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Anxiety and Suicidality in the College Student Population

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Title: Anxiety and Suicidality in the College Student Population
Language: English
Authors: Danielle M. Moskow (ORCID 0000-0002-3117-0091), Sarah K. Lipson, Martha C. Tompson
Source: Journal of American College Health. 2024 72(3):881-888.
Availability: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 8
Publication Date: 2024
Sponsoring Agency: National Institute of Mental Health (NIMH) (DHHS/NIH)
Contract Number: K01MH121515
Document Type: Journal Articles
Reports - Research
Education Level: Higher Education
Postsecondary Education
Descriptors: Anxiety, Suicide, College Students, Depression (Psychology), Psychological Patterns, Symptoms (Individual Disorders), Correlation
DOI: 10.1080/07448481.2022.2060042
ISSN: 0744-8481
1940-3208
Abstract: Objective: This study examined symptoms of anxiety, depression and suicidality in a national sample of college students. Participants: Using national survey data from the Healthy Minds Study (HMS), a random sample from 184 U.S. campuses from fall 2016 to spring 2019 was analyzed (N = 119,875). Methods: Prevalence rates were examined with the Generalized Anxiety Disorder 7-Item scale, Patient Health Questionnaire-9 and suicidality questions. Relationships between anxiety, depression and suicidality were assessed through Spearman's correlations, the Kruskal-Wallis H test and logistic regressions. Results: Findings revealed that screening only for depression would pick up 23% of suicidal ideation, increasing to 35% when also screening for anxiety. Those with anxiety and no to minimal depression had the second highest likelihood of suicide attempt, following those with anxiety and depression. The symptom "feeling afraid something awful might happen" doubled the odds of suicidal ideation. Conclusions: College campuses may benefit from assessing particular anxiety symptoms in relation to suicide.
Abstractor: As Provided
Entry Date: 2024
Accession Number: EJ1421413
Database: ERIC
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  Value: <anid>AN0176635060;acl01apr.24;2024Apr18.06:34;v2.2.500</anid> <title id="AN0176635060-1">Anxiety and suicidality in the college student population </title> <p>Objective: This study examined symptoms of anxiety, depression and suicidality in a national sample of college students. Participants: Using national survey data from the Healthy Minds Study (HMS), a random sample from 184 U.S. campuses from fall 2016 to spring 2019 was analyzed (N = 119,875). Methods: Prevalence rates were examined with the Generalized Anxiety Disorder 7-Item scale, Patient Health Questionnaire-9 and suicidality questions. Relationships between anxiety, depression and suicidality were assessed through Spearman's correlations, the Kruskal-Wallis H test and logistic regressions. Results: Findings revealed that screening only for depression would pick up 23% of suicidal ideation, increasing to 35% when also screening for anxiety. Those with anxiety and no to minimal depression had the second highest likelihood of suicide attempt, following those with anxiety and depression. The symptom "feeling afraid something awful might happen" doubled the odds of suicidal ideation. Conclusions: College campuses may benefit from assessing particular anxiety symptoms in relation to suicide.</p> <p>Keywords: Anxiety; college students; depression; risk; suicide</p> <p>According to the World Health Organization,[<reflink idref="bib1" id="ref1">1</reflink>] anxiety disorders are the most common mental health problem in the United States, with rates continuing to climb. Contributing to this rise are factors such as an increased tendency to report, reduced stigma, increased recognition of symptoms, and greater comfort with utilizing services.[<reflink idref="bib2" id="ref2">2</reflink>] Other factors associated with increased anxiety rates include psychosocial vulnerabilities and increased use of technology and social media.[<reflink idref="bib3" id="ref3">3</reflink>] Additionally, consumer culture has shifted toward individualism, with society emphasizing the importance of pursuing extrinsic goals, leading to individuals setting higher expectations that are often less attainable.[<reflink idref="bib4" id="ref4">4</reflink>] As the price of education continues to rise, the job market is becoming increasingly competitive and school acceptance rates are declining.[<reflink idref="bib5" id="ref5">5</reflink>] Many of these challenges are hitting young adults hard, potentially contributing to the increased psychological distress in this population.</p> <p>Epidemiological studies indicate that 75% of the onset of lifetime mental illness occurs by age 24,[<reflink idref="bib6" id="ref6">6</reflink>] with the average age of anxiety onset from early adolescence to young adulthood. College student populations represent a particularly important group to study. Over half of each birth cohort enrolls in college each year, with over 20 million in U.S. postsecondary education.[<reflink idref="bib7" id="ref7">7</reflink>] In addition to the enhanced risk associated in young adulthood, college students are exposed to unique stressors that place them at risk for mental illness.[<reflink idref="bib8" id="ref8">8</reflink>] Some unique factors that shape mental health risk for college students include student debt[<reflink idref="bib9" id="ref9">9</reflink>]; uncertainties about job prospects,[<reflink idref="bib10" id="ref10">10</reflink>] academic pressures,[<reflink idref="bib11" id="ref11">11</reflink>] "culture shock," especially for first-generation students[<reflink idref="bib12" id="ref12">12</reflink>] and separation from the family unit, which can be especially challenging for students from particular cultures.[<reflink idref="bib13" id="ref13">13</reflink>] Thus, college students represent a crucial population for screening, prevention, early intervention, and implementation of effective treatments.</p> <hd id="AN0176635060-2">Anxiety and depression in college populations</hd> <p>As of 2019, an annual report by the American College Health Association–National College Health Assessment (ACHA-NCHA) revealed that a large portion of students were experiencing distressing symptoms.[<reflink idref="bib14" id="ref14">14</reflink>] Students reported feeling: overwhelmed by all they had to do (87%), very sad (71%), and overwhelming anxiety (66%). Furthermore, 13% reported seriously considering suicide. Lipson and colleagues[<reflink idref="bib15" id="ref15">15</reflink>] analyzed data from the 2012–2015 Healthy Minds Study (HMS) samples—a public health initiative collecting data on college mental health. The results from 43,375 students revealed that 18% were experiencing anxiety, measured as a score of ≥10 on the Generalized Anxiety Disorder 7-Item Scale (GAD-7). Eisenberg and colleagues[<reflink idref="bib2" id="ref16">2</reflink>] reported on data from the 2016–2017 HMS sample and found that out of 1,347 students, 39% were struggling with symptoms related to their mental health. The authors reported that 4% of undergraduates and 4% of graduate students endorsed symptoms of anxiety, while 14% of undergraduates and 11% of graduate students endorsed symptoms of depression, measured by the Patient Health Questionnaire-9 (PHQ-9). Not only are these rates alarming, but rates have been increasing over time. Duffy and colleagues examined trends in mental health outcomes among U.S. college students from 2007 to 2018 across the ACHA-NCHA and HMS and found a worsening of anxiety and depression.[<reflink idref="bib16" id="ref17">16</reflink>] In fact, rates of moderate to severe anxiety rose from 17.9% in 2013 to 34.4% in 2018 and rates of moderate to severe depression rose from 23.2% in 2007 to 41.1% in 2018.[<reflink idref="bib16" id="ref18">16</reflink>] These findings underscore the importance of focusing on the college student population to be able to better prioritize and focus intervention and treatment.</p> <hd id="AN0176635060-3">Suicidality and anxiety in college students</hd> <p>Just as anxiety is increasing in college populations, rates of suicide are also on the rise.[<reflink idref="bib17" id="ref19">17</reflink>] Suicide is the second leading cause of death in the college student population.[<reflink idref="bib17" id="ref20">17</reflink>] Whereas prevalence rates and associations between depression and suicidality have been a focus of prior research,[<reflink idref="bib18" id="ref21">18</reflink>] less is known about the correlates, prevalence or treatment of suicidal behavior amongst individuals with anxiety.[<reflink idref="bib19" id="ref22">19</reflink>] Auerbach and colleagues[<reflink idref="bib20" id="ref23">20</reflink>] reported on data from 14,348 first year college students across 19 institutions and found that students with high diagnostic comorbidity, particularly those with GAD, may be at elevated risk for attempting suicide. Studies have found relationships between panic disorder (PD), GAD and suicide risk.[<reflink idref="bib21" id="ref24">21</reflink>],[<reflink idref="bib22" id="ref25">22</reflink>] Khan and colleagues[<reflink idref="bib23" id="ref26">23</reflink>] studied 20,076 anxious patients that were participating in clinical trials assessing new anti-anxiety medications. The researchers found that individuals with anxiety disorders were at 10 times greater risk of suicide attempt than individuals in the general population. Studies have also found associations between anxiety and suicidality in non-clinical samples. A study by Abdel-Khalek and Lester[<reflink idref="bib24" id="ref27">24</reflink>] found that suicidal ideation was positively and significantly associated with increased anxiety in undergraduate students. Several studies have also found symptoms of anxiety correlated with suicidal thinking and suicide rumination.[[<reflink idref="bib25" id="ref28">25</reflink>], [<reflink idref="bib27" id="ref29">27</reflink>]]</p> <p>Although these findings are intriguing, researchers have speculated that co-occurring mood disorders may be accounting for the increase in suicidality seen across anxious samples,[<reflink idref="bib21" id="ref30">21</reflink>],[<reflink idref="bib22" id="ref31">22</reflink>] as anxiety disorders and major depression are highly comorbid, with rates of co-occurrence as high as 60%.[<reflink idref="bib28" id="ref32">28</reflink>] Depression appears to play a causal role in suicidal behavior, with evidence from a wide range of studies demonstrating strength of association and controlling for confounding factors.[<reflink idref="bib29" id="ref33">29</reflink>],[<reflink idref="bib30" id="ref34">30</reflink>] For instance, Lamis and Jan[<reflink idref="bib31" id="ref35">31</reflink>] reported a strong relationship between hopelessness, negative affect and suicidality. From a developmental perspective, transitional periods put individuals at a higher risk, and many who are in college and have fewer social supports, psychological resources, and higher negative affect are at a higher risk for suicidal thoughts and behaviors.[<reflink idref="bib31" id="ref36">31</reflink>],[<reflink idref="bib32" id="ref37">32</reflink>]</p> <p>Referencing findings that the relationship between anxiety and suicide risk may instead be due to comorbid depression, Sareen and colleagues[<reflink idref="bib33" id="ref38">33</reflink>] studied suicidality in individuals without a history of mood disorders. Data collected over three years from 7,076 individuals participating in a prospective population-based survey revealed that anxiety disorder diagnosis, without history of a mood disorder, was in fact significantly associated with increased risk of suicidal ideation and suicide attempt. Norton, Temple and Pettit[<reflink idref="bib34" id="ref39">34</reflink>] replicated and extended these findings in a sample of 166 college students and found a significant association between anxiety and suicide risk after controlling for depression symptoms.</p> <p>Given the significant overlap between anxiety and depression symptoms, it is difficult to ascertain if the relationship between depression and suicidality is purely accounted for by depression or if anxiety anxiety plays a role. It is possible that the association between anxiety and suicidality could be weak once parsing out the covariance of anxiety and depression.[<reflink idref="bib35" id="ref40">35</reflink>],[<reflink idref="bib36" id="ref41">36</reflink>] Although there is a clear association between depression and suicidality, not every person experiencing depression is suicidal. Likewise, suicide attempts do not always happen when a person is in a depressive episode.[<reflink idref="bib37" id="ref42">37</reflink>] Much of the work focused on understanding the interplay of anxiety, depression and suicidality has been conducted in clinical populations; focusing on a general college population may aid in understanding this interplay in an at-risk group.</p> <hd id="AN0176635060-4">Research aims</hd> <p>This study had several aims related to better understand the relationship between anxiety and suicidality. First, we sought to investigate the relationship between suicidality and anxiety, both with and without depression, in a large college sample. Second, we sought to examine which specific symptoms of anxiety are most predictive of suicide risk. Our aim with studying anxiety at the symptom level was to provide further insight into more nuanced ways of understanding the relationship between anxiety and suicide, which could ultimately lead to better, more targeted identification and treatment.</p> <hd id="AN0176635060-5">Materials and methods</hd> <p></p> <hd id="AN0176635060-6">Study design</hd> <p>This study utilized national survey data obtained from HMS. The present study is an analysis of HMS data, which are made publicly available for research purposes. Colleges elect to participate in the Healthy Minds Study and there are no exclusionary criteria for institutional enrollment. Recruitment was open to all types of institutions. In the present study, we analyze data from three waves (2016–2019). There were 54 participating institutions in 2016–2017, 60 in 2017–2018 and 79 in 2018–2019, with a total of 184 unique institutions included in this analysis. Recruitment was open to all types of institutions. The sample of colleges and universities included a diversity of institutions, broadly representing all types of higher education across the United States. The HMS has been completed by both urban and rural institutions, public and private, of varying sizes. The HMS annual web-based survey assesses factors such as demographic information, mental health status, service utilization and barriers to treatment among undergraduate and graduate students. Data were collected through Qualtrics, and the study was approved by the Institutional Review Board (IRB) at all campus sites. Additionally, the study was covered by a National Institutes of Health (NIH) Certificate of Confidentiality. Further details about the study design of HMS have been reported on widely and additional information is available on the HMS website: https://healthymindsnetwork.org/hms/.</p> <hd id="AN0176635060-7">Student recruitment</hd> <p>At each institution with ≥4,000 students, a random sample of 4,000 students ages 18 or older was invited to participate in the online survey; on smaller campuses, all students were invited to participate. The only inclusion criteria was that students had to be at least 18 years of age. Recruitment was conducted via email across all sites. A total of $2000 worth of incentives were distributed each year. Students were informed they would be entered into a drawing to win one of several prizes (ten $100 and two $500 gift cards per year). All randomly sampled students on participating campuses were eligible for the incentives each year. Participants provided informed consent. Survey response rates were 24% in 2016–2017, 24% in 2017–2018, and 16% in 2018–2019. Sample probability weights were constructed to adjust for potential differences between responders and nonresponders. Administrative data on students' sex, race/ethnicity, degree level, and grade point average were obtained from participating schools. These data were used to construct response weights, equal to one divided by the estimated probability of response, using a logistic regression to predict the likelihood of response associated with each variable.</p> <hd id="AN0176635060-8">Measures</hd> <p></p> <hd id="AN0176635060-9">Generalized anxiety disorder 7-Item scale (GAD-7)</hd> <p>The GAD-7[<reflink idref="bib38" id="ref43">38</reflink>] is a 7-item screening tool that assesses symptoms of anxiety over the past two weeks. In completing this valid and reliable measure,[<reflink idref="bib39" id="ref44">39</reflink>] participants rate each question on a Likert scale from 0 (not at all) to 3 (nearly every day). Scores range from 0–21. Following standard scoring protocol, participants were placed into four groups based on their GAD-7 scores: none to minimal (score <5), mild (5–9), moderate (10–14) and severe anxiety (>14). Further, using a standard cutoff of ≥10, participants were placed into anxiety or no to minimal anxiety groups. Finally, the relationship between individual GAD-7 items and suicidality was examined. For this analysis, the items were transformed into binary variables, whereby 0 was coded as no and any score >0 was coded as yes for endorsing that symptom.</p> <hd id="AN0176635060-10">Patient health questionnaire-9 (PHQ-9)</hd> <p>The PHQ-9[<reflink idref="bib40" id="ref45">40</reflink>] was used to measure depression over the past two weeks. PHQ-9 scores demonstrate high internal consistency and are highly correlated with clinical diagnosis.[<reflink idref="bib41" id="ref46">41</reflink>],[<reflink idref="bib42" id="ref47">42</reflink>] Subjects rate each question on a Likert scale from 0 (not at all) to 3 (nearly every day). Following standard scoring protocol, PHQ-9 scores were divided categorically into five groups, consisting of: none to minimal (score <5), mild (5–9), moderate (10–14), moderately severe (15–19) and severe (>19). Participants were also grouped dichotomously into depression or no to minimal depression groups based on a standard cutoff of ≥10.</p> <hd id="AN0176635060-11">Suicidality questions from the national comorbidity survey (NCS-R)</hd> <p>Past-year suicidal ideation and suicide attempt were assessed using yes/no questions originally developed for the NCS-R.[<reflink idref="bib6" id="ref48">6</reflink>] The first question was: "In the past year, did you ever seriously think about attempting suicide?" If the response was "yes," then participants were asked: "In the past year, did you attempt suicide?" These questions have been used to assess for suicidality in many other HMS papers.[<reflink idref="bib15" id="ref49">15</reflink>],[<reflink idref="bib43" id="ref50">43</reflink>]</p> <hd id="AN0176635060-12">Demographic characteristics</hd> <p>Demographics were assessed through self-report measures (see Table 1). Subjects reported their current age, race/ethnicity, nationality, gender identity and undergraduate or graduate status.</p> <p>Table 1. Sample demographics.</p> <p> <ephtml> <table><thead><tr><td /><td>N (total = 127,555)</td><td>Weighted %</td></tr></thead><tbody valign="top"><tr><td>Age</td><td /><td /></tr><tr><td> 18–19</td><td>39,229</td><td>30.8</td></tr><tr><td> 20–21</td><td>44,408</td><td>34.8</td></tr><tr><td> 22–25</td><td>30,556</td><td>24.0</td></tr><tr><td> 26–30</td><td>13,364</td><td>10.5</td></tr><tr><td>Race/Ethnicity<xref ref-type="table-fn" rid="tfn1">a</xref></td><td /><td /></tr><tr><td> African American/Black</td><td>10,958</td><td>8.6</td></tr><tr><td> American Indian or Alaskan native</td><td>2,345</td><td>1.8</td></tr><tr><td> Asian American/Asian</td><td>16,825</td><td>13.2</td></tr><tr><td> Hispanic/Latino</td><td>13,654</td><td>10.7</td></tr><tr><td> Middle Eastern, Arab or Arab American</td><td>2,667</td><td>2.1</td></tr><tr><td> Native Hawaiian or Pacific Islander</td><td>980</td><td>0.8</td></tr><tr><td> White</td><td>90,980</td><td>71.3</td></tr><tr><td> Self-identify</td><td>2,621</td><td>2.1</td></tr><tr><td>Nationality</td><td /><td /></tr><tr><td> International</td><td>9,437</td><td>7.4</td></tr><tr><td>Gender identity</td><td /><td /></tr><tr><td> Male</td><td>51,451</td><td>40.3</td></tr><tr><td> Female</td><td>72,034</td><td>56.5</td></tr><tr><td> Trans male</td><td>559</td><td>0.4</td></tr><tr><td> Trans female</td><td>188</td><td>0.1</td></tr><tr><td> Genderqueer/Nonconforming</td><td>2,192</td><td>1.7</td></tr><tr><td> Self-identity</td><td>993</td><td>0.8</td></tr><tr><td>Degree status<xref ref-type="table-fn" rid="tfn1">a</xref></td><td /><td /></tr><tr><td> Graduate</td><td>30,105</td><td>23.6</td></tr><tr><td> Undergraduate</td><td>94,728</td><td>74.3</td></tr><tr><td> Other</td><td>2,816</td><td>2.2</td></tr></tbody></table> </ephtml> </p> <p>1 <sups>a</sups>Race/ethnicity and Degree Status select all that apply so total over 100%.</p> <hd id="AN0176635060-13">Data analysis</hd> <p>For each of the demographic characteristics, we calculated and reported on prevalence rates and frequencies, which were weighted using the non-response weights described above (see Table 1). For each of the four levels of anxiety and five levels of depression, we reported on the proportions of suicidal ideation and attempt. We ran Spearman's Rho correlations on anxiety and depression overall scores to understand the correlation between the diagnoses. In conducting group comparisons, we used the Kruskal-Wallis H test. Finally, we conducted two logistic regressions to understand which items of the GAD-7 are most predictive of suicidal ideation and suicide attempt. We reported odds ratios (ORs), 95% confidence intervals (CIs), standard errors, standardized and unstandardized betas and <emph>p</emph>-values. All analyses were conducted using SPSS Version 24.</p> <hd id="AN0176635060-14">Results</hd> <p></p> <hd id="AN0176635060-15">Sample characteristics</hd> <p>Our study analyzed data from 119,875 students on 184 U.S. campuses who completed the HMS survey from fall of 2016 to spring of 2019. Given the young adult age of onset for anxiety, the analytic sample was restricted to survey respondents ages 18–30 years (M = 21.26 SD = 2.99). The sample was 56.6% female, 71.3% White, 92.6% U.S. citizen. See Table 1 for additional demographic information.</p> <hd id="AN0176635060-16">Clinical characteristics</hd> <p>Descriptive statistics were run to understand the prevalence of anxiety, depression, suicidal ideation and suicide attempt in the population. The mean anxiety level was mild (GAD-7 = 7.2, SD = 5.7). Results revealed that 40.1% of students had no to minimal anxiety (GAD-7 < 5), 28.9% had mild anxiety (GAD-7 = 5–9), 17.6% had moderate anxiety (GAD-7 = 10–14) and 13.4% had severe anxiety (GAD-7 > 14). The mean depression level of the population was mild (PHQ-9 = 8.5, SD = 6.3). Results also revealed that 32.0% of students had no to minimal depression (PHQ-9 < 5), 31.5% had mild depression (PHQ-9 = 5–9), 18.8% had moderate depression (PHQ-9 = 10–14), 10.7% had moderately severe depression (PHQ-9 = 15–19) and 7.0% had severe depression (PHQ-9 > 19). In terms of suicide risk over the past year, 14.3% of students reported suicidal ideation and 1.4% attempted suicide.</p> <hd id="AN0176635060-17">Relationships between depression, anxiety and suicidality</hd> <p>A Spearman's Rho correlation was run to assess the relationship between anxiety and depression. Results showed that depression and anxiety total scores were significantly correlated at r<subs>s</subs>=0.76, <emph>p</emph> < 0.001. Figure 1 presents the percentage of individuals with varying levels of anxiety and depression who also reported suicidal ideation and attempt. Of those with no to minimal anxiety and no to minimal depression (N = 70,2777), 4.6% reported ideation and 0.3% reported an attempt. Of those with anxiety and no to minimal depression (N = 8,795), 9.5% reported ideation and 0.8% reported an attempt. Of those with depression and no to minimal anxiety (N = 14,016), 22.5% reported ideation and 2.0% reported an attempt. Finally, of those with anxiety and depression (N = 26,787), 34.5% reported ideation and 4.0% reported an attempt.</p> <p>PHOTO (COLOR): Figure 1. Anxiety, depression and suicidality.</p> <p>The Kruskal-Wallis H test showed a statistically significant difference in suicidal ideation between the different groups, χ<sups>2</sups>(<reflink idref="bib3" id="ref51">3</reflink>) = 16924.36, <emph>p</emph> < 0.01. Specifically, those with depression and anxiety had significantly higher ideation than all other groups (Mean rank = 76646.71); those with depression and no to minimal anxiety (Mean rank = 68863.49) were higher than those with anxiety and no to minimal depression (Mean rank = 60534.79); those with both no to minimal anxiety and depression were lower than all other groups on ideation (Mean rank = 57439.73)</p> <p>Similarly, the Kruskal-Wallis H test showed a statistically significant difference in suicide attempt between groups, χ<sups>2</sups>(<reflink idref="bib3" id="ref52">3</reflink>) = 70.39, <emph>p</emph> < 0.01, but with a varying pattern of differences. Specifically, those with both anxiety and depression (Mean rank = 9131.66) differed from all other groups as they were the most likely to report a suicide attempt. Those with depression and no to minimal anxiety (Mean rank = 8851.83), those with those with anxiety and no to minimal depression (Mean rank = 8854.74) and those with both no to minimal anxiety and depression (Mean rank = 8712.7) did not significantly differ from one another in risk for suicide attempt.</p> <hd id="AN0176635060-18">Anxiety subscale items</hd> <p>To investigate the relationship between individual items of the GAD-7 and suicide risk, we ran logistic regressions related to suicidal ideation and attempt (see Table 2). When examining individual symptoms of anxiety, as measured by the GAD-7, six of seven items were significant predictors of suicidal ideation. Item 3 ("worrying too much about different things") was not a significant predictor. Endorsing item 7 ("feeling afraid as if something awful might happen") was associated with two times higher odds of suicidal ideation (OR = 2.22, 95% CI = 2.13–2.31, <emph>B</emph> = 0.80, <emph>p</emph> < 0.001). For suicide attempt, item 4 ("trouble relaxing;" OR = 1.45, 95% CI = 1.19–1.78, <emph>B</emph> = 0.37, <emph>p</emph> < 0.001) and item 5 ("being so restless that it is hard to sit still;" OR = 1.35, 95% CI = 1.19–1.52, <emph>B</emph> = 0.30, <emph>p</emph> < 0.001) were significant. Item 1 "Feeling nervous, anxious, or on edge" was also significant, however this was in the negative direction (OR = 0.76, 95% CI = 0.62–0.94, <emph>B</emph>= −0.28, <emph>p</emph> = 0.01).</p> <p>Table 2. Anxiety symptoms and suicidality.</p> <p> <ephtml> <table><thead><tr><td /><td><italic>B</italic></td><td>S.E.</td><td>Sig.</td><td>Exp(B)</td><td>Lower CI</td><td>Upper CI</td></tr></thead><tbody valign="top"><tr><td>Anxiety items and suicidal ideation</td><td>Item 1</td><td char=".">0.24</td><td char=".">0.03</td><td char=".">0.00</td><td char=".">1.28</td><td char=".">1.20</td><td char=".">1.36</td></tr><tr><td>Item 2</td><td char=".">0.46</td><td char=".">0.03</td><td char=".">0.00</td><td char=".">1.59</td><td char=".">1.50</td><td char=".">1.69</td></tr><tr><td>Item 3</td><td char=".">0.03</td><td char=".">0.04</td><td char=".">0.34</td><td char=".">1.03</td><td char=".">0.97</td><td char=".">1.11</td></tr><tr><td>Item 4</td><td char=".">0.45</td><td char=".">0.03</td><td char=".">0.00</td><td char=".">1.57</td><td char=".">1.48</td><td char=".">1.65</td></tr><tr><td>Item 5</td><td char=".">0.42</td><td char=".">0.02</td><td char=".">0.00</td><td char=".">1.52</td><td char=".">1.46</td><td char=".">1.57</td></tr><tr><td>Item 6</td><td char=".">0.37</td><td char=".">0.03</td><td char=".">0.00</td><td char=".">1.45</td><td char=".">1.38</td><td char=".">1.52</td></tr><tr><td>Item 7</td><td char=".">0.80</td><td char=".">0.02</td><td char=".">0.00</td><td char=".">2.22</td><td char=".">2.13</td><td char=".">2.31</td></tr><tr><td>Anxiety items and suicide attempt</td><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Item 1</td><td char=".">−0.28</td><td char=".">0.11</td><td char=".">0.01</td><td char=".">0.76</td><td char=".">0.62</td><td char=".">0.94</td></tr><tr><td>Item 2</td><td char=".">0.20</td><td char=".">0.11</td><td char=".">0.06</td><td char=".">1.22</td><td char=".">0.99</td><td char=".">1.51</td></tr><tr><td>Item 3</td><td char=".">0.03</td><td char=".">0.12</td><td char=".">0.78</td><td char=".">1.04</td><td char=".">0.82</td><td char=".">1.31</td></tr><tr><td>Item 4</td><td char=".">0.37</td><td char=".">0.10</td><td char=".">0.00</td><td char=".">1.45</td><td char=".">1.19</td><td char=".">1.78</td></tr><tr><td>Item 5</td><td char=".">0.30</td><td char=".">0.06</td><td char=".">0.00</td><td char=".">1.35</td><td char=".">1.19</td><td char=".">1.52</td></tr><tr><td>Item 6</td><td char=".">−0.09</td><td char=".">0.08</td><td char=".">0.23</td><td char=".">0.91</td><td char=".">0.78</td><td char=".">1.06</td></tr><tr><td>Item 7</td><td char=".">0.06</td><td char=".">0.07</td><td char=".">0.40</td><td char=".">1.06</td><td char=".">0.93</td><td char=".">1.20</td></tr></tbody></table> </ephtml> </p> <ulist> <item>2 Any endorsement of each item was considered a "yes" for each anxiety symptom.</item> <item>3 GAD-7 Items Endorsed Over Past 2 Weeks:</item> <item>4 Q1: Feeling nervous, anxious, or on edge.</item> <item>5 Q2: Not being able to stop or control worrying.</item> <item>6 Q3: Worrying too much about different things.</item> <item>7 Q4: Trouble relaxing.</item> <item>8 Q5: Being so restless that it's hard to sit still.</item> <item>9 Q6: Becoming easily annoyed or irritable.</item> <item>10 Q7: Feeling afraid, as if something awful might happen.</item> </ulist> <hd id="AN0176635060-19">Discussion</hd> <p>This is one of the largest known studies to examine the relationship between anxiety and suicidality in college students—a highly vulnerable population with rising rates of mental health concerns.[<reflink idref="bib2" id="ref53">2</reflink>],[<reflink idref="bib5" id="ref54">5</reflink>] Several important findings emerged and include: (<reflink idref="bib1" id="ref55">1</reflink>) high rates of anxiety and depression across the college population; (<reflink idref="bib2" id="ref56">2</reflink>) anxiety as an added risk factor for suicide above and beyond depression alone; and (<reflink idref="bib3" id="ref57">3</reflink>) assessing for specific symptoms of anxiety may increase accuracy in identifying suicide risk.</p> <p>Our findings reflect alarming rates of anxiety, depression and suicidality in the college population, which is consistent with prior literature[<reflink idref="bib14" id="ref58">14</reflink>],[<reflink idref="bib15" id="ref59">15</reflink>] Indeed, although the mean anxiety and depression levels were reported to be mild, over 17% of students reported moderate anxiety and over 13% reported severe anxiety. In addition, over 18% of students reported moderate depression, over 10% reported moderately severe depression and 7% reported severe depression. Over that prior year, more than 14% of students reported suicidal ideation and over 1% reported an attempted suicide.</p> <p>An important implication of these findings is that if we were to only screen for depression, we may identify approximately 23% of suicidal ideation in students, whereas if we also screen for anxiety, we would identify approximately 35% of students with suicidal ideation. Not surprisingly, depression remained a significant risk factor for suicidal ideation in this sample. However, importantly, students with co-occurring positive screens for depression and anxiety had approximately double the rates of suicide attempts than those with depression alone.</p> <p>When suicidal ideation and attempt were compared across groups, those with anxiety and depression had the highest risk of suicidal ideation and attempt. Those with depression and no to minimal anxiety had the second highest likelihood of suicidal ideation. Of note, those with anxiety and no to minimal depression had the second highest likelihood of suicide attempt. In addition to the increased risk of anxiety in those who are also depressed, it turns out anxiety may be an important flag for who may attempt suicide even in those with no to minimal depression.</p> <p>Another important aim of this research was to study anxiety at the symptom level, to improve our understanding of which symptoms may be most indicative of suicidality. Almost every anxiety item was correlated with suicidal ideation. The item "feeling afraid as if something awful might happen" was most predictive of suicidal ideation. This finding is important, as it can be used for prediction purposes when assessing for suicide risk. This item may reflect feelings of pessimism or hopelessness about the future. Psychiatry has long recognized that these negative future oriented thoughts may be more predictive of suicide than depression itself.[<reflink idref="bib43" id="ref60">43</reflink>] Endorsement of this symptom may trigger further evaluation of pessimism and hopelessness.</p> <p>"Trouble relaxing" was positively associated with suicide attempt. Prior literature has found that subjective complaints of restlessness[<reflink idref="bib45" id="ref61">45</reflink>] can lead to an energy to act on impulses that had been suppressed.[<reflink idref="bib46" id="ref62">46</reflink>] Studies have suggested this may lead to de novo suicidal ideation[<reflink idref="bib45" id="ref63">45</reflink>] and can worsen preexisting suicidal ideation,[<reflink idref="bib47" id="ref64">47</reflink>] as well as case reports have found close temporal association between restlessness and attempted suicide.[<reflink idref="bib45" id="ref65">45</reflink>] At the same time, "Feeling nervous, anxious, or on edge" was significantly and negatively correlated with suicide attempt. One possible explanation for this could be that anxiety sensitivity and attempting suicide appear to be negatively related.[<reflink idref="bib48" id="ref66">48</reflink>] Anxiety sensitivity is when an individual notices physical sensations more often and is more likely to interpret those symptoms are harmful or dangerous. Future research would benefit from carefully examining these two symptoms to better understand the differences between feeling nervous, anxious or on edge and symptoms of restlessness.</p> <p>Limitations should be noted when interpreting these findings. First, single binary measures for suicidal ideation and suicide attempt do not fully and adequately capture suicidal behavior. Additionally, the GAD-7 only asks about anxiety over the past two weeks and the suicidality questions ask over the past year. Thus, some relationships between suicidality and episodic anxiety may not be captured within this assessment window. Another limitation is that the cross-sectional nature of these data precludes the possibility of clearly inferring the directionality of the relationship between anxiety and suicidality. Although anxiety may increase risk for subsequent suicidality, it is also possible that the experience of suicidality in the past may increase anxiety or that a third variable may increase risk for both outcomes. Future longitudinal research tracking the emergence of suicidal ideation and anxiety over time is needed to address this relationship more clearly. Additionally, the response rate of 16–24% should be noted. Although this is a typical response rate for online surveys,[<reflink idref="bib49" id="ref67">49</reflink>] this does raise the potential question of response bias. As described above, we adjusted estimates with nonresponse weights along known characteristics, although there may be differences between responders and nonresponders on unobserved characteristics. It would also be important to replicate these findings in a non-collegiate young adult population. Perhaps this developmental period more broadly lends itself to increased anxiety, depression and suicidality, rather than just the college environment. It would therefore be useful to study these relationships in a more general population. Another limitation of our study was that there were nine institutions that participated two or more times in the years examined. Inclusion of all participating campuses during this time is consistent with prior publications of HMS data. Finally, as we shift toward a more transdiagnostic approach to understanding underlying symptoms, future research should encompass all anxiety symptoms, as the GAD-7 only technically assesses for generalized anxiety, rather than all anxiety disorders or associated symptoms. Evidence that particular anxiety symptoms increase risk for suicidality also points to the need to move away from studying diagnoses and toward understanding risk at the symptom level across the general population.</p> <hd id="AN0176635060-20">Conclusions</hd> <p>Our findings suggest the importance of considering anxiety symptoms as potential indicators for suicide risk. Although depression remains the most prominent predictor of suicidal thoughts and behavior,[<reflink idref="bib22" id="ref68">22</reflink>] our findings highlight the importance of assessing for anxiety as a compounding factor for suicide risk, and even suggest that anxiety alone could be a risk factor for suicide attempt. From a prevention angle, there are benefits for colleges to screen for both anxiety and depression to reach high‐risk students in need of help and to identify those at greatest risk for suicidal thoughts and behaviors. Studying anxiety at the symptom level may provide greater insight as to who is more at risk, leading to better referral options and safety.</p> <p>Similar to other studies investigating college mental health, the results of this study emphasize the importance of increasing the number of available programs on college campuses that address anxiety and suicide risk (e.g., Active Minds, National Alliance on Mental Illness, the Reflect Organization).[<reflink idref="bib50" id="ref69">50</reflink>] Trainings could also be implemented at the beginning of college to make students aware of signs of anxiety and how to properly seek help. This approach to intervention and treatment would be in accordance with newer research and treatment models emphasizing the need to focus on profiles or symptoms of disorders rather than a specific diagnosis (e.g., Process-Based Therapy; Unified Protocol).[<reflink idref="bib51" id="ref70">51</reflink>],[<reflink idref="bib52" id="ref71">52</reflink>] Lastly, as HMS has and continues to collect data from college students over more recent years, it will be important to investigate the effect the COVID-19 pandemic has had on college mental health, anxiety and suicidality. The pandemic has had a great impact on college students and we anticipate this will continue to impact mental health in this population. Given what is known about college student mental health, and the results of this study, it is important for colleges to continue working toward identifying high‐risk students and offering indicated prevention services, early intervention, and effective treatment options.</p> <hd id="AN0176635060-21">Acknowledgements</hd> <p>All individuals who contributed significantly to this work are acknowledged as authors on this manuscript.</p> <hd id="AN0176635060-22">Conflict of interest disclosure</hd> <p>There are no relevant financial or non-financial competing interests to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of United States of America and received approval from the Institutional Review Board of Boston University.</p> <ref id="AN0176635060-23"> <title> References </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> World Health Organization. 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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Anxiety and Suicidality in the College Student Population
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Danielle+M%2E+Moskow%22">Danielle M. Moskow</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-3117-0091">0000-0002-3117-0091</externalLink>)<br /><searchLink fieldCode="AR" term="%22Sarah+K%2E+Lipson%22">Sarah K. Lipson</searchLink><br /><searchLink fieldCode="AR" term="%22Martha+C%2E+Tompson%22">Martha C. Tompson</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Journal+of+American+College+Health%22"><i>Journal of American College Health</i></searchLink>. 2024 72(3):881-888.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 8
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2024
– Name: SourceSuprt
  Label: Sponsoring Agency
  Group: SrcSuprt
  Data: National Institute of Mental Health (NIMH) (DHHS/NIH)
– Name: NumberContract
  Label: Contract Number
  Group: NumCntrct
  Data: K01MH121515
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Audience
  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Higher+Education%22">Higher Education</searchLink><br /><searchLink fieldCode="EL" term="%22Postsecondary+Education%22">Postsecondary Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Anxiety%22">Anxiety</searchLink><br /><searchLink fieldCode="DE" term="%22Suicide%22">Suicide</searchLink><br /><searchLink fieldCode="DE" term="%22College+Students%22">College Students</searchLink><br /><searchLink fieldCode="DE" term="%22Depression+%28Psychology%29%22">Depression (Psychology)</searchLink><br /><searchLink fieldCode="DE" term="%22Psychological+Patterns%22">Psychological Patterns</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Correlation%22">Correlation</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/07448481.2022.2060042
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0744-8481<br />1940-3208
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Objective: This study examined symptoms of anxiety, depression and suicidality in a national sample of college students. Participants: Using national survey data from the Healthy Minds Study (HMS), a random sample from 184 U.S. campuses from fall 2016 to spring 2019 was analyzed (N = 119,875). Methods: Prevalence rates were examined with the Generalized Anxiety Disorder 7-Item scale, Patient Health Questionnaire-9 and suicidality questions. Relationships between anxiety, depression and suicidality were assessed through Spearman's correlations, the Kruskal-Wallis H test and logistic regressions. Results: Findings revealed that screening only for depression would pick up 23% of suicidal ideation, increasing to 35% when also screening for anxiety. Those with anxiety and no to minimal depression had the second highest likelihood of suicide attempt, following those with anxiety and depression. The symptom "feeling afraid something awful might happen" doubled the odds of suicidal ideation. Conclusions: College campuses may benefit from assessing particular anxiety symptoms in relation to suicide.
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  Data: As Provided
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  Label: Entry Date
  Group: Date
  Data: 2024
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1421413
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1421413
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  BibEntity:
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      – Type: doi
        Value: 10.1080/07448481.2022.2060042
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 8
        StartPage: 881
    Subjects:
      – SubjectFull: Anxiety
        Type: general
      – SubjectFull: Suicide
        Type: general
      – SubjectFull: College Students
        Type: general
      – SubjectFull: Depression (Psychology)
        Type: general
      – SubjectFull: Psychological Patterns
        Type: general
      – SubjectFull: Symptoms (Individual Disorders)
        Type: general
      – SubjectFull: Correlation
        Type: general
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      – TitleFull: Anxiety and Suicidality in the College Student Population
        Type: main
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          Name:
            NameFull: Danielle M. Moskow
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            NameFull: Sarah K. Lipson
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            NameFull: Martha C. Tompson
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              Type: published
              Y: 2024
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              Value: 1940-3208
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              Value: 72
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            – TitleFull: Journal of American College Health
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