 10% report a serious suicide attempt. An estimated 80% to 90% of college students who died by suicide were not receiving help from college counseling centers [387]. A study published in 2019 from the American College Health Association/National College Health Assessment survey assessed mental health diag- noses and suicidality from more than 67,000 undergraduate students across 108 institutions [388]. According to the results, one in five students have had thoughts of suicide, with 9% making a suicide attempt and 20% reporting self-injury [388]. Students leaving home for college face unique challenges that may increase suicide risk in vulnerable students, including separation from support systems and social networks, academic stress, pressure to succeed, feelings of isolation, poor coping skills, and mental health stigma. Gender and Sexual Minority Youth The Centers for Disease Control and Prevention published the first-ever nationally representative survey on the health risks of gay, lesbian, and bisexual high school students in 2016 [389]. Nationwide, 88.8% of students identified as heterosexual, 2.0% as gay or lesbian, 6.0% as bisexual, and 3.2% as unsure of their sexual identity [389]. Overall, sexual minority youth are more likely than their heterosexual counterparts to experi- ence adverse experiences and suicidality ( Table 7 ). Sexual orientation or gender identity harassment and being threatened or injured with a weapon at school are the most damaging forms of school-based victimization for sexual minor- ity adolescents, and these factors have the greatest association with suicidality [390]. For sexual minority youth, risk factors for bullying and violence include social isolation, lack of parental support, lack of safety or support at school, and harmful norms about masculinity and femininity associated with violence against those seen as not masculine or feminine enough [389]. Bullying and violent victimization of youth perceived as violat- ing gender norms can occur through sexual orientation-based victimization (from perceived or actual same-sex attraction) or gender-variant-based victimization (from presentation perceived to resemble gay or lesbian stereotypes) [391; 392]. Heterosexual youth whose appearance, mannerisms, or behaviors are perceived by peers as violating gender norms are also vulnerable to gender-variant-based victimization. This type of victimization is significantly associated with suicidal thoughts and behaviors in middle and high school students and potentially serious psychologic outcomes similar to those experienced by same-sex attracted adolescents [393].
PATHOPHYSIOLOGY OF SUICIDAL BEHAVIOR Suicidality is a distinct, multidimensional clinical condition now thought to result from interactions among biologic, social, and psychologic vulnerability factors, proximal biopsychosocial events acting as precipitants, and epigenetic factors [350; 351; 376]. The pathophysiology of suicide is distinct from comorbid psychiatric diagnoses. Previous research identified underlying processes in suicidal ideation, but assumptions that ideation predicted suicide attempts is now disproven, with efforts focused on identifying the underlying pathways to suicide. To advance this research, two empirically confirmed models of suicide have been developed. The stress-diathesis model of suicidal behavior describes long-term vulnerability to suicide, activated by psychosocial or psychiatric crises [376]. The interpersonal theory of suicide proposes desire and capabil- ity as the principal factors contributing to suicidal behavior. Suicidal desire is explained by high levels of burdensomeness (i.e., a belief one is an unwanted burden to family/peers) and thwarted belongingness (i.e., social alienation and loneliness). Capability of suicide reflects the sum of noxious stimuli, trau- matic events, and experiences of death and pain [377]. Some suicide neurobiology has also been established, such as associations between suicide and gene variations in the HPA axis, serotonin systems, noradrenergic systems, and polyamines that promote functional alterations. In the absence of gene variations, gene expression can become altered by exposure to extreme or chronic stress, becoming both cause and effect of neurobiologic response [376; 378]. Abnormal function in several neurobiologic systems is asso- ciated with suicidal behavior, including the HPA axis, sero- tonergic system, and noradrenergic system. Dysfunction of these systems is associated with impaired regulation of anxiety, impulsivity, and aggression, which may result from genetic variation and environmental stressors (and their interaction) [379; 380]. This may lead to dysfunctional information process- ing, eventually contributing to increased capability of suicide [378; 381]. Immune system dysregulation is also believed to contribute to suicidality, but the role of inflammatory condi- tions has not been clearly delineated [382].
SUICIDE AND SPECIAL POPULATIONS Youth
Before 18 years of age, 12.1% of youth report suicide ideation and 4.1% make at least one attempt [383]. In 2019, 534 chil- dren died by suicide, a rate of 2.6 for every 100,000 children between the ages 10 and 14 years [384]. Between 2008 and 2015, encounters for suicide ideation or attempt at children’s hospitals nearly doubled [385]. The presence of acne is associ- ated with social and psychologic problems and twice the rate of suicidal ideation [386].
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