- Email: [email protected]
Association between perceived public stigma and suicidal behaviors among college students of color in the U.S.
Journal Pre-proof
Association between perceived public stigma and suicidal behaviors among college students of color in the U.S. Janelle R. Goodwill MSW , Sasha Zhou MPH, MHSA PII: DOI: Reference:
S0165-0327(19)32096-8 https://doi.org/10.1016/j.jad.2019.10.019 JAD 11208
To appear in:
Journal of Affective Disorders
Received date: Revised date: Accepted date:
6 August 2019 20 September 2019 11 October 2019
Please cite this article as: Janelle R. Goodwill MSW , Sasha Zhou MPH, MHSA , Association between perceived public stigma and suicidal behaviors among college students of color in the U.S., Journal of Affective Disorders (2019), doi: https://doi.org/10.1016/j.jad.2019.10.019
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier B.V.
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
Highlights
Perceived public stigma is associated with suicide ideation, planning, and attempt Asian international and Black students reported greater odds of suicide attempt Sexual minority students reported greater odds of across all three suicide outcomes
1
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
Title Association between perceived public stigma and suicidal behaviors among college students of color in the U.S.
Authors: Janelle R. Goodwill, MSW1, 2 and Sasha Zhou, MPH, MHSA3 1. University of Michigan School of Social Work, Ann Arbor, MI USA 2. University of Michigan Department of Psychology, Ann Arbor, MI USA 3. University of Michigan School of Public Health, Department of Health Management and Policy, Ann Arbor, MI USA
Corresponding Author: Janelle R. Goodwill, MSW PhD Candidate in Social Work & Psychology University of Michigan | School of Social Work 1080 S. University Ave. Room B660 Ann Arbor, MI 48109-1106 734.707.1127 [phone] [email protected] [email]
Abstract
2
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
3
Background: Suicide is the 2nd leading cause of death among college students and 10 to 34-yearolds in the U.S. While rates of suicide among young people of color have increased, less is known about factors that contribute to suicidality among racial minority students who are sorely underrepresented within existing research. Thus, we sought to explore the association between perceived public stigma of receiving mental health treatment and suicidality among Black, Asian Domestic, Asian International, Latinx, Multiracial, Arab/Arab American, American Indian/Alaska Native, and White college students.
Methods: We analyzed cross-sectional survey responses from racially diverse sample of 153, 635 college students who participated in the Healthy Minds Study from years 2007 – 2018. Multivariable logistic regression was used to examine associations between perceived public stigma and suicide ideation, suicide planning, and suicide attempt.
Results: Perceived public stigma was significantly associated with greater odds of suicide ideation, planning, and attempt. Odds of having attempted suicide within the past year were significantly greater among Asian International and Black college students. Sexual minority students broadly, and bisexual students specifically, were also at elevated risk for suicidal behavior.
Limitations: Cross-sectional survey responses were assessed and causality cannot be determined.
Conclusions: Students who endorsed more perceived public stigma also reported significantly greater odds of having experienced suicide ideation, planning, and attempt within the past 12 months. Subsequent interventions should account for concerns surrounding public perceptions of stigma when working to prevent suicide among students of color. Keywords: stigma; suicide; college students; students of color
Abstract word count: 239 words Abstract word limit: 250 words
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
4
INTRODUCTION It is well established that stigma acts as a barrier to seeking help for mental health concerns (Corrigan and Watson, 2002; Gaddis et al., 2018). Research demonstrates that persons who adhere to stigmatized beliefs about mental health are less likely to seek professional help and oftentimes experience worse mental health outcomes (Latalova et al., 2014; Vogel et al., 2007). More pointedly, public stigma— the belief that most people hold negative views towards persons experiencing a mental health condition—has been linked to increased rates of anxiety and depressive symptoms (Cheng et al., 2013; Corrigan and Watson, 2002). However, few studies have sought to explore whether perceived public stigma is associated with other adverse mental health outcomes, like suicide ideation and attempt (exceptions include Downs and Eisenberg, 2012; Gaddis et al., 2018; Oexle et al., 2019). Exploring whether psychological factors like stigma are associated with suicidal behaviors is particularly important to assess among young people, as suicide is the 2nd leading cause of death among college students (Brody, 2018) and 10-34 year-olds in the U.S. (Centers for Disease Control and Prevention, 2018). While disturbing trends of suicide death are notably high for young people across race groups (CDC, 2018), there are important gaps in the extant literature that limit our understanding of suicide specifically among young people of color. As such, immediate efforts are needed to redress disparities in representation of racial minorities in suicide research, while also working to uncover which factors promote and prevent suicidal behaviors among young (or “emerging” (Arnett, 2000)) adults. The current study aims to rectify these concerns by analyzing crosssectional survey responses from a racially diverse sample of 153, 653 college students who participated in the Healthy Minds Study from years 2007 – 2018. Implications for practice and intervention are discussed.
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
5
Drawing from Link’s labeling theory (Link, 1987), Corrigan and Watson (2002) assert that public stigma is shaped by popular beliefs and perceptions regarding mental illness, and ultimately manifests in the form of stereotypes, prejudicial beliefs, and discriminatory acts (Corrigan et al., 2012). As such, public stigma related to mental illness has become commonplace within U.S. culture and customs, despite its potentially deleterious effects on mental health and psychological well-being. Although Corrigan and colleagues focus specifically on public stigma related to mental illness, it seems plausible that perceptions of public stigma related to receiving mental health treatment may also be harmful towards an individual’s wellbeing (Pedersen and Paves, 2014). Some researchers have already begun to examine these matters among college students, as previous studies report that perceived stigma is not related to mental health service utilization (Eisenberg et al., 2009; Golberstein et al., 2008) but is significantly associated with greater prevalence of depression, anxiety, self-harm, and suicide ideation (Downs and Eisenberg, 2012; Gaddis et al., 2018). Additional work is, however, needed to substantiate whether the relationship between perceived public stigma and suicidal outcomes (e.g. ideation, planning, and attempt) holds among diverse race groups. Critically interrogating the role of perceived public stigma within the context of receiving mental health treatment is a necessary step that will offer much needed insight into the mental health experiences of those from understudied groups and communities of color. Furthermore, it is worthwhile to consider how perceptions of stigma are relevant to conversations of race, as racial and ethnic minorities typically report higher rates of stigma, yet lower rates of mental health service utilization (Kosyluk et al., 2016; Lipson et al., 2018). Findings yielded from a recent investigation found that both individual and school-level perceptions of stigma related to mental health treatment seeking were associated with greater
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
6
likelihood of suicide ideation among college students broadly, though findings specific to students of color were not observed (Gaddis et al., 2018). Race is an important factor to consider, as earlier investigations report that students of color are less likely to engage in suicidal behaviors when compared to White students (Silverman et al., 1997; Stephenson et al., 2005). Since then researchers have examined suicidal behaviors specifically among Asian college students (Wong et al., 2011), Black college students (Harris and Molock, 2000; Wang et al., 2012), American Indian college students (Muehlenkamp et al., 2009), and Latina college students (Chesin and Jeglic, 2012), while others have focused on differences between Black and White student samples (Lester and Walker, 2017; Walker and Bishop, 2005). Though these efforts are laudable, more work is needed to evaluate factors related to suicide among racial and ethnic minority groups, as rates of suicide death among young people of color has increased within the past 20 years (Bridge et al., 2018, 2015). Notably the rates of suicide death for young people across all races groups remain highest among American Indian/Alaska Native youths and young adults (Wexler et al., 2015), though many suicide-related research studies fail to center the experiences of college students of color. Thus, it is evident that more studies of suicidality among racially diverse college students are warranted. A recent study by Lipson and colleagues (Lipson et al., 2018) found that not only were college students of color less likely to seek help when faced with mental health concerns, but also that both Asian and Multiracial college students reported significantly higher rates of suicide ideation when compared to students of other races. We are interested in extending this work using Corrigan and Watson‘s framework (2002) to determine whether perceived public stigma related to receiving mental health treatment is associated with increased risk for suicide ideation,
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
7
planning, and attempt among a racially diverse sample of Asian, Black, Latinx, American Indian/Alaska Native, Arab/Arab American, Multiracial, and White college students.
METHODS Data were collected from the Healthy Minds Study (HMS) — an annual survey designed to address the unique mental health needs of college students in the U. S. (Eisenberg et al., 2009). Beginning in 2007, members of the HMS team partnered with colleges and universities across the nation in efforts to prioritize and promote mental wellness at the university level. All surveys were administered online; consent was also obtained electronically. Both currentlyenrolled graduate and undergraduate students are eligible to participate. Study recruitment is determined by school enrollment numbers, as random sampling procedures are used only at institutions whose student body enrollment exceeds 4,000. Conversely, the entire study body is invited to participate at schools whose enrollment is less than 4,000. Survey content is presented in a module format where all participants receive the same three primary modules (e.g. demographics, mental health status, mental health service utilization and help-seeking behaviors), though administrators at each institution can opt to include additional modules in the surveys students on their campus receive. Additional details regarding the sampling procedures and study design are available at healthymindsnetwork.org. The current study analyzed crosssectional survey responses from 153, 635 students who completed the HMS survey from 20072018. The response rate was approximately 25% across all years. Measures Demographics. Information regarding participants‘ age, gender, and sexual orientation were included as covariates. Race was captured using a single-item that asked participants to ―select all that apply.‖ Therefore, students who selected more than one race were considered
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
8
Multiracial. Potential response options included Asian, Black/African American, Latino/a, American Indian/Alaska Native, Arab/Arab American, and White. We disaggregated the Asian students by international student status, as approximately 40% of students who identified as Asian were also international students. Age was dichotomized into two groups where group 1 included participants who were 18-30 years old, and group 2 included participants who were >30 years old. Response options for the age variable were not captured consistently across each years. For example, in some years students were asked to list their specific age, while in other years students were asked to identify whether they were between 18 to 25-years-old, 26 to 30years-old, and so on. Therefore, in order to utilize all data sources from 2007-2018, we needed to collapse the age variable into the two overarching categories (18-30 and 31 and older). Sexual orientation was categorized into four groups represented as 1=heterosexual/straight, 2=bisexual, 3=gay, lesbian, or queer, and 4=questioning or other. Additional demographic information is provided in Table 1. Perceived Public Stigma. Perceived public stigma was assessed using three revised items from the Perceived Devaluation-Discrimination Scale (Link et al., 1991). Items used in the HMS survey were reworded to reflect stigma related to receiving mental health treatment (Eisenberg et al., 2009; Golberstein et al., 2008). Response options were captured using a 5-point Likert scale that ranged from ―1= Strongly disagree‖ to ―6= Strongly agree.‖ Sample items include, ―Most people would willingly accept someone who has received mental health treatment as a close friend, Most people feel that receiving mental health treatment is a sign of personal failure, and Most people think less of a person who has received mental health treatment.” The items noting
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
9
―mental health as a sign of personal failure‖ and ―thinking less of someone who received mental health treatment‖ were both reverse-scored. A mean score was calculated; Cronbach‘s alpha reliability coefficients across race groups ranged from 0.75 to 0.81. This measure has been used in others studies using HMS data and has shown good internal consistency (Downs and Eisenberg, 2012; Eisenberg et al., 2009; Golberstein et al., 2008).
Depressive Symptoms. Depressive symptoms were measured using the PHQ-9 (Kroenke et al., 2001). Participants were asked to report how often they have been bothered by various problems within the past 2 weeks. Response options were captured using a Likert scale with options ranging from ―0= Not at all‖ to ―3=Nearly every day,‖ with higher score representing greater depressive symptomatology. Sample items include, ―Little interest or pleasure in doing things,‖ and ―Feeling down, depressed, or hopeless.‖ A total score of depressive symptoms was calculated. The Cronbach‘s alpha reliability coefficients for depressive symptoms across all race groups ranged from 0.87 to 0.90. Past Year Suicide Ideation. Suicide ideation was measured using a single item that asked students to indicate whether they had ever seriously considered ending their life within the past 12 months (1=yes, 0=no). Past Year Suicide Planning. Suicide planning was measured using a single item that asked students whether they had made a plan to end their life within the past 12 months (1=yes, 0=no). Past Year Suicide Attempt. Suicide attempt was measured using a single item that asked respondents to indicate whether they had attempted to end their life within the past 12 months (1=yes, 0=no).
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
10
Analytic Plan First we calculated the prevalence of descriptive characteristics and mental health conditions, stratified by race categories. Next we conducted three separate logistic regression tests to examine associations between perceived public stigma and outcomes of suicide ideation, suicide planning, and suicide attempt. The final analytic sample was restricted to 7,198 Black, 8,402 Latinx, 11,514 Asian domestic, 7,054 Asian International, 11,484 Multiracial, 474 American Indian/Alaska Native, 1,652 Arab/Arab American, and 105,857 White students who represented the largest proportion of students and served as the reference group. Race, age, gender, sexual orientation, and depressive symptoms were included as covariates in each model. Sampling weights were applied to account for differences in response rates between responders and non-responders in gender, race, academic level and GPA. Responses were examined via the svy suite where clustered standard errors were specified to account for clustering within schools. All analyses were conducted using Stata version 15 SE (StataCorp, 2017). RESULTS Endorsement of perceived public stigma was highest among Black students and lowest among White students. The percentage of students across all race groups who reported suicide ideation in the past year ranged between 6.34% and 13.25%. The percentage of students who made a suicide plan within the past year ranged between 2.12 % and 5.48%. Further, the percentage of students who attempted suicide within the past year ranged between 0.06 % and 1.18%, respectively. Additional information is provided in Table 1. Results from the first multivariable logistic regression test of suicide ideation are presented in Table 2. When controlling for depressive symptoms, perceived public stigma was
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
11
significantly associated with greater odds of 12-month suicide ideation (odds ratio [OR] = 1.18; 95% CI= 1.15, 1.21). Asian International, Latinx, and Arab/Arab American students were less likely to experience suicide ideation when compared to White students. This association, however, was positive among Multiracial students, who reported the greatest odds of past-year suicide ideation (OR= 1.21; 95% CI = 1.10, 1.34). Women reported significantly lower odds of suicide ideation relative to men (OR= .87; 95% CI = 0.82, 0.92). Odds of having experienced suicidal thoughts in the past 12 months were significantly greater among sexual minority students as compared to their heterosexual peers. Moreover, 18 to 30-year-old students had significantly greater odds of suicide ideation relative to older students. Results from the second multivariable logistic regression test revealed a similar pattern in that perceived public stigma was associated with greater odds of suicide planning (OR= 1.26; 95% CI=1.21, 1.31). Odds of having made a suicide plan within the past 12 months were significantly lower among Asian International and Latinx students, but were significantly higher for Multiracial students. Further, students who identified as gay, lesbian, bisexual, or questioning were more likely to have made a suicide plan within the past 12 months. Again, odds of having made a suicide plan within the past 12 months were significantly higher among 18 to 30-year-old students. Additional details are provided in Table 3. Results from the final multivariable logistic regression test indicate that when controlling for depressive symptoms, perceived public stigma was again significantly associated with greater odds of past-year suicide attempt (OR= 1.27; 95% CI=1.16, 1.38). Asian International (OR= 1.87; 95% CI=1.33, 2.61) and Black college students (OR= 1.48; 95% CI=1.08, 2.03) were more likely to have attempted suicide in the past 12 months than were White college students. Odds of past-year suicide attempt were significantly higher among women than for men (OR= 1.27; 95%
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
12
CI=1.07, 1.51). Eighteen to 30-year-old students were more likely to have attempted suicide within the past 12 months in comparison to older students (OR= 2.55; 95% CI= 1.66, 3.89). Also, the odds of past-year suicide attempt were significantly higher among bisexual (OR= 2.48; 95% CI= 2.01, 3.05), gay/lesbian/queer (OR=2.03; 95% CI= 1.54, 2.68), and students questioning their sexual orientation (OR=1.80; 95% CI= 1.33, 2.44). DISCUSSION This study purposed to examine the relationship between perceived public stigma and suicidality among college students of color in the U.S. Guided by Corrigan and Watson‖s (2002) framework, findings from this investigation highlight that greater endorsement of perceived public stigma is associated with increased odds of suicide ideation, planning and attempt. These results also reveal important new insights involving perceived public stigma and its association with the highest odds of suicide attempt for Asian International students, followed by Black college students. Our study also contributes to the growing body of literature examining the experiences of sexual minority students who consistently report significantly greater odds of suicidal behavior compared to their heterosexual peers (Haas et al., 2011; Liu et al., 2019; Mueller et al., 2015). As such, our findings point to the salience of both race and sexual orientation in understanding stigma and suicidality among college students. Suicide is a complex phenomenon that is often linked to underlying mental health disorders. Although mental illness is strongly associated with suicide, not everyone that screens positive for mental health conditions experiences suicidality (Miret et al., 2013). Perceived public stigma has been found to account for some of the observed variability in suicide risk. Many of the negative psychosocial consequences of perceived public stigma, such as loneliness, shame, and hopelessness are also predictors of suicidality (Rüsch et al., 2014). The pressure to
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
13
conceal mental illness that results from high levels of perceived public stigma could lead to cognitive and emotional distress and hypervigilance, which has been hypothesized to be a stigma-coping mechanism that drives suicidal behaviors (Oexle et al., 2019). It will be worthwhile for future research to more closely consider these factors among racial minority students. A recent investigation disclosed that individual-level endorsement of public stigma was positively associated with suicide ideation, though school-level stigma was negatively associated with suicide ideation (Gaddis et al., 2018). As a result, the researchers advocated for targeting all individuals in campaigns that focus on overall campus climate surrounding stigma (Gaddis et al., 2018). While their analysis offers an important first step, findings from this study suggest that colleges and universities should also invest in a more tailored approach to anti-stigma campaigns— particularly through intervention efforts with culturally specific messaging. In general, targeted interventions are found to be more effective in reducing stigma than broad interventions (Thornicroft et al., 2016). Designing and implementing more culturally tailored outreaches may be especially salient for Asian International and Black college students, as underscored not only by our analysis, but also previous research that has found these students to report low rates of help-seeking for mental health concerns (Downs and Eisenberg, 2012; Lipson et al., 2018). Interestingly, odds of having attempted suicide within the past 12 months were significantly higher for Black college students. This finding departs from previous research that identifies Black college students as having lowered risk for suicidality when compared to students from other race groups (Silverman et al., 1997). Black college students unfortunately remain underrepresented in existing reports on suicide, and research that focuses exclusively on
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
14
their experiences is limited. Therefore, more race-specific queries that intentionally explore both the interpersonal and societal determinants associated with suicide will be required in order to mitigate further suicide risk for this noticeably understudied group. Results from this study also demonstrate that Black students reported more perceived public stigma when compared to their peers. These findings support much of the previous research on endorsement of mental health stigma among Blacks and other college students of color (Corrigan et al., 2016; Masuda et al., 2009), who oftentimes report feeling particularly uneasy about seeking help for mental health concerns. Matters related to stigma may be exacerbated for Black students enrolled at Predominately White Institutions (PWIs), as concerns persist regarding underrepresentation and retention of minority students on college campuses. Additional efforts should be made to consider whether perceived public stigma and rates of suicide attempt vary among students attending PWIs versus Historically Black College and Universities or other Minority Serving Institutions. International Asian students also reported significantly higher odds of suicide attempt. This finding aligns with other work which affirms that Asian students not only experience high levels of stigma and consequently low levels of help-seeking, but also the greatest severity of distress upon intake at campus treatment centers (Lipson et al., 2018; Zhang and Dixon, 2003). International Asian students are an especially vulnerable population as they often hold a doublemarginalized status on campus— both as students of color and non-citizens (as do many Latinx students). These students are also further separated from informal support systems such as family and childhood friends compared to their domestic peers. Mental health advocacy is particularly important for this group, as over 75% of all international students studying in the U.S. are from Asian countries (Student Exchange and Visitor Program, U.S. Immigration and Customs
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
15
Enforcement, 2017). Perceived stigma surrounding use of mental health services is also especially severe in Asian countries, and thus efforts to reduce mental health stigma for this population should be designed with sensitivity to country of origin. Similarly, more concerted efforts are needed to further consider the mental health experiences of Multiracial students on college campuses. Findings from this investigation are consistent with recent research noting that Multiracial youth and young adults report higher rates of suicidality when compared to peers of other race groups (Anderson et al., 2015; Liu et al., 2019; Lipson et al., 2018; Wong et al., 2012). Anderson et al., (2015) speculate that stigma influences youth‘s willingness to respond to questions about suicide history. Few direct explanations, however, have been offered that specifically address the unique lived experiences of Multiracial students. As mentioned earlier, we did not examine specific subgroups of Multiracial students, though examining group-specific experiences will be an important next step in working to promote wellness among members of this group. In this we see that while much more work is needed to prevent suicide among students of color, perceived public stigma does appear to function as an important conduit for improving help-seeking and decreasing the prevalence of suicidal behaviors in university students. When considering that studies that examine associations between perceived public stigma and suicidal behaviors are rare (Downs and Eisenberg, 2012; Gaddies et al., 2018; Oexle et al., 2019), some viable next steps may include assessing various social and environmental factors that moderate or mediate the link between perceived public stigma and suicidality. This is just one of several ways to build upon results generated from this exploratory study. Moreover, employing the use of qualitative or mixed methods approaches will also be important in working to explicate the role, prevalence, and impact of stigma within and across communities of color.
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
16
Limitations and future research Our study is not without limitations. HMS does not include a random sample of campuses as schools themselves elect to participate in the study. Additionally, our study does rely on self-report data, and it is unclear how the self-report nature of this study may yield different levels of bias across racial groups for our constructs of interest. Further, while we disaggregated Asian students by international status, HMS does not collect specific Asian subgroup demographic information. The same considerations apply for other race groups, and in turn it is difficult to parse out potential ethnicity correlates and variations. We created one overarching ‗Multiracial‘ group and did not examine differences within various sub-groups of students who reported identifying as more than one race. We recognize and respect that the experiences of Multiracial students are not monolithic, and encourage future studies to take a more nuanced approach in studying these populations. In addition, we encourage future studies to further investigate individual race and ethnic groups, as our study generated insight from a high level overview and could not fully elucidate the multidimensional pathways that connect perceived public stigma and suicide. Lastly, our study utilizes cross-sectional data, and findings from the current investigation assess associations between stigma and suicidal behaviors only. Therefore, causality among key study variables cannot be assumed. Our findings align closely with a recent report that used data from the American College Health Association and found increased risk for suicidality among Multiracial and bisexual students (Liu et al., 2019). This points to sexual orientation broadly, and bisexuality specifically, as important factors to consider when exploring the relationship between perceived stigma and suicidality. There is evidence to suggest that bisexual youth and young adults have unique experiences of stigma and stereotyping, including differential treatment by both heterosexual
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
17
peers and members of other sexual minority groups (Hequenourg and Brailler, 2009; Botswick, 2012; Zhou et al., 2018). Bisexual students are thus in a complicated position of confronting various forms of exclusion, oftentimes resulting in adverse mental health experiences (Hequenourg and Brailler, 2009; Botswick, 2012; Zhou et al., 2018). For these reasons additional research that examines variability within sexual minority groups should be considered. Taken together, results yielded from this investigation suggest that perceived public stigma is a pernicious psychological correlate that is related suicide ideation, planning, and attempt. Thus, a deeper exploration of the mechanisms between perceived public stigma and suicidality is needed. While our study offers preliminary evidence in establishing these links, it is our hope that future studies further examine the interpersonal, community, and structural factors that may influence the pathway between perceived public stigma and suicidality— culminating towards more avenues of suicide prevention and intervention efforts for students of color throughout their time at the university and beyond.
Author Statement JRG conceptualized the study and led the writing of the manuscript. SZ acquired the data and led the data analysis. SZ also contributed to writing the manuscript. JRG contributed to the analyses. Both authors reviewed and approved the final version of the manuscript.
Conflicts of Interest The authors have no conflicts of interest to report.
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS Acknowledgements The authors would like to thank Dr. Daniel Eisenberg and the Healthy Minds Study team for making the data available.
Funding Sources This study was supported by a Ford Foundation Predoctoral Fellowship awarded to Janelle R. Goodwill from the National Academies of Sciences, Engineering, and Medicine.
18
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
19
References Anderson, L. M., Lowry, L. S., Wuensch, K. L. 2015. Racial differences in adolescents‘ answering questions about suicide. Death Stud. 39, 600-604. https://doi.org/10.1080/07481187.2015.1047058 Arnett, J.J., 2000. Emerging adulthood: A theory of development from the late teens through the twenties. Am. Psychol. 55, 469–480. https://doi.org/10.1037/0003-066X.55.5.469 Bostwick, W. 2012. Assessing bisexual stigma and mental health status: A brief report. J Bisex. 12, 214–222. https://doi.org/10.1080/15299716.2012.674860 Bridge, J.A., Asti, L., Horowitz, L.M., Greenhouse, J.B., Fontanella, C.A., Sheftall, A.H., Kelleher, K.J., Campo, J. V., 2015. Suicide trends among elementary school-aged children in the United States From 1993 to 2012. JAMA Pediatr. 169, 673–677. https://doi.org/10.1001/jamapediatrics.2015.0465 Bridge, J.A., Horowitz, L.M., Fontanella, C.A., Sheftall, A.H., Greenhouse, J., Kelleher, K.J., Campo, J. V., 2018. Age-Related Racial Disparity in Suicide Rates AmongUS Youths From 2001 Through 2015. JAMA Pediatr. 172, 696. https://doi.org/10.1001/jamapediatrics.2018.0263 Brody, J.E., 2018. Preventing suicide among college students [WWW Document]. New York Times. URL https://www.nytimes.com/2018/07/02/well/preventing-suicide-among-collegestudents.html (accessed 4.8.19). Centers for Disease Control and Prevention, 2018. Preventing Suicide. Retrieved from https://www.cdc.gov/violenceprevention/pdf/suicide-factsheet.pdf Cheng, H.L., Kwan, K.L.K., Sevig, T., 2013. Racial and ethnic minority college students‘ stigma associated with seeking psychological help: Examining psychocultural correlates. J. Couns. Psychol. 60, 98–111. https://doi.org/10.1037/a0031169 Chesin, M.S., Jeglic, E.L., 2012. Suicidal Behavior Among Latina College Students. Hisp. J. Behav. Sci. 34, 421–436. https://doi.org/10.1177/0739986312445271 Corrigan, P.W., Kosyluk, K.A., Markowitz, F., Brown, R.L., Conlon, B., Rees, J., Rosenberg, J., Ellefson, S., Al-Khouja, M., 2016. Mental illness stigma and disclosure in college students. J. Ment. Heal. 25, 224–230. https://doi.org/10.3109/09638237.2015.1101056 Corrigan, P.W., Morris, S.B., Michaels, P.J., Rafacz, J.D., Rüsch, N., 2012. Challenging the Public Stigma of Mental Illness: A Meta-Analysis of Outcome Studies. Psychiatr. Serv. 63, 963–973. https://doi.org/10.1176/appi.ps.201100529 Corrigan, P.W., Watson, A.C., 2002. Paradox of self-stigma and mental health. Clin. Psychol. Sci. Pract. 9, 35–53. https://doi.org/10.1093/clipsy/9.1.35 Downs, M.F. Eisenberg, D., 2012. Help seeking and treatment use among suicidal college students. J Am Coll Health. 60, 104-114. https://doi.org/10.1080/07448481.2011.619611 Eisenberg, D., Downs, M.F., Golberstein, E., Zivin, K., 2009. Stigma and Help Seeking College Students. Med. Care Res. Rev. 66, 522–541. https://doi.org/10.1177/1077558709335173
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
20
Gaddis, S.M., Ramirez, D., Hernandez, E.L., 2018. Contextualizing public stigma: Endorsed mental health treatment stigma on college and university campuses. Soc. Sci. Med. 197, 183–191. https://doi.org/10.1016/j.socscimed.2017.11.029 Golberstein, E., Eisenberg, D., Gollust, S.E., 2008. Perceived stigma and mental health care seeking. Psychiatr. Serv. 59, 392–399. https://doi.org/10.1176/ps.2008.59.4.392 Haas, A., Eliason, M., Mays, V. M., Mathy, R. M., Cochran, S. D., D‘Augelli, A. R., et al. 2011. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. J Homosex, 58, 10–51. https://doi.org/10.1080/00918369.2011.534038 Harris, T. L., Molock, S. D. 2000. Cultural orientation, family cohesion, and family support in suicide ideation and depression among African American college students. Suicide Life Threat Behav. 30, 341-353. https://doi.org/10.1111/j.1943-278X.2000.tb01100.x Hequembourg, A. L., & Brallier, S. A. 2009. An exploration of sexual minority stress across the lines of gender and sexual identity. Journal Homosex, 56, 273-298. https://doi.org/10.1080/00918360902728517 Kosyluk, K.A., Al-Khouja, M., Bink, A., Buchholz, B., Ellefson, S., Fokuo, K., Goldberg, D., Kraus, D., Leon, A., Michaels, P., Powell, K., Schmidt, A., Corrigan, P.W., 2016. Challenging the Stigma of Mental Illness Among College Students. J. Adolesc. Heal. 59, 325–331. https://doi.org/10.1016/j.jadohealth.2016.05.005 Kroenke, K., Spitzer, R.L., Williams, J.B.W., 2001. The PHQ-9: Validity of a Brief Depression Severity Measure Kurt. J. Gen. Intern. Med. 16, 606–613. https://doi.org/10.1046/j.15251497.2001.016009606.x Latalova, K., Kamaradova, D., Prasko, J., 2014. Perspectives on perceived stigma and selfstigma in adult male patients with depression. Neuropsychiatr. Dis. Treat. 10, 1399–1405. https://doi.org/10.2147/NDT.S54081 Lester, D., Walker, R.L., 2017. Religiosity Is a Protective Factor for Suicidal Ideation in European American Students but Not in African American Students. Omega (Westport). 74, 295–303. https://doi.org/10.1177/0030222815598452 Link, B.G., 1987. Understanding Labeling Effects in the Area of Mental Disorders : An Assessment of the Effects of Expectations of Rejection Author ( s ): Bruce G . Link Source : American Sociological Review , Vol . 52 , No . 1 ( Feb ., 1987 ), pp . 96-112 Published by : A. Am. Sociol. Rev. 52, 96–112. Link, B.G., Mirotznik, J., Cullen, F.T., 1991. The Effectiveness of Stigma Coping Orientations : Can Negative Consequences of Mental Illness Labeling be Avoided ? Author ( s ): Bruce G . Link , Jerrold Mirotznik , Francis T . Cullen Published by : American Sociological Association Stable URL : http://. J. Health Soc. Behav. 32, 302–320. https://doi.org/10.2307/3644186 Lipson, S.K., Kern, A., Eisenberg, D., Breland-Noble, A.M., 2018. Mental Health Disparities Among College Students of Color. J. Adolesc. Heal. 63, 348–356. https://doi.org/10.1016/j.jadohealth.2018.04.014 Liu, C. H., Stevens, C., Wong, S. H., Yasui, M., & Chen, J. A. 2019. The prevalence and
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
21
predictors of mental health diagnoses and suicide among US college students: Implications for addressing disparities in service use. Depress Anxiety, 36(1), 8-17. https://doi.org/10.1002/da.22830 Masuda, A., Anderson, P.L., Twohig, M.P., Feinstein, A.B., Chou, Y.Y., Wendell, J.W., Stormo, A.R., 2009. Help-seeking experiences and attitudes among African American, Asian American, and European American college students. Int. J. Adv. Couns. 31, 168–180. https://doi.org/10.1007/s10447-009-9076-2 Miret, M., Ayuso-Mateos, J.L., Sanchez-Moreno, J., Vieta, E., 2013. Depressive disorders and suicide: Epidemiology, risk factors, and burden. Neurosci. Biobehav. Rev. 37, 2372–2374. https://doi.org/10.1016/j.neubiorev.2013.01.008 Muehlenkamp, J.J., Marrone, S., Gray, J.S., Brown, D.L., 2009. A College Suicide Prevention Model for American Indian Students. Prof. Psychol. Res. Pract. 40, 134–140. https://doi.org/10.1037/a0013253 Mueller, A.S., James, W., Abrutyn, S., Levin, M.L., 2015. Suicide ideation and bullying among US adolescents: Examining the intersections of sexual orientation, gender, and race/ethnicity. Am. J. Public Health 105, 981–985. https://doi.org/10.2105/AJPH.2014.302391 Oexle, N., Waldmann, T., Staiger, T., Xu, Z., Rüsch, N., 2019. Mental illness stigma and suicidality: the role of public and individual stigma. Epidemiol. Psychiatr. Sci. 27, 169–175. https://doi.org/10.1017/S2045796016000949 Pedersen, E.R., Paves, A.P., 2014. Comparing perceived public stigma and personal stigma of mental health treatment seeking in a young adult sample. Psychiatry Res. 219, 143–150. https://doi.org/10.1161/ATVBAHA.114.303112.ApoA-I Rüsch, N., Zlati, A., Black, G., Thornicroft, G., 2014. Does the stigma of mental illness contribute to suicidality? Br. J. Psychiatry 205, 257–259. https://doi.org/10.1192/bjp.bp.114.145755 Silverman, M.M., Meyer, P.M., Sloane, F., Raffel, M., Pratt, D.M., June, L.N., Williams, G., Pope Curry, B., Douce, L., Taylor, K., Glover, S., Seals, T., Joffe, P., Jolly, A., Trimble, R.W., Bessai, J., Stone, G., Cochran, S., Gauthier, E., Scott, L., Whiteside, J., 1997. The Big Ten Student Suicide Study: A 10-Year Study of Suicides on Midwestern Unitersity Campuses. Suicide Life-Threatening Behav. Am. Assoc. Suicidol. 27. https://doi.org/10.1111/j.1943-278X.1997.tb00411.x StataCorp. 2017. Stata Statistical Software: Release 15. College Station, T.S.L. Stephenson, J., Belesis, M., Balliet, W., 2005. Variability in College Student Suicide: Age, Gender, and Race. J. Clin. Child Adolesc. Psychol. 19, 5–33. https://doi.org/10.1300/J035v19n04 Student Exchange and Visitor Program, U.S. Immigration and Customs Enforcement, 2017. SEVIS by the numbers: Biannual report on international student trends. Thornicroft, G., Mehta, N., Clement, S., Evans-Lacko, S., Doherty, M., Rose, D., Koschorke, M., Shidhaye, R., O‘Reilly, C., Henderson, C., 2016. Evidence for effective interventions to
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
22
reduce mental-health-related stigma and discrimination. Lancet 387, 1123–1132. https://doi.org/10.1016/S0140-6736(15)00298-6 Vogel, D.L., Wade, N.G., Hackler, A.H., 2007. Perceived public stigma and the willingness to seek counseling: The mediating roles of self-stigma and attitudes toward counseling. J. Couns. Psychol. 54, 40–50. https://doi.org/10.1037/0022-0167.54.1.40 Walker, R. L., Bishop, S. 2005. Examining a model of the relation between religiosity and suicidal ideation in a sample of African American and White college students. Suicide Life Threat Behav. 35, 630-639. https://doi.org/10.1521/suli.2005.35.6.630 Wang, M.C., Nyutu, P.N., Tran, K.K., 2012. Coping, reasons for living, and suicide in black college students. J. Couns. Dev. 90, 459–466. https://doi.org/10.1002/j.15566676.2012.00057.x Wexler, L., Chandler, M., Gone, J.P., Cwik, M., Kirmayer, L.J., LaFromboise, T., Brockie, T., O‘Keefe, V., Walkup, J., Allen, J., 2015. Advancing suicide prevention research with rural American Indian and Alaska Native populations. Am. J. Public Health 105, 891–9. https://doi.org/10.2105/AJPH.2014.302517 Wong, S. S., Sugimoto-Matsuda, J. J., Chang, J. Y., & Hishinuma, E. S. 2012. Ethnic differences in risk factors for suicide among American high school students, 2009: The vulnerability of multiracial and Pacific Islander adolescents. Arch Suicide Res, 16(2), 159-173. https://doi.org/10.1080/13811118.2012.667334 Wong, Y.J., Koo, K., Tran, K.K., Chiu, Y.C., Mok, Y., 2011. Asian American college students‘ suicide ideation: A mixed-methods study. J. Couns. Psychol. 58, 197–209. https://doi.org/10.1037/a0023040 Zhang, N., Dixon, D.N., 2003. Acculturation and attitudes of Asian international students toward seeking psychological help. J. Multicult. Couns. Devel. 31, 205–222. https://doi.org/10.1002/j.2161-1912.2003.tb00544.x Zhou, S., King, E., Gjogiovska, J., Mihajlov, A., Stojanovski, K. 2018. Self-concealment, discrimination and mental health in Macedonia: Disparities experienced by sexual and gender minorities. Glob Public Health. 14, 1075-1086. https://doi.org/10.1080/17441692.2018.1560484
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
23
Table 1. Participant Demographics and Characteristics d
Age 18-30 Female Heterosexual Bisexual Gay/lesbian/queer Questioning/other Undergrad First gen student Public stigma (mean, range 1-5) Mental Health Measures e Past Year Suicide ideation Past Year Suicide plan Past Year Suicide attempt
Asian Int n= 7054 91.56 51.56 90.61 3.95 2.58 2.85 47.60 29.31 3.23
Asian Dom n= 11,514 94.41 59.03 89.60 3.71 3.27 3.42 73.46 35.07 3.20
Black n= 7198 82.95 58.54 88.66 4.00 4.30 3.03 71.47 55.90 3.34
Latinx n= 8402 89.18 60.48 87.49 4.68 4.89 2.95 70.04 65.88 3.16
6.34 c 2.12 c 1.18 b
9.59 3.19 0.88
9.09 2.82 1.04 a
8.55 2.86 0.88
Multiracial White n= 11,484 n= 105,857 93.01 91.13 60.80 58.64 82.62 89.48 7.49 4.52 5.33 3.53 4.56 2.46 74.74 73.84 38.84 33.20 3.14 3.05
13.25 c 4.68 c 1.15 c
8.82 c 2.89 b 0.65 c
AI/AN n= 474 75.65 66.05 85.48 7.57 3.04 3.91 61.96 71.38 3.22
Arab n= 1652 91.04 50.02 89.87 2.13 2.38 5.62 63.94 36.43 3.24
12.49 a 5.48 b 0.06
7.56 3.03 1.15
Depression (positive screen, PHQ-9 23.42 25.54 c 25.27 c 26.72 c 28.28 c 20.85 c 27.78 a 27.88 c score >10) Received MH treatment f 8.13 c 12.03 c 12.13 c 13.73c 24.34 c 24.48 c 27.32 13.80 c a b c d e p ≤ .05; p ≤ .01; p ≤ .001; percentages reported unless otherwise noted; p-values based on two-tailed chi-squared tests, with significant differences determined between students who identify as each particular race/ethnicity and those who do not f participants were asked to indicate whether they received mental health treatment within the past 12 months
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
24
Table 2. Association between Perceived Public Stigma and Suicide Ideation with Odds Ratios and 95% Confidence Intervals Variable
OR (95% CI)
P Value
Age 31 and older 18 - 30
REF 1.34 (1.18, 1.52)
<.001
Gender Men Women
REF .87 (.82, .92)
<.001
Sexual Orientation Heterosexual
REF
Bisexual
2.29 (2.11, 2.49)
<.001
Gay/Lesbian/Queer
1.92 (1.69, 2.18)
<.001
Questioning or Other
1.94 (1.72, 2.20)
<.001
Race White
REF
Asian International
.62 (.53, .72)
<.001
Asian Domestic
.92 (.83, 1.01)
.079
Black/African American
.97 (.87, 1.08)
.291
Latinx
.77 (.68, .88)
<.001
Multiracial
1.21 (1.10, 1.34)
<.001
American Indian/Alaska Native
1.21 (.79, 1.84)
.374
.63 (.48, .843
.001
1.20 (1.19, 1.20)
<.001
Arab/Arab American Depressive Symptoms
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS Perceived Public Stigma
1.18 (1.15, 1.21)
25 <.001
Table 3. Association between Perceived Public Stigma and Suicide Plan with Odds Ratios and 95% Confidence Intervals Variable
OR (95% CI)
P Value
Age 31 and older 18 - 30
REF 1.58 (1.30, 1.91)
<.001
Gender Men Women
REF .92 (.84, 1.00)
.056
Sexual Orientation Heterosexual
REF
Bisexual
2.48 (2.19, 2.81)
<.001
Gay/Lesbian/Queer
1.98 (1.69, 2.31)
<.001
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS Questioning or Other
1.96 (1.66, 2.32)
26 <.001
Race White
REF
Asian International
.68 (.53, .87)
.002
Asian Domestic
.90 (.77, 1.06)
.208
Black/African American
.87 (.70, 1.08)
.197
Latinx
.79 (.65, .97)
.021
Multiracial
1.19 (1.02, 1.39)
.028
American Indian/Alaska Native
1.56 (.91, 2.66)
.103
Arab/ Arab American
.83 (.56, 1.23)
.353
Depressive Symptoms
1.20 (1.19, 1.20)
<.001
Perceived Public Stigma
1.26 (1.21, 1.31)
<.001
Table 4. Association between Perceived Public Stigma and Suicide Attempt with Odds Ratios and 95% Confidence Intervals Variable
OR (95% CI)
Age 31 and older
REF
P Value
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS 18 - 30
2.55 (1.66, 3.89)
27 <.001
Gender Men Women
REF 1.27 (1.07, 1.51)
.006
Sexual Orientation Heterosexual
REF
Bisexual
2.48 (2.01, 3.05)
<.001
Gay/Lesbian/Queer
2.03 (1.54, 2.68)
<.001
Questioning or Other
1.80 (1.33, 2.44)
<.001
Race White
REF
Asian International
1.87 (1.33, 2.61)
<.001
Asian Domestic
1.11 (.83, 1.49)
.465
Black/African American
1.48 (1.08, 2.03)
.016
Latinx
1.12 (.82, 1.54)
.460
Multiracial
1.24 (.88, 1.74)
.222
American Indian/Alaska Native
.63 (.22, 1.78)
.381
Arab/Arab American
1.53 (.79, 2.93)
.205
Depressive Symptoms
1.19 (1.17, 1.20)
<.001
Perceived Public Stigma
1.27 (1.16, 1.38)
<.001
Association between perceived public stigma and suicidal behaviors among college students of color in the U.S. Janelle R. Goodwill MSW , Sasha Zhou MPH, MHSA PII: DOI: Reference:
S0165-0327(19)32096-8 https://doi.org/10.1016/j.jad.2019.10.019 JAD 11208
To appear in:
Journal of Affective Disorders
Received date: Revised date: Accepted date:
6 August 2019 20 September 2019 11 October 2019
Please cite this article as: Janelle R. Goodwill MSW , Sasha Zhou MPH, MHSA , Association between perceived public stigma and suicidal behaviors among college students of color in the U.S., Journal of Affective Disorders (2019), doi: https://doi.org/10.1016/j.jad.2019.10.019
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier B.V.
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
Highlights
Perceived public stigma is associated with suicide ideation, planning, and attempt Asian international and Black students reported greater odds of suicide attempt Sexual minority students reported greater odds of across all three suicide outcomes
1
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
Title Association between perceived public stigma and suicidal behaviors among college students of color in the U.S.
Authors: Janelle R. Goodwill, MSW1, 2 and Sasha Zhou, MPH, MHSA3 1. University of Michigan School of Social Work, Ann Arbor, MI USA 2. University of Michigan Department of Psychology, Ann Arbor, MI USA 3. University of Michigan School of Public Health, Department of Health Management and Policy, Ann Arbor, MI USA
Corresponding Author: Janelle R. Goodwill, MSW PhD Candidate in Social Work & Psychology University of Michigan | School of Social Work 1080 S. University Ave. Room B660 Ann Arbor, MI 48109-1106 734.707.1127 [phone] [email protected] [email]
Abstract
2
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
3
Background: Suicide is the 2nd leading cause of death among college students and 10 to 34-yearolds in the U.S. While rates of suicide among young people of color have increased, less is known about factors that contribute to suicidality among racial minority students who are sorely underrepresented within existing research. Thus, we sought to explore the association between perceived public stigma of receiving mental health treatment and suicidality among Black, Asian Domestic, Asian International, Latinx, Multiracial, Arab/Arab American, American Indian/Alaska Native, and White college students.
Methods: We analyzed cross-sectional survey responses from racially diverse sample of 153, 635 college students who participated in the Healthy Minds Study from years 2007 – 2018. Multivariable logistic regression was used to examine associations between perceived public stigma and suicide ideation, suicide planning, and suicide attempt.
Results: Perceived public stigma was significantly associated with greater odds of suicide ideation, planning, and attempt. Odds of having attempted suicide within the past year were significantly greater among Asian International and Black college students. Sexual minority students broadly, and bisexual students specifically, were also at elevated risk for suicidal behavior.
Limitations: Cross-sectional survey responses were assessed and causality cannot be determined.
Conclusions: Students who endorsed more perceived public stigma also reported significantly greater odds of having experienced suicide ideation, planning, and attempt within the past 12 months. Subsequent interventions should account for concerns surrounding public perceptions of stigma when working to prevent suicide among students of color. Keywords: stigma; suicide; college students; students of color
Abstract word count: 239 words Abstract word limit: 250 words
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
4
INTRODUCTION It is well established that stigma acts as a barrier to seeking help for mental health concerns (Corrigan and Watson, 2002; Gaddis et al., 2018). Research demonstrates that persons who adhere to stigmatized beliefs about mental health are less likely to seek professional help and oftentimes experience worse mental health outcomes (Latalova et al., 2014; Vogel et al., 2007). More pointedly, public stigma— the belief that most people hold negative views towards persons experiencing a mental health condition—has been linked to increased rates of anxiety and depressive symptoms (Cheng et al., 2013; Corrigan and Watson, 2002). However, few studies have sought to explore whether perceived public stigma is associated with other adverse mental health outcomes, like suicide ideation and attempt (exceptions include Downs and Eisenberg, 2012; Gaddis et al., 2018; Oexle et al., 2019). Exploring whether psychological factors like stigma are associated with suicidal behaviors is particularly important to assess among young people, as suicide is the 2nd leading cause of death among college students (Brody, 2018) and 10-34 year-olds in the U.S. (Centers for Disease Control and Prevention, 2018). While disturbing trends of suicide death are notably high for young people across race groups (CDC, 2018), there are important gaps in the extant literature that limit our understanding of suicide specifically among young people of color. As such, immediate efforts are needed to redress disparities in representation of racial minorities in suicide research, while also working to uncover which factors promote and prevent suicidal behaviors among young (or “emerging” (Arnett, 2000)) adults. The current study aims to rectify these concerns by analyzing crosssectional survey responses from a racially diverse sample of 153, 653 college students who participated in the Healthy Minds Study from years 2007 – 2018. Implications for practice and intervention are discussed.
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
5
Drawing from Link’s labeling theory (Link, 1987), Corrigan and Watson (2002) assert that public stigma is shaped by popular beliefs and perceptions regarding mental illness, and ultimately manifests in the form of stereotypes, prejudicial beliefs, and discriminatory acts (Corrigan et al., 2012). As such, public stigma related to mental illness has become commonplace within U.S. culture and customs, despite its potentially deleterious effects on mental health and psychological well-being. Although Corrigan and colleagues focus specifically on public stigma related to mental illness, it seems plausible that perceptions of public stigma related to receiving mental health treatment may also be harmful towards an individual’s wellbeing (Pedersen and Paves, 2014). Some researchers have already begun to examine these matters among college students, as previous studies report that perceived stigma is not related to mental health service utilization (Eisenberg et al., 2009; Golberstein et al., 2008) but is significantly associated with greater prevalence of depression, anxiety, self-harm, and suicide ideation (Downs and Eisenberg, 2012; Gaddis et al., 2018). Additional work is, however, needed to substantiate whether the relationship between perceived public stigma and suicidal outcomes (e.g. ideation, planning, and attempt) holds among diverse race groups. Critically interrogating the role of perceived public stigma within the context of receiving mental health treatment is a necessary step that will offer much needed insight into the mental health experiences of those from understudied groups and communities of color. Furthermore, it is worthwhile to consider how perceptions of stigma are relevant to conversations of race, as racial and ethnic minorities typically report higher rates of stigma, yet lower rates of mental health service utilization (Kosyluk et al., 2016; Lipson et al., 2018). Findings yielded from a recent investigation found that both individual and school-level perceptions of stigma related to mental health treatment seeking were associated with greater
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
6
likelihood of suicide ideation among college students broadly, though findings specific to students of color were not observed (Gaddis et al., 2018). Race is an important factor to consider, as earlier investigations report that students of color are less likely to engage in suicidal behaviors when compared to White students (Silverman et al., 1997; Stephenson et al., 2005). Since then researchers have examined suicidal behaviors specifically among Asian college students (Wong et al., 2011), Black college students (Harris and Molock, 2000; Wang et al., 2012), American Indian college students (Muehlenkamp et al., 2009), and Latina college students (Chesin and Jeglic, 2012), while others have focused on differences between Black and White student samples (Lester and Walker, 2017; Walker and Bishop, 2005). Though these efforts are laudable, more work is needed to evaluate factors related to suicide among racial and ethnic minority groups, as rates of suicide death among young people of color has increased within the past 20 years (Bridge et al., 2018, 2015). Notably the rates of suicide death for young people across all races groups remain highest among American Indian/Alaska Native youths and young adults (Wexler et al., 2015), though many suicide-related research studies fail to center the experiences of college students of color. Thus, it is evident that more studies of suicidality among racially diverse college students are warranted. A recent study by Lipson and colleagues (Lipson et al., 2018) found that not only were college students of color less likely to seek help when faced with mental health concerns, but also that both Asian and Multiracial college students reported significantly higher rates of suicide ideation when compared to students of other races. We are interested in extending this work using Corrigan and Watson‘s framework (2002) to determine whether perceived public stigma related to receiving mental health treatment is associated with increased risk for suicide ideation,
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
7
planning, and attempt among a racially diverse sample of Asian, Black, Latinx, American Indian/Alaska Native, Arab/Arab American, Multiracial, and White college students.
METHODS Data were collected from the Healthy Minds Study (HMS) — an annual survey designed to address the unique mental health needs of college students in the U. S. (Eisenberg et al., 2009). Beginning in 2007, members of the HMS team partnered with colleges and universities across the nation in efforts to prioritize and promote mental wellness at the university level. All surveys were administered online; consent was also obtained electronically. Both currentlyenrolled graduate and undergraduate students are eligible to participate. Study recruitment is determined by school enrollment numbers, as random sampling procedures are used only at institutions whose student body enrollment exceeds 4,000. Conversely, the entire study body is invited to participate at schools whose enrollment is less than 4,000. Survey content is presented in a module format where all participants receive the same three primary modules (e.g. demographics, mental health status, mental health service utilization and help-seeking behaviors), though administrators at each institution can opt to include additional modules in the surveys students on their campus receive. Additional details regarding the sampling procedures and study design are available at healthymindsnetwork.org. The current study analyzed crosssectional survey responses from 153, 635 students who completed the HMS survey from 20072018. The response rate was approximately 25% across all years. Measures Demographics. Information regarding participants‘ age, gender, and sexual orientation were included as covariates. Race was captured using a single-item that asked participants to ―select all that apply.‖ Therefore, students who selected more than one race were considered
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
8
Multiracial. Potential response options included Asian, Black/African American, Latino/a, American Indian/Alaska Native, Arab/Arab American, and White. We disaggregated the Asian students by international student status, as approximately 40% of students who identified as Asian were also international students. Age was dichotomized into two groups where group 1 included participants who were 18-30 years old, and group 2 included participants who were >30 years old. Response options for the age variable were not captured consistently across each years. For example, in some years students were asked to list their specific age, while in other years students were asked to identify whether they were between 18 to 25-years-old, 26 to 30years-old, and so on. Therefore, in order to utilize all data sources from 2007-2018, we needed to collapse the age variable into the two overarching categories (18-30 and 31 and older). Sexual orientation was categorized into four groups represented as 1=heterosexual/straight, 2=bisexual, 3=gay, lesbian, or queer, and 4=questioning or other. Additional demographic information is provided in Table 1. Perceived Public Stigma. Perceived public stigma was assessed using three revised items from the Perceived Devaluation-Discrimination Scale (Link et al., 1991). Items used in the HMS survey were reworded to reflect stigma related to receiving mental health treatment (Eisenberg et al., 2009; Golberstein et al., 2008). Response options were captured using a 5-point Likert scale that ranged from ―1= Strongly disagree‖ to ―6= Strongly agree.‖ Sample items include, ―Most people would willingly accept someone who has received mental health treatment as a close friend, Most people feel that receiving mental health treatment is a sign of personal failure, and Most people think less of a person who has received mental health treatment.” The items noting
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
9
―mental health as a sign of personal failure‖ and ―thinking less of someone who received mental health treatment‖ were both reverse-scored. A mean score was calculated; Cronbach‘s alpha reliability coefficients across race groups ranged from 0.75 to 0.81. This measure has been used in others studies using HMS data and has shown good internal consistency (Downs and Eisenberg, 2012; Eisenberg et al., 2009; Golberstein et al., 2008).
Depressive Symptoms. Depressive symptoms were measured using the PHQ-9 (Kroenke et al., 2001). Participants were asked to report how often they have been bothered by various problems within the past 2 weeks. Response options were captured using a Likert scale with options ranging from ―0= Not at all‖ to ―3=Nearly every day,‖ with higher score representing greater depressive symptomatology. Sample items include, ―Little interest or pleasure in doing things,‖ and ―Feeling down, depressed, or hopeless.‖ A total score of depressive symptoms was calculated. The Cronbach‘s alpha reliability coefficients for depressive symptoms across all race groups ranged from 0.87 to 0.90. Past Year Suicide Ideation. Suicide ideation was measured using a single item that asked students to indicate whether they had ever seriously considered ending their life within the past 12 months (1=yes, 0=no). Past Year Suicide Planning. Suicide planning was measured using a single item that asked students whether they had made a plan to end their life within the past 12 months (1=yes, 0=no). Past Year Suicide Attempt. Suicide attempt was measured using a single item that asked respondents to indicate whether they had attempted to end their life within the past 12 months (1=yes, 0=no).
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
10
Analytic Plan First we calculated the prevalence of descriptive characteristics and mental health conditions, stratified by race categories. Next we conducted three separate logistic regression tests to examine associations between perceived public stigma and outcomes of suicide ideation, suicide planning, and suicide attempt. The final analytic sample was restricted to 7,198 Black, 8,402 Latinx, 11,514 Asian domestic, 7,054 Asian International, 11,484 Multiracial, 474 American Indian/Alaska Native, 1,652 Arab/Arab American, and 105,857 White students who represented the largest proportion of students and served as the reference group. Race, age, gender, sexual orientation, and depressive symptoms were included as covariates in each model. Sampling weights were applied to account for differences in response rates between responders and non-responders in gender, race, academic level and GPA. Responses were examined via the svy suite where clustered standard errors were specified to account for clustering within schools. All analyses were conducted using Stata version 15 SE (StataCorp, 2017). RESULTS Endorsement of perceived public stigma was highest among Black students and lowest among White students. The percentage of students across all race groups who reported suicide ideation in the past year ranged between 6.34% and 13.25%. The percentage of students who made a suicide plan within the past year ranged between 2.12 % and 5.48%. Further, the percentage of students who attempted suicide within the past year ranged between 0.06 % and 1.18%, respectively. Additional information is provided in Table 1. Results from the first multivariable logistic regression test of suicide ideation are presented in Table 2. When controlling for depressive symptoms, perceived public stigma was
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
11
significantly associated with greater odds of 12-month suicide ideation (odds ratio [OR] = 1.18; 95% CI= 1.15, 1.21). Asian International, Latinx, and Arab/Arab American students were less likely to experience suicide ideation when compared to White students. This association, however, was positive among Multiracial students, who reported the greatest odds of past-year suicide ideation (OR= 1.21; 95% CI = 1.10, 1.34). Women reported significantly lower odds of suicide ideation relative to men (OR= .87; 95% CI = 0.82, 0.92). Odds of having experienced suicidal thoughts in the past 12 months were significantly greater among sexual minority students as compared to their heterosexual peers. Moreover, 18 to 30-year-old students had significantly greater odds of suicide ideation relative to older students. Results from the second multivariable logistic regression test revealed a similar pattern in that perceived public stigma was associated with greater odds of suicide planning (OR= 1.26; 95% CI=1.21, 1.31). Odds of having made a suicide plan within the past 12 months were significantly lower among Asian International and Latinx students, but were significantly higher for Multiracial students. Further, students who identified as gay, lesbian, bisexual, or questioning were more likely to have made a suicide plan within the past 12 months. Again, odds of having made a suicide plan within the past 12 months were significantly higher among 18 to 30-year-old students. Additional details are provided in Table 3. Results from the final multivariable logistic regression test indicate that when controlling for depressive symptoms, perceived public stigma was again significantly associated with greater odds of past-year suicide attempt (OR= 1.27; 95% CI=1.16, 1.38). Asian International (OR= 1.87; 95% CI=1.33, 2.61) and Black college students (OR= 1.48; 95% CI=1.08, 2.03) were more likely to have attempted suicide in the past 12 months than were White college students. Odds of past-year suicide attempt were significantly higher among women than for men (OR= 1.27; 95%
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
12
CI=1.07, 1.51). Eighteen to 30-year-old students were more likely to have attempted suicide within the past 12 months in comparison to older students (OR= 2.55; 95% CI= 1.66, 3.89). Also, the odds of past-year suicide attempt were significantly higher among bisexual (OR= 2.48; 95% CI= 2.01, 3.05), gay/lesbian/queer (OR=2.03; 95% CI= 1.54, 2.68), and students questioning their sexual orientation (OR=1.80; 95% CI= 1.33, 2.44). DISCUSSION This study purposed to examine the relationship between perceived public stigma and suicidality among college students of color in the U.S. Guided by Corrigan and Watson‖s (2002) framework, findings from this investigation highlight that greater endorsement of perceived public stigma is associated with increased odds of suicide ideation, planning and attempt. These results also reveal important new insights involving perceived public stigma and its association with the highest odds of suicide attempt for Asian International students, followed by Black college students. Our study also contributes to the growing body of literature examining the experiences of sexual minority students who consistently report significantly greater odds of suicidal behavior compared to their heterosexual peers (Haas et al., 2011; Liu et al., 2019; Mueller et al., 2015). As such, our findings point to the salience of both race and sexual orientation in understanding stigma and suicidality among college students. Suicide is a complex phenomenon that is often linked to underlying mental health disorders. Although mental illness is strongly associated with suicide, not everyone that screens positive for mental health conditions experiences suicidality (Miret et al., 2013). Perceived public stigma has been found to account for some of the observed variability in suicide risk. Many of the negative psychosocial consequences of perceived public stigma, such as loneliness, shame, and hopelessness are also predictors of suicidality (Rüsch et al., 2014). The pressure to
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
13
conceal mental illness that results from high levels of perceived public stigma could lead to cognitive and emotional distress and hypervigilance, which has been hypothesized to be a stigma-coping mechanism that drives suicidal behaviors (Oexle et al., 2019). It will be worthwhile for future research to more closely consider these factors among racial minority students. A recent investigation disclosed that individual-level endorsement of public stigma was positively associated with suicide ideation, though school-level stigma was negatively associated with suicide ideation (Gaddis et al., 2018). As a result, the researchers advocated for targeting all individuals in campaigns that focus on overall campus climate surrounding stigma (Gaddis et al., 2018). While their analysis offers an important first step, findings from this study suggest that colleges and universities should also invest in a more tailored approach to anti-stigma campaigns— particularly through intervention efforts with culturally specific messaging. In general, targeted interventions are found to be more effective in reducing stigma than broad interventions (Thornicroft et al., 2016). Designing and implementing more culturally tailored outreaches may be especially salient for Asian International and Black college students, as underscored not only by our analysis, but also previous research that has found these students to report low rates of help-seeking for mental health concerns (Downs and Eisenberg, 2012; Lipson et al., 2018). Interestingly, odds of having attempted suicide within the past 12 months were significantly higher for Black college students. This finding departs from previous research that identifies Black college students as having lowered risk for suicidality when compared to students from other race groups (Silverman et al., 1997). Black college students unfortunately remain underrepresented in existing reports on suicide, and research that focuses exclusively on
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
14
their experiences is limited. Therefore, more race-specific queries that intentionally explore both the interpersonal and societal determinants associated with suicide will be required in order to mitigate further suicide risk for this noticeably understudied group. Results from this study also demonstrate that Black students reported more perceived public stigma when compared to their peers. These findings support much of the previous research on endorsement of mental health stigma among Blacks and other college students of color (Corrigan et al., 2016; Masuda et al., 2009), who oftentimes report feeling particularly uneasy about seeking help for mental health concerns. Matters related to stigma may be exacerbated for Black students enrolled at Predominately White Institutions (PWIs), as concerns persist regarding underrepresentation and retention of minority students on college campuses. Additional efforts should be made to consider whether perceived public stigma and rates of suicide attempt vary among students attending PWIs versus Historically Black College and Universities or other Minority Serving Institutions. International Asian students also reported significantly higher odds of suicide attempt. This finding aligns with other work which affirms that Asian students not only experience high levels of stigma and consequently low levels of help-seeking, but also the greatest severity of distress upon intake at campus treatment centers (Lipson et al., 2018; Zhang and Dixon, 2003). International Asian students are an especially vulnerable population as they often hold a doublemarginalized status on campus— both as students of color and non-citizens (as do many Latinx students). These students are also further separated from informal support systems such as family and childhood friends compared to their domestic peers. Mental health advocacy is particularly important for this group, as over 75% of all international students studying in the U.S. are from Asian countries (Student Exchange and Visitor Program, U.S. Immigration and Customs
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
15
Enforcement, 2017). Perceived stigma surrounding use of mental health services is also especially severe in Asian countries, and thus efforts to reduce mental health stigma for this population should be designed with sensitivity to country of origin. Similarly, more concerted efforts are needed to further consider the mental health experiences of Multiracial students on college campuses. Findings from this investigation are consistent with recent research noting that Multiracial youth and young adults report higher rates of suicidality when compared to peers of other race groups (Anderson et al., 2015; Liu et al., 2019; Lipson et al., 2018; Wong et al., 2012). Anderson et al., (2015) speculate that stigma influences youth‘s willingness to respond to questions about suicide history. Few direct explanations, however, have been offered that specifically address the unique lived experiences of Multiracial students. As mentioned earlier, we did not examine specific subgroups of Multiracial students, though examining group-specific experiences will be an important next step in working to promote wellness among members of this group. In this we see that while much more work is needed to prevent suicide among students of color, perceived public stigma does appear to function as an important conduit for improving help-seeking and decreasing the prevalence of suicidal behaviors in university students. When considering that studies that examine associations between perceived public stigma and suicidal behaviors are rare (Downs and Eisenberg, 2012; Gaddies et al., 2018; Oexle et al., 2019), some viable next steps may include assessing various social and environmental factors that moderate or mediate the link between perceived public stigma and suicidality. This is just one of several ways to build upon results generated from this exploratory study. Moreover, employing the use of qualitative or mixed methods approaches will also be important in working to explicate the role, prevalence, and impact of stigma within and across communities of color.
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
16
Limitations and future research Our study is not without limitations. HMS does not include a random sample of campuses as schools themselves elect to participate in the study. Additionally, our study does rely on self-report data, and it is unclear how the self-report nature of this study may yield different levels of bias across racial groups for our constructs of interest. Further, while we disaggregated Asian students by international status, HMS does not collect specific Asian subgroup demographic information. The same considerations apply for other race groups, and in turn it is difficult to parse out potential ethnicity correlates and variations. We created one overarching ‗Multiracial‘ group and did not examine differences within various sub-groups of students who reported identifying as more than one race. We recognize and respect that the experiences of Multiracial students are not monolithic, and encourage future studies to take a more nuanced approach in studying these populations. In addition, we encourage future studies to further investigate individual race and ethnic groups, as our study generated insight from a high level overview and could not fully elucidate the multidimensional pathways that connect perceived public stigma and suicide. Lastly, our study utilizes cross-sectional data, and findings from the current investigation assess associations between stigma and suicidal behaviors only. Therefore, causality among key study variables cannot be assumed. Our findings align closely with a recent report that used data from the American College Health Association and found increased risk for suicidality among Multiracial and bisexual students (Liu et al., 2019). This points to sexual orientation broadly, and bisexuality specifically, as important factors to consider when exploring the relationship between perceived stigma and suicidality. There is evidence to suggest that bisexual youth and young adults have unique experiences of stigma and stereotyping, including differential treatment by both heterosexual
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
17
peers and members of other sexual minority groups (Hequenourg and Brailler, 2009; Botswick, 2012; Zhou et al., 2018). Bisexual students are thus in a complicated position of confronting various forms of exclusion, oftentimes resulting in adverse mental health experiences (Hequenourg and Brailler, 2009; Botswick, 2012; Zhou et al., 2018). For these reasons additional research that examines variability within sexual minority groups should be considered. Taken together, results yielded from this investigation suggest that perceived public stigma is a pernicious psychological correlate that is related suicide ideation, planning, and attempt. Thus, a deeper exploration of the mechanisms between perceived public stigma and suicidality is needed. While our study offers preliminary evidence in establishing these links, it is our hope that future studies further examine the interpersonal, community, and structural factors that may influence the pathway between perceived public stigma and suicidality— culminating towards more avenues of suicide prevention and intervention efforts for students of color throughout their time at the university and beyond.
Author Statement JRG conceptualized the study and led the writing of the manuscript. SZ acquired the data and led the data analysis. SZ also contributed to writing the manuscript. JRG contributed to the analyses. Both authors reviewed and approved the final version of the manuscript.
Conflicts of Interest The authors have no conflicts of interest to report.
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS Acknowledgements The authors would like to thank Dr. Daniel Eisenberg and the Healthy Minds Study team for making the data available.
Funding Sources This study was supported by a Ford Foundation Predoctoral Fellowship awarded to Janelle R. Goodwill from the National Academies of Sciences, Engineering, and Medicine.
18
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
19
References Anderson, L. M., Lowry, L. S., Wuensch, K. L. 2015. Racial differences in adolescents‘ answering questions about suicide. Death Stud. 39, 600-604. https://doi.org/10.1080/07481187.2015.1047058 Arnett, J.J., 2000. Emerging adulthood: A theory of development from the late teens through the twenties. Am. Psychol. 55, 469–480. https://doi.org/10.1037/0003-066X.55.5.469 Bostwick, W. 2012. Assessing bisexual stigma and mental health status: A brief report. J Bisex. 12, 214–222. https://doi.org/10.1080/15299716.2012.674860 Bridge, J.A., Asti, L., Horowitz, L.M., Greenhouse, J.B., Fontanella, C.A., Sheftall, A.H., Kelleher, K.J., Campo, J. V., 2015. Suicide trends among elementary school-aged children in the United States From 1993 to 2012. JAMA Pediatr. 169, 673–677. https://doi.org/10.1001/jamapediatrics.2015.0465 Bridge, J.A., Horowitz, L.M., Fontanella, C.A., Sheftall, A.H., Greenhouse, J., Kelleher, K.J., Campo, J. V., 2018. Age-Related Racial Disparity in Suicide Rates AmongUS Youths From 2001 Through 2015. JAMA Pediatr. 172, 696. https://doi.org/10.1001/jamapediatrics.2018.0263 Brody, J.E., 2018. Preventing suicide among college students [WWW Document]. New York Times. URL https://www.nytimes.com/2018/07/02/well/preventing-suicide-among-collegestudents.html (accessed 4.8.19). Centers for Disease Control and Prevention, 2018. Preventing Suicide. Retrieved from https://www.cdc.gov/violenceprevention/pdf/suicide-factsheet.pdf Cheng, H.L., Kwan, K.L.K., Sevig, T., 2013. Racial and ethnic minority college students‘ stigma associated with seeking psychological help: Examining psychocultural correlates. J. Couns. Psychol. 60, 98–111. https://doi.org/10.1037/a0031169 Chesin, M.S., Jeglic, E.L., 2012. Suicidal Behavior Among Latina College Students. Hisp. J. Behav. Sci. 34, 421–436. https://doi.org/10.1177/0739986312445271 Corrigan, P.W., Kosyluk, K.A., Markowitz, F., Brown, R.L., Conlon, B., Rees, J., Rosenberg, J., Ellefson, S., Al-Khouja, M., 2016. Mental illness stigma and disclosure in college students. J. Ment. Heal. 25, 224–230. https://doi.org/10.3109/09638237.2015.1101056 Corrigan, P.W., Morris, S.B., Michaels, P.J., Rafacz, J.D., Rüsch, N., 2012. Challenging the Public Stigma of Mental Illness: A Meta-Analysis of Outcome Studies. Psychiatr. Serv. 63, 963–973. https://doi.org/10.1176/appi.ps.201100529 Corrigan, P.W., Watson, A.C., 2002. Paradox of self-stigma and mental health. Clin. Psychol. Sci. Pract. 9, 35–53. https://doi.org/10.1093/clipsy/9.1.35 Downs, M.F. Eisenberg, D., 2012. Help seeking and treatment use among suicidal college students. J Am Coll Health. 60, 104-114. https://doi.org/10.1080/07448481.2011.619611 Eisenberg, D., Downs, M.F., Golberstein, E., Zivin, K., 2009. Stigma and Help Seeking College Students. Med. Care Res. Rev. 66, 522–541. https://doi.org/10.1177/1077558709335173
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
20
Gaddis, S.M., Ramirez, D., Hernandez, E.L., 2018. Contextualizing public stigma: Endorsed mental health treatment stigma on college and university campuses. Soc. Sci. Med. 197, 183–191. https://doi.org/10.1016/j.socscimed.2017.11.029 Golberstein, E., Eisenberg, D., Gollust, S.E., 2008. Perceived stigma and mental health care seeking. Psychiatr. Serv. 59, 392–399. https://doi.org/10.1176/ps.2008.59.4.392 Haas, A., Eliason, M., Mays, V. M., Mathy, R. M., Cochran, S. D., D‘Augelli, A. R., et al. 2011. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. J Homosex, 58, 10–51. https://doi.org/10.1080/00918369.2011.534038 Harris, T. L., Molock, S. D. 2000. Cultural orientation, family cohesion, and family support in suicide ideation and depression among African American college students. Suicide Life Threat Behav. 30, 341-353. https://doi.org/10.1111/j.1943-278X.2000.tb01100.x Hequembourg, A. L., & Brallier, S. A. 2009. An exploration of sexual minority stress across the lines of gender and sexual identity. Journal Homosex, 56, 273-298. https://doi.org/10.1080/00918360902728517 Kosyluk, K.A., Al-Khouja, M., Bink, A., Buchholz, B., Ellefson, S., Fokuo, K., Goldberg, D., Kraus, D., Leon, A., Michaels, P., Powell, K., Schmidt, A., Corrigan, P.W., 2016. Challenging the Stigma of Mental Illness Among College Students. J. Adolesc. Heal. 59, 325–331. https://doi.org/10.1016/j.jadohealth.2016.05.005 Kroenke, K., Spitzer, R.L., Williams, J.B.W., 2001. The PHQ-9: Validity of a Brief Depression Severity Measure Kurt. J. Gen. Intern. Med. 16, 606–613. https://doi.org/10.1046/j.15251497.2001.016009606.x Latalova, K., Kamaradova, D., Prasko, J., 2014. Perspectives on perceived stigma and selfstigma in adult male patients with depression. Neuropsychiatr. Dis. Treat. 10, 1399–1405. https://doi.org/10.2147/NDT.S54081 Lester, D., Walker, R.L., 2017. Religiosity Is a Protective Factor for Suicidal Ideation in European American Students but Not in African American Students. Omega (Westport). 74, 295–303. https://doi.org/10.1177/0030222815598452 Link, B.G., 1987. Understanding Labeling Effects in the Area of Mental Disorders : An Assessment of the Effects of Expectations of Rejection Author ( s ): Bruce G . Link Source : American Sociological Review , Vol . 52 , No . 1 ( Feb ., 1987 ), pp . 96-112 Published by : A. Am. Sociol. Rev. 52, 96–112. Link, B.G., Mirotznik, J., Cullen, F.T., 1991. The Effectiveness of Stigma Coping Orientations : Can Negative Consequences of Mental Illness Labeling be Avoided ? Author ( s ): Bruce G . Link , Jerrold Mirotznik , Francis T . Cullen Published by : American Sociological Association Stable URL : http://. J. Health Soc. Behav. 32, 302–320. https://doi.org/10.2307/3644186 Lipson, S.K., Kern, A., Eisenberg, D., Breland-Noble, A.M., 2018. Mental Health Disparities Among College Students of Color. J. Adolesc. Heal. 63, 348–356. https://doi.org/10.1016/j.jadohealth.2018.04.014 Liu, C. H., Stevens, C., Wong, S. H., Yasui, M., & Chen, J. A. 2019. The prevalence and
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
21
predictors of mental health diagnoses and suicide among US college students: Implications for addressing disparities in service use. Depress Anxiety, 36(1), 8-17. https://doi.org/10.1002/da.22830 Masuda, A., Anderson, P.L., Twohig, M.P., Feinstein, A.B., Chou, Y.Y., Wendell, J.W., Stormo, A.R., 2009. Help-seeking experiences and attitudes among African American, Asian American, and European American college students. Int. J. Adv. Couns. 31, 168–180. https://doi.org/10.1007/s10447-009-9076-2 Miret, M., Ayuso-Mateos, J.L., Sanchez-Moreno, J., Vieta, E., 2013. Depressive disorders and suicide: Epidemiology, risk factors, and burden. Neurosci. Biobehav. Rev. 37, 2372–2374. https://doi.org/10.1016/j.neubiorev.2013.01.008 Muehlenkamp, J.J., Marrone, S., Gray, J.S., Brown, D.L., 2009. A College Suicide Prevention Model for American Indian Students. Prof. Psychol. Res. Pract. 40, 134–140. https://doi.org/10.1037/a0013253 Mueller, A.S., James, W., Abrutyn, S., Levin, M.L., 2015. Suicide ideation and bullying among US adolescents: Examining the intersections of sexual orientation, gender, and race/ethnicity. Am. J. Public Health 105, 981–985. https://doi.org/10.2105/AJPH.2014.302391 Oexle, N., Waldmann, T., Staiger, T., Xu, Z., Rüsch, N., 2019. Mental illness stigma and suicidality: the role of public and individual stigma. Epidemiol. Psychiatr. Sci. 27, 169–175. https://doi.org/10.1017/S2045796016000949 Pedersen, E.R., Paves, A.P., 2014. Comparing perceived public stigma and personal stigma of mental health treatment seeking in a young adult sample. Psychiatry Res. 219, 143–150. https://doi.org/10.1161/ATVBAHA.114.303112.ApoA-I Rüsch, N., Zlati, A., Black, G., Thornicroft, G., 2014. Does the stigma of mental illness contribute to suicidality? Br. J. Psychiatry 205, 257–259. https://doi.org/10.1192/bjp.bp.114.145755 Silverman, M.M., Meyer, P.M., Sloane, F., Raffel, M., Pratt, D.M., June, L.N., Williams, G., Pope Curry, B., Douce, L., Taylor, K., Glover, S., Seals, T., Joffe, P., Jolly, A., Trimble, R.W., Bessai, J., Stone, G., Cochran, S., Gauthier, E., Scott, L., Whiteside, J., 1997. The Big Ten Student Suicide Study: A 10-Year Study of Suicides on Midwestern Unitersity Campuses. Suicide Life-Threatening Behav. Am. Assoc. Suicidol. 27. https://doi.org/10.1111/j.1943-278X.1997.tb00411.x StataCorp. 2017. Stata Statistical Software: Release 15. College Station, T.S.L. Stephenson, J., Belesis, M., Balliet, W., 2005. Variability in College Student Suicide: Age, Gender, and Race. J. Clin. Child Adolesc. Psychol. 19, 5–33. https://doi.org/10.1300/J035v19n04 Student Exchange and Visitor Program, U.S. Immigration and Customs Enforcement, 2017. SEVIS by the numbers: Biannual report on international student trends. Thornicroft, G., Mehta, N., Clement, S., Evans-Lacko, S., Doherty, M., Rose, D., Koschorke, M., Shidhaye, R., O‘Reilly, C., Henderson, C., 2016. Evidence for effective interventions to
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
22
reduce mental-health-related stigma and discrimination. Lancet 387, 1123–1132. https://doi.org/10.1016/S0140-6736(15)00298-6 Vogel, D.L., Wade, N.G., Hackler, A.H., 2007. Perceived public stigma and the willingness to seek counseling: The mediating roles of self-stigma and attitudes toward counseling. J. Couns. Psychol. 54, 40–50. https://doi.org/10.1037/0022-0167.54.1.40 Walker, R. L., Bishop, S. 2005. Examining a model of the relation between religiosity and suicidal ideation in a sample of African American and White college students. Suicide Life Threat Behav. 35, 630-639. https://doi.org/10.1521/suli.2005.35.6.630 Wang, M.C., Nyutu, P.N., Tran, K.K., 2012. Coping, reasons for living, and suicide in black college students. J. Couns. Dev. 90, 459–466. https://doi.org/10.1002/j.15566676.2012.00057.x Wexler, L., Chandler, M., Gone, J.P., Cwik, M., Kirmayer, L.J., LaFromboise, T., Brockie, T., O‘Keefe, V., Walkup, J., Allen, J., 2015. Advancing suicide prevention research with rural American Indian and Alaska Native populations. Am. J. Public Health 105, 891–9. https://doi.org/10.2105/AJPH.2014.302517 Wong, S. S., Sugimoto-Matsuda, J. J., Chang, J. Y., & Hishinuma, E. S. 2012. Ethnic differences in risk factors for suicide among American high school students, 2009: The vulnerability of multiracial and Pacific Islander adolescents. Arch Suicide Res, 16(2), 159-173. https://doi.org/10.1080/13811118.2012.667334 Wong, Y.J., Koo, K., Tran, K.K., Chiu, Y.C., Mok, Y., 2011. Asian American college students‘ suicide ideation: A mixed-methods study. J. Couns. Psychol. 58, 197–209. https://doi.org/10.1037/a0023040 Zhang, N., Dixon, D.N., 2003. Acculturation and attitudes of Asian international students toward seeking psychological help. J. Multicult. Couns. Devel. 31, 205–222. https://doi.org/10.1002/j.2161-1912.2003.tb00544.x Zhou, S., King, E., Gjogiovska, J., Mihajlov, A., Stojanovski, K. 2018. Self-concealment, discrimination and mental health in Macedonia: Disparities experienced by sexual and gender minorities. Glob Public Health. 14, 1075-1086. https://doi.org/10.1080/17441692.2018.1560484
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
23
Table 1. Participant Demographics and Characteristics d
Age 18-30 Female Heterosexual Bisexual Gay/lesbian/queer Questioning/other Undergrad First gen student Public stigma (mean, range 1-5) Mental Health Measures e Past Year Suicide ideation Past Year Suicide plan Past Year Suicide attempt
Asian Int n= 7054 91.56 51.56 90.61 3.95 2.58 2.85 47.60 29.31 3.23
Asian Dom n= 11,514 94.41 59.03 89.60 3.71 3.27 3.42 73.46 35.07 3.20
Black n= 7198 82.95 58.54 88.66 4.00 4.30 3.03 71.47 55.90 3.34
Latinx n= 8402 89.18 60.48 87.49 4.68 4.89 2.95 70.04 65.88 3.16
6.34 c 2.12 c 1.18 b
9.59 3.19 0.88
9.09 2.82 1.04 a
8.55 2.86 0.88
Multiracial White n= 11,484 n= 105,857 93.01 91.13 60.80 58.64 82.62 89.48 7.49 4.52 5.33 3.53 4.56 2.46 74.74 73.84 38.84 33.20 3.14 3.05
13.25 c 4.68 c 1.15 c
8.82 c 2.89 b 0.65 c
AI/AN n= 474 75.65 66.05 85.48 7.57 3.04 3.91 61.96 71.38 3.22
Arab n= 1652 91.04 50.02 89.87 2.13 2.38 5.62 63.94 36.43 3.24
12.49 a 5.48 b 0.06
7.56 3.03 1.15
Depression (positive screen, PHQ-9 23.42 25.54 c 25.27 c 26.72 c 28.28 c 20.85 c 27.78 a 27.88 c score >10) Received MH treatment f 8.13 c 12.03 c 12.13 c 13.73c 24.34 c 24.48 c 27.32 13.80 c a b c d e p ≤ .05; p ≤ .01; p ≤ .001; percentages reported unless otherwise noted; p-values based on two-tailed chi-squared tests, with significant differences determined between students who identify as each particular race/ethnicity and those who do not f participants were asked to indicate whether they received mental health treatment within the past 12 months
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS
24
Table 2. Association between Perceived Public Stigma and Suicide Ideation with Odds Ratios and 95% Confidence Intervals Variable
OR (95% CI)
P Value
Age 31 and older 18 - 30
REF 1.34 (1.18, 1.52)
<.001
Gender Men Women
REF .87 (.82, .92)
<.001
Sexual Orientation Heterosexual
REF
Bisexual
2.29 (2.11, 2.49)
<.001
Gay/Lesbian/Queer
1.92 (1.69, 2.18)
<.001
Questioning or Other
1.94 (1.72, 2.20)
<.001
Race White
REF
Asian International
.62 (.53, .72)
<.001
Asian Domestic
.92 (.83, 1.01)
.079
Black/African American
.97 (.87, 1.08)
.291
Latinx
.77 (.68, .88)
<.001
Multiracial
1.21 (1.10, 1.34)
<.001
American Indian/Alaska Native
1.21 (.79, 1.84)
.374
.63 (.48, .843
.001
1.20 (1.19, 1.20)
<.001
Arab/Arab American Depressive Symptoms
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS Perceived Public Stigma
1.18 (1.15, 1.21)
25 <.001
Table 3. Association between Perceived Public Stigma and Suicide Plan with Odds Ratios and 95% Confidence Intervals Variable
OR (95% CI)
P Value
Age 31 and older 18 - 30
REF 1.58 (1.30, 1.91)
<.001
Gender Men Women
REF .92 (.84, 1.00)
.056
Sexual Orientation Heterosexual
REF
Bisexual
2.48 (2.19, 2.81)
<.001
Gay/Lesbian/Queer
1.98 (1.69, 2.31)
<.001
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS Questioning or Other
1.96 (1.66, 2.32)
26 <.001
Race White
REF
Asian International
.68 (.53, .87)
.002
Asian Domestic
.90 (.77, 1.06)
.208
Black/African American
.87 (.70, 1.08)
.197
Latinx
.79 (.65, .97)
.021
Multiracial
1.19 (1.02, 1.39)
.028
American Indian/Alaska Native
1.56 (.91, 2.66)
.103
Arab/ Arab American
.83 (.56, 1.23)
.353
Depressive Symptoms
1.20 (1.19, 1.20)
<.001
Perceived Public Stigma
1.26 (1.21, 1.31)
<.001
Table 4. Association between Perceived Public Stigma and Suicide Attempt with Odds Ratios and 95% Confidence Intervals Variable
OR (95% CI)
Age 31 and older
REF
P Value
PERCEIVED PUBLIC STIGMA AND SUICIDAL BEHAVIORS 18 - 30
2.55 (1.66, 3.89)
27 <.001
Gender Men Women
REF 1.27 (1.07, 1.51)
.006
Sexual Orientation Heterosexual
REF
Bisexual
2.48 (2.01, 3.05)
<.001
Gay/Lesbian/Queer
2.03 (1.54, 2.68)
<.001
Questioning or Other
1.80 (1.33, 2.44)
<.001
Race White
REF
Asian International
1.87 (1.33, 2.61)
<.001
Asian Domestic
1.11 (.83, 1.49)
.465
Black/African American
1.48 (1.08, 2.03)
.016
Latinx
1.12 (.82, 1.54)
.460
Multiracial
1.24 (.88, 1.74)
.222
American Indian/Alaska Native
.63 (.22, 1.78)
.381
Arab/Arab American
1.53 (.79, 2.93)
.205
Depressive Symptoms
1.19 (1.17, 1.20)
<.001
Perceived Public Stigma
1.27 (1.16, 1.38)
<.001