Tuesday, October 10, 2006

Suicidal Students

This past March, The Washington Post ran an article about a college student who was forced to withdraw from George Washington University after he was hospitalized for suicidal ideation.

About 2 a.m. one sleepless night, sophomore Jordan Nott checked himself into George Washington University Hospital.
He was depressed, he said, and thinking about suicide.

Within a day and a half of arriving there, he got a letter from a GWU administrator saying his "endangering behavior" violated the code of student conduct. He faced possible suspension and expulsion from school, the letter said, unless he withdrew and deferred the charges while he got treatment.
In the meantime, he was barred from campus.

I thought of writing a post back then, but perhaps there was more to the story? How could a student be dismissed for suicidal ideation? It's like the thought police, and does the school dismiss every student hospitalized for depression (--let's face it, you just don't get hospitalized unless you say you're going to kill yourself, so almost by definition....)? Not that the media has ever biased a story, but I was left hoping this just couldn't be and that there was more to it. Just in case the reader isn't sympathetic enough to this poor young man's plight, the article goes on to tell us that his depression began after a close friend, his would-be roommate, died by throwing himself out the window while Jordan pounded outside his locked door. The event is a few years old and the young man now attends another university-- it's news now because he's suing GW.

Just the idea got me worked up: if college students know they can be suspended/expelled/dismissed for suicidal thoughts, of course they won't get treatment. Un- and under-treated depressives will proliferate, students who might otherwise succeed may fail out, suicide rates will rise. Just the idea that someone should suffer what amounts to an academic public hanging for Seeking Care, is outrageous from this psychiatrist's point of view.

So, I journeyed over to The Last Psychiatrist where he/she is posting about a Hunter College student who successfully sued the university after being expelled for a suicide attempt. The student returned from a four-day hospitalization after an overdose to find her dorm room locks had been changed. The school settled for $65,000, probably a lot less than the settlements on cases where parents sue the schools after a child has had a completed suicide.

What surprised me was that The Last Psychiatrist sides with the schools: he titles his post "Psychiatrists On the Wrong Side of Civil Rights, Again" and his link to the article about the lawsuit is titled Hunter College Caves to Lawyers. He feels suicidal students should be dismissed from colleges:

The problem with this statement is its logical conclusion: when can a school exclude students who seek help? Never? Let's say the next time she tries suicide by turning the gas on, and she blows the dorm up. Oops?

Hmmm....what about on a case-by-case basis? What they're doing with these blanket, or partial blanket (GW has 200 students/year treated for depression &/or suicidal thoughts, they don't all get thrown out) is making it so students don't get treatment. Face it, college students commit suicide, sometimes they give warning signals and attempt to get help first, often they don't. Just because you're afraid you'll get kicked out of school if you tell someone you're thinking of blowing up the dorm, doesn't mean you Won't do it. It's a little like being a pedophile who wants to get treatment: the barriers to getting treatment may outweigh the risk of not getting help (go to town, ClinkShrink).

I brought this topic up at Coffee with the Judge and another friend this morning (my dog Max's playgroup). I was surprised that they both felt suicidal students should be dismissed: too much liability for the school-- if the school is aware there's a risk and a student suicides, the parent might then sue. The Judge thought that all students treated for depression should be forced to sign agreements that their parents can be informed of their illness as a condition of attendance, so the school could be released from liability. What an interesting thought.

And to think, with all those commercials, with mentally ill celebrities coming out, with mental health awareness issues and disability discrimination legislation, one might have believed we were destigmatizing mental illness. I don't think so.


Anonymous said...

I'm a physician (not a psychiatrist, though), and I sometimes screen for suicidal ideation, but I'm not convinced that anybody would say "yes" when I ask "Are you having any thoughts about hurting yourself or anybody else?", (in the 4 years since I finished medical school, nobody has; I'm never sure if it's because that may not be a particularly effective way to screen, or because people don't generally admit to suicidality, or if I just have a particularly happy nonsuicidal group of patients).

I agree that creating negative consequences for seeking treatment for depression and suicidality seems to discourage people from getting treatment, and I can imagine someone (or their family, if something unfortunate happened) suing over it, claiming that they couldn't seek treatment for their depression because they thought they'd be kicked out of school, so I don't even think that that policy really limits liability (even if the schools feel like it does).

I wonder if its a reaction to the school violence that's been more on everybody's radar since the whole Columbine thing?

Anonymous said...

There are a few reasons I come down on the school's side:

1. They are evicting the student from housing, not kicking them out of school. It's hard (though not impossible) to make the argument that suicide endangers the scholastic system. But it is very easy to make the argument that suicide endangers other dorm residents (my gas example).

2. They're not evicting her for being depressed or even feeling suicidal-- they are evicting her for attempting suicide. We can argue whether being depressed is biological or under volitional control; but certainly, unquestionably, suicide attempts are entirely the free will of the individual. The causes for the attempt may be out of their control, but the act is theirs alone. Behaviors have consequences. Illness or not, she does not retain the right to attempt suicide _on her terms_, on school property, etc.

3. The argument that this inhibits "patients" from getting the help they need isn't obviously true. Why would it? Remember, you don't get evicted for having suicidal thoughts; you get evicted for putting knife to wrist. Are we saying that an eviction rule make it _more_ likely they will attempt suicide?

4. I'm all for looking at things on a case by case basis. But it's untenable, because no one will accept the responsibility. At the end of the case review, who signs off? Does the psychiatrist say, "she's okay to return" and thus accept the liability? Does the school get to say, "well, psych said it was ok, so you can't blame us?" We're in this trap because _someone_ has to be responsible; and if we are saying it isn't her, then it _is_ someone else.

The Last Psychiatrist

Dinah said...

To Anonymous: gosh, most of my patients have suicidal thoughts at times (some at lots of times) and most have passive death wishes when they are feeling depressed. Then again, I'm a psychiatrist.

To TLP: the GW student was hospitalized for Suicidal Thoughts, forced to withdraw from classes, and barred from the campus: my only source is the Washington post article so if there is more to the story, I'm clueless. I imagine there may be. These cases are addressed by disciplinary committees, not as health issues. I'm not completely certain as to where the line is for a suicide attempt (an extra sleeping pill? Exactly how many tylenol?).

To AC: wishfully true that a request for help is a desire to live, and mostly I think you're right, but there are people who seek treatment and still kill themselves before they give it a chance to work.

Sarebear said...

I SO agree with this post.

DrivingMissMolly said...

There have been many opportunities recently for the media to engage or provoke meaningful discussion about mental illness. They failed.

In Texas, Dallas Cowboy Terrell Owens was rushed by ambulance to the hospital after his publicist called 911. At first it was reported to have been a suicide attempt, but then it was spun to be a bad reaction caused by mixing pain meds with "natural" supplements. There was a mad rush to push the entire "suicide attempt" thing under the rug and it seemed that he was rushed to practice and play again to prove he was well. If indeed he was suicidal, he did not get the help he needed and although I am not fond of the guy, I hope that he doesn't try to kill himself in the future resulting in his maiming or death. I heard the 911 audio. It sounded like a suicide attempt to me.

Then there's the case of Trenton Duckett,the 2 year old toddler who allegedly was abducted from his mother's Leesburg, Florida home. Later, the authorities deemed the mother, Melinda Duckett, to be the primary suspect in the case. She comitted suicide shortly after an interview with the hard-hitting Nancy Grace. On Nancy's show it was revealed that Melinda suffered from OCD and had a history of cutting behavior. Nancy Grace's response? "If she did that to herself imagine what she would do to another person." I was shocked that an intelligent, educated woman would intimate that self-injury could go hand in hand with murder/kidnapping (the baby is probably dead).

Finally, there is the case of Anna Nicole Smith's son, Daniel. Before the American pathologist's report came out stating that Daniel's death was caused by a fatal arrhythmia brought about by a mixture of Lexapro, methadone and Zoloft, every headline screamed; "There were anti-depressants in his system!" as if that alone should be explanation enough for his untimely demise. Heaven forbid someone have antidepressants in their system!

It's not enough that suicidality, depression and mental illness in general are stigmatized, people in the media sometimes disseminate wrong information and that just makes the situation worse.

There is one positive note played by Oprah, however. Last week she had a show that featured three suicide attempt survivors. Although the show focused more on the individual stories, she did give some attention to signs of depression and of impending suicide which was good. She gave out phone numbers for help lines as well.

I was recently out on disability for a couple of weeks due to depression/mental illness issues. When I came back only one person asked me how I was. If I had been out for a broken leg or surgery or cancer, there is no doubt the response would have been different.

Anonymous said...

Responding to Alison Cummins's gay example:

the analogy isn't sound. The analogy you are making is

"being suicidal" is to "acting out the suicidality" as "being gay" is to "having gay sexual contact"

I think you see the flaw. "Being gay" is a description of identity; "being suicidal" is a description of a state.

If you want to use a sexual analogy, then it has to be one based on volition, not identity.

suicidal:acting out the suicidality::having lustful thoughts for someone other than your spouse:acting out on having lustful thoughts on your spouse.

I don't mean to make it judgmental in the sense of morality; just to show it is a choice to act on an impulse which is not part of the necessary fiber of your being.

Which refers to why these issues are handled by diciplnary committees and not mental health committees: they aren't judging the acceptability of the student's mental health, they're making judgments about the acceptability of their behaviors. And they find them unacceptable.

That's the school's right; they get to set the rules on behavior, as long as it doesn't violate constitutional rights. Well, it _was_ their right, anyway.

Anonymous said...

Being a university student in the UK who has attempted suicide a number of times, I find this totally baffling. If suicide attempts had led to exclusion, I wouldn't even have finished high school, let alone got an honours degree followed by a diploma and gone on to my masters course. Maybe we just have different ligigation climates.

Anonymous said...

Sp - for ligigation read litigation.

FooFoo5 said...

If "liability" is the primary variable in clinical decision-making, how in the world can you practice psychiatry? Shall we hospitalize for 72-hours everyone who reports a SI, just to be safe? Then notify their employer, their landlord, and their neighbors (consider the moron doctor who blew himself & his home up in Manhattan recently) because of their possible exposure to "endangering behaviour?"

This sort of logic flies in the face of psychiatry as evidence-based medicine. What point, then, is research and bodies of evidence in psychiatry? Apparently no better than "cover my ass, I'm going to lunch." This is stumping psychiatry as either voodoo or "casino" science.

You do not lose lawsuits for decisions that are evidence-based, clinically sound, and made in "good faith," even if your decision is ultimately proved incorrect. You lose lawsuits for negligence: being and acting stupid. I, for one, had a great score on the LSAT.

And shame on those at GWU Hospital for not stepping up to defend this student if he was not a danger to others. They, first and foremost, should have been his mental health advocates.

PS Dinah, your computer crashes on my site because I had someone hang a chicken foot over your front door. It was a sound medical decision.

NeoNurseChic said...
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ClinkShrink said...

I can always tell when Dinah has put up a new post because I open my mailbox and have 20 new comments. Sheesh, nobody comments on my posts like that. I'm going to go eat worms.

What I think is interesting is the Coffee with the Judge opinion. This is the attitude we deal with in corrections so it didn't come as a surprise to me at all. I have seen judges order that someone be stripped down and placed in an observation cell for no other reason than that the person has a risk factor for suicide---like who in the correctional system doesn't have a risk factor---even when the person is asymptomatic and not expressing SI.

Inmates regularly deny suicide attempt histories at intake and I never accept a mental health screen form as gospel truth. They either completely deny a history or minimize the number of attempts. It's not until I reassure them that they won't get punished for telling me that they tell me the truth, often with significant relief.

Litigation is the only proper response to policies like this. When they realize they are spending more money to defend the policy than they would have spent paying out a suicide-related claim, they will change.

And Foo, if you hung out the chicken foot can I put giblets in her mailbox?

Anonymous said...

I know the GWU story well. I live here and actually had friends attending GW dring the rash of suicides at the school and when this story became big news in the area. The kid had no idea his personal psychiatric information would become known to the school administration. I'm sure if he had known, he might have gone to Georgetown hospital or some other local one.

I remember when I first read the story and how shocked I was at what the school did. I lost a lot of respect for GW after this incident. They showed that they care more about protecting themselves than the students the school was created to educate. I still get mad when I think about this story.

Some of these comments are defending the school, but this poor kid did the right thing getting help. The school failed him. I can't even imagine what this kid went through. You have to remember, he saw one of his best friends commit suicide and then was reminded of it shortly after when some more students committed suicide at the school. That would put anyone over the edge and make them depressed. He wasn't a danger to anyone except himself. If the school had issues with his suicidal thoughts, they should have approached the school couselors he was seeing and handled the matter privately (not that its their business anyways!). GWU messed up big time and I really hope they learned from their mistake.

This is one of the most stressful cities in the country. If the school wants to stop these suicides, then they need to be more open with the students and encourage them to talk when they need help...not bottle it up for fear of being kicked out of the school of their dreams. Aaargh!

Anonymous said...

EEK, In this post patriot act era, yes there really are thought police. What ever happened to patient confidentiality?? Are college students seeking help not eligible for this privledge??? You can anwer me at home later love abf

Anonymous said...

Back in the 90s, when I was in college, I became depressed and, yes, suicidal. I did what I thought I was supposed to do: I sought help. Being a poor college student, this meant going to the student mental health center, which was free. It had professional psychologists and such, though, so I though it would be perfect. (This was a large university, so they had quite a few resources.) I confessed my suicidal ideation to the psychologist I started seeing and he tried to help.

A couple weeks after I started seeing him, I was summoned to the Honor Code office. I wasn't told why I had to go, and it didn't make any sense. I hadn't cheated or broken any rules. The guy I met with asked if I knew why I was there. I told him no. He said he was there because of my suicidal issues. I was shocked. Wasn't this sort of thing supposed to be private?! The guy told me the school was considering kicking me out because of it because I was a liability, but they were going to be gracious and give me one more chance (I'm still not sure what that meant). I was so confused and freaked out (I just couldn't believe the things I told the psychologist weren't private) that I didn't even fight it or anything. I wish I had.

Obviously I didn't trust the psychologist any more, so I only saw him a few more times and told him nothing more so it was pointless. Still miserably depressed and, yes, still suicidal, I dropped out of school. Working part-time at a grocery store and not being independently wealthy, I had no means to see any other therapist, and I admit that first time made me not exactly trusting of the profession (an opinion I still hold today, though it has been some years).

Obviously I managed to not kill myself, and I did go back to school about a year later. However, not having the resources while I was out of school, nor desire once I was back in school (why go through the same thing again?), I never got help. I found my own way around killing myself: I ended up directing the suicidal depression into an eating disorder and cutting, which the school never knew about and thus I had no academic consequences, which lasted many years. I still struggle with the eating disorder.

I wonder today how much my life would be different (better?) if they school had not interfered. Would I have avoided some of the hell of the last decade? I sought help. Students should be able to do that without worrying about getting kicked out.

Steve & Barb said...

It seems that the throw-the-bum-out proponents are, as noted by several commenters, primarily motivated by risk management concerns. Problem is, by not getting help, the college now has many other *unsupervised* students contemplating who knows what.

Thus, this position increases the overall risk. And, an unfortunate family whose child suicides after worsening illness due to fear of getting help because of the school's policy would most likely also sue the school.

So, I argue that the school should do what's "right", rather than what appears to be least frought with liability.

Okay, now I'm coming from another logical direction... Say they *should* be expelled ("dismissed" is too polite, like they're getting up from the dinner table) because they are a public safety problem (like, maybe she'll jump off the balcony and land on another student).

I can think of others who should be expelled under the same reasoning...
...folks with seizure disorders (they could seize and cause severe burns from the sulfuric acid they had in their hand in chem lab)
...students who are morbidly obese (they could fall on the spotter while climbing ropes in the gym)
...folks with ALS (their motorized wheelchair could malfunction.

It is important for the GW student's suit to not get settled... otherwise more schools may take this dangerous approach of expelling students who admit to any kind of dangerous *thought* in therapy. For these students, they will never risk seeing a therapist again... truly making this one their Last Psychiatrist.

NeoNurseChic said...
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NeoNurseChic said...
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Anonymous said...

I think students need to be extremely careful about using the mental health services at a university. A lot of times the psychotherapy notes end up as part of your general medical file. If you're okay with your dermatologist reading what you discussed with your psychiatrist then okay - but it was really awful for me to find that out. I never went back.

Anonymous said...

Whew. I'm going back to my blog where it's safe.

Alison said: "Many people who have sexual contacts with people of the same sex identify as straight, so sexual orientation is sometimes an identity and sometimes not."

Ok, good point, you got me there, let me think about this.

But our disagreement basically is around how necessary it is for a suicidal person to attempt suicide, or how impossible it is for them not to attempt it. If you think that suicide attempts necessarily (as opposed to possibly) follow from feeling depressed or suicidal, then you are essentially saying that in a suicidal state, a person has lost the capacity for rational judgment, and cannot be held accountable for their behavior (i.e. the suicide attempt.)

Which is where I have the problem. Substitute "homicidal" for "suicidal" and my point is clearer. And lest you think this is semantics, note the increase of suicide-homicides among white male suiciders.

Neonursechic (and others who were once suicidal and are angry at this school's policy): Based onyour descriptions,_you_ wouldn't have been kicked out of school. No one would have known what you discussed with your psychiatrist. Again, let me repeat the facts of the case: Hunter kicked her out of the DORM for ATTEMPTING suicide in the DORM-- not thinking about it, or attempting it in a hotel on spring break, etc. Hunter's issue isn't simply liability (which is massive, let's face it), but also public safety. Go back to my gas example. Answer this: why should other people have to live in the dorm with her if she threatens their safety? That's the issue. Give me a good answer to that and I'll help change Hunter's policy.

P.S. Of course there should be case by case analysis, psychiatric input, etc. But the default should be to kick out OF THE DORM, because being there is a privilege, not a right.

Dinah said...

Your blog is not safe. You just think it is.

The GWU student was banned from campus for suicidal IDEATION (if you believe the Washington Post article, but we're playing it here on what info is accessible).

Oh, and Hunter changed their policy, read the article you linked to.
I'm working on another post on this.

Anonymous said...

I know Hunter changed their policy; I'm saying that's bad.

Ok, we all want to talk about GWU?

The Case Of Jordan Nott

Steve & Barb said...

The Hunter student took 20 Tylenol PM pills and then called 911. Explain to me how that places fellow students at risk. Falling asleep with the water running? Toxic vomit?

I could see if she set a fire in the dorm, or tied explosives around her waist, how that would be a good reason to expel her from the dorm (or even from the college). But "suicidal ideation" does not equal reckless disregard for others' safety.

I still fail to see how these two things are connected, other than by stigma.

Anonymous said...

I had the director of our dorm try to kick me out after I had another student drive me to the ER because she thought I had a seizure. At the time I was going through severe headaches, tremor, etc. When He found out He implied me having a seizure disorder was a risk to the college, and maybe "this wasn't the place" for me. Maybe I should have slept in a padded room with restraints and a helmet in case I had a seizure huh? In the end I wrote a "madder than hell" letter to the dean, and my parents got involved. I ended up staying in the dorm just to prove i could survive it, but it was a horrible year, having to deal with the director all the time. What a Moron!

Miette said...

I've never heard of this situation happening up here in Canada, and although I'm glad about that, I'm also scared that it has and that I just don't know about it. I'm suddenly very grateful that I'm still carrying on in medical school with MDD (and SI), diagnosed by the university psychiatrist. (luckily in full remission now, hopefully forever *fingers crossed*)