Walking the Edge
Jillian Twomey hadn't heard about the rash of suicides at New York University, where five students jumped to their deaths between September and June. But over the summer, as she prepared for her first year at NYU, Twomey received the school's newly revamped request for a medical historya questionnaire that, with its probing inquiries, shows how hard it has become for universities to balance legal liability, individual privacy, and appropriate care.
"There were some things on the form that I didn't think related to my health at school," says Twomey, an 18-year-old freshman from Plymouth, Massachusetts, who dutifully filled out the form. "But it's my first year in college and I wasn't really sure what I was supposed to let them know."
Sandwiched among standard yes-no questions about allergies and immunizations was a handful of inquiries into students' psychiatric records. Have you ever had back pain? Chicken pox? Psychosis/schizophrenia? Are you taking medicine for acne? For headaches? How about for anxiety or depression? Made any suicide attempts?
The psychiatric questions, never before posed to NYU students, were part of an extensive mental health and wellness program debuting at the private school this year. Officials say the idea is to try to better understand the needs of their community and to make sure those needs get met.
"The university was pleased with the responses in terms of both quantity and honesty," says spokesperson Josh Taylor.
A letter accompanying the formwhich was sent to 5,650 new studentsexplained that only the information about immunization was mandatory, yet the first sentence on the form read, "All NYU students are required to complete this health history." The mental health questions came on page two, under the heading "All Students Must Complete Questionnaire."
Twomey says she thinks NYU is correct in seeking the information and in acting on it. "I do think they have the right to ask so they can keep track of people who have those types of problems," she says.
While Twomey and others may not have minded the intrusion, and NYU may have been well-intentioned, the questionnaire appears to some to have run afoul of federal laws about individual privacy and fair treatment for people with handicaps.
Jennifer Mathis, senior staff attorney at the Bazelon Center for Mental Health Law, cites potential violations of the Americans With Disabilities Act. "Even the general principle is problematic," Mathis says. "As a civil rights matter it's troubling and appears to violate the ADA."
Courts have found that questions about mental health may violate the law if they lead to discrimination. Particularly problematic for Mathis is that university officials plan to use students' answers to identify those in need of mental health services. That in itself could amount to discrimination. "Nothing is set in stone when it comes to civil rights law," Mathis says. "But I think many situations could arise where a court would find these questions to violate the ADA."
NYU could also face another kind of legal issuethe threat of legal action from grieving parents. The family of Elizabeth Shin, a Massachusetts Institute of Technology student who committed suicide in 2000, is suing the school in state court, claiming that M.I.T. did not provide adequate care. The suit also alleges that M.I.T. was so concerned with Elizabeth's privacy that it wrongly failed to alert the Shins when school counselors learned she was suicidal. The Shin case follows one in which Ferrum College, in Virginia, paid an undisclosed financial settlement last year to the family of Michael Frentzel, a freshman who hanged himself in 2000.
So far, NYU hasn't faced a similar suit. But even as the university has been trying to balance its need to care for students with federal mandates about those students' rights, the list of suicides has grown. On September 9, the day before classes began, Joanne Leavy, 24, a graduate student in the film department, jumped to her death from the roof of the 12-story Tisch Building.
Sophomore Jimmy Lynch's roommate was the second student to jump from the upper reaches of NYU's Bobst Library last year. Stephen Bohler's death was later ruled an accident after it was discovered that he, a member of the diving team, was under the influence of marijuana and hallucinogenic mushrooms when he leaped from the 10th floor into the atrium.
Lynch has mixed feelings about the medical questionnaire. "I doubt that the people who committed suicide would've declared themselves in need of help," he says. "At least the university is doing something."
Mental health programs, complete with assessments and follow-up counseling, are becoming more common at American universities. The legal points may be tricky, but from a treatment perspective, if you ask students questions, you have a responsibility to use what you learn. Professor Ralph Rickgarn, a suicidologist at Normandale Community College in Minnesota, believes assessment is a step in the right direction. "But now the university is obligated to follow up," he says.
Rickgarn, like many other suicide and mental health experts, praised NYU's wellness program, but warned of a slippery slope. "You can't take general information and then mandate treatment," he says. In research for his book, Perspectives on College Student Suicide, he encountered students who were penalized after sharing intimate mental health issues.
He cites the case of a woman attending a private school in Illinois. After confessing suicidal thoughts to a school counselor, she was thrown out of campus housing "for fear she would become disruptive," Rickgarn says. "It is very unethical to say to someone seeking help, 'Go away.' "
Determining the success of any suicide prevention program is difficult.
While few schools have thoroughly studied the problem on their own campuses, Dr. Paul Joffe, chair of the Suicide Prevention Team at the University of Illinois, leads the only one in the country that offers empirical data. He says the policy, called mandated assessment, decreased the number of student suicides at the University of Illinois by 58 percent over an 18-year period. The program runs on the theory that suicidal college students can be easy to spot. "I was struck by the number of students known to be suicidal that went on to commit suicide, that were given no treatment," Joffe says.
Following a suicide attempt or threat, the university assigns four mandatory counseling sessions. If a student fails to complete the four sessions, the school considers a variety of punishments, including expulsion. "Leaving school is always a possibility," Joffe says. The university has withdrawn only one student, a person who complied with the program but remained suicidal.
Since the advent of the program in 1984, some 2,000 students have gone through the mandated sessions, none of whomto the best of the program's knowledgewent on to commit suicide.
In some respects, the spate of suicides at NYU mirrors what's happening nationwide. According to the Centers for Disease Control, suicide rates among young people nearly tripled between 1952 and 1995. In 1998, suicide killed more young adults than AIDS, heart disease, cancer, birth defects, pneumonia, stroke, lung disease, and influenza combined. Suicide today is the second leading cause of death among college-age students.
A 2002 survey of counseling directors at 283 colleges, reported the Chronicle of Higher Education, revealed that 95 percent were seeing more students on psychiatric medication than in previous years. The counseling directors also noted an increase in the number of students attending university with severe mental health concerns.
One of the most common psychiatric problems among young adults is depression. Standard treatment for it has become a point of debate. Currently Prozac is the only antidepressant approved by the FDA for use in young adults, though doctors often prescribe other popular drugs like Paxil and Zoloft.
Last week, an FDA advisory committee called for stronger warning labels on antidepressant medication, saying that previously hushed data revealed an increase in suicidal tendencies for children and teenagers who regularly take the drugs. The committee took into consideration emotional testimony from families who had lost a child on antidepressants to suicide. The panel also considered convincing data found in an independent study conducted by Columbia University. Out of 100 young patients treated with antidepressants, two or three will likely display evidence of suicidal thoughts or actions that otherwise would not have appeared, Columbia found.
Dr. Morton Silverman, senior adviser to the suicide prevention resource center in Newton, Massachusetts, has served as a consultant for NYU over the last year. Silverman is strongly in favor of "black box" warning labels for antidepressants. He agrees that the number of college-age students using them has increased. "They have now been approved for eating disorders, panic disorders, depression, and obsessive-compulsive disorder," he said.
That's no secret to officials on Washington Square. "Irrespective of events of the past year, NYU has seen what every other college and university has seena demand for more mental health services," university spokesperson John Beckman says. "Students who are coming into college these days have more emotional problems than in the past."
While toxicology reports have not been made public for the NYU students who committed suicide, two of the six reportedly had a history of taking antidepressantswhich may or may not prove anything. "We still don't know that there is a link to suicide," said Kay Redfield Jamison, author of Night Falls Fast: Understanding Suicide. "There is a link to suicidal thinking, but there is a big leap from suicidal thinking to killing yourself."
As the FDA is reconsidering antidepressants and young users, so too are universities weighing steps to better help students, a task that has been difficult for NYU amid the frenzy over campus suicides. "The press has been all over the map," Beckman says, adding that the school "holds its breath" when some stories are published. NYU, and suicide experts, are wary of glamorizing suicide in any way, particularly by media attention and "misdirected" campus dialogues. The school has a policy against holding memorials.
As a result, many students and some faculty have criticized the administration for being tight-lipped about the issue. Allen Salkin, a former adjunct professor at NYU, used his website last year to criticize the university's handling of the suicides. "NYU is still acting like a multinational corporation with an unsafe product," he says. He argues that the school leadership has a strategy of deflecting blame before acknowledging the sadness and the tragedy of the student deaths.
NYU is certainly not the only school trying to deal with recent waves of suicide. George Washington University, for example, has had six student deaths since December of 2003, three of which were suicides. NYU has, however, become a focal point of this national, even global, epidemic.
"What is wrong with NYU that all these kids are taking their lives?" says Rachel Basse, a junior in the university's general studies program.
Experts say the problem isn't NYU at all. "The deaths at NYU are tragic, but not remarkable," Silverman says. "It doesn't indicate something is wrong with the university."
Many students seem to agree, though some say NYU's quiet way of handling the deaths has created student apathy. Roy Miler, a freshman from Long Island, says the suicides didn't affect his decision to go to college there at all. Miler does say he's angry about one thing. "A buddy of mine told me that we were supposed to have a couple days off after a suicide, that a lot of schools do that," he says. As for the mandatory health and mental health presentation all freshmen were required to attend during orientation, Miler says he didn't go.
Basse remembers that the first suicides in Bobst Library were hard to deal with. "But now the reaction is, 'Oh, another one,' " she says.
If the students have become ho-hum, the school hasn't. Caught between asking too much and not doing enough, NYU seems to be struggling to find an antidote that doesn't exist.
"Even with most comprehensive, carefully designed prevention and intervention efforts, there is always going to be someone who is intent on killing themselves," says Dr. Madelyn Gould, an epidemiologist from Columbia University who specializes in suicide epidemics.
Despite its best efforts, NYU has entered murky territory. Emily Stewart, a policy analyst with the Health Privacy Project, says nothing in the Family Educational Rights and Privacy Act (FERPA) explicitly prevents a university from sharing information internally. Yet she says the idea of following up with students who filled out a confidential form is "alarming."
Most problematic for Stewart was the potential that the information would be shared with the dormitory staff. "This could have a chilling effect on students," she says. "It could have a negative impact on how students seek care at NYU."
NYU does not have a policy for dealing with troubling responses found on its new questionnaire. Each student will be dealt with "on a case-by-case basis," Taylor says.
That wouldn't necessarily shield the school from charges of discrimination, Mathis says. "It is very fact-dependent, but many courts would find many types of follow-up discriminatory because they are unduly intrusive and can make people feel excluded," she explains.
In taking an active role with regard to its students' mental health, any university walks a fine line between trying not to violate civil rights and trying to save lives. "There will always be ethical, legal, and civil rights concerns," Jamison says. "But there are also concerns about doing nothing."
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