Role of university in preventing students’ suicide ideation (Part 2)

Following on my last post, Shek & Wong in their article proposed a string of actions that universities could do, including holding credit-bearing courses that emphasize social responsibility, mental health awareness and leadership skills for college students of all concentrations.  This is what my university has been doing except the second component and yet three students committed suicide within one year.  This has raised huge concerns at the university, even prompting marketing campaigns to parents of prospective students’ through meetings and newspaper publicity.  For the social responsibility aspects, we have tons of NGO and corporate projects to promote social responsibility, and I myself have proposed and am teaching a leadership skill course. 

Why the limited effectiveness of the measures?  In my opinion, it is to do with the mental health issues. Shek and Wong mentioned that in Hong Kong, poor mental health among local university students is an issue that deserves attention.  I can’t agree more.  The three students who had committed suicide, and those who have the suicide ideations, would never come to speak to us, the instructors.  The persons whom would have noticed are the peers.  Whilst we have peer mentors programs, we never provide adequate training to these peer mentors.  I have also just known that we have only one clinical psychologist or counseling on site for 13,000 students!  The university has been spending much effort on rolling out compulsory academic advisory services for all undergraduates.  But my point is it is highly unlikely for those who have suicidal thoughts to approach their advisors.  I really think there should be credit bearing courses on mental health issues.  There is one topic which I firmly believe is of tremendous value to university students, namely “how to handle failure”. 

 

Since we were kids, our parents taught us not to make mistakes, not to fail…..  Then teachers teach and inspire us on how to be successful.  No one really has taught me how to handle failure.  Coupled with the worsening of mental health in local adolescents and young adults, a course on how to handle failure would add tremendous value.  E.g. how do we handle situation when we fail in an examination, how do we handle the situation when we did not receive any interview opportunities having sent 100 application letters.  Universities should invest in improving students’ mental health.   

p.s. It seems I have found a new meaning in what I am doing with my doctorate in clinical psychology study.  After my completion, I want to be able to design a mass educational program on how to handle failure, which is in line with my interest in positive psychology.  This is what I should start looking into to prepare for my thesis.

Role of universities in preventing students’ suicide ideation (Part 1)

Recently I came across an article by Shek & Wong (2011) which discussed the need for holistic development in university students.  There are three things that caught my attention when I reflect on my experiences.  They are (1) Impact of depression on suicidal ideations, (2) the high similarities of characteristics between US and HK college students and (3) the need for university involvement.

Impact of depression on suicidal ideations

The authors reported that besides psychosocial stressors (e.g. examinations and financial stresses), mental health is a growing concern among university students.  Depression is the leading instigator to a variety of negative outcomes contributing to the bulk of suicides on college campuses.  A web-based survey of 2,843 Midwestern undergraduates found a prevalence rate of 15.6% for depressive or anxiety disorder.  Suicide is the second leading cause of death among college students in the US after homicides and accidents.  According to the Big Ten College Study, the death rate of suicide among college students is at an astonishing high rate of 7.5/100,000!  This data indeed supported the research I mentioned in my post dated 13 Dec about the mediation effect of depression to academic stress and suicidal ideations.  Whilst I do not have the Hong Kong statistics, the university which I am acquainted with does have a high suicidal rate, and I understand all of them had prior history of depression or anxiety.

 

The “dark side” of college students” (Shek & Wong, 2011)

I am truly amazed to find out what was described as the dark side for US students can be found in my HK students through the self-reflections logs they handed in as their assignments.  The Me Generations are not empathetic with rising narcissistic personalities especially in business students.  They are more self-interested than team-oriented.  In addition, many students are often not prepared to be young adults with all the responsibilities.  Moreover, there is a significant shift in college students’ values to a more self-focused and financially oriented philosophy, which is in line with a decrease in social responsibility and civic participation.  It was reported that the top two students’ goals were to be financially well-off (78.1) and raising a family (74.7%). 

 

What does this mean?  I believe the focus on extrinsic needs adds onto the stress and anxiety that an undergraduate face, especially so for Asian societies like HK which tends to evaluate a person’s success measured by career achievements and how much people earn.  This is worsened by the fact, as reported in the article that these students are not prepared to take on responsibilities.  I feel the level of anxiety or stress tolerance is lower than that of the Gen X (I know because I am one of them).  What causes this?  My educated guess is that these students used to enjoy parents’ warmth and protectiveness up to their high school years; but when they are at the university, they are derived from such parental type of warmth and protectiveness, coupled with their lack of willingness or capability to take on responsibilities as a young adult, they become stressed, feel high level of anxiety and even depressed.  A research mentioned in my previous post proposed that parenting warmth and protectiveness decreases level of depression.  Does it mean university educators need to take on the role of parenting to provide such warmth and protectiveness?  How should universities respond?  This is what I will discuss in my next post.

 

Reference

Shek, D.T.L and Wong, K.K. (2011).  Do adolescent developmental issues disappear overnight?  Reflections about holistic development in university students.  The ScientificWorld Journal, 11, 353-361. Doi:10.1100/tsw.2011.5

Academic stress, depression & suicidal ideation

Inspired by the article posted by fellow course-mate Edwin about academic stress and suicidal ideation, I decided to look into this area in my blog (thanks Edwin).  Specifically the article stated that adolescent depression is a mediator (as a third variable) for academic stress and suicide ideation.  This means the significance of the relationship between academic stress and suicidal ideation was significantly reduced in magnitude when depression was included in the research model.  This has huge implications on interventions because purely focusing on reducing academic stress may not be as effective as one would hope.  One should also look into addressing depression. 

 

I have mentioned in my previous posts the role of parents in preventing adolescents and young adults’ suicidal attempts (see post on 28 Oct).  To what extent parenting is responsible for causing major depression?  According to a research on perceived parenting and risk for major depression in Chinese women (Gao et al. 2012), it was found that high level of authoritarianism were associated with an increased risk for major depression while high levels of warmth were associated with a decreased risk for major depression.  This finding is the same as that in Western countries.  What is most interesting is that high level of protectiveness from both mothers and fathers were associated with a decreased risk for major depression, which is the opposite pattern of that observed in the Western samples.  One explanation the authors provided is that perhaps in mainland China, the father has a psychological role in a child therefore women in China have a different interpretation of the meaning of “protectiveness” when coming from the father.  Whilst more research is needed to confirm the effects of “protectiveness”, adolescents and young adults can make good use of a bit more warmth, caring and respect from their parents.  The next question is what stops the parents from doing so despite it is quite an obvious behavior?

Perhaps the answer is that the parents themselves are not happy!  According to today’s report in the South China Morning Post, “middle-class people earning less than HK$40,000 a month are the least satisfied with their lot, according to an annual “happiness” index.  But Hongkongers as a whole are less happy this year – with the index slipping from 71.3 to 70.5, the Lingnan University survey found.”  Well, it seems the simple answer to academic stress, depression and suicide ideation are rooted from staying happy. 

Reference

Gao, J., Li, Y., Cai., Chen, Y., Shen, S., Wei, Y., …Tao, M. (2012).  Perceived parenting and risk for major depression in Chinese women.  Psychological Medicine, 42, 921-930. Doi:10.1017/S0033291711001942

Another UG student committed suicide at HKUST yesterday

I am shocked to read from the news that a 19-year old first year undergraduate majoring in maths jumped from his Tsuen Wan flat yesterday.  The newspaper reported that it was attributed to the stress from midterms, since October is the peak season for midterm exams.  Is it study environment so stressful for students to handle?  In the real commercial world, the level of stress is much higher than that in a university.  Or is it that the stress tolerance level for the post-90s is much lower than say the post 50s, 60s or 70s?  Or is it the parents exert undue pressure onto their children?  Or is it the societal system which we celebrate "success" has been absorbed in quantifiable achievements?  I wish I had the answer.

The Dean emailed to all professors requesting their assistance to refer to the university counselors should they see any psychological issues with the students.  However, I think the professors or the parents are usually the last one to know, or rather never know since the students who have problem would hardly approach the professors.  Instead, I suspect the peers / friends would be the first to notice.  So why not the university provide some training for peer support groups?  This is what I have proposed to the Dean.  I am curious to know what his response would be.

Separately, three weeks ago I opened a thread titled "let's support each other" in the discussion forum of my course for students to write encouragement or share their motivational songs to support each other during this stressful month.  May I share with you two threads from my students and their motivational song.  I trust we can make more use of such peer sharing, and motivation to show them that they are not alone.

One student wrote: "Guys, I know Oct has been tough because we all are so packed with studies,job applications and personal things. This video is very touching, it is about Derek Redmond going down in this race with a pulled hamstring, he did not stop but continued the event! The world cheered for his courage and bravery!

Yes, life is not always like what we have planned. If we put a lot of effort in one thing, and if it turns out that we may not be able to harvest at the end, DO NOT GIVE UP, the process is sometimes more important !!!! We got to be strong because we are not alone, the world is supporting us as long as we work hard and stay strong all the time!!!!!!!

So, once you are on the field track , you have to try your best to finish the event!!!

Guys, never say never!! :))"

Another student wrote:  "This is one of the songs that I have been listening to a lot recently. And it's rather uplifting in my opinion. Specifically the "you shot me down, but i won't fall" part."

 

 

Lessons learnt: A 14-year-old girl committed suicide yesterday

I was saddened by the news in today’s newspaper that a 14-year-old local Hong Kong Chinese girl hung herself in her bedroom at home in Tsim Sha Tsui after a dispute with her parents.  It was reported that the parents objected to their daughter to having a close relationship with her boyfriend because of her young age.  However, to this girl, having a relationship was the most important thing.  After hearing the parent’s objection, the girl returned to her bedroom and hung herself.  The parents discovered later in the evening at 6pm when they knocked on the door and there was no reply.

 Two immediate contradictory thoughts came to mind: (1) is there anything wrong with the 14-year old?  Surely the parents’ stance is justified.  (2) What the parents could have done to prevent this?  I think many people would almost have a reflex action and jump to conclusion of putting blames on the new generation, whose generational values are known to be the “i-generation”, characterized by high self-centeredness.  However, being a clinical psychology student now, I realize I am more attuned to the second question of seeking prevention.  I have a vast interest in positive psychology since I first exposed to the concept in my advanced psychopathology class with Dr Wedding. 

I had a quick search on the Internet and happily found that there are quite a lot of material on positive psychology and suicide.  Love and humility works well for depression. Often times, persons who are depressed and eventually commit suicide speak of feeling of being alone in the world. They feel that if one person would have cared for them they would not have done this. Many times a person’s family is not able to lend out emotional support for their depressed relative.  This may well be the case for this 14-year-old girl.  What the parents could have done is to provide I nurturance, reciprocal attachment and kindness.

What I would like to share here is some tips with parents or we as adults that I learnt from the Internet to apply positive psychology to talk to unhappy youths or young adults.  I have used the “three good things” for a while myself, and have told my undergraduate students to do the same when they are down.  I find it pretty effective.

 

•Gratitude Exercise: The youth is told to think of someone who has been good to them or influential in a positive way. This may be a parent, friend, teacher, or coach, anyone who comes to mind as being a positive influence. The youth is then told to write this person a letter, expressing thanks and gratitude, being sure to include what this meant and how the youth feels. This exercise is most meaningful if the letter can be read to the intended recipient in person.

 •Appreciation: This is another form of the gratitude exercise. At the end of the day, we can ask a child to identify something occurring that day for which he or she is appreciative. Anything, no matter how large or small, can be appreciated.

 •Three Good Things: In this exercise, the youth is asked, to name three good things that occurred that day. We should not accept a response of "nothing good happened," instead encouraging the child to focus on even little events that are good, such as a sunny day, a good dinner, or play with a friend.

I should continue to learn more about positive psychology and depression / suicide.  Hopefully I can develop a set of instruments of positive psychotherapy to help parents and teachers to apply at school or at home.  Or even develop a tool kit for youths and young adults for them to extend peer / social support. 

Attitudes of Hong Kong Youth and Young Adults Towards Suicide

We have gone through some basic understanding of broad suicide situations and risk factors, and compared between the West and Asia suicides, we can now focus on issues specific to Hong Kong, and our target groups youths and young adults.  Hong Kong has experienced a roller coaster cycle of suicides rates with a 50% increase from 12.5 per 100,000 in 1997 to a historical high of 18.6 in 2003, followed by a 23% decrease to 13.8 in 2009.  The peak rate from 1997 to 2003 can be attributed to the 1997 Asian financial crisis coupled with the SARS disease outbreak in 2003. 

What worth our attention is that youth suicide is the leading cause of death among the 15-24-year-old age group.  Figures showed that more teenagers attempted suicide (completed and uncompleted) than other age groups.  The suicide rate of male teenagers (15-24) has experienced a 30% rise from 8.9 to 11.7 per 100,000 between 2008 and 2009.  In addition, among school drop-outs, the underemployed and unemployed, these young people are experiencing a 10 to 20-fold increase in suicide rate compared to those who are at school for the same age group.  Some of the common reported probable risk factors include lack of problem-management skills, low self-esteem, low need for achievement, depression, general anxiety, poor help-seeking tendencies and withdrawal from life.  I will discuss these in the later posts.  For now, I would like to explore a basic question, namely what are the attitudes of Hong Kong youths and young adults towards suicide.

First and foremost, it is interesting to note that there is no mastery theory that adequately explains how Chinese people perceive suicide.  Rather, suicide might be endorsed and/or condemned by particular individuals under a variety of life situations.  Of special interest here is the type of stressful life events perceived by Hong Kong Chinese that may trigger them to consider suicide.  I have suggested in my earlier post that an underlying cause that explains the differences of the nature in stressful life events between Asian and the West is the Confucian notion of hierarchy and familial relationships.  Lee, Tsang, Li, Phillips and Kleinman (2007) reported that the top six difficult life scenarios that respondents might consider suicide were: (i) “being terminally ill”, (ii) “having a chronic psychiatric illness,” (iii) “being severely depressed”, (iv) “being a burden to others and feeling hopeless about the future”, (v) “being heavily indebted because of gambling” and (vi) “not having anyone to provide financial or emotional support in old age.”  In my personal view, these six scenarios reflect a strong tendency of Hong Kong Chinese not want to bring trouble or burden to their family members.  This is consistent with the collectivist Chinese culture in which people are more willing to consider others’ feelings and avoid arousing negative emotions. 

Nonetheless, there are four findings from my readings about youths and young adults’ attitudes that caught my attention.  First, “negative appraisal and fatalistic view of suicide decreased with age.” (Lee et al., 2007, p.568).  Second, findings from a cross-cultural study between Chinese and Norwegian respondents reported that Chinese demonstrated more agreement to “suicide happens without previous warnings” and less agreement with “suicide can be prevented”.  Third, there are other studies that found “superstition was positively correlated with anxiety level among adolescents” (Okebukola in Wong, 2012, p.58).  Fourth, young people tend to have more fears of deaths than older adults.  How do I make sense from these findings?

To me, I would interpret that since youths have strong death anxiety and fear of death, coupled with the fact they do not want to bring trouble or cause their family to lose face, they regard suicide as a form of their fate / destiny.  This echoes with the frequent reports that the youths commit suicide because they feel hopelessness.  They do not see there is an alternative since Chinese tend to disagree that “suicide can be prevented”, this goes back to the fatalistic view.  Moreover, despite the high level of fear / anxiety of death, even in Hong Kong, death is a taboo topic.  Chinese may be considered among one of the most superstitious nations in the world.  In Hong Kong, we have “Feng Shui” and “Tong Sing” which lists a person’s luck in that year.  It is a commonly held superstitious belief that discussing death and dying will bring bad luck or consequences.  This in turn supports the above-mentioned view held by Chinese that “suicide happens without previous warnings” because Chinese including youths, just do not talk about it.  Choosing suicide as their ultimate solution also coincides with the strong support of the Chinese to follow the terror management theory (TMT).   This theory suggests that culture is the crucial factor in explaining and giving meaning to death.  In the presence of terror, a Hong Kong Chinese youth or young adult may well interpret the “misfortunes” of his/her present life is due to the wrong deeds of their previous lives which they do not have control.  By ending their lives may well benefit to their parents as a repent for their wrong deeds.  As a result, following such cultural beliefs help the youth / young adults legitimize their suicidal acts.

From the above analysis of the attitudes of youths and young adults towards suicide, I am of the opinion that an effective means of suicide prevention is to let them know there is hope.  Encouragement and positive psychology I believe can be one avenue to explore.  I would like to end this post by borrowing the words from a very touching video from Nick Vujucic “Failure is not the end.  It matters how you finish.  Are you going to finish strong?”  I am still very touched and inspired every time I watch this video.  I show this video in my class with undergraduate students when we talk about courage.  A few of them told me this video changed their perspectives of how they see failure.  I hope you will spare two minutes to watch it.

http://www.youtube.com/watch?v=KIy8OytmFkA&feature=related

References

Lee, S., Tsang, A., Li, X.Y., Phillips, M.R. & Kleinman, A. (2007). Attitudes toward suicide among Chinese people in Hong Kong.  Suicide and life-threatening behavior, 37(5), 565-575.

 

Wong, S.H. (2012) Does superstition help?  A study of the role of superstitions and death beliefs on death anxiety amongst Chinese undergraduates in Hong Kong.  Journal of death & dying, 65(1), 55-70.

Yip, P. & Chak, S. (2011) Suicide in Hong Kong: epidemiology, changing patterns, associated phenomena and prevention.  Irish Psychiatrist, 12(1), 23-24.

Suicide in Asia

The purpose of this post is to highlight the differences in epidemiologic characteristics and the risk factors between Asia and Western suicides.  A study by Chen, Wu, Yousuf & Yip (2011) reported that the overall suicide rate in Asia is approximately 19.3 per 100,000, about 30% higher than the global rate of 16.0 per 100,000. (p.129).  During a 12-year period (from 1995-2009), the top three suicide rates countries are Japan (24 per 100,000), South Korea (31.0) and Sri Lanka (23.0).  Hong Kong and China stood at 13.8 and 6.6, respectively. 

Unlike the Western countries, where suicide rates for males are about 3-4 times higher than those for females, in several Asian countries like Hong Kong, the gap between male and female suicide rates is smaller.  Whilst Hong Kong and Australia have similar suicide rates, the gender ratio (male-to-female) are about 4 and 2, respectively.  The gender ratio for the US was 3.8 in 2009.  This implies that the suicide rates for Hong Kong females is higher than that of the Australian and US females, while a lower suicide rate for males in Hong Kong is observed compared to the Western counterparts.

Although the risk factors for suicide such as mental disorders, alcohol-related disorders, previous history of suicide attempt, and stressful life event appear to be universal (as reported in the earlier blog post), there are differences with respect to mental disorders and stressful life events.  As mentioned in an earlier blog post, Tondo and Baldessarini (2011) that 90% of suicides in the US occur in persons with a clinically diagnosable psychiatric disorder, particularly patients with bipolar depression disorder.  However, it was reported that in China 40% of suicides suffered from depression and that the overall rate of mental disorders in suicide completers is 63%.  In Hong Kong, depression was found in 51% and 53% of middle-aged and old adult suicides, respectively. 

An underlying cause that explains the differences of the nature in stressful life events between Asian and the West is the Confucian notion of hierarchy and familial relationships.  This in turn can also help explain the narrower gender ratio gaps in Asia.  Family dispute is a critical factor for suicide among women in many Asian countries.  The low social status of women has been suggested as a potential link to the high suicide rates for Asian women involved in abusive family relationships.  Abusive marriage relationship is a common cause for women suicides reported in Hong Kong.  Moreover, under a family-centered culture where the male is the head of a family, unemployment or job-related stress is a more common reason of suicide among Asian men than their Western counterparts.

 

An important implication of these differences in risk factors between Asian and the West is a need to develop cultural-specific intervention strategies.  Social support is likely to be a critical protective factor for preventing suicidal behavior in Asia.  In addition, community-based suicide intervention programs are an effective tool in light of the strong family and community ties in Asia.

In the coming posts, I will focus on the topic of this blog - suicide of youths and young adults in Hong Kong.  Besides sharing on research article reviews, I will also provide some personal views of how to prevent youth suicide.  Stay-tune!

References

Chen, Y. Y., Wu, K.C.C., Yousuf, S. & Yip, P.S.F. (2011). Suicide in Asia: opportunities and challenges.  Epidemiologic Reviews, 34, 13, 129-144. Doi: 10.1093/epirev/mxr025