S1E1 / Communication & Contagion / Dan Reidenberg, Jacqueline Basulto, Jennifer Michael Hecht, Sean Ryan

How do we communicate responsibly about depression and suicide without fueling contagion? During the 2016-2017 academic year, Columbia University was rocked by at least five student suicides.

Note: This season of American Diagnosis was originally published under the title In Sickness & In Health. 

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Celine Gounder: This is “In Sickness and in Health.” I’m Dr. Celine Gounder.

In this episode, we’re going to talk about topics that some parents may find unsuitable for young children. Parental discretion is advised.

Jacqueline Basulto: I just started to lose my sense of self completely. I think that’s the most difficult part of depression. You are no longer yourself and you’re completely — or you feel completely — helpless. It was so bad that I couldn’t get out of bed. I couldn’t fall asleep on my own. I’d have to go for walks in the middle of the night at like 3 AM.

Celine Gounder: This is Jacqueline Basulto, a recent graduate of Columbia University.

Jacqueline Basulto: This was just the beginning of myself feeling like that. But by the time my first appointment came around, two weeks later, I was so distraught I couldn’t be alone by myself without having suicidal thoughts.

Celine Gounder: Over the next five episodes, I’m going to be talking about mental health in a group that all too often feels misunderstood and unheard — our youth.

Depression and anxiety afflict every age group — but they can be especially troublesome for young people. And it’s been getting worse over the last couple decades. In fact, suicide is now the second leading cause of death for kids, teens, and young adults. Only accidents — mostly car crashes — kill more kids every year. That may be a shocking statistic to a lot of people. And while still a relatively rare event, deaths in young people are tragic whenever they occur. Understanding these premature, untimely deaths might help us bring those numbers down.

College campuses are unique worlds… made up, mostly, of young people… teens and twenty-somethings… away from home, often for the first time… away from parents and adult supervision… away from support systems. They experiment and push the envelope… And, at the same time, these young people are starting their own adult lives… taking on new responsibilities… and along with those… new pressures. They’re tested in new ways… perhaps a big fish at home… but “just average” now… or realizing they’ll soon be graduating… with lots of debt… and unclear job prospects… It can be a really scary time in a young person’s life.

Unfortunately… on a lot of college campuses… when young people seek help coping, they can’t get the help they really need. That’s what happened to Jacqueline Basulto.

Jacqueline Basulto: My name is Jacqueline Basulto. I am a graduate of Columbia University. I graduated in the fall of 2016. I grew up in Staten Island, NY. My parents are first generation immigrants. My mom is Puerto Rican and my dad is Cuban. I grew up in a very middle class household where going to college wasn’t the norm.

Celine Gounder: Jacqueline was the first from her family to graduate from college.

Jacqueline Basulto: My parents wanted me to have a better life than they had. They both grew up relatively impoverished. … They just wanted to see me succeed, whatever that meant for me. I was always really passionate about school and learning. I always placed that pressure on myself. And then there was this stake of having my family being so proud of what I was doing, especially when I got into Columbia, it was like a miracle for my whole family.

Celine Gounder: Jacqueline’s transition from high school to college wasn’t easy. The academic competition was fierce. And she had to juggle more than most of her classmates.

Jacqueline Basulto: Coming into college, it was overwhelming because I didn’t have the time for myself anymore, to do things that I loved as much. Also the caliber of students is very different. At a place like Columbia, every student is trying to get the best grade, every student is super accomplished. I was also put into a community of people with really highly educated families and a lot of financial support. I had to work. It wasn’t that common.

Celine Gounder: Jacqueline worked really hard all four years of college, but her senior year at Columbia was especially tough. She had just finished an internship at Google. She was president of her sorority, building a startup, and handling difficult classes.

Jacqueline says she’d felt anxiety before, but she knew this was different.

Jacqueline Basulto: Since I was a senior who was really involved in campus, I knew about the resources that were available to me, so I reached out to Columbia’s psychological services. I was put on a list for an initial phone screening, four days later I had the phone screening. I told the operator that I was having thoughts about hurting myself, that I was really lost and scared, I didn’t know what to do, I couldn’t sleep, my classes… I felt like I was going to do poorly in my classes if this kept going on. And she told me that I could have an appointment in two weeks, and I said, okay, what should I do until then? And she said, ‘I don’t know what you mean.’

Celine Gounder: So she waited for two weeks. And in that time, Jacqueline says, she went from vague disjointed thoughts about wanting to hurt herself  to specific, concrete thoughts about wanting to kill herself. Anytime she was alone, says Jacqueline, suicidal thoughts would come to the surface. And she explained that when she finally did get to see a therapist on campus.

Jacqueline Basulto: I kept saying, like, I don’t know what’s wrong. It’s not any one thing. I’m in really deep pain. I can’t keep living like this. Um. And he just asked me if I could come back in two weeks.

Celine Gounder: But Jacqueline knew what two weeks could mean for her mental health. She couldn’t take “wait” for an answer.

Jacqueline Basulto:  And I said, please, help me right now. Get me a referral to an outside doctor. I can’t wait. Um. And he — he said, well, maybe you should see a general physician for your body pains.

Celine Gounder: The way that doctor glossed over Jacqueline’s concerns? It’s as dangerous as it sounds. No physician would turn away a patient who came in with a lethal wound.

A couple months ago, STAT News reported on the state of mental health services at American colleges and universities across the country. It’s not uncommon for students to wait weeks for an appointment. Many schools don’t have psychiatrists, who can prescribe medications for anxiety and depression. Columbia is by no means alone. They actually have more counselors for the size of their student body than most of the other schools included in the STAT News survey. But that wasn’t enough.

Between September of 2016 and January 2017, at least five students died by suicide at Columbia University. Two more died in apparent drug overdoses. Jacqueline’s experience led her to ask questions, and she discovered that a lot of students at Columbia were suffering from depression, and just like her, they weren’t receiving the help they felt they needed.

Jacqueline Basulto: Once I started seeing that a lot of students on campus were suffering from depression and committing suicide, I just became furious and I felt horrible, because I had the — not the courage, but I was in the position to be able to tell someone that I was feeling suicidal. And as a freshman, or as a transfer student from another culture where mental health is not accepted, being able to say something like that, or even give an indication of depression, warrants much more attention than I got when I flat out said, ‘I feel suicidal. Please help me.’

Celine Gounder: Jacqueline did find help, but not through Columbia. She says she was lucky enough to have a friend who reached out to an off-campus psychiatrist and secured an appointment for her in two days, not two weeks. The sessions cost $350 a piece, and Jacqueline isn’t from a wealthy family. But, Jacqueline said, she explained to her family that these visits really were necessary. They listened.

Jacqueline Basulto: I felt like, immediately, like someone was caring about me and my situation, and like, eventually I would get better. But without that outside support from somebody who understands depression, it’s difficult to see yourself getting better.

Celine Gounder: There’s no great secret to Jacqueline’s experience. She was sick, she received treatment, and she got better. And while depression and suicidal thoughts aren’t the same thing, and treatment may vary from patient to patient, the chances of this illness being lethal are far less when someone has support. Effective psychotherapy has been shown to decrease the risk of suicide reattempt after a first attempt by half. That’s huge.

After surviving her own suicidal thoughts, it horrified Jacqueline to think of the others who could have been saved if they’d received the help she did. Or if they knew that help was available at all. Jacqueline describes Columbia as an isolating place, where community is hard to find and support systems weren’t readily apparent or available. There were at least five suicides in five months. And yet, Jacqueline says, she didn’t think Columbia was going to take significant steps until its public image was at stake. So she decided to go public with what had happened at her school.

Jacqueline Basulto: I started the petition on Change.org in early January 2017 to call for more mental health awareness and resources on Columbia’s campus. And I was really amazed to see a lot of people from different backgrounds, alumni, other colleges, Columbia, sharing their own experiences with depression and their own experiences with campus health resources.

Celine Gounder: What Jacqueline discovered was that her school wasn’t as divided or devoid of community spirit as she’d thought. There simply wasn’t the infrastructure to bring students, especially those struggling with mental health issues, together. Jacqueline received over 850 signatures on the petition that called for Columbia, and 18 other Universities, to improve their mental health awareness efforts and treatment.

Jacqueline says that one of the hardest things about those suicides on campus was the way the school communicated, or didn’t communicate, about the problem. Vague emails and a dearth of support seemed, to her, to brush the obviously vital conversation about mental health under the rug. I contacted multiple officials and experts at Columbia University. None would comment for this story.

With most illnesses, it’s pretty widely accepted that talking about it can make it better. In HIV, we say “silence equals death.” We share our experiences with breast cancer and our fears of Alzheimer’s. The more we talk about these diseases, the more we can do to try to prevent them and cope with them. And when we lose someone, we mourn them. Often, we do it publicly.

But while we hold cancer patients up as heroes of sorts, we don’t idolize them. You don’t hear about someone dying of lung cancer, and then decide to take up chain smoking yourself in the hopes of contracting it. With most diseases, talking about a victim doesn’t create more victims.

But something very different happens when we talk about suicide. Now don’t get me wrong, talking about suicide doesn’t cause others to take their own lives. But how we talk about it can make all the difference.

Dan Reidenberg: The most important thing is that we do not memorialize someone who’s died by suicide on a college campus or in a school.

Celine Gounder: This is Dan Reidenberg. He’s the Executive Director of SAVE: Suicide Awareness Voices of Education. His organization, which was one of the first in the country to do this, takes a multifaceted approach to preventing suicide at the national, state and local levels. And this is one of Dan’s number one pieces of advice to school administrators. Do not memorialize a suicide victim. Don’t post pictures, notes and flowers on their locker, don’t plant a tree in the courtyard, don’t install a bench outside the school.

Dan Reidenberg: Anything like that memorializes that person who died by suicide. And while it might help the family to feel that that person isn’t forgotten — even the friends who don’t want to forget that person — tragically, what happens is that for others who are at risk of dying by suicide, or they’re struggling with their own depression, that outpouring, that overwhelming sense of grief and support, sometimes tragically leads to contagion, and we see increased risk of other suicides.

Celine Gounder: Contagion. This probably isn’t something you associate with mental health. The common cold, the flu or measles, sure. But suicide isn’t something you catch at school, right?

Deep in the heart of Silicon Valley, something is going terribly wrong with young people. My Nightline co-anchor Byron Pitts takes us to an affluent community that now has a teen suicide rate nine times the national average.

In the last three years, nine teenagers and young adults have killed themselves in the Manasquan area – seven were connected in some way to Manasquan High School, either by attending or having a close relationship with those at the school.

Seven student suicides since last fall, that stunning and grim statistic tonight from the campus of Columbia University, one of the country’s best and most prestigious. This epidemic of suicides and student depression tonight is now front and center.

An alarming cluster of youth suicides is commanding the attention of parents tonight after a third Clovis West High School student took his life. The sheriff’s office says a total of eleven children have committed suicide this year. And parents are worried that number will climb.

Celine Gounder: These are called suicide clusters, or copycat suicides. And they’re common enough that the Centers for Disease Control and Prevention has launched multiple studies into the phenomenon. They even have recommended protocols to prevent these clusters. As a matter of fact, that’s where Dan and his organization, SAVE, get their advice from the CDC itself. These clusters are far and away more common among adolescents and young adults. And news stories, like those that you just heard, are partially to blame.

Dan Reidenberg: The reality is that we have over a hundred studies now from around that world that demonstrate how media reports on suicide increases risk of contagion. So when there is more reporting, when it is either sensationalized or it glamorizes the person, it doesn’t give balanced perspective on the person who died, when there is information in a story that’s about methods, or location, details of a death, suicide, we see increased risk of contagion.

Celine Gounder: It’s not that all media reporting on suicide is bad. But dramatic headlines and sensational coverage can increase the risk for others. What is happening when a young person is influenced into having suicidal thoughts? What is it about those details — especially the who, the where and the how — that makes it contagious? It’s not how close we were to that person who died by suicide. It’s about how much we had in common with them, and how we play the act out in our minds, and how we throw ourselves into their shoes.

Jennifer Michael Hecht: And if you find yourself around a table with a bunch of people who look like you and who are all eating cake, you eat the cake.

Celine Gounder: This is Jennifer.

Jennifer Michael Hecht: Okay. Hi, I’m Jennifer Michael Hecht. I’m a historian and a poet. I specialize in intellectual history and I wrote a book called Stay: A History of Suicide and the Arguments Against It.

Celine Gounder: Suicide, Jennifer says, the suicide of anyone in a community, drastically changes the way we perceive the world. It’s temporary, but it’s powerful. The baseline expectation, Jennifer says, is that we humans want to be here, and we’re doing our best to keep going, to keep on living. But…

Jennifer Michael Hecht: When you have an example of someone who made this other choice — so, it does this rattling thing where it sort of scoops out how you are usually responding to things. And then it sort of adds to your notion of what people do.

Celine Gounder: And when one person adds suicide to the list of what’s normal and what’s OK to do, others do as well. Maybe not as a definite plan, but as an option. Jennifer says that, despite our years of evolution and ideas about independence and self-determination, we’re very much social creatures.

Jennifer Michael Hecht: We quit smoking together, we gain weight together, we decide to have three children, or we decide to have only one child, or no children, or get married, not get married. Huge, huge decisions that change our lives or end our lives are made in groups.

Celine Gounder: So when you take this extreme choice, couple it with a social mindset, and throw adolescent brains into the mix, you end up creating conditions ripe for contagion. Jennifer says it’s important to remember that, until the age of 25, our brains are still maturing. Neuroscientists have found that the prefrontal cortex — the part of the brain that controls impulses and allows you to make plans — is still refining its neural connections until your mid 20s. And the brain’s reward system goes into high gear in your teens and early 20s, which is one of the reasons why young people that age are more susceptible to peer pressure and more likely to engage in risky activities.

Jennifer Michael Hecht: The idea of the future self – to think in particular, it’s important for all of us at every stage of life to realize that you’re not really the same you all the time. You change a lot, and a lot changes in ways that you don’t think that, well, that you don’t have any control over. The hormonal changes that happen to boys and girls over the course of their long lives create radical shifts in their ability to appreciate different things or put up with different things, but there’s none so drastic as the change between people who are under 25 and people who are over 25.

Celine Gounder: Everything is in flux for an adolescent person. Lows can seem apocalyptic, and anxieties morph into obsessions. A moment of depression can seem like it’s going to last forever. And once suicide is on the table, a person might find themselves in real danger of taking permanent action to solve what’s most often a temporary problem.

But Jennifer says there’s a strength in adolescent communities that can help draw them away from the possibility of suicide.

Jennifer first made her argument against suicide in a poem called, “No Hemlock Rock,” then in a blogpost on a poetry website. The response from readers was enough to inspire a full-length history and philosophy book. She received feedback from people around the world. People who had been considering suicide until she helped them realize that they could, and ought to, choose a different path. Any other path. When you take your own life, you’re also putting at risk the lives of others around you, even people you don’t know personally. You’ve made suicide an OK alternative. The point, as Jennifer writes, is that you owe it to other people to stick around. It’s a moral responsibility. And that’s an idea that a lot of young people seem to be responding to.

Jennifer Michael Hecht: They realize that they would be putting friends — a whole, huge range of secondary acquaintances, or people who are like you — who, who see themselves in you, even if they don’t know you well — those people are put at risk. And college students have a very moral response to that. That they would do anything for their friends, and so, realizing that they could have a fatal effect, thereby are able to see the virtue in staying.

Celine Gounder: Jennifer acknowledges, though, that her approach to this problem is only one important element of suicide prevention in young people.

Jennifer Michael Hecht: Psychology, in a traditional way, is crucial. But not everybody can get it when they need it. And even more, many people don’t even try to get it, right? Like, half the suicides on college campuses never even went to the counseling service. So there are times where you try to get counselling and you can’t. But just a tremendous number of people who end up attempting, or further, never even try to get help, because no one told them why.

Celine Gounder: It may seem like professional help is an obvious step for anybody suffering from depression, anxiety or thoughts of suicide. But the information and resources aren’t always available. And for some, there may be additional barriers to getting help.

This series of tragedies at Columbia… it’s a complicated problem. It’s about access, it’s about communication… and it’s also about recognizing those communities at risk… and understanding why they’re at risk.

I spoke to another student at Columbia. Another student who, like Jacqueline Basulto, was troubled by the trend in mental health issues at the school. Sean Ryan is co-chair of the student affairs committee, and he’s done a lot of research into suicide at the school. The trend isn’t isolated to this past academic year. In fact, Sean says that Columbia has seen at least 24 suicides since 2000 by his count. And that isn’t something that can be pinned to the administration alone.

Sean Ryan: Counseling and psychological services at Columbia really do a pretty good job. And, really, over the past couple of years, based on student feedback, they’ve added at least eight clinicians from diverse backgrounds. But for whatever reason, it’s almost as if the demand for those services is growing. And so, students are still experiencing long wait times.

Celine Gounder: Sean says that Columbia’s system — a two-step triage that eventually leads to an appointment – is largely considered best practice. The disconnect is in that protocol not actually being tailored to student needs.

Sean Ryan: Because, if you’re a student that is recognizing a mental health need, especially somebody who doesn’t have experience really talking about those issues or dealing with issues of mental health, or comes from an area of the country, or a family or a culture where that stuff isn’t really spoken about, to even take that step to call can be a really big decision to make. And then when you start adding layers between you, and getting in to talk to a professional, that makes it even harder.

Celine Gounder: And then there are the communities for whom there may already be a disconnect — a heightened need for mental health care and a greater barrier between themselves and the community. Sean says that the numbers speak for themselves in terms of students at greater risk.

Sean Ryan: It seems to be students who are in some kind of transition. Some students coming in, students coming out – so, freshmen, seniors. Exchange students. I think that’s a lot of what we’ve seen this year. And we cannot ignore that 63% of people who killed themselves at the University were people of color. I mean, that is a trend in itself. Two of the past seven were LGBT. That is also a trend. So I think those two pieces are kind of the connective tissue there.

Celine Gounder: Columbia has pledged to step up its efforts. The University is organizing a mental health week to raise awareness. It’s training students to recognize when someone’s in trouble and how to support their friends and classmates. It’s doing more to let students know about the services that exist both on and off campus. It’s creating more space and opportunity for students to come together as a community on campus. And Columbia is giving special attention to students of color, LGBTQ students, students with disabilities, veterans and international students, who are at increased risk for mental health issues.

This is something that gives Sean Ryan hope. That, in the wake of this difficult and dangerous period, the University will bolster against things like this happening again.

Sean Ryan: There are changes being made. People are thinking about this. This is something that is hitting everyone at a personal, emotional place, including decision makers. And so, the great thing looking forward is that, you know, this happened in a horrible circumstance. But people are beginning to really meaningfully engage with what it means to be a student in this high pressure institution at a high pressure time. And so that really gives me hope for this upcoming generation of Columbia Lions who are going to come in and go through this experience. I think it is going to get ever so slightly better.

Celine Gounder: And moments like this — when a school and its student body are in transition or need — is where people like Dan Reidenberg come in. And his goal is to push beyond “ever so slightly better.” He’s the Executive Director of that suicide awareness and prevention organization, SAVE, who we met earlier. The one who says that memorializing… photos, benches, trees… is the wrong thing to do after a campus suicide. To that extent, Columbia followed protocol. But protocol to prevent contagion,  protocol to prevent suicides, and protocol to protect the University’s reputation aren’t the same thing. And I think that’s what has students like Jacqueline Basulto — who we heard from at the beginning of the episode — upset. They want to see administrators and faculty at the University speak openly and frankly about the issue, to strip it of its secrecy and shame.

Dan Reidenberg: The way to destigmatize mental health is to make it okay to talk about it.

Celine Gounder: Stigma is a pretty well-acknowledged issue when it comes to mental health. But many communities don’t know how to address it, let alone prevent it. SAVE encourages administrators and teachers to bring depression and suicide into conversations before tragedies occur. Demystifying suicide can actually help prevent it, Dan says.

Dan Reidenberg: Second is to make sure that you, and young adults, understand that having a mental health issue is no different than any other medical issue. You have a stomach problem and you go to the doctor. You have a heart problem, and you go to the doctor. You have a problem that’s happening in your head, you go to the doctor.

Celine Gounder: SAVE hosts events on campuses: everything from concerts to paint throwing-parties. The only difference between this and any other campus event is that they facilitate conversations about suicide — a preventable death — while young people hang out and socialize casually.

Dan Reidenberg: Those kinds of events provide you an entry point to say to young people, these people can be talked about and dealt with much like cancer can, and all the cancer runs and walks, and all of the other kinds of events that happen throughout the year. So we take away that stigma and the shame around it by making it a fun and positive, uplifting event, and making it something that they’re okay talking about.

Celine Gounder: Dan says that community — connection and conversation — is crucial to the mental health of young people. It creates a safe space — one that can diffuse danger rather than incubate it.

Suicide is a difficult subject. It’s a tricky subject — precarious and complicated. Dan acknowledges this. We’re nervous and confused about how best to talk about it. But you can’t have an environment where suicide is preventable until it’s alright to bring it up.

Dan Reidenberg: There is an ongoing debate about how much is too much. Or is there too little going on? I think that we know best is that if you are concerned, or at all worried about somebody who might be at risk of suicide — basically, if your gut is telling you something is going on, it’s best to ask the question.

Celine Gounder: It’s crucial that schools not wait until they’ve had a tragedy on their campus to act. We know that the need is there. A third of college students who seek counseling services admit to having seriously considered suicide at some point. Our young people need our help now before it’s too late.

In our next episode, we’ll focus on one group of young Americans that’s been in the news a lot lately, and that’s at especially high risk for mental health issues like depression, anxiety and suicide: lesbian, gay, bisexual, transgender and queer youth. You’ll hear the story of a family caught in the crosshairs of these issues and from a doctor who’s doing what she can to help trans teens be themselves.

If someone you know is in crisis or thinking of hurting themself:

• Do not leave them alone.

• Remove any firearms, alcohol, drugs or sharp objects that could be used in a suicide attempt.

• Take them to an emergency room or seek help from a medical or mental health professional.

• Call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255).

• Or text the Crisis Text Line at 741-741.

• Another resource for LGBTQ youth is the Trevor Project’s Lifeline at 866-488-7386.

• Thank you for listening.

Credits: Today’s episode of “In Sickness and in Health” was produced by Hannah McCarthy and me. Our theme music is by Allan Vest.